Coronary revascularization: off-pump versus on-pump--a comparison of behavior of biochemical cardiac ischemia markers

BACKGROUND: Recently, coronary artery bypass grafting (CABG) on the beating heart with avoidance of extracorporeal circulation (off-pump CABG technique) has been gaining increasing importance in modern cardiac surgery. The object of this prospective study was to compare postoperative kinetic and patterns of cardiac troponin I (cTnI), T (cTnT), and creatine kinase MB (CKMB) activities after off-pump CABG versus conventional on-pump CABG. METHODS: We studied 106 patients who underwent first-time elective on-pump (group I, n = 69, 56 male, 13 female, mean age: 64.3 +/- 9.9 years, mean ejection fraction: 56 +/- 15%) or off-pump (group II, n = 37, 24 male, 13 female, mean age: 68.4 +/- 9.1 years, mean ejection fraction: 57 +/- 13%) CABG surgery via median sternotomy. CTn I and cTnT levels, total creatine kinase (CK) and CK-MB activities in the serum were measured before operation, up on arrival at the ICU and 6, 12, 24, 48 and 120 hours later. Serial 12-lead ECGs were recorded preoperatively and on days 1, 2 and 5. RESULTS: Serum concentrations of cardiac troponins in all patients were preoperatively either not detectable or in the normal range and significantly increased after surgery. In group I, one patient developed a Q wave myocardial infarction, one patient a non-Q wave infarction and two patients a new left bundle branch block on the ECG. One patient of group II developed a new Q-wave myocardial infarction and another patient permanent atrial fibrillation associated with a continuous arrhythmia. All patients with a myocardial infarction in the ECG showed significant elevation of concentrations or activities of these biochemical markers. The median postoperative peak values for cTnI were measured at 24 h in both groups (2.7 micrograms/l, 95%-CI: [2.2, 3.2] in group I and 1.1 micrograms/l, 95%-CI: [0.5, 1.3] in group II). CTnT postoperatively presented an earlier median peak of 0.128 microgram/l at 12 h in group II (95%-CI: [0.041, 0.146]) than in group I at 48 h (0.298 microgram/l, 95%-CI: [0.254, 0.335]). CONCLUSIONS: All patients undergoing CABG surgery with or without extracorporeal circulation postoperatively showed an increase of cardiac troponin levels. After uncomplicated coronary revascularization, patients with the off-pump CABG technique continuously presented lower serum cardiac troponin concentrations than those with the on-pump CABG technique. CTnI showed the same patterns of release in both groups with different median postoperative peak values at 24 h. The patterns off cTnT release following CABC surgery with or without extracorporal circulation were different: CTnT reaches its postoperative peak value in patients with the off-pump CABG technique earlier than those with the on-pump CABG technique (12 h postoperatively versus 48 h).     

Myocardial injury in coronary artery bypass grafting: On-pump versus off-pump comparison by measuring heart-type fatty-acid-binding protein release

This prospective study uses heart-type fatty-acid-binding protein (hFABP) and creatine kinase-MB (CK-MB) release to compare myocardial injury in on-pump versus off-pump coronary artery bypass grafting (CABG). Fifty patients were randomly assigned to on-pump or off-pump CABG. The hFABP and CK-MB concentrations were measured in serial venous blood samples drawn before heparinization in both groups and after aortic unclamping at 1, 2, 4, 8, 24, 48, and 72 hours in the on-pump group. In the off-pump group, samples were taken after the last distal anastomosis at the same time intervals as in the on-pump group. The total amount of hFABP and CK-MB released was significantly higher in the on-pump than in the off-pump group (hFABP = 100.43 +/- 77.63 vs 3.94 +/- 0.36 ng/mL, P < 0.0001; CK-MB = 33.33 +/- 3.81 vs 28.65 +/- 3.91 log units, P < 0.001). In all patients, hFABP levels peaked as early as 1 hour after declamping (on-pump group) or 2 hours after the last distal anastomosis (off-pump group), whereas CK-MB peaked only at 4 hours after declamping (on-pump group) or 24 hours after the last distal anastomosis (off-pump group). The lower release of hFABP and CK-MB in the off-pump CABG group indicates that on-pump CABG with cardioplegic arrest causes more myocardial damage than does off-pump CABG. Heart-type fatty-acid-binding protein is a more rapid marker of perioperative myocardial damage, peaks earlier than CK-MB, and may predict the requirement for intensive monitoring for postoperative myocardial infarction.     

Comparison of left ventricular diastolic function after on-pump versus off-pump coronary artery bypass grafting

We evaluated diastolic function in patients who underwent elective revascularization by standard on-pump coronary artery bypass graft (CABG) surgery versus off-pump CABG. Diastolic function improved in both groups, but indexes of early diastolic filling and myocardial relaxation improved more in patients who underwent on-pump than off-pump CABG.     

Current State of Anticoagulants to Treat Deep Venous Thrombosis

Coronary artery bypass grafting (CABG) remains the preferred treatment in patients with complex coronary artery disease. However, whether the procedure should be performed with or without the use of cardiopulmonary bypass, referred to as off-pump and on-pump CABG, is still up for debate. Intuitively, avoidance of cardiopulmonary bypass seems beneficial as the systemic inflammatory response from extracorporeal circulation is omitted, but no single randomized trial has been able to prove off-pump CABG superior to on-pump CABG as regards the hard outcomes death, stroke or myocardial infarction. In contrast, off-pump CABG is technically more challenging and may be associated with increased risk of incomplete revascularization. The purpose of the review is to summarize the current literature comparing outcomes of off-pump versus on-pump coronary artery bypass surgery.     

Perioperative Outcomes after On- and Off-Pump Coronary Artery Bypass Grafting

Although numerous reports describe the results of off-pump coronary artery bypass grafting (CABG) at specialized centers and in select patient populations, it remains unclear how off-pump CABG affects real-world patient outcomes. We conducted a large, multicenter observational cohort study of perioperative death and morbidity in on-pump (ON) versus off-pump (OFF) CABG.We reviewed Veterans Affairs Surgical Quality Improvement Program data for all patients (N=65,097) who underwent isolated CABG from October 1997 through April 2011 (intention-to-treat data were available from 2005 onward). The primary outcome was perioperative (30-day or in-hospital) death; the secondary outcomes were perioperative stroke, dialysis dependence, reoperation for bleeding, mechanical circulatory support, myocardial infarction, ventilator support ≥48 hr, and mediastinitis. Propensity scores calculated from age, 17 preoperative risk factors, and year of surgery were used to match 8,911 OFF with 26,733 ON patients.In the complete cohort, compared with the ON patients (n=53,468), the OFF patients (n=11,629) had less perioperative death (2.02% vs 2.53%, P=0.0012) and lower incidences of all morbidities except perioperative myocardial infarction. In the matched cohort, perioperative death did not differ significantly between OFF and ON patients (1.94% vs 2.28%, P=0.06), but the OFF group had lower incidences of all morbidities except for perioperative myocardial infarction and mediastinitis. A subgroup intention-to-treat analysis yielded similar but smaller outcome differences between the ON and OFF groups.Off-pump CABG might be associated with decreased operative morbidity but did not affect operative death, compared with on-pump CABG. Future studies should examine the effect of off-pump CABG on long-term outcomes.     

Early mortality from off-pump and on-pump coronary bypass surgery in Canada: a comparison of the STS and the EuroSCORE risk prediction algorithms

OBJECTIVE: Early mortality from off-pump and on-pump coronary artery bypass graft (CABG) surgery was assessed and compared with two widely used risk algorithms for CABG: The Society of Thoracic Surgeons (STS) and the European System for Cardiac Operative Risk Evaluation (EuroSCORE). METHOD: From March 12, 2001, to December 31, 2002, 1657 consecutive patients were treated with off-pump CABG and 1693 consecutive patients were treated with on-pump CABG. The predicted risk of mortality scores for the STS and EuroSCORE models were calculated. The predictive accuracy for early mortality was assessed by comparing the observed and expected mortalities for equal-sized quantiles of risk using the Hosmer-Lemeshow goodness-of-fit test. The discriminatory power of the models was evaluated by calculating the area under the receiver operating characteristic (ROC) curves. RESULTS: The observed postoperative mortality was 1.8% (95% CI 1.3% to 2.4%) for off-pump CABG and 1.5% (95% CI 1.1% to 2.1%) for on-pump CABG. For both on-pump and off-pump CABG surgery, the Hosmer-Lemeshow goodness-of-fit test indicated good accuracy. The area under the ROC curve was 0.81 (95% CI 0.73 to 0.90) for the STS and 0.79 (95% CI 0.71 to 0.88) for EuroSCORE in off-pump CABG (P=0.567). The area under the ROC curve was 0.82 (95% CI 0.73 to 0.91) for STS and 0.81 (95% CI 0.71 to 0.90) for EuroSCORE in on-pump CABG (P=0.616). The STS-predicted risk of stroke, prolonged ventilation and renal failure were similar to the observed data, with relatively good discriminatory powers for both off-pump and on-pump CABG. CONCLUSION: Both the STS and EuroSCORE risk algorithms are good predictors of early mortality from off-pump or on-pump CABG surgery. However, the generalizability of these results in the Canadian context would require a broader sampling of Canadian centres, including ones that provide both on-pump and off-pump CABG.     

非体外循环下冠状动脉旁路移植术治疗冠心病的疗效

目的 观察非体外循环下冠状动脉旁路移植术（CABG）治疗冠心病的疗效。方法 170例冠心病患者随机分为体外循环下CABG组（On-pump组，n=85例）和非体外循环不停跳CABG组（Off-pump组，n=85例）。观察两组患者氧合指数（OI）、肺泡-动脉氧差（AaDO2）、呼吸机辅助时间、正性肌力药物使用量及时间、术后24 h出血量、输血量及心肌酶值。结果 Off-pump组在出血量、输血量、辅助呼吸时间、呼吸指标均明显优于On-pump组，正性肌力药物使用时间及心肌酶值显著少于On-pump组（P<0.05，P<0.01）。结论 采用非体外循环进行CABG治疗冠心病优于体外循环。     

A cost comparison of off-pump CABG versus on-pump CABG at one-year: The Canadian off-pump CABG registry

BACKGROUND: Evidence suggests that off-pump coronary artery bypass graft surgery (CABG) is as safe and effective as on-pump CABG, and the cost of initial hospitalization for off-pump CABG is less expensive than on-pump CABG. However, it is uncertain whether the cost savings are sustained over a longer period of time. OBJECTIVE: To assess in-hospital and one-year direct medical costs of off-pump CABG versus on-pump CABG in the context of the Canadian health care system. METHODS AND RESULTS: From March 2001 to December 2002, 1657 consecutive patients enrolled in the Canadian Off-Pump CABG Registry were compared with 1693 consecutive on-pump patients from Hamilton Health Sciences CABG database. At one year, patients of both groups were followed by telephone interview. An economic analysis was conducted from the perspective of the Ontario Ministry of Health and Long-Term Care, and the data analysis was based on propensity score-matched registry patients (1233 pairs) to ensure the comparability of the two study groups. Clinical event and resource use information was collected from all patients. Unit costs from the Hamilton Health Sciences case-costing system were used to estimate hospital costs; all costs were reported in 2003 Canadian dollars. Sensitivity analyses were performed to account for uncertainties. The cost of initial hospitalization for off-pump CABG was significantly less than on-pump CABG (11,744 dollars versus 13,720 dollars, P < 0.001). Although follow-up costs were similar between the groups, the one-year total cost per patient for off-pump CABG remained significantly less than on-pump CABG (12,063 dollars versus 14,141 dollars, P < 0.001). CONCLUSION: Off-pump CABG offers significant savings during initial hospitalization that are also sustained after one year.     

Mortality and Readmissions After On-Pump Versus Off-Pump Redo Coronary Artery Bypass Surgery

IntroductionLarge institutional and administrative datasets that have compared on pump versus off pump first time coronary artery bypass grafting (CABG). However, comparison of off-pump vs on-pump outcomes in patients undergoing redo CABG are limited in current literature.MethodsAll patients who underwent redo CABG for coronary artery disease from 2011 to 2017 at our institution were included in the study. Cox regression analysis was performed to identify variables associated with 5-year mortality and readmission.ResultsThree hundred and fifty patients underwent redo CABG; of which, 309 underwent on-pump CABG and 41 underwent off-pump CABG. Blood product transfusion (31.7% vs 58.9%; p = 0.001) and new onset atrial fibrillation (17.1% vs 35.6%; p = 0.018) were higher in the on-pump cohort. There was no difference in 30-day (2.4% vs 8.1%; p = 0.209), 1-year (4.9% vs 16.5%; p = 0.074), or 5-year mortality (31.7% vs 35.6%; p = 0.213) for off vs on pump redo CABG. There was no difference in 30-day or 1- hospital readmissions between groups. Five-year all cause readmissions (76.9% vs 55.3%; p = 0.037) was significantly higher in the off-pump redo CABG group. On multivariable analysis, on vs. off pump CABG was not significantly associated with mortality or readmission at 5 years.ConclusionThere was no short or long-term survival advantage for on-pump vs off-pump CABG despite risk adjustment. Hospital readmissions at 5-years were higher in the off-pump group.     

Full-sternotomy off-pump versus on-pump coronary artery bypass procedures: in-hospital outcomes and complications during one year in a single center

We prospectively compared, according to their preoperative clinical profiles, the in-hospital outcomes of patients operated on consecutively (but without randomization) for isolated coronary artery disease with on-pump or off-pump techniques. During 2001, 324 patients underwent coronary artery bypass grafting: 216 patients (mean age, 66.7 +/- 8.9 years; range, 41-85 years) underwent on-pump revascularization, and 108 patients (mean age, 676 +/- 10 years; range, 37-90 years) underwent full-sternotomy off-pump revascularization. The 2 groups were homogeneous with regard to female sex (22.6% vs 26.8%), previous cardiac operation (2.8% vs 4.6%), cardiogenic shock (1.3% vs 1.9%), diabetes (30% vs 33%), and chronic renal failure that required hemodialysis (3% vs 3.5%). Postoperative complications, including bleeding, myocardial infarction, acute renal failure, mediastinitis with sternal dehiscence, cerebrovascular events, and prolonged respiratory assistance were more frequent in on-pump patients (P = 0.004). The total number of grafts and the grafts per patient ratio were significantly higher in on-pump patients (P = 0.0001), whereas the total number of full arterial revascularizations was higher in off-pump patients (P = 0.0001). Off-pump patients showed a significantly shorter intensive care unit stay (P = 0.02), and less need for intra-aortic balloon pump insertion (P = 0.04). In-hospital mortality was 2.8% in on-pump patients and 2.7% in off-pump patients (P = NS). Although the hospital mortality rate was comparable for the 2 techniques, the in-hospital comparison between the 2 groups showed how the avoidance of cardiopulmonary bypass can significantly reduce the cumulative postoperative incidence of complications in patients undergoing coronary artery bypass grafting.     

Off-pump coronary artery bypass graft surgery: the incidence of postoperative atrial fibrillation

Atrial fibrillation (AF) occurs in one quarter to one third of patients after coronary artery bypass graft surgery (CABG). Conventional CABG uses cardiopulmonary bypass, a process that is itself associated with a systemic vascular inflammatory response that contributes to postoperative morbidity. The avoidance of cardiopulmonary bypass is associated with a significant reduction in the inflammatory response and in the release of markers of myocardial necrosis when compared with conventional CABG. There is speculation that off-pump CABG may reduce the incidence of postoperative AF through reduced trauma, ischaemia, and inflammation. Current data, however, do not emphatically answer the question of whether the incidence of post-CABG AF is reduced by off-pump surgery. The evidence from both observational and randomised studies is conflicting and many studies have weaknesses in design, conduct, or interpretation. It remains an attractive hypothesis that postoperative AF is reduced by off-pump CABG but more robust data are required.     

Coronary surgery without extracorporeal circulation: the short-term results in high-risk patients

BACKGROUND: This study was conducted to assess the impact of coronary bypass surgery (CABG) without cardiopulmonary bypass (CPB) on high-risk patients. METHODS: From February 1997 to July 1998, 71 patients considered at high-risk underwent a CABG off-pump. Using the "Higgins score", eleven preoperative risk factors were identified and stratified in this group of patients. Among 1271 patients who underwent CABG with CPB in the same period, using a computer-based matched comparison, a second identical group of patients was selected according to the 11 risk variables and the number with coronary disease, so that complete preoperative matching included the year of operation, score index and coronary target. Moreover, among seven other preoperative variables that were not included in the matching comparison, the two groups differed only in mean age (64 +/- 10.9 vs 61.6 +/- 7.3 in groups off and on-pump, respectively, p < 0.05). Postoperative outcome and complications and blood requirement were compared. Myocardial cell injury and left ventricular performance were also assessed in the two groups. RESULTS: The global incidence of neurologic complications in the off-pump group was significantly lower (9.8 vs 0%, in on and off-pump groups, respectively; p = 0.02). Patients undergoing CABG off-pump required blood far less often (% of transfused patients: 26.7% for the patients with CPB and 11.2% for the patients without CPB; p = 0.032). Three patients from the on-pump group (4.2%) had a perioperative myocardial infarction (AMI), versus 0% of the off-pump cases (p = ns). Postoperative atrial fibrillation accounted for 14.1% in off-pump patients and 30.9% in on-pump patients (p = 0.027). One patient in both groups (1.4%) suffered from postoperative heart failure. Mean ventilation time and ICU stay did not differ significantly between the two groups. However, hospital discharge occurred earlier in the off-pump group (9.3 +/- 3 vs 12.6 +/- 8, p = 0.007). In-hospital death occurred in one case from the on-pump group (1.4%) versus 0% of patients operated off-pump. CPK-MB release in patients without perioperative AMI was significantly lower in off-pump patients 6 and 12 hours after the operation (36.6 +/- 17 IU/l vs 69.8 +/- 23 IU/l after 6 hours, p < 0.05; and 36.7 +/- 19 IU/l vs 67.3 +/- 26 IU/l after 12 hours, p < 0.05, in off and on-pump groups, respectively) and LVSWI turned out to be better in off-pump patients 6 hours postoperatively (34.2 +/- 2 g*m/m2 vs 27.2 +/- 3 g*m/m2, p < 0.01). CONCLUSIONS: CABG without CPB seems to be a promising technique for high-risk patients. It offers better neurologic and cardiac protection, shortens postoperative hospital stay and reduces the need for blood transfusion.     

The Canadian off-pump coronary artery bypass graft registry: a one-year prospective comparison with on-pump coronary artery bypass grafting

BACKGROUND: The authors sought to examine in-hospital and one-year outcomes of off-pump coronary artery bypass grafting (CABG) and to determine the subgroups of patients most likely to benefit from the off-pump procedure in a regular surgical practice. METHODS: From March 2001 to December 2002, 1657 consecutive patients were treated with off-pump CABG and 1693 consecutive patients were treated with on-pump CABG. Propensity score modelling was performed to control for treatment and selection bias. A propensity-matched analysis was performed to identify factors associated with survival benefit from the off-pump procedure. RESULTS: The mortality was similar postoperatively and at one year after surgery. The rate of stroke was decreased in the off-pump group postoperatively (OR=0.49, 95% CI 0.23 to 1.06) and significantly at one year after surgery (OR=0.49, 95% CI 0.27 to 0.90). A significant reduction in acute renal dialysis and a significant increase in myocardial infarction rates were seen in off-pump patients during the initial hospitalization but these differences disappeared during the follow-up period. The number of grafts completed was significantly lower in off-pump CABG than in on-pump CABG (2.62+/-1.00 versus 3.36+/-0.92, respectively; P<0.001). Hospital length of stay and the percentage of patients who required mechanical ventilation were significantly lower in the off-pump group than in the on-pump group. At one year after surgery, the adjusted rate of coronary angiogram and revascularization was similar between the two groups, and the adjusted rate of self-reported angina and memory status was significantly better in the off-pump CABG group. Almost all subgroups of patients had a neutral effect or a survival benefit with the off-pump technique. CONCLUSIONS: The results from a Canada-wide multicentre registry showed the safety and effectiveness of off-pump CABG in most subgroups of patients in a regular surgical practice.     

Off-pump coronary artery bypass grafting improves in-hospital mortality in patients with dialysis-dependent renal failure

ObjectivePatients with chronic dialysis-dependent end-stage renal disease are increasingly referred for coronary artery bypass grafting (CABG) and their early outcome is less favorable. Off-pump CABG (OPCAB) has achieved encouraging results in high-risk patients. Therefore, we designed this retrospective study to test the hypothesis that OPCAB reduced surgical risks in dialysis patients.MethodsFrom January 2000 to December 2005, 294 dialysis-dependent patients received isolated CABG at the Washington Hospital Center. Among them, 168 underwent OPCAB (off-pump group), and 126, CABG with cardiopulmonary bypass (CPB) (on-pump group). The in-hospital outcomes were analyzed.ResultsThe two groups were comparable in terms of preoperative characteristics. The Parsonnet's Bedside Score of the off-pump group was similar to that of the on-pump group (32.0 vs. 32.0, P=.57). The in-hospital mortality of the off-pump group was significantly lower than that of the on-pump group (5.4% vs. 11.9%, P=.04). Although the percentage of patients who received transfusions was similar, the on-pump group received more total transfusions. Logistic regression analysis revealed that use of CPB independently predicted in-hospital mortality [odds ratio (OR), 5.0; 95% confidence interval, 1.78–13.85; P<.01] and perioperative myocardial infarction (MI; OR, 5.1; 95% confidence interval, 1.18–22.40; P=.03). No significant difference in long-term survival at 4 years was absorbed between the two groups of hospital survivors.ConclusionsOur data suggest that OPCAB is a safe alternative to on-pump CABG in dialysis patients. Avoiding CPB resulted in less perioperative blood utilization, MI, and hospital mortality.     

复合辅酶对冠心病患者围术期心肌保护和肝脏保护作用的研究

目的:探讨冠心病(CAD)患者体外循环(CPB)冠状动脉旁路移植(CABG)术中使用复合辅酶对心肌和肝脏保护的效果。方法:70例择期CPB下进行CABG的CAD患者,随机分为试验组与对照组各35例,试验组术中给予辅酶A1000u和辅酶I1.0mg,对照组不给复合辅酶。观察CPB时间、主动脉阻断时间、正性肌力药使用情况、ICU停留时间、术后住院时间、围术期心肌梗死和脑卒中等临床指标。2组分别于手术开始前、手术结束时、手术后6h、12h、24h和术后3d采集患者中心静脉血,检测红细胞压积、肌酸激酶、肌酸激酶同工酶和肌钙蛋白I;于手术开始前、手术结束时、手术后3d和手术后7d采血检测谷丙转氨酶、谷草转氨酶、总胆红素和直接胆红素。结果:2组术后心肌酶谱均较术前升高(P0.01),但在术后6h、12h和24h试验组心肌酶谱显著低于对照组(P0.01)。2组术后转氨酶和胆红素水平均较术前升高(P0.01),但在术后3d试验组的转氨酶和胆红素水平显著低于对照组(P0.01)。结论:CAD患者围术期应用复合辅酶具有一定的心肌保护和肝脏保护作用。     

Tumor necrosis factor-alpha gene -308G>A polymorphism is associated with ST-elevation myocardial infarction and with high plasma levels of biochemical ischemia markers

OBJECTIVES: As is well known, acute myocardial infarction presents two electrocardiogram (EKG) patterns, ST-elevation (STEMI) and no ST-elevation (NSTEMI), characterized by different coronary artery thrombotic occlusion. Growing evidence shows that inflammation plays a central role in the pathogenesis of acute myocardial infarction. Among the factors that promote inflammation and arterial thrombosis, one of the most important is the proinflammatory cytokine tumor necrosis factor-alpha. The expression of this cytokine is modulated by a polymorphism located at nucleotide -308 of tumor necrosis factor-alpha promoter gene. The objective of our study is to verify whether tumor necrosis factor-alpha -308 polymorphism is associated with risk of acute myocardial infarction (STEMI and NSTEMI) or with biochemical myocardial ischemia markers, such as troponin I, creatine kinase-MB, lactate dehydrogenase and myoglobin. METHODS: We analyzed tumor necrosis factor-alpha -308 polymorphism in a total of 603 study participants: 293 elderly patients affected by acute myocardial infarction (STEMI and NSTEMI) and 310 healthy controls. RESULTS: We found that individuals carrying the tumor necrosis factor-alpha -308 AG+AA genotypes are significantly more represented among acute myocardial infarction patients affected by STEMI than among NSTEMI patients (OR = 1.86, 95% CI 1.08-3.21, p = 0.027) and healthy controls (OR = 1.64, 95% CI 1.03-2.64, p = 0.046). Furthermore, the patients carrying tumor necrosis factor-alpha -308 AG+AA genotypes displayed significant increased levels of biochemical myocardial ischemia markers. CONCLUSIONS: Our study shows a significant association between the tumor necrosis factor-alpha -308 polymorphism and the occurrence of STEMI, and suggests that the tumor necrosis factor-alpha -308 polymorphism could play a role in the pathogenesis of cardiac ischemic damage, AA+AG genotype carrier individuals being likely to be affected by more severe ischemic damage than the rest of the population.     

冠心病患者冠状动脉旁路移植术不同术式的临床疗效比较

目的对比研究冠心病患者体外循环冠状动脉旁路移植术和非体外循环冠状动脉旁路移植术的手术效果。方法106例择期行冠状动脉旁路移植术患者分为两组,体外循环冠状动脉旁路移植术组59例,非体外循环冠状动脉旁路移植术组47例,对两组相关指标进行对比分析。结果两组在平均搭桥支数、平均动脉桥支数、死亡率以及术后并发症的发生率方面无明显差异(P>0.05);而非体外循环冠状动脉旁路移植术组术后呼吸机支持时间、ICU天数、平均住院天数以及胸腔引流量和输血量均低于体外循环冠状动脉旁路移植术组(P<0.05)。结论非体外循环冠状动脉旁路移植术和体外循环冠状动脉旁路移植术均是冠心病外科治疗有效的方法;与体外循环冠状动脉旁路移植术相比,非体外循环冠状动脉旁路移植术在缩短呼吸机支持时间、减少胸腔引流量、输血量和平均住院天数等方面具有一定的优势。     

老年患者体外与非体外循环行冠状动脉旁路移植术对围术期血气的影响

目的比较非体外循环（off-pump）和体外循环（on-pump）冠状动脉旁路移植手术（CABG）对年龄大于65岁老年患者围术期血气的影响。方法32例患者接受CABG手术,其中16例采用off-pump,16例采用传统的on-pump,收集两组患者术前肺功能、手术时间、旁路移植血管数、气管插管留置时间和ICU留住时间。测定患者术前、手术开始、手术结束时和术后24、48、72 h的动脉血气。结果两组患者术前肺功能、手术时间、旁路移植血管数无明显差异,但off-pump组的气管插管留置时间和ICU留住时间均明显短于on-pump组（P<0.05）。两组患者术前、手术开始和术后48、72 h的动脉血气相似,但是手术结束时on-pump组PaO2和红细胞压积（Hct）明显低于off-pump组（P<0.05）;术后24 h on-pump组PaO2仍显著低于off-pump组（P<0.05）。结论与传统的on-pump CABG相比,off-pump可改善年龄大于65岁老年患者术后早期的血气,并能缩短ICU留住时间。     

The relation between surgeon volume and outcome following off-pump vs on-pump coronary artery bypass graft surgery

STUDY OBJECTIVE: Off-pump coronary artery bypass graft (CABG) surgery has been recently reintroduced into clinical practice. In light of the relatively low level of experience of most cardiac surgeons with off-pump CABG surgery, and the exceptional technical challenge of working on a "beating heart," off-pump CABG surgery presents a unique opportunity to explore the effect of surgeon case volume on surgical outcome after controlling for the effects of patient case mix and hospital volume. DESIGN: A retrospective cohort study analyzing the association between surgeon volume and in-hospital mortality rate for off-pump and on-pump CABG surgery using random-effects logistic regression modeling. SETTING AND PATIENTS: The analyses were based on the New York State clinical CABG surgery registry. The study sample consisted of 36,930 patients undergoing isolated CABG surgery between 1998 and 1999 that was performed by 181 surgeons at 33 hospitals. INTERVENTIONS: None. RESULTS: There is no association between the number of CABG procedures performed off-pump by an individual surgeon and in-hospital mortality rates (p = 0.93) after controlling for hospital CABG surgery volume and patient-level risk factors. There is also no association between the off-pump CABG surgery mortality rate and the total number of both off-pump and on-pump CABG surgery cases (p = 0.78). In the on-pump CABG surgery cohort, surgeons performing a high volume of CABG procedures had significantly lower risk-adjusted mortality rates among their patients compared to those performing a very low volume, a low-volume, and a medium volume of CABG procedures (p < 0.006). CONCLUSION: For off-pump CABG surgery, surgeons performing a high volume of procedures do not have better mortality outcomes than those performing a low volume of procedures. However, higher surgeon case volumes are associated with lower mortality rates for on-pump CABG surgery. The absence of a volume-outcome association for off-pump CABG surgery is especially surprising in light of the more technically demanding nature of off-pump CABG surgery compared to on-pump CABG surgery.     

70岁以上高龄冠状动脉旁路移植患者的临床特征分析

目的探讨高龄因素对冠状动脉旁路移植术(CABG)治疗安全性的影响及围术期管理。方法收集2016年1月至2019年2月于首都医科大学宣武医院接受CABG治疗冠状动脉(冠脉)病变70岁以上高龄患者共71例,其中男性48例,女性23例,发病年龄为(70~83)岁,平均为(74.23±6.8)岁。按照手术方法的不同,分为停跳和不停跳两组,比较两组患者的术前、围手术期以及住院死亡的情况。结果高龄患者中,53例实施了停跳CABG治疗,18例实施了不停跳CABG治疗。高血压和糖尿病病史多见于停跳CABG治疗的患者,差异有显著统计学意义(P<0.01),其他合并症两组间均无统计学差异(P>0.05)。冠脉三支病变患者接受停跳CABG治疗比例高于不停跳CABG患者,差异有统计学意义(P<0.01)。在CABG中,使用左侧乳内动脉和完全血管重建多见于停跳CABG治疗中,差异有统计学意义(P<0.01)。胸腔积液多见于不停跳CABG治疗后的患者,差异有统计学意义(P<0.05),其他术后并发症两组之间均无统计学差异(P>0.05)。总住院时间为(19.1±7.3)d,住院死亡率为5.6%,两组之间均无统计学差异(P>0.05)。结论术前全面详尽检查,术中严密监测生命体征、维持血流动力学稳定,及早发现并处理并发症,对于高龄患者行CABG具有重要意义。