Role of surgical revascularization in diabetic patients with coronary artery disease

Diabetes is a well-known risk factor for morbidity and mortality associated with coronary artery disease. Currently, diabetics represent approximately a quarter of patients requiring coronary revascularization in the USA. The purpose of this article is to review and analyze the available data in surgical revascularization of diabetic patients with coronary artery disease. The review will also examine new developments in myocardial revascularization and assess their probable impact on the long-term outcome of diabetic patients.     

国产药物涂层支架用于CABG术后冠状动脉再次血管重建及1年随访结果分析

目的 评估国产药物涂层支架( drug-eluting stent,DES)治疗冠状动脉旁路移植术(coronary artery bypass graft,CABG)后心肌缺血患者的疗效,明确相关因素对植入国产DES术后主要心脑血管不良事件(major adverse cardiovascular and cerebral events,MACCE)发生率的影响。方法 入选2008年9月至2009年10月于北京安贞医院接受国产DES治疗的CABG术后病例83例,随访1年,观察国产DES植入治疗CABG术后心肌缺血患者的疗效,并利用Logistic回归分析相关因素与MACCE的相关性。结果 国产DES植入手术成功率97.5％,随访结果显示10例患者发生MACCE (12.0％),其中死亡1例(1.2％),缺血性脑中风l例(1.2％),心肌梗死l例(1.2％),再次血管重建8例(9.6％),靶病变重建l例(1.2％)。结论 国产DES植入治疗CABG后心肌缺血患者安全,近中期疗效良好,血栓发生率低。罪犯血管完全血管重建是MACCE的独立预测因子。     

连续护理方法在心脏外科冠脉搭桥术后中的作用分析

目的：探讨连续护理方法在心脏外科冠脉搭桥术后中的作用。方法：纳入2020年5月~2022年5月期间我院收治的进行心脏外科冠脉搭桥术后病人160例,根据随机数字表法分组,对照组80例实施常规护理,观察组80例实施连续护理方法,比较两组干预前后的健康知识掌握情况、健康相关行为评分、6min步行距离(6MWT)及SF-36量表评分。结果：干预后,观察组健康知识掌握率高于对照组,P＜0.05。干预后,观察组健康相关行为评分高于对照组,P＜0.05。干预后,观察组6MWT长于对照组,SF-36评分高于对照组,P＜0.05。结论：连续护理方法应用于心脏外科冠脉搭桥术后护理可提高患者的健康知识掌握率,改善患者的健康行为,改善心功能,提高生活质量,值得推广应用。     

氯吡格雷对冠状动脉旁路移植术临床与出血事件的影响

Objective To evaluate the effect of clopidogrel premedication on in-hospital major adverse cardiovascular and cerebral events (MACCE) and bleeding outcomes before coronary artery bypass graft surgery (CABG). Method A total of 2021 patients who underwent CABG from July 2003 to September 2005 were divided into either clopidogrel ( n = 479) or no clopidogrel (1542) group before CABG. Patients with clopidogrel administration ( n = 479) were subdivided into < 5 d ( n = 154) ,5～7d(n = 183)and >7d(n = 142) group according to timing of clopidogrel withdrawal before surgery. In-hospital MACCE and perioperative bleeding outcomes were analyzed among groups. Results Patients who took clopidogrel before surgery had nonsignificantly rates of bleeding and in-hospital MACCE compared with those patients not administered clopidogrel. No differences were found about the incidence of total bleeding,minor bleeding,transfusions of red blood cells,fresh frozen plasma,whole blood and in-hosptial MACCE among three subgroups.The < 5 d group had higher incidence of major bleeding and more platelets transfusions than 5 ～ 7 d [47.8% vs. 31.9%,P < 0.017; (0.08 ±0.38) U vs. (0.00±0.00) U,P <0.017,respectively]and >7 d group [47.8% vs. 20.3%,P <0.017; (0.08±0.38) U vs. (0.00±0.00) U,P <0.017,respectively). However,there were no significant differences between 5 ～ 7 d and > 7 d group ( P > 0.05). Conclusions Gopidogrel administration before CABG does not increase the incidence of in-hospital MACCE events. However,the perioperative risk of bleeding will rise if the patients withhold clopidogrel less than five days before surgery.     

氯吡格雷对冠状动脉旁路移植术临床与出血事件的影响

Objective To evaluate the effect of clopidogrel premedication on in-hospital major adverse cardiovascular and cerebral events (MACCE) and bleeding outcomes before coronary artery bypass graft surgery (CABG). Method A total of 2021 patients who underwent CABG from July 2003 to September 2005 were divided into either clopidogrel ( n = 479) or no clopidogrel (1542) group before CABG. Patients with clopidogrel administration ( n = 479) were subdivided into < 5 d ( n = 154) ,5～7d(n = 183)and >7d(n = 142) group according to timing of clopidogrel withdrawal before surgery. In-hospital MACCE and perioperative bleeding outcomes were analyzed among groups. Results Patients who took clopidogrel before surgery had nonsignificantly rates of bleeding and in-hospital MACCE compared with those patients not administered clopidogrel. No differences were found about the incidence of total bleeding,minor bleeding,transfusions of red blood cells,fresh frozen plasma,whole blood and in-hosptial MACCE among three subgroups.The < 5 d group had higher incidence of major bleeding and more platelets transfusions than 5 ～ 7 d [47.8% vs. 31.9%,P < 0.017; (0.08 ±0.38) U vs. (0.00±0.00) U,P <0.017,respectively]and >7 d group [47.8% vs. 20.3%,P <0.017; (0.08±0.38) U vs. (0.00±0.00) U,P <0.017,respectively). However,there were no significant differences between 5 ～ 7 d and > 7 d group ( P > 0.05). Conclusions Gopidogrel administration before CABG does not increase the incidence of in-hospital MACCE events. However,the perioperative risk of bleeding will rise if the patients withhold clopidogrel less than five days before surgery.     

Agreement of central venous saturation and mixed venous saturation in cardiac surgery patients

Objective Comparison of the bias and the limits of agreement (LOA; 2 SD) of the central venous saturation (S_cvO₂) before, during and after coronary artery bypass graft surgery with a simultaneous measurement of the mixed venous saturation (S_vO₂). Design and setting Prospective controlled study in a university hospital department of anaesthesiology. Patients 60 patients with coronary artery bypass surgery, 300 paired measurements of S_vO₂ and S_cvO₂. Measurements and results S_cvO₂ and S_vO₂ were analysed after induction of anaesthesia 15 min after cardiopulmonary bypass and 1, 6 and 18 h after admission to the intensive care unit. Regression analysis for the pooled measurements of S_cvO₂ and S_vO₂ showed a correlation R ² = 0.52. After induction of anaesthesia 15 min after weaning from cardiopulmonary bypass and 6 h after admission to the intensive care unit the correlation coefficient was R ² = 0.46, on admission to the intensive care unit it was R ² = 0.42, and at 18 h it was R ² = 0.38. Bland–Altman analysis for the measurements of S_cvO₂ and S_vO₂ showed a mean bias and LOA of 0.3% and −11.9 to +12.4%. In patients with a low S_cvO₂ there was a trend to overestimate the S_vO₂ by using the S_cvO₂. The only factor that influenced the ΔS_vO₂ − S_cvO₂ was the oxygen extraction rate (R ² = 0.16). In patients with S_cvO₂ below 70% this association was more pronounced (R ² = 0.60). Conclusions Our findings demonstrate that oxygen extraction rate is the major factor in the difference between S_vO₂ and S_cvO₂. Under certain circumstances S_cvO₂ differed substantially from S_vO₂. Therefore in selected patients both parameters should be monitored to exclude general or focal hypoperfusion. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. This study was financially supported by a research grant from the German Research Society (DFG-SA 1346/4–1) and institutional research grants of the Charité Medical School.     

How to revascularize patients with diabetes mellitus—

Summary The diabetic patient is at high risk for coronary artery disease. Incidence as well as severity of the disease is highly increased in comparison to non–diabetic patients. The revascularization of the diabetic patient is a great challenge, since the longterm results are disappointing when compared to non–diabetic patients. The success of coronary artery bypass grafting is limited by increased perioperative mortality and a faster occlusion of especially venous bypass grafts. In percutaneous interventions the excessive high restenosis rates worsen longterm results. Several clinical trials investigated the outcome of the two revascularization strategies and could demonstrate at least a tendency towards better results when the operative approach was chosen. Particularily, the BARI trial showed reduced mortality for surgery when compared to percutaneous coronary interventions. However, in this trial, in 87% of patients undergoing bypass surgery all stenoses were succesfully treated, whereas in patients undergoing percutaneous coronary intervention only 76% of all stenoses were primarily succesfully treated. In addition, no stents were used in this trial. Furthermore, the enrollment of the previous trials dates one decade ago. These trials do therefore not necessarily represent the current standard therapy, especially for percutaneous coronary interventions. The restenosis rate could be decreased in recent years by means of drug–eluting stents and an aggressive antiplatelet therapy from more than 50% to less than 10% leading to considerably improved long–term results. Therefore, percutaneous coronary interventions have developed to be a reasonable alternative to bypass surgery. Different clinical trials are currently underway (BARI 2D, CarDIA, FREEDOM) comparing the outcome of the two approaches.     

体外循环下冠状动脉旁路手术患者围手术期甲状腺激素水平变化及意义

目的 探讨行体外循环(cardiopulmonary bypass,CPB)下心脏停跳冠状动脉旁路手术患者围手术期甲状腺激素水平变化及临床意义.方法 行CPB下心脏停跳冠状动脉旁路手术患者25例为CPB组,非CPB心脏不停跳冠状动脉旁路手术患者28例为非CPB组,分别测定2组术前及术后24 h血浆甲状腺素、促甲状腺激素水平,并进行比较.结果 2组均未行心脏机械辅助治疗,未发生围手术期心肌梗死,无围手术期死亡;CPB组术后24 h总三碘甲状腺原氨酸、游离三碘甲状腺原氨酸水平分别为(1.01±0.14) nmol/L、(3.06±0.49) prnol/L,较术前((1.26±0.13) nmol/L、(4.22±0.63) pmol/L)明显降低(P＜0.05);非CPB组术后24 h总三碘甲状腺原氨酸、游离三碘甲状腺原氨酸水平分别为(1.19±0.23) nmol/L、(3.89±0.46) pmol/L,与术前((1.21±0.45) nmol/L,(4.53±1.15) pmol/L)比较差异无统计学意义(P＞0.05);2组手术前及术后24 h总甲状腺素、游离甲状腺素和促甲状腺素水平比较差异无统计学意义(P＞0.05).结论 CPB下心脏停跳冠状动脉旁路手术可致术后发生正常甲状腺病态综合征.     

冠状动脉旁路移植术中红外监测导航技术初探

目的应用自主研发的心脏红外长波摄像监测系统,对冠状动脉旁路移植手术行术中监测,通过对红外热图分析,探讨该技术在心肌缺血诊断,心脏搭桥效果判断及不良事件应急处理方面的应用价值。方法随机选取行胸骨正中开胸心脏停跳下冠状动脉旁路移植手术患者20例,术中全程行红外摄像实时监控,采集并分析热图,并与术前信息比对,发现不良信息,指导手术操作。结果红外摄像获取的心脏热图能够准确判断心肌缺血部位,同时能够判断桥血管及吻合口是否通畅、可对搭桥术后缺血心肌血供恢复状况加以判断并推测手术效果。结论红外摄像监控技术对冠状动脉旁路移植手术具有术中指导意义和临床推广价值。     

The effect of inhalation aromatherapy in patients undergoing cardiac surgery: A systematic review and meta-analysis of randomized controlled trials

ObjectiveThe goal of this study was to synthesize evidence regarding the efficacy of inhalation aromatherapy in patients undergoing cardiac surgery.MethodsWe conducted an electronic search of four authentic databases. Randomized controlled trials (RCTs), which compared inhalation aromatherapy versus control in patients undergoing cardiac surgery, were included. Data were extracted from eligible studies and pooled in a meta-analysis model. We sought to evaluate anxiety, pain, stress, and vital signs including heart rate, systolic and diastolic blood pressure.ResultsNine RCTs were included in this study with a total of 656 patients. Our analysis showed inhalation aromatherapy was significantly effective in reducing anxiety (MD= −3.11, 95 % CI [−5.26, −0.96], p = 0.005), and pain (MD= −0.83, 95 % CI [−1.59, −0.07], p = 0.03) in patients undergoing cardiac surgery. Additionally, inhalation aromatherapy significantly reduced heart rate compared to control group (MD= −5.49, 95 % CI [−9.07, −1.81], p = 0.003). However, no significant differences were found between both groups in mental stress, systolic and diastolic blood pressure.ConclusionInhalation aromatherapy administration especially with lavender can significantly reduce anxiety, pain, and heart rate in patients performed cardiac surgery. However, it is not associated with significant differences in systolic and diastolic blood pressure. Further studies are needed to confirm our results.     

The relationship between quality of life,sense of coherence and self-esteem in persons after coronary artery bypass graft surgery

We examined the contribution of Antonovsky's sense of coherence in explaining the variance of quality of life (QOL) in 84 patients 1-2 years following coronary artery bypass graft surgery. The hypothesis was: after controlling for variables related to poor health vulnerability, perceived support, self-esteem, and chronic illness trajectory instability and work, the addition of sense of coherence will significantly add to the explained variance of quality of life. The first two variables explained 49% of the variance of the QOL scale. Adding perceived social support, self-esteem and sense of coherence increased explained variance to 64%, 69%, and 75%, respectively. These findings supported our hypothesis.     

目标导向液体治疗对冠脉搭桥手术患者rSO2、POCD的影响

目的 探究目标导向液体治疗对冠脉搭桥手术患者脑氧饱和度(rSO2)、认知功能障碍(POCD)的影响.方法 选取本院122例行全身麻醉冠脉搭桥患者,采取目标导向液体治疗的80例患者作为研究组,采取常规液体治疗的42例患者作为对照组.比较两组术前30min(T0)、麻醉诱导后15min(T1)、术中1h(T2)、2h(T3...     

Effect of Benson and progressive muscle relaxation techniques on sleep quality after coronary artery bypass graft: A randomized controlled trial

ObjectiveThis study aimed to investigate the effect of Benson relaxation (BR) and progressive muscle relaxation (PMR) techniques on the sleep quality of patients undergoing coronary artery bypass graft (CABG) surgery.MethodThis study was a three-arm, parallel, randomized controlled trial. 120 patients who underwent CABG surgery at two academic hospitals in an urban area of Iran were randomly allocated into three groups (40 per group): the BR, PMR, and control groups. Patients in the BR and the PMR groups performed relevant exercises twice a day for four weeks. Sleep quality was measured before and immediately after the intervention using Pittsburgh Sleep Quality Index.ResultsWithin-group comparison in the BR (t = 3.51, p = 0.001) and the PMR (t = 4.58, p < 0.001) group showed that the overall sleep quality showed a significant improvement after the intervention when compared to baseline. The between-group comparison showed that both the BR and PMR groups showed significant improvements in subjective sleep quality (F = 3.75, p = 0.02), habitual sleep efficiency (F = 4.81, p = 0.01), and overall sleep quality (F = 5.53, p = 005) when compared to the control group after the intervention. However, no statistically significant differences were identified among the three study groups in terms of sleep latency, sleep duration, sleep disturbances, sleeping medication, and daytime dysfunction after the intervention (p > 0.05).ConclusionThe study showed that a four-week program of both PMR and BR can be effective in the overall improvement of sleep quality in patients following CABG. Further research is required to replicate the findings of the present study.     

Comparative effectiveness of revascularization strategies in stable ischemic heart disease: current perspective and literature review

Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are established strategies for coronary revascularization in the setting of ischemic heart disease. Multiple randomized controlled trials and observational studies have compared the impact of the two modalities on the patients’ quality of life, mortality and morbidity, as well as the cost–effectiveness of these modalities in different clinical setting. CABG is the preferred strategy for revascularizations in patients with multi-vessel disease, especially in those with higher risk secondary to associated diabetes, left ventricular dysfunction or more complex lesions. PCI is a reasonable revascularization modality in patients with ischemia and single or low-risk multi-vessel disease and those with unprotected left main with low complexity anatomy. Compared with PCI, CABG is associated with less repeat revascularization, better quality of life and improved survival in high-risk patients. Although CABG is associated with higher cost, it is probably associated with a reasonable cost per quality-adjusted life-year gained in many patients. Therefore, CABG will often be a cost-effective strategy, especially in patients with high angiographic complexity and/or diabetes.     

Association of ABO-mismatched platelet transfusions with morbidity and mortality in cardiac surgery

BACKGROUND: The transfusion of ABO-mismatched platelets has been associated with increased morbidity and mortality during induction therapy for acute leukemia and allogeneic progenitor cell transplantation. STUDY DESIGN AND METHODS: Reported here is a cohort study of 153 patients undergoing primary coronary artery bypass graft or coronary valve replacement surgery by two surgeons in one institution during 1997 and 1998. All statistics employed nonparametric two-sided tests (Mann-Whitney; Fisher's exact test). RESULTS: Patients receiving at least one ABO-mismatched pool of platelets had a significantly longer hospital stay, more days of fever, greater total hospital charges, and more RBC transfusions. Mortality, hours in the intensive care unit, days on antibiotics, and numbers of platelet transfusions were also greater in recipients of ABO-mismatched platelets, but these differences were of less statistical significance. When the analysis was restricted to the 139 patients who received no more than two pools of platelets, the trends for increased morbidity and mortality (8.6% vs. 1.9%; p = 0.10) in recipients of ABO-mismatched platelets persisted. The number of RBC transfusions required in this latter cohort was 50 percent greater (mean, 6.1 vs. 9.2; p = 0.02), despite the fact that the number of platelet transfusions given was similar (mean, 1.2 vs. 1.3 pools; p = 0.22). CONCLUSIONS: ABO-mismatched platelet transfusions are associated with unfavorable outcomes in cardiac surgery, a relationship that remains unexplained. As this association has been found in three cohort studies in various clinical settings, further investigation of this association is warranted.     

Coronary artery bypass graft surgery in a patient with ureterosigmoidostomy

A 75-year-old male patient had stable angina pectoris. After coronary angiography we decided to perform a coronary artery bypass graft surgery. Twenty years ago the patient underwent radical cystectomy and bilateral ureterosigmoidostomy because of bladder cancer. After that, his micturition was via the rectum. We did not experience that before. As is known, monitoring of urine output is very important after cardiac surgery. The patient was consulted with an urologist for how to monitor urine output in him. Transrectal catheterization was recommended for our follow-up, but before the catheterization bowel cleansing is necessary. Four-vessel on-pump coronary artery bypass graft surgery was performed without any problem. Peroperative urine volume and arterial blood gas results were normal. Urine output is a sensitive variable reflecting the patient’s effective blood volume and tissue perfusion. Urinary catheterization is a standard for all cardiac surgeries, and it allows the patients’ urine to drain freely from the bladder for collection. Monitoring of urine output in patients with ureterosigmoidostomy is impossible by standard urinary catheterization method. In this case we performed transrectal catheterization for Urine flow follow-up. Urine flow follow-up is essential after the open-heart surgery and it can be measured in different ways, as in our case.     

Osteopathic treatment leads to significantly greater reductions in chronic thoracic pain after CABG surgery: A randomised controlled trial

BackgroundThere are a number of long-term postoperative complications after coronary artery bypass graft (CABG) surgery. Pulmonary function is decreased by 12% and 30%–50% of the patients have chronic thoracic pain.MethodsThis randomised controlled trial with two parallel groups aimed to explore the effectiveness of osteopathic treatments (OTs) on these conditions. The standard care (SC) group and the and OT group received a 12-week standard cardiac rehabilitation programme, which was supplemented with four OTs for the OT group only. The outcome assessors were blinded to the patients’ allocation.ResultsEighty-two patients with median sternotomy after CABG surgery were randomly allocated in a 1:1 ratio (SC: n = 42, OT: n = 42). Slow vital capacity and pain intensity were measured at baseline and at 12 weeks and 52 weeks after surgery. Pain intensity was significantly lower in the OT group 12 weeks after surgery (3.6–0.80 vs. 2.6 to 1.2, p = 0.030). One year after surgery, there still was a significantly lower pain intensity in the OT group (3.6–0.56, vs. 2.6 to 1.2, p = 0.014). No significant changes between groups were found in pulmonary function. There were no adverse events reported.ConclusionsFrom this study, it can be concluded that the addition of OT to exercise-based cardiac rehabilitation may lead to significantly greater reductions in thoracic pain after CABG surgery.Trial registrationThis study was registered on ClinicalTrials.gov (NCT01714791).     

氯吡格雷对冠状动脉旁路移植术临床与出血事件的影响

目的 比较冠状动脉旁路移植术(CABG)前使用氯吡格雷及停用氯吡格雷时间对围手术期出血和院内主要不良心脑血管事件(MACCE)的影响.方法 入选2003年07月到2005年09月于北京安贞医院行CAJBG患者2021例.根据术前是否使用氯吡格雷分为未使用组(n=1542)和使用组(n=479).根据术前停用氯吡格雷时间将使用组分为停用<5 d组(n=154),5～7 d组(n=183)和>7 d组(n=142).回顾性分析各组间院内MACCE事件和围手术期出血及输血情况.统计学方法采用t检验、卡方检验、方差分析.结果 未使用和使用组的围手术期出血及院内MACCE事件发生率差异无统计学意义.停用<5 d组,5～7 d组和>7 d组三组院内MACCE事件、所有出血和小出血发生率以及输注悬浮红细胞、新鲜冰冻血浆与全血量差异无统计学意义;三组大出血发生率和输注血小板量存在显著差异,停用<5 d组明显高于停用5～7 d组[47.8%vs.31.9%P<0.017;(0.08±0.38)U vs.(0.00±0.00)u,P<0.017]或>7 d组[47.8%、vs.20.3%P<0.017;(0.08±0.38)Uvs.(0.00±0.00)U P<0.017],停用5～7 d组与7 d组之间无差异.结论 冠状动脉旁路移植术前使用氯吡格雷并不增加院内主要不良心脑血管事件,术前使用氯吡格雷并停药时间不足5 d围手术期大出血发生率较高.     

Revascularization strategies in patients with Type 2 diabetes mellitus

This review aims to describe new developments in coronary revascularization strategies for patients with pre-existing Type 2 diabetes mellitus (DM). Recommended strategies for revascularization have been an active area of study with recent important developments. In patients with Type 2 DM and multivessel coronary artery disease (CAD), coronary artery bypass graft (CABG) surgery is the preferred method for revascularization. Patients with DM are at increased risk for diffuse cardiovascular disease due to the proinflammatory, prothrombotic effects of chronic hyperglycemia. In patients undergoing percutaneous coronary intervention, drug-eluting stents and more potent antiplatelet agents especially in those presenting with acute coronary syndromes should be employed.     

The Association of Neurocognitive Decline and Other Variables With Return to Work,Hobbies, and Activities of Daily Living After Coronary Artery Bypass Graft Surgery

ABSTRACT

Purpose: Coronary artery bypass graft (CABG) surgery is an integral method of palliative treatment for coronary artery disease. Despite many advances in surgical techniques, some patients continue to have neurocognitive deficits after surgery. The impact of these deficits on the patient's ability to return to work (RTW), daily activities of life, and hobbies has not been evaluated fully. The goal of this research project is to describe variables associated with the patients’ ability to RTW and necessary and essential activities. Methods: Sixty-three subjects who had CABG surgery with cardiopulmonary bypass (CPB) and who participated in neurocognitive testing preoperatively and postoperatively were interviewed by telephone 7–8 years after CABG surgery. Information was obtained on functional status measured by the Nottingham Health Profile (NHP), symptoms of depression measured by the Center for Epidemiological Studies Depression Scale, RTW status, and ability to participate in hobbies and activities of daily living (ADL) after CABG surgery. Bivariate and multivariate analyses were used to describe the relationship of neurocognitive, clinical, and social variables to RTW, hobbies, and ADL. Results: The ability to return to hobbies and ADL did not vary between individuals who experienced neurocognitive decline and those who did not (p = 0.755). Age and presence of angina were significantly associated with difficulty in returning to work (p = 0.009, p = 0.042). Higher scores on the Center for Epidemiological Studies Depression Scale after surgery were significantly associated with higher NHP scores (p = 0.000) and presence of shortness of breath (p = 0.000). Presence of angina (p = 0.035) was significantly associated with higher scores on the NHP. Conclusions: The relationship of neurocognitive decline after CABG surgery with RTW and activities remains unclear. Studies with larger sample size will further elucidate these relationships.