Off-pump coronary artery bypass grafting in India

Off-pump Coronary Artery Bypass Grafting (OPCAB) is the latest innovation in cardiac surgery. However OPCAB is not adopted universally. Even there have been suggestions of abandoning OPCAB in a special report. In India, OPCAB has been successfully adopted across the board. There are various evidences which favor OPCAB and are discussed in this review. The purpose of this review is to put forward the perspective of the OPCAB surgeons of our country and critically look at the suggestion of abandoning OPCAB.     

冠心病伴重度心功能不全患者非体外循环冠状动脉旁路移植术22例临床分析

目的:分析心功能不全冠心病患者行非体外循环冠状动脉搭桥(OPCABG)的临床资料,总结围术期规律,提出治疗方法。方法:回顾性分析2008年1月至2012年6月,同一术式手术的22例射血分数(EF)<30%的冠心病患者行OPCABG的资料(组1)。同时随机选择同数目的 EF在30%～40%(组2),>40%(组3)的患者的资料作对比。结果:所有患者均痊愈出院。组1与组3比较,在院术前调整天数,室壁瘤手术例数,IABP使用例数及时间,ICU停留时间,使用强心药种类,术后住院天数和住院费用,差异均有统计学意义(P<0.05)。组2、组3术后住院天数,住院费用差异无统计学意义(P>0.05)。结论:心功能不全患者行OPCABG风险大,手术费用高,所占医疗资源多,应慎重选择病例。此类患者通过合理方式的再血管化,积极的围术期处理,亦可得到良好的治疗效果。     

非体外循环冠状动脉旁路移植术后低氧血症相关因素分析

目的:分析非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass,OPCABG)后,低氧血症发生的相关因素并探讨预防及处理措施。方法:143例OPCABG患者,术后发生低氧血症40例,对低氧血症患者的年龄、体质量、术前心功能状态、不良习惯、手术时间、术中输液量、尿量、出血量、术中及术后输血量与非低氧血症患者之间,进行相关危险因素分析。结果:低氧血症患者与非低氧血症患者之间,在体质量、术前是否吸烟、手术时间、术中输液量及术后输血量之间,存在明显差异,所有低氧血症患者,在应用利尿、抗感染、呼吸末正压通气、延长机械通气时间治疗后好转,未出现死亡病例。结论:OPCABG术后,低氧血症易发生在体质量大、术前抽烟、手术时间长及术中输液量多的患者,应用抗感染、利尿、加用呼吸末正压等治疗后可纠正低氧血症。     

非体外循环下多支冠状动脉病变的旁路移植术

目的：探讨非体外循环冠状动脉旁路移植术的手术技巧和术中处理方法。方法：连续57例患接受非体外循环冠状动脉旁路移植术。术中予以适量扩容、小剂量α受体兴奋剂以维持血流动力学平稳，采用心脏稳定器控制局部心肌运动幅度，阻断冠状动脉或在置入血管塞控制冠状动脉出血情况下进行血管吻合。全组吻合前降支57例，对角支21例，右冠状动脉27例，钝缘支42例，后降支20例。结果：术后1例死于并发感染和急性肾功能衰竭，余患痊愈出院。随访所有患心绞痛症状均消失，冠状动脉造影示桥路和吻合口通畅。结论：选择合适的病例进行非体外循环冠状动脉旁路移植术可获得满意的临床效果。术中血流动力学稳定极为重要。弹力线阻断靶血管近远端或腔内置入血管塞法均能有效地控制切开的冠状动脉出血。冠状动脉吻合的顺序应是先行前降支和右冠系统的吻合。     

Hybrid coronary revascularization versus coronary artery bypass grafting in patients with multivessel coronary artery disease: A meta‐analysis

The stimulus to create this document was the recognition that ionizing radiation‐guided cardiovascular procedures are being performed with increasing frequency, leading to greater patient radiation exposure and, potentially, to greater exposure for clinical personnel. Although the clinical benefit of these procedures is substantial, there is concern about the implications of medical radiation exposure. The American College of Cardiology leadership concluded that it is important to provide practitioners with an educational resource that assembles and interprets the current radiation knowledge base relevant to cardiovascular procedures. By applying this knowledge base, cardiovascular practitioners will be able to select procedures optimally, and minimize radiation exposure to patients and to clinical personnel. Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness is a comprehensive overview of ionizing radiation use in cardiovascular procedures and is published online. To provide the most value to our members, we divided the print version of this document into 2 focused parts. Part I: Radiation Physics and Radiation Biology addresses the issue of medical radiation exposure, the basics of radiation physics and dosimetry, and the basics of radiation biology and radiation‐induced adverse effects. Part II: Radiological Equipment Operation, Dose‐Sparing Methodologies, Patient and Medical Personnel Protection covers the basics of operation and radiation delivery for the 3 cardiovascular imaging modalities (x‐ray fluoroscopy, x‐ray computed tomography, and nuclear scintigraphy) and will be published in the next issue of the Journal.     

低射血分数患者非体外循环下冠状动脉搭桥术的应用

目的总结分析30例心脏超声检查射血分数〈30％的冠心病患者进行非体外循环冠状动脉搭桥术（OPCAB）的临床效果。方法2003年1月至2010年1月进行选择性OPCAB手术30例,全部经心脏超声检查测定射血分数为25-30（25．3±6．1）％。有心梗史23例,急性心肌梗死后1个月内6例,不稳定型心绞痛19例;心功能Ⅱ级7例、Ⅲ级18例、Ⅳ级5例。冠状动脉造影提示双支病变3例、三支病变21例、左主干6例。结果全部病例均完成OPCAB手术,平均远端吻合口（3．6±0．7）个,使用主动脉内球囊反搏3例。无死亡病例。有3例术后出现急性左心衰、低心排综合征,安放主动脉内球囊反搏后保守治疗好转。2例患者术后出现室颤,均复苏成功。结论低射血分数患者实施OPCAB手术有良好的可行性。     

非体外循环冠状动脉旁路移植术在左主干重度狭窄患者中的应用

目的总结左主干重度狭窄冠心病患者行非体外循环下冠状动脉旁路移植术（OPCAB）的治疗效果和临床经验。方法回顾分析2005年1月至2012年6月,83例左主干狭窄〉70％的患者接受了非体外循环下冠状动脉旁路移植术,其中27例急诊手术,三支病变62例,两支病变21例,术中改为体外循环5例;使用主动脉内球囊反搏7例。结果远端吻合口平均（3．34±0．83）个,死亡2例（2．4％）。随访2个月至2年,仅1例心绞痛复发,余者均未出现心绞痛症状。手术效果及手术并发症的发生与非左主干病变组差异无统计学意义（P〉0．05）。结论左主干重度狭窄行非体外循环下冠状动脉旁路移植术临床效果良好。     

186例老年冠心病患者是、否体外循环下冠脉旁路移植术的比较

目的:比较老年冠心病患者体外循环与非体外循环下冠状动脉旁路移植术的疗效。方法:A组选择87例65岁以上的老年患者在体外循环下行冠状动脉旁路移植术(CCABG);B组选择79例65岁以上的老年患者在非体外循环下行冠状动脉旁路移植术(OPCABG)。结果:B组死亡率低于A组(P<0.05),术后胸腔引流量明显少于A组(P<0.05)。结论:老年冠心病患者行冠状动脉旁路移植术是安全的。     

Mid-term outcomes of off-pump versus on-pump coronary artery bypass graft surgery

OBJECTIVE:

To evaluate survival and readmissions to hospital for cardiac events or coronary revascularization (REVASC) in patients having off-pump (OPCAB) versus conventional on-pump (CCAB) coronary artery bypass graft surgery (CABG).

METHODS:

Of 11,368 consecutive patients undergoing isolated CABG between 1996 and 2002, 514 had OPCAB surgery. Using propensity scores, 503 CCAB patients were randomly matched to 503 OPCAB patients.

RESULTS:

There were no clinical or statistical differences between the two groups for any prognostic variable. However, OPCAB patients received significantly fewer distal anastomoses than the CCAB group (2.6±1.0 versus 3.1±1.0; P<0.001). There was no difference in operative mortality (OPCAB 1.0%, CCAB 1.4%; P=0.6), but the OPCAB group had significantly fewer operative strokes (0.2% versus 1.8%; P=0.01). Follow-up was 99.7% complete at 2.2±1.2 years (range 0 to 6 years). Twice as many OPCAB patients (n=24) required REVASC compared with the CCAB (n=11) group. The following five-year actuarial outcomes are presented for CCAB and OPCAB, respectively: survival: 77±6%, 76±8%, P=0.8; freedom from REVASC: 95±3%, 92±2%, P=0.02; and cardiac event-free survival: 76±5%, 62±8%; P=0.05. Cox regression revealed that OPCAB was a significant independent predictor of poorer freedom from REVASC (RR 2.2, 95% CI 1.0 to 4.6; P=0.04) and cardiac event-free survival (RR 1.6, 95%CI 1.1 to 2.2; P=0.02).

CONCLUSIONS:

The use of OPCAB remains controversial. These results, from this early experience, suggest that despite improved hospital outcomes, the lesser degree of REVASC raises concerns about the need for repeat revascularization in the OPCAB group.     

Effect of revascularization on coronary chronic total occlusion in patients undergoing coronary artery bypass grafting

BackgroundBypass grafting for chronic total occlusions (CTOs) remains surgically challenging and controversial. Therefore, we evaluated the incidence and clinical outcomes of revascularization on CTOs undergoing coronary artery bypass grafting (CABG).MethodsAmong 828 patients who underwent isolated CABG from January 2010 to December 2018, 245 patients (29.6%) diagnosed with at least one CTO were included and retrospectively reviewed. Primary endpoints were 30-day and overall mortality. Secondary endpoint was the composite outcome of major adverse cardiac and cerebrovascular events (MACCE).ResultsWith a mean follow-up of 56.6±6.5 months in 245 patients with CTOs, 51 patients (20.8%) received incomplete revascularization (ICR) for CTO lesions. Risk factor analysis showed that ICR was associated with increased 30-day [odds ratio 8.62; 95% confidence interval (CI): 1.64–50; P=0.011] and overall mortality (hazard ratio (HR) 2.13; 95% CI: 1.07–4.21; P=0.03). ICR also increased the risk of MACCE (HR 1.98; 95% CI: 1.12–3.54; P=0.01). Freedom from overall mortality was 92.8%, 90.4%, and 86.8% in the complete revascularization group, and 86.3%, 80.0%, and 72.7% in the ICR group, at 1, 3, and 5 years, respectively (P=0.004).ConclusionsIn patients with CTOs undergoing CABG, the rate of ICR was 20.8%, and it significantly increased the risk of mortality and MACCE. Further studies in a large cohort are needed.     

非体外循环冠状动脉旁路移植术在左心室功能低下患者中的应用

目的:分析左心室功能低下(EF<40%)冠心病患者,接受非体外循环冠状动脉旁路移植手术(OPCAB)的疗效,改进左心室功能低下冠心病患者的治疗策略。方法:回顾性分析2006年以来我院手术组对37例左心室功能低下的冠心病患者,行OPCAB后手术前后疗效的对比。结果:2例患者死亡,1例死于术后肺部感染,1例死于术后低心排出量综合征(低心排),病死率5%。21例患者使用主动脉内球囊反搏器(IABP),其中7例在术前放置,14例在术中或术后放置。35例患者术后左心室射血分数(EF值)较术前有明显改善(P<0.05);左心室舒张末期内径、左心室收缩末径均较术前下降(P<0.05)。结论:对于左心室功能低下的冠心病患者,OPCAB是一种有效的治疗方法。及时使用主动脉球囊反搏,以及合理应用正性肌力药物对于降低患者病死率,减少患者住院时间具有重要意义。     

Off-pump bypass grafting in patients with significant left main coronary artery stenosis

The aim of this study was to investigate and determine whether patients with significant (%50) left main coronary artery stenosis could undergo coronary bypass on the beating heart and compare the results to those obtained using the conventional method. Prospectively collected data of patients with significant left main coronary artery disease who had undergone coronary bypass on the beating heart (group A, n = 100) or with the conventional method (group B, n = 100) were evaluated retrospectively. EuroSCORE values, preoperative and operative details, postoperative morbidity and mortality, and early results were compared. Groups were similar in terms of EuroSCORE, demographics, and preoperative variables. Number of distal anastomoses per patient was 3.1 ± 0.9 in the beating heart group while it was 3.3 ± 0.9 in the conventional group (P = 0.09). Patients operated on with the conventional method had higher levels of peak creatine kinase-myocardial band, blood and blood product transfusions, and inotropic requirements, while mechanical ventilation times and hospital stay were longer. The incidence of postoperative atrial fibrillation, mediastinitis, and intra-aortic balloon usage were comparable between the groups. There was no neurological complication in group A whereas five major neurological complications (three transient ischemic attacks, two strokes) occurred in group B (P = 0.06). Thirty-day mortality occurred in one patient in the beating heart group whereas five early deaths were observed in the conventional group (P = 0.21). In significant left main coronary artery stenosis coronary bypass on the beating heart is a safe and effective alternative to the conventional method with the same or better early results. The long-term results need to be evaluated.     

非体外循环心脏跳动下冠状动脉搭桥418例临床分析

目的总结418例非体外循环下冠脉搭桥术的临床经验。方法在非体外循环下行冠脉搭桥术418例,其中经正中切口414例,左外侧小切口4例。患者搭桥数目1￣5(3.1±0.9)根,应用左侧乳内动脉274根,桡动脉21根。结果术后气管插管时间为2￣6h,平均胸腔引流量为(365.0±23.0)ml,输库血146例(34.9%),二次开胸12例(2.9%),早期心肌梗死4例(0.9%),心绞痛6例(1.4%),心功能不全8例(1.9%),心律失常30例(7.2%),早期死亡4例(0.9%)。结论非体外循环下冠脉搭桥术创伤小,并发症少。     

Off-pump coronary artery bypass grafting using a bilateral internal mammary artery Y graft

Objectives To evaluate the outcome of off-pump coronary artery bypass grafting (OPCABG) using a bilateral internal mammary artery (BIMA) Y configuration graft to achieve total arterial myocardial revascularization. Methods From October 2002 to December 2008, 208 patients (196 males and 12 females) underwent OPCABG using a BIMA Y configuration graft. The average age of the patients was 56.5 ± 11.3 years, with an age range of 33–78 years. A total of 167 (80.2%) cases had triple-vessel disease. Left main stem disease was found in 33 (15.9%) cases, and double-vessel disease was found in 8 (3.9%) cases. The semi-skeletonization technique was used to harvest the two internal mammary arteries (IMAs), and then the free right internal mammary artery was connected end-to-side to the left internal mammary artery (LIMA) in situ to complete the Y configuration graft. Off-pump and sequential anastomosis methods were used to perform coronary artery bypass surgery in all patients. Graft patency was assessed intra-operatively with the HT311 transit time flowmeter. Results A total of 728 distal anastomoses were performed in 208 patients, with the average being 3.5 ± 1.3 per person. No one died or experienced recurrent angina within 30 days after the operation. Conclusions OPCABG using the BIMA Y graft was safe and effective to achieve total arterial revascularization. This method avoids surgical operation on the ascending aorta and other incisions.     

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。     

非体外循环冠状动脉旁路移植术围麻醉期处理的分析

目的：探讨非体外循环冠状动脉旁路移植术(OPCABG)麻醉期处理的合理性。方法：回顾性分柝41例被施行OPCABG病人的临床观察和处理资料。结果：39例病人痊愈出院，有2例改为体外循环心脏不停跳下完成手术，其中术中急性循环衰竭死亡1例。3周后因多器官衰竭死亡1例。结论：在麻醉期合理应用心血管活性药物，维护血流动力学的相对稳定，备好体外循环及采取血液保护是手术成功的关键。     

Initial experience with off-pump coronary artery bypass grafting

Off-pump coronary artery bypass grafting (OPCAB) is clearly preferable for patients with extracardiac complications. The aim of this study was to evaluate the initial outcome of OPCAB, and its validity for patients with extracardiac complications. One hundred and fifty-seven consecutive coronary artery bypass graft (CABG) patients were divided into two groups: 30 OPCAB patients and 127 on-pump CABG patients. The early outcomes of the two groups were compared. Preoperatively, OPCAB patients had more extracardiac risk factors than on-pump CABG patients. There were no differences in age or cardiac function between the groups, but the off-pump group had a higher incidence of previous surgery, cerebrovascular disease, and renal failure. There were no differences in graft patency, stroke, or mortality between the two groups, even though the OPCAB patients had more risk factors than the on-pump patients. Our initial experience with OPCAB showed that it is acceptable for high-risk patients in view of the serious nature of their extracardiac condition. Received: April 12, 2001 / Accepted: August 17, 2001     

非体外循环冠状动脉旁路移植术的总结(附105例分析)

目的:总结105例非体外循环下(off—pump)冠状动脉旁路移植术的经验。方法:105例患者中男87例,女18例。年龄48～74(平均59.l±9.06)岁。手术在全麻常温下进行,正中切口。单支病变18例,双支病变20例,三支病变62例,左主干病变15例;急性心梗1例,陈旧性心梗3例。搭1支桥8例,搭2支桥26例,搭3支桥43例,搭4支桥22例,搭5支桥6例,内膜剥脱1例。平均每例搭桥2.9支。结果:全组无手术死亡,平均带气管插管时间10.9±10.78小时,平均在ICU45.9小时。术后平均胸腔引流量394 ml,术后1例1年内经冠脉造影提示血管桥堵塞。结论:非体外循环下的冠状动脉旁路移植术是安全可行的;适用于左主干病变,三支病变及心梗患者;可以做到完全再血管化,对于冠心病患者应为首选。     

高龄冠心病患者冠状动脉搭桥术

目的比较冠脉搭桥术（CABG）的术式选择对高龄冠心病患者的影响,讨论高龄冠心病患者的围手术期管理方法。方法以我院心脏血管外科2003年1月至2009年12月所实施的514例CABG患者为研究对象,其中75岁以上患者49例,为高龄患者组,占同期CABG的9．5％;75岁以下患者465例,为非高龄患者组,占同期CABG的90．5％。结果患者的年龄、不稳定型心绞痛、有无急性心梗、冠脉危险因子、术前血红蛋白含量比例两组相比差异无统计学意义;左室射血分数〈30％,既往合并肾功能异常、脑梗塞及患有三支冠状动脉病变的患者比例两组相比差异有统计学意义。主动脉内气囊反搏（IABP）、移植血管种类、手术时间两组相比差异无统计学意义,但远心端吻合口数及完全性血运再建例数比例、跳动下冠状动脉搭桥手术（OPCAB）比例两组之间比较差异有统计学意义。术后气管插管时间、留置ICU时间两组之间比较差异无统计学意义,患者住院天数两组之间比较差异有统计学意义。术后肺部感染、肾衰、并发症脑梗塞发生率两组之间比较差异无统计学意义。围手术期死亡率两组之间比较差异无统计学意义。术后平均39个月的电话随访,心衰、心梗发生率及心源性死亡率两组之间比较差异无统计学意义。结论对于高龄患者的CABG要多考虑采用OPCAB方式及动、静脉移植血管相组合等低侵袭性手术方法,术后应早期下床进行康复训练。     

体外循环与非体外循环下冠状动脉旁路移植术治疗老年人冠心病的比较研究

目的总结70岁以上冠心病患者非体外循环下冠状动脉旁路移植手术(OPCAB)的疗效和特点.方法比较52例OPCAB手术与28例常规体外循环下冠状动脉旁路移植手术(CCABG)的临床资料.结果OPCAB组与CCABG组术后并发症11.5%和25.1%,平均ICU时间(18.52±6.49)h和(31.63±15.26)h,平均住院时间(11.34±2.28)d和(15.71±3.97)d.结论OPCAB手术安全可行,更适合年老、合并多脏器功能障碍患者;具备独特的技术特点.