胸廓内动脉、桡动脉及大隐静脉在冠状动脉旁路移植术中的应用

目的　报告胸廓内动脉和桡动脉在冠状动脉旁路移植术中的应用。　方法　 2 9例冠状动脉粥样硬化性心脏病患者接受冠状动脉旁路移植术 ,共用移植血管 84根 ,平均每例移植血管 2 .9根。左侧胸廓内动脉 19根 (游离胸廓内动脉 2根 ) ,桡动脉 10根 ,大隐静脉 5 5根 (序贯吻合 3根 )。左侧胸廓内动脉与左前降支吻合 19例 ;桡动脉与左前降支吻合 8例 ,与右冠状动脉吻合 1例 ,与对角支吻合 1例 ;左前侧壁室壁瘤切除术 1例。平均主动脉阻断时间 97.3±16 .5分钟 ,平均体外循环时间 16 5 .2± 2 8.2分钟。　结果　术后 1例并发低心排血量 ,1例并发十二指肠溃疡穿孔 ,1例再次开胸止血。全部患者均痊愈出院 ,术后平均住院时间 12 .5± 2 .5天。术后随访 ,无心绞痛发作 ,心电图正常。　结论　胸廓内动脉是冠状动脉旁路移植术的首选材料 ;桡动脉内径大于胸廓内动脉 ,有足够长度 ,取材容易 ,是理想的移植血管材料之一。     

降主动脉"Y"形血管桥在微创冠状动脉搭桥术中的应用

目的探讨降主动脉"Y"形血管桥在冠状动脉搭桥术的临床疗效和价值.方法对16例升主动脉增宽、钙化的冠心患者在胸腔镜下游离乳内动脉,小切口左侧开胸非体外循环下实施冠状动脉搭桥术,其中男11例,女5例.年龄51～75岁,平均(60.5±10.5)岁.均为多支冠状动脉病变.术中应用"Y"形血管桥与降主动脉端侧吻合.结果全组无死亡,术后机械辅助呼吸平均(8.7±6.5)h.ICU滞留时间平均(3.1±0.5)d.全组病例均未输血.术后随访1～17个月.所有患者心绞痛症状消失,活动量增加.结论采用降主动脉"Y"形血管桥供血可避免升主动脉壁损伤是实施冠状动脉搭桥术微创化的一种新术式,早期结果令人满意.     

微创冠状动脉搭桥术(附23例报告)

目的　探索冠状动脉搭桥术的微创治疗方法。　方法 1999年 1月至 2 0 0 0年 8月 ,用Octo pus方法给 2 3位冠状动脉狭窄的患者行冠状动脉搭桥术。搭桥数 1根 1例 ,2根 3例 ,3根以 19例。移植部位 :前降支 2 3例 ,对角支 8例 ,回旋 15例 ,右冠 14例 ,后降支 8例。移植血管 :左乳内动脉 2 0根 ,大隐静脉 4 8根。　结果　无手术死亡 ,无中转体外循环 ,术后心绞痛消失 ,MRI提示桥血管通畅。　结论　非体外循环下冠状动脉搭桥术适用于多支血管病变 ,包括回旋支和后降支。桥血管通畅率与常规冠状动脉搭桥术相同。并发症少 ,费用低 ,是一种安全、经济的微创手术方法。     

机器人微创非体外循环冠状动脉旁路移植术

目的 评价da Vincis机器人系统进行胸廓内动脉(IMA)游离、小切口非体外循环下冠状动脉旁路移植术的安全性和手术效果.方法 2007年1月到2011年3月,105例患者接受机器人IMA游离、小切口非体外循环下冠状动脉旁路移植术.其中男性77例,女性28例,年龄33～77岁,平均(59±10)岁.患者术前行64排CT检查评估IMA质量,2例患者左LIMA纤细或走行异常弃用.术者于操作台前、三维成像系统下遥控机器人游离IMA并完成动脉桥与靶血管的徒手吻合.其中4例患者旁路移植后接受了杂交技术于回旋支或右冠状动脉行支架植入术.术中均以超声血流检测仪测量桥血管的波形及血流.术后以冠状动脉造影或64排CT评估桥血管的通畅性,并进行随访.结果 所有患者成功接受上述手术,无手术死亡病例.术中平均IMA血管桥血流量为(21±13) ml/min.1例于术后第1天突发心跳骤停经抢救后痊愈,复查桥血管通畅.1例合并脑梗死患者术后肺部感染,痊愈后出院.其余患者无并发症发生.术中及术后出血少,术后恢复快.随访1～51个月,平均(30±12)个月.术后冠状动脉造影或64排CT复查未见桥血管狭窄或闭塞,心绞痛症状缓解.结论 机器人IMA游离、小切口非体外循环冠状动脉旁路移植术创伤小、疗效确切、安全性好,是微创冠状动脉再血管化的重要方向之一.     

全动脉化冠状动脉搭桥的临床应用

目的 介绍全动脉移植物行冠状动脉搭桥的早期效果和临床经验。方法 采用全动脉移植物87例冠心病患者实施冠状动脉搭桥。其中男性患者82例,女性5例;单支冠状动脉病变14例,2支病变19例,3支病变54例。62例患者术前有心肌梗死,7例合并室壁瘤,1例合并主动脉瓣关闭不全。71例患者在体外循环下行冠状动脉搭桥术,16例在非体外循环下行冠状动脉搭桥术。同时行室壁瘤切除术7例,行主动脉瓣替换1例,行冠状动脉内膜剥脱2例。应用左乳内动脉84例次,右乳内动脉46例次,胃 网膜右动脉37例次,左桡动脉51例次。单个远端吻合14例,2个19例,3个50例,4个4例。结果 围手术期死亡2例（病死率2．3％）,1例为围手术期心肌梗死低心排,1例为顽固性心律失常。3例术后发生胸骨裂开切口感染,再次清创处理后痊愈。本组患者随访1．0－30．0个月（平均13．2个月）,1例患者因突发脑血管意外在术后40d死亡,其余患者术后均恢复良好,无心绞痛症状再发。B超检查乳内动脉移植血管均通畅。结论 全动脉化冠状动脉搭桥具有良好的临床应用效果,尤其适合于年轻的冠心病患者。     

应用预扩张胸廓内动脉穿支皮瓣修复41例胸部大面积瘢痕疙瘩手术创面

目的探讨应用预扩张胸廓内动脉穿支皮瓣修复胸部大面积瘢痕疙瘩手术创面的临床效果。方法对2017年1月至2021年9月北京协和医院应用预扩张胸廓内动脉穿支皮瓣修复胸部大面积瘢痕疙瘩手术创面患者的临床资料进行回顾性分析。治疗分为2个阶段:第1阶段, 将皮肤软组织扩张器置入胸部胸廓内动脉穿支供血区正常皮肤深层, 扩张器每周注水;第2阶段, 扩张量达到预期扩张目标后取出扩张器, 同时切除瘢痕疙瘩, 并以相应的胸廓内动脉穿支血管为蒂形成预扩张胸廓内动脉穿支皮瓣, 修复切除后创面。术后围手术期进行辅助放疗和高压氧治疗。术后随访治疗效果, 分析术后并发症, 记录复发率和患者满意率。结果共纳入41例患者, 男20例, 女21例, 年龄24～64岁, 平均32.1岁。平均患病时间11.9年;瘢痕疙瘩大小平均约9 cm×8 cm; 置入扩张器数量1～4枚, 容量80～600 ml, 平均300 ml;平均注水时间约3个月。术中切取扩张穿支皮瓣大小平均约9 cm×8 cm。术后随访4～19个月, 平均8.6个月, 2例(4.9%)合并小面积皮瓣远端皮肤坏死;5例(12.2%)出现部分切口瘢痕增生, 随访期内无...     

冠状动脉内膜剥脱联合旁路移植治疗弥漫性冠状动脉狭窄病变的近中期效果

目的探讨冠状动脉内膜剥脱术(CE)联合冠状动脉旁路移植术(CABG)治疗弥漫性冠状动脉狭窄病变的近中期效果。方法回顾性分析2010年1月至2019年1月在南京市第一医院心胸血管外科接受CE+CABG的248例弥漫性冠状动脉狭窄病变患者的临床资料。男性201例,女性47例;年龄(65.6±8.5)岁(范围:43～79岁)。体外循环手术156例,非体外循环手术92例。共对269根病变血管完成CE,包括前降支108根,右冠状动脉140根,钝缘支21根。共完成旁路移植872支,包括左胸廓内动脉248支,桡动脉48支,大隐静脉576支,每例患者移植(3.5±0.8)支(范围:2～6支)。CE后平均血流量为(26±8)ml/min(范围:13～59 ml/min),血流指数为3.1±0.8(范围:2.0～6.7)。采用t检验或χ2检验比较体外循环和非体外循环患者的手术结果及术后通畅率。结果全组围手术期病死率为1.2%(3/248),2例死于肾功能衰竭,1例死于术后顽固性低心排血量。9例发生围手术期心肌梗死。随访(41.8±21.4)个月(范围:1～68个月)。旁路血管术后1年通畅率为78.4%(1...     

非体外循环冠状动脉旁路移植术的临床应用

目的　总结 36例冠状动脉粥样硬化性心脏病患者在非体外循环下行冠状动脉旁路移植术 (OPCAB)的临床经验。　方法　采用胸骨正中切口 ,应用心脏表面固定器、头低脚高位、心包深部放置牵引线、冠状动脉内置入分流器和吹雾器行 OPCAB。　结果　所有患者均使用左乳内动脉 (L IMA) ,移植血管 1～ 4根 ,平均 2 .6根 ;平均手术时间 16 1分钟 ;术中平均失血 32 0 ml。 1例在术中改为常规体外循环冠状动脉旁路移植术。术后 2 4小时平均引流量 380ml,平均输血或血液制品 32 0 ml。4例患者手术后在手术室内拔除气管内插管 ,ICU平均机械辅助通气时间 4.2小时 ;ICU平均监护时间 12 .6小时 ,术后平均住院时间 12 .5天。 1例术后 14天死于严重的肺部感染。术后随访 1～ 7个月 ,所有存活患者心绞痛症状消失。　结论　OPCAB创伤小、安全、经济、临床效果好 ,适用于单支、多支冠状动脉病变和具有高危因素的患者。     

冠状动脉旁路移植术中胸腔镜与小切口直视获取胸廓内动脉的对比研究

目的 对比胸腔镜和小切口直视获取左侧胸廓内动脉进行微创冠状动脉旁路移植手术的效果。方法 回顾性研究2020年1月～2022年6月完成的胸腔镜辅助微创冠状动脉旁路移植术18例和小切口直视冠状动脉旁路移植术20例。2组年龄、左室射血分数、左室舒张末内径差异无统计学意义(P>0.05)。腔镜组使用胸腔镜器械获取左侧胸廓内动脉,应用微创心脏稳定器在左前外侧胸部小切口、非体外循环下完成冠状动脉旁路移植手术,包括左侧胸廓内动脉与冠状动脉前降支单支旁路移植16例,多支冠状动脉旁路移植2例。小切口组20例行左前外侧胸部小切口直视获取左侧胸廓内动脉,与前降支行旁路移植手术。结果 腔镜组18例中16例成功获取左侧胸廓内动脉,1例转为肋间小切口直视获取左侧胸廓内动脉,1例胸腔镜获取血管时损伤远端,经肋间小切口直视修补后完成血管吻合。小切口组20例均成功获取胸廓内动脉并行旁路移植手术。与小切口组相比,腔镜组术后呼吸机使用时间短[(4.9±2.0)h vs.(6.5±2.3)h,t=-2.318,P=0.026],术后住院时间短[(4.5±0.9)d vs.(5.3±0.8)d,t=-2.859,P=0....     

左胸小切口与胸骨正中切口冠状动脉搭桥术的比较

目的比较微创左胸小切口与传统胸骨正中切口冠状动脉搭桥术的优缺点。方法从2006年3月至2008年3月,对66例冠心病经左胸微创小切口实施非体外循环左乳内动脉前降支搭桥术,时42例冠心病经传统正中切口实施非体外循环左乳内动脉前降支搭桥术。比较术前基本情况及手术切口长度、切口感染情况与住院时间,术后第1、2、3周及1、2、3、6个月进行随访。结果左胸小切口组与胸骨正中切口组均无手术死亡,无术后出血,无心绞痛症状,仅胸骨正中切口组出现1例切口感染,其余无切口感染裂开。左胸小切口组较胸骨正中切口组手术切口小,住院时间短。随访半年无心脏事件发生。结论左胸微创小切口非体外循环冠状动脉搭桥术安全、可靠,近期临床效果显著。适用于单支血管病变或联合经皮冠状动脉支架术治疗重症冠心病。     

Failure of autologous fresh frozen plasma to reduce blood loss and transfusion requirements in coronary artery bypass surgery

BACKGROUND: Previous studies failed to demonstrate any benefit from prophylaxis with fresh frozen plasma (FFP) after cardiopulmonary bypass (CPB). The results, however, were limited by either retrospective study design or use of FFP in subtherapeutic doses (2-3 units). The authors evaluated whether a therapeutic dose (15 ml/kg) of FFP reduces blood loss and transfusion requirements in elective coronary artery bypass surgery. The risks of multiple allogeneic blood donor exposure were circumvented by using autologous plasma. METHODS: Sixty adult patients scheduled for elective primary coronary artery bypass grafting were randomized to receive, after CPB, an intravenous infusion of 15 ml/kg of either autologous FFP (30 patients) or 6% hydroxyethyl starch 450/0.7 (HES; 30 patients). Autologous plasma was obtained by platelet-poor plasmapheresis several weeks before surgery. Perioperative blood transfusions were administered per protocol. Postoperative blood loss was defined as the chest tube drainage during the first 24 h after surgery. RESULTS: The data from 56 patients (FFP group, 27 patients; HES group, 29 patients) who completed the study according to protocol were analyzed. Median postoperative blood loss was 630 ml (range, 450-1,840 ml) and 830 ml (range, 340-1,980 ml) in the FFP and HES groups, respectively (P = 0.08). Both postoperative (0-24 h) and total perioperative erythrocyte transfusion requirements did not differ significantly between the groups (P = 0.32 and 0.14, respectively). CONCLUSION: The prophylactic administration of a therapeutic dose (15 ml/kg) of autologous FFP after CPB failed to reduce blood loss and transfusion requirements in patients undergoing uncomplicated, elective, primary coronary artery bypass surgery.     

Reoperative coronary artery bypass grafting using a minimally invasive direct coronary artery bypass procedure

OBJECTIVE: Reoperative coronary artery bypass grafting with cardiopulmonary bypass tends to cause a higher mortality and morbidity than the primary operation. The purpose of this study was to discuss the effectiveness and safety of a minimally invasive coronary artery bypass procedure for patients who had previously undergone coronary artery bypass surgery. METHODS: We performed redo single coronary artery bypass grafting to the left anterior descending coronary artery in 9 patients and to the right coronary artery in 3 patients using minimally invasive cardiac surgery. The graft to the left anterior descending coronary artery was taken from the left internal thoracic artery in 5 patients, the right gastroepiploic artery in 3 patients, and from the saphenous vein in the other 1 patient. The graft to the right coronary artery was from the right gastroepiploic artery in all 3 patients. RESULTS: All grafts were patent. There was no major postoperative complication and no surgical or hospital death except one late death. CONCLUSIONS: In selected patients, we could safely and completely perform coronary artery bypass re-grafting to the left descending coronary artery or right coronary artery using a minimally invasive operation.     

Failure of Autologous Fresh Frozen Plasma to Reduce Blood Loss and Transfusion Requirements in Coronary Artery Bypass Surgery

Background: Previous studies failed to demonstrate any benefit from prophylaxis with fresh frozen plasma (FFP) after cardiopulmonary bypass (CPB). The results, however, were limited by either retrospective study design or use of FFP in subtherapeutic doses (2-3 units). The authors evaluated whether a therapeutic dose (15 ml/kg) of FFP reduces blood loss and transfusion requirements in elective coronary artery bypass surgery. The risks of multiple allogeneic blood donor exposure were circumvented by using autologous plasma.

Methods: Sixty adult patients scheduled for elective primary coronary artery bypass grafting were randomized to receive, after CPB, an intravenous infusion of 15 ml/kg of either autologous FFP (30 patients) or 6% hydroxyethyl starch 450/0.7 (HES; 30 patients). Autologous plasma was obtained by platelet-poor plasmapheresis several weeks before surgery. Perioperative blood transfusions were administered per protocol. Postoperative blood loss was defined as the chest tube drainage during the first 24 h after surgery.

Results: The data from 56 patients (FFP group, 27 patients; HES group, 29 patients) who completed the study according to protocol were analyzed. Median postoperative blood loss was 630 ml (range, 450-1,840 ml) and 830 ml (range, 340-1,980 ml) in the FFP and HES groups, respectively (P = 0.08). Both postoperative (0-24 h) and total perioperative erythrocyte transfusion requirements did not differ significantly between the groups (P = 0.32 and 0.14, respectively).     

Troponin as a marker of myocardial damage during coronary surgery with and without cardiopulmonary bypass

BACKGROUND: The use of coronary surgery without cardiopulmonary bypass (CBP) has been growing during the last years. In order to compare myocardial damage during coronary surgery with and without CBP, perioperative Troponin T determinations were done. METHODS: Experimental design and setting: prospective, comparative. Cardiovascular surgery department. Patients, interventions and measures: 29 prospective patients who underwent elective coronary surgery were enrolled. Troponin T determinations (ng/ml) were done before surgical procedure, after a 2-hour and after a 12-hour postoperative. Population was divided in two groups: group 1, with CBP (17 patients); group 2, without CBP (12 patients). Variables in relation with population characteristics, myocardial damage and immediate postoperative haemodynamic results were all analyzed. RESULTS: Population characteristics and basal Troponin levels were similar for the two groups. Troponin T average levels at 2-hour postoperative period was 0.729 ng/ml and 0.067 ng/ml for group 1 and 2, respectively (p<0.00002). At 12 hours postoperative period Troponin T was 1.047 ng/ml and 0.183 ng/ml for group land 2 (p<0.0002). Haemodynamic performance was better in the group without CBP. CONCLUSIONS: Troponin T levels were significantly elevated in group 1, showing that surgical procedures without CBP caused less myocardial damage.     

Autologous platelet sequestration in patients undergoing coronary artery bypass grafting

OBJECTIVES: Blood conservation remains an important issue for patients undergoing cardiac surgery with cardiopulmonary bypass. Platelet sequestration (PSQ) is an aggressive autologous blood conservation method, whose effectiveness is still debated. The main objective of the present study was to evaluate whether PSQ reduces postoperative blood transfusion requirements in patients undergoing coronary artery bypass grafting (CABG) and to determine if PSQ is a cost-effective blood conservation method. MATERIAL AND METHODS: All adult patients admitted for CABG entered the study. Exclusion criteria were: recent blood transfusion (<7 days), a platelet count of 150x10(3)/microl or less, hematocrit less than 35% and body weight 50 kg or less. The sequestration was aim 20% or more of the total platelet plasma volume. The sequestration protocol was three sequestration cycles performed just prior to surgery. The concentrated platelet portion was reinfused after weaning from the cardiopulmonary bypass. Hundred seven parameters/patients were recorded. Sixty patients entered the study; 30 in the PSQ group and 30 controls (CTR). RESULTS: Patient characteristics, operation data, preoperative hematology and coagulation parameters did not differ between the groups. In the PSQ group a mean of 433+/-34 ml concentrated platelet portion was collected. The mean platelet count in the concentrated platelet portion was 749+/-157x10(3)/microl, resulting in a platelet yield of 28+/-6% (2040%). The average total chest tube blood loss was 423 ml (PSQ) compared to 858 ml (CTR), p<0.001. A greater number of CTR patients required blood transfusion postoperatively (23) compared to PSQ (3), P<0.001, and fluid requirements were also significantly increased in the control group, P<0.001. No statistical differences in hematology and coagulation parameters between the groups were observed. The hospital mortality was low and the incidence of postoperative complications was few and without group differences. Post-extubation gas exchange was better in PSQ patients compared to CTR. CONCLUSIONS: A preoperative PSQ of a minimum 20% of the total platelet plasma volume resulted in significantly lower postoperative blood loss and fluid and blood transfusion requirements compared to controls. Post-extubation gas exchange was also better after PSQ. Only one patient did not tolerate the sequestration. No other adverse effects of the procedure were observed.     

Off-pump CABG attenuates myocardial enzyme leakage but not postoperative brain natriuretic peptide secretion.

BACKGROUND: Off-pump coronary artery bypass surgery is considered to be less invasive compared with a conventional coronary artery bypass surgery, while objective assessment of its invasiveness has not been well established. The grade of invasiveness of off-pump CABG was evaluated by biochemical markers released from the myocardium. METHODS: Perioperative serial changes of myocardial enzyme leakage (creatine kinase-MB isoenzyme and troponin T) were evaluated in 217 patients who underwent coronary artery bypass surgery (28 off-pump CABG patients and 189 conventional CABG patients). Serial changes of atrial natriuretic peptide and brain natriuretic peptide secretion as markers of heart failure were also evaluated in 12 off-pump CABG patients and 49 conventional CABG patients. RESULTS: Myocardial enzyme leakage was significantly less in the off-pump CABG group, while increase of brain natriuretic peptides secretion were similar in both groups with its peak at the first postoperative day (246+/-46 pg/ml in the off-pump CABG group and 312+/-57 pg/dl in the conventional CABG group). CONCLUSIONS: Although off-pump CABG seems to be less invasive to the myocardial cells from the aspect of enzyme leakage, ischemic stress to the heart assessed by brain natriuretic peptide secretion was similar to that of conventional CABG. Careful monitoring and management throughout postoperative period is mandatory even in off-pump CABG procedure.     

"Keyhole" coronary artery bypass surgery.

OBJECTIVE: The objective of this study was to identify the utility of "keyhole" thoracotomy approaches to single vessel coronary artery bypass surgery. SUMMARY BACKGROUND DATA: Although minimally invasive surgery is efficacious in a wide variety of surgical disciplines, it has been slow to emerge in cardiac surgery. Among 49 selected patients, the authors have used a left anterior keyhole thoracotomy (6 cm in length) combined with complete dissection of the eternal mammary artery (IMA) pedicle under thoracoscopic guidance or directly through the keyhole incision to accomplish IMA coronary artery bypass grafting (CABG) to the left anterior descending (LAD) coronary artery circulation or to the right coronary artery (RCA). METHODS: Keyhole CABG was accomplished in 46 of 49 patients in which this approach was attempted. All patients had significant (> 70%) obstruction of a dominant coronary artery that had failed or that was inappropriate for endovascular catheter treatment (percutaneous transluminal coronary angioplasty or stenting). Forty-four of the 49 patients had proximal LAD and 5 had proximal RCA stenoses. The mean age of the patients (35 men and 14 women) was 61 years, and their median New York Heart Association anginal class was III. The mean left ventricular ejection fraction was 42%. Femoral cardiopulmonary bypass support was used in 9 (19%) of 46 patients successfully managed with the keyhole procedure. Short-acting beta-blockade was used in the majority of patients (38 of 46) to reduce heart rate and the vigor of cardiac contraction. RESULTS: As 49 patients have survived operation, which averaged 248 minutes in duration. Median, postoperative endotracheal intubation time for keyhole patients was 6 hours with 25 of 46 patients being extubated before leaving the operating room. The median hospital stay was 4.3 days. Conversion to sternotomy was required in three patients to accomplish bypass because of inadequate internal mammary conduits or acute cardiovascular decompensation during an attempted off-bypass keyhole procedure Postoperative complications were limited to respiratory difficulty in three patients and the development of a deep wound infection in one patient. Nine (19%) of 46 patients received postoperative transfusion. There have been no intraoperative or postoperative infarctions, and angina has been controlled in all but one patient who subsequently had an IMA-RCA anastomotic stenosis managed successfully with percutaneous transluminal coronary angioplasty. CONCLUSIONS: These early results with keyhole CABG are encouraging. As experience broadens, keyhole CABG may become a reasonable alternative to repeated endovascular interventions or sternotomy approaches to recalcitrant single-vessel coronary arterial disease involving the proximal LAD or RCA.     

完全腹腔镜下脾切除术的临床应用(附63例报道)

目的:探讨腹腔镜脾切除术(laparoscopic splenectomy,LS)的临床应用。方法:我们2001年至2008年共实施LS63例,其中特发性血小板减少性紫癜(idiopathic thrombocytopenic purpura,ITP)42例,门脉高压继发性脾功能亢进11例,白血病5例。结果:全部病例均在腹腔镜下完成手术,无中转开腹。平均手术时间140min,术中平均失血120ml,术后出血1例,每天约20ml,保守治疗12d后痊愈;术后胃漏1例,手术缝合及引流后痊愈。术后平均住院6d。结论:LS具有创伤小,患者恢复快、痛苦轻和住院时间短等优点,适用于脾脏体积正常至中度增大的有切脾指征的各类患者。     

Perfusion during coronary and mitral valve surgery utilizing minimally invasive Port-Access technology

Minimally invasive surgery has been used in the treatment of some cardiovascular diseases. Port-Access surgery is a new minimally invasive technique that utilizes cardiopulmonary by-pass and a specialized catheter system that provides cardiopulmonary support and myocardial preservation. Extrathoracic cardiopulmonary support is established with femero-femoral bypass with kinetic assisted venous drainage. An endovascular catheter system allows for all the benefits of mechanical support as well as myocardial preservation. This catheter system includes an endoaortic balloon catheter which functions as an aortic cross clamp and antegrade cardioplegia delivery catheter, endopulmonary vent, and endocoronary sinus catheter used for administration of retrograde cardioplegia. An initial cohort of 20 patients was treated by the Port-Access surgical approach with cardiopulmonary bypass. Ten patients had coronary artery surgery and 10 patients had mitral valve surgery. The average bypass times were 94.4 min (coronary artery) and 152.8 min (mitral valve). The mean aortic occlusion times were 49.7 min (coronary artery) and 112.6 min (mitral valve). All patients were weaned from bypass. This initial patient series demonstrated that Port-Access surgery was feasible in selected patients.     

The effect of prophylactic epsilon-aminocaproic acid on bleeding, transfusions, platelet function, and fibrinolysis during coronary artery bypass grafting.

BACKGROUND: Antifibrinolytic medications administered before skin incision decrease bleeding after cardiac surgery. Numerous case reports indicate thrombus formation with administration of epsilon-aminocaproic acid (epsilon-ACA). The purpose of this study was to examine the efficacy of epsilon-ACA administered after heparinization but before cardiopulmonary bypass in reducing bleeding and transfusion requirements after primary coronary artery bypass surgery. METHODS: Seventy-four adult patients undergoing primary coronary artery bypass surgery were randomized to receive 125 mg/kg epsilon-ACA followed by an infusion of 12.5 mg x kg(-1) x h(-1) or an equivalent volume of saline. Coagulation studies, thromboelastography, and platelet aggregation tests were performed preoperatively, after bypass, and on the first postoperative day. Mediastinal drainage was recorded during the 24 h after surgery. Homologous blood transfusion triggers were predefined and transfusion amounts were recorded. RESULTS: One patient was excluded for surgical bleeding and five patients were excluded for transfusion against predefined criteria One patient died from a dysrhythmia 2 h postoperatively. Among the remaining 67, the epsilon-ACA group had less mediastinal blood loss during the 24 h after surgery, 529+/-241 ml versus 691+/-286 ml (mean +/- SD), P < 0.05, despite longer cardiopulmonary bypass times and lower platelet counts, P < 0.05. Platelet aggregation was reduced in both groups following cardiopulmonary bypass but did not differ between groups. Homologous blood transfusion was similar between both groups. CONCLUSIONS: Prophylactic administration of epsilon-ACA after heparinization but before cardiopulmonary bypass is of minimal benefit for reducing blood loss postoperatively in patients undergoing primary coronary artery bypass grafting.