非体外循环冠状动脉旁路移植术中血流动力学的变化

目的分析非体外循环冠状动脉旁路移植术(off-pum p coronary artery bypass grafting,OPCAB)中血流动力学的变化特点。方法连续100例冠心病患者接受OPCAB,术中对各病变血管进行旁路移植血管吻合时的血流动力学指标进行监测。全组完成左乳内动脉(L IM A)与左前降支(LAD)吻合97例,大隐静脉或桡动脉与右冠状动脉(RCA)主干、后降支(PDA)、左心室后支(PLB)吻合84例,左回旋支(LCX)吻合50例,钝缘支(OM)吻合27例,对角支(DG)吻合25例。每例患者移植血管支数为3.1±0.7支。结果吻合LAD、DG时除心率(HR)较基础值增快,平均动脉压(M AP)和左心室每搏做功指数(LV SW I)较基础值降低外(P<0.05),其它指标无明显变化。吻合LCX、PDA、PLB和OM时血流动力学指标有明显的变化,HR、中心静脉压(CVP)较基础值明显升高(P<0.05),M AP、心脏指数(C I)、每搏指数(S I)、右心室射血分数(RVEF)、右心室舒张期末容积(RVEDV)、LV SW I、右心室每搏做功指数(RV SW I)较基础值明显降低或减少(P<0.05)。术毕各指标均趋于正常,C I有明显的改善。结论OPCAB中吻合LAD和DG时对血流动力学影响较小,而吻合LCX、PDA、PLB和OM时对血流动力学有明显的影响,术毕各血流动力学指标趋于正常,心脏功能有明显的改善。     

非体外循环冠状动脉旁路移植术的血流动力学研究

目的：分析非体外循环冠状动脉旁路移植术中血流动力学的变化。方法：2000年6月至2001年1月，连续32例病人接受非体外循环冠状动脉旁路移植术，术中、术后对各吻合血管的血流动力学指标进行持续监测。全组完成前降支吻合32例、右冠状动脉26例、回旋支28例、对角支8例。结果：本组死亡例。行前降支冠状动脉吻合时血流动力学指标无明显变化。右冠状动脉吻合时影响右心功能。回旋支及对角支冠状动脉吻合时对血流动力学有明显的影响，导致平均肺动脉压（MPAP）、肺毛细血管楔压（PAWP）、中心静脉压（CVP）明显升高，每搏指数（SVI）及左室每搏功指数（LVSWI）有明显下降；心排指数（CI）有一定的下降趋势。行主动脉近心端吻合时尽管已无心脏搬动，但MPAP、SVRI及肺循环阻力指数（PVRI）仍较诱导后有明显升高，CI有明显下降。术毕及术的2、6、16h各血流动力学指标趋于正常，CI有明显改善。结论：非体外循环冠状动脉旁路移植行前降支及右冠状动脉吻合时对血流动力学影响较小，回旋支及对角支冠状动脉吻合时对血流动力学有明显的影响，术毕及术后2、6、16h各血流动力学指标趋于正常，心脏功能有明显改善。     

常规与非体外循环下冠状动脉3支病变旁路移植血管通畅性对比分析

目的　评价非体外循环下冠状动脉旁路移植术 (OPCAB)与体外循环下冠状动脉旁路移植术 (CCABG)治疗冠状动脉三支病变术中旁路早期通畅性。方法　 6 0例 3支血管病变的病人分为OPCAB组和CCABG组 ,每组各 30例。行冠状动脉旁路移植术 ,OPCAB组胸骨正中切口 ,在非体外循环心脏不停跳下完成手术 ;CCABG组建立常规体外循环 ,心脏停跳下完成手术。术中应用即时血流测量技术对旁路血管进行流量测量。对比分析两组术前、术后的各项指标及各血管旁路流量、搏动指数和血流波形。结果　两组病人术前一般情况差异无统计学意义。OPCAB组与CCABG组移植旁路血管分别为 (3 6±0 6 )支与 (4 3± 0 9)支 (P <0 0 1) ;两组前降支及右冠状动脉旁路血流量、搏动指数差异无显著性。CCABG组回旋支序贯旁路和远端吻合口多 ,血流量较OPCAB组高。两组弥漫病变血管旁路血流量小。结论　OPCAB与CCABG治疗 3支病变 ,两组血管旁路早期通畅性差异无显著性。     

非体外循环冠状动脉旁路移植术的手术策略对术中血流动力学的影响

目的 研究非体外循环冠状动脉旁路移植术(CABG)的术中手术策略在吻合不同部位靶血管时对血流动力学的影响,探讨非体外循环CABG术中稳定血流动力学的措施.方法 2005年3月至2007年3月进行手术治疗的67例冠状动脉粥样硬化性心脏病患者,男性45例,女性22例,年龄44～81岁,均为严重三支病变.所有患者均先作左胸廓内动脉一前降支(LIMA-LAD)吻合,再作钝缘支(OM)及后降支(PDA)的序贯吻合.根据吻合的顺序不同将患者分为三组:组Ⅰ吻合顺序为PDA-OM-主动脉(Ao),共22例;组Ⅱ吻合顺序为Ao-PDA-OM,共14例;组Ⅲ为Ao-OM-PDA,共31例.以LIMA-LAD吻合前的血流动力学指标为基础值,在LAD吻合时及吻合后、PDA吻合时、OM吻合时各时间点测定血流动力学指标,并与基础值相比较.结果 67例患者均顺利施行了非体外循环CABG,无手术死亡.行LIMA-LAD吻合时,各项血流动力学指标变化不显著.LIMA-LAD完成后,各项指标显著改善.吻合OM时,组Ⅰ、组Ⅲ的心率(HR)、中心静脉压(CVP)显著升高(P＜0.05),平均动脉压(MAP)、心指数(CI)、左室做功指数(LVSWI)及右室做功指数(RVSWI)均显著降低(P＜0.05),但组Ⅱ上述指标变化均不显著(P＞0.05).吻合PDA时,组Ⅰ、组Ⅱ的HR、CVP均显著升高(P＜0.05),MAP、CI、LVSWI及RVSWI均显著降低(P＜0.05),但组Ⅲ上述指标变化不显著(P＞0.05).结论 先吻合桥血管的近端,再序贯吻合靶血管,这样的手术策略有利于非体外循环CABG时完成显露、吻合困难的OM、PDA部位的手术.     

非停跳冠脉搭桥术中病人心脏形态和功能的变化

目的观察非停跳冠脉搭桥术（OPCAB）中病人心脏形态和功能的变化。方法择期行OPCAB病人30例，ASAll或Ⅲ级。麻醉诱导后气管插管，经右侧颈内静脉放置CCO／SVO，／CEDV导管，连续监测血液动力学参数，经口放人多平面经食管彩色超声诊断仪探头，监测食管超声心动图（TEE）参数。分别于打开心包时（基础值）、前降支（LAD）搭桥、回旋支（LCX）搭桥、右冠状动脉（RCA）搭桥、吻合完毕时测定TEE参数及血液动力学参数。结果与基础值比较，LAD搭桥时二尖瓣血流E波减速时间（DL）缩短，经过二尖瓣口的左心流量（Q；）降低，MAP、HR下降，CVP升高；LCX搭桥时左心室舒张末直径（LVEDD）、右心室舒张末直径（RVEDD）、三尖瓣环直径（TVD）、射血分数（EF）、Q，、经过中尖瓣口的右心流量（Q2）、左心室流出道舒张变化率[（DDL—SDL）／DDL]、三尖瓣血流E／A比值（E2／A2）、TVD降低，二尖瓣血流E／A比值（E1／A1）升高，DL、三尖瓣血流E波减速时间（DT2）缩短，HR、MAP、每搏量（sV）、混合静脉血氧饱和度（蹄01）、右心室舒张末容积（RVEDV）、右心室收缩末容积（RVESV）、右心室射血分数（RVEF）、右心室舒经末容积指数（RVEDVI）降低，CVP升高；RCA搭桥时LVEDD、LVESD、二尖瓣环直径、Q，、E2／A2、HR、MAP、平均肺动脉压、SV、SvO2、RVEVD、RVESV、RVEF、RVEDVI降低，CVP升高，DT1缩短，右心室流出道舒张直径（RVOTDD）、右心室流出道收缩直径（RVOTSD）增加（P＜0．05）；吻合完毕时各指标恢复到基础值水平（P＞0．05）。心脏形态学表明LAD、RCA搭桥时以左心室直接受压为主，LCX搭桥时以右心室受压为主。结论在OPCAB中LAD、LCX、RCA搭桥时左右心室同时受压，但左右心室受压的程度随着搭桥血管、心脏位置不同而不同；心功能呈一过性的损害，在完成血管搭桥后均能恢复。     

6%羟乙基淀粉对冠状动脉旁路移植术血浆胶体渗透压的影响

目的观察6%羟乙基淀粉130/0.4对非体外循环冠状动脉旁路移植术（OPCAB）中血浆胶体渗透压（COP）的影响。方法 34例行OPCAB患者（NYHAⅠ或Ⅱ级）,麻醉诱导时开始输注6%羟乙基淀粉至血管吻合完毕,总量控制为25～35ml/kg。分别于输注前（T0）、离断乳内动脉后（T1）、桥血管吻合完毕时（T2）监测血浆COP及血流动力学变化,并记录输液量、失血量、Hb、Hct及心脏指数（CI）。结果手术过程血流动力学稳定。T1时失血量（120±30）ml,输注6%羟乙基淀粉（998±110）ml,血浆COP由T0时（21.7±1.4）mmHg升高至（22.3±1.3）mmHg（P〈0.05）;T2时失血量（778±179）ml,输注6%羟乙基淀粉（2190±135）ml,血浆COP降至（21.5±1.4）mmHg。T2时Hb和Hct较T0时明显下降（P〈0.01）,但CI显著升高（P〈0.05）。结论 6%羟乙基淀粉可稳定OPCAB术血浆COP。     

非体外循环冠状动脉旁路移植术对右心室血流动力学的影响

目的应用连续心排血量测定的方法,观察在进行非体外循环冠状动脉旁路移植术(OPCABG)中右心功能的变化. 方法冠状动脉粥硬化性心脏病178例,均为2～3支血管病变需行冠状动脉旁路移植术.术前心功能Ⅱ级72例,Ⅲ级84例,Ⅳ级22例.左心室射血分数0.35～0.82,平均搭桥数3.3根.所有病人均行Swan-Ganz漂浮导管,用连续心输出量监测仪连续监测血流动力学指标,包括心率(HR),平均动脉压(MAP),中心静脉压(CVP),平均肺动脉压(MPAP),右房压(RAP),肺毛细血管楔压(PCWP),心输出量(CO),心脏指数(CI),每搏容量指数(SVI),体循环阻力指数(SVRI),肺循环阻力指数(PVRI),混合静脉血饱和度(SvO2),右室射血分数(RVEF),右室收缩末容量(RVESV),右室舒张末容量(RVEDV),右室收缩末容量指数(RVESVI),右室舒张末容量指数(RVEDVI).设定时间点观察血流动力学指标:麻醉诱导后血流动力学稳定后,准备搬动心脏前(T1),吻合前降支前(T2),吻合回旋支或对角支前(T3),吻合右冠状动脉或后降支前(T4),心脏回位后,关胸前(T5).结果 4例死亡,其中2例为术前急性心肌梗死急诊手术,术后3天死于严重低心排血量综合征,1例术后7天死于严重呼吸衰竭,1例于术后4天死于急性肺栓塞.与T1相比,T2时,MPAP,PCWP,RAP和PVRI明显增加而SvO2明显降低;T3时,血流动力学变化明显,MPAP,PCWP,RAP和PVRI明显增加,SvO2明显降低,CI,SVI,RVEF明显下降,SVRI明显增加;T4时,HR,RAP明显增加而SvO2明显降低;T5时未恢复正常水平. 结论在进行纯缘支吻合时,右心功能有所下降,主要是CI及RVEF有明显的变化,而在前降支及右冠状动脉的吻合时,对右心血流动力学影响不大,因此,在OPCABG中监护右心功能具有重要意义,尤其是对右心功能受到损害的患者.     

60岁以上男性多支冠状动脉病变旁路移植术后血流动力学研究

目的研究60岁以上男性多支冠状动脉病变旁路移植术后早期血流动力学的变化。方法对20例60岁以上男性体外循环下多支冠状动脉病变旁路移植术患者术前及术后血流动力学变化进行监测。结果术后2～6小时心脏指数（CI）、每搏指数（SVI）明显降低（P〈0.05）,肺循环指数（PVRI）、体循环指数（SVRI）明显升高（P〈0.05）;24～48小时后心功能明显改善,CI、左室每搏做功指数（LVSWI）明显增高（P〈0.05）。结论多支冠状动脉病变旁路移植术后早期CI明显下降,术后24小时内应有效降低体循环阻力,以降低左心室后负荷并以此增强左心室收缩功能及心排出量     

非体外循环冠状动脉旁路移植术后大隐静脉序贯桥与单支桥中期通畅率的比较

目的比较非体外循环冠状动脉旁路移植术（OPCAB）后大隐静脉序贯桥与单支桥的中期通畅率,评价序贯吻合技术在OPCAB的应用效果。方法回顾性分析2005年6月至2009年3月中国人民解放军总医院398例冠心病患者分别采用大隐静脉序贯桥和单支桥行OPCAB的临床资料,其中男301例,女97例;年龄53～82岁（63.6±10.3岁）。患者于术后3个月～5年（19.8±23.6个月）行64层螺旋CT血管造影（64-MSCTA）检查,共有448支大隐静脉桥上的714个远端吻合口接受评估,分别比较血管桥血流、血管桥及吻合口的通畅率,并分析不同位置对吻合口通畅率的影响。结果大隐静脉双支序贯桥（37.11±16.70ml/min vs.25.15±14.24ml/min,P=0.042）和3支序贯桥（37.56±19.58ml/min vs.25.15±14.24ml/min,P=0.048）的近段血流速度均显著高于单支桥。序贯桥总吻合口通畅率高于单支桥（95.1%vs.90.1%,P=0.013）。序贯桥中间吻合口通畅率分别高于序贯桥远端吻合口（97.0%vs.93.1%,P=0.002）和单支桥远端吻合口（97.0%vs.90.1%,P=0.041）。序贯桥远端吻合口通畅率与单支桥比较差异无统计学意义（P=0.253）;不同吻合方式下各冠状动脉系统（左前降支系统、右冠状动脉系统和回旋支系统）间差异无统计学意义,序贯桥吻合口在右冠状动脉系统的通畅率高于单支桥吻合口（P=0.008）。结论 OPCAB术后大隐静脉序贯桥的中期通畅率较单支桥更满意,序贯吻合时应尽量选择条件较好的靶血管作为序贯桥的最远端血管,条件较差的血管放在序贯桥的中间     

非心肺转流冠脉搭桥围术期IL-2和IL-4的变化

目的：研究两种复合全麻下，非心肺转流冠脉搭桥（OPCAB）围术期辅助性T淋巴细胞的免疫应激反应，方法：24例患者随分入丙泊酚－芬太尼全凭静脉麻醉组（P组）和异氟醚－芬太尼静吸复合麻醉组（Ⅰ组），于诱导前，术中打开心包和旁路血管开放时及术后2h采集血标本，应用放免法检测血清白细胞介素2（IL－2）和白细胞介素4（IL－4）的含量。结果：IL－2两组均减少，P组术中、术后均较诱导前有非常显著性降低（P＜0．01），Ⅰ组打开心包时降低明显（P＜0．05），旁路血管开放时降低更显著（P＜0．01）。两组相比，Ⅰ组IL－2于旁路血管开放时比P组下降更明显（P＜0．01）。旁路血管开放时，P组IL－4明显高于Ⅰ组（P＜0．05）。结论：丙泊酚－芬太尼静脉麻醉行OPCAB术对抑制免疫应激反应有益，是有利于机体的保护性免疫反应。     

Deep Pericardial Traction Suture versus Vacuum-Assisted Apical Suction to Expose the Posterior Wall of the Heart in Off-Pump Coronary Artery Bypass: A Prospective, Randomized Study

Background: Displacement of the heart to expose the posterior vessels during off-pump coronary artery bypass (OPCAB) may cause hemodynamic instability. Deep pericardial traction suture (DPTS) and vacuum-assisted apical suction (VAS) with the Starfish positioning device help to provide good exposure without relevant hemodynamic changes. Our aim was to compare these two methods in patients undergoing multivessel OPCAB.Methods: We prospectively randomized 20 patients undergoing multivessel OPCAB to the use of VAS or DPTS. The Octopus device was used in both groups to stabilize the target vessel. Hemodynamic parameters, including venous oxygen content (SvO2), cardiac index (CI), central venous pressure (CVP), mean arterial pressure (MAP), pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP), were measured before grafting (baseline), after heart positioning, and during performance of peripheral anastomoses.Results: Perioperative data for the two groups were similar. During exposure of the lateral wall, there were fewer hemodynamic changes in the DPTS group (increase in CVP) than in the VAS group (increases in CVP, PAP, and PCWP); the CVP was significantly higher in the DPTS group (P < .05). During exposure of the posterior wall, significant hemodynamic changes occurred only in the DPTS group (increase in PCWP). Values for all other parameters were similar, including anastomosis time, graft flow, postoperative myocardial enzymes, and inotropic support.Conclusions: Heart positioning during OPCAB with either VAS or DPTS is a safe and effective maneuver for exposure of coronary arteries. In our study, the use of the VAS device produced less hemodynamic impairment during exposure of the lateral and posterior walls.     

Efficacy of continuous intraoperative administration of low-dose milrinone during the circumflex artery anastomosis of off-pump coronary artery bypass

BACKGROUND : We have experienced instability of hemodynamic state during off-pump coronary artery bypass (OPCAB), especially, circumflex (Cx) artery anastomosis. Although some reports have implied the efficacy of mirlinone in OPCAB anastomosis due to its characteristic inotropic effect without increasing myocardial oxygen consumption, we examined the effect of smaller doses of mirlinone during Cx anastomosis. METHODS : Fourteen patients received milrinone (M group) continuously at a rate of 0.15-0.30 microg x kg(-1) min(-1) after sternotomy until the end of operation. Sixteen patients in the control group (C group) received saline. Norepinephrine was concomitantly administered for maintaining systolic blood pressure above 100 mmHg. We measured hemodynamic parameters during Cx anastomosis and postoperative myocardial isozymes, and examined arrhythmias. RESULTS : In the M group mean pulmonary arterial pressure (MPAP) decreased significantly and cardiac index (CI) and SvO2 increased significantly, compared with C group. M group showed lower incidence of atrial fibrillation for 2 days. CONCLUSIONS : We conclude that low-dose milrinone has a good influence on intraoperative and postoperative managements of OPCAB surgery.     

Active distal coronary perfusion to prevent regional myocardial ischemia in off-pump coronary artery bypass grafting.

Regional myocardial ischemia during anastomosis in off-pump coronary artery bypass (OPCAB) can occasionally cause hemodynamic instability. To prevent regional myocardial ischemia and stabilize the hemodynamics during the procedure, perfusion of the distal coronary artery to the anastomotic site is necessary as the only reliable method. We have applied an active coronary perfusion method using a servo-controlled pump in selected patients in place of conventional passive perfusion methods (intraluminal shunt and external shunt). We present a case in which the active perfusion method proved useful in avoiding regional myocardial ischemia. A 74-year-old male patient with triple-vessel coronary disease underwent OPCAB for unstable angina. During revascularization of the main right coronary artery, the hemodynamics collapsed due to regional myocardial ischemia. As soon as the distal coronary artery was perfused at a high flow rate around 80 ml/min, the hemodynamics stabilized and the operation was completed successfully. This active coronary perfusion method in OPCAB is particularly useful in cases in which regional myocardial ischemia cause hemodynamic instability.     

Hemodynamic changes during cardiac manipulation in off-CPB surgery: relevance in brain perfusion

The recent introduction of various cardiac stabilization and positioning devices, alone or in combination with deep pericardial traction sutures, has greatly increased the ability to perform beating heart surgery to accomplish multi-vessel coronary revascularization without the need for cardiopulmonary bypass (CPB), with its associated risks. However, positioning the heart for anastomosis of the circumflex (Cx) and the posterior descending artery poses a risk of inducing hypotension, impaired cardiac output, and generalized hemodynamic instability with risk of cerebral compromise. This report discusses clinical studies suggesting that compromised right ventricular diastolic filling as a result of direct ventricular compression, rather than impaired contractility or ischemia, may be the primary mechanism for producing hemodynamic instability during OPCAB surgery. Foremost among measures to minimize ventricular compression is optimal placement of the myocardial stabilization device. Secondary measures include steep Trendelenburg positioning, fluid loading, right-sided pleuro-pericardial window that allows rotation of the heart by partial herniation into the right pleural cavity, and possibly certain pharmacological agents. This report also analyzes the effect that variable degrees of hemodynamic disturbance accompanying displacement of the heart for OPCAB surgery has on endorgan perfusion and considers the effects of hypotensive agents, direct cerebral dilators, and patient-specific factors on cerebral blood flow. The role of the partial aortic occlusion clamp and risk of stroke is also considered. We conclude that for cardiac surgery patients considered at increased risk of adverse central nervous system events, direct monitoring of cerebral function and avoidance of aortic manipulation is strongly recommended.     

Analysis of hemodynamic changes during beating heart surgical procedures

BACKGROUND: Coronary artery bypass grafting on the beating heart causes significant hemodynamic compromise during displacement of the heart. The precise mechanisms causing altered hemodynamics have not been clearly understood. The purpose of this study was to define the hemodynamic changes caused by displacing the heart in patients undergoing beating heart surgical procedures. METHODS: Forty-four patients (35 men, 9 women; mean age, 64.5 +/- 9.6 years) underwent off-pump coronary artery bypass grafting. The hemodynamic variables were collected before and after positioning the heart for anastomosis of the left anterior descending, circumflex, and posterior descending coronary arteries. RESULTS: There was a significant increase in right ventricular end-diastolic pressure during positioning for all vessels, and in left ventricular end-diastolic pressure during positioning for the left anterior descending and circumflex coronary arteries. Positioning for the circumflex artery showed the largest increase of left and right ventricular end-diastolic pressure, resulting in the greatest hemodynamic compromise. CONCLUSIONS: In the clinical setting of diseased human hearts, there is a biventricular contribution to altered hemodynamics. The increase of right ventricular end-diastolic pressure in all positions suggests that the major cause of hemodynamic changes is disturbed diastolic filling of the right ventricle, especially by direct ventricular compression.     

Change in right ventricular function during off-pump coronary artery bypass graft surgery.

OBJECTIVES: Hemodynamic derangement during displacement of beating heart in off-pump coronary artery bypass graft (OPCAB) surgery might be related with right ventricular (RV) dysfunction. We evaluated RV function and hemodynamic alterations using a thermodilution pulmonary artery catheter. METHODS: The study included 30 patients undergoing OPCAB, using single pericardial suture and tissue stabilizer. A thermodilution pulmonary artery catheter for continuous monitoring of the cardiac output (CO), right ventricular ejection fraction (RVEF) and RV volume was inserted before anesthesia. The hemodynamic variables were measured after the induction of anesthesia, 5 min after the heart was positioned for each coronary anastomosis and after the sternum was closed. RESULTS: There was no significant change in the RVEF and cardiac index during anastomosis of the left anterior descending artery and right coronary artery. However, the significantly reduced RVEF accompanied by an increase in RV afterload and decrease in the CO was observed during anastomosis of the obtuse marginal (OM) artery. RV volumes did not significantly change during anastomoses, though the right atrial pressure increased during anastomoses of all coronary arteries. CONCLUSIONS: The displacement of beating heart for positioning during anastomosis of the graft to OM artery caused significant derangement of RV function and decrease in CO. A thermodilution catheter continuously measuring the CO and RVEF was useful to monitor the change in RV function and volume during OPCAB.     

Evaluation of serial haemodynamic changes during coronary artery anastomoses in patients undergoing off-pump coronary artery bypass graft surgery: initial experiences using two deep pericardial stay sutures and octopus tissue stabilizer

Objective: This study was designed to evaluate the serial haemodynamic changes during coronary artery anastomoses using two deep pericardial stay sutures and octopus tissue stabilizer in patients undergoing initial experiences of off-pump coronary artery bypass graft surgery (OPCAB) using continuous cardiac output and mixed venous oxygen saturation (SvO₂) monitoring. Methods: With IRB approval, thirty patients undergoing OPCAB were studied. Pulmonary artery catheter (PAC) for continuous cardiac output and SvO₂ monitoring was inserted before anaesthesia. Haemodynamic measurements were recorded after pericardiotomy for baseline value. During each coronary artery anastomosis, haemodynamic variables were measured at 1,3,5,10, and 15 min after the application of tissue stabilizer and after the removal. Vasopressors were used to maintain mean arterial pressure (MAP) higher than 60 mmHg. Results: MAP and heart rate (HR) were maintained without significant change during the anastomoses of all three arteries. Cardiac index (CI), and SvO₂ decreased significantly after stabilizer application in all three arteries. CI was below 2.5 l/min/m² and SvO₂ was under 70% during left circumflex artery (LCX) anastomosis. The decrease in CI and SvO₂ were significantly greater during LCX anastomosis. The increase in mean pulmonary artery pressure (MPAP) and pulmonary capillary wedge pressure (PCWP) was significant only in left anterior descending artery (LAD). Central venous pressure (CVP) increased significantly during the anastomosis of all three coronary arteries. The differences in MPAP, PCWP and CVP among the three coronary arteries were not statistically significant. The highest dose of vasoconstrictor was used during LCX anastomosis. Conclusions: When the coronary anastomoses were performed with two deep pericardial stay sutures and octopus tissue stabilizer on the beating heart, CI and SvO₂ decreased significantly during all coronary artery anastomoses immediately after the stabilizer application and the degree of reduction in CI and SvO₂ increased with time, though MAP was maintained constantly. CI and SvO₂ during LCX anastomosis were consistently below normal values. Therefore close monitoring and proper managements are needed during graft anastomoses.     

前列腺素E1在老年患者非体外循环冠状动脉旁路移植术中的应用

目的探讨前列腺素E1（PGE1）对非体外循环冠状动脉旁路移植术（OPCAB）后患者的作用，以确定其疗效。方法选取我科2005年10-12月行OPCAB的老年患者40例，随机分为两组，每组20例。对照组患者接受常规治疗；PGE1组患者在返回ICU后静脉持续泵人PGE1制剂（剂量为5～20ng／kg·min），维持24-48h。于术后不同时间点监测心脏指数、体循环阻力、肺血管阻力等血流动力学指标，测量红细胞压积、凝血指数、动脉血氧分压、血清肌酐（Cr）及尿素氮（BUN）等指标，并进行比较。结果PGE1组患者术后体循环阻力和肺血管阻力均较对照组明显下降（P〈0．05），而心脏指数则显著升高（P〈0．05）。两组患者术后红细胞压积均下降，凝血功能术后当天下降、术后第1d升高，但PGE1组高凝状态较对照组明显减轻（P〈0．05）；术后两组患者的Cr和BUN水平均较术前升高，但PGE1组较对照组含量低（P〈0．05）。结论PGE1在OPCAB患者术后恢复中发挥了有益的作用。     

体外循环与非体外循环下冠脉搭桥术患者术中血液动力学的比较

目的比较体外循环(CPB)与非CPB下冠脉搭桥术患者术中血液动力学的变化。方法同期行CPB下冠状动脉搭桥术(CABG)与非CPB下冠状动脉搭桥术(OPCAB)患者各70例,分别为CABG组和OPCAB组,分别在麻醉诱导后手术开始前(术前)和术毕用Swan-Ganz导管监测血液动力学指标。结果与术前比较,两组术毕心率(HR)、平均动脉压(MAP)、肺动脉平均压(PAMP)、肺毛细血管嵌压(PAWP)、中心静脉压(CVP)及左室作功指数(LVSWI)差异无统计学意义(P>0.05),心输出量(CO)、心脏指数(CI)均升高;OPCAB组术毕心搏指数(SVI)升高,体循环阻力指数(SVRI)、肺循环阻力指数(PVRI)降低(P<0.05),CABG组术毕SVI、SVRI、PVRI差异无统计学意义(P>0.05);与CABG组比较,OPCAB组术毕SVRI、PVRI降低(P<0.05)。结论两组患者术后心功能均得到了改善,OPCAB 组在改善心功能、降低体、肺循环阻力方面,优于CABG组。