4303例不同年龄组冠状动脉旁路移植术早期疗效分析

目的 探讨不同年龄组冠状动脉旁路移植术手术效果及组间差异.方法采集单纯冠状动脉旁路移植术4 303例临床资料.按年龄分为青年组(≤45岁)、中年组(46～60岁)、低龄老年组(61～74岁)和高龄老年组(≥75岁),对各组患者术前、术中因素,术后死亡率及并发症进行比较.结果 青、中年组患者高血压史、合并轻度二尖瓣或主动脉瓣关闭不全比例、术前血清肌酐、大隐静脉与前降支吻合比例、呼吸机辅助时间、ICU停留时间低于老年组患者,而体外循环及全动脉化桥比例高于老年组患者.青、中年组患者术后死亡率(0.35%和1.52%)明显低于低龄(2.62%)和高龄老年组患者(5.45%).高龄老年组患者术后心房颤动(8.18%)和低心排综合征发生率(3.18%)最高.结论 大隐静脉与前降支吻合、年龄及体外循环是影响术后死亡的独立危险因素.冠状动脉病变支数、全动脉化桥比例、合并轻度二尖瓣关闭不全或主动脉瓣关闭不全比例及术前血清肌酐与死亡率有一定关系.术后肾功能不全可能与术前糖尿病史和术前血清肌酐水平有关.     

Increments in Circulating Homocysteine before and after Coronary Artery Bypass Surgery in Diabetic and Non-diabetic Patients

This study aims to assess total plasma homocysteine levels in diabetic and non-diabetic patients who underwent coronary artery bypass grafting (CABG) and to determine the effect of cardiopulmonary bypass (CPB) on homocysteine levels. Twenty diabetic and twenty non-diabetic patients who had CABG were enrolled in the study. Plasma samples for the assays were obtained before and after the CPB and on sixth day following the operation. Diabetic patients seemed to have higher levels of plasma total homocysteine in pre-CPB, post-CPB, and postoperative sixth day blood samples. There was a significant difference in total homocysteine levels between pre-CPB and post-CPB both in diabetic and non-diabetic patients. Although an association between the preoperative plasma total homocysteine levels and the frequency of 1-year graft occlusion could not be demonstrated, our data claims attention to the increased homocysteine levels during CPB, which sustained until the sixth day after the surgery.     

Activation of Coagulation and Fibrinolysis During Coronary Artery Bypass Grafting: A Comparison Between On-Pump and Off-Pump Techniques

Coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) is associated with intense activation of hemostatic mechanisms. But the precise knowledge of the effects of eliminating CPB in patients undergoing off-pump coronary artery bypass grafting (CABG) are not well established. The present study was carried out to compare and document the changes in selected coagulation and fibrinolysis variables in patients undergoing on-pump and off-pump CABG (OPCAB). A total of 42 patients of on-pump and 31 patients of off-pump CABG were selected for the study. Platelet count, prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), Fibrinogen and D-dimer levels were measured immediately, 24 h and 7 days after operation and compared with the baseline preoperative values. Statistical analysis was done by mixed ANOVA for repeated measures and Post-hoc tests using the Bonferroni correction, Chi square and unpaired t test. All the parameters were significantly changed (P < 0.05) with the time. Platelet counts, fibrinogen and D-dimer levels were significantly different between on-pump and off-pump CABG patients on immediate and 24 h postoperative period and attained almost same level after 7 days of operation. Fibrinogen level and platelet counts were increased after a sharp fall in the immediate post-operative period whereas D-dimer levels were persistently increased with a sharp peak of rise in the immediate post-operative period in on-pump group. On-pump surgery was associated with excessive fibrinolytic activity immediately after operation. The off-pump group demonstrated less activation of coagulation and fibrinolysis and delayed postoperative response that became almost equal to the on-pump group in the later postoperative period.     

冠状动脉搭桥术后早期心律失常相关因素分析

对冠状动脉 (简称冠脉 )搭桥术后早期心律失常的相关因素进行回顾分析 ,将 6 0例冠脉搭桥病人按术后是否发生心律失常以及手术方式分组 ,心律失常组 15例 (A组 )、非心律失常组 4 5例 (B组 ) ;常规搭桥组 39例 (Ⅰ组 ) ,非体外搭桥术组 2 1例 (Ⅱ组 )。结果 :心律失常的发生率为 2 5 .0 %。A组病人的年龄、术前射血分数 (EF)、心胸比例、搭桥支数、呼吸辅助时间、心肌阻断时间、ICU滞留时间均显著高于B组 ,但血K+ 浓度则明显降低。Ⅱ组的室性心律失常发生率、心律失常持续时间、呼吸机辅助呼吸时间、ICU滞留时间均较Ⅰ组明显降低。结论 :患者术前心功能情况、手术方式及冠脉搭桥支数、心肌阻断时间等影响心脏状况的指标与其术后心律失常的发生率有关。     

Infusion of low-dose vasopressin improves left ventricular function during separation from cardiopulmonary bypass: a double-blind randomized study

We aimed to investigate whether low-dose vasopressin administered to patients undergoing coronary artery bypass grafting (CABG) surgery with preexisting mild to moderate systolic dysfunction can produce sustained improvement in cardiac function. This double-blind randomized study was conducted in a hospital where a single anesthetic and surgical team performed elective CABG. Twenty patients aged 32-61 years who underwent elective CABG between January 2007 and December 2007 were enrolled in this study. The patients randomly received either vasopressin 0.03 IU/min (Group A) or normal saline (Group B) in equal volume for 60 min after cardiopulmonary bypass (CPB). The cardiac output, cardiac index, stroke volume index, fractional area of contraction and systemic vascular resistance index were significantly higher in Group A than in Group B. Adrenaline (mean dose: 0.06 μg/kg x min-1) was required in seven patients from Group B but in none of the Group A patients on initial separation from CPB (P< 0.05). Of the 10 patients in Group B, five required phenylepherine to maintain the mean arterial pressure (MAP) >65 mmHg, whereas none of the Group A patients required phenylephrine for MAP regulation (P< 0.05). We conclude that Infusion of low-dose vasopressin for patients with mild to moderate left ventricular systolic dysfunction during separation from CPB is beneficial for the postoperative hemodynamic profile, reduces the catecholamine doses required and improves left ventricular systolic function.     

23例冠状动脉搭桥术同时行心脏瓣膜置换术的麻醉处理

本文总结23例冠状动脉搭桥术同时行心脏瓣膜置换术的麻醉。20例术前有ST-T改变。选用对循环影响轻的麻醉方式。用大剂量芬太尼麻醉，复合异丙酚，氨氟醚维持，效果良好。术中应用硝酸甘油，硝普钠降低前后负荷。体外循环后7例低心排病人用多巴肢和10例心动过缓病人用异丙肾上腺素治疗，效果显著。     

Suppression of the inflammatory response to cardiopulmonary bypass

The inflammatory response to major surgery, especially cardiac surgery using cardiopulmonary bypass (CPB) is now a well established entity. A whole body inflammatory response can lead to severe organ dysfunction, postoperative bleeding disorders, respiratory distress syndrome and sometimes death. There is, however, controversy over various methods and their efficacy towards suppression of this response. We studied forty consecutive patients undergoing coronary artery bypass grafting (CABG) using CPB. Ten patients in group A served as control while ten patients in group B received piroxicam, a non steroidal anti-inflammatory drug (NSAID). Ten patients in group C received aprotinin, a kallikrein inhibitor and ten patients in group D underwent haemofiltration during CPB. Inflammatory response by way of increase in total white blood cell (WBC) count (p<0.007), decrease in lymphocyte count (p<0.005), increase in C-reactive protein (CRP, p <0.005) was observed in all four groups at 24 hour after CPB. A decrease in complement C3 and C4 (p<0.01) was observed in groups A and C at 24 hours after CPB. The response observed was not severe enough to cause any organ damage in any group. None of the methods studied could effectively suppress the inflammatory response to CPB but the response was altered in some way by each method.     

慢性肾功能不全合并冠心病病人行冠状动脉旁路移植术15例

目的 :探讨慢性肾功能不全合并冠心病病人行冠状动脉旁路移植术 (CABG)的安全性及可行性。　　方法 :1996年 6月至 2 0 0 1年 6月术前诊断为慢性肾功能不全合并冠心病的病人 15例。 9例在体外循环下行CABG ,6例行非体外循环心脏跳动下CABG (OPCABG)。　　结果 :9例在体外循环下手术的病人 ,术后早期肾功能指标均较术前差 ;6例行OPCABG的病人 ,术后早期肾功能较术前无明显变化。围术期腹膜透析 4例 ,血液透析 2例 ,其中 1例行术中血液透析 ,肾功能指标均有所改善 ;全组无术中死亡 ,1例术后第 3天死于多器官功能衰竭。　　结论 :术前肾功能不全的病人 ,经过适当的术式选择及积极的术中及围术期处理 ,大多可以安全渡过肾功能衰竭关 ,接受CABG ,达到改善症状延长生命的目的。     

微创心脏手术中周围体外循环120例总结

目的 :总结分析不开胸的体外循环及心肌保护 12 0例。方法 :对 12 0例胸腔镜心脏手术所采用的不开胸体外循环及心肌保护技术进行回顾分析。全组均采用股动、静脉或加上腔静脉插管建立体外循环 ,右侧胸壁打孔胸腔镜下长阻闭钳阻闭升主动脉 ,冷晶体停跳液顺行灌注保护心肌。结果 :全组无手术死亡病例。术中泵压偏高 8例 ,灌注流量不足 3例 ,术后血红蛋白尿 13例 ,肝功能损害 7例 ,术后右下肢轻度肿胀 3例 ,右下肢局部麻木、疼痛 4例 ,右股动脉处可闻及杂音 3例。结论 :周围体外循环及心肌保护安全、可行。并发症以血红蛋白尿 ,肝功能损害 ,股动、静脉损伤为常见。     

The risk of stroke following CABG: one possible strategy to reduce it?

OBJECTIVE: Stroke remains a devastating complication of coronary artery bypass grafting (CABG): we evaluated whether a more aggressive diagnostic and therapeutic approach can reduce its incidence. METHODS: Between January 1998 and January 2002, 1388 consecutive patients underwent isolated on pump CABG with blood cardioplegia. Among the first 627 patients (Group A), Echo-Doppler study (DS) was performed only in selected patients (58) with history of cerebrovascular disease (CVD) and/or carotid bruit; in 761 patients (Group B), DS was performed routinely. Carotid endarterectomy (CEA) was performed in 45 patients in Group A associated to CABG during cardiopulmonary bypass (CPB) and in 90 patients in Group B under local anaesthesia before CABG. Brain CT scan was performed in all cases with postoperative neurological symptoms. RESULTS: The two groups were homogeneous for age, sex, associated diseases, history of CVD, number of graft and CPB time. There were no differences in terms of hospital mortality between Group A (22/627: 3.5%) and Group B (21/761: 2.75%); p=0.5. Postoperative stroke was observed in 24/627 (3.82%) patients of Group A and in 2/761 (0.26%) of Group B (p<0.001). Hospital mortality for stroke was higher in Group A (12/627: 1.91%) than in Group B (0/761; p<0.001) as well as the incidence of non-fatal stroke (Group A 12/627: 1.91% versus Group B 2/761: 0.26% p=0.006). CONCLUSIONS: Preoperative DS, performed in all cases of CABG, followed by CEA under local anaesthesia in patients with critical carotid stenosis reduces the incidence of postoperative stroke.     

Clinical experience of coenzyme Q10 to enhance intraoperative myocardial protection in coronary artery revascularization

Seventy-eight patients undergoing coronary artery bypass grafting (CABG) were compared retrospectively to evaluate whether pretreatment with coenzyme Q₁₀ (CoQ) is effective in preventing left ventricular depression in early reperfusion following CABG. CoQ (5 mg/kg, intravenously) was given to 60 patients, 2 hours prior to the onset of cardiopulmonary bypass (CPB). CABG was performed using saphenous vein under CPB associated with cold cardioplegia in the standard fashion. Heart rate, mean arterial pressure, and cardiac index showed no significant difference between the CoQ and control groups. However, left ventricular stroke work index was significantly elevated at 6 and 10 hours of reperfusion following CABG in the CoQ-treated group compared with the controls. Serum MB-CK was lower at 0 and 6 hours of reperfusion in the CoQ group compared with the controls. These results suggest that pretreatment with intravenous CoQ is effective in preventing left ventricular depression in early reperfusion and in minimizing myocardial cellular injury during CABG followed by reperfusion.     

Trimetazidine reduces oxidative stress in cardiac surgery.

BACKGROUND: Trimetazidine is an anti-ischemic agent that is used to treat angina and it has cardioprotective effects without inducing any significant hemodynamic changes. It inhibits the long-chain mitochondrial 3-ketoacyl coenzyme A thiolase enzyme in the myocyte and can improve cardiac mitochondrial metabolism, as well as scavenge free radicals. The aim of this double-blind prospective randomized study was to investigate the effect of preoperative use of trimetazidine on the reduction of oxidative stress during coronary artery bypass grafting (CABG) under cardiopulmonary bypass (CPB). METHODS AND RESULTS: The study group (group T) and the control group (group C) each comprised 12 patients. Pretreatment began 2 weeks before CABG with trimetazidine (60 mg/day po); the control group did not receive any medication. Serial blood samples were collected before and after CPB for measurement of the serum concentrations of these major endogenous antioxidant enzyme systems, which are markers for oxidative degradation of the cellular membranes; postoperative levels were significantly different between the groups (p<0.05). There were no significant difference in hemodynamic values. CONCLUSION: The findings suggest that pretreatment with trimetazidine alleviates malondialdehyde production and preserves endogenous antioxidant capacity during CABG with CPB and cardioplegic arrest.     

Efficacy of the phosphodiesterase inhibitor enoximone in complicated cardiac surgery

Acute myocardial dysfunction during cardiac surgery involves various pathophysiologic mechanisms such as reduction in myocardial contractility and an increase in afterload induced by peripheral vasoconstriction. In 30 consecutive patients undergoing coronary artery bypass grafting (CABG) and ten consecutive patients with aortic valve replacement (AVR), in whom therapy with catecholamines was expected to be necessary during and after weaning from cardiopulmonary bypass (CPB) on the basis of a retrospective study ("control" patients), 1.0 mg/kg of the phosphodiesterase (PDE) inhibitor enoximone was administered ten minutes prior to weaning from bypass (enoximone group). In eight CABG and four AVR patients weaning was possible without further pharmacologic support. Significantly less epinephrine was used in enoximone pretreated patients (8.8 +/- 3.0 micrograms/min) than in the control patients (21.4 +/- 4.4 micrograms/kg). The use of additional vasodilators was significantly less pronounced in these patients as well. Seven CABG and four AVR patients in the enoximone group needed additional vasoconstrictors (norepinephrine) to counteract marked, unwanted decrease in peripheral vascular resistance with a decrease in mean arterial pressure (MAP). Hemodynamic monitoring revealed a higher level in heart rate in the control patients with arrhythmia in seven of the CABG patients: MAP, right atrial pressure, cardiac index, and pulmonary capillary wedge pressure were without significant differences between the groups. Pulmonary artery pressure and TSR, however, increased more in the control group, indicating an increase in right and left ventricular afterload. The results of this study demonstrate that patients at risk of circulatory failure during or after weaning from CPB profit from pretreatment with PDE-III inhibitor enoximone due to a reduction in catecholamines and an improvement in hemodynamics.     

Off-pump coronary artery bypass graft surgery is standard of care: Where do you stand?

The cardiopulmonary bypass (CPB) has allowed the establishment of coronary artery bypass graft surgery (CABG) to be a safe and effective treatment for patients with ischemic heart disease. However, the concern that CPB may be responsible for CABG-related morbidity has been raised, and it has been suggested that CABG itself would be safer without CPB. The development of commercially available cardiac stabilization devices resulted in several large, nonrandomized retrospective case series. The studies demonstrated that CABG can be performed safely without CPB (off-pump surgery), and suggested that there are benefits compared with conventional CABG. However, the randomized controlled studies published to date have been, as a whole, unable to conclusively demonstrate advantages of off-pump CABG. The results of these randomized studies are likely responsible for the failure of off-pump CABG to become established as the standard of care.     

Combination of autologous Transfusion and Retrograde Autologous Priming Decreases Blood Requirements

In a prospective study, 60 patients posted for coronary artery bypass graft (CABG) surgery on cardiopulmonary bypass (CPB) were assigned to 2 groups of 30 each. (group A =combination of acute normovolaemic haemodilution (ANH) and retrograde autologous priming (RAP), group B=control). The aim was to investigate whether retrograde autologous priming reduces haemoditution as compared to control cases. Patients who had a history of previous cardiac surgery and patients with severe left ventricular dysfunction, were excluded. Group A patients were subjected to pre-CPB intraoperative autologous blood collection prior to heparin administration. Heparin was given (300IU/Kg) and the aorta was cannulated. In addition, prior to bypass, if the patients had a systolic BP>100 mm Hg, 300cc of their blood was withdrawn in a retrograde manner via aortic cannula into the CPB circuit up to the arterial filter, while the 'displaced' asanguinous prime was diverted into a transfer bag. The total bank blood (whole blood) used intra-op was 26 units in the study group [mean 0.86 unit per patient] versus 52 units in the control group (mean 1.73 units per patient) (P<0.001). Blood components and products were not used in this study. The average fall in haematocrit (Hct) on CPB was 27.03% in the study group versus 39.5% in the control group (P < 0.001). Thus retrograde autologous griming in combination with autologus transfusion significantly reduces the need for bank blood.     

Does off-pump coronary artery bypass grafting really preserve renal function?

It is well known that the use of cardiopulmonary bypass (CPB) influences renal function and occasionally results in renal failure following cardiac surgery. Coronary artery bypass grafting (CABG) without CPB may avoid this and preserve the perioperative renal function. The present study enrolled 52 patients undergoing CABG without CPB (OPCAB group) and matched them for renal function and prognostic variables with 53 patients undergoing conventional CABG (CABG group). Perioperative renal function and early clinical results were assessed. The OPCAB group had significantly less increase in creatinine levels (0.16 +/- 0.05 vs 0.45 +/- 0.06 mg/dl; p = 0.01) and greater creatinine clearance (81.6 +/- 7.3 vs 56.3 +/- 4.8ml/min; p = 0.01) postoperatively. Postoperative recovery of free water clearance was more prompt in the OPCAB group. The duration of intubation and intensive care unit stay was significantly shorter, and the creatine kinase-MB release and blood transfusion requirements were significantly less in the OPCAB group. The OPCAB technique preserved glomerular filtration rate and prevented the increase in creatinine levels. The results suggest that the technique enables earlier patient recovery and gives superior renal protection compared with conventional CABG.     

Increments in circulating homocysteine before and after coronary artery bypass surgery in diabetic and non-diabetic patients

This study aims to assess total plasma homocysteine levels in diabetic and non-diabetic patients who underwent coronary artery bypass grafting (CABG) and to determine the effect of cardiopulmonary bypass (CPB) on homocysteine levels. Twenty diabetic and twenty non-diabetic patients who had CABG were enrolled in the study. Plasma samples for the assays were obtained before and after the CPB and on sixth day following the operation. Diabetic patients seemed to have higher levels of plasma total homocysteine in pre-CPB, post-CPB, and postoperative sixth day blood samples. There was a significant difference in total homocysteine levels between pre-CPB and post-CPB both in diabetic and non-diabetic patients. Although an association between the preoperative plasma total homocysteine levels and the frequency of 1-year graft occlusion could not be demonstrated, our data claims attention to the increased homocysteine levels during CPB, which sustained until the sixth day after the surgery.     

心肌肌钙蛋白I测定对判定体外循环心内直视手术心肌损伤的价值

目的探讨心肌肌钙蛋白I(cTnI)的测定对体外循环心内直视手术心肌损伤的判定价值。方法40例心脏瓣膜置换手术患者随机分为两组,冷晶体停跳液组(A组),温血停跳液组(B组),每组20例,分别于围术期多时点采取中心静脉血,测定血清cTnl、CK及CK—MB的水平。结果术前两组患者的cTnI、CK及CK—MB水平均在正常范围,开放主动脉后1h至术后24h达峰值,其后缓慢下降。术后24h、48h B组cTnI水平明显低于A组(P＜0．05)。CK—MB在开放主动脉后1hB组低于A组(P＜0．05)。cTnI峰值浓度与主动脉阻时间呈直线正相关(P＜0．05)。结论cTnI判定心内直视手术围术期心肌损伤的敏感性及特异性明显优于CK、CK—MB,对围术期心肌缺血损伤的诊断、预后及心肌保护效果的评价具有重要的临床价值。     

Levosimendan for weaning from cardiopulmonary bypass after coronary artery bypass grafting

BACKGROUND: Although cathecholamines are well-established agents of myocardial support during weaning from cardiopulmonary bypass (CPB), there has been little experience with a new inotropic agent, levosimendan. Our aim was to present our experience with levosimendan usage in patients manifesting failure-to-wean from CPB after coronary artery bypass grafting (CABG) when conventional inotropic and intraaortic balloon counterpulsation (IABP) therapies proved to be insufficient. METHODS: Fifteen patients undergoing CABG received levosimendan as a loading dose of 12-24 microg/kg over 10 min, followed by a continuous infusion of 0.1-0.2 microg/(kg min) for 24h. Hemodynamic measurements were performed at baseline and at 1, 24 and 48 h postoperatively. RESULTS: Mean patient age was 63.2+/-2.2 years. CPB time was 149.7+/-19.5 min, while cross-clamp time was 67.8+/-10.5 min. All patients showed evidence of hemodynamic improvement with the start of levosimendan infusion and 14 patients (93.3%) were successfully weaned from CPB. Eight patients (53.3%) experienced significant increases in cardiac index and blood pressure leading to a lessening of the need for catecholamine support. Five patients (33.3%) were lost postoperatively in the ICU. CONCLUSION: Levosimendan appears to be useful in failure-to-wean from CPB after cardiotomy when conventional inotropic therapy proves inadequate.     

A Comparison of Hemostatic Parameters in Hypothermic Versus Normothermic Cardiopulmonary Bypass

Ten patients who underwent PCPS (group A) at our institution were evaluated for hemostatic abnormalities and compared to an age matched population undergoing open CPB (group B) to study the effects of CPB independent of the effects of hypothermia. Both groups had hemostatic parameters measured prior to, 1 hour after, and 16–24 hours following completion of the procedure. The mean duration of perfusion for group A was 53.7 ± 13.5 minutes and group B 108.1 ± 26.5 minutes (P < 0.0001). There were no significant differences in hemoglobin, platelet count, coagulation factors, and tests of in vitro platelet function between groups A and B at the different time points. While bleeding times for group B returned to baseline within an hour following bypass, they remained significantly prolonged in group A 24 hours later (P = 0.02). Conclusion: Normothermic bypass used during PCPS results in platelet function abnormalities similar to open hypothermic CPB suggesting the dominant role of the membrane oxygenator over hypothermia in inducing the platelet dysfunction .