非体外循环下冠状动脉旁路移植术

目的 总结110例非体外循环心脏跳动下冠状动脉旁路移植术经验，探讨其手术适应证、优缺点及手术方法。方法 常温、全身麻醉，胸正中切口，非体外循环心脏跳动下，应用特殊心表固定器行冠状动脉旁路移植术，平均搭桥3．9支，血管桥为乳内动脉、大隐静脉及桡动脉。结果 全组无手术死亡，术后心绞痛症状消失。手术时间平均为210min，术后气管插管时间平均为4．8h。术后住院时间平均为10d，住院费用平均为4．4万元。其中3例术中出现不可逆血压过低、室颤而转为体外循环冠状动脉旁路移植术。结论 非体外循环心脏跳动下冠状动脉旁路移植术是一种安全、有效的治疗方法。特别适合于老年及心功能差的患者，可减少体外循环并发症，缩短术后住院时间，降低住院费用，但不能完全替代体外循环旁路移植术。     

Off-pump coronary artery bypass grafting in two renal transplant patients

Coronary artery disease is a critical problem for a renal transplant patient. This paper reports offpump coronary artery bypass grafting (OPCABG) in two cases after renal transplantation. The first, a 65-year-old woman, experienced chest pain 5 years after a renal transplantation. Coronary angiography (CAG) revealed stenosis of the left anterior descending artery (LAD) and the first diagonal artery (DB1). OPCABG [left internal thoracic artery (LITA) to DB1 and LAD] was performed. The second, a 67-year-old man, underwent percutaneous coronary intervention in the LAD 10 years ago. He experienced chest pain 2 years after a renal transplantation. CAG revealed restenosis of LAD. OPCABG (LITA to LAD) was performed. The patients’ postoperative course was uneventful. OPCABG for a renal transplant patient was safe and useful since it is a less invasive procedure and easily managed perioperatively.     

Off-pump coronary artery bypass grafting attenuates proinflammatory markers

Objective: Cardiac surgery with cardiopulmonary bypass (CPB) has been considered the main causative factors of postoperative inflammatory reactions. The aim of this study was to compare surrogate markers of the proinflammatory response in patients who underwent coronary artery bypass grafting (CABG) with or without CPB. Methods and Results: Twenty patients undergoing first-time CABG were enrolled in the study, 10 with and 10 without CPB. Blood samples were drawn at the following times: at the anesthetic induction, the end of surgery, and thereafter at 12 and 24 hours postoperatively. Neutrophil elastase, interleukin (IL)-6 , and serum soluble Fas were chosen to evaluate the extent of the systemic inflammatory response. The groups were similar in terms of age, gender ratio, number of grafts per patient. There were no operative mortality or serious postoperative complications. Two of each group received blood transfusion postoperatively. Neutrophil elastase showed a significantly higher value in the on-pump group compared with the off-pump group at the end of surgery. Soluble Fas level showed a higher value at the end of surgery compared with baseline, while it had no significant changes in the off-pump patients. IL-6 levels in the on-pump group were consistently higher compared to the off-pump group but showed no statistically significant differences between the groups. Conclusion: Compared with off-pump CABG, on pump CABG induced higher serum levels of proinflammatory markers including neutrophil elastase and soluble Fas.     

Off-pump versus on-pump coronary artery bypass surgery and postoperative pulmonary dysfunction

OBJECTIVE: To investigate how off-pump coronary artery bypass grafting (CABG) affects postoperative pulmonary function when compared with on-pump CABG. DESIGN: Prospective clinical study. SETTING: University-affiliated teaching hospital. PARTICIPANTS: Adult patients (n = 39) undergoing elective coronary artery bypass surgery with or without cardiopulmonary bypass. INTERVENTIONS: Two groups of patients were compared: 19 consecutive patients undergoing off-pump CABG surgery and 20 consecutive patients undergoing conventional CABG surgery. MEASUREMENTS AND MAIN RESULTS: Pulmonary function tests (flow volume loops and lung volumes with plethysmography) were done preoperatively and 72 hours postoperatively. Arterial blood gases and PaO2/FIO2 were measured at various stages. Sequential chest x-rays were obtained and evaluated for pleural changes, pulmonary edema, and atelectasis. In both groups, PaO2/FIO2 ratios decreased progressively throughout the perioperative period, with no significant differences between the groups at any stage during the study. There was a significant decline in postoperative pulmonary function tests in both groups, but there was no difference between groups at 72 hours postoperatively. No differences were found in the time to extubation, atelectasis scores, or postoperative complications. CONCLUSIONS: Off-pump CABG does not confer major protection from postoperative pulmonary dysfunction compared with CABG surgery with CPB. Strategies for minimizing pulmonary impairment after CABG surgery should be directed to factors other than the use of CPB.     

Off-pump coronary artery bypass combined with abdominal aortic aneurysm repair in an 88-year-old male

We present the case of an 88-year-old patient who underwent off-pump coronary artery bypass using an aortic connector followed by repair of an abdominal aortic aneurysm to reduce surgical invasiveness. This approach merits consideration for high-risk patients.     

Off-pump coronary artery bypass grafting in a patient with liver cirrhosis

We report a case of unstable angina pectoris and alcohol-related Child-Pugh class B cirrhosis. The patient was a 60-year-old man who was admitted to hospital with chest pain. He had previously been diagnosed to have Child B cirrhosis due to alcoholic liver dysfunction at 58 years of age. He also had experienced ruptured esophageal varices, moderate ascites, and hyperammonemia. We performed percutaneous catheter intervention; however, he developed re-stenosis in the right coronary artery, and progression in the disease in other coronary arteries. We then performed coronary artery bypass grafting on the beating heart without cardiopulmonary bypass. He was discharged on the 13th postoperative day without any complications. This case demonstrated that off-pump coronary artery bypass grafting was safe for such a patient.     

Early results of off-pump coronary artery bypass

Objective: The purpose of this study is to compare the operative results of off-pump coronary artery bypass (OPCAB) and on-pump (conventional) coronary artery bypass (CCAB), to clarify qualitative problems and whether OPCAB is less invasive or not. Methods: OPCAB was consecutively performed in 63 patients and CCAB in 63 patients between July 1998 and December 2003. Results: The mean number of bypass grafts was 2.43 ±0.82 in the OPCAB group and 2.70±0.71 in the CCAB group (p=0.096). In-hospital mortality was 0% in the OPCAB group and 3.2% in the CCAB group. The incidence of perioperative myocardial infarction was 0% in the OPCAB group and 3.2% in the CCAB group. The incidence of postoperative major complications was significantly lower in the OPCAB group than in the CCAB group (OPCAB group=4 complications, CCAB group=13 complications). Cerebrovascular accidents occurred in 1.6% of patients in both groups. The incidence of sternal infection or mediastinitis was 0% in the OPCAB group and 3.2% in the CCAB group. The early patency rate of graft was 94.0% in the OPCAB group and 92.8% in the CCAB group, and was not significantly different (p=0.822). Conclusion: Operative mortality and major complications after surgery in OPCAB were lower than that in CCAB. The early patency rate in OPCAB was as good as that in CCAB. It is considered that OPCAB is less invasive and the quality of bypass in OPCAB is as good as that in CCAB.     

Off-pump coronary artery bypass grafting: A single center experience

Background Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) is gaining popularity as an effective alternative to conventional CABG using cardiopulmonary bypass. With the advent of mechanical tissue stabilization systems and intra coronary shunts the technique of off-pump CABG (OPCAB) is now applicable to revascularize the patients with multi-vessel disease. Methods A total of 293 patients underwent surgical myocardial revascularization without cardiopulmonary bypass between July 1996 and October 2000 at our hospital. Of these, 245 patients received 2 or more grafts: two in 193 patients, 3 in 46 patients and 4 in 7 patients. A mechnical tissue stabilization system (CTS or Octopus II/III) was used in all patients. In majority of the patients intra coronary shunts were also used. A total of 550 distal anastomoses were made and the vessels grafted were LAD (n=245), diagonal (n=90), ramus intermedius (n=16), obtuse marginal branches (n=58), distal right coronary artery (n=88) and posterior descending artery (n=52). Results There was no incidence of perioperative myocardial infarction. Three patients had transient ST segment elevation postoperatively which was normalized in the first few hours. Hospital mortality was 0.4%. No patient needed reexploration for bleeding. No patient had neurological event or pulmonary problems. All these patients except one were discharged from the hospital between 6 and 9 days. Conclusion In selected patients multi vessel OPCAB is a safe and reproducible technique and the mechanical tissue stabilization systems have made the procedure less difficult to perform. Its usefulness is more pronounced in high risk patients with comorbidities and the patients who undergo this procedure are free from major complications.     

The superiority of pulmonary function after minimally invasive direct coronary artery bypass

OBJECTIVE: We determined whether minimally invasive direct coronary artery bypass (MIDCAB) leads to excellent postoperative pulmonary function, and which contributes more to this--minithoracotomy or avoidance of cardiopulmonary bypass. METHODS: Pulmonary function 1 week before and 2 weeks after surgery was evaluated in 8 patients undergoing MIDCAB (Group M), 10 undergoing off-pump coronary artery bypass (Group O), and 12 undergoing conventional coronary artery bypass grafting (Group C). Parameters were adjusted by their predicted values and postoperative values were expressed as a ratio to preoperative ones. RESULTS: Only Group M maintained postoperative vital capacity and forced expiratory volume in 1 second close to the preoperative level and thus, showed significantly better recovery than Groups O and C. No significant difference was seen between Groups O and C. CONCLUSIONS: MIDCAB provides better recovery of pulmonary function early postoperatively than other procedures thanks to minithoracotomy rather than avoidance of cardiopulmonary bypass.     

Surgical considerations in off-pump coronary artery bypass grafting

Off pump coronary artery bypass grafting remains an important technique particularly in the care of high-risk patients. Consistently successful adoption of this technique requires a cooperative team approach and standardization across all phases of patient care. This review describes our approach to off pump coronary surgery.     

Off-pump quintuple coronary artery bypass grafting for situs inversus totalis

Dextrocardia associated with situs inversus totalis is a rare condition. A 49-year-old man with dextro-cardia and situs inversus totalis underwent off-pump quintuple coronary artery bypass grafting using bilateral internal thoracic arteries and bilateral radial arteries. The operative technique was similar to that of off-pump coronary artery bypass grafting for situs solitus. His postoperative recovery was uneventful.     

Off-pump coronary artery bypass surgery: physiology and anaesthetic management

Increasing interest is being shown in beating heart (off-pump)coronary artery surgery (OPCAB) because, compared with operationsperformed with cardiopulmonary bypass, OPCAB surgery may beassociated with decreased postoperative morbidity and reducedtotal costs. Its appears to produce better results than conventionalsurgery in high-risk patient populations, elderly patients,and those with compromised cardiac function or coagulation disorders.Recent improvements in the technique have resulted in the possibilityof multiple-vessel grafting in all coronary territories, witha graft patency comparable with conventional surgery. Duringbeating-heart surgery, anaesthetists face two problems: first,the maintenance of haemodynamic stability during heart enucleationnecessary for accessing each coronary artery; and second, themanagement of intraoperative myocardial ischaemia when coronaryflow must be interrupted during grafting. The anaesthetic techniqueis less important than adequate management of these two majorconstraints. However, experimental and recent clinical datasuggest that volatile anaesthetics have a marked cardioprotectiveeffect against ischaemia, and might be specifically indicated.OPCAB surgery requires team work between anaesthetists and surgeons,who must be aware of each other’s constraints. Some surgicalaspects of the operation are reviewed along with physiologicaland anaesthetic data. Br J Anaesth 2004; 92: 400–13     

Off-pump coronary artery bypass grafting in a patient with beh?et’s disease

We report the case of a 58-year-old man with Beh?et’s disease who developed chest pain. Coronary angiography showed severe triple-vessel disease, and the patient was transferred to our department for urgent coronary artery bypass grafting. Because of the risk of anastomotic leakage or pseudoaneurysm formation, we performed off-pump coronary artery bypass grafting with the aortic no-touch technique. Postoperative coronary angiography showed that all the grafts were patent and no anastomotic pseudo-aneurysms were observed. Pathological examination of the right internal thoracic artery specimen revealed mild intimal thickening and disruption of elastic fibers in the medial layer, both of which are characteristics of Beh?et’s disease. These findings indicated that the patient must be monitored carefully for postoperative pseudoaneurysm formation.     

Off-pump coronary artery bypass grafting for spontaneous coronary dissection in a 26-year-old patient two weeks post-partum: a case report and review

Spontaneous coronary artery dissections are an infrequent cause of myocardial infarction and have been reported in late stages of pregnancy and in the puerperium phase. We report a case of a 26-year-old post-partum woman who was diagnosed with a spiral coronary dissection of the left anterior descending artery, with a compromised diagonal branch. She underwent an emergent surgical revascularization without the use of cardiopulmonary bypass. The patient's in-hospital clinical course, prognosis, treatment, and potential etiologies are discussed.     

Anaesthesia for off-pump coronary artery bypass grafting

Achieving surgical revascularization of the heart, while avoiding the insult of cardiopulmonary bypass, is particularly desirable in specific high-risk patient groups. The relatively recent advances in surgical technique allowing high-quality grafting without mechanical arrest have led to an increase in popularity of off-pump coronary artery bypass surgery. Nonetheless, operating on the beating heart, manipulating it and purposely inducing ischaemia, invariably has significant haemodynamic consequences which must be carefully yet aggressively managed. To compound the situation, the intraoperative monitoring typically employed to evaluate cardiac function, such as electrocardiography and echocardiography, are of limited efficacy at crucial moments in the procedure. It is therefore essential that the anaesthetist is able to assimilate information from a multitude of sources in order to safely navigate the patient through a period of continually changing cardiovascular stress.     

微创冠状动脉旁路移植术处理前降支病变的围术期结果

目的研究胸腔镜辅助下经左胸小切口微创直视下冠状动脉旁路移植术(minimally invasive direct coronary artery bypass grafting,MIDCAB)处理前降支病变的围术期结果及其安全性。方法回顾性分析2014年5月至2018年10月在我院接受MIDCAB 92例患者的临床资料,其中男72例(78.26%),年龄42~78(61.29±7.48)岁,女20例(21.74%),年龄30~80(61.30±12.26)岁。分析围术期并发症发生率、血制品使用情况、左心功能变化情况、呼吸机使用时间、住ICU时间及住院时间等指标。结果2例(2.17%)患者中转正中开胸手术,5例(5.43%)术中输入血液制品,2例(2.17%)二次开胸止血,4例(4.34%)术后低氧血症,1例(1.08%)再次气管插管。呼吸机使用时间3~227(22.35±35.39)h,住ICU时间16~777(78.85±108.62)h,术后住院时间2~36(8.86±6.05)d。住院死亡1例(1.08%)。结论MIDCAB处理前降支病变具有较好的围术期结果,尤其适用于孤立性前降支病变,可缩短术后呼吸机使用时间、减少血液制品使用、缩短住ICU时间及住院时间。     

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.     

Anaesthesia for off-pump coronary artery bypass grafting

Achieving surgical revascularization of the heart, while avoiding the insult of cardiopulmonary bypass, is particularly desirable in specific high-risk patient groups. The relatively recent advances in surgical technique allowing high-quality grafting without mechanical arrest have led to an increase in popularity of off-pump coronary artery bypass surgery. Nonetheless, operating on the beating heart, manipulating it and purposely inducing ischaemia, invariably has significant haemodynamic consequences which must be carefully yet aggressively managed. To compound the situation, the intraoperative monitoring typically employed to evaluate cardiac function, such as electrocardiography and echocardiography, are of limited efficacy at crucial moments in the procedure. It is therefore essential that the anaesthetist is able to assimilate information from a multitude of sources in order to safely navigate the patient through a period of continually changing cardiovascular stress.     

Perioperative myocardial infarction in patients undergoing off-pump coronary artery bypass grafting

Two patients in whom myocardial infarction in the inferior wall occurred after off-pump coronary artery bypass grafing (OPCAB) are described. In both patients, the right coronary artery had no critical lesion and was not grafted. There was no ischemic episode during operation. Coronary artery spasms and/or intracoronary thrombus formation may have been causes of these events. To our knowledge, this is the first report on perioperative myocardial infarction in OPCAB.     

Impact of off-pump coronary artery bypass surgery on postoperative renal dysfunction: current best available evidence

SUMMARY:   Renal dysfunction is a serious complication after coronary artery bypass surgery with cardiopulmonary bypass. Cardiopulmonary bypass-related non-pulsatile flow, hypothermia, haemolysis, systemic inflammatory reactions and emboli are mentioned as possible causes for this postoperative renal dysfunction. In an attempt to avoid these deleterious effects of cardiopulmonary bypass, off-pump coronary artery bypass surgery has been rediscovered. Resurgence of interest in off-pump coronary artery bypass surgery is associated with the expectation that avoiding deleterious effects of the cardiopulmonary bypass leads to better outcomes and possibly decreased costs and resource use. We are currently practising in an era of evidence-based medicine that mandates the prospective randomized controlled trial as the most accurate tool for determining a treatment benefit compared with a control population. The present review article attempts to evaluate the current best available evidence from randomized controlled trials on the impact of off-pump coronary artery bypass surgery on postoperative renal dysfunction.