心瓣膜置换术同期行冠状动脉旁路移植术患者长期预后的危险因素探讨

目的 探讨影响心瓣膜置换术同期行冠状动脉旁路移植术(CABG)患者长期预后的危险因素.方法 57例同期行心脏瓣膜置换术和冠状动脉旁路移植术的患者,同行CABG和主动脉手术13例,同行CABG和双瓣膜手术16例,同行CABG和二尖瓣手术28例;移植血管(1.97±1.36)支.通过随访获取数据,对潜在危险因素先用Cox比例风险模型进行单变量分析,再将有统计学意义(P＜0.05)的危险因素纳入Cox多变量回归.结果 失访2例,随访55例,平均随访时间(57.37±13.98)个月,随访期间共7例死亡;高龄(年龄＞70岁)、术前合并糖尿病、有心肌梗死史、慢性肺疾病和左心室射血分数≤40％为影响心瓣膜置换术和CABG同行患者长期预后的独立危险因素.结论 高龄、术前合并糖尿病、有心肌梗死史、有慢性肺疾病和左心室射血分数过低(≤40％)是影响两类手术同行患者长期预后的危险因素.     

影响冠状动脉旁路移植术加心瓣膜手术患者远期预后的危险因素分析

目的探讨影响行冠状动脉旁路移植术（CABG）加心瓣膜手术患者远期预后的危险因素。方法 2003年1~10月北京阜外心血管病医院共收治冠状动脉粥样硬化性心脏病合并心瓣膜疾病患者68例,纳入研究66例（院内死亡2例）,男23例,女43例;年龄50~76岁（61.33±6.60岁）。行CABG＋主动脉瓣手术19例,CABG＋二尖瓣手术32例,CABG＋双瓣膜手术15例;移植血管1.79±1.18支。先将各变量分别进行Cox风险模型单变量分析,再将所有有统计学意义的变量同时纳入Cox风险模型多变量分析。结果随访65例,随访时间50.65±17.98个月,随访期间死亡11例,其中死于胃癌2例,抗凝并发症脑出血1例,心源性猝死4例和心力衰竭4例。失访1例。Cox风险模型多变量分析结果显示：左心室射血分数（LVEF）≤40%（RR=5.960,P=0.010）、术前有糖尿病史（RR=7.170,P=0.004）是影响患者术后远期预后的独立危险因素。结论 LVEF和术前有糖尿病史是影响CABG加心瓣膜手术患者远期预后的危险因素,术后严格控制血糖和提高心功能能改善患者的远期预后。     

新疆地区心脏瓣膜置换术后死亡危险因素分析

目的分析新疆地区心脏瓣膜置换术后患者在院死亡的危险因素。方法回顾性分析2011年5月至2014年3月新疆医科大学第一附属医院心脏外科施行心脏瓣膜置换术214例患者的临床资料,其中男96例、女118例,年龄(49.91±13.27)岁。根据术后是否死亡将患者分为2组(死亡组21例、存活组193例),分析围手术期死亡的危险因素。结果全组在院死亡21例(9.81%),2组患者在术前凝血酶原时间(PT)、左心室射血分数(LVEF)≤50%、术前心功能Ⅳ级、肺动脉压力60 mm Hg、体外循环时间≥2 h、是否合并冠心病、肾功能不全方面差异有统计学意义(P0.05)。Logistic回归分析表明,术前PT缩短、肺动脉压力60 mm Hg、心功能Ⅳ级、LVEF≤50%为心脏瓣膜置换术后在院死亡的独立危险因素。结论新疆地区患者心脏瓣膜置换术后在院死亡的独立危险因素为术前PT缩短、肺动脉压力60 mm Hg、心功能Ⅳ级、LVEF≤50%,对于合并有上述危险因素的患者,应提高警惕,积极调控危险因素后再行外科手术。     

左心室巨大室壁瘤手术治疗的中远期随访研究

目的了解左心室巨大室壁瘤手术治疗的中、远期效果. 方法采用多次信访、电话随访和门诊复查相结合的方法, 对58例左心室巨大室壁瘤行手术治疗后生存的56例患者中的49例进行了随访,随访率87.5% ,随访时间(47.6±22.4)个月,随访时间最长者90.0个月. 结果患者随访期内死亡10例,5年生存率为63.7%.术后患者左心室舒张末径有明显缩小;术后29.0个月左心室射血分数与术前相比,有显著提高.所有患者均无再次心肌梗死发生,心绞痛复发6例,程度较术前减轻.NYHA心功能分级由术前的(2.5±0.7 )级转为(1.3±0.5)级.统计分析显示,左心室舒张末径大于70 mm 及左心室射血分数小于35%,为独立相关危险因素. 结论左心室巨大室壁瘤手术治疗患者,中、远期疗效较好,绝大部分无心绞痛发生,生活质量提高,生存率与国外报道相似.     

二尖瓣成形术治疗中重度黏液样退行性二尖瓣关闭不全远期疗效的影响因素

目的 探讨并总结二尖瓣成形术治疗中、重度黏液样退行性二尖瓣关闭不全远期疗效的影响因素.方法 分析1993年1月至2008年1月261例因中、重度黏液样退行性二尖瓣关闭不全行二尖瓣成形术的患者临床资料和随访资料.结果 围术期死亡7例,生存254例,生存患者二尖瓣成形效果良好.230例随访≥36个月,平均(77.3±30.3)个月,随访率90.6％；24例失访.多因素Cox regression分析显示,年龄≥60岁、左心室射血分数＜0.50、同期行冠状动脉旁路移植术是术后远期死亡的独立危险因素；左心室射血分数＜0.50、心功能(NYHA)Ⅲ-Ⅳ级、前瓣叶脱垂是术后远期二尖瓣再次中、重度反流的独立危险因素,成形环或塑形带成形是术后远期二尖瓣再次中、重度反流的保护因素.结论 年龄≥60岁、左心室射血分数＜0.50、同期行冠状动脉旁路移植术、心功能分级Ⅲ-Ⅳ级、前瓣叶脱垂、成形环或塑形带成形等因素与中、重度黏液样退行性二尖瓣关闭不全患者二尖瓣成形术后远期不良事件密切相关.     

主动脉瓣关闭不全合并巨大左心室外科治疗的危险因素分析及远期结果

目的探讨主动脉瓣关闭不全合并巨大左心室患者外科治疗的适应证、危险因素及远期结果。方法回顾性分析了2004年3月至2012年12月共收治主动脉瓣关闭不全合并巨大左心室患者42例(左心室舒张期末内径≥70mm和左心室收缩期末内径≥50mm)的临床资料。其中男38例、女4例,年龄16~73(45.86±14.99)岁。所有患者均行主动脉瓣置换术,术前、术后1周、术后3个月行超声心动图检查,并对患者随访12~132个月,分析影响术后心功能恢复及导致死亡的危险因素。结果术后早期死亡1例,远期死亡5例。41例患者术后1周经胸超声心动图检查,左心室舒张期末内径(62.00±13.21)mm、左心室收缩期末内径(50.71±14.02)mm、左心室舒张期末内径指数(35.23±8.58)mm/m~2、左心室收缩期末内径指数(28.92±9.08)mm/m~2,与术前相比均明显减小(P0.01)。左心室射血分数(46.41%±12.4%)明显低于术前(P0.01)。术前心功能分级、射血分数、左心室舒张期末内径、左心室舒张期末内径指数是预测术后早期左心室功能恢复的预测因子。左心功能不全及室性心律失常是导致术后死亡的危险因素。术后1年、5年、10年生存率分别为92.9%、90.2%和83.8%。结论大多数主动脉瓣关闭不全合并巨大左心室患者仍有手术指征,术后疗效满意。但术前左心功能不全、室性心律失常是影响手术疗效和远期存活的危险因素。     

主动脉瓣关闭不全合并心脏射血分数低下的外科治疗

目的探索合并心脏射血分数低下的主动脉瓣关闭不全的外科治疗效果。方法回顾性分析2012年1月至2013年12月于沈阳军区总医院行心脏瓣膜置换术或心脏瓣膜成形术的主动脉瓣关闭不全合并心脏射血分数低下患者34例的临床资料,其中男27例、女7例,年龄21~74(51.03±12.06)岁。所有手术均在全身麻醉体外循环下完成。结果全组无手术死亡,体外循环时间40~155(60.92±22.89)min,主动脉阻断时间24~79(37.12±12.61)min,术后4~67(16.12±12.74)h脱离呼吸机辅助,术后住院时间8~15(11.03±2.04)d;出院前射血分数为30%~48%(41%±4%),较术前明显改善(P0.01);肺动脉收缩压33~50(38.35±4.35)mm Hg,较术前明显下降(P0.01);左心室舒张期末容积168~380(269.12±52.01)ml,较术前明显缩小(P0.01)。结论对心脏功能低下的主动脉瓣关闭不全患者可进行外科治疗,疗效满意。     

重组人脑利钠肽治疗非体外循环冠状动脉旁路移植术后撤呼吸机困难的疗效分析

目的探讨重组人脑利钠肽（rhBNP）治疗非体外循环冠状动脉旁路移植术（OPCAB）后撤呼吸机困难患者的有效性及安全性。方法回顾性分析2010年2月至2011年7月四川省人民医院接受OPCAB,术后带机时间超过48 h 20例患者的临床资料,其中男14例、女6例,年龄（64.03±12.71）岁。对20例撤机困难患者在常规治疗的基础上加用重组人脑利钠肽1.5μg/kg静脉冲击,此后以0.075μg/（kg？min）持续滴注48~72 h。比较使用重组人脑利钠肽前、后各临床指标的变化。结果围术期死亡3例（15%）,死亡原因：2例发生严重感染,1例家属放弃治疗。5例术后发生急性肾功能衰竭（ARF）,其中3例接受持续肾脏替代治疗（CRRT）;4例患者术后出现肺部感染。总体带呼吸机时间（4.31±1.95）d,使用重组人脑利钠肽（2.02±0.38）d后脱机。20例患者住ICU时间（6.23±1.87）d,住院时间（26.75±7.82）d。使用重组人脑利钠肽后左心室舒张期末内径（LVEDD）较术前明显缩小,左心室射血分数（LVEF）较术前明显增加;脑利钠肽（BNP）、中心静脉压（CVP）、血钠（Na）较术前明显降低（P〈0.05）。17例患者均进行随访,随访时间3~6个月,患者恢复良好。结论基因重组人脑利钠肽可以扩张血管、降低中心静脉压、排钠利尿、延缓心肌重塑、减轻心脏负荷、增加心脏射血分数、从而改善OPCAB患者的临床结果。     

双侧乳内动脉Y型桥冠状动脉旁路移植术中远期临床疗效分析

目的评价双侧乳内动脉Y型桥冠状动脉旁路移植术的中远期疗效,分析影响疗效的因素,提高手术的成功率。方法回顾性分析2000年1月至2004年5月165例冠心病患者术前、术后及中远期随访的临床资料,比较心功能变化。采用logistic回归分析影响死亡的危险因素。结果全组共移植血管561支,平均每例移植血管3．4支。围术期无死亡,术后发生并发症16例,包括心绞痛复发、心肌梗死、低心排血量、伤口愈合不良等,均经相应的处理治愈出院。随访160例（97％）,随访时间5．6±1．2年。随访期间死亡23例,其中心源性死亡10例,包括再次心肌梗死3例,心力衰竭4例,恶性心律失常3例;非心源性死亡13例,包括胃肠道出血4例,癌症3例,不明原因6例。发生心脏相关并发症25例,包括心绞痛复发18例,心肌梗死4例,再次手术包括冠状动脉介入治疗和冠状动脉旁路移植3例。术后左心室射血分数较术前明显提高（54％±6％vs．43％±12％）;术后1年,3年,5年实际生存率分别为98．2％±0．3％,96．2％±0．5％和90．5％±1.9％,免于心脏相关事件发生率分别为95．5％±1．2％,91．3％±2．1％和86．6％±1．5％。单因素分析显示：年龄〉65岁、糖尿病、射血分数〈30％、心功能分级（NYHA）Ⅲ／Ⅳ级和低心排血量需主动脉内球囊反搏治疗是术后发生主要心血管事件的危险因素。logistic多因素分析结果显示：年龄〉65岁（OR=11．6）、糖尿病（OR=21．4）、射血分数〈30％（OR=37．5）和心功能分级（NYHA）Ⅲ／Ⅳ级（OR=40．2）是预示晚期死亡的危险因素。结论双侧乳内动脉Y型桥冠状动脉旁路移植术能减少术后心血管相关事件的发生率,提高远期生存率。心功能分级Ⅲ／Ⅳ级、射血分数〈30％、糖尿病、年龄〉65岁是影响远期疗效的独立危险因素。     

左心室室壁瘤的外科治疗

目的评估心肌梗死后左心室室壁瘤(post-infarct left ventricular aneurysm,LVA)行左心室重建术和线性修补术的治疗效果,总结室壁瘤的外科治疗经验。方法 2004年5月至2011年12月上海交通大学医学院附属仁济医院心血管外科共收治47例LVA患者;行左心室重建术25例(男21例、女4例),线性修补术18例(男14例、女4例),直接缝闭术4例(男3例、女1例)。同期行冠状动脉旁路移植术42例。术后通过电话及门诊随访6~24个月,患者均行超声心动图复查左心室射血分数(LVEF)、生活质量及活动能力。结果左心室重建术组术后LVEF较术前明显改善(49.2%±13.6%vs.32.5%±12.9%,P0.05),线性修补术组术后LVEF同样较术前改善(47.5%±11.6%vs.36.9%±11.6%,P0.05);线性修补术组死亡1例,病死率5.5%;左心室重建术组死亡1例,病死率4.0%;直接缝闭术组无死亡;全组总病死率4.2%。结论线性修补术或左心室重建术治疗心脏室壁瘤均可取得满意效果,根据患者个体情况制订合理方案,能够最大程度恢复左心室功能,近远期治疗效果良好。     

Postoperative clopidogrel improves mid-term outcome after off-pump coronary artery bypass graft surgery: a prospective study.

OBJECTIVE: Clopidogrel decreases recurrent ischemic events and improves intracoronary stent patency. There are scarce data on the effect of short-term and long-term clopidogrel on symptom recurrence and adverse cardiac events following off-pump coronary artery bypass graft surgery (OPCAB). METHODS: Postoperative antiplatelet medication use was prospectively evaluated in 591 OPCAB patients. Clopidogrel was administered for 30 days in 186 patients and 139 received long-term clopidogrel (mean 33.6+/-12.0 months) in addition to aspirin. Follow-up was 37.7+/-13.4 months. Symptom recurrence (angina and congestive heart failure), adverse cardiac events (myocardial infarction, coronary reintervention, and sudden cardiac death), and overall mortality were prospectively recorded. Multivariate Cox regression analysis was used to evaluate predictors of end points. RESULTS: There was no difference with respect to preoperative risk factors between patient groups. In the multivariate analysis, postoperative clopidogrel independently decreased symptom recurrence (p<0.0001, OR 0.3 [0.15-0.99]; 95% CI) and adverse cardiac events (p<0.0001, OR 0.2 [0.10-0.45]; 95% CI). Clopidogrel receivers had significantly lower angina recurrence, myocardial infarction, coronary reintervention, and sudden cardiac death during follow-up. There was no difference in the incidence of end points between short-term (30 days) and long-term receivers of the drug. There were 17 bleeding complications (4 major and 13 minor) in 15 patients during the follow-up period. Of the 15 patients, 6 were on clopidogrel in addition to aspirin (1.8%) while the remaining 9 were on aspirin (3.3%) only at the time of bleeding (p=0.8). CONCLUSIONS: Clopidogrel therapy was independently associated with decreased symptom recurrence and adverse cardiac events following OPCAB. Extending clopidogrel use beyond 30 days did not have a significant effect on defined end points.     

Total arterial off-pump coronary surgery: time to change our habits?

Background

This was a single-institutional study about total arterial myocardial off-pump coronary artery bypass grafting (OPCAB) surgery.

Methods

We studied 569 multivessel coronary artery bypass patients who underwent total arterial OPCAB (42.7% of total OPCAB and 42.4% of total coronary artery bypass grafting operations) between June 2000 and June 2003. Risk profile was moderate to high, with a mean logistic EuroSCORE of 6.2 ± 5.1. Univariate and multivariate analysis were used to find determinants of in-hospital death, neurologic events, and cardiac-related events at follow-up. Overall survival was determined by the Kaplan-Meier method. Linearized complication rates at follow-up are reported.

Results

In-hospital mortality was 2.3%. At univariate analysis, significant determinants of in-hospital mortality were age, logistic EuroSCORE greater than 15, diabetes, extracardiac arteriopathy, New York Heart Association class IV, ejection fraction less than 30%, and intraaortic balloon pump. At multivariate analysis, extracardiac arteriopathy and New York Heart Association class IV were the independent predictors for in-hospital mortality. Neurologic events were 1.1%. At univariate analysis, significant determinants of neurologic events were age, logistic EuroSCORE greater than 15, and extracardiac arteriopathy. At multivariate analysis no independent factor for neurologic events was found. Survival at 36 months was 95.6% ± 0.9%, and freedom from cardiac-related events at follow-up was 91.6% ± 1.7%. Linearized rates of cardiac-related events during follow-up were as follows: recurrence of angina, 1.1% ± 0.3%/y; myocardial infarction, 0.6% ± 0.2%/y; congestive heart failure, 1.2% ± 0.3%/y; graft occlusion, 0.4% ± 0.2%/y; and re-coronary artery bypass grafting, 0.2% ± 0.1%/y.

Conclusions

Total arterial OPCAB has a safe outcome in terms of mortality and neurologic events and has a low linearized rate of cardiac-related events at follow-up, even for patients with a moderate- to high-risk profile.     

非体外循环冠状动脉旁路移植术加颈动脉内膜剥脱术治疗冠心病合并颈动脉狭窄

目的总结非体外循环冠状动脉旁路移植术（OPCAB）加颈动脉内膜剥脱术（CEA）治疗冠心病合并颈动脉狭窄的临床经验,探讨治疗方法和效果。方法回顾性分析2003年1月至2009年12月期间南京医科大学附属南京第一医院121例冠心病合并颈动脉狭窄患者同期行OPCAB和CEA治疗的临床资料,其中男81例,女40例;年龄62~72岁（67.2±4.5岁）。均为3支冠状动脉病变,左主干病变3例。单侧颈动脉狭窄（≥50%）95例,双侧狭窄（≥50%）26例。术后观察围手术期脑卒中、心肌梗死、心绞痛及其他并发症的发生情况,并进行随访。结果所有患者均行单侧CEA,其中左侧71例,右侧50例,颈动脉阻断时间20.5±7.0 min。在OPCAB中,每例远端吻合口数为2.9±0.3个。围术期无死亡,无心绞痛、心肌梗死和脑卒中发生,手术前后自觉神经精神症状好转87例,无明显变化32例,加重2例。随访121例,随访率100%,随访时间67.5±12.5个月。患者生活质量良好,无脑卒中、新发生的心肌梗死和新发生的神经精神症状。结论同期行OPCAB和CEA治疗冠心病合并颈动脉狭窄是较好的治疗方法,能显著减少OPCAB术后脑卒中的发生,而远期疗效尚待积累手术经验、远期随访观察,并进一步的研究阐明。     

Outcome events in patients with claudication: a 15-year study in 2777 patients

OBJECTIVE: The purpose of this study was to delineate the natural history of claudication and determine risk factors for death. METHODS: We reviewed the key outcomes (death, revascularization, amputation) in 2777 male patients with claudication identified over 15 years at a Veterans Administration hospital with both clinical and noninvasive criteria. Patients with rest pain or ulcers were excluded. Data were analyzed with life-table and Cox hazard models. RESULTS: The mean follow-up was 47 months. The cohort exhibited a mortality rate of 12% per year, which was significantly (P <.05) more than the age-adjusted US male population. Among the deaths in which the cause was known, 66% were due to heart disease. We examined several baseline risk factors in a multivariate Cox model. Four were significant (P <.01) independent predictors of death: older age (relative risk [RR] = 1.3 per decade), lower ankle-brachial index (RR = 1.2 for 0.2 change), diabetes requiring medication (RR = 1.4), and stroke (RR = 1.4). The model can be used to estimate the mortality rate for specific patients. Surprisingly, a history of angina and myocardial infarction was not a significant predictor. Major and minor amputations had a 10-year cumulative rate less than 10%. Revascularization procedures occurred with a 10-year cumulative rate of 18%. CONCLUSIONS: We found a high mortality rate in this large cohort and four independent risk factors that have a large impact on survival. Risk stratification with our model may be useful in determining an overall therapeutic plan for claudicants. A history of angina and myocardial infarction was not a useful predictor of death, suggesting that many patients in our cohort presented with claudication before having coronary artery symptoms. Our data also indicate that claudicants have a low risk of major amputation at 10-year follow-up.     

Risk factors in surgically treated mitral valve disease

Risk factors for operative mortality and long term survival were identified in 144 patients undergoing mitral valve replacement (MVR). The 3-year survival was 77% at a median follow-up time of 3.01 years, including an early mortality of 7.6%. Nineteen preoperative and perioperative variables were analysed by univariate and multivariate methods. The sole risk factor independently predictive of postoperative death was a poor functional class with a relative risk (RR) of 3.17 compared to patients with a better functional class. Independent risk factors of long term survival were; prior heart operation, presence of mitral regurgitation, age at operation and poor functional class. Estimation of the parameters of the Cox's model gave a predicted 3-year survival ranging from 95% to 11% for the most favourable and the less favourable risk factor combinations. Risk factors that affected late death were the presence of ischemic coronary etiology and poor functional class. Two modes of late death were identified each with its prognostic factor. The most common mode was cardiac-related death, its sole risk factor was the presence of ischemic coronary etiology. The RR ratio was 3.2 for patients with ischemic coronary etiology, compared to patients with other etiologies. Sudden cardiac death was the next, its independent risk factor was the age at operation with increasing hazard for younger patients. The RR ratio was 8.55 for a 35-year-old patient compared to a 60-year-old patient.     

The morbidity and mortality of reoperation for coronary artery disease and analysis of late results with use of actuarial estimate of event-free interval

To determine late survival and functional status after second revascularization procedures for coronary artery disease, we studied 106 consecutive patients operated on between June, 1969, and December, 1980. The mean age of the 96 men and 10 women was 49 +/- 8 years (range 22 to 65 years). Before reoperation, 101 patients (95%) were judged to be in New York Heart Association Class III or IV with angina, and 81 patients (76%) had three-vessel involvement. Angina recurrence was most commonly caused by bypass graft occlusion alone and in combination with progressive disease of the native arteries (60 patients, 57%). Three patients (2.8%) died within 30 days of reoperation; each death resulted from myocardial infarction. An average of 2.2 coronary arteries were bypassed in each patient. Complete follow-up data (mean 43 months) were available for 105 patients. Actuarial survival of patients dismissed alive is 94% at 5 years and 89% at 7 years. All late cardiac-related deaths occurred in patients with three-vessel disease. When recurrence of any angina, need for a third operation, and myocardial infarction are included with cardiac-related deaths, event-free survival is 28% at 5 years and 26% at 7 years. Late survival and functional status could not be predicted by the cause of recurrent angina or the presence of risk factors. Repeat myocardial revascularization can apparently be undertaken with low risk and with prospects for excellent long-term survival. After reoperation, recurrence of mild angina is not uncommon, but freedom from serious cardiac events and relief of severe symptoms were noted in more than 60% of patients 5 years later.     

非体外循环冠状动脉旁路移植术在高危冠心病中的应用

目的 探讨用非体外循环冠状动脉旁路移植术(OPCAB)的方法，以避免体外循环对冠心病高危因素患者产生的不良影响。方法 对100例冠心病患者行OPCAB，其中69例伴有冠心外科手术的高危因素。血管病变主要涉及左、右冠状动脉各分支。结果 手术死亡1例(1.4％)，手术转换2例(2．9％)，移植血管失功1例(1.4％)，术后非致命性心肌梗死4例(5．8％)，肾功能衰竭1例(1．4％)，胸骨感染1例(1．4％)，24小时内拔除气管内插管68例(98.6％)，接受输血17例(25．O％)。术后随访56例，随访时间1—13个月，死亡2例，心绞痛复发4例，充血性心力衰竭2例。术后无脑血管意外、再次手术止血、室性心律失常、下胶切口感染和呼吸衰竭等并发症发生。随访病例中14例做冠状动脉血管造影术，仅1例移植血管狭窄大于50％。所有乳内动脉血管桥均通畅。结论 对某些具有冠心外科手术高危因素的患者，采用OPCAB可降低并发症发生率和手术死亡率。然而，这种技术较适用于冠状动脉解剖条件较好的病例。远期结果需要长期随访进一步加以证实。     

高龄冠心病病人非体外循环冠状动脉旁路移植术后心房颤动的临床分析

目的 探讨高龄冠心病病人非体外循环冠状动脉旁路移植术术后心房颤动的相关因素.方法 111例高龄非体外循环冠状动脉旁路移植术,分为心房颤动和无心房颤动两组,回顾性分析冠状动脉病变情况、旁路移植血管的部位及支数、术后电解质变化、循环血容量变化、抗心律失常药物的使用等因素对心房颤动发生率的影响.结果 27例手术后心房颤动,发生率24.3%.在单因素分析中,房颤组病人与非房颤组病人术后中心静脉压、术后血清K+、Mg2+、动脉血SPO2等指标差异有统计学意义,P<0.05.结论 围术期电解质、血氧饱和度、循环血容量改变及发生围术期心梗是高龄病人冠状动脉旁路移植手术后发生心房颤动的危险因素.     

Myocardial revascularization for severe left ventricular dysfunction. Factors influencing early and late survival

The results of coronary bypass surgery have been assessed in 102 patients with severe left ventricular dysfunction who had a preoperative left ventricular ejection fraction of ⩽0.35 (mean(s.e.m.) 0.29 (0.01)). Independent risk factors influencing operative mortality were obesity (P = 0.0290) and the need for preoperative intra-aortic balloon counterpulsation (P = 0.0010). Cox regression analysis using as its end-point ‘cardiac-related death’ demonstrated three variables; the need for preoperative intra-aortic balloon counterpulsation (P = 0.001), advanced age (P = 0.011), and obesity (P = 0.036). In a subset of 43 patients who did not have these risk factors, the 4-year cardiac-related death rate was 95.1 (3.4)%. The operative mortality and long-term survival can be expected to be satisfactory in patients with severe left ventricular dysfunction, provided they have a viable myocardium rather than myocardial fibrosis.     

急性心肌梗死近期行非体外循环冠状动脉旁路移植术的临床分析

目的探讨急性心肌梗死(AMI)后患者近期行非体外循环冠状动脉旁路移植术(OPCAB)的临床疗效和围术期处理方法。方法 2006年1月至2010年3月,上海交通大学医学院附属仁济医院连续239例患者在发生AMI后14～27(20.55±3.91)d行OPCAB(AMI组),术前磷酸肌酸激酶同工酶(CK-MB,15.82±6.24)U/L,心肌肌钙蛋白Ⅰ(cTnI,0.07±0.04)ng/ml;将同期406例无心肌梗死史的OPCAB患者作为对照(对照组);比较、分析两组患者的临床资料。结果术后30 d AMI组死亡率为2.51%(6/239),其中死于循环衰竭4例,主动脉内球囊反搏(IABP)导致下肢缺血、坏死1例,肺部感染合并休克1例。AMI组患者术后应用多巴胺明显多于对照组(61.51%vs.37.44%,P=0.001),术中/术后行IABP亦多于对照组,但差异无统计学意义(P>0.05)。AMI组术后引流量及输注红细胞悬液量均多于对照组[(385.18±93.22)ml vs.(316.41±70.05)ml,P=0.022;(373.68±69.54)ml vs.(289.78±43.33)ml,P=0.005],但两组二次开胸止血率差异无统计学意义(P>0.05)。两组术后新发心房颤动发生率差异无统计学意义(P>0.05);AMI组急性肾损伤发生率高于对照组(13.81%vs.8.62%,P=0.038)。AMI组术后30 d死亡率高于对照组(2.51%vs.1.48%),但差异无统计学意义(P>0.05)。两组住ICU时间[(2.01±0.95)dvs.(1.78±0.98)d]和术后住院时间[(10.33±4.16)d vs.(9.89±4.52)d]差异均无统计学意义(P>0.05)。AMI组随访211例(88.28%),随访时间(2.89±1.02)年;失访28例(11.72%)。随访期间死亡25例,其中心源性死亡14例;1年生存率为97.63%,5年生存率88.15%。结论在AMI发生2～4周、待CK-MB和cTnI水平恢复至正常范围后,行OPCAB是相对安全的。