非体外循环下冠状动脉旁路移植术

目的 报告微创非体外循环冠状动脉旁路移植术(OPCABG),探讨其手术指征及外科处理要点。方法 回顾性总结5例OPCABG的临床资料。结果 5例顺利完成非体外循环冠状动脉旁路移植术。随访3～4个月,无死亡,无明显心绞痛及心肌缺血表现。结论 对于选择的患者,OPCABG安全、经济、有效,是一种值得推广的微创心脏手术方法。     

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 redo coronary artery bypass grafting

BACKGROUND: Conventional redo coronary artery bypass grafting is associated with significant morbidity. The danger of reoperation is mainly in reopening the sternum and in the manipulation of the heart and the old grafts. Therefore, off-pump redo coronary artery bypass grafting with a patient-specific approach in selected cases seems an ideal technique. METHODS: Between October 1995 to September 1999, 50 patients with mean age of 61.8+/-8 years underwent reoperative coronary artery bypass grafting without cardiopulmonary bypass. Isolated left internal mammary artery (LIMA) to left anterior descending artery (LAD) anastomosis was carried out in 25 cases through left anterior minithoracotomy. In 1 patient LIMA was grafted on a previous vein graft to LAD, which was critically stenosed proximally but distal anastomosis was patent. In another case LIMA was grafted to Ramus intermedius branch. Midsternotomy approach was used to carry out LAD and right coronary artery grafting in 21 cases. In 2 patients a posterolateral thoracotomy approach was used to bypass obtuse marginal branches without cardiopulmonary bypass; in these cases proximal anastomosis was performed on the descending aorta. RESULTS: Mortality rate was 4% (2 deaths). Two patients sustained perioperative myocardial infarction. No patient was reexplored for hemorrhage and 38 patients did not require homologous blood transfusion. Sixteen patients underwent check angiogram and all of them were found to have patent redo grafts. Cardiac recovery room stay was 22+/-7 hours and hospital stay 5+/-2 days. CONCLUSIONS: In selected patients, reoperative coronary artery bypass grafting can be performed without cardiopulmonary bypass with a low perioperative morbidity and mortality and satisfactory graft patency.     

Off-pump coronary artery bypass grafting in Japan

The number of coronary artery bypass grafting (CABG) procedures has reached more than 20,000 per year in Japan, and the operative mortality rate has decreased to less than 1.5% including emergent surgery. The mortality and morbidity rates of CABG are still high in patients with risk factors such as cerebrovascular disease, chronic renal failure on hemodialysis, atheromatous and calcified ascending aorta, and older age when cardiopulmonary bypass is used. Minimally invasive direct coronary bypass on a beating heart through a small left lateral anterior thoracotomy, in which the left internal thoracic artery (LITA) is used to revascularize the left anterior descending artery, was introduced for high-risk patients with single-vessel disease in the mid-1990s, although is not widely performed at present. Since the late 1990s off-pump coronary artery bypass grafting (OPCAB) has been widely performed as a treatment for multivessel disease through a median sternotomy with the evolution of stabilizers and apical suction devices, refined anesthetic management, and sophisticated surgical techniques. In 2004, 60% of all CABG procedures in Japan were performed without cardiopulmonary bypass. Due to competition from percutaneous coronary intervention with drug-eluting stents and better long-term outcomes, CABG with arterial grafts alone was carried out in 52% of total cases and in 66% of OPCAB cases. OPCAB is becoming the standard CABG in Japan.     

Off-pump coronary artery bypass grafting in octogenarians

Objectives: Off-pump coronary artery bypass grafting (CABG) has become accepted for myocardial revascularization because it reduces perioperative morbidity. We assessed the safety and efficacy of bypass surgery on the beating heart in elderly patients. Methods: Off-pump CABG was done in 25 patients aged 80 years or older between February 1996 and February 2001. We retrospectively compared clinical results for these patients to those of 18 consecutive age-matched patients undergoing on-pump CABG during the same period. Results: Mean patient age in both groups was similar −82.2±2.3 years in the off-pump group vs 81.9±2.0 years in the on-pump group (p=0.66). Preoperative risk was similar in both groups, but significantly more patients in the on-pump group had triple-vessel disease. Distal anastomoses were significantly fewer in the off-pump group than in the on-pump group at 2.0±1.0 vs 2.8±0.5 (p<0.01). The off-pump group had a shorter postoperative ventilation −13.4±17.2 hours vs 45.2±52.8 hours (p<0.05)—, and less blood transfused −16% vs 89% (p<0.01)—than the on-pump group. Mean postoperative hospitalization and intensive care unit stay were 18.6 days and 3.2 days in the off-pump group, versus 37.1 days and 9.4 days in the on-pump group (p<0.05). No difference was seen in the incidence of major postoperative complications between groups. No hospital deaths occurred in the off-pump group. Conclusion: Off-pump CABG is thus a safe and effective for myocardial revascularization in the elderly.     

Off-pump coronary artery bypass grafting: the Zurich experience

Coronary artery bypass grafting (CABG) is the surgical procedure of choice for treatment of multi-vessel coronary artery disease. The rising risk profile of the patients requiring isolated CABG and the economic pressure have prompted us to devise new operative strategies to treat these patients. Elimination of the cardiopulmonary bypass is one possible answer to the dilemma of maintaining the quality of care and reducing the exploding costs of our health system. Therefore, we developed the off-pump coronary artery bypass grafting (OPCAB) for patients requiring isolated CABG. In our experience the key to successful OPCAB relies on the order of revascularization of the myocardial walls (anterior, inferior, lateral), use of intracoronary shunt, no-touch technique for the proximal aortic anastomosis with heart string a (Guidant, IN, USA), close collaboration with the anesthesiologists, early and aggressive administration of anti-platelet therapy, endoscopic vein harvest by perfusionists, and improved body temperature control. Following these concepts, we have been able to offer the OPCAB procedure to over 90% of our patients and to reduce perioperative morbidity and global costs.     

Off-pump coronary artery bypass grafting for elderly patients

Background. The use of off-pump coronary artery bypass grafting (CABG) has recently become widespread, and it has been proven to be less invasive and to facilitate early recovery. In this study, we investigated the efficacy of off-pump CABG for patients aged 75 years or more.

Methods. A retrospective chart review was carried out for patients who underwent isolated off-pump and on-pump CABG at Shin-Tokyo Hospital between January 1997 and December 2000. The patients’ demographic, operative data, and postoperative results were collected.

Results. The off-pump group consisted of 60 men and 44 women with a mean age of 78.8 years, and the on-pump group consisted of 54 men and 20 women with a mean age of 77.6 years. Distal anastomoses were significantly fewer in the off-pump group (2.4 in off-pump group versus 3.7 in on-pump group), but total arterial bypass was more frequently achieved in off-pump group (82.7% versus 25.7%). Intubation time (8.4 versus 18.4 hours), intensive care unit stay (2.2 versus 3.5 days), and postoperative stay (13.8 versus 20.0 days) were significantly shorter in the off-pump group than in the on-pump group (p < 0.05). The frequency of the occurrence of major complications was significantly lower in the off-pump group than the on-pump group, especially in regard to postoperative stroke and respiratory failure (p < 0.05). Multivariate analysis showed that off-pump CABG significantly reduced patient recovery period and the incidence of postoperative complications. Early follow-up results, cardiac event-free and survival rates, did not significantly differ between the two groups.

Conclusions. Off-pump CABG is safe for the elderly patient. Off-pump CABG successfully facilitates early recovery and reduces the incidence of postoperative complications among elderly patients.     

Off-pump coronary artery bypass: early results.

BACKGROUND: Coronary artery bypass grafting (CABG) on a beating-heart has gained the attention of cardiac surgeons and shown favorable initial results. However, only a few follow-up results have been reported. We report herein our one-year experiences of off-pump CABG performed at Shin-Tokyo Hospital. METHODS: Retrospective chart review was performed for patients who underwent off-pump CABG and conventional isolated CABG between 01/01/98 and 12/31/98. Preoperative, perioperative, and follow-up data were collected. RESULTS: Among 315 cases of isolated CABG, 94 cases were off-pump CABG (male/female 69/25, mean age 67.7). Mean number of distal anastomoses performed by off-pump CABG was 1.7 +/- 0.7 (42 cases of single-vessel revascularization and 52 cases of more than double- vessel revascularization). In off-pump CABG, there were no hospital deaths and 6 major complications including 2 incidences of perioperative myocardial infarction. Postoperative angiography before hospital discharge was performed in 56 patients (59.6%, 98 anastomosis) and revealed 5 occlusions, giving a graft patency rate of 94.9%. During the follow-up (11.4 +/- 4.1 months), there was 1 late non-cardiac death and 11 cardiac events. The event-free rate at 18 months was 94.0% in off-pump CABG, showing no significant difference from the event-free rate after conventional CABG (94.0% at 18 months, p = 0.135). Follow-up angiography was performed in 21 patients (33 anastomoses) at a mean interval of 3.6 months and showed 4 graft occlusions, giving a patency rate of 92.7%. CONCLUSION: Both hospital and early results of off-pump CABG were acceptable. Off-pump CABG can be safely performed in selected patients.     

高风险患者非体外循环冠状动脉旁路移植

目的 评价高风险患者非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass grafting,OPCAB)的安全性、效果及术式的选择.方法 回顾分析2002年6月～2005年12月OPCAB术的临床资料,根据欧洲心脏手术风险评分模型(European system for cardiac operative risk evaluation,EuroSCORE)计算每一病例的风险分数,＞5分者作为高风险病例进入本研究,共113例,以同期行体外循环冠状动脉旁路移植(cardiopulmonary bypass coronary artery bypass grafting,CCAB)的76例高风险患者作为对照.分别统计两组的手术前风险因素,并对手术中情况、手术后结果进行统计分析对比.结果 两组EuroSORE分别为9.0±2.6和8.3±2.1(t=2.016,P=0.045).移植血管数OPCAB组(3.2±0.9)少于CCAB组(3.8±0.9)(t=-4.267,P=0.000).术后肌酸激酶、肌酸激酶同功酶OPCAB组[570(61～8246)U/L、20(1～282)U/L]显著低于CCAB组[870(246～8155)U/L、55(12～300)U/L](Z=-3.648、-5.767,P=0.000).输血量OPCAB组显著少于CCAB组[(775±693)ml vs(1088±712)ml,t=-2.887,P=0.004].术后并发症差异无显著性.死亡率OPCAB组3.5%(4/113),CCAB组6.6%(5/76),差异无显著性(χ2=0.925,P=0.336).结论 对于高风险病人采纳OPCAB的方法是安全的,临床效果满意.但对于有不同风险因素的病人应采用不同的手术方法.     

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.     

Early angiographic results of multivessel off-pump coronary artery bypass grafting.

OBJECTIVES: Recently off-pump coronary artery bypass grafting (CABG) is being widely used for coronary revascularization. However, there is some evidence that off-pump surgery increases the risk of recurrent angina and the need for reintervention, suggesting poor graft quality or incomplete revascularization. We describe our experience to demonstrate the feasibility of multiple coronary revascularization in off-pump CABG (OPCAB). PATIENTS AND METHODS: From January 2002 to March 2003, 168 patients underwent OPCAB at our institute. In 16 of them, 6 to 9 vessels were revascularized in each patient. There were 14 males and 2 females with a mean age of 66 years (47 to 74 years). All patients had triple-vessel disease. Ten patients received in situ arterial grafts only which were harvested with the skeletonization technique using an ultrasonic scalpel. We used the Starfish heart positioner to expose lateral, posterior, and inferior walls of the heart with minimal hemodynamic compromise. RESULTS: All patients were discharged from the hospital without any serious complications. Postoperative angiography was performed in 87.5% within 1 month after operation. The patency rate was 96.6%. CONCLUSION: These results indicate that complete revascularization can be achieved in OPCAB in patients with diffuse coronary arterial disease. Complete revascularization with in situ arterial conduits only is technically feasible and yields a high early graft patency, even in the off-pump situation.     

非停跳冠状动脉搭桥术病生理改变及临床监测

非停跳冠状动脉搭桥术(OPCABG)因其避免了体外循环的不良反应,在临床上得到了广泛应用.术中心脏位置的变化和应用心脏固定器,会引起显著的血流动力学波动、心肌缺血等病生理改变,进而导致心室功能障碍.近年的研究表明,心室舒张功能障碍和右心功能不全是引起血流动力学变化的重要因素.临床上多采用肺动脉导管(PAC)和经食道超声心动图(TEE)来监测术中血流动力学和心功能的变化.新型的PAC能够将容量监测和压力监测结合起来,拓展了其监测范围和功能;而TEE在术中辅助诊断和监测的可靠性、有效性得到了广泛认可.心室压力一容量环作为一种非容量依赖性的方法,在监测心功能方面越来越受到重视.     

非体外循环冠状动脉旁路移植术343例治疗体会

目的 总结非体外循环冠状动脉旁路移植术治疗冠心病的手术经验、围手术期治疗及疗效.方法 回顾性分析我院非体外循环下冠状动脉旁路移植术343例患者的临床资料.结果 术后(13.2±7.8)h拔除气管插管,ICU监护时间(4.0±2.1)d,住院时间(21.7±8.2)d,术后7例使用主动脉球囊反搏,9例行床边血液透析治疗,主要并发症包括心律失常106例(30.9%),一过性精神症状67例(19.5%),低氧血症63例(18.4%),应激性溃疡45例(13.1%),糖尿病酮症酸中毒2例(0.6%).住院死亡2例(0.6%),死亡原因为顽固性低心排综合征合并多器官功能衰竭综合征.结论 非体外循环冠状动脉旁路移植术安全可行,疗效满意.正确地掌握其手术适应证、熟练的手术技巧和细致全面的围术期处理是确保手术顺利进行及术后获得满意疗效的关键.     

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.     

Off-pump long onlay bypass grafting using left internal mammary artery for diffusely diseased coronary artery

Surgical treatment of a diffusely diseased coronary artery has been considered a relative contraindication for off-pump coronary artery bypass grafting. To our knowledge, long onlay-patch grafting with off-pump coronary artery bypass grafting has not been described. Two sets of Octopus 3 tissue stabilizers were placed longitudinally along the target coronary artery. This allowed us to perform surgical angioplasty and bypass grafting without cardiopulmonary bypass support (double Octopus technique). We report our early experience with off-pump long onlay bypass grafting in patients with a diffusely diseased coronary artery using double Octopus tissue stabilizers.Diffusely diseased coronary artery; off-pump coronary artery bypass grafting; coronary artery reconstruction; coronary artery bypass grafting; onlay patch anastomosis