冠状动脉旁路移植术围术期心肌肌钙蛋白Ⅰ动态变化

目的 观察心肌肌钙蛋白Ⅰ和ＣＫ－ＭＢ在冠状动脉旁路移植术（ＣＡＢＧ）围术期变化，以判断心肌损伤状况。方法 １９例ＣＡＢＧ病人，其中３例同时行左室室壁瘤切除。 平均体外循环时间１２１ｍｉｎ，阻断升主动脉５６ｍｍ，灌注冷血停跳液保护心肌，平均每例搭桥３．２支，围术期２０个时间点取静脉血标本，留血浆测ｃＴｎＩ和ＣＫ－ＭＢ。术主术后第７ｄ作标准１２导联心电图（ＥＣＧ）。结果 ｃＴｎＩ术前５例升主同者，停机     

心血管手术同期施行冠状动脉搭桥

为提高心血管手术同期施行冠状动脉搭桥（ＣＡＢＧ）的疗效,降低手术死亡率,作者于１９８４年１１月至１９９６年７月施行此类手术５１例,其中瓣膜手术４５例,室间隔穿孔和室壁瘤切除４例,左房粘液瘤摘除术和腹主动脉瘤切除术各１例。术后早期死亡３例,死亡率５．８８％（１９９０年以后为４．１７％）,晚期死亡３例。作者认为：５０岁以上或有心绞痛症状和心电图缺血依据的心血管外科患者,应常规行冠状动脉造影。对狭窄程度＞５０％的主要分支,在纠正其他心血管病变同时,须行ＣＡＢＧ。术中充分再血管化,注意心肌保护,尽量减少升主动脉阻断时间。     

冠状动脉搭桥术围术期血浆内皮素变化及其意义的研究

体外循环下施行冠状动脉搭桥术 (ＣＡＢＧ)期间 ,血液中的内皮素 (ＥＴ)可发生变化 ,这种变化与ＣＡＢＧ术中及术后心功能的维持与恢复、冠状动脉桥的通畅与否、围术期疗效等有密切的关系。我们观察内皮素在ＣＡＢＧ围术期的变化 ,以期找出其变化的规律及可能的作用机制以及内皮素变化与血液动力学各参数、围术期疗效等临床指标之间的关系。资料和方法　根据选择性冠状动脉造影资料 ,选择 32例冠状动脉硬化性心脏病病人 ,其中男 2 6例 ,女 6例 ;年龄40～ 72岁。冠状动脉 2支病变 5例 ,3支病变 13例 ,4支病变12例 ,5支病变 2例。全部病人均在…     

川崎病冠状动脉病变及搭桥手术

目的 探讨川崎病后严重冠状动脉病变及搭桥手术（ＣＡＢＧ）后的近期及远期效果。方法随访发现,６例川崎病后严重冠状动脉病变的病儿均有左冠状动脉前降支（ＬＡＤ）病变,右冠状动脉（ＲＣＡ）病变５例,左冠状动脉回旋支（ＬＣＸ）病变３例,左冠状动脉主干（ＬＭＴ）病变２例,心肌梗死３例。共行１５支ＣＡＢＧ;单支２例,３支３例,４支１例;左胸廓内动脉（ＬＩＴＡ）至ＬＡＤ６例;右胸廓内动脉（ＲＩＴＡ）至ＬＡＤ１例。     

急性心肌梗死心源性休克反复室颤紧急冠状动脉搭桥2例

我们对２例急性心肌梗死（ＡＭＩ）、心源性休克、反复室颤病人施行心肺复苏和紧急冠状动脉搭桥（ＣＡＢＧ）手术,效果满意。例１　男,４０岁。急性广泛前壁心梗伴心源性休克、脑梗塞。置入主动脉内球囊反搏（ＩＡＢＰ）,冠脉造影示左冠状动脉主干（ＬＭ）狭窄大于９５％,直接送手术室,２次发生室颤,经胸外挤压配合药物及胸外电除颤转复。紧急建立体外循环（ＣＰＢ）,用大隐静脉行冠状动脉搭桥２支。开放升主动脉后心脏自动复跳,病人顺利脱机。术后第５天再次脑梗塞,经治疗２５天基本恢复,术后１个月康复出院。例２　男,５７岁。…     

外源性磷酸肌酸对冠状动脉搭桥病人围术期免疫系统的影响

目的 观察用外源性磷酸肌酶（ＣＰ）对冠状动脉搭桥（ＣＡＢＧ）病人围术期补体及免疫球蛋白的变化,评价其对免疫系统的影响。方法 ２８例ＣＡＢＧ病人随机分为ＣＰ组１７例,对照组１１例,ＣＰ组于术前、后备用ＣＰ３～７ｄ,每天２ｇ静脉滴注,术中将ＣＰ加入心脏停搏液中,对照组椁前、中、后均不用ＣＰ。观察两组病人术前１周、麻醉诱导后、术中阻断升主动脉后５、３５、６５ｍｉｎ（１４例病人）、术毕、术后２４ｈ、术后１     

全动脉化冠状动脉搭桥术32例

自１９９６年１２月至１９９８年３月，为３２例冠心病病人施行以乳内动脉（ＩＭＡ）、胃网膜右动脉（ＧＥＡ）及桡动脉（ＲＡ）为血管材料的全动脉化冠状动脉（ＣＡ）搭桥术，同时施行贲门癌切除、胃食管吻合术１例，心梗后室间隔穿孔修补术１例，心梗后室壁瘤切除术６例。全组７例取用ＧＥＡ，２９例取用ＲＡ（１０例双侧），每例均取用左侧ＩＭＡ（１５例双侧），以人均２．９个动脉桥完成人均３．５个远端吻合（最多者６个）。７例采用了３种动脉桥，２５例采用ＩＭＡ和ＲＡ２种动脉桥。１７例用ＲＡ做“蛇”形桥。１例用右ＩＭＡ做第１室间隔支搭桥。创用“Ｖ”字形ＲＡ自体血管壁加宽近端吻合口的方法，成功地完成了较细ＲＡ与主动脉间的近端吻合。全组未发现与取材有关的并发症。术后心电图、超声心动图和核素心肌显像提示，搭桥区域的心肌灌注和心室功能均较术前明显改善。初步实践证明，全动脉化ＣＡ搭桥术虽然难度较大，但术后效果好，并可望比传统的静脉桥有更理想的远期通畅率     

风湿性瓣膜病合并冠心病的外科治疗

报告１９９１年１月至１９９５年１１月期间１５例风湿性瓣膜病合并冠心病病人瓣膜替换及冠脉桥术（ＣＡＢＧ）的体会。手术均在低温体外循环下进行。其中二尖瓣替换＋ＣＡＢＧ６例，主动脉瓣替换＋ＣＡＢＧ６例、双瓣替换＋ＣＡＢＧ３例，术后死亡３例，其余治愈出院，作者强调了术前明确诊断的重要性，并就冠脉搭桥、心肌保护、主动脉气囊反搏（ＩＡＢＰ）及药物的应用加以讨论。     

连续170例冠状动脉旁路移植术治疗冠心病

目的 回顾应用冠状动脉旁路移植术（ＣＡＢＧ）治疗冠心病的早期效果和经验。方法 １７０例（男１５２例,女１８例;年龄３５－８０岁,平均６６．７岁）冠心病病人中９７％为多支冠状动脉病变。８１例左室射血分数≤４５％,其中２１例〈３０％。８４％病人心绞痛ＣＣＳⅢ－Ⅳ级。除１例在左前外侧小切口非体外循环下手术,余均为正中开胸低温体外循环下ＣＡＢＧ。     

完全性冠状动脉血运重建

作者应用大隐静脉以序贯式搭桥术对２５例冠心病患者行完全性冠状动脉血运重建。患者均为三支血管病变，左心室射血分数为２２％～６０％，左室舒张未压为１．３～４．０ｋＰａ。接受２～５支桥，人均搭桥３．６支。无围术期心肌梗塞及手术死亡，术后恢复顺利，心绞痛症状明显改善。作者对序贯式搭桥的技术特点及优点进行了讨论。     

非体外循环下冠状动脉内膜剥脱后搭桥治疗弥漫性冠状动脉病变

目的探讨非体外循环心脏跳动下冠状动脉内膜剥脱后搭桥治疗弥漫性冠状动脉病变的早期临床结果和经验。方法2003年5月—2005年5月,对53例弥漫性冠状动脉病变患者行非体外循环下冠状动脉内膜剥脱后搭桥手术治疗。53例中,男性41例、女性12例,年龄55～79(64±7)岁。加拿大心脏病协会心绞痛分级：Ⅰ～Ⅱ级15例,Ⅲ级6例,Ⅳ级32例。有心肌梗死史26例(49%)。冠状动脉造影：双支病变3例,3支病变50例,其中合并左主于病变9例。左心室射血分数0．26～0．65(0．52±0．17)。53例共行70支冠状动脉内膜剥脱：左前降支系统38支,其中5例内膜剥脱后先用大隐静脉片行前降支成形,再在补片上用乳内动脉搭桥;回旋支的钝缘支8支;右冠状动脉系统24支。应用左乳内动脉53支,桡动脉2支,余均为大隐静脉桥,人均搭桥(3．8±1．1)支,再血管化指数1．03±0．07。结果术中桥血流测定显示63支桥血流满意,7支欠满意。术后2例发生围手术期心肌梗死,但对血流动力学无明显影响。53例皆痊愈出院。44例随访6～29个月,无心绞痛发作;9例失访。6例在手术后3～27个月复查冠状动脉造影,显示桥血管均通畅。结论非体外循环下冠状动脉内膜剥脱后搭桥,安全可行,再血管化程度高,是治疗弥漫性冠状动脉病变的有效方法。     

冠心病手术方式对IABP应用的影响

目的:探讨冠心病手术方式对主动脉内球囊反搏(intra-aortic balloon pump,IABP)的影响。方法;冠心病手术176例,27例为非体外循环心脏跳动下的手术。在149例体外循环(cardio-pulmonary bypass,CPB)下的手术中,单纯冠状动脉搭桥(coronary artery bypass grafting,CABG)35例,CABG 激光心肌血管重建(Transmyocardial Laser Revascularization,TMLR)联合手术114例,其中29例加做室壁瘤切除、室间隔穿孔修补、瓣膜置换手术,9例于术中安置临时心外膜起搏器。结果:149例体外循环下的手术中共置入IABP23例,其中120例常规手术组中应用IABP15例,29例有附加手术组中应用IABP8例,而27例非体外循环下的手术中无IABP的应用。结论:(1)应用LABP数量在常规手术组与术中加做室壁瘤切除、瓣膜置换术或成型术、室间隔穿孔修补术(p<0.05),安置临时心外膜起搏器(P<0.01),组比较结果均有统计学意义;(2)激光心肌血管重建术,无论与何种冠心病手术联合应用,无论激光打孔数量多少,都没有增加IABP的应用;(3)未发现冠脉搭桥数量与IABP有关。     

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。     

冠状动脉旁路移植术1018例临床分析

目的总结、探讨冠状动脉搭桥术的外科技术及临床治疗效果。方法回顾分析1997—2004年同一术者完成的冠状动脉搭桥术1018例患者的临床资料,其中非体外循环冠状动脉旁路移植术(OPCAB)510例,体外循环下冠状动脉旁路移植术(CCABG)508例。≥60岁的患者582例(57.2%)。不稳定性心绞痛患者852例;术前同时合并其他疾病患者784例(77.0%),包括瓣膜病、高血压病、糖尿病、陈旧性心肌梗死、室壁瘤、室间隔穿孔、脑梗死、阻塞性肺疾病(COPD)、慢性肾功能不全、恶性肿瘤术后等。左主干病变156例;三支病变671例,三支病变以下347例。结果死亡4例(0.39%),总体并发症(胸骨哆开、脑梗死、纵隔炎)发生率1.6%(16/1018)。OPCAB者平均搭桥(2.5±0.4)支,CCABG者平均搭桥(3.3±0.6)支。左乳内动脉使用率93.8%(955/1018),术后早期使用主动脉内气囊反搏29例。全组随访2个月～7年,随访1002例(98.4%)。结论科学的外科策略,精湛的手术技术及麻醉、体外循环技术的改进,可使CABG术的死亡率和并发症明显下降,冠状动脉旁路移植术安全、可靠,效果满意。     

High myocardial lactate concentration is associated with poor myocardial function prior to cardiopulmonary bypass

AIM: This study was designed to analyse the relationship between myocardial lactate--determined by microdialysis--and hemodynamics during coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). METHODS: Twenty consecutive patients with coronary artery disease were enrolled for this prospective, observational study. Microdialysis measurements were performed in the apical region of the heart during periods of 15 to 20 min before, during, and after CPB; hemodynamics and plasma lactate concentrations were determined correspondingly. Correlation analysis revealed a relationship between myocardial lactate concentration and right ventricular ejection fraction at baseline (Spearman's r: 0.6; P=0.02). Patients were thus grouped according to the myocardial lactate concentration at baseline into a high-lactate group (2.5+/-0.7 mmol.l(-1), n=10) and low-lactate group (0.9+/-0.5 mmol.l(-1), n=10). RESULTS: Preoperative left ventricular ejection fraction was not different between the groups (high-lactate group: 53+/-16%; low-lactate group: 57+/-15%; P=n.s.) Patients in the high-lactate-group had a lower stroke volume index (P=0.005) and right ventricular ejection fraction (P=0.04) before, and higher central venous and pulmonary artery pressures (P<0.01) after CPB. Plasma lactate was significantly higher during CPB in the high-lactate-group (P<0.05). No correlation was observed between myocardial and plasma lactate. Six patients in the high-lactate but none in the low-lactate-group needed inotropic support after weaning from CPB (P=0.01). CONCLUSIONS: These data are suggestive of an association between subtle myocardial ischemia--detected by microdialysis--and perioperative myocardial dysfunction in patients undergoing CABG. The microdialysis technique may be a valuable adjunct for monitoring myocardial metabolism during cardiac surgery.     

非体外循环下冠脉搭桥术的围术期管理

目的：比较非体外循环搭桥术与体外循环搭桥术病人的术中及术后早期恢复情况。方法39例病人接受了非体外循环下冠脉搭桥术,同时期33例病人接受了体外循环冠脉搭桥术。两组均采用中等剂量阿片静脉复合全麻,结果：病人的麻醉时间、手术时间、术后机械通气时间和在监护室的停留时间,非体外循环组明显短于体外循环组（P＜0．01）。围术期平均输血量和血血病人数在1支桥病人中非体外循环组明显少于体外循环组（P＜0．05）。术后房颤发生率和围术期心肌梗死发生率两组间无明显差异,术后脑卒中,低心排及死亡的发生率各组均为0％。结论与外循环搭桥术相比,非体外循环搭桥术缩短了病人的麻醉、手术及在监护室停留时间,加快了病人的恢复、从耐而提高了手术的安全性,并降低了手术费用。     

Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in high-risk patients?: a comparative study of 1398 high-risk patients.

OBJECTIVE: Although there has been some evidence supporting the theoretical and practical advantages of off-pump coronary artery bypass (OPCAB) over the conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB), it has not yet been determined which group of patients would benefit most from it. It has been advocated recently that high-risk patients could benefit most from avoidance of CPB. The aim of this retrospective study is to assess the efficacy of the OPCAB technique in multi-vessel myocardial revascularization in a large series of high-risk patients. METHODS: The records of 1398 consecutive high-risk patients who underwent primary isolated CABG at Harefield Hospital between August 1996 and December 2001 were reviewed retrospectively. Patients were considered as high-risk and included in the study if they had a preoperative EuroSCORE of > or =5. Two hundred and eighty-six patients were operated on using the OPCAB technique while 1112 patients were operated on using the conventional CABG technique with CPB. The OPCAB patients were significantly older than the CPB patients (68.1+/-8.3 vs. 63.7+/-9.9 years, respectively, P<0.001). The OPCAB group included significantly more patients with poor left ventricular (LV) function (ejection fraction (EF) < or =30%) (P<0.001) and more patients with renal problems (P<0.001). RESULTS: There was no significant difference in the number of grafts between the groups. The CPB patients received 2.8+/-1.2 grafts per patient while OPCAB patients received 2.8+/-0.5 grafts per patient (P=1). Twenty-one (7.3%) OPCAB patients had one or more major complications, while 158 (14.2%) CPB patients (P=0.008) developed major complications. Thirty-eight (3.4%) CPB patients developed peri-operative myocardial infarction (MI) while only two (0.7%) OPCAB patients developed peri-operative MI (P=0.024). The intensive therapy unit (ITU) stay for OPCAB patients was 29.3+/-15.4 h while for CPB patients it was 63.6+/-167.1 h (P<0.001). There were ten (3.5%) deaths in the OPCAB patients compared to 78 (7%) deaths in the CPB patients (P=0.041) within 30 days postoperatively. CONCLUSIONS: This retrospective study shows that using the OPCAB technique for multi-vessel myocardial revascularization in high-risk patients significantly reduces the incidence of peri-operative MI and other major complications, ITU stay and mortality. Even though the OPCAB group included a significantly higher proportion of older patients with poor LV function (EF < or =30%) and renal problems, the beneficial effect of OPCAB was evident.     

Combining off pump coronary artery bypass with mitral valve replacement

Background Conventional approach to combined coronary artery bypass grafting (CABG) and mitral valve replacement (MVR) is associated with longer cardiopulmonary bypass (CPB) and aortic cross clamp (ACC) time leading to high operative risk. Methods We conducted a retrospective review of nine consecutive patients undergoing coronary artery bypass grafting/mitral valve replacement combining the off pump technique with cardioplegic arrest. Elective intra aortic balloon pump (IABP) support was instituted in all cases. CABG was first done in all cases without cardiopulmonary bypass support. Mitral valve replacement was then done using conventional cardiopulmonary bypass and cardioplegic arrest using the superior septal approach. Results Nine consecutive patients underwent coronary artery bypass grafting with mitral valve replacement including three patients with acute myocardial infarction. Preoperative echocardiogram revealed a mean ejection fraction (EF) of 38.4 ± 6.0%. Intra aortic balloon pump was inserted in all patients preoperatively. The average number of grafts were 3.0 ± 0.7. Eight patients received bioprosthetic valve while one patient received mechanical prosthesis. The average length of stay in intensive care unit was 3.3 ± 0.5 days. There was no mortality. One patient had superficial wound infection. Conclusion The data suggest that the combined technique (off pump coronary artery bypass grafting and conventional mitral valve replacement) is a safe method to perform coronary artery bypass grafting/mitral valve replacement with minimal morbidity and mortality.     

Simultaneous antegrade and retrograde reperfusion after cardioplegic arrest for coronary artery bypass

Retrograde coronary sinus reperfusion with warm blood during proximal anastomoses permits completion of myocardial revascularization under a single cross-clamp application. Reperfusion with both antegrade (via arterial and vein grafts) and retrograde (via coronary sinus catheter) warm blood has raised concerns about maldistribution of perfusate or overpressurization of capillary beds. This prospective, randomized design compares postcardioplegic myocardial recovery among patients receiving retrograde reperfusion only and patients receiving simultaneous antegrade/retrograde reperfusion. Twenty-four patients were selected among all presenting as outpatients for elective coronary artery bypass (CAB). Each patient underwent CAB with cardioplegic arrest and single cross-clamp technique. During proximal anastomoses the heart was reperfused with warm blood from the cardiopulmonary bypass (CPB) circuit. Twelve received retrograde reperfusion only, and 12 received simultaneous antegrade/retrograde reperfusion via an internal mammary artery (IMA) graft, all vein grafts, and the coronary sinus catheter. Vein graft perfusion was interrupted in each vein as the proximal anastomosis was performed. Myocardial recovery time (interval from initiating reperfusion until electrical and mechanical activity), cardioversion incidence, requirement for inotropic support, and Swan-Ganz hemodynamic parameters measured immediately 6 and 24 hours postoperatively were compared between groups. There were no differences between groups in age, ventricular function, number of grafts, or CPB time. Also, there were no differences in cardioversion, inotropic need, or postoperative hemodynamic performance. Myocardial recovery time was reduced in patients receiving simultaneous antegrade/retrograde reperfusion (13.9+/-7.0 vs 2.6+/-2.1 minutes). Simultaneous reperfusion of warm blood antegrade and retrograde is not deleterious to the myocardium. More rapid recovery of myocardial function may represent a shorter period of warm ischemia but does not appear to translate to improved postoperative myocardial performance.