Technical considerations in patients undergoing combined aortic valve replacement and aortocoronary bypass surgery.

Forty-nine patients have undergone combined aortic valve replacement and aortocoronary saphenous vein bypass graft surgery using a technique of distal coronary perfusion. Vein grafts are placed before replacement of the aortic valve, and continuously perfused by siting the proximal anastomoses high on the aortic root or individually perfusing the grafts before proximal anastomosis. Continuous coronary ostial perfusion is used as well during aortic valve replacement. There were 3 (6.1%) operative deaths and 1 (2%) perioperative myocardial infarction. A comparison of this technique with other reported results suggests that attention to myocardial perfusion distal to significant coronary artery stenosis may decrease the incidence of perioperative myocardial infarction in patients requiring both aortic valve replacement and coronary bypass graft operation.     

Combined aortic valve replacement and myocardial revascularization: results in 220 patients.

During a 7.5-year period ending in June 1977, 220 patients underwent combined aortic valve replacement and myocardial revascularization. Early (30-day) mortality was 5.4% (12 patients), and was significantly affected by the development of perioperative myocardial infarction. For 23 patients with electrocardiographic and enzymatic evidence for definite infarction, hospital mortality was 17%; for 66 patients with probable infarction mortality was 5%; and for 116 patients without evidence for infarction mortality was 3%. The difference in mortality between the definite and no infarction groups was significant (p less than 0.01). The incidence of perioperative infarction was influenced by the type of myocardial protection employed during the operative procedure. Definite infarction occurred in 24% of 41 patients who had mild (28-32 degrees C), intermittent hypothermic coronary perfusion, in 9% of 142 patients with hypothermic ischemic arrest (myocardial temperature 20 to 27 degrees C) and in none of 22 patients with hypothermic, potassium-induced cardioplegia (myocardial temperature 8--18 degrees C). The difference in the rate of infarction between the coronary perfusion and the two hypothermic ischemic arrest groups was significant (p less than 0.01). The mean duration of followup for 100% of the hospital survivors was 22.5 months. Cumulative survival was 88% at 1 year and 77% at 3 years. These figures do not differ significantly from those for patients without coronary artery disease having isolated aortic valve replacement in our institution, and are superior to those reported for patients with coronary and aortic valve disease undergoing only aortic valve replacement. We conclude that combined aortic valve replacement and myocardial revascularization should be performed in all patients in whom the lesions coexist. Hypothermic ischemic arrest, preferably in combination with potassium-induced cardioplegia, provides the most myocardial protection during operation.     

Direct myocardial revascularization without extracorporeal circulation: technique and initial results

In a 10-month period, 68 patients underwent saphenous vein bypass revascularization without extracorporeal circulation. Distal sutures were performed with interruption of coronary flow without any devices for perfusion of the coronary artery; the proximal sutures were completed with tangential clamping of the aorta. Most frequently, the anterior descending and the distal right coronary arteries were revascularized; of 225 patients who underwent bypass surgery, this technique was possible in 68 cases (30.2%). The 30-day hospital mortality was 1.5%, and perioperative myocardial infarction, as determined by daily electrocardiograms (ECGs) and creatine phosphokinase isoenzyme (CKMB), occurred in two patients. Control hemodynamic studies were performed in 22 of the 68 patients (32.4%) with a patency rate of 84.2% in the grafts restudied.     

Direct myocardial revascularization without cardiopulmonary bypass

The authors present their experience with 160 patients who underwent coronary artery saphenous vein bypass revascularization without cardiopulmonary bypass. The distal sutures were performed with interruption of the coronary flow without any devices for perfusion of the coronary artery: the proximal sutures were made with tangential clamping of the aorta. Vessels most frequently revascularized were the anterior descending and the distal right coronary artery. Out of 597 patients who underwent bypass surgery in this period, this technique could be employed in 160 cases (26.8%). Hospital mortality was 3.1% (5/160) and perioperative myocardial infarction as determined by daily EKGs and CKMB occurred in 4 patients (2.5%). Control hemodynamic studies were performed in 41 of the 160 patients (25.6%) with a patency rate of 83.9% in the 62 grafts restudied. We conclude that direct myocardial revascularization can be performed safely without major difficulties and with efficient anastomoses. The main advantages of the technique are that it does not require the use of extracorporeal circulation and, consequently, the use of any blood, as well as its low cost due to shorter hospitalization periods.     

Aortic valve replacement combined with myocardial revascularization. Late clinical results and survival of surgically-treated aortic valve patients with and without coronary artery disease.

From 1967 through 1973, 80 consecutive patients underwent simultaneous aortic valve replacement (AVR) and coronary bypass grafting. Fourteen (18%) experienced no angina pectoris and had no history or electrocardiographic evidence of coronary atherosclerosis. Seven of these 14 had severe multiple vessel disease. All operations were performed under normothermic conditions without coronary perfusion. Seven patients (9%) died during operation. Intra-operative myocardial infarction was documented in eight (10%). After a mean follow-up of 35 months, overall mortality was highest in aortic regurgitation patients [seven of 13 (54%)] compared to aortic stenosis [17 of 54 (31%)] (P less than 0.07), and mixed pathology [1 of 13 (8%)]. Thirty-one of 34 (91%) grafts in 25 patients were patent an average of 12 months postoperatively. After 42 months a 65% actuarial survival was found in the combined AVR and graft(s) series versus a 76% survival in 300 AVR patients proven by angiography not to have severe coronary atherosclerosis.     

Morbidity and mortality of reoperation for coronary artery bypass grafting: significance of atheromatous vein grafts.

Reoperation ('redo') for coronary artery disease shows a significant increase in morbidity and mortality compared to primary surgery. Some technical approaches have been advocated to decrease myocardial injury, presumably due to coronary artery embolization from atheromatous vein grafts. From 1984 to 1989, 321 'redo' operations were performed at the Montreal Heart Institute. Patients with patent and atherosclerotic vein grafts at preoperative coronary angiography (239 patients) were compared to those with normal or occluded grafts (82 patients). Perioperative myocardial infarction and death rates were 19% and 13%, respectively. They were particularly high among patients with three or more patent and atherosclerotic vein grafts at reoperation (32% and 29%, respectively). Among the 239 patients with patent atherosclerotic grafts, the results of three different surgical techniques were studied retrospectively. A first group of 66 patients had early ligation of patent atheromatous grafts before cardioplegia was administered by antegrade infusion during single aortic clamping for coronary anastomoses, and maintained for the confection of aortic anastomoses. In a second group of 35 patients, early ligation of diseased graft, antegrade cardioplegic delivery, and partial aortic cross clamping for aortic anastomoses of vein grafts was done. In the third group of 138 patients, venous grafts were not interrupted before antegrade cardioplegic infusion and partial aortic cross clamping for aortic anastomoses of vein grafts was used. No significant difference in hospital mortality or perioperative myocardial infarction rate was observed between the three groups of patients. Thus, the modified techniques so far recommended for repeat coronary artery bypass grafting, such as early ligation of patent atherosclerotic grafts, have failed to improve the early results of 'redo' operations.     

Graft patency and myocardial viability after aorto-coronary bypass surgery evaluated by exercise 201T1 myocardial SPECT

To evaluate graft patency and myocardial viability after aorto-coronary (AC) bypass surgery, 58 patients (29 with old myocardial infarction and 29 with effort angina) underwent symptom-limited exercise 201T1 myocardial SPECT using a bicycle ergometer before and after surgery. The results were as follows: 1. The overall angiographic graft patency was 87% (97 of 112 grafts). 2. According to the stress SPECT images, graft patencies were 98% for areas with postoperative improvement by 201T1 uptakes, 79% for areas with unchanged patterns, and 53% for areas with worsened patterns. In spite of patent grafts, among cases with worsened 201T1 uptakes the etiologies included perioperative infarction, anastomotic strictures, and poor run-off distal to the anastomoses. 3. Following patency of grafts, postoperative normalized perfusion patterns were observed in 69% (27 of 39 segments) of segments with persistent preoperative low uptakes and 25% (4 of 16 segments) of segments with persistent preoperative defects. Thus, exercise 201T1 myocardial SPECT proved a useful diagnostic means of assessing graft patency and effectiveness. However, after AC bypass surgery, 25% of the regions which had persistent defects before surgery exhibited normal perfusion patterns. These findings suggest that persistent defects may represent hypoperfusion of viable myocardium, and that we should carefully diagnose myocardial scars.     

非体外循环冠状动脉旁路移植术中应用主动脉近端吻合器的临床效果

目的评价主动脉近端吻合器在非体外循环冠状动脉旁路移植术中应用的临床效果。方法对84例冠状动脉粥样硬化性心脏病患者行非体外循环下冠状动脉旁路移植术。静脉桥近端吻合口摒弃传统侧壁钳钳夹下吻合的方法,应用主动脉近端吻合器完成。结果全组病例无死亡,无围术期心肌梗死,无围术期脑出血、脑梗塞等神经系统并发症。术后开胸止血1例,迟发性心包填塞1例,急性肾功能衰竭1例,上消化道大出血1例,均痊愈。结论冠状动脉旁路移植术中应用主动脉近端吻合器,操作简单、安全,可降低术后脑血管并发症的发生率。     

A versatile technique for aortic root replacement without pre-manufactured composite graft: a 12-year experience

BACKGROUND AND AIM OF THE STUDY: Replacement of the aortic root is the treatment of choice for aneurysmal dilatation. Many modifications of the Bentall technique have been described, as have valve-sparing procedures. The study aim was to determine the outcome of a versatile modification of composite replacement that has been adopted over the past 12 years. Separate graft and prosthetic valve components were used to allow freedom of valve choice and the use of an appropriately sized graft for the distal aortic anastomosis. METHODS: Between January 1990 and March 2002, 59 patients (45 males, 14 females; mean age 56 +/- 14 years) underwent aortic root replacement using this technique. Indications for surgery were elective in 35 patients and emergent (usually type A aortic dissection) in 24. The range of valve prostheses used, their size, and the size of aortic graft used in each case was assessed. Durations of ischemia and cardiopulmonary bypass were recorded, as was postoperative blood loss and subsequent patient progress, including valve-related events, perioperative mortality and actuarial survival. RESULTS: A wide range of aortic graft sizes was combined with both mechanical and tissue valves (from 1-7 mm larger in diameter). Median postoperative blood loss was 550 ml (IQR 400-800 ml). Perioperative mortality was 5.1%. There were no valve- or technique-related deaths, and the median actuarial survival was 13.17 years. During a 12-year follow up there were no proximal aortic reoperations. CONCLUSIONS: This technique had favorable perioperative mortality, produced a secure proximal suture line, and allowed the surgeon free choice of both valve type and size of aortic graft. This minimized tension at the distal suture line, and produced good hemostasis, especially in those patients with fragile dissected tissues.     

Late results of combined mitral valve replacement and coronary bypass surgery

The incremental risk of coronary bypass surgery was analyzed in 718 patients undergoing mitral valve replacement between 1971 and 1983. Ninety-eight patients (14%) had significant coronary artery disease requiring coronary bypass surgery. In 70 of these patients, the origin of the mitral valve disease was nonischemic, whereas 28 patients had ischemic mitral regurgitation unsuitable for conservative valve surgery. There were six operative deaths (9%) and four perioperative myocardial infarctions (6%) after mitral valve replacement and coronary bypass surgery for nonischemic mitral valve disease. Operative mortality was related to low output cardiac failure before operation or perioperative myocardial infarction. Actuarial curves predict survival (+/- standard error) of 55 +/- 7% at 5 years and 43 +/- 8% at 10 years. Preoperative functional class was the only significant predictor of long-term survival in this group (p less than 0.05). The actuarial survival of the 620 patients without coronary artery disease who underwent mitral valve replacement alone was 63 +/- 3% at 10 years. This was significantly better than that of the 70 patients who underwent mitral valve replacement and coronary bypass surgery for nonischemic mitral valve disease (p less than 0.001). Conversely, 5 year survival of the 28 patients with ischemic mitral regurgitation was 43 +/- 10%. This confirms the negative detrimental effect of an ischemic origin of mitral valve disease on survival after mitral valve replacement and coronary bypass surgery (p less than 0.0001).     

Prolonged safe ischemic cardiac arrest using hypothermic Bretschneider cardioplegia combined with topical cardiac cooling. Clinical experience with cardiac arrest of up to 180 minutes in a few borderline cases

Out of 494 patients operated upon using Bretschneider cardioplegia, 8 complicated surgical procedures (3 cases of single or double valve replacement combined with coronary bypass grafting, 2 cases of double valve replacement, 2 cases of multiple coronary bypass procedures and one case of aortic valve replacement with replacement of the ascending aorta) required a mean aortic cross-clamp time of 164 minutes. Four patients had a single infusion, and 4 other patients 2 or more infusions, of cold cardioplegic solution. With the aid of topical cooling, the myocardial temperature was reduced to a mean value of 12.8 degrees C. Postoperatively the heart in all patients resumed a good contractile activity. None sustained myocardial infarction during the perioperative or postoperative period. One patient died on the 19 postoperative day because of subdural hemorrhage not related to the cardioplegic procedure. All other patients have survived from 10 to 63 months (mean 23 months).     

Surgical implications and results of combined aortic valve replacement and myocardial revascularization.

To better define the indications for and results of simultaneous aortic valve replacement and myocardial revascularization, a cohort of 271 patients with angiographically defined coronary anatomy who underwent xenograft bioprosthetic aortic valve replacement were analyzed. Two hundred and twelve patients had predominant aortic stenosis, and 55 had pure aortic regurgitation. Discordance between the clinical assessment of angina and the angiographic assessment of coronary artery disease was apparent in 39 percent of the patients with aortic stenosis and 45 percent of the patients with aortic regurgitation. Thirty-seven percent of patients in the aortic stenosis subgroup without angina and 41 percent of patients in the aortic regurgitation subgroup without angina had hemodynamically significant coronary artery disease. Concomitant coronary artery bypass grafting and aortic valve replacement were performed in 101 patients. The incidence of perioperative myocardial infarction and operative death was significantly greater (P < 0.05) in the subsets of patients with coronary disease than in those without coronary disease (9.9 percent versus 0.7 percent and 8.3 percent versus 2.2 percent, respectively). Late postoperative angina and myocardial infarction also correlated with the preoperative presence of coronary artery disease. Excluding operative mortality, the late actuarial survival rate (mean follow-up, 1.6 years; maximal follow-up, 4.9 years) was not statistically lower for the patients with coronary disease.It is concluded that angina pectoris in patients with aortic valve disease is not a reliable indicator of coronary artery disease and that patients with coronary disease who undergo aortic valve replacement have an increased risk. It is inferred from this study that preoperative coronary arteriography is advisable in most adults undergoing the evaluation of aortic valve disease and that simultaneous aortic valve replacement and myocardial revascularization may provide some protection against late attrition due to the combined effects of coexistent aortic valve and coronary artery disease.     

Percutaneous transluminal angioplasty of saphenous vein graft stenosis: long-term follow-up

Percutaneous transluminal angioplasty was used to treat 101 patients with saphenous vein bypass graft stenosis at a mean of 50.1 months (range 2 to 196) after coronary artery bypass surgery. The patients presented between March 1981 and April 1987. A total of 107 saphenous vein grafts were dilated at 117 sites. The primary success rate was 91.8%. The incidence of cardiac complications was 7.1%. There were no cardiac complications in 53 patients with grafts implanted less than 36 months before angioplasty (Group 1). The 48 patients with grafts implanted for greater than 36 months (Group 2) had a 12.5% incidence rate of myocardial infarction, a 4% incidence rate of emergent bypass surgery and a 4% incidence rate of death for an overall cardiac complication rate of 14.9% (p less than 0.01). Follow-up was obtained at a mean of 16.8 +/- 13.9 months (range 1 to 54) in 87 patients (97% of successful cases). Repeat coronary angiography was performed in 49 patients and revealed restenosis in 30 patients (61.2%), with no difference in recurrence rates for proximal, mid or distal graft sites. Clinical recurrence (defined as recurrence of symptoms, myocardial infarction, repeat angioplasty, surgery or death) was 33.1% for Group 1 patients and 64.1% for Group 2 patients (p less than 0.01). The complication and recurrence rates of saphenous vein graft angiography are significantly higher when performed for late (greater than 36 months) vein graft failure. All therapeutic options should be carefully examined before proceeding with angioplasty for saphenous vein graft stenosis in this type of patient.     

The surgical treatment of aneurysms of the ascending aorta with associated aortic insufficiency. Total replacement with reimplantation of the coronary arteries]

We reviewed our experience with replacement of the ascending aorta and aortic valve with a composite graft and reimplantation of coronary arteries to the tube graft during 8 years interval from April, 1982, to April 1990. 24 patients underwent repair, the mean age was 49.83 years. Annuloaortic ectasia was the most common indication (58.33%), followed by aortic dissection (acute or chronic). Emergency operation was carried out in nine patients with aortic dissection (37.5%) and elective in 15. The mean duration of cardiopulmonary bypass was 118 +/- 4 minutes and of aortic clamping 83.85 +/- 2 minutes. Hospital mortality was 4.17%, reoperation for hemorrhage was 12.5% and perioperative morbidity for other causes was 34.7%. There were one late death. 20 patients were follow-up with a total of 638 patients-months (two patients excluded with insufficient follow-up and one late death). At last follow-up 14 patients were in functional class I. Eight year actuarial survival for the 24 patients was 91%. We believe that replacement of the ascending aorta and aortic valve with a composite graft and coronary arteries reimplantation to the tube graft is more than one satisfactory alternative to supracoronary graft replacement and aortic valve replacement. It offers the advantage of excluding all abnormal aortic tissue, eliminating the risk for later development of complications in the non excluded disease aorta. It supposes the method of choice for patients with anuloaortic-ectasia, aneurysms of the sinuses of Valsalva with aortic insufficiency, and aortic dissection with proximal affectation of coronary arteries and aortic valve.     

Myocardial revascularization combined with aortic valve replacement

We reviewed 50 consecutive patients who had undergone complete myocardial revascularization combined with aortic valve replacement during a 5-year interval ending in June 1983. A cold blood cardioplegia technique, utilizing not only the native circulation but also the vein conduits, was used. All patients had greater than 70% stenoses of the major coronary arterial system. No patient had valve replacement alone, and no patient was refused operation. The mean number of arteries grafted was 2.3. There were two hospital deaths. One patient had evidence of perioperative myocardial infarction. There were two late deaths and one non-fatal myocardial infarction during the follow-up period, which averaged 16 months. The technique of hypothermic blood cardioplegia used provides a uniform distribution for myocardial protection, especially in the hypertrophied ventricle, and is superior to previously employed methods. This study indicates that myocardial revascularization combined with aortic valve replacement should be performed in patients with coexisting aortic valvular and coronary disease.     

Coronary flow reserve provided by sequential internal mammary artery grafts

Although internal mammary artery bypass grafts have a high patency rate, the adequacy of blood flow through such conduits, particularly if used sequentially, has been questioned. To evaluate this issue, coronary flow reserve was studied in 20 patients after coronary bypass surgery. Nine patients had sequential internal mammary grafts to the diagonal and left anterior descending coronary arteries; five had a single internal mammary graft to the left anterior descending artery and six had sequential saphenous vein grafts. Fifteen additional single vein grafts were also placed in these patients. Coronary flow reserve was measured after contrast-induced hyperemia by a digital subtraction angiographic technique an average of 25 days after surgery. There was no difference in coronary flow reserve between the proximal and distal anastomotic regions in either the sequential internal mammary graft group (2.14 +/- 0.50 versus 2.29 +/- 0.68, n = 8, p = NS) or the sequential vein group (1.77 +/- 0.49 versus 2.08 +/- 0.78, n = 6, p = NS). In addition, the flow reserve provided to either vascular bed of the sequential internal mammary graft was not different from that provided by a single internal mammary graft (1.64 +/- 0.39, n = 5), a single vein graft (1.95 +/- 0.95, n = 15) or nonstenotic native coronary arteries (2.04 +/- 0.87, n = 34). No cases of intracoronary steal were observed. Although some patients had unequal flow reserves between the proximal and distal anastomotic zones, these occurred in the setting of residual coronary stenoses distal to the site of graft insertion or prior myocardial infarction in the grafted distribution.(ABSTRACT TRUNCATED AT 250 WORDS)     

Myocardial infarction determined by technetium-99m pyrophosphate single-photon tomography complicating elective coronary artery bypass grafting for angina pectoris

The incidence of acute myocardial infarction (AMI) complicating coronary artery bypass grafting (CABG) has previously been based on concordance of electrocardiographic, enzymatic and scintigraphic criteria. Technetium-99m pyrophosphate (Tc-PPi) single-photon emission computed tomography now enables detection of AMI with high sensitivity and specificity. Using this technique, perioperative AMI was detected in 12 of 58 patients (21%) undergoing successful elective CABG for stable angina pectoris. Stepwise multivariate logistic regression analysis was performed to compare the predictive value of preoperative (New York Heart Association class, left ventricular ejection fraction and use of beta blockers) and intraoperative (number of grafts constructed, use of internal mammary anastomoses, use of sequential saphenous vein grafts, smallest grafted distal vessel lumen caliber and aortic cross-clamp time) variables. Preoperative New York Association class (p = 0.04) and smallest grafted distal vessel lumen caliber (p = 0.03) were significant multivariate predictors of perioperative AMI. Only 1 perioperative patient with AMI (and 1 pyrophosphate-negative patient) developed new Q waves. Serum creatine kinase-MB was higher in patients with AMI by repeated measures analysis of variance (p = 0.0003). Five AMIs occurred in myocardial segments revascularized using sequential saphenous vein grafts, and 7 in segments perfused by significantly stenosed epicardial vessels with distal lumen diameter and perfusion territory considered too small to warrant CABG. At 6-month follow-up, the mean left ventricular ejection fraction increased from 0.61 to 0.65 in Tc-PPI-negative patients (p = 0.01), but not in perioperative patients with AMI.(ABSTRACT TRUNCATED AT 250 WORDS)     

Iatrogenic ostial stenosis of the left coronary artery. Report of a case with Starr-Edwards aortic prosthesis (author's transl)

A case of a 41 years-old-man, who had undergone surgical intervention ten years previously for aortic valve replacement in ECC with the coronary perfusion technique, is reported. This patient was studied because of the appearance of angina pectoris three months after the intervention and its progressive development. Selective left coronary angiography showed an ostial subocclusive stenosis; the run-off from the right coronary artery provided distal blood supply to the left coronary artery. A venous bypass was implanted between the aorta and the left anterior descending branch; the prosthesis was substituted because it was altered and caused hemolysis' problems. In accordance with most Authors late ostial coronary stenosis is a complication of the coronary perfusion technique, which is adopted for myocardial protection during surgical interventions for aortic valve replacement.     

Mid-Term Outcome of Surgical Coronary Ostial Plasty: Our Experience

Abstract The conventional coronary artery bypass procedure that uses venous or arterial conduit for isolated critical stenosis of the left main coronary artery (LMCA) restores a less physiological perfusion of the myocardium and uses an appreciable length of bypass material, Coronary ostial plasty has been described as an alternative surgical technique in proximal obstructive coronary artery disease without calcifications. Here we report 23 patients (15 males and 8 females aged 37–78 years; mean age 57 years) who underwent surgical ostial plasty. Ostial reconstruction with fresh pericardial patch was performed in all patients: 15 patients with LMCA stenosis, 6 patients with right coronary (RC) ostial stenosis. and 2 patients with both RC artery and LMCA stenosis. In seven cases, coronary artery bypass grafting was added for contralateral distal stenosis with a total of five arterial conduits and six venous grafts. One patient died; the ostial plasty and grafts were patent at necropsy. Thal-lium-201 myocardial scintigraphy under stress at 30 days to 6 months after operation demonstrated good myocardial perfusion in 21 of 22 patients. Coronary angiography at follow-up (49 ± 8 months) demonstrated good surgical ostial plasty results in 21 of 22 patients and good coronary flow in 19 of 22 patients; angiographic study at mid-term follow-up revealed only one failure of the surgical ostial plasty technique associated with venous graft obstruction. In 2 other patients CABG failure due to venous graft obstruction (1 patient) or distal stenotic lesions of the left coronary artery (1 patient) was noted. The overall successful outcome of the surgical ostial plasty was 22 of 23. We believe that surgical angioplasty of the coronary ostia may be used in the presence of proximal noncalcified obstructive lesions as an alternative technique, which offers a more physiological revascularization; it also spares grafting material and allows subsequent percutaneous transluminal angioplasty or coronary artery bypass surgery. (J Card Surg 7999; 14:294–300)     

Enclose Ⅱ在148例非体外循环冠脉旁路移植术中的临床应用分析

目的 总结冠脉搭桥近端吻合辅助器（Enclose Ⅱ）在不停跳冠状动脉脉旁路移植术（OPCAB）中应用的临床经验和体会.方法 自2009年8月至2013年5月我们对148例冠心病患者在施行OPCAB手术时应用Enclose Ⅱ行主动脉近端吻合,男性109例,女性39例,年龄51～83（60.1±3.2）岁.结果 应用Enclose Ⅱ完成近端吻合口298个,其中大隐静脉与升主动脉近端吻合263个,桡动脉35个,平均（2.01±0.80）个吻合口/例.围术期无死亡,无心肌梗死和脑卒中,术中未出现升主动脉破裂和急性主动脉夹层.结论 OPCAB术中应用EncloeⅡ完成近端吻合口,减少和减轻了对升主动脉的操作和损伤,尤其对主动脉钙化严重的患者,能有效避免因主动脉操作而引起主动脉破裂和急性主动脉夹层的发生,降低因斑块脱落引起的围术期心肌梗死和脑卒中的发生.