Diabetes in patients undergoing coronary artery bypass grafting. Impact on perioperative outcome

Summary Diabetes mellitus is an established risk factor related to significant morbidity and mortality after coronary artery bypass grafting. Data on 9682 patients undergoing coronary artery bypass grafting either with (n=8917) or without cardiopulmonary bypass (off-pump coronary artery bypass grafting; n=765) were subjected to an univariate analysis to identify potential associations between diabetes mellitus and 26 a priori selected perioperative outcome variables. Those having a significant association with diabetes were then subjected to a stepwise logistic regression model to identify the impact of diabetes as compared to additional 22 different a priori chosen patient related risk factors and treatment variables. Prevalence of outcome variables independently associated with diabetes has been determined in the subgroup of diabetics undergoing coronary artery bypass grafting with cardiopulmonary bypass or off-pump coronary artery bypass grafting surgery to evaluate the effect of avoiding cardiopulmonary bypass on perioperative patient outcome. Diabetes mellitus was defined as glucose intolerance either treated dietary, with oral hypoglycemics or with insulin. According to this definition of diabetes mellitus we found an overall prevalence of 37.1% (coronary artery bypass grafting with cardiopulmonary bypass: 37.5%; off-pump coronary artery bypass grafting: 32.5%). Eleven outcome variables having a significant association with diabetes were identified. Diabetes could be identified as an independent predictor of postoperative delirium, renal dysfunction and respiratory insufficiency. Prevalence of these three variables was lower in diabetics undergoing offpump coronary artery bypass grafting as in those undergoing coronary artery bypass grafting with cardiopulmonary bypass surgery reaching statistical significance with regard to postoperative delirium and respiratory insufficiency. In conclusion, diabetes mellitus is a significant independent predictor for three postoperative outcome variables in coronary artery bypass surgery. Avoiding cardiopulmonary bypass in diabetics seems to have a beneficial effect.     

非体外循环冠状动脉旁路移植术对血小板功能的影响

目的 探讨非体外循环冠状动脉旁路移植术对患者凝血及血小板功能的影响。方法 回顾分析了2015年1～4月间82例行非体外循环冠状动脉旁路移植术的患者的临床资料,男性60例,女性22例,年龄（65.27±8.41）岁,体重（61.22±9.74）kg,通过对患者术前与术后血液血栓弹力图进行分析,记录R时间、K时间、α角、MA值、INHADP及INHAA等指标变化。结果 手术前后R时间、K时间、α角未见统计学差异（P>0.05）;与术前相比,术后MA值显著降低（56.6±12.1比60.8±9.7）、INHADP（61.2±17.7比30.7±12.4）及INHAA（31.6±13.9比16.9±9.8）显著增高（P<0.05）。结论 非体外循环冠状动脉旁路移植术造成患者血小板损伤,影响患者凝血功能。     

Sialic acid or troponin T to detect perioperative myocardial damage in patients undergoing elective coronary artery bypass grafting.

Sialic acid (SA), a family of acetylated derivatives of neuraminic acid, is elevated in patients with coronary heart disease. Cardiac troponin T (cTnT), myoglobin (Mb), and creatine kinase-MB (CK-MB) are specific markers of myocardial injury and are, at present, widely used to detect perioperative myocardial damage during coronary artery bypass grafting (CABG) surgery. The present study investigated the net myocardial release of SA and the cardiac markers (cTnT, Mb, CK-MB) during reperfusion after hypothermic cardioplegic cardiac arrest in 25 patients undergoing elective CABG. Additional paired arterial, central venous, and coronary sinus blood samples were obtained after atrial cannulation before aortic cross-clamping (preischemic sample) and at 1 and 10 min after aortic declamping (reperfusion samples). There were no increase in the SA, cTnT, Mb and CK-MB concentrations before aortic cross-clamping, but there was considerable release of these markers within 10 min after aortic declamping: cTnT release was significantly higher compared with baseline values before aortic cross-clamping. In contrast to SA, Mb, and CK-MB, the difference between baseline and release values for cTnT at 1 min after aortic declamping was not significant. The rate of increase for SA was significantly higher than for Mb, CK-MB and cTnT. SA is a unique and novel marker that could be particularly useful in assessing myocardial cell damage in patients undergoing cardiac surgery.     

零平衡超滤对老年冠状动脉搭桥围术期心肺功能的影响

目的评估体外循环（ECC）中采用零平衡超滤对老年冠状动脉搭桥围术期心肺功能的影响。方法选取拟行冠状动脉搭桥术患者20例，随机分为两组，超滤组和对照组。分别在术前0．5h（T1）、主动脉阻断后30min（T2）、ECC结束后1h（T3）、8h（T4）、24h（T5）、48h（T6）抽取静脉血，测定血浆肌酸肌酶同工酶（CK-MB）、心肌肌钙蛋白I（cTnI）、肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）的水平．监测并记录T1～T6各时间的肺泡-动脉血氧分压差P（A-a）O2，并记录患者心脏自动复跳率及术后恢复情况。结果超滤组患者心脏自动复跳率明显高于对照组；超滤组术后机械通气时间及ICU停留时间显著短于对照组（P〈0．05）；两组患者ECC后CK-MB、cTnI、TNF-α、IL-6血浆浓度均有不同程度升高，但超滤组患者血浆CK—MB、IL-6浓度在T2～T6均低于对照组（P〈0．01或P〈0．05）．超滤组cTnI浓度在T2～T5、TNF-α浓度在T3～T5低于对照组（P〈0.05）；超滤组肺泡-动脉血氧分压差在T3低于对照组（P〈0．05）。结论ECC中采用零平衡超滤对老年冠状动脉粥样硬化性心脏病患者的心肺功能有一定程度的保护作用。     

Influence of preoperative lipid-lowering therapy on postoperative outcome in patients undergoing coronary artery bypass grafting

Statin therapy has recently been shown to decrease adverse perioperative events in patients undergoing vascular surgery. The potential beneficial effect of lipid-lowering therapy in patients undergoing coronary artery bypass grafting (CABG) is not well known. This was an observational analysis of 4,739 patients who underwent first-time isolated CABG at a single institution from 1995 to 2001. Patients were categorized into 2 groups based on treatment with a lipid-lowering agent within 30 days before surgery. Univariate and multivariate analyses were used to determine the association between lipid-lowering therapy and survival to hospital discharge. Patients in the lipid-lowering group (n = 2,334) tended to be younger (mean age 66 +/- 10 vs 68 +/- 10 years), were more likely to be diabetic (31% vs 28%), and on beta blockers (77% vs 70%) than patients in the nonlipid-lowering group (n = 2,405). In-hospital mortality was significantly lower in the lipid-lowering group than in the nonlipid-lowering therapy group (1.4% vs 2.2%, odds ratio 0.62, 95% confidence interval 0.40 to 0.96, p = 0.03). A multivariable model demonstrated a loss of statistical significance for the effect of lipid-lowering therapy on in-hospital mortality (adjusted odds ratio 0.83, 95% confidence interval 0.5 to 1.37, p = 0.46). In conclusion, preoperative use of lipid-lowering therapy in patients undergoing CABG appears safe and is associated with improved survival to hospital discharge compared with patients not receiving lipid-lowering therapy. However, patient risk factors and other cardioprotective medication use associated with the use of preoperative lipid-lowering therapy appear to explain the association with improved survival.     

Effects of 2 different antiplatelet regimens with abciximab or tirofiban on platelet function in patients undergoing coronary stenting

Background

We sought to compare the antiplatelet effects of the glycoprotein IIb-IIIa receptor blockers abciximab or tirofiban, combined with an adjuvant therapy with clopidogrel and aspirin.

Study design and methods

Twenty patients undergoing coronary stenting were randomly assigned to receive either abciximab or tirofiban combined with aspirin and clopidogrel. Serial blood samples were taken to assess platelet aggregation, P-selectin expression, thrombin generation, and platelet-induced endothelial cell expression of MCP-1, uPAR, and ICAM-1.

Results and conclusions

The therapy with aspirin plus clopidogrel attenuated agonist-induced platelet aggregation and P-selectin surface exposure (P < .05 vs aspirin monotherapy). Both tirofiban and abciximab further reduced agonist-induced platelet aggregation (P < .05), and decreased thrombin generation but had no effect on platelet α-granule release. None of the antithrombotic strategies significantly affected platelet-induced endothelial cell activation. Since platelet adhesion/degranulation initiates an inflammatory/mitogenic response in the vascular wall, future therapeutic strategies will have to be aimed at the inhibition of platelet release reactions.     

非体外与体外循环下冠状动脉旁路移植术病人的心肌酶变化

目的 比较患者在非体外循环下冠状动脉旁路移植术(off-pump coronary artery bypass grafting,OPCAB)与体外循环下冠状动脉旁路移植术(on-pump coronary artery bypass grafting,CCABG)围术期心肌酶的变化.方法 择期手术的冠心病患者52例,分为OPCAB组和CCABG组.分别于术前1天,术后1,3,5,8日晨测定血清天冬氨酸转氨酶(glutamic-oxal (o)acetic transaminase,GOT),肌酸激酶(creatine kinase,CK)及心肌型肌酸激酶同工酶MB(MB isoenzyme of creatine kinase,CK-MB),乳酸脱氢酶(lactate dehydrogenase,LDH)及同工酶1(LDH-1).结果 两组择期手术的冠心病患者术前心肌酶的测定结果均在正常范围;术后第1天两组的心肌酶释放达到高峰(P＜0.05),术后第3天均有不同程度的恢复;OPCAB组的所有心肌酶释放量与手术前相比差异无统计学意义(P＞0.05),CCABG组的CK-MB也恢复到手术前水平(P＞0.05),但CCABG组在术后第5天和第8天的LDH和LDH-1仍明显高于术前水平(P＜0.05);两组病人术后第3天的CK-MB恢复到术前水平,但CCABG组其他心肌酶在术后第1天和第3天都明显高于OPCAB组(P＜0.05),CCABG组在术后第5天和第8天的LDH和LDH-1仍明显高于OPCAB的对应值(P＜0.05).结论 OPCAB组的心肌的损伤要轻于CCABG组,表现为心肌酶的释放少而且恢复快.     

音乐疗法对冠状动脉旁路移植术围术期患者焦虑及抑郁影响的研究

目的:探讨音乐疗法在改善冠状动脉旁路移植手术前后,患者焦虑及抑郁心理的作用。方法:将300例拟行冠状动脉旁路移植患者采用随机数字表法分为干预组和对照组各150例,干预组患者除给予常规心外科护理外接受音乐疗法,对照组给予常规心外科护理。结果:全组患者无手术死亡,手术前将两组研究对象进行比较,差异无统计学意义,术后5天重复进行医院焦虑抑郁量表(HAD)量表测试,干预组与对照组间焦虑值和抑郁值均存在非常显著差异,干预组明显优于对照组。结论:音乐疗法适用于冠状动脉旁路移植术围术期焦虑、抑郁的患者,其辅助作用可以使焦虑、抑郁症状得到改善。     

冠状动脉旁路移植术中体外循环对肾功能的影响

目的:了解冠状动脉旁路移植术中体外循环对病人肾功能损伤的影响。方法:689例行冠状动脉搭桥术患者按施行体外循环与否及体外循环时间进行分组。分析术前及术后的肾功能指标水平。结果:冠状动脉旁路移植术后肾功能指标:血肌酐(Cr)、尿素氮(BUN),尿α-微量蛋白(MG)各指标水平较术前均有明显升高(P<0.01).体外循环组较非体外循环组升高更明显(P<0.05～<0.01);体外循环时间超过150 min者的升高最明显(P<0.01)。结论:非体外循环CABG术对病人肾功能损害影响的小于有体外循环的CABG术,过长时间的体外循环时间对肾功能损害的影响更大。     

Myocardial oxygen balance and cardiopulmonary bypass in patients undergoing coronary artery bypass grafting

The frequency of anaerobic myocardial metabolism was studied in 14 patients undergoing coronary artery bypass surgery during enflurane-supplemented high-dose fentanyl anesthesia and compared with other clinical monitors of myocardial ischemia including the configuration of the pulmonary capillary wedge pressure (PCWP) and electrocardiographic findings. Hemodynamic parameters, coronary sinus blood flow, myocardial oxygen and lactate extractions, and a seven-lead ECG were recorded before and after cannulation of the aorta and vena cava, during total cardiopulmonary bypass (CPB) in a vented heart, during rewarming after global myocardial ischemia and cold cardioplegia, and 15 minutes after coming off bypass. The cannulation for CPB induced no changes in the central or coronary hemodynamics, but four patients had abnormal lactate metabolism. Two of these also had ST segment depression, and two had prominent AC waves on the PCWP tracing. Coronary sinus blood flow and myocardial oxygen extraction were maintained at the beginning of CPB, but lactate extraction decreased markedly or turned to lactate production, and ECG changes indicating myocardial ischemia were seen in five patients. During rewarming and after CPB, all patients had abnormal lactate metabolism despite decreased myocardial oxygen extraction, adequate coronary perfusion pressure, and adequate coronary sinus blood flow. During these periods most patients also had cardiac conduction disturbances that made the interpretation of the ST segment impossible. Only one patient had clearly abnormal AC and V waves on the PCWP tracing after CPB. Two patients had ECG evidence of a perioperative myocardial infarction, but they had no significant clinical consequences. Four patients had a fascicular block at discharge. These results indicate that anaerobic myocardial metabolism is common during and after CPB, and that associated myocardial ischemia cannot always be reliably detected by changes in the ECG or the PCWP tracings.     

围术期停用他汀对冠状动脉旁路移植术后心房颤动的影响

目的探讨常规接受他汀治疗的患者围术期停用他汀对冠状动脉旁路移植术(CABG)后心房颤动(AF)的影响。方法 207例CABG前已在服用他汀至少1个月的患者,按围术期是否停用他汀,随机分为他汀组(n=103)与停用他汀组(n=104)。分析比较两组患者术后AF发生情况及超敏C反应蛋白(hs-CRP)水平变化。结果两组在临床资料、围术期参数方面无显著差异(P>0.05)。停用他汀组AF发生率显著高于他汀组(30.8%vs13.6%),症状性AF发生率、AF持续时间、最快心室率亦均显著高于他汀组(P均<0.05)。多因素Logistic回归分析显示停用他汀是CABG后发生AF的独立危险因素(OR=2.9,95%CI:1.3～6.3,P=0.007)。hs-CRP水平在两组变化趋势相似,停用他汀组术后不同时间hs-CRP均显著高于他汀组(P均<0.05)。结论冠心病患者CABG围术期停用他汀可增加术后AF发生率,这可能与炎症反应反弹有关。     

Associated vascular lesions in patients undergoing coronary artery bypass grafting

Atherosclerotic involvement of extracoronary arteries in patients undergoing myocardial revascularization can cause severe postoperative complications and increase postoperative mortality. Between January and November 1998, routine preoperative echo-Doppler study of carotid vessels, abdominal aorta and iliac-femoral arteries was performed in all patients undergoing coronary artery bypass grafting (CABG) at our institution, in order to assess the prevalence and the degree of associated vascular lesions. Correlations between echo-Doppler findings, angiographic patterns of coronary lesions and atherosclerotic risk factors were analyzed in all cases. Among 302 patients undergoing CABG, 186 (61.6%) had carotid disease, with a haemodynamically significant stenosis (>70%) of internal carotid in 31 (10.2%). Twenty-three patients had asymptomatic severe carotid disease. A significant correlation between severity of coronary disease and prevalence of severe carotid disease was found (p = 0.02). An abdominal aortic dilatation (diameter > 25 mm) was found in 20 cases (6.6%), with a diameter >35 mm in 7 patients (2.3%), 6 with triple-vessel coronary disease, and 1 with double-vessel disease. Atherosclerotic lesions of iliac-femoro-popliteal axis were found in 165 (54.6%) patients, with a strong correlation to the severity of coronary disease (p = 0.02); lesions were haemodynamically significant (> 70%) in 48 (15.8%) cases. Symptoms of carotid and peripheral vascular disease are no reliable predictors of perioperative risk in patients undergoing CABG. Non-invasive complete arterial investigation should be routinely performed in these patients, in order to plan the most suitable operative approach and to prevent perioperative vascular complications.     

非体外循环冠状动脉旁路移植术中血糖调控的应用

目的 探讨非糖尿病患者非体外循环冠状动脉旁路移植术围术期血糖调控的效果。方法 将70例行OPCAB的非糖尿病患者随机分为2组,每组35例。分别接受胰岛素输注(试验组)或生理盐水输注(对照组),观察麻醉诱导前、搭桥前、搭桥后、关胸后、术后ICU1h、ICU6h、ICU12h、血糖值。结果 1.试验组与对照组相比,术后呼吸机使用时间(13.78±6.42vs19.02±9.74)、术后住院时间(19.54±5.72vs22.48±6.45)均显著缩短,术后心律失常发生率显著降低。2.试验组与对照组相比较,血糖在麻醉诱导前无统计学差异,而搭桥前、搭桥后、关胸后、ICU1h、ICU6h、ICU12h的血糖显著降低。结论 非糖尿病患者行OPCAB围术期高血糖可能影响预后,输注胰岛素输注可以有效控制血糖、改善雨后。     

抗血小板治疗冠状动脉旁路移植术患者围手术期抗纤溶治疗效果的荟萃分析

目的 评价实施抗血小板治疗的冠状动脉旁路移植术(CABG)患者围手术期抗纤溶治疗的效果.方法 采用Cochrane系统评价方法,检索PubMed、EMbase、Highwire、CENTREN及其下属各临床注册试验数据中心数据库、中国生物医学文献数据库、中国期刊全文数据库.收集2000至2010年,实施抗血小板治疗(包括抑肽酶和氨甲环酸)的CABG患者围手术期抗纤溶治疗有效性方面的临床随机对照试验.按Cochrane系统评价方法,由2名评价者独立评价所纳入研究的文献质量,提取有效数据后,采用RevMan 5.0软件进行荟萃分析.结果 纳入11项研究,共计725例患者.荟萃分析显示:与空白对照治疗比较,实施抗血小板治疗CABG患者围手术期抗纤溶治疗的术后24h出血量较少(MD=-306.52 ml,95%CI:-351.52～-261.52,P＜0.01),需要输血的人数较少(OR=0.37,95%CI:0.26～0.51,P＜0.01),平均输血量较少(MD=-0.59 U,95%CI:-0.69～-0.50,P＜0.01),二次手术人数较少(OR=0.27,95%CI:0.09～0.78,P=0.02),血栓事件的发生率较低(OR=0.49,95%CI:0.25～0.97,P=0.04).结论 实施抗血小板治疗的CABG患者围手术期合理抗纤溶治疗可以有效减少术后24 h出血量、输血量和二次手术,并且不增加血栓事件的发生率.

Abstract：

Objective To evaluate the efficacy of antifibrinolytic agents in coronary artery bypass grafting (CABG) patients receiving antiplatelet. Methods We searched PubMed, EMbase, Highwire,CENTREN and its affiliated clinical trial registration data center, CBMdisc and CNKI databases from 2000 to 2010. Randomized controlled trials investigating the efficacy of anti-fibrinolytic agents (aprotinin and tranexamic acid) in CABG patients were identified. Study selection and meta-analysis were conducted according to the Cochrane Handbook for systematic reviews. Date were extracted from these trials by 2 reviewers independently and analyzed by RevMan 5.0 software. Result Eleven RCT trials ( n = 725 ) were included and data confirmed the efficacy of antifibrinolytic therapy in terms of reducing bleeding within 24 hours after operation(MD = - 306. 5 ml, 95% CI: - 351.52 to - 261.52, P ＜ 0. 01 ), number of patients who need blood transfusion ( OR = 0. 37, 95% CI: 0. 26 to 0. 51, P ＜ 0. 01 ), amount of blood transfusion ( MD = - 0. 59 U,95 % CI: - 0. 69 to - 0. 50, P ＜ 0. 01 ), surgical re-exploration ( OR = 0. 27,95 % CI: 0. 09 to 0. 78 ,P =0. 02), and thrombotic events( OR =0. 49,95% CI:0. 25 to 0. 97 ,P =0. 04) in CABG patients receiving antiplatelet, while compared with blank treatment. Conclusion This analysis showed that antifibrinolytic agents are effective for reducing bleeding within 24 hours after operation, amount of blood transfusion, surgical re-exploration and do not increase the incidence of thrombotic events in CABG patients receiving antiplatelet before operation.     

Outcomes of preoperative Angiotensin-converting enzyme inhibitor therapy in patients undergoing isolated coronary artery bypass grafting

The association between preoperative use of angiotensin-converting enzyme (ACE) inhibitors and outcomes after coronary artery bypass grafting (CABG) remain controversial. Our aim was to study in-hospital outcomes after isolated CABG in patients on preoperative ACE inhibitors. A retrospective analysis of 8,889 patients who underwent isolated CABG from 2000 through 2011 was conducted. The primary outcome of interest was the incidence of major adverse events (MAEs) defined as a composite of mortality, postoperative renal dysfunction, myocardial infarction, stroke, and atrial fibrillation during index hospitalization. The secondary outcome was the incidence of individual outcomes included in MAEs. Logistic regression analyses were performed. Of 8,889 patients, 3,983 (45%) were on preoperative ACE inhibitors and 4,906 (55%) were not. Overall incidence of MAEs was 38.1% (n = 1,518) in the ACE inhibitor group compared to 33.6% (n = 1,649) in the no-ACE inhibitor group. Preoperative use of ACE inhibitors was independently associated with MAEs (odds ratio 1.13, 95% confidence interval 1.03 to 1.24), most of which was driven by a statistically significant increase in postoperative renal dysfunction (odds ratio 1.18, 95% confidence interval 1.03 to 1.36) and atrial fibrillation (odds ratio 1.15, 95% confidence interval 1.05 to 1.27). In-hospital mortality, postoperative myocardial infarction, and stroke were not significantly associated with preoperative ACE inhibitor use. Analyses performed after excluding patients with low ejection fractions yielded similar results. In conclusion, preoperative ACE inhibitor use was associated with an increased risk of MAEs after CABG, in particular postoperative renal dysfunction and atrial fibrillation.     

米力农治疗冠状动脉旁路移植术后左室功能障碍的短期疗效

目的：评价米力农对冠状动脉搭桥术（CABG）中左室功能障碍患者短期疗效。方法：62例CABG术后低心排患者（左心室射血分数〈35％）纳入该研究。将患者随机分为米力农组[n=31,米力农（50μg／kg）静脉注射并于术后24h0．5μg／（kg·min）持续泵入]和对照组（n=31,生理盐水作为安慰剂）。左室功能障碍采用血流动力学参数和经胸廓的超声心动图进行评估。结果：两组患者的基线水平有差异,术前米力农组患者的左心室射血分数低于对照组,术后两组无明显差异。米力农组的血清肌酸磷酸激酶（CK）及其同工酶（CK—MB）、发生心肌缺血或梗死和应用正性肌力药物的时间均显著低于对照组（P〈0．05,P〈0．01）。室性心律失常、使用主动脉内球囊反博的时间、机械通气和24h病死率两组无明显差异。结论：对于接受CABG,尤其是左室射血分数较低的的患者,应用米力农可以减少心肌梗死发生的风险和应用正性肌力药物支持的时间。     

Comparative study of risk factors in patients undergoing coronary or femoropopliteal artery bypass grafting.

OBJECTIVE--To compare risk factors in two populations of patients with advanced atheroma requiring coronary or femoropopliteal artery bypass grafting to try to account for the different localisations of vascular disease. DESIGN--Cross sectional epidemiological study. SETTING--Cardiovascular surgery department of a university hospital. SUBJECTS--464 men (mean age 59.25 (SD 8.57) years) undergoing coronary artery bypass grafting; 74 men (mean age 56.28 (13.3) years) undergoing femoropopliteal artery bypass grafting; and 204 control men (mean age 45.07 (6.59) years) who had been recruited in a preventive medicine department. INTERVENTIONS--Blood samples were drawn 24 hours before surgery. METHODS--Lipid and lipoprotein concentrations were measured for each patient and with adjustment for age were compared by analysis of covariance. The main risk factors (smoking, arterial hypertension, obesity, and diabetes) were determined by a standardised history, and the chi 2 test was used to compare the results in the two patient groups. Pairwise comparisons between the three populations were performed by logistic discriminant analysis. RESULTS--Both patient groups showed a significant rise in triglyceride concentration and in the ratio of total cholesterol to high density lipoprotein cholesterol (R1) and a drop in apolipoprotein AI and high density lipoprotein cholesterol concentrations. Disturbances were greater in patients undergoing coronary artery bypass grafting than in those undergoing femoropopliteal artery bypass grafting for the R1 ratio, apolipoprotein B concentration, and the ratio of apolipoprotein AI to apolipoprotein B (R2). A higher proportion of smokers was found in the femoropopliteal bypass group than in the coronary bypass group, whereas were often obese. Logistic discriminant analysis with adjustment for age and with the coronary bypass as the reference group selected three factors: smoking, the R2 ratio, and obesity. CONCLUSION--Disturbances in lipid and apoprotein concentrations varied with respect to bypass site. Other risk factors played a part in accelerating the atherogenic process, especially smoking in patients undergoing femoropopliteal artery bypass grafting and, to a lesser degree, obesity in patients undergoing coronary artery bypass grafting.     

Analysis of mortality in low-risk patients undergoing coronary artery bypass grafting

Aim

The aims of this study were to determine the early mortality rate in low-risk coronary artery bypass graft (CABG) patients and examine the causes of death, to identify problems that could be avoided in future surgeries.

Methods

All low-risk patients (EuroSCORE ≤ 2) who died after CABG were included. Their peri-operative information was meticulously studied by internal and independent external reviewers to identify causes of death, which were classified as: cardiac or non-cardiac; and a further division as: (1) non-preventable, (2) preventable (technical error), and (3) preventable (system error).

Results

Early mortality was 0.93% (24/2 570). Eleven patients (45.8%) were classified as preventable deaths. In six of them the main problem was identified as graft thrombosis, which was secondary to a technical error of either the harvesting or anastomosis of the left internal mammarian artery. There were also five system errors identified as delays in the treatment of an identified and potentially reversible problem.

Conclusions

Correction of technical and system errors, such as harvesting of the left internal mammarian artery, haemostasis during surgery, and establishing standard protocols for the transfer of patients from ward to intensive care units will eventually lead to improvement in both the quality of care and patient outcomes, even in low-risk groups.     

非体外循环下冠状动脉搭桥术的麻醉管理

目的 :总结 2 8例非体外循环下多支冠状动脉搭桥术的麻醉管理。方法 :术前依据患者心脏功能及全身状况 ,给予营养心肌、扩冠、降压、利尿等治疗。采用静吸复合麻醉 ,气管插管控制呼吸 ,在非体外循环下行冠状动脉搭桥术。结果 :手术期间 4例血压过低 ,2例 ST段显著抬高伴室性心律失常 ,改为体外循环辅助下手术 ,余 2 2例术中血流动力学平稳。术毕非体外循环组 2 2例 6～ 8h内拔管 ,明显少于体外循环组 （10～ 16h）。 2 8例预后良好 ,无麻醉并发症。结论 :维持血流动力学平稳和心肌氧供需平衡 ,是非体外循环下冠状动脉搭桥术麻醉的关键