非体外循环冠状动脉旁路移植术围术期护理

<正>非体外循环冠状动脉旁路移植术(OPCAB)是不采用体外循环在跳动的心脏上进行冠状动脉搭桥的手术,是一种具有微创性的心脏外科手术,减少乃至避免了常规体外循环下冠状动脉旁路移植术所引起的心肌缺血再灌注损伤和体外循环损伤,较常规体外     

非体外循环冠状动脉旁路移植术围术期肌钙蛋白(TnI)及磷酸激酸(CK-MB)变化的研究

目的近年来随着心脏外科手术器械的发展、外科手术技艺的不断提高,微创心脏外科已逐渐成为心脏外科领域的一大特点。由此,迫使麻醉医师去迎接新的挑战,不断探索新的麻醉方法、新的心肌保护方法。本研究初步观察非体外循环冠状动脉旁路移植术(off-pump CABG)围术期肌钙蛋白I(TnI)及磷酸激酸(CK-MB)的变化,探讨TnI及CK-MB在评价心肌损伤和心肌保护效果的临床价值。方法30例行off-pump CABG病人,分别在麻醉诱导后、开放主动脉侧壁钳后5 min、6 h、24 h及48 h采集深静脉血,测定血浆TnI、CK-MB浓度;并仔细观察记录围术期心肌缺血及其它并发症的发生情况。结果30例病人麻醉诱导后血浆TnI、CK-MB水平分别为(0．98±1．5)ng／ml、(4．5±4．4)ng／ml,开放主动脉侧壁钳后5 min(6．39±5．3、13．37±7．90)、6 h(14．39±9．4、24．54±13．9)、24 h(14．34±8．3、20．09±16．9)、48 h(8．89±8．4、10．22±8．2)血浆TnI、CK-MB均较麻醉诱导后显著升高(P<0．05)。TnI、CK-MB的峰值浓度与冠状动脉旁路桥的远端吻合时间无明显正相关。结论非体外循环冠状动脉旁路移植术术中及术后血浆TnI、CK-MB均明显升高,提示有心肌损伤; TnI、CK-MB的峰值浓度与冠状动脉旁路桥的远端吻合时间无明显正相关,提示off-pump CABG心肌损伤的程度不仅仅与心脏操做有关,还可能与其技术本身的缺陷、麻醉方法等有关。     

非体外循环冠状动脉旁路移植术中转体外循环后的临床转归

目的：总结非体外循环冠状动脉旁路移植术（OPCABG）中转为体外循环冠状动脉旁路移植手术（ONCABG）对临床转归的影响,为合理选择术式,改善外科疗效提供依据.方法：自2010年4月至2013年5月,93例患者在我院接受OPCABG手术治疗过程中未能顺利实施,而中转为ONCABG手术.其中80例为紧急中转,13例为选择性中转.回顾分析中转手术病死率、严重并发症发生率、循环辅助手段应用情况、住院时间等指标,判断中转手术方式对疗效的影响.结果：与选择性中转对比,OP-CABG紧急中转为ONCABG,延长了呼吸机治疗时间[18（13.5,33.5） vs.40.5（19,120.3）h,P＜0.05]、呼吸机通气＞48 h患者的比例明显升高（7.7％ vs.46.3％,P＜0.05）,监护室时间增加[48 （21.5,49）vs.76（27,142.3）h,P＜0.05],住院时间延长[18（14.5,21.5） vs.8（11,23.8）d,P＜0.05],围术期心肌梗死发生率高（7.7％ vs.38.8％,P＜0.05）,增加了主动脉内球囊反搏（IABP）（15.4％ vs.87.5％,P＜0.01）及体外人工肺支持系统（ECMO）使用率（零vs.26.3％,P＜0.05）,手术病死率增高显著（零vs.37.5％,P＜0.01）.结论：OPCABG术中紧急中转术式对临床转归有不良影响,应采取综合措施预防和避免.     

非体外循环冠状动脉旁路移植术围手术期CK-MB、cTnI的变化

分别测定不同时点体外循环下冠状动脉旁路移植术（CABG）和非体外循环下冠状动脉旁路移植术（OPCAB）患者肌酸磷酸激酶同工酶（CK-MB）、心肌肌钙蛋白（cTnI）的平均血浆浓度的变化。结果心肌再灌注6h及再灌注24h,CABG组患者CK-MB、cTnI血浆浓度较OPCAB患者明显增高。认为CABG对心肌的损伤程度较OPCAB严重,OPCAB有较好的心肌保护作用。     

非体外循环和体外循环冠状动脉旁路移植术桥流量变化的对比分析

目的通过超声瞬间血流仪在术中测定体外和非体外循环冠状动脉旁路移植术患者血管桥流量和血流搏动指数变化,了解非体外循环冠状动脉旁路移植术血管桥吻合口的质量.方法91例患者采用非体外循环方法(非体外组)行冠状动脉旁路移植术,同期有107例应用体外循环方法(体外组)行冠状动脉旁路移植术,测定两组间不同旁路移植术部位的血管桥流量和血流搏动指数变化.结果冠状动脉旁路移植术两组间每个吻合口的平均血流量分别为(25.94±12.84)ml/min和(30.29±11.42)ml/min(P＜0.05);血流搏动指数分别为2.06±0.76和2.12±0.78(P＞0.05).除前降支和用大隐静脉为移植材料的对角支部位,体外组较非体外组冠状动脉桥的平均血流量明显增多(P均＜0.05)外;其余部位的平均血流量两组间无显著差异.两组间各部位总的血流搏动指数也无显著差异.结论尽管非体外循环冠状动脉桥血流量偏低,但其血流搏动指数尚满意,说明术后早期吻合口质量可靠.     

老年非体外循环冠状动脉旁路移植术患者围手术期心肌肌钙蛋白T和心肌酶的变化

目的　观察老年患者非体外循环冠状动脉 (冠脉 )旁路移植术 (OPCAB)围术期心肌肌钙蛋白T(cTNT)和心肌酶的变化 ,评估心肌损伤程度及恢复情况。　方法　监测 30例行OPCAB手术的老年患者围术期血浆cTNT、肌酸激酶同工酶 (CK MB)、肌酸激酶 (CK)、天冬氨酸转氨酶 (AST)、乳酸脱氢酶 (LDH)及羟丁酸脱氢酶 (HBDH)的浓度。　结果　患者术前各项监测指标均在正常参考值范围内 ,关胸即刻明显升高 (P <0 0 5或P <0 0 1)。cTNT和CK MB在术后 2h达高峰 ,分别为 (0 2 8± 0 12 ) μg/L和 (10 5± 6 4 ) μg/L(P <0 0 1,术后第 2天均降到正常参考值范围内。CK在术后第 2天达高峰〔(4 6 4± 2 2 8)U/L ,P <0 0 1〕 ,术后第 5天降至正常参考值范围内。AST、LDH和HBDH均在术后 2h达高峰 (P <0 0 1) ,其中AST和HBDH于术后第 1天降至正常参考值范围内 ,LDH于术后第 2天降至正常范围内。　结论　OPCAB手术对老年患者心肌的可逆性损伤多在术后5天内恢复 ,临床效果满意 ;但对术前表现为顽固性不稳定型心绞痛的老年患者 ,应谨防围术期心肌梗死的发生。     

非体外循环冠状动脉旁路移植术的麻醉和围术期管理

目的 探讨非体外循环冠状动脉旁路移植术(OPCAB)的麻醉和围术期管理。方法 择期OPCAB患者18例,ASA分级Ⅲ～Ⅳ级,采用咪达唑仑、依托咪酯、普鲁泊福、芬太尼、维库溴铵、异氟烷等行常温静吸复合全麻。术中应用硝酸甘油、艾司洛尔、去氧肾上腺素、尼卡地平、山莨菪碱。结果18例手术均在非体外循环下完成,围术期循环稳定,无麻醉并发症,所有患者均痊愈出院。结论 OPCAB的麻醉和围术期管理的关键在于维持心肌氧供需的平衡,避免加重心肌缺血,同时要维持血液动力学平稳。     

非体外循环冠状动脉旁路移植术40例临床观察

实施非体外循环冠状动脉旁路移植术（OPCAB）的患者4JD例。术后呼吸机辅助呼吸时间（18.2&#177;1.9）h，ICU监护时间（46.1&#177;13.7）h，住院（11.3&#177;3.7）d，院内死亡2例，发生并发症8例（胸骨哆开或胸骨感染、肺部感染、切口感染各1例，新发生心房颤动3例，低心排血量2例，均经相应的治疗而治愈）。38例术后访2-63个月，无心绞痛复发，心功能恢复至I-Ⅱ级。认为OPCAB治疗冠心病安全、有效、并发症少。正确掌手术适应证、手术技巧和围手术期处理方法，术中保证血管吻合质量及血管活性药物的合理应用是手术成功关键。     

非体外循环冠状动脉旁路移植术围术期TNF-α、CRP的变化

20 0 0年 6～ 1 2月 ,我们对 30例非体外循环冠状动脉旁路移植术 ( OPCAB)患者连续进行术前至术后2 4小时血液中肿瘤坏死因子 ( TNF- α)及 C反应蛋白( CRP)变化测定 ,以了解 OPCAB的炎性反应程度及围术期的特点 ,为临床选择手术方法提供依据。1　资料与方法1 .1　临床资料　本组 30例患者 ,男 2 7例 ,女 3例 ;年龄 5 0～ 72岁 ,平均 ( 61 .6± 5 .2 )岁。冠状动脉病变为三支 2 8例 ,两支 2例。患者有高血压病病史 2 3例 ,糖尿病病史 6例 ,陈旧性心肌梗死史 1 4例。采用胸部正中切口 ,开胸后常规游离左乳内动脉及大隐静脉备用。肝素…     

非体外循环冠状动脉旁路移植术分析

目的:总结非体外循环冠状动脉旁路移植术(OPCAB)的经验。方法:在非体外循环条件下对31例冠心病患者进行冠状动脉旁路移植术,观察手术效果、并发症及预后等情况。结果:全组均在非体外循环下完成手术,死亡 1例;余患者心绞痛症状全部缓解,心功能恢复至Ⅰ～Ⅱ级,恢复正常生活。结论:非体外循环冠状动脉搭桥手术安全有效,在一些高危患者较之体外循环更显出其优势。     

Comparative analysis of cardiac troponin i and creatine kinase-MB as markers of acute myocardial infarction

Background: The World Health Organization (WHO) criteria for the diagnosis of acute myocardial infarction (AMI) includes presentation of chest pain over 20 min, evolutionary changes on the electrocardiogram (ECG), and abnormal levels of cardiac enzymes. Hypothesis: A multicenter study was conducted to evaluate the efficacy of cardiac troponin I (cTnI) in detecting and ruling out AMI. Methods: The normal range for cTnI in 149 apparently healthy subjects without known history of cardiac or other diseases was 0 to 0.5 ng/ml. Cutoffs of 2.5 ng/ml for cTnI and 5.0 ng/ml for creatine kinase-MB (CK-MB) were used. Results: The diagnostic sensitivity of blood collected from 291 consecutive patients with suspicion of AMI was 95.0 and 96.4%, respectively, for samples obtained at 4–48 h after AMI onset. CK-MB was more sensitive during the early 4–8 h interval (84 vs. 74%); both had 100% sensitivity from 12–36 h. CTnI remained at 100% for 72 h, while CK-MB declined to 57%. The clinical specificity was 97.4 vs. 85.8%, respectively, on non-AMI patients with cardiac and noncardiac diseases, and those with renal disease. Conclusion: cTnI is an excellent marker for detecting and ruling out AMI, because it has better specificity and a wider diagnostic window than the accepted standard, CK-MB.     

Initial experience with off-pump coronary artery bypass grafting

Off-pump coronary artery bypass grafting (OPCAB) is clearly preferable for patients with extracardiac complications. The aim of this study was to evaluate the initial outcome of OPCAB, and its validity for patients with extracardiac complications. One hundred and fifty-seven consecutive coronary artery bypass graft (CABG) patients were divided into two groups: 30 OPCAB patients and 127 on-pump CABG patients. The early outcomes of the two groups were compared. Preoperatively, OPCAB patients had more extracardiac risk factors than on-pump CABG patients. There were no differences in age or cardiac function between the groups, but the off-pump group had a higher incidence of previous surgery, cerebrovascular disease, and renal failure. There were no differences in graft patency, stroke, or mortality between the two groups, even though the OPCAB patients had more risk factors than the on-pump patients. Our initial experience with OPCAB showed that it is acceptable for high-risk patients in view of the serious nature of their extracardiac condition. Received: April 12, 2001 / Accepted: August 17, 2001     

冠心病围术期心肌肌钙蛋白T动态变化及意义

目的比较心肌肌钙蛋白T(cardiac troponin T,cTnT)和心肌型肌酸激酶同工酶(MB isoenzyme of crcatine kinase,CK-MB)在冠状动脉旁路移植术(coronary artery bypass graft,CABG)围术期变化。方法在体外循环下行CABG术40例,年龄(61±18)岁,每例平均旁路移植2．8支,体外循环时间(118±57) min,主动脉阻断时间(58±35)min。围术期9个时间点取静脉血标本,测定cTnT与CK-MB。心肌缺血或心肌梗死的诊断用心电图、超声心动图及生化指标。结果主动脉阻断钳开放后cTnT与CK-MB均明显升高,开放后10 h达峰值,术后5 d CK-MB恢复至术前水平,而cTnT术后10 d才恢复至术前水平。手术期间心肌梗死(perioperative myocardial infarction,PMI)4例,cTnT。在整个围术期均显著高于无PMI者,在术后10 d仍明显高于正常范围,因PMI术后死亡2例(2／4)。结论cTnT与CK-MB在CABG术后前阶段改变化相似,但cTnT持续在正常值以上的时间长,诊断心肌损伤的敏感性与CK-MB类似,是预测CABG术预后的可靠指标。     

Association of early elevated cardiac troponin I concentration and longitudinal change after off-pump coronary artery bypass grafting and adverse events: a prospective cohort study

BackgroundThe elevation of troponin after coronary artery bypass grafting (CABG) is common This study aimed to investigate the association between very early cardiac troponin I (cTnI) concentration and its longitudinal change within 24 hours after CABG and 30-day adverse events.MethodsThis study prospectively enrolled 633 patients who underwent isolated off-pump CABG from January 2019 to May 2019. Serum cTnI levels were measured in all patients at two examinations within 24 hours postoperatively (1 hour and 12–18 hours), and a proportional hazards model was used to determine the association between cTnI levels and their change with adverse events, which were defined as a composite of 30-day mortality, stroke, heart failure, myocardial infarction (MI), and ventricular fibrillation.ResultscTnI levels of the two examinations and absolute change of cTnI levels were significantly higher in the event group than in the non-event group (P<0.01, both). Earlier and later cTnI concentrations were associated with 30-day complications [adjusted hazard ration (HR) 1.598, 95% confidence interval (CI), 1.158–2.204 and HR 1.499, 95% CI, 1.228–1.831, respectively]. With regard to longitudinal change in cTnI levels, participants with persistently high levels of cTnI and those with progression from a low level to high level concentration experienced a significantly increased risk of adverse events than did participants who had a trend of persistently low cTnI levels (HR 3.105, 95% CI, 1.748–5.517 versus HR 2.944, 95% CI, 1.488–5.824).ConclusionsLongitudinal change in cTnI levels within 24 hours and early cTnI concentrations, even less than 1 hour after CABG, are associated with adverse events. These data will be useful in identifying patients at an increased risk of complications.     

体外与非体外循环冠状动脉旁路移植术后血清miR-1、miR-133a、miR-208a水平变化及分析

目的探究行体外循环冠状动脉旁路移植术(ONCABG)与非体外循环冠状动脉旁路移植术(OPCABG)患者术后血清miR-1、miR-133a、miR-208a水平变化。方法选取2016年2月—2019年2月本院多支冠状动脉病变需要行CABG的患者94例。根据手术方式,将94例患者分为ONCABG组47例和OPCABG组47例。利用荧光实时定量PCR法检测所有患者术前、术后不同时间血清miR-1、miR-133a、miR-208a水平。采用化学发光免疫分析仪检测所有患者术前、术后不同时间血清心肌肌钙蛋白I(cTnI)、肌酸激酶同工酶(CK-MB)水平。分析血清miR-1、miR-133a、miR-208a水平与cTnI、CK-MB水平的相关性。结果与术前相比,两组患者术后4 h、24 h血清miR-1、miR-133a、miR-208a、cTnI、CK-MB水平升高(P0.05)。与术后4 h相比,两组患者术后24 h血清miR-1、miR-133a、miR-208a、cTnI、CK-MB水平降低(P0.05)。与ONCABG组相比,OPCABG组术后4 h、术后24 h血清miR-1、miR-133a、miR-208a、cTnI、CK-MB水平降低(P0.05)。Pearson分析显示,两组患者术后4 h、术后24 h血清miR-1、miR-133a、miR-208a水平与cTnI、CK-MB水平均呈正相关(P0.05)。结论 miR-1、miR-133a、miR-208a有望作为判断ONCABG与OPCABG后心肌损伤的重要生物标志物。本研究为ONCABG与OPCABG在临床上的选择提供了一定的参考依据。     

非体外循环和体外循环冠状动脉旁路移植术生活质量比较

目的:用一个普适生活质量量表和一个疾病特异量表随机对照研究非体外循环和体外循环冠状动脉旁路移植术患者生活质量改变的情况。方法:应用健康标准化量表简短表格36(SF-36),西雅图心绞痛调查问卷(SAQ)分析研究2006-01-2010-10这5年间147例冠状动脉旁路移植术患者资料,其中非体外循环冠状动脉旁路移植术组96例、体外循环组51例。调查时间是术前1周,术后6～12个月。结果:术前两组患者问卷结果相似。术后6～12个月,SF-36问卷显示在生理职能、社会功能、精神健康等方面,非体外循环组优于体外循环组;SAQ问卷在心绞痛程度、心绞痛频率、生活质量方面,非体外循环组优于体外循环组。结论:术后6～12个月非体外循环较体外循环冠状动脉旁路移植术对患者生活质量改善更明显。     

体外循环与非体外循环冠状动脉旁路移植术早期疗效分析

目的:探讨体外循环冠状动脉旁路移植术(CCABG)和非体外循环冠状动脉旁路移植术（OPCABG）早期疗效的差异。方法: 采集自2003年10月~2008年1月我院单纯冠状动脉旁路移植术5325例临床资料,分为CCABG组（343例）与OPCABG组（4 982例）。对两组患者各项术前因素、术中因素、手术死亡率及并发症进行比较。结果: OPCABG组实际手术死亡率（1.7％）明显低于CCABG组（6.7％）,P<0.01;术后二次开胸止血、肾功能不全等并发症的发生率及ICU停留时间、呼吸机辅助时间、术后住院时间都低于CCABG组（P<0.05,P<0.01）。风险调整后CCABG组手术死亡率仍高于OPCABG组6个百分点,术后并发症的发生率均略高于OPCABG组（P<0.05）。结论: CCABG与OPCABG早期临床疗效均令人满意,后者更好一些。     

非体外循环下冠状动脉搭桥术后甲状腺激素水平的变化

目的:评价非体外循环下冠状动脉搭桥术后甲状腺激素水平的变化,研究其临床意义。方法:选取我院2006年6月至2006年12月非体外循环下冠状动脉搭桥术患者8例A组,同时选取体外循环(cardiopulmonary bypass,CPB)下冠状动脉搭桥术患者15例为B组,分别测定2组术前及术后一周血浆甲状腺激素和促甲状腺激素(TSH)的浓度。结果:在CPB下冠状动脉搭桥术的患者其三碘甲状腺原氨酸(T3)、游离三碘甲状腺原氨酸(FT3)术后一周呈下降低趋势P<0.05,甲状腺素(T4)、游离甲状腺素(FT4)和TSH手术前后差异无显著性,而非CPB下冠状动脉搭桥术的患者T3和FT3术后一周略有下降,但与术前相比差异无显著性(P>0.05)。结论:在CPB下冠状动脉搭桥手术对甲状腺激素的代谢有影响,术后表现为低T3综合征,而非CPB下冠状动脉搭桥手术对甲状腺激素水平的影响较小。提示非CPB下冠状动脉搭桥手术对机体垂体-甲状腺轴的影响相对小、安全性高、预后更好。     

Intraoperative cardiac troponin T release and lactate metabolism during coronary artery surgery: comparison of beating heart with conventional coronary artery surgery with cardiopulmonary bypass

OBJECTIVE: To compare cardiac troponin T release and lactate metabolism in coronary sinus and arterial blood during uncomplicated coronary grafting on the beating heart with conventional coronary grafting using cardiopulmonary bypass. DESIGN: A prospective observational study with simultaneous sampling of coronary sinus and arterial blood: before and 1, 4, 10, and 20 minutes after reperfusion for analysis of cardiac troponin T and lactate. Cardiac troponin T was also analysed in venous samples taken 3, 6, 24, 48, and 72 hours after surgery. SETTING: Cardiac surgical unit in a tertiary referral centre. PATIENTS: 18 patients undergoing coronary grafting on the beating heart (10 single vessel and eight two-vessel grafting) and eight undergoing two-vessel grafting with cardiopulmonary bypass. RESULTS: Cardiac troponin T was detected in coronary sinus blood in all patients by 20 minutes after beating heart coronary artery surgery before arterial concentrations were consistently increased. Peak arterial and coronary sinus cardiac troponin T values on the beating heart during single (0.03 (0 to 0. 05) and 0.09 (0.07 to 0.16 microg/l, respectively) and two-vessel grafting (0.1 (0.07 to 0.11) and 0.19 (0.14 to 0.25) microg/l) were lower than the values obtained during cardiopulmonary bypass (0.64 (0.52 to 0.72) and 1.4 (0.9 to 2.0) microg/l) (p < 0.05). The area under the curve of venous cardiac troponin T over 72 hours for two-vessel grafting on the beating heart was less than with cardiopulmonary bypass (13 (10 to 16) v 68 (26 to 102) microg.h/l) (p < 0.001). Lactate extraction began within one minute of snare release during beating heart coronary surgery while lactate was still being produced 20 minutes after cross clamp release following cardiopulmonary bypass. CONCLUSIONS: Lower intraoperative and serial venous cardiac troponin T concentrations suggest a lesser degree of myocyte injury during beating heart coronary artery surgery than during cardiopulmonary bypass. Oxidative metabolism also recovers more rapidly with beating heart coronary artery surgery than with conventional coronary grafting. Coronary sinus cardiac troponin T concentrations increased earlier and were greater than arterial concentrations during beating heart surgery, suggesting that this may be a more sensitive method of intraoperative assessment of myocardial injury.