非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植术125例

目的总结非体外循环下采用双侧乳内动脉Y型桥进行完全心肌血运重建的冠状动脉旁路移植手术125例的近期疗效。方法2002年10月至2005年12月,完成125例不停跳非体外循环下双侧乳内动脉Y型桥的冠状动脉旁路移植手术,术中采用带蒂半骨骼化的方法分别取材左、右侧的乳内动脉,将左、右乳内动脉端侧吻合成Y型桥;在非体外循环下,应用序贯吻合的方法进行冠状动脉搭桥手术。结果全组125例患者共搭桥413支,平均搭桥支数3．3支／例。术中流量测定桥血管均通畅。全组患者无围手术期死亡。结论非体外循环下双乳内动脉Y型桥的冠状动脉旁路移植手术是安全、有效的方法,可以实现全动脉化的完全心肌血运重建,又避免手术中对升主动脉的操作,近期效果满意。     

Reoperative off-pump coronary artery bypass surgery for restenosis after percutaneous coronary intervention as a part of hybrid revascularization chronic renal failure on hemodialysis; report of a case

60-year-old man on chronic hemodialysis had hybrid revascularization. Percutaneous coronary intervention (PCI) for right coronary artery (RCA) combined with left internal mammary artery-left anterior descending artery anastomosis through left anterior small thoracotomy were performed. But, frequent re-stenosis after PCI necessitated 4 repeated PCI. Finally, the patient agreed to re-do, and underwent reoperative off-pump coronary artery bypass through midsternotomy. Right internal mammary artery-saphenous vein lengthened composite graft was successfully anastomosed to heavily calcified RCA without heart-lung machine. Strategy of revascularization for hemodialysis patient was discussed.     

机器人非体外循环冠状动脉旁路移植与支架置入杂交手术

目的 总结"达芬奇S"(da Vinic S)机器人下非体外循环冠状动脉旁路移植与支架置入杂交手术技术特点和优势.方法 2007年1～8月使用da Vinic S机器人系统,完成非体外循环冠状动脉旁路移植共42例,其中10例因双支冠脉病变,在机器人旁路手术后行支架置入术.病人平均年龄为(62.3±12.1)岁,其中男8例,女2例.病人冠状动脉造影均显示严重的前降支病变,并合并有回旋支或右冠状动脉的局限性狭窄.所有病人肺功能良好,无胸膜炎和左侧胸腔手术史.机器人手术过程中无需正中开胸,仅左侧胸壁打直径为1 cm的器械臂孔3个,术者于da Vinic S系统的操作台前、三维成像系统下遥控机器人全程游离乳内动脉;其中4例直接行全机器人非体外行循环下冠状动脉旁路移植术(TECAB),另6例于左侧胸壁第4肋间作6～8cm的小切口,在心脏跳动下行乳内动脉和前降支的吻合(SVST).术后1周左右经股动脉常规行回旋支或右冠状动脉支架置入术.置入术中行乳内动脉造影评价再血管化效果.结果 病人术后恢复顺利,并成功接受支架置入术,乳内动脉旁路血管通畅,无并发症发生.结论 应用机器人微创冠脉旁路手术和支架置入杂交手术治疗冠心病,可最大限度的减小手术创伤并实现完全再血管化.     

Hybrid coronary revascularization in the era of drug-eluting stents

Left internal mammary artery to left anterior descending coronary artery bypass grafting integrated with percutaneous coronary angioplasty (hybrid procedure) offers multivessel revascularization with minimal morbidity in high-risk patients. This is caused in part by the avoidance of cardiopulmonary bypass-related morbidity and manipulation of the aorta coupled with minimally invasive techniques. Hybrid revascularization is currently reserved for particularly high-risk patients or those with favorable anatomic variants however, largely because of the emergence of off-pump coronary artery bypass grafting, which permits more complete multivessel revascularization, with low morbidity in high-risk groups. The wider introduction of hybrid revascularization is limited chiefly by the high number of repeat interventions compared with off-pump coronary artery bypass grafting, which occurs because of the target vessel failure rate of percutaneous coronary intervention. Other demerits are the costs and logistic problems associated with performing two procedures with differing periprocedural management protocols. Recently, drug-eluting stents have reduced the need for repeat intervention after percutaneous coronary intervention, and this has raised the possibility that the results of hybrid revascularization may now equal or even better those of off-pump coronary artery bypass grafting. Although undoubtedly effective at reducing in-stent restenosis, drug-eluting stents will not address the issues of incomplete revascularization or the logistic problems associated with hybrid. Uncertainty regarding the long-term effectiveness of drug-eluting stents in many patients, as well as their high cost when compared with those of off-pump coronary artery bypass grafting surgery, also militates against the wider introduction of hybrid revascularization.     

Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury,transfusion requirements,and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting

OBJECTIVE: Retrospective comparisons of selected patients undergoing off-pump versus conventional on-pump coronary artery bypass grafting have yielded inconsistent results and raised concerns about completeness of revascularization in off-pump coronary artery bypass grafting. METHODS: Two hundred unselected patients referred for elective primary coronary artery bypass grafting were randomly assigned to undergo off-pump coronary artery bypass grafting with an Octopus tissue stabilizer (Medtronic, Inc, Minneapolis, Minn) or conventional coronary artery bypass grafting with cardiopulmonary bypass by a single surgeon. Revascularization intent determined before random assignment was compared with the revascularization performed. All management followed strict, unbiased, criteria-driven protocols. Patients and nonoperative care providers were blinded to surgical group. RESULTS: Baseline characteristics were similar. The number of grafts performed per patient (mean +/- SD 3.39 +/- 1.04 for off-pump coronary artery bypass grafting, 3.40 +/- 1.08 for conventional coronary artery bypass grafting) and the index of completeness of revascularization (number of grafts performed/number of grafts intended, 1.00 +/- 0.18 for off-pump coronary artery bypass grafting, 1.01 +/- 0.09 for conventional coronary artery bypass grafting) were similar. Likewise, the index of completeness of revascularization was similar between groups for the lateral wall. Combined hospital and 30-day mortalities and stroke rates were similar. Postoperative myocardial serum enzyme measures were significantly lower after off-pump coronary artery bypass grafting, suggesting less myocardial injury. Adjusted postoperative thromboelastogram indices, fibrinogen, international normalized ratio, and platelet levels all showed significantly less coagulopathy after off-pump coronary artery bypass grafting. Patients undergoing off-pump coronary artery bypass grafting received fewer units of blood, were more likely to avoid transfusion altogether, and had a higher hematocrit at discharge. Cardiopulmonary bypass was an independent predictor of transfusion (odds ratio 2.42, P =.0073) by multivariate analysis. More patients undergoing off-pump coronary artery bypass grafting were extubated in the operating room and within 4 hours. Postoperative length of stay (in days) was shorter for off-pump coronary artery bypass grafting (5.1 +/- 6.5 for off-pump coronary artery bypass grafting, 6.1 +/- 8.2 for conventional coronary artery bypass grafting, P =.005 by Wilcoxon test). One patient (in the conventional coronary artery bypass grafting group) required angioplasty for graft closure within 30 days. CONCLUSIONS: When compared with conventional coronary artery bypass grafting with cardiopulmonary bypass, off-pump coronary artery bypass grafting achieved similar completeness of revascularization, similar in-hospital and 30-day outcomes, shorter length of stay, reduced transfusion requirement, and less myocardial injury.     

Current indications for left thoracotomy in coronary revascularization and valvular procedures

BACKGROUND: Left thoracotomy is infrequently used for cardiac procedures, but its application in reoperative and minimally invasive coronary revascularization and in valvular procedures has been reported recently. METHODS: Three case reports and a review of the current literature illustrate the unique benefits of this approach for myocardial revascularization and valve replacement. RESULTS: Reoperative coronary revascularization of the left anterior descending and circumflex coronary arteries was performed off-pump via a left posterolateral thoracotomy. For the second case, this approach was used for coronary artery bypass grafting of the right coronary and left anterior descending arteries with femoral-femoral cardiopulmonary bypass in a patient with congestive heart failure and coronary artery disease who also required closure of a patent ductus arteriosus. In the third case, mitral valve replacement using femoral venous and aortic cannulation for cardiopulmonary bypass was performed via a left thoracotomy to avoid a retrosternal gastric conduit in a patient with severe mitral stenosis and congestive heart failure. All patients returned to normal activity and are asymptomatic. CONCLUSIONS: These case reports and a comprehensive review of the literature demonstrate the utility of left thoracotomy as an alternative approach to standard median sternotomy in selected cases of revascularization and valvular procedures.     

On-pump versus off-pump coronary artery bypass graft surgery. What do the evidences show?

The main purpose of the off-pump coronary artery bypass surgery is to reduce morbidity and mortality due cardiopulmonary bypass. However, even though many studies have shown that off-pump coronary artery bypass is feasible and provides hospital morbidity and mortality similar to the on-pump coronary artery bypass graft surgery, probably better in some aspects, its long-term results have been questioned, since some trials have shown reduced survival with off-pump coronary artery bypass. It is likely that incomplete revascularization and/or poor graft patency with off-pump coronary artery bypass probably are responsible for such unfavorable outcome.     

Impact of off-pump coronary artery surgery on myocardial performance and beta-adrenoceptor function

OBJECTIVE: To determine the hemodynamic changes during beating heart revascularization of the left anterior descending artery, the circumflex artery, and the right coronary artery as well as cardiovascular beta-adrenoceptor function before and after off-pump coronary artery bypass surgery. DESIGN: Prospective study. SETTING: University department of cardiothoracic anesthesia. PARTICIPANTS: Twenty patients scheduled for off-pump coronary artery bypass surgery using the Octopus 2 stabilizer system. INTERVENTIONS: Isoproterenol, 4 microg, was administered intravenously after induction of anesthesia and again after surgery to monitor cardiac beta-receptor function. MEASUREMENTS AND MAIN RESULTS: The hemodynamic responses to isoproterenol and cardiovascular variables were monitored before, during, and after immobilization of the target coronary artery with catheters in the radial and pulmonary arteries. During surgery on the left anterior descending artery (n = 23), stroke volume and cardiac index decreased 17 mL (21%) and 400 mL (17%). During revascularization of the circumflex artery (n = 9), stroke volume and cardiac index decreased 19 mL (28%) and 300 mL (17%). During surgery on the posterior aspect of the heart (n = 13), stroke volume and cardiac index decreased 22 mL (29%) and 400 mL (17%). All the cardiovascular variables had returned to baseline values 5 minutes after releasing the heart. The hemodynamic responses to isoproterenol were equal before and after surgery. CONCLUSION: This study provides evidence that the hemodynamic changes associated with off-pump surgery on the 3 major coronary arteries are similar and of short duration. No desensitization of cardiovascular beta-adrenoceptors was found. This finding is in contrast to the deterioration in beta-adrenoceptor function seen after surgery with cardiopulmonary bypass.     

Combined use of off-pump techniques and a sutureless proximal aortic anastomotic device reduces cerebral microemboli generation during coronary artery bypass grafting

OBJECTIVE: Intraoperative cerebral microemboli are associated with the development of postoperative stroke and neurocognitive decline in patients undergoing coronary artery bypass grafting. Although cardiopulmonary bypass is responsible for the generation of a significant number of such emboli, the elimination of cardiopulmonary bypass alone has not been conclusively shown to improve neurocognitive outcome. The current study was performed to determine the effects of combined off-pump coronary artery bypass grafting and sutureless proximal aortic anastomotic techniques on the generation of intraoperative cerebral microemboli compared with standard coronary artery bypass grafting techniques of cardiopulmonary bypass and hand-sewn proximal anastomoses. METHODS: Fifty-three patients underwent off-pump coronary artery bypass grafting by using the sutureless Symmetry aortic connector device (St Jude Medical, St Paul, Minn) for all proximal anastomoses. Eighteen of these patients received intraoperative transcranial Doppler ultrasonography to determine right- and left-sided cerebral microembolic counts. These results were compared with those obtained from a similar group of 17 patients undergoing standard coronary artery bypass grafting, in whom cardiopulmonary bypass and hand-sewn proximal anastomoses were used. RESULTS: Our use of the proximal anastomotic device in patients undergoing coronary artery bypass grafting was safe, with no aortic complications, postoperative strokes, or in-hospital deaths. Microembolic counts to both the right and left cerebral circulation were significantly reduced in the patients undergoing off-pump coronary artery bypass grafting (right = 21.9 +/- 20.7 emboli, left = 24.9 +/- 19.2 emboli) compared with those in patients undergoing standard coronary artery bypass grafting (right = 181.6 +/- 85.3, left = 189.9 +/- 60.401, P <.0001). CONCLUSIONS: Our use of a sutureless proximal anastomotic device during off-pump coronary artery bypass grafting is safe and significantly decreases cerebral microembolism when compared with standard coronary artery bypass grafting with cardiopulmonary bypass and hand-sewn anastomoses. Long-term follow-up is needed to determine the effects of this technical strategy on neurocognitive outcome.     

Off-pump coronary artery bypass is an alternative to conventional cardiopulmonary bypass when repair of traumatic coronary artery injuries is indicated

Coronary artery injuries after penetrating cardiac trauma are rare. The standard approach to these injuries has traditionally been coronary artery ligation. When cardiac perfusion is profoundly compromised, cardiopulmonary bypass has been used to facilitate revascularization, although with serious morbidity. We report a case of traumatic left anterior descending coronary artery transection repaired off-pump in a young stabbing victim. Penetrating traumatic cardiac injuries are highly lethal injuries. Cardiopulmonary bypass has been used for myocardial revascularization when cardiac perfusion is compromised, although with significant complications. Off-pump coronary artery bypass is a safe alternative in the traumatized patient.     

Off-pump coronary artery bypass in patients with Takayasu's disease

We report 2 patients with ostial stenoses of coronary arteries and heavy aortic calcification caused by Takayasu's disease in which severe angina was successfully relieved by off-pump coronary artery bypass grafting. In one case, visceral arteries such as the right gastroepiploic artery, the superior mesenteric artery, and the splenic artery were used as proximal blood sources of saphenous vein grafts. In another case, an aortic connector system was employed for proximal anastomoses of saphenous vein grafts. The use of off-pump coronary artery bypass grafting techniques should be considered in surgical coronary revascularization in patients with Takayasu's disease, thus leading to wide-spreading indication for the surgery.     

Collateral flow reserve and right coronary occlusion: evaluation during off-pump revascularization

The aim of this study was the determination of the pressure-derived collateral fractional flow reserve (FFR(coll)) in patients with three vessel disease and chronic occlusion of the right coronary artery undergoing surgical complete revascularization with the off-pump technique. The angiograms of eight patients were preoperatively analysed to quantify collaterality. FFR(coll) was determined before any revascularization (FFR(coll) 0), and after revascularization of the left coronary arteries, (FFR(coll) 1). FFR(coll) 0 was compared to the Rentrop grade, to the left ventricular ejection fraction (LVEF), and to FFR(coll) 1. No correlation was demonstrated between preoperative Rentrop grade and FFR(coll) 0. There was a linear statistically significant correlation between FFR(coll) 0 and LVEF (P;ie0.001). No significant variation of the FFR(coll) index was observed after performing left coronary artery bypass grafts. Collaterality observed on the coronary angiogram cannot be used as an estimation of the functional collaterality, which can be better appreciated with the LVEF. The absence of variation of FFRcoll before and after left coronary artery revascularization suggests that grafting of the occluded right coronary artery remains justified.     

Off-pump coronary bypass surgery for left main coronary artery stenosis 10 years after heart transplantation: case report.

A patient with asymptomatic left main coronary artery stenosis 10 years after heart transplantation was treated successfully with off-pump coronary bypass surgery using both mammary arteries. New advances in bypass surgery may decrease the risk of revascularization in cardiac transplant recipients.     

Off-pump coronary artery bypass grafting for a patient with anomalous origin of the right coronary artery from the pulmonary artery.

We report on a case of a 70-year-old chronic hemodialysis patient. He presented with anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) and severe left anterior descending coronary artery (LAD) stenosis, which supplied collateral flow to the right coronary artery (RCA). The patient complained of myocardial ischemic symptoms during routine hemodialysis. We performed off-pump coronary artery bypass grafting (OPCABG) surgery and ligation of the origin of the ARCAPA. Previous reports described that the myocardial ischemia was a rare complication with the ARCAPA patients. However, this case required coronary revascularization because of the atherosclerotic LAD stenosis as a collateral source of the RCA.     

Combined off-pump coronary revascularization: ascending aorta to carotid bypass

A 76-year-old man with symptomatic cerebral vascular disease and coronary artery disease was treated with simultaneous off-pump bypass and cerebral revascularization. With the emergence of off-pump coronary artery operation as a viable option for coronary revascularization we believe that this procedure will become our method of choice for combined cerebral and coronary artery disease.     

Off-pump coronary artery bypass grafting using graft to coronary shunt for acute coronary syndrome

We developed graft to coronary shunt during off-pump anastomosis. Proximal anastomosis of saphenous vein graft (SVG) was done formerly, and vinyl chloride tube, 5 cm long and 2 mm in diameter, was inserted into SVG. Another end was inserted into coronary artery, and continuous suture around the tube was performed before removing the tube. This technique is fit to use for the anastomosis between SVG and #3. Because the tube is easily inserted into those parts without injury of intima, and distal right coronary artery needs enough blood supply. After the revascularization of left anterior descending artery and #3, the heart can be displaced to expose circumflex artery. We adopted this technique to 3 patients with acute coronary syndrome (ACS). Though this technique is not adopted for the patients having stenosis on #4, we conclude that SVG to coronary shunt could be a important part of the strategies of off-pump coronary artery bypass grafting (OPCAB) for ACS patients.     

Total arterial off-pump coronary artery bypass grafting for revascularization of the total coronary system: clinical outcome and angiographic evaluation

Background

We assessed the clinical outcome and conducted an angiographic study of total arterial off-pump coronary artery bypass grafting for revascularization of the total coronary system.

Methods

Of 382 consecutive patients who underwent off-pump coronary artery bypass between April 2000 and December 2002, 235 patients (193 men and 42 women, mean age 66 ± 9 years) with three-vessel disease underwent off-pump coronary artery bypass with all arterial grafts. A total of 872 vessels were bypassed (average number of grafts 3.7 ± 0.8). The internal thoracic arteries, radial arteries, and gastroepiploic arteries were used for revascularization of 306, 542, and 24 coronary arteries, respectively. Two hundred twenty-five patients underwent revascularization with composite grafts that were connected to the in situ internal thoracic artery (Y configuration 181, I configuration 55, K configuration 27, X configuration 3, T configuration 1); 10 patients underwent revascularization with all in situ grafts.

Results

Three (1.3%) hospital deaths and 1 late death occurred. There were no occurrences of clinical underperfusion syndrome or new intraaortic balloon pump insertion. Cerebral infarction occurred in 2 patients (0.8%). Early postoperative angiography was performed on 833 grafts in 223 patients (95%); the overall patency rate was 98%. Stratified by coronary distribution, the patency rate was 99% (218/221) in the left anterior descending artery, 97% (84/87) in the diagonal artery, 99% (70/71) in the obtuse marginal artery, 98% (262/268) in the posterolateral artery, 98% (167/170) in the posterior descending artery, and 100% (16/16) in the right coronary artery.

Conclusions

Total arterial off-pump coronary artery bypass yielded good clinical results and an excellent patency rate of revascularization for the total coronary system.     

Combined endovascular treatment of a descending thoracic aortic aneurysm and off-pump myocardial revascularization-a case report

Endovascular intervention is an alternative form of treatment for patients with thoracic aortic aneurysms. Coexistent cardiovascular diseases may adversely influence the postoperative course and affect the long-term prognosis. The case of a 76-year-old man with severe coronary artery disease and a thoracic aortic aneurysm is reported. A single-stage procedure of off-pump coronary artery revascularization and endoluminal exclusion of the descending thoracic aortic aneurysm was performed. The patient was treated first with off-pump coronary artery bypass graft (left internal mammary artery on the left anterior descending coronary artery and two single venous grafts from ascending aorta to obtuse marginal artery and posterior descending artery). After heart revascularization, two Thoracic Excluder endovascular grafts (34 x 100 and 37 x 100 mm) were implanted to treat the descending thoracic aortic aneurysm. Follow-up with computed tomography angiography showed successful exclusion of the thoracic aneurysm 12 months after the procedure. The patient is well and free of symptoms 18 months later.     

Marsupialization of intramyocardial left anterior descending artery: a novel approach for easy access during revascularization

The left anterior descending (LAD) artery is the most important vessel bypassed during coronary revascularization procedures. This artery usually runs a superficial course, making it easy for localization and grafting. However, many times it takes a course deep in the myocardium or is embedded in thick epicardial fat, which results in technical challenges to the surgeon for localization and grafting. So far, many techniques are described for overcoming these problems, but all require cardiopulmonary bypass (CPB), and in fact, intramyocardial LAD is considered a relative contraindication for off-pump coronary artery bypass grafting (OPCAB). In the present era of enhanced interest in OPCAB, these techniques are not as helpful as they are for conventional CABG with CPB. Here, we describe a novel approach of marsupialization of the LAD for revascularization of intramyocardial LAD that is useful for off-pump as well as conventional revascularization procedures and makes grafting simple and reproducible.     

Off-pump coronary artery bypass grafting: not a flash in the pan

During the past decade, technical improvements have made off-pump coronary artery bypass operations a routine procedure. During this time, off-pump coronary artery bypass has been audited against conventional techniques by many observational, case-matched, and prospective randomized studies. There is evidence in the literature suggesting that off-pump coronary artery bypass operations reduce postoperative morbidity, organ dysfunction, and costs, without compromising midterm outcome compared with conventional coronary operations. The available evidence also supports the view that high-risk patients might benefit the most from revascularization on the beating heart. High quality follow-up data are still needed to assess the impact of off-pump coronary artery bypass operations on long-term clinical outcome.