犬不停跳冠状动脉搭桥模型的构建

目的比较两种不同方法构建不停跳冠状动脉搭桥动物模型,探讨模型构建方法的可行性和优劣性。方法家犬20只随机分为头臂干组和降主动脉组,以小口径异种血管为桥血管。左侧第4肋间切口入胸,先行头臂干动脉或降主动脉端血管吻合,再行冠状动脉端血管吻合,术毕结扎左冠状动脉前降支近端。结果 2组犬均无术中死亡。头臂干组和降主动脉组主动脉端血管吻合用时分别为(33.9±4.8)min和(29.6±3.5)min(P0.05),冠状动脉端血管吻合用时分别为(28.5±3.0)min和(28.1±2.3)min(P0.05),2组术中出血量分别为(77.5±16.2)mL和(66.5±12.3)mL(P0.05)。降主动脉组术中侧壁钳夹降主动脉后股动脉血压明显降低,术后2只犬出现黑便。结论将小口径异种血管吻合在头臂干动脉或降主动脉均可成功构建犬不停跳冠状动脉搭桥模型;降主动脉组股动脉血压波动大,存在腹腔脏器缺血再灌注损伤;头臂干组血管吻合用时稍长,但术中股动脉血压波动小,模型构建相对更安全。     

Clinical experience with Smart Care after off-pump coronary artery bypass for early extubation

The purpose of this study was to compare the intubation time using Smart Care, a knowledge-based system for automated weaning, with that of conventional physician-controlled weaning after off-pump coronary artery bypass (OPCAB) and to determine the efficacy of Smart Care. During 2004, 53 sequential patients were scheduled for isolated coronary artery bypass grafting without cardiopulmonary bypass. Patients were divided into two groups: the Smart Care group (n = 10) and the control group (n = 35). Eight patients requiring hemodialysis and patients undergoing the awake OPCAB method were excluded. The intubation times were 172.6 ± 51.6 min in the Smart Care group compared with 342.0 ± 239.0 min in the control group (P = 0.032). No specific complications occurred with this computer-driven expert weaning system. In conclusion, the Smart Care system reduced the duration of mechanical ventilation and the respiratory care workload. This system was effective in the care of patients without complications requiring mechanical ventilation after OPCAB.     

Sternal closure by rigid plate fixation in off-pump coronary artery bypass grafting: a comparative study

Sternal instability or dehiscence results in serious sternal wound infection. We sought to assess the early outcomes with such a plating system for sternal closure in comparison to the conventional wiring technique in off-pump coronary artery bypass grafting (CABG). Patients who underwent off-pump CABG were enrolled. Thirty-one patients received plate sternal fixation. A total of 64 patients who underwent off-pump CABG by a single surgeon at our hospital from July 2013 to December 2014 were enrolled. Thirty-one patients received plate sternal fixation (Plate group), while 33 received conventional wire closure (Wire group). The early outcomes, including the pain score and analgesic usage count were compared. Dietary intake was also recorded to assess the duration of appetite loss. At discharge, the largest sternal displacement was measured on computed tomography. In the Plate group, the pain scores were significantly lower on post-operative day 5–8 and POD 9–12 from those in the Wire group. The analgesic usage count on POD 9–12 was significantly lower in the Plate group. The duration of appetite loss and hospital stay was significantly shorter in the Plate group. The displacement in both the anterior–posterior and lateral directions was significantly smaller in the Plate group. Sternal closure by rigid plate fixation contributes to a more rapid post-operative recovery through reduced pain.     

预防应用主动脉内球囊反搏在低射血分数患者非体外循环冠状动脉旁路移植术的临床研究

目的：分析预防应用主动脉内球囊反搏(intra-aortic balloon pump,IABP)对术前低射血分数(EF值<40%)的冠心病患者在非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass grafting, OPCAB)中的疗效和预后影响。方法：回顾分析复旦大学附属中山医院心外科2010年1月至2015年1月术前低射血分数的冠心病拟行OPCAB术的患者300例。其中术前预防应用IABP后行OPCAG的患者140例(试验组),术前未预防应用IABP直接行OPCAB术的患者160例(对照组)。比较二组患者术中被迫紧急改为体外循环下冠状动脉旁路移植术的比例、术后应用体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)的比例、术后低心排及术后肾功能不全的发生率、室性心率失常的发生率、住院期间病死率;比较二组术后气管插管时间、ICU时间及术后住院天数;比较两组术后1、2、5 d血浆肌钙蛋白I(cardiac troponin I,cTnI)、肌酸磷酸激酶同工酶(creatine phosphokinase isoenzyme,CKMB)水平以及两组术后1年及5年生存率。结果：术中对照组被迫紧急改为体外循环下冠状动脉移植比例高于对试验组(P<0.05);术后应用ECMO的比例对照组高于试验组(P<0.05),术后气管插管时间、ICU时间及术后住院天数试验组明显低于对照组(P<0.05);术后低心排及术后肾功能不全的发生率明显减少(P<0.05)术后1、2 d cTnI及CKMB水平试验组明显低于对照组(P<0.05),术后5 d cTnI及CKMB水平试验组与对照组相比较无明显差异(P>0.05);住院期间病死率试验组明显低于对照组(P<0.05),但术后1年及5年生存率两组无差异(P>0.05)。结论：术前低EF值冠心病预防性应用IABP是安全有效的,能够改善心功能,减少术后心梗、低心排、肾功能不全等严重并发症的发生,从而降低围术期病死率,提高低术前EF值病人OPCAB的手术疗效。     

Extracorporeal circulation system for coronary artery perfusion in the closed-chest dog.

An adjustable constant-flow coronary artery perfusion system has been developed for use in the anesthetized closed-chest dog. Coronary flow and perfusion pressure measurements are obtained over the entire autoregulatory range. Coronary flow was briefly diverted to a bypass cannula and then returned to its original level. Coronary vasodilatation resulted in a fall of perfusion pressure below its preocclusion value, but recovery of vascular tone was complete in about twice the time required during unrestricted reactive hyperemia. It is concluded that no flow debt repayment is required for the restoration of vascular tone after brief occlusions. In the measurements made with this system, intramyocardial pressure distribution is not influenced by thoracotomy, pericardotomy, or positive-pressure respiration, and surgical trauma is minimal.     

非体外循环冠脉搭桥术中参附注射液对血流动力学和氧代谢的影响

目的 观测非体外循环冠脉搭桥术(OPCABG)中参附注射液对血流动力学和全身氧代谢的影响.方法 选择本院冠心病择期行OPCABG手术患者56例,美国麻醉医师协会(ASA)Ⅱ～Ⅲ级,完全随机分为参附组(SF组,29例)和生理盐水对照组(NS组,27例).SF组在手术切皮前和吻合心脏血管前各静脉注射参附注射液40 ml,NS组则分别注射等量生理盐水.用漂浮导管和动脉、混合静脉血气分析监测麻醉手术过程中麻醉诱导完成并血流动力学稳定时(T1)、锯胸骨后(T2),吻合血管前(T3),吻合前降支时(T4),吻合后降支或右冠状动脉时(T5),吻合左回旋支或对角支时(T6),血管吻合完成后心脏恢复原位置(T7),闭合胸骨前(T8)及手术结束时(T9)9个时点的血流动力学和全身氧代谢.结果 在T5和T6时点,两组的心脏指数(CI)和每搏指数(SI)均明显低于T1时点[(2.1±0.6)和(2.0±0.5)比(2.3±0.5)L·min-1· m-2,(1.7±0.6)和(1.8±0.6)比(2.1±0.5)L·min-1·m-2;(24±10)和(23±8)比(32±7)ml·beat-1· m-2,(22±9)和(22±8)比(32±9) ml·beat-1·m-2,P＜0.05],其中T2和T5时点,SF组的CI略高于NS组[(2.5±0.7)比(2.1±0.6)L·min-1 ·m-2,(2.1±0.6)比(1.7 ±0.6) L·min-1 ·m-2,P＜0.05].整个麻醉手术期间,SF组的心率(HR)、平均动脉压(MAP)、左室工作指数(LVWI)和右室工作指数(RVWI)均略高于NS组(P＜0.05).两组的pH在手术开始后均呈降低变化,其中SF组术毕的pH明显低于NS组(P＜0.05).手术期间两组的碳酸氢根离子(HCO3-)、剩余碱(BE-E)和总二氧化碳(TCO2)均下降,两组间在多个时间点差异有统计学意义(P＜0.05).SF组在麻醉后时点的氧供(DO2)高于NS组,但术中两组间氧耗(vO2)、氧摄取率(O2ext)和体温(T)的变化差异无统计学意义(P＜0.05).结论 ASAⅡ～Ⅲ级患者非体外循环冠脉搭桥术中,在循环功能和氧供-氧耗相对稳定条件下静脉给予参附注射液,未见对血流动力学和氧代谢参数产生显著影响.     

Safety and efficacy of a simple cardiotomy suction system as a blood salvage procedure during off-pump coronary artery bypass surgery

Journal of Artificial Organs - The ideal blood-salvaging strategies for off-pump coronary artery bypass graft procedures have not been determined. We developed a new blood-salvaging system that...     

非体外循环下冠状动脉旁路移植围术期血浆脑钠肽释放及其相关性研究

背景：B型脑钠肽已成为心血管疾病诊断重要的血清标志物,作为心血管疾病危险因素分层的重要因子。 目的：分析冠状动脉旁路移植前后B型脑钠肽与各项血流动力学参数的关系。 方法：选择30例冠心病行冠脉旁路移植患者,分为左室射血分数≥ 50%心功能正常患者13例;左室射血分数< 50%心功能不全患者17例。观察患者移植前1 d、移植后7 h、移植后1,3,5,7 d血浆B型脑钠肽水平变化趋势,分析移植前后B型脑钠肽与心功能各项指标的相关关系。 结果与结论：左室射血分数≥ 50%组患者冠脉旁路移植前后血浆B型脑钠肽水平显著低于左室射血分数< 50%组;组内比较移植后血浆B型脑钠肽水平均显著高于移植前(P < 0.05或P < 0.001)。患者冠脉旁路移植前B型脑钠肽水平与纽约心脏病协会心功能分级、左房内径、左室内径呈正相关(r=0.61;r=0．34;r=0．67);与左室射血分数、心排血量呈负相关(r=-0.75;r=-0.70)。患者移植后B型脑钠肽峰值浓度与出院前纽约心脏病协会心功能分级、超声心动图左室舒张末期内径、肺动脉压力呈正相关(r=0.72;r=0.70;r=0.45)。结果说明冠心病患者冠脉旁路移植前血浆B型脑钠肽质量浓度与左心室射血分数及左心室舒张末期内径有很好的相关性,能准确反映冠脉旁路移植前后的心功能状态。 中国组织工程研究杂志出版内容重点：组织构建;骨细胞;软骨细胞;细胞培养;成纤维细胞;血管内皮细胞;骨质疏松;组织工程全文链接：     

The effect of postoperative positive end-expiratory pressure on postoperative bleeding after off-pump coronary artery bypass grafting

Introduction

To compare postoperative prophylactic use of two positive end-expiratory pressure (PEEP) levels in order to prevent postoperative bleeding in patients undergoing off-pump coronary artery bypass grafting (CABG) surgery.

Material and methods

Sixty patients undergoing an elective off-pump CABG operation were included in this prospective, nonrandomized clinical trial. Patients were divided into two groups as receiving either 5 cm H₂O (group 1) or 8 cm H₂O PEEP (group 2) after the operation until being extubated. Chest tube outputs, use of blood products and other fluids, postoperative hemoglobin levels, accumulation of pleural and pericardial fluid after the removal of chest tubes, and duration of hospital stay were recorded and compared.

Results

Low- and high-pressure PEEP groups did not differ with regard to postoperative chest tube outputs, amounts of transfusions and crystalloid/colloid infusion requirements, or postoperative hemoglobin levels. However, low-pressure PEEP application was associated with significantly higher pleural (92 ±37 ml vs. 69 ±29 ml, p = 0.03) and pericardial fluid (17 ±5 ml vs. 14 ±6 ml, p = 0.04) accumulation. On the other hand, high-pressure PEEP application was associated with significantly longer duration of hospitalization (6.25 ±1.21 days vs. 5.25 ±0.91 days, p = 0.03).

Conclusions

Prophylactic administration of postoperative PEEP levels of 8 cm H₂O, although safe, does not seem to reduce chest-tube output or transfusion requirements in off-pump CABG when compared to the lower level of PEEP. Further studies with larger sample sizes are warranted to confirm the benefits and identify ideal levels of PEEP administration in this group of patients.     

Changes in N-terminal pro B-type natriuretic peptide concentration: comparative study of percutaneous transluminal coronary angioplasty and off-pump coronary artery bypass graft

The goal of this study was to compare the effects of different reperfusion methods on N-terminal B-type natriuretic peptide (NT-proBNP) in percutaneous transluminal coronary angioplasty (PTCA) or off-pump coronary artery bypass (OPCAB) patients. Fifty subjects were enrolled in the study, 32 patients received PTCA and 18 OPCAB. An NT-proBNP measurement was performed before intervention and at 1, 3, and 7 days after the procedures. NT-proBNP levels were not significantly different before intervention (PTCA group 297+/-147.3 vs. OPCAB group 235+/-167.8 pg/mL, p>0.05). However, 1 day after the procedures, NT-proBNP levels were higher in the OPCAB group (PTCA 375+/-256.4 vs. OPCAB 1,415+/-737.6 pg/mL, p<0.05), after 3 days NT-proBNP reached peak levels (PTCA 480+/-363.0 vs. OPCAB 2,119+/-818.4 pg/mL, p<0.05), and levels were reduced after 7 days (PTCA 292+/-243.7 vs. OPCAB 522+/-334.0 pg/mL, p>0.05). PTCA induced a mild and transient increase in NT-proBNP concentration, but OPCAB caused sustained high NT-proBNP levels during the 7 day postoperatively. However, differences between NT-proBNP levels associated with these two modalities showed a tendency to decrease rapidly postoperatively.     

胃网膜动脉与冠状动脉搭桥术的应用解剖

为胃网膜动脉与冠状动脉搭桥术提供解剖学资料。本文在30具成年尸体上对胃网膜动脉、网膜动脉和冠状动脉进行了观测。测量结果:胃网膜动脉弓长度为29.3cm;而胃网膜右动脉的起始部至主动脉根部为28.9cm;胃网膜左动脉起始部至主动脉根部为29.2cm。测量数据表明,应用胃网膜动脉移位术足以吻接任何冠状动脉。     

Comparison of coronary artery bypass grafting with percutaneous coronary intervention for unprotected left main coronary artery disease

Purpose

Coronary artery bypass grafting (CABG) is the optimal treatment option for left main coronary artery disease (LMCAD). However, LMCAD remains a constant topic of discussion between cardiac surgeons and interventional cardiologists. The aim of this study was to assess the efficacy of LMCAD treatments by comparing the mid-term outcomes of CABG and percutaneous coronary intervention (PCI) using bare metal stents or drug-eluting stents (DESs).

Materials and Methods

The study population was comprised of 199 consecutive patients admitted with unprotected LMCAD. All of the patients were assigned to PCI (88 patients) or CABG (111 patients). The primary clinical end point indicated death, stroke of acute coronary syndrome (ACS).

Results

Patients assigned to PCI were at higher operative risk than patients scheduled for CABG (6.49±4.09 vs. 4.81±2.67, p=0.0032). Comparison of the group that received DESs with the CABG group did not reveal any differences in major adverse cardio-cerebral events (MACCE) occurrence (21% vs. 16%, p=NS). Patients in the CABG and PCI groups died with similar frequency (11% vs. 16%, p=NS). The mortality rate in the CABG group was higher than among those treated with DES (11% vs. 3%, p=0.049). The rate of ACS was higher in the PCI group than in the CABG group (13% vs. 4%, p=0.016).

Conclusion

Despite the fact that patients treated with PCI were at higher operative risk, PCI with DES was shown to be comparable to CABG in terms of mortality, stroke and ACS. However, the frequency of repeat revascularizations remains a constant concern with PCI.     

Pre-operative education for the patient having coronary artery bypass surgery

Patient education is an important element of care for people having a range of investigations and treatments. The potentially beneficial effect on outcomes has been explored. In particular research, and meta-analyses of the studies, have demonstrated the positive effect of pre-operative education on post-operative outcomes in patients having a variety of surgical procedures. However, application of the findings to defined groups of specialist patients may be difficult. This paper seeks to establish whether pre-operative education benefits patients following coronary artery bypass surgery and to identify the outcomes affected. A broad search strategy revealed 10 studies which examined pre-operative education and measured post-operative outcomes. Data were extracted which revealed there is limited evidence to suggest that pre-operative education benefits patient's recovery from coronary artery bypass surgery. However, this finding should be considered with caution as this body of research suffered from weak design and there was limited available data.     

Perioperative blood pressure control in hypertensive and normotensive patients undergoing off-pump coronary artery bypass grafting: prospective study of current anesthesia practice

Aim

To analyze blood pressure changes during intra- and immediate postoperative period in patients undergoing off-pump coronary artery bypass grafting.

Methods

The study included 355 consecutive patients undergoing off-pump coronary artery bypass grafting between January 5, 2004 and December 30, 2005. Out of these patients, 325 were allocated into groups with preoperative history of hypertension (n = 115) and without preoperative history of hypertension (n = 210). Systolic, diastolic, and mean arterial blood pressure was measured at the following four time points: on the day before surgery, before anesthesia induction, after the last graft, and on entry to intensive care unit.

Results

Mean arterial pressure was significantly higher in patients with a history of hypertension on the day before surgery (97 vs 92 mm Hg, P = 0.003, Mann-Whitney test) and before anesthesia induction (107 vs 98 mm Hg; P = 0.003). It was higher at all measuring points (after the last graft, 79 vs 78 mm Hg; and on entry to intensive care unit, 88 vs 86 mm Hg), but this difference was neither statistically nor clinically significant. The study showed that mean arterial pressure followed similar dynamics over time in both patient groups (P<0.001 both), with no significant time-dependent between-group differences.

Conclusion

Current anesthesia techniques that include deep opioid analgesia in combination with vasodilators provide a satisfactory control of intraoperative hypertension. Management of blood pressure changes during intra- and immediate postoperative period in off-pump coronary artery bypass grafting patients with preoperative hypertension was no more difficult than in patients without preoperative hypertension.Monitoring of hemodynamic stability, especially blood pressure and heart rate during perioperative period, is an important consideration (1). During conventional open heart surgery, hypertension can occur at almost any time, ie before, during, or after surgery, and is most commonly mediated by an increase in sympathetic tone.Off-pump coronary artery bypass grafting is a procedure that may achieve better in-hospital outcome, including shorter length of stay (2,3). Hypertension associated with off-pump coronary artery bypass grafting is typically not a result of dramatic increase in systemic vascular resistance (4).The reported incidence of perioperative hypertension associated with conventional coronary artery bypass grafting (CABG) ranges from 30 to 80%, and this wide range may explain different definitions of the condition and preoperative comorbid states (5).To the best of our knowledge, there are no studies dealing with off-pump coronary artery bypass grafting. The aim of our study was to analyze perioperative hypertensive response in patients undergoing off-pump coronary artery bypass grafting. We hypothesized that it was more difficult to control perioperative hypertension in these patients who had been preoperatively hypertensive than in those who had not.