非体外循环冠状动脉旁路移植术患者术中血糖波动水平与短期预后的关系

目的 评价非体外循环冠状动脉旁路移植术患者术中血糖波动水平与短期预后的关系.方法 择期行非体外循环冠状动脉旁路移植术的患者214例,ASA分级Ⅰ～Ⅲ级,NYHA分级Ⅰ～Ⅲ级,稳定性心绞痛分级Ⅰ～Ⅲ级,左室射血分数≥30%.于麻醉诱导后10 min时至关胸骨后10min时,每隔1 h取动脉血样1 ml,测定血糖,计算术中血糖波动水平,即术中血糖最高值与最低值之差.记录预后各指标的发生情况,包括监护室内滞留(在监护室内停留时间≥24 h)、机械通气时间延长(机械通气时间≥12 h)、术后并发症(包括新发的心功能不全、心律失常、心肌梗死、呼吸功能不全、脑卒中、感染、胸腔积液、外科出血,发生其中一项即为发生了并发症)和术后住院时间延长(术后住院时间≥7 d).以术中血糖波动水平400 mg/L作为分界点,将患者分为2组:<400 mg/L组(L组)和≥400 mg/L组(H组).绘制术中血糖波动水平与预后各指标发生率之间的受试者工作特征曲线,计算曲线下面积及其95%可信区间,以此评估术中血糖波动水平预测患者的短期预后的准确性.结果 术中血糖水平波动预测监护室内滞留时间、机械通气时间延长、术后并发症和术后住院时间延长的受试者工作特征曲线下面积及其95%可信区间分别为0.804(0.739～0.869)、0.604(0.415～0.793)、0.801(0.720～0.882)、0.615(0.523～0.707).与L组比较,H组监护室内滞留时间延长,术后并发症和术后住院时间延长的发生率升高(P<0.01),机械通气时间延长发生率差异无统计学意义(P>0.05).结论 术中血糖波动水平可较好地预测非体外循环冠状动脉旁路移植术患者的短期预后;血糖波动水平≥400 mg/L的患者预后较差.

Abstract：

Objective To investigate the effect of intraoperative fluctuation in blood glucose concentration (BGCF) on short-term clinical outcomes in patients after off-pump coronary artery bypass graft (CABG) .Methods Two hundred and fourteen ASA Ⅰ -Ⅲ patients ( NYHA grade Ⅰ -Ⅲ ) of both sexes aged 18-64 yr with body mass index 23-29 kg/m2 underwent elective off-pump CABG. Their left ventricular ejection fraction was ≥30% .Blood samples were obtained once an hour for determination of blood glucose concentration (BGC) between 10 min after induction of anesthesia and 10 min after closure of sternum. The maximum and minimum BGCs were record-ed . Intraoperative BGCF was defined as the difference between the maximum and minimum BGCs. Other factors which may influence clinical outcome were also recorded, including prolonged ICU stay ( ≥24 h), prolonged me-chanical ventilation ( ≥12 h) , postoperative complications (cardiac insufficiency secondary to operation, arrhyth-mia, myocardial infarction, respiratory insufficiency, stroke, infection, pleural effusion and surgical bleeding) and prolonged postoperative hospital stay ( ≥ 7 d) . The patients were divided into 2 groups using intraoperative BGCF 400 mg/L as cutoff point: group L < 400 mg/L and group H ≥400 mg/L. Receiver operating characteristic (ROC)curve was used to evaluate if intraoperative BGCF was a good index of postoperative outcomes. Results The area under the ROC curve of intraoperative BGC against prolonged ICU stay was 0. 804 (0.739-0. 869), against prolonged mechanical ventilation 0. 604 ( 0.415-0.793 ), against postoperative complications 0.801 ( 0.720-0. 882 )and against postoperative hospital stay 0.615 (0.523-0.707). The duration of ICU stay was significantly longer and the incidences of complications and prolonged postoperative hospital stay were higher in group H than in group L (P < 0.01). Conclusion Intraoperative BGCF is closely related to postoperative outcomes in patients after offpump CABG. The patients with the BGC≥400 mg/L has a poor prognosis.     

非体外循环冠状动脉旁路移植术患者术中血糖波动水平与短期预后的关系

Objective To investigate the effect of intraoperative fluctuation in blood glucose concentration (BGCF) on short-term clinical outcomes in patients after off-pump coronary artery bypass graft (CABG) .Methods Two hundred and fourteen ASA Ⅰ -Ⅲ patients ( NYHA grade Ⅰ -Ⅲ ) of both sexes aged 18-64 yr with body mass index 23-29 kg/m2 underwent elective off-pump CABG. Their left ventricular ejection fraction was ≥30% .Blood samples were obtained once an hour for determination of blood glucose concentration (BGC) between 10 min after induction of anesthesia and 10 min after closure of sternum. The maximum and minimum BGCs were record-ed . Intraoperative BGCF was defined as the difference between the maximum and minimum BGCs. Other factors which may influence clinical outcome were also recorded, including prolonged ICU stay ( ≥24 h), prolonged me-chanical ventilation ( ≥12 h) , postoperative complications (cardiac insufficiency secondary to operation, arrhyth-mia, myocardial infarction, respiratory insufficiency, stroke, infection, pleural effusion and surgical bleeding) and prolonged postoperative hospital stay ( ≥ 7 d) . The patients were divided into 2 groups using intraoperative BGCF 400 mg/L as cutoff point: group L < 400 mg/L and group H ≥400 mg/L. Receiver operating characteristic (ROC)curve was used to evaluate if intraoperative BGCF was a good index of postoperative outcomes. Results The area under the ROC curve of intraoperative BGC against prolonged ICU stay was 0. 804 (0.739-0. 869), against prolonged mechanical ventilation 0. 604 ( 0.415-0.793 ), against postoperative complications 0.801 ( 0.720-0. 882 )and against postoperative hospital stay 0.615 (0.523-0.707). The duration of ICU stay was significantly longer and the incidences of complications and prolonged postoperative hospital stay were higher in group H than in group L (P < 0.01). Conclusion Intraoperative BGCF is closely related to postoperative outcomes in patients after offpump CABG. The patients with the BGC≥400 mg/L has a poor prognosis.     

非体外循环冠状动脉旁路移植术

目的:总结非体外循环冠状动脉旁路移植术(OPCAB)的临床经验。方法:自2001年3月～2002年10月我院共完成OPCAB9例,在进行旁路移植吻合时,冠状动脉的暴露和制动借助于特制胸骨牵开器和配套的冠状动脉固定器。结果:无手术死亡,无围手术期心肌梗死等严重并发症发生,短期随访临床效果满意。结果:OPCAB安全可行,可减少输血,减轻手术创伤与并发症,近期疗效满意。     

非体外循环下冠状动脉旁路移植术

目的 总结110例非体外循环心脏跳动下冠状动脉旁路移植术经验，探讨其手术适应证、优缺点及手术方法。方法 常温、全身麻醉，胸正中切口，非体外循环心脏跳动下，应用特殊心表固定器行冠状动脉旁路移植术，平均搭桥3．9支，血管桥为乳内动脉、大隐静脉及桡动脉。结果 全组无手术死亡，术后心绞痛症状消失。手术时间平均为210min，术后气管插管时间平均为4．8h。术后住院时间平均为10d，住院费用平均为4．4万元。其中3例术中出现不可逆血压过低、室颤而转为体外循环冠状动脉旁路移植术。结论 非体外循环心脏跳动下冠状动脉旁路移植术是一种安全、有效的治疗方法。特别适合于老年及心功能差的患者，可减少体外循环并发症，缩短术后住院时间，降低住院费用，但不能完全替代体外循环旁路移植术。     

非体外循环冠状动脉旁路移植术术后处理

目的　总结47例非体外循环冠状动脉旁路移植术(OPCAB)术后处理的临床经验，并对其进行初步探讨。方法　1999年6月～2000年6月我院共完成OPCAB47例，其中单支血管病变3例，双支病变5例，三支病变39例。采用乳内动脉、桡动脉和／或大隐静脉共移植血管150支，平均每例3.2支。　结果　平均术后辅助呼吸时间6±2.5小时、平均ICU监护治疗时间36小时，31例患者未输血，术后早期发生心律失常15例，出血、二次手术3例，二次气管内插管2例，术后1个月切口感染2例，胸骨骨不连1例，无住院死亡病例。术后平均住院14天。　结论　OPCAB术后早期应适时尽早拔出气管内插管，调整血容量，水、电解质平衡及术前所用药物，预防和及时处理心律失常等并发症。     

非体外循环和体外循环冠状动脉旁路移植术在二次冠状动脉旁路移植术中的应用

目的研究对比在二次冠状动脉旁路移植术(re-CABG)患者中分别采用非体外循环和体外循环下冠状动脉旁路移植术(off-pump CABG和on-pump CABG)的临床早期结果,探讨通过合理手术方式的选择,提高re-CABG的手术疗效。方法自2000年4月到2006年6月,21例首次CABG后因心绞痛复发患者在阜外心血管病医院接受了re-CABG手术,其中10例行off-pump CABG(off-pump组),11例行on-pump CABG(on-pump组)。两组患者术前性别、年龄、体重、心肺功能、心绞痛程度、左心室舒张期末内径、射血分数、合并高血压、糖尿病等方面差异无统计学意义(P>0.05)。结果 On-pump组中患者术后死亡1例,冠状动脉远端吻合口数多于off-pump组(P<0.05);off-pump组无手术死亡,在手术时间、术后呼吸机辅助时间、胸腔引流液量、输血量和手术后住院时间等方面,均明显少于on-pump组(P<0.05)。结论 Off-pump CABG和on-pump CABG技术在re-CABG中都可以取得满意疗效,off-pump CABG下施行re-CABG安全可靠。     

非体外循环下冠状动脉旁路移植术

目的　探讨和评价微创非体外循环冠状动脉旁路移植术 (OPCAB)的临床效果。　方法　 38例 OPCAB患者中左冠状动脉主干病变 4例 ,1支血管病变 10例 ,2支 14例 ,3支 10例 ,均经胸骨正中切口行 OPCAB,每例移植血管 1～ 5支 ,平均移植血管 2 .42支。应用左乳内动脉 38支 ,大隐静脉 5 4支。　结果　全组无手术死亡 ,36例顺利完成手术 ,2例转为心肺转流术下冠状动脉旁路移植术。38例均在手术后 2～ 12小时 ,平均 4.9± 2 .6小时顺利拔除气管内插管。全组均顺利康复 ,15例手术后 1个月内恢复了原工作。　结论　对有适应证的患者 ,OPCAB是一项安全有效的术式     

非体外循环冠状动脉旁路移植术中转体外循环的经验与教训

目的总结分析非体外循环冠状动脉旁路移植术(OPCAB)中转为体外循环冠状动脉旁路移植术(onpum p CABG)的原因及临床资料,以提高OPCAB的成功率。方法8例患者中转为on pum p CABG的原因为:2例术中发现心肌桥,处理时出血难以控制;6例因术中严重的低血压,其中3例是在搬动心脏时,另外3例在切开靶血管时。中转患者中2例在心脏不停跳下完成,其他均在低温体外循环下完成,体外循环时间为101.8±8.5 m in。结果8例中转患者中无住院死亡;1例发生轻度的中枢神经系统并发症,其他患者无严重并发症发生;1例中转后术中用主动脉内球囊反搏(IABP)辅助完成手术。OPCAB患者与中转on pum p CABG患者比较左心室舒张期末压(13.5±4.5mmHg vs.19.1±6.7mmHg)差别有统计学意义(t=2.180,P=0.04)。结论左心室舒张期末压增高是OPCAB的高危风险因素,如果>20 mmHg应首选on pum p CABG;急诊手术、心肌桥亦是OPCAB的风险因素。     

非体外循环下冠状动脉旁路移植术

目的 报告微创非体外循环冠状动脉旁路移植术(OPCABG),探讨其手术指征及外科处理要点。方法 回顾性总结5例OPCABG的临床资料。结果 5例顺利完成非体外循环冠状动脉旁路移植术。随访3～4个月,无死亡,无明显心绞痛及心肌缺血表现。结论 对于选择的患者,OPCABG安全、经济、有效,是一种值得推广的微创心脏手术方法。     

机器人微创非体外循环冠状动脉旁路移植术

目的 评价da Vincis机器人系统进行胸廓内动脉(IMA)游离、小切口非体外循环下冠状动脉旁路移植术的安全性和手术效果.方法 2007年1月到2011年3月,105例患者接受机器人IMA游离、小切口非体外循环下冠状动脉旁路移植术.其中男性77例,女性28例,年龄33～77岁,平均(59±10)岁.患者术前行64排CT检查评估IMA质量,2例患者左LIMA纤细或走行异常弃用.术者于操作台前、三维成像系统下遥控机器人游离IMA并完成动脉桥与靶血管的徒手吻合.其中4例患者旁路移植后接受了杂交技术于回旋支或右冠状动脉行支架植入术.术中均以超声血流检测仪测量桥血管的波形及血流.术后以冠状动脉造影或64排CT评估桥血管的通畅性,并进行随访.结果 所有患者成功接受上述手术,无手术死亡病例.术中平均IMA血管桥血流量为(21±13) ml/min.1例于术后第1天突发心跳骤停经抢救后痊愈,复查桥血管通畅.1例合并脑梗死患者术后肺部感染,痊愈后出院.其余患者无并发症发生.术中及术后出血少,术后恢复快.随访1～51个月,平均(30±12)个月.术后冠状动脉造影或64排CT复查未见桥血管狭窄或闭塞,心绞痛症状缓解.结论 机器人IMA游离、小切口非体外循环冠状动脉旁路移植术创伤小、疗效确切、安全性好,是微创冠状动脉再血管化的重要方向之一.     

非体外循环冠状动脉搭桥术的近期疗效评价

目的　分析非体外循环 (OPCAB)与常规体外循环下冠状动脉搭桥术 (cCABG)后监护特点和近期疗效。　方法　比较OPCAB组 (6 0例 )和cCABG组 (6 2例 )术后引流量和输血量、血管活性药物的使用、一般监护治疗和恢复情况及近期临床疗效。　结果　OPCAB组术后引流量小于 4 0 0ml的例数明显多于cCABG组 (χ2 =7.316 ,P <0 .0 1) ,而大于 80 0ml的例数明显少于cCABG组 (χ2 =13.2 16 ,P <0 0 0 1)。OPCAB组术后未输血例数明显多于cCABG组 (χ2 =37.793,P <0 0 0 1)。OPCAB组使用硝普钠的例数较cCABG组多 (χ2 =12 .0 0 6 ,P <0 .0 0 1) ,而使用多巴胺的例数明显少于cCABG组 (χ2 =32 .198,P<0 .0 0 1) ,且未使用多巴酚丁胺。OPCAB组术后辅助通气 (5 .9± 3.3)h ,心电监测 (4.8± 1.7)d ,术后(18 1± 4 .1)h坐起 ,(15 .2± 5 .0 )h开始进食 ,平均 (2 .3± 0 .9)d拔除引流管 ,均明显短于cCABG组 (t =14 .0 2 5 ,5 .4 71,5 .791,8.95 3,5 .80 0 ,P <0 .0 1)。OPCAB组死亡 1例 ,围术期心肌梗死 1例 ,心律失常 4例 ,使用IABP 1例 ,较cCABG组少 ,但差别均无显著性 (χ2 =1.776 ,1.776 ,1.937,1.77,P >0 .0 5 )。　结论　OPCAB术后循环稳定 ,创伤小 ,恢复快 ,体现出微创手术的优越性     

非体外循环冠状动脉旁路移植术后的阿司匹林抵抗

目的 通过检测非体外循环冠状动脉旁路移植术(OPCAB)后患者血小板聚集率以及尿11-脱氢-血栓烷B2(11-DH-TXB2)指标,动态观察术后阿司匹林抵抗(AR)的发生情况,探索术后AR的危险因素。方法 冠心病患者290例,首次行OPCAB患者145例(手术组),接受内科药物治疗患者145例(非手术组)。手术组患者于术前及术后服用阿司匹林后第1、4、10天及6个月,检测血小板聚集率以及尿11-DH-TXB2。非手术组患者于服药前及服药后第1、4、10天检测上述指标。同时记录患者各项临床资料。结果 手术组患者服用阿司匹林后第1天的AR发生46例(32％)(抵抗组),其余为非抵抗组。用药后第4天和第10天AR患者下降至19例(13％)和5例(3％)。半年随访中未发现有AR患者存在。非手术组患者,服药后第1天,血小板聚集率均下降至20％以下,平均(8.8±6.8)％,未见AR现象出现。手术组患者术后血小板计数显著高于术前(P＜0.05)。Logistic回归分析发现,OPCAB患者中,体重大于75 kg(OR =0.38,95％CI:0.18～0.79)和术后引流量超过500 ml(OR=3.12,95％CI:1.29～7.53)为术后出现AR的危险因素。结论 OPCAB术后早期,阿司匹林的抗血小板作用受到不同程度抑制,部分患者出现AR现象,予以更为积极有效的抗血小板治疗有重要临床意义。     

Early results of off-pump coronary artery bypass

Objective: The purpose of this study is to compare the operative results of off-pump coronary artery bypass (OPCAB) and on-pump (conventional) coronary artery bypass (CCAB), to clarify qualitative problems and whether OPCAB is less invasive or not. Methods: OPCAB was consecutively performed in 63 patients and CCAB in 63 patients between July 1998 and December 2003. Results: The mean number of bypass grafts was 2.43 ±0.82 in the OPCAB group and 2.70±0.71 in the CCAB group (p=0.096). In-hospital mortality was 0% in the OPCAB group and 3.2% in the CCAB group. The incidence of perioperative myocardial infarction was 0% in the OPCAB group and 3.2% in the CCAB group. The incidence of postoperative major complications was significantly lower in the OPCAB group than in the CCAB group (OPCAB group=4 complications, CCAB group=13 complications). Cerebrovascular accidents occurred in 1.6% of patients in both groups. The incidence of sternal infection or mediastinitis was 0% in the OPCAB group and 3.2% in the CCAB group. The early patency rate of graft was 94.0% in the OPCAB group and 92.8% in the CCAB group, and was not significantly different (p=0.822). Conclusion: Operative mortality and major complications after surgery in OPCAB were lower than that in CCAB. The early patency rate in OPCAB was as good as that in CCAB. It is considered that OPCAB is less invasive and the quality of bypass in OPCAB is as good as that in CCAB.     

舒芬太尼在非体外循环冠脉搭桥术应用中的临床研究

目的 观察舒芬太尼在非体外循环冠状动脉搭桥手术应用中的安全性和有效性.方法 择期行OPCABG病人54例,被随机分成两组,舒芬太尼组和芬太尼组,每组27例,麻醉诱导应用丙泊酚1 mg/ks～2 ms/ks,同时分别静注舒芬太尼0.5 μg/ks～1μg/kg,或芬太尼4 μg/ks-8 μg/ks,同时吸入安氟醚维持麻醉,持续输注舒芬太尼0.08 μg·ks-1min-1,或芬太尼0.6 μg·ks-1·min-1.记录各组气管插管、切片、麻醉维持和拨除气管导管各时间的收缩压和舒张压.结果 在气管插管过程中,浅麻醉反应的病人数舒芬太尼组明显低于芬太尼组,在气管插管切皮,麻醉维持和拔管期间,芬太尼组收缩压、舒张压明显高于舒芬太尼组,术后清醒和拔管时间两组病人无统计学差异.结论 舒芬太尼的麻醉效果优于芬太尼,舒芬太尼能提供术中更稳定的血液动力学.     

心肺转流冠状动脉旁路移植术中血糖波动水平与术后高血糖及患者短期预后的关系

目的探讨心肺转流冠状动脉旁路移植术（CABG）中血糖波动水平与术后高血糖及患者短期预后的关系。方法入选116例无糖尿病患者择期心肺转流CABG。我们按照以下固定时间采集2ml动脉血进行血糖测定:术前1d空腹（T₀）、麻醉诱导后5min（T₁）、术中最高血糖时（T₂）、术中最低血糖时（T₃）、关胸骨后5min（T₄）、入心脏重症监护室（CSICU）即刻（T₅）、回CSICU后2h（T₆）,在T₁和T₄之间每隔30分钟进行一次血糖测定。所有标本均由同一血气分析仪进行测定。根据术中血糖波动水平分为两组,L组为血糖波动<2.2mmol/L,H组为血糖波动≥2.2mmol/L。观察并记录术后高血糖率、房颤发生率、心肌缺血率、呼吸支持时间、自动复跳和术前、术后射血分数（EF）值。结果 L组为76例,H组为40例,T₂、T₄～T₆时L组患者血糖明显低于H组,且术后高血糖发生率明显低于H组（P<0.01或P<0.05）。L组患者术后房颤发生率、心肌缺血率明显低于H组,呼吸支持时间明显短于H组,L组自动复跳率和术后EF值明显高于H组（P<0.01或P<0.05）。结论在心肺转流CABG患者中,术中血糖波动水平与术后高血糖发生有一定相关性,血糖波动水平可以预测患者的短期预后,而血糖波动水平≥2.2mmol/L的患者预后可能存在明显恶化趋势。     

Predictors of atrial fibrillation after off-pump coronary artery bypass graft surgery

OBJECTIVE: Atrial fibrillation is the most common complication after coronary artery bypass graft surgery. This arrhythmia may lead to hemodynamic compromise, prolonged hospitalization, and increased risk for cerebral thromboembolism. Older age is the only variable consistently associated with the development of postoperative atrial fibrillation; however, no strong predictive model exists. The purpose of this study was to identify perioperative characteristics associated with new-onset atrial fibrillation in patients undergoing off-pump coronary artery bypass grafting. DESIGN: Prospective, observational. SETTING: University tertiary care hospital. PARTICIPANTS: One hundred sixty consecutive patients undergoing off-pump coronary artery bypass grafting. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Incidence of postoperative atrial fibrillation was the major outcome. Atrial fibrillation occurred in 33 patients (20.6%). Multivariate analysis identified reintervention (odds ratio 26.8), revascularization of the ramus medianus (odds ratio 3.9), and age (odds ratio 1.069 per year) as the only independent predictors of postoperative atrial fibrillation. All patients were in sinus rhythm at hospital discharge. One hospital death was noted. CONCLUSIONS: Despite the less invasive approach, the incidence of postoperative atrial fibrillation is high after off-pump coronary artery bypass grafting. Older age, grafting of the ramus medianus, and a redo operation were predictors of new-onset postoperative atrial fibrillation. It is possible that left atrial stretching with heart dislocation during revascularization of the lateral wall could lead to postoperative atrial fibrillation.     

Perioperative myocardial infarction in patients undergoing off-pump coronary artery bypass grafting

Two patients in whom myocardial infarction in the inferior wall occurred after off-pump coronary artery bypass grafing (OPCAB) are described. In both patients, the right coronary artery had no critical lesion and was not grafted. There was no ischemic episode during operation. Coronary artery spasms and/or intracoronary thrombus formation may have been causes of these events. To our knowledge, this is the first report on perioperative myocardial infarction in OPCAB.     

A comparison of early clinical outcomes of off-pump and on-pump coronary artery bypass grafting surgery in elderly patients

Background: The reply of question of “which coronary artery bypass grafting (CABG) technique is superior in elderly patients, off-pump or on-pump CABG surgery?” is controversial. We aimed to compare the early clinical outcomes in elderly patients undergoing off-pump and on-pump CABG.

Methods: From January 2009 to January 2015, 344 elderly patients (aged 70 or older) underwent off-pump (n?=?137) or on-pump (n?=?207) CABG. Patients’ medical records were retrospectively reviewed, and their baseline preoperative characteristics, operative data and postoperative outcomes were analyzed, thereby a comparison of early outcomes between off-pump and on-pump patients was performed.

Results: Mean age of patients was 74.4?±?3.8 years. Both groups were statistically similar in terms of baseline preoperative characteristics. Number of distal bypass was significantly lower in off-pump group than in on-pump group. Postoperative length of intensive care unit and hospital stay were similar between two groups. Amounts of transfused blood products were significantly lower in off-pump CABG group. There were no significant differences in terms of postoperative complications and mortality between two groups.

Conclusions: Our results did not reveal a significant benefit of either surgical technique with respect to early-term clinical outcomes in elderly CABG patients. Further investigations are needed to determine whether off-pump CABG is superior than on-pump CABG in elderly patients.