冠状动脉旁路移植治疗冠状动脉肌桥9例分析

目的回顾冠状动脉旁路移植术治疗症状性肌桥的外科治疗经验及结果。方法选取2004年3月至2011年1月因冠状动脉肌桥导致冠状幼脉血流堵塞需行冠状动脉旁路移植术的患者资料9例,采用胸廊内动脉到前降支进行旁路移植,2例取大隐静脉与其他病变冠状动脉进行旁路移植。结果全组无患者死亡,无术中相关并发症发生。所有患者随访4个月至7年,临床症状均明显改善,无心绞痛发生,无心肌梗死及其他主要心血管不良事件（再血管化或死亡等）发生。结论冠状动脉旁路移植治疗有症状的肌桥安全、有效。     

395例体外循环下冠状动脉旁路移植术临床分析

目的总结分析冠状动脉旁路移植术(CABG)治疗冠心病的疗效和经验。方法 2002年1月至2012年12月我们完成CABG有395例,其中男299例,女96例,平均年龄62.3岁,均在中低温体外循环下完成手术,其中18例同期行室壁瘤切除术。结果本组平均搭桥3.2支。体外循环时间62~170 min,平均88 min,主动脉阻断时间25~102 min,平均68 min。术后机械通气时间12~72 h,平均18 h。围手术期死亡8例,死亡率2.0%,其中多器官功能衰竭6例,术后发生室颤抢救无效死亡1例,围术期急性心肌梗死1例。心功能均明显改善,195例心绞痛症状完全缓解,85例症状较前减轻。随访280例,随访时间8个月至11年,远期死亡5例,死亡原因不明。结论常规中低温体外循环下CABG是治疗冠心病安全、有效的方法。     

非体外循环冠状动脉旁路移植治疗高危冠心病的评价

背景：非体外与体外循环冠状动脉旁路移植是治疗冠状动脉粥样硬化性心脏病的外科学方法,但目前尚无二者对高危冠心病患者疗效比较的系统评价。 目的：通过Meta分析评价非体外与体外循环冠状动脉旁路移植对高危冠心病患者围手术期的疗效和安全性差异。 方法：计算机检索PubMed、EMbase、中国期刊全文数据库、中国生物医学文献数据库、维普数据库、万方数据库和Cochrane Library(2012年第8期),并辅以检索相关文献的参考文献,语种限制为中文和英文,检索时间为1993年1月至2012年6月。严格按照纳入和排除标准进行筛选研究。由2位评价员独立对纳入的研究进行质量评价与提取资料并交叉核对,最后将提取的资料用RevMan 5.1软件进行数据处理与分析。 结果与结论：共纳入16个研究包括2个随机对照试验与14个观察性研究;共6 441例患者,其中非体外循环冠状动脉旁路移植组2 948例患者,常规体外循环下冠状动脉旁路移植组3 493例患者。Meta 分析结果显示：非体外循环冠状动脉旁路移植与常规体外循环下冠状动脉旁路移植比较,在围手术期脑卒中、主动脉内球囊反搏使用、再发心肌梗死、呼吸功能不全与死亡率,呼吸机辅助时间、ICU时间、住院时间,输血量及术后引流量方面的差异均有显著性意义,而在房颤、急性肾功能损伤、伤口感染及二次开胸率方面的差异均无显著性意义。结果提示,在围手术期方面与常规体外循环下冠状动脉旁路移植相比,对高危冠心病患者采用非体外循环冠状动脉旁路移植是安全有效的,且具有创伤少,手术死亡率低,术后恢复快,术后并发症少的优点,但是由于纳入文献数量有限且大多为非随机对照试验,因此非体外循环冠状动脉旁路移植并不能取代常规体外循环下冠状动脉旁路移植,其具体疗效与中远期疗效需要进一步通过更高质量、大样本量、多中心的随机双盲对照试验研究及长期的观察才能得出肯定的结论。     

多层螺旋CT与冠状动脉造影对心肌桥的比较研究

目的探讨多层螺旋CT（MSCT）与冠状动脉造影（CAG）对心肌桥的诊断与比较。方法运用MSCT和冠状动脉造影对63例患者进行比较，经CT室及CAG医师判断心肌桥（MB）情况，并对MB进行血管形态学分析，判断两种方法对MB判断的差异与不同。结果双盲法MSCT发现MB23例25处（占36．5％），CAG发现MB9例11处（占14．3％），MSCT对冠状动脉节段迂曲、成角处有一定优势，两种方法比较有显著性差异（P〈0．05）。结论MSCT比CAG较容易发现MB，尤其在冠状动脉节段迂曲、成角处有明显优势。     

多层螺旋CT冠状动脉造影初步探讨

目的探讨多层螺旋CT冠状动脉造影的可行性及不同心率下冠状动脉的显示能力.方法16例多层螺旋CT冠状动脉造影.东芝AQUILION多层螺旋CT采集原始数据,扫描速度0.32s/270°,层厚2mm,螺距1.0-1.2.对比剂安射力2ml/kg,注射速率3.5ml/s.延迟时间20s,SGI02图像后处理工作站,后处理软件为ALATOVIEW版本Version1.42;采用遮盖容积重建(SVR)、多平面重建(MPR)、曲面重建(CPR)后处理技术.结果心率＜60次/min时冠状动脉主干及主要分支(前降支、回旋支)显示最清晰,心率60～79次/min时冠状动脉主干及主要分支显示较清晰,心率＞80次/min时冠状动脉主要分支显示不清.结论一定心率及扫描参数、对比剂使用合适前提下,多层螺旋CT冠状动脉造影可获得满意的冠状动脉主干及主要分支图像.     

冠状动脉旁路移植术后静脉桥再狭窄的基因治疗研究进展

冠状动脉旁路移植术是治疗缺血性心脏病安全、有效的方法.自体大隐静脉是术中最常用的移植血管材料.但是血栓形成、内膜增厚和粥样硬化导致的静脉桥再狭窄严重影响了其通畅率,而且至今尚无有效的治疗药物.分子生物学技术理论的发展为冠状动脉旁路移植术后静脉桥再狭窄的防治提供了新思路,基因治疗静脉桥再狭窄已成为目前研究的热点.本文主要从静脉桥再狭窄防治的目的基因、基因导入方式、基因载体等方面,对静脉桥再狭窄基因治疗的研究进展进行综述.     

血液回收对非体外循环冠状动脉旁路移植患者红细胞和血液粘度的影响

目的观察血液回收技术对非体外循环冠状动脉旁路移植患者红细胞、血小板和血液粘度的影响。方法2005年8月~2007年10月间,共完成46例非体外循环冠状动脉旁路移植术,随机分为实验组(血液回收组)和对照组(不使用血液回收机组),每组23例。观察两组用血液制品的数量和术后24h的引流量,比较两组术前和术后24h的红细胞计数、血红蛋白、红细胞压积、血小板计数、低切全血粘度和高切全血粘度。结果实验组用浓缩红细胞和血浆的量明显少于对照组,两组术后24h引流量、术前和术后24h的红细胞计数、血红蛋白、红细胞压积、血小板计数、低切全血粘度和高切全血粘度之间的差异无显著性意义。结论血液回收技术在非体外循环冠状动脉旁路移植患者中能减少输血,对红细胞、血小板和血液粘度无不利影响。     

非体外循环冠状动脉旁路移植术围手术期护理

非体外循环冠状动脉旁路移植术是在全麻、常温、胸骨正中切口心脏跳动下进行的手术。我院2001年12月率先在我市开展了这项手术，现将围手术期护理总结如下。     

非体外循环冠状动脉旁路移植术中血流动力学和氧供需变化及麻醉处理

目的 观察非体外循环冠状动脉旁路移植术中处理三支主要冠状动脉分支引起的血流动力学和氧供需改变，并对原因作初步分析，为麻醉处理提供依据。方法 选择我院2004年1月-2005年12月择期行非体外循环冠状动脉旁路秽植术符合标准的60倒病人。手术开始后，记录以下5点的血流动力学数值：（1）开胸始；（2）暴露和固定前降支后；（3）暴露和固定左回旋支冠状动脉后；（4）暴露和固定右冠状动脉后；（5）术毕。记录（1），（4），（5）点血气。结果 血流动力学发生了明显的改变，平均动脉血压、心指数下降，而心率、中心静脉压升高，平均肺动昧压、肺动脉楔压升高。动脉血气改变，动脉血乳酸水平升高。结论 本组病人行非体外循环冠状动脉旁路移植时，血流动力学发生了变化，经及时处理完成手术。氧供逐渐减少，氧耗量没有明显的改变，氧代谢紊乱及缺氧程度较轻。     

电子束CT冠状动脉血管造影与冠状动脉造影结果的关联性研究

目的　探讨电子束CT冠状动脉血管造影 (eletronbeamcomputedtomographicangiography ,EBA)与冠状动脉造影结果的关联性。方法　 2 4例临床怀疑冠心病患者分别行EBA及冠状动脉造影 (coronaryangiography,CAG) ,所有EBCT图像均经三维重建显像 ,按照AHA分段方法进行分段 ,每套重建显像血管分成左主干 (leftmainartery ,LM)及前降支 (leftanteriordescendingcoronaryartery ,LAD)、左旋支 (leftcircumflexartery ,LCx)、右冠脉 (rightcoronaryartery,RCA)各近、中、远三段共 10段血管 ,由 2名医生对LM和LAD、LCx、RCA的近、中段共 16 8段血管进行分析 ,其结果与CAG结果对比 ,比较EBA与CAG所示冠状动脉狭窄间的关系。结果　在 16 8个近段和中段血管中有 147段 (87.5 0 %)EBA能够清楚显像 ,其中LAD近段和中段清晰显像的百分比都为 95 .83%,而RCA近段和中段分别为 91.6 7%和 5 8.33%,LCx近段和中段为 91.6 7%、79.17%,而在 16 8个近段和中段血管中CAG全部清晰显像 ;如果以 >5 0%狭窄作为有意义狭窄 ,则EBA与CAG比较发现狭窄的敏感性和特异性是 83.33%和 92 .13%,其中LM是 10 0 .0 0%和 95 .6 5 %,LAD近段是 10 0 .0 0 %和 75 .0 0 %,LAD中段是 82 .35 %和 6 6 .6 7%,RCA近段是 80 .0 0 %和 71.43%,RCA中段是 5     

Assessment of coronary artery bypass graft patency by multislice computed tomography

The recently developed multislice computed tomography (MSCT) is capable of rapid imaging of cardiac structures, including coronary arteries, during a single breath-hold. We evaluated coronary artery bypass graft (CABG) patency by comparing MSCT results to those of contrast angiography. MSCT and contrast angiography were performed in 39 patients (10 women, 29 men and mean age 60.0 +/- 7.8 years) with a total of 115 bypass grafts including 36 left internal mammary arteries, 4 right internal mammary arteries, 19 radial arteries, 2 gastroepiploic arteries and 54 vein grafts. Patients were investigated for an average of 14 +/- 27 months (range 1 - 108 months) after CABG surgery. Contrast angiography showed a patency rate of 87.0% (100/115). Ninety-nine of these 100 patent grafts by contrast angiography and 14 of the remaining 15 occluded grafts were correctly classified by MSCT (93.3% sensitivity and 99.0% specificity for bypass graft occlusion). The positive and negative predictive values for bypass graft occlusion were 93.3% and 99%, respectively, with an overall diagnostic accuracy of 98.3% (97.2% for left internal mammary artery, 100% for radial artery, 98.1% for vein graft and 100% for other grafts). In conclusion, MSCT is a useful and accurate diagnostic tool for the evaluation of bypass graft patency.     

运用CTA影像定量评价冠脉重构及斑块发展

目的目前运用CT血管造影(computed tomography angiography,CTA)对冠脉斑块的定量评估多采用自动分析软件,进行由于CTA影像存在斑块伪影极易导致测量不准确,且多数研究只分析冠脉局部病变部位的即时斑块情况,本文将采用手动测量方法,追踪研究整支右侧冠状动脉(right coronary artery,RCA)的斑块发展。方法选择RCA无支架植入、随访时间约12个月的急性冠脉综合征患者12例,获取患者基线和随访时的CTA影像数据,然后利用Osiri X影像处理软件进行整支RCA的弯曲多平面重建,随后按照每隔3mm进行RCA分割和横断面重建,并在一定窗宽和窗口水平条件下进行横断面测量,最后采用类似IVUS分析方法测量获取斑块形态学评价参数,即最小管腔面积、斑块负荷、斑块体积及冠脉重构等,并通过观察这些参数的变化研究整支RCA的动脉粥样硬化斑块的发展。结果对于纳入研究的365段冠脉血管段,在12个月的随访过程中,RCA最小管腔面积减小了0.16 mm2,斑块负荷轻微增加了0.38%,但斑块体积几乎无变化。发生冠脉正性重构占39.2%,负性重构占43.3%,没有重构占17.5%。结论当合理设置窗宽和窗口水平时,运用CTA影像定量评价技术可以纵向评估冠脉斑块的发展。     

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.     

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。     

Thinking inside the graft: applications of optical coherence tomography in coronary artery bypass grafting

Recent advances in catheter-based optical coherence tomography (OCT) have provided the necessary resolution and acquisition speed for high-quality intravascular imaging. Complications associated with clearing blood from the vessel of a living patient have prevented its wider acceptance. We identify a surgical application that takes advantage of the vascular imaging powers of OCT but that circumvents the difficulties. Coronary artery bypass grafting (CABG) is the most commonly performed major surgery in America. A critical determinant of its outcome has been postulated to be injury to the conduit vessel incurred during the harvesting procedure or pathology preexistent in the harvested vessel. As a test of feasibility, intravascular OCT imaging is obtained from the radial arteries (RAs) and/or saphenous veins (SVs) of 35 patients scheduled for CABG. Pathologies detected by OCT are compared to registered histological sections obtained from discarded segments of each graft. OCT reliably detects atherosclerotic lesions in the RAs and discerns plaque morphology as fibrous, fibrocalcific, or fibroatheromatous. OCT is also used to assess intimal trauma and residual thrombi related to endoscopic harvest and the quality of the distal anastomosis. We demonstrate the feasibility of OCT imaging as an intraoperative tool to select conduit vessels for CABG.     

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.     

Blood volume after coronary artery bypass grafting

Patients with stable angina pectoris are reported to have a markedly reduced blood volume (BV). In the present study, average BV was still 19% less than that predicted in 77 men examined 5 years after coronary artery bypass grafting. Beneficial effects of the operation such as relieved angina, absence of medication, complete revascularization status at repeat angiography, and restored physical fitness were not found to be associated with a normalization of the BV. No significant correlation was found between BV and body weight, heart volume, exercise capacity, ejection fraction or left ventricular end-diastolic pressure. The reduced BV in patients with angina pectoris after successful revascularization and the absence of correlation with physiological variables indicate a persisting disturbed regulation mechanism.     

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.     

Clopidogrel improves aspirin response after off-pump coronary artery bypass surgery

We sought to assess the incidence of aspirin resistance after off-pump coronary artery bypass （OPCAB） surgery, and investigate whether clopidogrel can improve aspirin response and be safely applied early after OPCAB surgery. Sixty patients who underwent standard OPCAB surgery were randomized into two groups. One group （30 patients） received mono-antiplatelet treatment （MAPT） with aspirin 100 mg daily and the other group received dual anfiplatelet treatment （DAPT） with aspirin 100 mg daily plus clopidogrel 75 mg daily. Platelet aggregations in response to arachi- donic acid （PLAA） and adenosine diphosphate （ADP） （PLADP） were measured preoperatively and on days 1 to 6, 8 and 10 after the antiplatelet agents were administered. A PLAA level above 20% was defined as aspirin resistance. Postoperative bleeding and other perioperative variables were also recorded. There were no significant differences between the two groups in baseline characteristics, average number of distal anastomosis, operation time, postoperative bleeding, ventilation time and postoperative hospital stay. However, the incidence of aspirin resistance was significantly lower in the DAPT group than that in the MAPT group on the first and second day after antiplatelet agents were given （62.1% vs, 32.1%, 34.5% vs. 10.7%, respectively, both P 〈 0.05）. There was no significant difference in postoperative complication between the two groups. DAPT with aspirin and clopidogrel can be safely applied to OPCAB patients early after the procedure. Moreover, clopidogrel reduces the incidence of OPCAB-related aspirin resistance.