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。     

Coronary artery spasm after off-pump coronary artery bypass grafting

BACKGROUND: Coronary artery spasm (CAS) in the immediate postoperative period has been recognized as a possible cause for perioperative myocardial ischaemia after off-pump coronary artery bypass grafting (CABG). It varies in severity and can be associated with circulatory collapse and death. The purpose of this study was to present our experiences on CAS after off-pump CABG and detail its management. METHODS: The case reports of three patients with similar clinical presentations of ischaemic heart disease who underwent CABG using an off-pump technique are reviewed. Severe manifestations of CAS in the immediate postoperative period with documented angiographic findings are presented. RESULTS: Three patients (two men and one woman) with angina pectoris were diagnosed with coronary artery disease using coronary angiography. The elective off-pump CABG was uneventful; however, severe manifestation of myocardial ischaemia with abrupt onset developed at the intensive care unit. All three patients underwent immediate coronary angiography to verify the diagnosis of CAS. Apart from intracoronary nitroglycerine infusion and medical support with inotropic agents, extracorporeal membranous oxygenation was carried out because of severe haemodynamic deterioration in one case, while support was required with intraaortic balloon pumping in another. All three patients made a full recovery. CONCLUSION: Coronary artery spasm can severely complicate the postoperative course for patients undergoing off-pump CABG, leading to myocardial ischaemia or infarction, life-threatening arrhythmias, persistent hypotension and even cardiac arrest. Early awareness and diagnosis of CAS with the establishment of appropriate management strategies may prevent its potentially lethal consequences.     

Off-pump coronary artery bypass grafting attenuates proinflammatory markers

Objective: Cardiac surgery with cardiopulmonary bypass (CPB) has been considered the main causative factors of postoperative inflammatory reactions. The aim of this study was to compare surrogate markers of the proinflammatory response in patients who underwent coronary artery bypass grafting (CABG) with or without CPB. Methods and Results: Twenty patients undergoing first-time CABG were enrolled in the study, 10 with and 10 without CPB. Blood samples were drawn at the following times: at the anesthetic induction, the end of surgery, and thereafter at 12 and 24 hours postoperatively. Neutrophil elastase, interleukin (IL)-6 , and serum soluble Fas were chosen to evaluate the extent of the systemic inflammatory response. The groups were similar in terms of age, gender ratio, number of grafts per patient. There were no operative mortality or serious postoperative complications. Two of each group received blood transfusion postoperatively. Neutrophil elastase showed a significantly higher value in the on-pump group compared with the off-pump group at the end of surgery. Soluble Fas level showed a higher value at the end of surgery compared with baseline, while it had no significant changes in the off-pump patients. IL-6 levels in the on-pump group were consistently higher compared to the off-pump group but showed no statistically significant differences between the groups. Conclusion: Compared with off-pump CABG, on pump CABG induced higher serum levels of proinflammatory markers including neutrophil elastase and soluble Fas.     

Transfusion and bleeding in coronary artery bypass grafting: an on-pump versus off-pump comparison

Blood transfusion rates in coronary artery bypass grafting (CABG) surgery using cardiopulmonary bypass (CPB) are typically higher compared with off-pump CABG (OPCAB). However, few studies have specifically examined intraoperative hemodilution as a contributing factor. The aim of this retrospective review was to compare the effect of using CPB or OPCAB on red blood cell (RBC) transfusion and postoperative bleeding. The lowest intraoperative hematocrit (Hct) was used as marker of intraoperative hemodilution. We reviewed the perioperative data of all isolated CABG patients at a metropolitan hospital from January 2003 to June 2005. Stepwise regression analyses were performed to determine whether CPB was an independent predictor of RBC transfusion, reoperation for bleeding, or postoperative chest drainage. Of a total of 1043 patients, there were 433 CPB and 610 off-pump cases. CPB use was not significantly related to increased RBC transfusions (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.63-1.52; p = .921) and was associated with a lower incidence of reoperations for bleeding (OR, 0.4; 95% CI, 0.2-0.8; p = .009). There was less chest drainage over the first 12 hours in patients undergoing CPB (p < .0001); however, total postoperative chest drainage was not significantly related to operative procedure (p = .122). The lowest documented intraoperative Hct was a significant factor in RBC transfusions (OR, 0.89; p < .0001), an increased reoperation rate for bleeding (OR, 0.9; p = .001) and more postoperative chest drainage (log10-transformed: at 12 hours, b = -0.009, p < .0001; total, b = -0.006, p < .0001). CPB is not an independent risk factor in the incidence of RBC transfusions and is not associated with increased postoperative bleeding for isolated CABG. However, intraoperative hemodilution is an independent risk factor, with a lower intraoperative Hct associated with more RBC transfusions, increased reoperations for bleeding, and increased postoperative chest drainage. Addressing intraoperative hemodilution is important in minimizing CPB-associated morbidities.     

Off-pump coronary artery bypass grafting in two renal transplant patients

Coronary artery disease is a critical problem for a renal transplant patient. This paper reports offpump coronary artery bypass grafting (OPCABG) in two cases after renal transplantation. The first, a 65-year-old woman, experienced chest pain 5 years after a renal transplantation. Coronary angiography (CAG) revealed stenosis of the left anterior descending artery (LAD) and the first diagonal artery (DB1). OPCABG [left internal thoracic artery (LITA) to DB1 and LAD] was performed. The second, a 67-year-old man, underwent percutaneous coronary intervention in the LAD 10 years ago. He experienced chest pain 2 years after a renal transplantation. CAG revealed restenosis of LAD. OPCABG (LITA to LAD) was performed. The patients’ postoperative course was uneventful. OPCABG for a renal transplant patient was safe and useful since it is a less invasive procedure and easily managed perioperatively.     

34例非体外循环冠状动脉搭桥术

目的：报告３４例非体外循环下的冠状动脉搭桥术，。方法：秣在全麻常温下进行，正中切口２１例，左前外侧切口１１例，右前外侧切口和左胸骨旁切口各１例。单支病变１７例，双支病变１１例，三支病变６例；平均每例搭桥１．４支，其中１例同时激光打孔心肌血运重建。结果：全组无手术死亡平均手术时间３．１小时，平均带气管插管时间１０．９小时，２２例病人（６４．７％）不需输血，平均住院花费３．４万元。术后ＵＦＣＴ或ＭＲＩ     

非停跳冠状动脉搭桥术病生理改变及临床监测

非停跳冠状动脉搭桥术(OPCABG)因其避免了体外循环的不良反应,在临床上得到了广泛应用.术中心脏位置的变化和应用心脏固定器,会引起显著的血流动力学波动、心肌缺血等病生理改变,进而导致心室功能障碍.近年的研究表明,心室舒张功能障碍和右心功能不全是引起血流动力学变化的重要因素.临床上多采用肺动脉导管(PAC)和经食道超声心动图(TEE)来监测术中血流动力学和心功能的变化.新型的PAC能够将容量监测和压力监测结合起来,拓展了其监测范围和功能;而TEE在术中辅助诊断和监测的可靠性、有效性得到了广泛认可.心室压力一容量环作为一种非容量依赖性的方法,在监测心功能方面越来越受到重视.     

Coronary artery bypass grafting for dialysis patients

OBJECTIVE: To assess the efficacy and safety of cardiopulmonary bypass during coronary artery bypass grafting (CABG) in dialysis patients. METHODS AND RESULTS: Sixty four isolated CABG patients who underwent on cardiopulmonary bypass and whose intraoperative body weight gains were accurately measured were studied retrospectively. The mean intraoperative body weight gain was 2.61 +/- 0.9 kg/m2 in the study group and 1.06 +/- 0.6 kg/m2 in controls, i.e.) 100 patients selected at random from CABG patients during the same period using cardiopulmonary bypass without chronic renal faulure, showing a statistically significant difference. Complete revascularization was successful in 98% of patients. Postoperative nonlethal complications involved brain infarction in 1 patient (1.7%), reintubation in 1 (1.7%), and paralytic ileus in 2 (3.4%). All were successfully extubated within 24 hours of surgery, and no sternal wound complications were found. Hospital mortality was 6.3% (4/64). Actuarial survival rates at 3, 5 and 8 years including all deaths were 90%, 70% and 56%, and estimated by cardiac deaths were 95%, 90%, and 90% respectively. Cardiac event free rates were 90%, 73% and 61% at 3, 5 and 8 years after CABG. CONCLUSIONS: In CABG for dialysis patients, the use of cardiopulmonary bypass demonstrates significant merits, and may expect long-term survival with minimal postoperative complications.     

体外循环和非体外循环冠状动脉旁路移植术围术期血小板数量和功能的变化研究

目的分析体外循环和非体外循环冠状动脉旁路移植术（CCABG和OPCAB）围术期血小板数量和功能的变化情况。方法随机选取接受CCABG和OPCAB的患者各30例,术后常规阿司匹林治疗（100mg,每天1次）,分别记录两组术前、术后当天、术后1d、5d和10d的血小板数量及二磷酸腺苷诱导的血小板聚集率（PAG）。描绘走行趋势图,分析术后血小板数量和PAG的变化规律。结果在术后常规阿司匹林治疗的情况下,CCABG组和OPCAB组患者术后早期血小板数量均短暂下降,然后显著上升并超过术前水平（P〈0．01）,这种变化在CCABG组更明显。两组的PAG术后均增高（P〈0．05）,于术后第10天,OPCAB组基本恢复正常,而CCABG组仍高于术前水平（P〈0．05）。结论无论是否应用体外循环,CABG术后均有血小板数量的增加和功能的提高,体外循环组的变化更明显。     

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。     

Off-pump coronary artery bypass grafting: A single center experience

Background Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) is gaining popularity as an effective alternative to conventional CABG using cardiopulmonary bypass. With the advent of mechanical tissue stabilization systems and intra coronary shunts the technique of off-pump CABG (OPCAB) is now applicable to revascularize the patients with multi-vessel disease. Methods A total of 293 patients underwent surgical myocardial revascularization without cardiopulmonary bypass between July 1996 and October 2000 at our hospital. Of these, 245 patients received 2 or more grafts: two in 193 patients, 3 in 46 patients and 4 in 7 patients. A mechnical tissue stabilization system (CTS or Octopus II/III) was used in all patients. In majority of the patients intra coronary shunts were also used. A total of 550 distal anastomoses were made and the vessels grafted were LAD (n=245), diagonal (n=90), ramus intermedius (n=16), obtuse marginal branches (n=58), distal right coronary artery (n=88) and posterior descending artery (n=52). Results There was no incidence of perioperative myocardial infarction. Three patients had transient ST segment elevation postoperatively which was normalized in the first few hours. Hospital mortality was 0.4%. No patient needed reexploration for bleeding. No patient had neurological event or pulmonary problems. All these patients except one were discharged from the hospital between 6 and 9 days. Conclusion In selected patients multi vessel OPCAB is a safe and reproducible technique and the mechanical tissue stabilization systems have made the procedure less difficult to perform. Its usefulness is more pronounced in high risk patients with comorbidities and the patients who undergo this procedure are free from major complications.     

Off-pump coronary artery bypass grafting in patients with significant left ventricular dysfunction

Objective  Off-pump coronary artery bypass grafting (OPCAB) is known to preserve left ventricular function better than conventional coronary artery bypass grafting (CCAB). This study was carried out to investigate the safety, feasibility and efficacy of off-pump coronary artery bypass grafting in patients with significant left ventricular dysfunction. Methods  Three hundred and eighty eight consecutive patients with preoperative left ventricular ejection fraction ≤ 39% who underwent CABG between January 2001 through October 2007 were included in this retrospective study. Two hundred and eleven patients were operated by off-pump technique (group 1) and 178 patients were operated by on-pump technique (CCAB) (group 2). The postoperative outcomes were analyzed. Of these, 204 (52.57%) patients were diabetics, 355 (91.49%) patients had documented prior myocardial infarction, 316 (81.44%) patients were in canadian cardiovascular society(CCS) class III and 47 (12.11%) patients were in CCS class IV. Results  There was no significant difference in the number of grafts per patient between the two groups [group 1 3.02 ± 0.76 vs group 2 3.18 ± 0.72 (P=0.07) and the index of completeness of revascularization was comparable [1.08 ± 0.08) (OPCAB) vs 1.04 ± 0.06 (CCAB) (p=0.52)] The left internal thoracic artery was anastomosed to left anterior descending artery in 98% of patients. Operative mortality was 2.8% (6 deaths) following OPCAB and 3.93% (7 deaths) following CCAB (p=0746). Postoperative usage of IABP support was higher in CCAB group (12 patients vs 4 patients: P<0.03) and usage of moderate or higher doses of inotropic support was also higher in the conventional group (p<0.0006). More worsening of preexisting renal insufficiency was observed in CCAB group (p=0.01) and no significant difference in the incidence of atrial fibrillation was observed between the groups. Conclusions  Off-pump coronary artery bypass grafting is feasible and safe in patients with depressed left ventricular function and the postoperative morbidity was less in OPCAB group compared to on-pump group.     

Off-pump coronary artery bypass grafting in a patient with liver cirrhosis

We report a case of unstable angina pectoris and alcohol-related Child-Pugh class B cirrhosis. The patient was a 60-year-old man who was admitted to hospital with chest pain. He had previously been diagnosed to have Child B cirrhosis due to alcoholic liver dysfunction at 58 years of age. He also had experienced ruptured esophageal varices, moderate ascites, and hyperammonemia. We performed percutaneous catheter intervention; however, he developed re-stenosis in the right coronary artery, and progression in the disease in other coronary arteries. We then performed coronary artery bypass grafting on the beating heart without cardiopulmonary bypass. He was discharged on the 13th postoperative day without any complications. This case demonstrated that off-pump coronary artery bypass grafting was safe for such a patient.     

Extended use of bilateral internal thoracic arteries for coronary artery bypass grafting in the elderly

Objective: Internal thoracic artery (ITA) grafts provide better early and long-term patency than saphenous vein (SV) grafts. Furthermore, bilateral ITA grafting has recently demonstrated better long-term results than unilateral ITA grafting. However, its use in the elderly is controversial. Methods: From March 1991 through November 2001, 307 consecutive patients aged 65 years or over undergoing isolated coronary artery bypass grafting (CABG) were reviewed, and the influence of bilateral ITA grafting on the early and long-term results was evaluated. All ITA grafts were harvested as a pedicle, and almost all of which were used as in-situ grafts. Results: Operative mortality in 138 patients undergoing bilateral ITA grafting was 1.4%, and in 108 patients undergoing unilateral ITA grafting, the rate was 0.9%. Predischarge angiography conducted in 97% of the subjects showed that the patency rate of all the ITA grafts (98.9%) was superior (p<0.0001) to that of all the SV grafts (93.6%). In comparisons of survival and freedom from cardiac events at 10 years after CABG, the bilateral use of ITA grafts was proved to be more beneficial than the unilateral use (p<0.05). Conclusions: It was demonstrated that bilateral ITA grafting could be performed with acceptable mortality and morbidity. Moreover, it offers better long-term survival and freedom from cardiac events than either unilateral ITA grafting or no ITA grafting. Bilateral ITA grafting thus can serve as a favorable procedure even in elderly patients.     

Successful off pump coronary artery bypass grafting in a patient with an undiagnosed pheochromocytoma

We report a successful off pump coronary artery bypass case in a patient with a pre-operatively undiagnosed pheochromocytoma. The patient had no signs of ischemia intra- or post-operatively due to aggressive antihypertensive treatment. We would also like to emphasize the importance of using an adequate stabilizing device in order to safely perform anastomoses in a situation like this.     

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.     

Coronary artery and graft spasm after off-pump coronary artery bypass grafting

We report a case of a 52-year-old man with severe coronary artery and graft spasm after triple-vessel off-pump coronary artery bypass grafting. Emergent coronary angiography was performed to identify the location and severity of the spasm. Intracoronary injections of several vasodilators failed to relieve the spasm. Observational treatments including intra-aortic balloon pump and inotropic drugs to increase coronary flow were performed until the spasm resolved. The patient recovered and was discharged. A follow-up coronary angiography revealed patent native coronary artery and bypass grafts without evidence of residual spasm.     

非体外循环冠状动脉旁路移植术40例

目的探讨报告非体外循环冠状动脉旁路移植术(OPCAB)的临床应用价值。方法40例患者均在全麻、常温下经胸骨正中切口行OPCAB术,其中单支病变1例,2支病变5例,3支病变16例,4支病变18例。结果全组无手术死亡,平均搭桥3.1支,术后平均呼吸机辅助时间为(8.0±2.5)h。结论对冠状动脉疾病,OPCAB是一种安全,有效的治疗方法。