非体外循环和常规冠状动脉旁路移植术疗效对比

非体外循环冠状动脉旁路移植术 (ｏｆｆ ｐｕｍｐｃｏｒｏｎａｒｙａｒｔｅｒｙｂｙｐａｓｓｇｒａｆｔｉｎｇ ,ＯＰＣＡＢ)是在全麻、常温、胸骨正中切口心脏跳动下进行的手术。 1999年 1月至 12月 ,我们共完成ＯＰＣＡＢ手术 46例 ,现与同期完成的常规冠状动脉旁路移植术(ＣＡＢＧ) 4 6例进行疗效对比研究。临床资料　ＯＰＣＡＢ组 46例中男 35例 ,女 11例 ;平均年龄 (6 3 1± 9 3)岁 ;心绞痛分级 2 5± 0 9;平均射血分数 0 49±0 0 8;冠状动脉 (冠脉 )单支病变 6例 ,2支病变 2 3例 ,3支病变 12例 ,左主干病变 5例 ;全组平均移植桥 (2…     

体外循环与非体外循环下冠状动脉旁路移植术孰优孰劣

近年来冠状动脉旁路移植术有了很大的进展。采用非体外循环冠状动脉旁路移植术能避免体外循环带来的并发症,而得到越来越多的重视,但其技术难度大;传统的冠状动脉旁路移植术在体外循环的辅助下可以提供较好的血管吻合条件,仍被广泛采用。现将对两种手术方法的移植血管通畅率、死亡率、炎症反应、凝血与抗凝的影响、器官系统损伤、住院时间和费用、术式转换等方面的比较进行综述。     

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。     

非体外循环与常规体外循环冠状动脉旁路移植术比较

1999年12月至2003年7月，我们对410例冠心病病人施行了心脏不停跳冠状动脉旁路移植手术(冠脉搭桥，OPCAB)，对318例施行传统体外循环冠脉搭桥手术(CCAB)，现对两种术式进行比较，报道如下。     

体外循环与非体外循环冠状动脉旁路移植术临床分析

目的 比较体外循环冠状动脉旁路移植术（on—pump CABG，on—pump）和非体外循环冠状动脉旁路移植术（off—pump CABG，off—pump）的临床应用效果。方法 回顾2003年12月-2005年1月间我院行冠状动脉旁路移植术（CABG）195例的临床资料，依据术中采用不同的手术方式分为on—pump组和off—pump组。并对两组患者的术前、术后临床资料、术后并发症发生情况进行分析。结果 两组患者术前一般临床资料比较差别无统计学意义；术后off—pump组发生并发症17例，on—pump组26例（P=0．000）；off-pump组住院死亡2例，on—pump组死亡6例（P=0．025）。结论 在多支左主干病变中，off—pump和on—pump在再血管化的应用上无差别；off—pump后的心电图改变、死亡率和并发症发生率比on—pump患者低，但是合并瓣膜病或严重的3支血管病变、左主干病变、室壁瘤形成的患者更适宜采用on—pump，off—pump不能取代on—pump。     

全动脉化冠状动脉旁路移植术与常规冠状动脉旁路移植术近期结果比较

目的比较使用桡动脉和乳内动脉全动脉化冠状动脉旁路移植术(CABG)与使用一根乳内动脉和静脉做常规CABG的近期手术结果。方法从1999年1月到2005年1月,阜外心血管病医院共有123例患者(男114例、女9例,年龄52.2±10.1岁)采用全动脉化CABG(全动脉化组),血管移植材料为乳内动脉和桡动脉,目标血管桥在2根以上;同期行常规CABG115例(男102例、女13例,年龄60.3±9.1岁),血管的移植材料为一根乳内动脉和若干静脉桥(常规手术组)。比较两组患者术前、术中和术后的临床结果。结果术前资料比较,全动脉化组的患者年龄更小,常规手术组3支病变患者较多(54.5%vs.86.1%,P=0.001),全动脉化组有更多患者选择非体外循环CABG(26.0%vs.57.4%,P=0.001);在体外循环CABG中,全动脉化组需要更长的手术时间;平均移植血管根数全动脉化组少于常规手术组(2.6±0.7根vs.3.4±0.9根,P=0.001);住院死亡率全动脉化组为0.8%,常规手术组为0.9%,两组比较差异无统计学意义(P=1.000);术后近期并发症发生情况两组结果相似。结论对选择适合的患者采用全动脉化CABG能够提供较为安全的近期手术结果。     

低手术风险患者体外循环与非体外循环冠状动脉旁路移植术早期结果分析

目的 总结低手术风险冠心病患者施行体外循环冠状动脉旁路移植术(on-pump CABG)与非体外循环冠状动脉旁路移植术(off-pump CABG)的早期临床效果.方法 对48例低手术风险冠心病患者(EuroSCORE≤2)分别施行on-pump CABG(on-pump组)与off-pump CABG(off-pump组),对比分析两组患者的手术情况、术后呼吸机辅助时间、胸腔引流量、血液制品的使用、主要并发症、特殊用药、住院时间及住院费用等临床指标;并监测血流动力学、心肌酶谱指标.结果 两组患者的手术时间、移植血管根数、胸腔引流量、术后主要并发症和住院时间等方面比较差异无统计学意义(P＞0.05),呼吸机辅助时间、血液制品的应用和住院总费用on-pump组高于off-pump组(P＜0.05).两组的血流动力学指标、心肌酶谱分析结果差异无统计学意义(P＞0.05).结论 off-pump CABG与on-pump CABG均为有效的冠状动脉再血管化的方法,对低手术风险冠心病患者应选择off-pump CABG手术方式.     

70岁以下多支冠状动脉病变患者体外与非体外循环冠状动脉旁路移植术的比较

目的比较非体外循环冠状动脉旁路移植术(off-pump CABG)与体外循环冠状动脉旁路移植术(on-pump CABG)治疗70岁以下多支冠状动脉病变患者的疗效,为其手术术式选择提供依据。方法 2007年6月至2009年6月,共收治了196例70岁以下多支血管病变患者,其中男152例,女44例;年龄46～69岁,平均年龄55.00岁。根据采用的手术术式不同,将196例患者分为两组,off-pump CABG组:94例,on-pump CABG组:102例。比较两组患者移植血管的种类和支数、术中输血量、术后呼吸机辅助时间、住院时间、围术期并发症发生率及病死率等。结果 off-pumpCABG组中有2例患者术中因循环不稳定改为on-pump CABG,最终有1例死于多器官功能衰竭。on-pumpCABG组术后死于严重低心排血量和心脏骤停各1例。两组移植血管材料、围术期并发症发生率和病死率差异无统计学意义(P0.05);而术中off-pump CABG组远端吻合口数量(3.22±0.65个vs.4.52±1.11个,t=9.807,P=0.000)、输血量(312.57±305.26mlvs.744.86±279.37ml,t=10.317,P=0.000)、术后呼吸机辅助时间(10.71±5.32hvs.17.12±4.67h,t=8.683,P=0.000)、住院时间(17.75±3.04dvs.21.24±6.46d,t=4.782,P=0.000)少于或短于on-pump CABG组。off-pump CABG组随访93例,on-pump CABG组随访100例,随访时间2～26个月。所有随访患者均生存,无心绞痛发作。结论 on-pump CABG和off-pump CABG治疗70岁以下多支冠状动脉病变患者的早期临床疗效差异无统计学意义,但on-pump CABG组血管化比较完全。off-pump CABG目前仍不能取代on-pump CABG,而远期预后仍有待长期随访观察。     

Off-pump versus on-pump coronary bypass in high-risk subgroups

BACKGROUND: Cardiopulmonary bypass (CPB) has pathophysiologic sequelae that may be more severe in high-risk subsets. We wanted to determine whether off-pump coronary bypass (OPCAB) could optimize outcomes. METHODS: Our database of 242 OPCAB patients undergoing complete revascularization was compared to a base of 483 CABG patients undergoing CPB. Results were compared for the overall series and in the following high-risk subsets: 80 years of age or older, ventricular dysfunction (ejection fraction (EF) < or = 0.25), prior neurologic event or renal failure, chronic obstructive pulmonary disease (COPD), and reoperation. RESULTS: In the overall series, OPCAB significantly reduced the incidence of intraoperative transfusion requirements and showed a trend toward reduced morbidity in terms of postoperative neurologic and renal complications, prolonged ventilator requirement greater than 3 days, and bleeding requiring reexploration. Mortality was less in the OPCAB group (0.4% versus 2.7%, p = not significant). Similar results were achieved in the following high-risk subgroups (n = off-pump/on-pump): 80 years of age or older (n = 28/58), EF less than or equal to 25% (n = 13/26), preoperative neurologic event (n = 25/36), preoperative renal failure (n = 27/46), COPD (n = 33/43), and reoperation (n = 28/76). OPCAB decreased the incidence of prolonged ventilation in COPD patients (0/33 [0%] versus 4/43 [9.3%] p = not significant) and decreased the incidence of renal complications in the elderly (1/28 [3.6%] versus 9/58 [15.5%] p = not significant). Off-pump coronary bypass reduced but did not eliminate neurologic events in the elderly (2/28 [7.1%] versus 8/58 [13.8%] p = not significant). CONCLUSION: Off-pump coronary bypass significantly reduced the incidence of transfusion requirement compared to the CPB counterparts and had a consistent trend in reducing morbidity and mortality overall and in all high-risk subsets. Neurologic events are not eliminated in OPCAB.     

Off-pump versus conventional coronary artery bypass grafting in octogenarians

Coronary artery bypass grafting (CABG) in elderly patients is becoming increasingly common. From January 1996 to February 2002, 836 patients underwent CABG in our hospital, of whom 33 patients (3.9%) were aged 80 years or older. We evaluated the clinical and short-term results of 7 cases of off-pump CABG (OPCAB) and 26 cases of conventional CABG (C-CABG). Mean patient age and preoperative risk factors were similar in both groups. The OPCAB group had significantly decreased operation time (218 versus 281 minutes, p<0.05), and the number of distal anastomoses was significantly fewer in the OPCAB group than in the C-CABG group (1.9 versus 3.8, p<0.05). The frequency of complete revascularization in C-CABG was significantly higher than that of the OPCAB group (84.6% versus 42.9%, p<0.05), and there were no differences in the incidence of major postoperative complications between the groups. There was no hospital death in either group. Cumulative cardiac event free rates were 75% at 1 year and 75% at 3 years in the OPCAB group and 100% at 1 year and 84.6% at 3 years in the C-CABG group (p<0.05). In conclusion, CABG is safe and effective for myocardial revascularization in octogenarians. Except for high-risk cases, complete revascularization with OPCAB or C-CABG should be performed, because favorable outcomes can be expected even in the elderly patients.     

Off-pump coronary artery bypass

OBJECTIVES: Off-pump coronary artery bypass grafting (CABG) on the beating heart has become popular procedure in cardiac surgery and its initial results appeared favorable. We report our early and mid-term results of off-pump CABG performed at Shin-Tokyo Hospital. METHODS: Medical records of patients undergoing off-pump or conventional on-pump CABG from September 1, 1996, to August 31, 1999 were retrospectively reviewed. Patients underwent off-pump CABG were further classified into 2 groups; MIDCAB (Off-pump CABG for single vessel revascularization via a small skin incision) and OPCAB (off-pump CABG mainly approached via midline sternotomy) group. Their preoperative, perioperative, and follow-up data were collected and analyzed. RESULTS: Among a total of 995 cases of CABG, 194 cases were off-pump CABG (male/female 142/52, mean age 66.9). The mean number of distal anastomoses in off-pump CABG was 1.9 +/- 0.9 (1.0 +/- 0.0 in MIDCAB and 2.3 +/- 0.7 in OPCAB), which was significantly fewer than in on-pump CABG (3.6 +/- 1.1), with p < 0.0001. Intubation time (5.3 +/- 5.7 hours in off-pump CABG vs 13.1 +/- 24.2 hours in on-pump CABG), ICU stay (1.7 +/- 1.1 vs 3.2 +/- 3.0 days), and postoperative hospital stay (14.0 +/- 7.9 vs 18.1 +/- 12.1 days) in off-pump CABG were significantly shorter than in on-pump CABG (p < 0.0001). In the off-pump CABG group, there were no in-hospital deaths and 14 major complications, fewer than in on-pump CABG (8 hospital deaths and 114 major complications). Postoperative angiography before hospital discharge was conducted in 80 patients (41.2%) and showed 2 occlusions, giving a graft patency rate of 98.6% in the off-pump group. During follow-up (0.9 +/- 0.6 year) period, there were 5 non-cardiac deaths and 20 cardiac events in the off-pump group. The actuarial survival rate at 36 months was 94.6% for off-pump CABG, showing no significant difference from the rate for conventional CABG patients (95.2% at 36 month, p = NS) The event-free rate was 84.0% at 36 months in off-pump CABG patients; however, which was less favorable than on-pump CABG patients (88.0% at 36 months, p < 0.05). CONCLUSIONS: Both in-hospital and mid-term results for off-pump CABG patients were acceptable. Isolated CABG can thus be safely performed without cardiopulmonary bypass. Advances in coronary stabilization have contributed to these improved results. The observed long-term cardiac events may be related to incomplete revascularization.     

Off pump versus conventional on pump coronary artery bypass: a review

Despite many years of clinical and experimental research, the contribution of Cardiopulmonary Bypass (CPB) and cardioplegic arrest to morbidity and mortality following cardiac surgery remains unclear. In the last few years, Off-Pump Coronary Artery Bypass grafting (OPCAB) has gained widespread attention as an alternative technique to conventional On-Pump Coronary Artery Bypass grafting (ONCAB). It has provided an opportunity to compare the operations, in similar patient groups, with or without CPB and cardioplegic arrest. Although initial studies performed on low risk patients preferably with single vessel disease showed favorable outcome, we currently lack larger properly randomized high quality studies which show definite benefit. Proponents of off-pump surgery state that the avoidance of the CPB leads to significantly reduced myocardial ischemia-reperfusion injury, post-operative systemic inflammatory response, postoperative pulmonary complications, hospital stay and cost, a feature that may improve the clinical and economical outcomes. However, perfection in surgical technique, completeness of revascularization and whether the off pump method leads to improved outcome are still burning issues. In this review, OPCAB is found to be significantly better than the ONCAB in reducing cost, hospital stay, blood transfusion requirements, incidence of post-operative pulmonary complications, systemic inflammation and post-operative atrial fibrillations in most of the studies. The comparison show almost equivocal results regarding mortality, survival, quality of life, re-intervention rate, risk of stroke, cognitive decline and GI complication.     

Off-pump versus on-pump coronary artery bypass: meta-analysis of currently available randomized trials

BACKGROUND: Off-pump coronary artery bypass (OPCAB) challenges the conventional on-pump coronary artery bypass grafting (CABG) as the standard of surgical therapy for coronary disease. The aim of this study is to assess the differences in clinical outcomes between CABG and OPCAB by meta-analysis of data published in randomized trials. METHODS: A literature search (Medline, Pubmed, Cochrane Controlled Trials Register, and the Cochrane Medical Editors Trial Amnesty of unpublished clinical trials) was done for the period starting from January 1990 until May 2002 and was supplemented with a manual bibliographic review for all peer-reviewed English language publications. A systematic overview (meta-analysis) of the randomized trials was done to define the risk of the composite end point (death, stroke, or myocardial infarction) in CABG versus OPCAB. RESULTS: A literature search yielded nine comparable randomized studies, for a total of 1090 patients, of whom 558 and 532 were randomly assigned to CABG and OPCAB, respectively. Meta-analysis of these studies showed a trend, albeit not statistically significant, toward reduction in the risk of the composite end point for patients who had OPCAB (odds ratio 0.48; 95% confidence interval 0.21 to 1.09; p = 0.08). CONCLUSIONS: Cumulative analysis of the few prospective randomized studies currently available found a potential clinical benefit of OPCAB, indicating that the avoidance of extracorporeal circulation might result in improved clinical outcomes. Further evidence, however, from large randomized trials is needed to assess potential advantages of OPCAB in terms of early outcomes.     

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 versus on-pump coronary artery bypass grafting in acute coronary syndrome: a clinical analysis

Background  

Although off-pump coronary artery bypass (OPCAB) surgery has many beneficial effects compared with on-pump surgery, switch to on-pump surgery has significantly higher risks of operative mortality. Benefits of OPCAB over on-pump surgery strategies concerning myocardial revascularization are still debatable. We have aimed to develop an "algorithm of off-pump surgical strategy" on preventing conversion to on-pump. This clinical study reports our clinical outcome of OPCAB in patients with acute coronary syndrome.