冠状动脉旁路移植术后心房颤动的危险因素分析

目的为预测冠状动脉旁路移植术（CABG）后是否发生心房颤动（AF）,对其术前危险因素进行分析。方法收集安贞医院2007年9月至2008年4月226例体外循环冠状动脉旁路移植术（CABG）或非体外循环冠状动脉旁路移植术（OPCAB）患者的临床资料,根据术后3d内是否出现AF持续5min以上分为非AF组和AF组,分析两组患者超声心动图检查指标及术前一般临床资料。两组患者均采用胸骨正中切口,并在相同条件下完成手术。结果术后24例患者（10．6％）发生AF.AF组中左心房前后径〉35mm的患者高于非AF组[41．7％（10例）vs．22．3％（45例）,χ^2=4．380,P=0．036）];二尖瓣反流患者高于非AF组[37．5％（9例）vs．17．3％（35例）,χ^2=5．568,P=0．018）];左主干病变患者高于非AF组[33．3％（8例）vs．12．4％（25例）,χ^2=7．560,P=0．006];年龄AF组高于非AF组（65．7±9．5岁vs．60．1±10．1岁,t=-2．724,P=0．010）。两组患者单因素分析结果：高龄、二尖瓣反流、左心房大、左主干病变等手术前临床指标是术后发生AF的危险因素;手术后呼吸机使用时间（χ^2=4．190,P=0．040）,心电监护时间（χ^2=5．948,P=0．015）,住院费用（χ^2=4．110,P=0．043）等两组间比较差异有统计学意义。结论CABG后发生AF与高龄、二尖瓣反流、左心房增大、左主干病变等危险因素有关。临床资料、心电图、超声心动图检查等有助于预测CABG后是否发生AF,以使更好地预防和治疗,降低术后AF的发生率。     

冠状动脉旁路移植术后心房颤动的相关因素分析

目的 了解冠状动脉旁路移植术（CABG）后心房颤动（Af)的发生率以及相关因素，并探讨可能的防治措施。方法 回顾性地总连续322例单纯CABG病例，并将患者分为Af组和非Af组。收集术前、术中、术后资料进行统计分析。结果 CABG术后Af的发病率为23．3％（75例），最常见于术后第1－3天。年龄大于65岁、右冠状动脉近－中段狭窄大于50％、术后早期未服用β阻滞剂为独立危险因素。结论 Af是CABG术后最常见的并发症，年龄和右冠状动脉病可以影响Af的发生，应用β阻滞剂和补充镁可能是预防术后早期Af发生最经济、有效的方法。     

非体外循环冠状动脉旁路移植术同期行心房颤动双极射频消融术

目的总结借助瑞克Ⅲ心脏固定器在非体外循环冠状动脉旁路移植术同期行双极心房颤动（房颤）射频消融术的手术效果。方法2008年1月至2013年10月北京安贞医院共有49例冠心病合并房颤患者接受非体外循环冠状动脉旁路移植术（OPCAB）加Atricure双极射频消融术。根据房颤的持续时间不同,将49例患者分为两组,持续性房颤组（A组）：14例,男9例、女5例,年龄（56．7±7．5）岁;阵发性房颤组（B组）：35例,男27例、女8例,年龄（60．2±10．5）岁。房颤病程为（9．4±6．0）个月。冠状动脉狭窄85％～100％。术后随访行动态心电图及超声心动图检查,观察房颤是否再发。结果无术中转为体外循环手术患者,围手术期无死亡。术后当天有81．6％的患者（40／49）转为窦性心律或交界性心律,18．4％的患者（9／49）仍为房颤心律,未出现Ⅱ～Ⅲ度房室传导阻滞。全组搭桥139支,平均2．8支。住院时间10～15（12±3）d。出院时患者维持窦性心律34例（69％）,其中A组9例（64％）,B组25例（71％）。所有患者均得到随访,随访率100％,随访时间5～12个月。维持窦性心律6个月以上39例（80％）,其中A组10例（71％）,B组29例（83％）;术后12个月窦性心律44例（90％）,A组11例（79％）,B组33例（94％）。两组差异无统计学意义（P〉0．05）。结论借助瑞克Ⅲ心脏固定器,在心脏不停跳冠状动脉旁路移植术同期行双极房颤消融手术是安全、有效、可行的。     

Intraoperative Angiography in Minimally Invasive Direct Coronary Artery Bypass Grafting

Intraoperative angiography in minimally invasive direct coronary artery bypass grafting without cardiopulmonary bypass and in hybrid procedures is reported. Twelve procedures were performed in a specially designed surgical-radiologic suite with a cross-disciplinary organization. In 2 patients the anastomosis was successfully revised on the basis of angiographic findings. In 4 of the 12 patients anastomosis of the left internal mammary artery to the left anterior descending coronary artery performed as a minimally invasive direct coronary artery bypass grafting procedure was combined with percutaneous transluminal coronary angioplasty of lesions in other coronary vessels in the same session. Intraoperative angiography allows a reliable diagnosis of an anastomosis or graft failure and prompt and reliable correction, and it allows the combination of minimally invasive direct coronary artery bypass grafting and angioplasty in one session.     

Intraoperative Angioplasty and Coronary Artery Bypass Grafting for the Treatment of Multisegmental Coronary Artery Disease

This report summarizes our experience with intraoperative angioplasty and coronary artery bypass graft surgery for the treatment of multisegmental coronary artery disease. The indication for intraoperative angioplasty was the presence of diffuse, symptomatic, coronary artery disease with at least one coronary artery having two or more areas of narrowing. The balloon catheter was introduced through an arteriotomy and advanced through the point of obstruction. The balloon was then inflated to 6 atmospheres for 15-20 seconds. This procedure was repeated two to three times. The time required for this technique averaged less than 5 minutes. Although there were no documented intraoperative perforations, intimal injuries were observed in two patients at the time of postoperative catheterization. Early and late postoperative angiograms showed that approximately 30% of angioplastied vessels had an improvement in their dilated lesions. Patients with discrete areas of narrowing had greater improvement in luminal diameter than those with diffuse narrowing (49% versus 17%). There was no difference in graft patency or left ventricular wall motion between vessels that did or did not undergo angioplasty.     

Relation of Cytokines to Vasodilation after Coronary Artery Bypass Grafting

Hemodynamic instability is frequent after coronary surgery. The present study tested the hypothesis that inflammation, as determined by circulating cytokine levels, may contribute to the difficulty of controlling arterial blood pressure after coronary artery bypass grafting. A group of 44 male patients undergoing elective coronary artery bypass grafting with cardiopulmonary bypass were studied. Plasma levels of tumor necrosis factor-, interleukin-6 (IL-6), IL-8, and IL-10 were measured before anesthesia induction, 5 minutes and 1 hour after reperfusion to the myocardium, and 2 and 18 hours after arriving in the intensive care unit (ICU). The 29 patients who did not need a vasopressor (norepinephrine) during their ICU stay were designated group I. They were compared to group II, which consisted of 15 patients who required a pressor agent in the ICU. Although no significant differences between groups were found regarding their hemodynamic variables, IL-6 and IL-8 levels were higher in the patients who used a pressor agent in the ICU. The norepinephrine dosage used in the ICU correlated with plasma IL-8 levels 2 hours after arriving in the ICU (r = 0.56, p = 0.031). Circulating IL-6 levels in group II were significantly higher than those in group I 2 hours after arriving in the ICU (126.5 ± 90.5 vs. 66.5 ± 48.2 pg/ml; p < 0.05). The mean IL-8 levels were higher in group II at 5 minutes (34.9 ± 25.7 vs. 17.3 ± 11.3 pg/ml) and 1 hour (38.6 ± 30.5 vs. 22.4 ± 16.7 pg/ml) after reperfusion, and 2 hours (33.0 ± 21.6 vs. 22.8 ± 16.7 pg/ml) after arriving in the ICU (p = 0.036). Postoperative vasodilation was associated with increased circulating IL-8 levels. Strategies that modulate cytokine responses may improve hemodynamic stability after coronary artery bypass grafting.     

影响非体外循环冠状动脉旁路移植术后心房纤颤术前因素的多因素分析

目的 探讨术前因素对非体外循环冠状动脉旁路移植术(off-pump coronary artery bypass grafting,OPCAB)后心房颤动(postoperative atrial fibrillation,POAF)发生率的影响.方法 回顾性分析我科2010年1月～2011年12月237例首次接受OPCAB的临床资料,对POAF的术前影响因素进行单因素和logistic回归分析.结果 POAF发生率16.9％(40/237).logistic回归分析显示年龄(OR=1.068,95％CI:1.019 ～1.118,P=0.006)、BMI(OR=1.138,95％ CI:1.010 ～1.281,P=0.034)、舒张压(OR=1.056,95％ CI:1.020 ～1.094,P=0.002)及左心房前后径(OR=1.089,95％ CI:1.002～1.184,P=0.046)是OPCAB后POAF的术前危险因素.结论 年龄、BMI、舒张压及左心房前后径是OPCAB后发生POAF的术前危险因素.     

Improved Health-related Quality of Life after Coronary Artery Bypass Grafting Is Unrelated to Use of Cardiopulmonary Bypass

This prospective study was instituted to assess whether the use of the on-pump method or the off-pump method affects changes in health-related quality of life (QOL) as evaluated a year after coronary artery bypass graft (CABG) surgery. Data including preoperative risk factors and postoperative morbidity up to discharge were collected from 508 CABG patients operated in the Heart Center of a university hospital and further treated in secondary referral hospitals. Four hundred and fifty-two (89.0%) patients underwent operation with the on-pump method and 56 (11.0%) with the off-pump method, i.e., without cardiopulmonary bypass (CPB). The RAND-36 Health Survey (RAND-36) was used as indicator of QOL. The primary outcome measure was a change in the physical component summary (PCS) and mental component summary (MCS) from the RAND-36. Symptomatic status was estimated according to New York Heart Association (NYHA) class. Assessments were made preoperatively and repeated 12 months later. The majority of patients operated on-pump (85.6%) and off-pump (92.9%) had a favorable outcome without major complications (p = 0.136). The present data showed significant improvement (p < 0.001) in all eight domains of QOL following on-pump CABG. Likewise, off-pump patients improved in all eight aspects, and the change was statistically significant in six dimensions. A highly significant (p < 0.001) pattern of change was seen in the RAND-36 MCS and PCS scores in both operative groups. Differences between the groups were nonsignificant. We conclude that most patients experience significant improvement in health-related QOL during the first year after CABG, and that cardiopulmonary bypass has no effect on patients subsequent health-related QOL, but its use depends on specific indications.     

冠状动脉旁路移植术后围术期心肌缺血

目的　　探讨冠状动脉旁路移植术 (CABG)术后出现围术期心肌缺血 (PMI)的相关危险因素及其处理措施。　方法　回顾性总结 2 6 80例 CABG患者的临床资料 ,并根据术后是否发生 PMI将其分为 PMI组 (30例 )和非PMI组 (2 6 5 0例 ) ,分析 CABG后出现 PMI的危险因素。　结果　 PMI组中 11例进行急诊再血管化 ,其余行主动脉内球囊反搏 (IABP)或药物治疗 ;院内死亡 7例 ,死亡率为 2 3.3%。心绞痛症状缓解 2 2例 ,心电图完全或部分复原 9例 ,残留心肌梗死改变 14例。非 PMI组院内死亡 5 8例 ,死亡率为 2 .2 %。两组死亡率之间比较差别具有显著性意义(χ2 =5 6 .0 4 ,P=0 .0 0 1)。多因素分析表明 ,术前无心肌梗死史、冠状动脉弥漫性病变和术中内膜剥脱为相关危险因素。结论　 PMI是 CABG术后一种比较危险的并发症 ,严重者可危及生命 ,及早诊断和适当的治疗尤为重要 ,对于因旁路血管堵塞造成的 PMI,急诊再次血管移植是挽救患者生命的必要措施。     

术中冠状动脉序贯桥即时血流测量的方法探讨

摘要：目的在冠状动脉旁路移植术（CABG）中探索一种使用即时血流测量仪（transittimeflowmeasurement,TTFM）测量序贯桥血流量的方法,从而能更可靠地反映吻合口的通畅程度。方法回顾性分析2012年4月至2013年1月北京安贞医院口例接受非体外循环冠状动脉旁路移植术（OPCAB）、术中以大隐静脉为桥血管（伴或不伴同期使用乳内动脉桥珩冠状动脉序贯吻合旁路移植术患者的临床资料,其中男92例,女39例;年龄（61．35±8．24）岁。术中采用两种方法对桥血管的血流量、搏动指数（PI）和舒张期血流灌注率进行测量,非阻断待测吻合口远端血流的测量方法（简称非阻断测量法）,即保持桥血管自然通畅状态,使用TTFM在桥血管距待测吻合口近端2cm处进行测量,并记录各数据;阻断待测吻合口远端血流的测量方法（简称阻断测量法）,即针对序贯桥,用哈巴狗血管夹暂时夹闭待测吻合口远端的桥血管,使用TTFM于桥血管距待测吻合口近端2cm处进行测量,并分别记录各数据、进行比较。结果采用阻断测量法测量的对角支[（27．43±15．22）ml／minVS．（59．28±30．13）ml／min]、钝缘支[（26．14±19．74）ml／minVS．（47．19±24．27）ml／min]以及左室后支[（19．16±8．92）ml／minVS．（38．83±20．11）ml／min]序贯吻合口血流量较非阻断测量法显著减少（P〈0．05）;采用阻断测量法测量的对角支（2．93±1．30VS．2.31±0．91）、钝缘支（2．62±1．17VS．2．01±0．87）以及左室后支（2．33±0．92VS．1．80±0．73）的PI值较非阻断测量法明显增加（P〈0．05）;两种方法各吻合口处舒张期血流灌注率比较差异无统计学意义,且均〉50％。通过非阻断测量法和阻断测量法分别发现1个和3个吻合口不通畅,重建后效果良好。结论序贯桥主干的血流流速高于单根桥血管,最示出其血流量大、血栓发生率低的优势。而阻断测量法更能精确地反映各个吻合口的通畅情况,敏感发现血管吻合通畅性不良的情况,从而及时进行吻合口重建,提高手术的成功率。     

Sinus Nodal Function and Risk for Atrial Fibrillation after Coronary Artery Bypass Graft Surgery

Background: Nonsurgical patients with sinus node dysfunction are at high risk for atrial tachyarrhythmias, but whether a similar relation exists for atrial fibrillation after coronary artery bypass graft surgery is not clear. The purpose of this study was to evaluate sinus nodal function before and after coronary artery bypass graft surgery and to evaluate its relation with the risk for postoperative atrial arrhythmias.

Methods: Sixty patients without complications having elective coronary artery bypass graft surgery underwent sinus nodal function testing by measurement of sinoatrial conduction time (SACT) and corrected sinus nodal recovery time (CSNRT). Patients were categorized based on whether postoperative atrial fibrillation developed.

Results: Twenty patients developed atrial fibrillation between postoperative days 1 through 3. For patients remaining in sinus rhythm (n = 40), sinoatrial conduction times were no different and corrected sinus nodal recovery times were shorter after surgery when compared with measurements obtained after anesthesia induction. Sinus node function test results before surgery were similar between the sinus rhythm and the atrial fibrillation groups. After surgery, patients who later developed atrial fibrillation had longer sinoatrial conduction times compared with the sinus rhythm group (P = 0.006), but corrected sinus nodal recover time was not different between these groups. A sinoatrial conduction time > 96 ms measured at this time point was associated with a 7.3-fold increased risk of postoperative atrial fibrillation (sensitivity, 62%; specificity, 81%; positive and negative predictive values, 56% and 85%, respectively; area under the receiver operator characteristic curve, 0.72).