冠状动脉旁路移植术的护理

针对５０例冠状动脉旁路移植术后维持心肌氧的供需平衡的护理问题，提出了术前的肺功能锻炼－－呼吸疗法；术后维持生命征平稳，改善心血管功能，降低心肌氧耗，防止完脉痉挛，保证有效的冠状动脉和组织灌注等护理要点；及时发现和控制开发症的发生和发展。从而保证了冠状动脉路移植术的顺利开展。     

冠状动脉旁路移植术治疗成人川崎病

1997年10月至2002年12月，我们为7例成人川崎病病人施行了冠状动脉旁路移植术（CABG）治疗。     

冠状动脉旁路移植术后长期随访

目的 总结１９８２年至１９９１年间３８例冠状动脉旁路移植术（ＣＡＢＧ）者的长期随访结果,以探讨术前危险因子对ＣＡＢＧ疗效的影响。方法 ３８例中男３６例,女２例。年龄４１－７３岁,平均５５．４岁,７３．７％病人年龄大于５０岁。有心肌梗死发作史者１５例,有心衰史者２例。ＰＴＣＡ失败后急症手术２例,３支,３支以上冠状动脉病变者１９例。心功能Ⅲ级及以上者３０例。应用Ｓｔａｔｉｓｔｉｃａ软件包中的Ｌｏｇｉｓ     

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。     

冠状动脉旁路移植术治疗冠心病的体会

冠状动脉粥样硬化性心脏病具有起病急骤、后果严重的特点。根据病情，治疗上有药物、介入、手术三种方法。我科2004年度采用冠状动脉旁路移植手术治疗冠状动脉粥样硬化心绞痛病人10例，手术治疗效果满意，报告如下。     

冠状动脉旁路移植术围术期心输出量变化的研究

冠状动脉旁路移植 (ＣＡＢＧ)手术是治疗冠心病的有效方法。用热稀释法连续测量心输出量〔1〕(ＣＯ) ,观察心功能的变化 ,可及时、准确、直接、方便地掌握病人的状况〔2〕。我们观察冠心病病人围术期的各项血流动力学指标 ,以及ＣＯ在围术期的变化规律 ,了解围术期心脏泵血功能的变化及其影响因素 ,探讨围术期心输出量变化与麻醉、手术、体外循环、临床用药的关系 ,以期指导临床治疗。临床资料　 1999年 8月至 2 0 0 0年 2月 ,我们行ＣＡＢＧ手术治疗冠心病病人 30例 ,其中男 2 5例 ,女 5例 ;年龄 4 5～ 74岁。所有病人均为冠状动脉多支病变…     

冠状动脉旁路移植术治疗冠心病64例体会

目的　总结 64例冠心病患者实施冠状动脉旁路移植术 (CABG)的经验。方法　胸部正中、左前臂和 /或小腿内侧切口 ,分别取左乳内动脉、左桡动脉及和 /或大隐静脉作为移植血管。体外循环 (PCAB)组 3 6例 :采用全麻、中低温体外循环 ,1∶4含血停跳液 (10℃～ 15℃ )行心肌保护。平均每例搭桥 3 .6根。非体外循环 (OPCAB)组 2 8例 :应用Medtronic公司生产的固定器 (八爪鱼 )行吻合口局部固定。平均每例搭桥 3 .4根。结果　两组患者在年龄、性别、临床症状、术前合并症、左室射血分数 (EF)、心胸比例、冠状动脉造影病变程度及移植血管支数等相对比均无显著性差异(P >0 .0 5 ) ,但手术时间、术后ICU时间、术后血管活性药物应用时间及并发症等均有明显的差别(P <0 .0 5 )。术后心电图均显示心肌缺血明显改善 ,左心室射血分数明显提高。结论　OPCAB下行CABG可避免PCAB对机体及心肌的再灌注损伤 ,明显降低术后并发症。熟练掌握乳内动脉和桡动脉取材方法 ,预防血管痉挛 ,提高吻合技术 ,是手术成功的关键。     

冠状动脉旁路移植术100例临床分析

目的总结100例非体外循环下冠状动脉旁路移植术的临床体会。方法回顾性分析2015-06—2016-09间收治的100例冠状动脉旁路移植术患者的临床资料。结果本组100例患者均顺利完成手术,无院内死亡病例。搭桥(3.0±0.8)支,手术时间(230.0±52.7)min,左乳内动脉使用率为97%。术前预防性使用主动脉内球囊反搏辅助3例。术后呼吸机辅助时间(23.2±24.8)h,住院时间(16.7±12.9)d。术后出现并发症7例,包括出血再次手术5例,肾功能不全1例,心脏骤停1例。随访(9.4±4.1)个月,患者心脏功能均不同程度得到改善,其中98例患者生活质量明显提高。结论非体外循环下冠状动脉旁路移植术是一种较为安全的冠心病治疗方法,可取得满意的近期效果。术前充分准备、术后积极处理是减少并发症的重要环节。     

微创伤冠状动脉旁路移植术的进展

冠状动脉旁路移植术是治疗冠心病的重要手段。目前，大部分手术是在体外循环下经胸骨正中切口施行。该方法视野开阔，易于显露吻合部位，低温体外循环下使心脏停搏，提供无血的吻合条件，远期通畅率高，并发症率及死亡率都很低〔１〕，被大多数医师和病人所接受。体外循环...     

冠状动脉旁路移植术

目的介绍我院冠状动脉旁路移植术的临床经验。方法采用常规体外循环和非体外循环下共完成90例冠状动脉旁路移植术。男65例，女25例，单支冠状动脉病变3例，2支病变10例，3支及以上病变77例。46例患者术前有心肌梗死，8例合并室壁瘤，2例合并二尖瓣关闭不全。30例患者在体外循环下手术，同时行室壁瘤切除术8例，行二尖瓣替换2例，60例在非体外循环下手术。应用左乳内动脉89例次，桡动脉45例次，大隐静脉170例次。结果围手术期死亡3例，病死率约3．3％，1例为围手术期心肌梗死低心排血量综合征，2例为鱼精蛋白过敏心脏骤停除颤后顽固性心律失常。本组患者随访3个月～5年（平均3年），临床症状均明显改善，心功能均有恢复。结论冠状动脉多支病变行冠状动脉旁路移植术具有良好的临床效果，其中非体外循环手术费用低，创伤小，术后恢复快。     

乳内动脉桡动脉大隐静脉的内皮型一氧化氮合酶表达

目的 应用免疫组织化学方法，探讨内皮型一氧化氮合酶(eNOS)在冠状动脉旁路移植术中常用的3种血管材料乳内动脉(LIMA)、桡动脉(RA)及大隐静脉(SV)中的定位及表达。方法取20例行冠状动脉旁移植术((LMIG)的冠心病病人的LIMA、RA及SV的废弃血管标本，行光镜观察及eNOS的免疫组织化学染色进行半定量观察。并行计算机图像分析，比较灰度值。结果eNOS在3种血管材料的内膜均有明显表达，LIMA灰度值明显高于RA及SV，RA灰度值高于SV；LIMA、RA的肌性中层可见eNOS的表达而SV无表达，LIMA灰度值明显高于RA。结论各种血管材料中eNOS的不同表达，可能是CABG术后的远期效果不同的原因之一。     

A retrospective audit of long-term lower limb complications following leg vein harvesting for coronary artery bypass grafting

Objective: To evaluate the prevalence of leg complications following leg-vein harvest for coronary artery bypass grafting. Method: A questionnaire was sent to patients who had coronary artery bypass surgery between January 1993 and December 1998. Questions addressed pain, numbness, infection, swelling and general healing. The relationship between the risk factors of diabetes, peripheral vascular disease, previous fractures/injuries to legs, previous deep vein clots and arthritis affecting the legs with post operative symptoms of pain, numbness, swelling and general healing was explored with multivariate analysis. Results: Of 700 questionnaires sent out 497 were returned, of which 422 (60%) were suitable for analysis. Numbness or tingling related to the wound was reported by 256 (61%), of whom 94 (37%) improved within 3 months. However, 105 (41%) had persistent numbness beyond 2 years. Pain in the wound was reported by 193 (46%), of whom 149 (77%) reported that this had improved by 3 months and only 19 (10%) had pain persisting beyond 2 years. A leg wound infection was reported by 126 (32%) patients, with 82 (65%) of these receiving antibiotics. A total of 336 (87% of 387 responses) described their wound as completely healed at 3 months. Unilateral leg swelling was reported by 175 (41%) with 98 of these (56% of those with swelling) improving by 3 months and 41 (23%) with swelling persisting beyond 2 years. There was no relation of wound problems to examined risk factors diabetes (P-values for numbness 0.31, wound healing 0.15, swelling 0.21, pain 0.22) and peripheral vascular disease (P-values for numbness 0.8, wound healing 0.21, swelling 0.18, pain 0.09). There was insufficient data to comment on the influence of fractures/injuries to legs, previous deep vein clots and arthritis affecting the legs. Conclusions: Wound complications are common following leg vein harvest. Prevalence of infection was higher than has previously been reported. Few people suffer long-term pain from saphenous nerve damage although paraesthesia and swelling were common long-term complications. We did not identify either diabetes or peripheral vascular disease as a risk factor for pain, numbness, swelling or problems with general healing. There is a need for a large multicentre prospective study.     

The back-approach technique of endoscopic saphenous vein harvesting in coronary artery bypass grafting

PurposeOne of the concerns during endoscopic saphenous vein harvesting (EVH) in coronary artery bypass grafting (CABG) is injury to the vein or its branches. The cutting edge of bipolar electrocautery scissors, used to divide the side branches of the saphenous vein, can cause vascular injury leading to reduced graft patency. We have developed a novel back-approach technique using a C-ring to divide the wide side branches of the saphenous vein during EVH. The aim of the study was to describe the technique and assess early outcomes of EVH using this technique. The back-approach technique is as follows: (a) insert the C-ring near the target branch, (b) push the C-ring over the proximal aspect of the target branch, (c) twist the C-ring forward to capture the target branch, and (d) cut the target branch by bipolar electrocautery.MethodsWe investigated 169 patients, including 35 women (mean age 70.1 ± 8.9 years), who underwent CABG at our hospital, using a novel EVH technique. The patients were categorized as those who underwent EVH (EVH group, n = 44) or open vein harvesting (OVH) (OVH group, n = 125). This method involves the creation of a small incision (2 cm), sufficient saphenous vein dissection near the skin incision, adequate dissection to separate the vein from the surrounding tissues, and the back-approach technique with C-ring to divide the side branch of the saphenous vein. The primary endpoint was the graft patency rate, and the secondary endpoints were leg wound complications and length of hospitalization.ResultsNo significant intergroup difference was observed in early patency of saphenous vein graft patency (OVH vs. EVH = 94.7 vs. 95.6%, p = 0.763). The incidence of lower extremity wound lymphorrhea was significantly lesser (OVH: EVH = 16.0: 0.0%, p = 0.005) and the length of hospitalization was also significantly shorter in the EVH group (OVH vs. EVH = 24.2 ± 9.8 vs. 19.0 ± 5.3 days, p = 0.001).ConclusionsEVH, using the back-approach technique, showed satisfactory short-term results; therefore, this technique performed with C-ring might be effective for vein harvesting during EVH.     

Study of coronary artery bypass using the PAS-Port device: assessment by multidetector computed tomography

Objective  The use of automatic anastomotic devices in coronary artery bypass grafting surgery is associated with lower patency rates in comparison to conventional anastomosis methods. This is thought to be caused by graft curvature occurring after closing of the chest wall. Methods  We evaluated 39 grafts in 28 patients who underwent off-pump coronary artery bypass surgery using the PAS-Port. After surgery, the proximal anastomotic angle of each stent, graft morphology, and patency were evaluated with axial and sagittal views. Results  The angle for the left anterior descending coronary artery segment was relatively obtuse on the left side of the ascending aorta, and the graft loop formation was not necessary. The angle for the left circumflex coronary artery segment was significantly acute for anastomosis from the upper left side of the ascending aorta. Because grafts are under the constraints of a large loop, graft length tended to become easily excessive or deficient. The angle for the right coronary artery segment was relatively obtuse. The space on the right side of the heart was so narrow that in some cases we had difficulty setting out the appropriate graft location to prevent graft curvature. No bending or stenosis was present in any graft, showing a patency rate of 100%. Conclusion  The short-term results of coronary bypass grafting using PAS-Port are satisfactory.     

胸腔镜辅助冠状动脉旁路移植术的应用

【摘要】〓目的〓研究全胸腔镜下冠状动脉旁路移植术临床应用体会。方法〓2005年9月至2013年7月,冠心病患者共9例,男性5例,女性4例。均在电视胸腔镜下游离乳内动脉,行胸腔镜下冠状动脉旁路移植术。其中8例行非体外循环下左乳内动脉与前降支吻合,1例在体外循环下行房间隔缺损修补术,同期行右乳内动脉与右冠状动脉吻合。结果〓9例患者均手术成功。乳内动脉游离时间为31~47 min(39.3±5.9 min)。乳内动脉与冠状动脉的吻合时间为6~7 min(5.2±1.4 min)。术后ICU停留时间为2~4 d。术后9~12 d顺利出院。结论〓全胸腔镜下游离乳内动脉行冠状动脉旁路移植术近期效果良好。     

非体外循环冠状动脉旁路移植术治疗重症冠状动脉粥样硬化性心脏病

目的探讨非体外循环冠状动脉旁路移植术治疗重症冠状动脉粥样硬化性心脏病(冠心病)的可行性. 方法回顾分析2002年1月～12月37例重症冠心病的临床资料.均采用全麻,胸骨正中切口,游离左乳内动脉及大隐静脉.心脏稳定器局部固定心肌,显露目标冠状动脉,切开后置入冠状动脉内血液分流器.一般先做左乳内动脉与左冠状动脉前降支的吻合,其余血管桥先做桥血管与主动脉的近心端吻合,然后再做桥血管与冠状动脉的吻合. 结果全组病例均在非体外循环下完成手术,搭桥1～6支,(3.2±0.5)支.术后10 d死亡1例,其余36例未发生围术期心肌梗死,无呼吸功能不全、肾功能不全、脑血管意外等严重并发症. 结论在成熟的手术技术和严格的围手术期管理的条件下,非体外循环冠状动脉旁路移植术治疗重症冠心病可行.     

冠状动脉旁路移植术218例临床分析

目的：总结冠状动脉旁路植术（CABG）治疗冠心病的经验。方法：回顾分析2001年1月－2002年2月完成的CABG218例，体外循环下冠状动脉旁路移植手术（CCABG）152例，非体外循环下冠状动脉旁路移植手术（OPCAB）66例，对手术方法、主要并发症和围术期治疗进行分析。结果：院内死亡5例。1例术后第14天死于肺部感染、急性肾功能衰竭；1例术后第3天死于心肌梗死；1例术后第2天死于急性肺梗死；2例因ARDS、多器官功能衰竭死亡。余213例治愈出院。随访有6例复发心绞痛，药物治疗有效。结论：严格掌握手术适应证、充分的术前准备、手术技巧的完善、良好的心肌保护及加强围术期处理是提高CABG早期疗效的关键因素。     

Tuberculous osteomyelitis of tibial diaphysis following saphenous vein graft harvest for coronary artery bypass: a case report

Tuberculosis in the tibial diaphysis following saphenous vein graft harvest for coronary artery bypass grafting has not been reported, to the best of authors’ knowledge. We report the first such clinical case in view of its clinical rarity and as a complication of the simple procedure like saphenous vein graft harvest.     

冠状动脉硬化性心脏病合并左锁骨下动脉严重狭窄非体外循环下同期手术的临床经验

目的探讨非体外循环冠状动脉旁路移植同时主动脉-锁骨下动脉旁路治疗冠状动脉硬化性心脏病(冠心病)合并锁骨下动脉重度狭窄的手术方法及效果.方法2003年1月～2004年5月,我院治疗须行冠状动脉旁路移植术同时合并左锁骨下动脉近端重度狭窄3例,术中先行主动脉-锁骨下动脉旁路,左乳内动脉获得满意的流量后,再行非体外循环冠状动脉旁路移植.结果手术时间210～340 min,平均283 min,出血量570～1 630 ml,平均963 ml.游离左乳内动脉后量杯测流量均＜5 ml/min,主动脉-锁骨下动脉旁路后量杯测流量均＞50 ml/min,乳内动脉远端与前降支吻合后流量仪测流量12～27 ml/min,平均20 ml/min.术后临床症状缓解,未发现冠脉-锁骨下动脉窃血综合征.3例随访3～6个月,平均5个月,无心绞痛发作.结论非体外循环冠状动脉旁路移植同时主动脉-锁骨下动脉旁路手术是治疗冠心病合并锁骨下动脉重度狭窄简单而有效的方法.     

川崎病冠状动脉病变及搭桥手术

目的 探讨川崎病后严重冠状动脉病变及搭桥手术（ＣＡＢＧ）后的近期及远期效果。方法随访发现,６例川崎病后严重冠状动脉病变的病儿均有左冠状动脉前降支（ＬＡＤ）病变,右冠状动脉（ＲＣＡ）病变５例,左冠状动脉回旋支（ＬＣＸ）病变３例,左冠状动脉主干（ＬＭＴ）病变２例,心肌梗死３例。共行１５支ＣＡＢＧ;单支２例,３支３例,４支１例;左胸廓内动脉（ＬＩＴＡ）至ＬＡＤ６例;右胸廓内动脉（ＲＩＴＡ）至ＬＡＤ１例。