冠状动脉搭桥围术期急性心肌梗死紧急再搭桥

目的：回顾性分析冠状动脉搭桥围术期急性心肌梗死急诊再搭桥的临床经验。方法：在510例冠状动脉搭桥患中，5例患在术后4h内因急性心肌梗死需急诊再搭桥，发生率0．98％。5例患中，男女比例为4：1，年龄56－77岁（平均63．6岁），均为冠状动脉三支血管病变（3例伴左主干病变），手术中搭桥3－5支（人均搭桥3．6支），左乳内动脉桥5根，其余为大隐静脉桥。2例在关胸后20min，3例在回重症监护病房后2－4h出现急性心肌缺血表现（明显心电图ST－T变化），伴室颤2例，5例血液动力学均不稳定，药物处理难以稳定血液动力学。全部患均立即送手术室（2例仍在手术室），急诊再次开胸。探查发现，2例患静脉桥（分别搭桥到回旋支第二钝缘支和右冠状动脉后降支）内急性血栓形成；另3例所有静脉桥良好，但左室前壁收缩运动明显减弱，结合心电图变化，诊断为左乳内动脉灌注不良。重新建立体外循环，清除桥内血栓重新搭桥2例（1例在非体外循环心脏跳动下进行）；另取一段静脉搭桥到左乳内动脉－左前降支吻合口远端的左前降支3例。结果：5例患顺利度过手术，均置入主动脉内球囊反搏，支持22－25h（平均42h）。手术后呼吸机支持4h－18d（平均7．3d）合并消化道出血4例，肾功能不全2例，肺部感染2例，切口感染1例。手术后住院时间12－35d，平均21d。全组均痊愈出院。结论：冠状动脉搭桥围术期急性心肌梗死应重在预防。如怀疑桥有问题，急诊再搭桥是良好选择，但手术后并发症发生率明显增加。     

Myonecrosis following isolated coronary artery bypass grafting is common and associated with an increased risk of long-term mortality.

AIMS: We sought to evaluate the risk of long-term mortality with respect to post-operative elevation of the isoenzyme CK-MB following first-time isolated coronary artery bypass grafting (CABG) surgery. METHODS: Patients undergoing first-time isolated CABG between September 1992 and December 2001, at the Mid America Heart Institute, were included in this registry analysis. A sole CK-MB measurement was obtained at an average of 15.2h following CABG. The main endpoint was long-term mortality. RESULTS: There were 3667 patients included in this registry. The mean follow up was 5.1 years. The event-free survival rate was 80%, 78% and 73%, for the normal, 1-3 and >3 times by ULN groups respectively; log-rank p=0.0058. The event-free survival for the four CK-MB groups was 80%, 78%, 75% and 72% for the normal, 1-3 times, >3-5, and >5 times ULN groups respectively, log-rank p=0.0078. The CK-MB elevation following CABG remained a significant predictor following multivariate adjustment. With a point estimate of 1.04, 95% confidence limits 1.009-1.062, p=0.007. CONCLUSION: Elevation of the isoenzyme CK-MB is an important predictor of longterm mortality following coronary bypass grafting. These data support routine use of creatinine kinase measurement following bypass surgery to further delineate long-term risk.     

Acute kidney injury after coronary artery bypass grafting and long-term risk of myocardial infarction and death

Background

Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) is associated with early mortality. Its impact on the risk of myocardial infarction (MI) over time and long-term mortality has not been well described.

Methods

We performed a nationwide population-based cohort study in 27,929 patients who underwent a first isolated CABG between 2000 and 2008 in Sweden. Acute kidney injury was divided into three categories based on the absolute increase in postoperative serum creatinine (sCr) concentration compared with the preoperative baseline: stage 1, sCr increase of 0.3 to 0.5 mg/dL; stage 2, sCr increase of > 0.5 to 1.0 mg/dL and stage 3, sCr increase of ≥ 1.0 mg/dL.

Results

The overall incidence of postoperative AKI was 13%, 6.3% met the criterion for stage 1, 4.3% for stage 2 and 2.3% for stage 3. During a mean follow-up of 5.0 years, there were 2119 (7.6%) MIs and 4679 (17%) deaths.Multivariable adjusted hazard ratios with 95% confidence intervals for MI were 1.35 (1.15 to 1.57), 1.80 (1.53 to 2.13) and 1.63 (1.29 to 2.07), in AKI stages 1, 2 and 3, respectively. The corresponding hazard ratios for all-cause mortality were 1.30 (1.17 to 1.44), 1.65 (1.48 to 1.83) and 2.68 (2.37 to 3.03), respectively.

Conclusions

Our results show that AKI after CABG is associated with an increased long-term risk of MI and death.     

急性心肌梗死急诊冠脉溶栓后行冠脉搭桥术12例分析

目的探讨部分急性心肌梗死（AMI）急诊不适合行PC]的患者行急诊冠脉溶栓术后再行急诊或择期冠脉搭桥术的效果。方法回顾分析12例AMI急诊冠脉溶栓后行急诊或择期冠脉搭桥术患者的临床资料。结果12例中梗死相关血管再通并达到TIMIⅡ～Ⅲ级血流10例,TIMIⅢ级血流9例,TIMIⅡ级血流1例。2例应用血栓抽吸装置抽吸血栓后达到TIMIⅢ级血流。2例行急诊冠脉搭桥术,10例行择期冠脉搭桥术。结论对于部分急诊不适合行PCI术的AMI患者,先行急诊冠脉溶栓术,然后根据病情及冠脉病变特点行急诊或择期冠脉搭桥术,是一种比较好的临床治疗方法。     

Five year clinical effect of coronary stenting and coronary artery bypass grafting in renal insufficient patients with multivessel coronary artery disease: insights from ARTS trial.

AIMS: To compare coronary stent implantation and bypass surgery for multivessel coronary disease in patients with renal insufficiency. METHODS AND RESULTS: In the ARTS trial, 142 moderate renal insufficient patients (Ccr<60 mL/min) with multivessel coronary disease were randomly assigned to stent implantation (n=69) or CABG (n=73). At 5 years, there was no significant difference between the two groups in terms of mortality (14.5% in the stent group vs. 12.3% in the CABG group, P=0.81), or combined endpoint of death, cerebrovascular accident (CVA), or myocardial infarction (MI) (30.4% in the stent group vs. 23.3% in the CABG group, P=0.35). Among patients who survived without CVA or MI, 18.8% in the stent group underwent a second revascularization procedure when compared with 8.2% in the surgery group (P=0.08). The event-free survival at 5 years was 50.7% in the stent group and 68.5% in the surgery group (P=0.04). CONCLUSION: At 5 years, the differences in mortality and combined incidence of death, CVA, and MI between coronary stenting and surgery did not reach statistically significant level. However, the occurrence of MACCE in the stent group was higher than in the CABG group, mainly driven by the higher incidence of repeat revascularization in the stent group.     

Analysis of mortality in low-risk patients undergoing coronary artery bypass grafting

Aim

The aims of this study were to determine the early mortality rate in low-risk coronary artery bypass graft (CABG) patients and examine the causes of death, to identify problems that could be avoided in future surgeries.

Methods

All low-risk patients (EuroSCORE ≤ 2) who died after CABG were included. Their peri-operative information was meticulously studied by internal and independent external reviewers to identify causes of death, which were classified as: cardiac or non-cardiac; and a further division as: (1) non-preventable, (2) preventable (technical error), and (3) preventable (system error).

Results

Early mortality was 0.93% (24/2 570). Eleven patients (45.8%) were classified as preventable deaths. In six of them the main problem was identified as graft thrombosis, which was secondary to a technical error of either the harvesting or anastomosis of the left internal mammarian artery. There were also five system errors identified as delays in the treatment of an identified and potentially reversible problem.

Conclusions

Correction of technical and system errors, such as harvesting of the left internal mammarian artery, haemostasis during surgery, and establishing standard protocols for the transfer of patients from ward to intensive care units will eventually lead to improvement in both the quality of care and patient outcomes, even in low-risk groups.     

70岁以上老年人冠状动脉旁路移植术的心肌保护

目的　对比观察非体外循环冠状动脉旁路移植术 (OPCAB)与体外循环下微温血和冷血停搏液灌注冠状动脉旁路移植术 (CABG)对老年患者的心肌保护效果。　方法　将 4 5例 70岁以上行CABG患者随机分为 3组 ,OPCAB组、间断微温血和冷血含氧心脏停搏液灌注组各 1 5例。 3组患者术前心功能、性别、年龄、冠状动脉病变情况差异无显著性 ;各组于围术期不同时点分别抽取静脉血测定肌酸激酶同工酶 (CK MB)、肌钙蛋白I(cTnI)及观察围术期监护情况。　结果　OPCAB组术中、术后各时点CK MB、cTnI与微温血和冷血CABG组比较差异有显著性 (P <0 0 5 ) ;CK MB在冷血CABG组术后 1d达到峰值 (5 7 75± 34 2 4 )U/L ,此时点OPCAB组和微温血CABG组CK MB值分别为 (2 2 6 4± 1 2 0 5 )和 (42 85± 2 9 0 4 )U/L ,cTnI在OPCAB组术后 6h达到峰值 (0 6 9± 0 2 0 )μg/L ,而微温CABG组与冷血CABG组比较差异有显著性 (P <0 0 5 ) ,OPCAB组围术期监护情况明显优于微温和冷血停搏CABG组 (P <0 0 5 )。　结论　对老年冠心病患者心肌保护中 ,OPCAB组心肌保护效果优于CABG组 ,微温血CABG组优于冷血CABG组。与CK MB相比 ,cTnI是评价心肌损害较敏感和特异的指标     

冠状动脉旁路移植手术315例临床分析

目的总结315例冠状动脉旁路移植手术的临床经验。方法对315例冠状动脉旁路移植手术患者的临床资料、手术方法、术后并发症及随访结果进行分析。结果本组患者围术期(术后30d)死亡1例(0.32%)。术后早期并发症包括心包填塞、低心排综合征、中枢神经系统并发症、肾功能不全和心律失常等。结论高危患者与常规患者冠状动脉旁路移植手术结果一样,手术近、远期结果满意。     

复合辅酶对冠心病患者围术期心肌保护和肝脏保护作用的研究

目的:探讨冠心病(CAD)患者体外循环(CPB)冠状动脉旁路移植(CABG)术中使用复合辅酶对心肌和肝脏保护的效果。方法:70例择期CPB下进行CABG的CAD患者,随机分为试验组与对照组各35例,试验组术中给予辅酶A1000u和辅酶I1.0mg,对照组不给复合辅酶。观察CPB时间、主动脉阻断时间、正性肌力药使用情况、ICU停留时间、术后住院时间、围术期心肌梗死和脑卒中等临床指标。2组分别于手术开始前、手术结束时、手术后6h、12h、24h和术后3d采集患者中心静脉血,检测红细胞压积、肌酸激酶、肌酸激酶同工酶和肌钙蛋白I;于手术开始前、手术结束时、手术后3d和手术后7d采血检测谷丙转氨酶、谷草转氨酶、总胆红素和直接胆红素。结果:2组术后心肌酶谱均较术前升高(P0.01),但在术后6h、12h和24h试验组心肌酶谱显著低于对照组(P0.01)。2组术后转氨酶和胆红素水平均较术前升高(P0.01),但在术后3d试验组的转氨酶和胆红素水平显著低于对照组(P0.01)。结论:CAD患者围术期应用复合辅酶具有一定的心肌保护和肝脏保护作用。     

不同剂量盐酸戊乙奎醚对体外循环冠脉搭桥手术患者心肌保护作用

目的 比较两种不同剂量盐酸戊乙奎醚对体外循环下行冠脉搭桥手术患者心肌保护作用.方法 2011年5月至2013年5月择期行冠脉搭桥手术患者75例,随机分成3组：对照组（25例）,给予等量生理盐水;小剂量组（25例）,戊乙奎醚 0.05 mg/kg;大剂量组（25例）,戊乙奎醚0.1 mg/kg.比较三组冠脉搭桥手术患者不同时间点的心肌肌钙蛋白I（cTnI）、肌酸磷酸激酶同工酶MB（CK-MB）、肌酸激酶（CK）、谷草转氨酶（AST）、α-羟丁酸脱氢酶（α-HBDH）、乳酸脱氢酶（LDH）浓度的变化.结果 三组患者cTnI、CK-MB、CK、AST、α-HBDH、LDH浓度,主动脉开放后1 h（T1）及主动脉开放后24 h（T2）与麻醉诱导前（T0）相比明显升高,差异均有统计学意义（P〈0.05）;T1、T2时间点组间比较,戊乙奎醚大、小剂量组低于对照组,差异有统计学意义（P〈0.05）,戊乙奎醚大剂量组与小剂量组相比差异无统计学意义（P＆gt;0.05）.结论 盐酸戊乙奎醚对体外循环冠脉搭桥手术患者具有心肌保护作用,安全性好,值得临床推广和应用,剂量上大剂量组并不优于小剂量组.     

The effect of pre-operative aspirin on bleeding, transfusion, myocardial infarction, and mortality in coronary artery bypass surgery: a systematic review of randomized and observational studies.

AIMS: To obtain estimates of the efficacy and safety of pre-operative aspirin in patients undergoing coronary artery bypass grafting (CABG). METHODS AND RESULTS: Eligible studies included randomized controlled trials (RCTs) and observational studies of patients undergoing CABG, comparing pre-operative aspirin with no aspirin/placebo, and reporting at least one of our primary outcomes. In eight RCTs (n = 805), pre-operative aspirin increased post-operative bleeding [Mean difference (MD), 104.9 mL; 95% confidence interval (CI), 19.2-190.6; P = 0.016] and reoperation [odds ratio (OR), 2.52; 95% CI, 1.18-5.38; P = 0.017), but not transfusion requirements (MD, 0.62 units; 95% CI, -0.06-1.30; P = 0.072). Subgroup analysis suggested that bleeding was increased with aspirin doses > or =325 mg/day, but not with lower doses. In 14 observational studies (n = 4485), pre-operative aspirin increased post-operative bleeding (MD, 113.6 mL; 95% CI, 45.2-182.0; P = 0.001) and transfusion requirements (MD, 0.34; 95% CI, 0.12-0.56 units; P = 0.002), but not reoperation (OR, 1.12; 95% CI, 0.69-1.83; P = 0.647). Neither analysis detected a significant effect on myocardial infarction or death. CONCLUSION: Pre-operative aspirin increases post-operative bleeding, but this may be avoided by the use of aspirin doses <325 mg/day. Most of the RCTs are old and the meta-analysis was underpowered for efficacy outcomes. A large randomized trial is necessary to determine the safety and efficacy of pre-operative aspirin in the setting of contemporary cardiac surgical practice.     

不停跳与体外循环下冠状动脉旁路移植术对患者心肌和肾功能影响的对比研究

目的 探讨不停跳下行冠状动脉旁路移植术(CABG)与体外循环下行CABG对患者心肌和肾功能影响.方法 将2015年1月至2018年1月间陕西省汉中市中心医院收治的100例冠心病患者随机分为不停跳组(50例)和体外循环组(50例)分别在不停跳下行冠状动脉旁路移植术(OPCABG)与体外循环下冠状动脉旁路移植术(CCABG...     

70岁及以上冠状动脉旁路移植患者临床特征分析

目的 观察70岁及以上冠状动脉旁路移植术(CABG)患者的手术危险因素特点及手术效果.方法 回顾分析我院2000年1月至2009年4月施行CABG的426例患者的临床资料,其中70～82岁组118例,24～69岁组308例,将两组患者手术危险因素、并发症及手术效果进行对比研究.结果 70～82岁组术前危险因素为女性、慢性阻塞性肺疾病、外周血管病变、心功能Ⅳ级、需静脉硝酸甘油治疗的不稳定心绞痛、左心室射血分数＜30%的比例、术后严重并发症的发生率、手术病死率、移植血管数和在重症监护病房时间均较24～69岁组高(P＜0.05);70～82岁组患者并存瓣膜病变和采用左乳内动脉桥较24～69岁组少,分别为16例(13.6%)和152例(49.4%),差异有统计学意义(P＜0.05).结论 我国70岁及以上患者手术危险因素组成特点与国外有区别,尽管施行CABG严重并发症发生率和手术病死率较高,但并未明显延长患者的手术恢复时间.

Abstract：

Objective To analyze the clinical characters in old patients undergoing coronary artery bypass grafting (CABG). Methods The clinical data of 426 patients undergoing CABG from January 2000 to April 2009 in our hospital were retrospectively analyzed. One hundred eighteen patients were 70-82 years old (older group), 308 patients were 24-69 years old (younger group). The perioperative risk factors, surgical complication and outcomes between the two groups were compared.Results The older group had higher incidences of post-operative complications than younger group.Pre-operative risk factors included the female, chronic obstructive pulmonary disease, peripheral vessel disease, New york heart association(NYHA) class Ⅳ, unstable angina requiring intravenous nitrates until arrival in the anaesthetic room, left ventricular ejection fraction ＜30%. The older group showed higher incidences of postoperative severe complication, operative mortality, and more grafts and longer time in intensive care unit (ICU), and had lower incidents of valve disease and less use of left internal mammary artery [16 patients (13. 6%) vs. 152 patients (49.4%), all P＜0. 05].Conclusions The many CABG risk factors in China are different from those in the western countries.Although the higher incidents of postoperative severe complication and higher operative mortality are found in the older patients, the recovery period after operation isn't obviously prolonged. The operative outcomes are satisfactory.     

45例老年人冠状动脉旁路移植术的分析

目的探讨老年人冠状动脉旁路移植术的可行性及手术适应证。方法回顾性总结４５例老年人、３１例非老年人冠状动脉旁路移植术的临床资料，作对照分析。结果老年组平均搭桥３．６±０．９根，心肌阻断时间９２．４±３８．３分钟，手术死亡率为２．２％，并发症发生率为３３．３％，住院时间为３０．３±１８．６天；与非老年组比较差异均无显著性。结论经过严格的手术适应证选择，老年人冠状动脉旁路移植术具有满意的临床效果     

三种不同肾功能评估方法对冠状动脉旁路移植术后死亡的预测

目的 比较三种不同肾功能评估方法对冠状动脉旁路移植术后死亡的预测作用.方法 回顾分析1999年1月至2005年12月收治的5559例冠状动脉旁路移植术患者的资料.以患者术前72 h内空腹血清肌酐值、Cockeroft-Gault公式和简化MDRD公式计算的估测肾小球滤过率作为肾功能的评估方法.通过受试者工作特征(ROC)曲线、Cox比例风险回归分析,比较三种不同肾功能评估方法对冠状动脉旁路移植术后死亡的预测作用.结果 ROC曲线分析显示,CoekcroftGault公式预测住院死亡的准确性最高(ROC曲线下面积:0.755,P＜0.01).Cox比例风险回归分析显示:Cockerofi-Gault公式估测肾小球滤过率对住院死亡的预测作用最高[相对危险度(HR):4.51,P＜0.01],优于简化MDRD公式估测肾小球滤过率(HR:3.43,P＜0.01)和血清肌酐(HR:2.86,P＜0.01);Cockerofi-Gault公式估测肾小球滤过率(HR:1.54,P＜0.01)和简化MDRD公式估测肾小球滤过率(HR:1.60,P＜0.01)对远期死亡的预测作用均优于血清肌酐(HR:1.40,P=0.11).结论 术前肾功能不全是冠状动脉旁路移植术后死亡的独立危险因素.Cockcroft-Gault公式估测肾小球滤过率对住院死亡的预测作用优于简化MDRD公式估测肾小球滤过率和血清肌酐,Cockcroft-Gault公式估测肾小球滤过率和简化MDRD公式估测肾小球滤过率对远期死亡的预测作用均优于血清肌酐.     

我国冠状动脉旁路移植术住院死亡预测模型研究及欧洲心血管手术危险评分系统效能检验

目的:分析并初步建立我国冠状动脉旁路移植术(coronary artery bypass grafting,CABG)风险预测模型,并与欧洲心血管手术危险因素评分系统即EuroSCORE及EuroSCORE对数回归模型对比。方法:回顾性分析2006年1月1日至2007年6月30日,北京安贞医院心脏外科行CABG手术或CABG合并手术的1637例患者资料。收集影响手术死亡的42个术前危险因素,经过单因素与多因素Logistic回归分析确立独立危险因素,并据此初步建立CABG手术死亡危险评估模型,再对模型进行分辨度、校准度检验,并与EuroSCORE及EuroSCORE对数回归模型进行对比研究。结果:全组患者年龄(61.9±9.7)岁,实际病死率4.03%(66/1637),CABG合并手术3.85%(63/1637),多因素Logistic回归分析结果:慢性肺部疾病、外周血管疾病、急性心肌梗死、既往介入治疗(PTCA、溶栓或支架)、心源性休克、主动脉瓣反流及二尖瓣反流为CABG手术死亡的独立危险因素。据此建立CABG手术死亡危险评估模型。并与EuroSCORE及EuroSCORE对数回归模型进行对比研究。受试者工作特征(Receiver-OperatingCharacteristic,ROC)曲线下面积:新建立风险模型(0.83)EuroSCORE对数回归模型(0.82)EuroSCORE模型(0.81),Hosmer-Lemeshowχ2检验新模型P=0.225,P0.05,即预计病死率与实际观测病死率差异无统计学意义;而其他2种模型P0.05。结论:慢性肺部疾病、外周血管疾病、急性心肌梗死、既往介入治疗(PTCA、溶栓或支架)、心源性休克、主动脉瓣反流及二尖瓣反流等7个因素为CABG手术死亡的独立危险因素。据此建立的CABG手术死亡危险评估模型具有良好的分辨度和校准度。     

186例老年冠心病患者是、否体外循环下冠脉旁路移植术的比较

目的:比较老年冠心病患者体外循环与非体外循环下冠状动脉旁路移植术的疗效。方法:A组选择87例65岁以上的老年患者在体外循环下行冠状动脉旁路移植术(CCABG);B组选择79例65岁以上的老年患者在非体外循环下行冠状动脉旁路移植术(OPCABG)。结果:B组死亡率低于A组(P<0.05),术后胸腔引流量明显少于A组(P<0.05)。结论:老年冠心病患者行冠状动脉旁路移植术是安全的。     

冠心病患者围术期应用磷酸肌酸的心肌保护作用研究

目的探讨冠心病患者体外循环冠脉旁路移植术中使用磷酸肌酸对心肌保护的效果。方法100例冠心病择期行体外循环冠脉旁路移植术患者,随机分为试验组与对照组各50例,试验组术中给予磷酸肌酸钠250mg,对照组不给磷酸肌酸钠。观察体外循环时间、阻断时间、心脏复跳情况、正性肌力药使用情况、ICU停留时间以及围术期心肌梗死和脑卒中等临床指标。两组分别于手术开始前、手术结束时、手术后6小时、12小时和24小时采集患者中心静脉血,检测红细胞压积、肌酸激酶、肌酸激酶同工酶和乳酸脱氢酶。结果试验组体外循环后心脏自动复跳率高,两组术后心肌酶谱均较术前升高,但试验组显著低于对照组。结论冠心病患者围术期应用磷酸肌酸具有一定的心肌保护作用。     

非体外循环冠状动脉旁路移植术329例疗效分析

目的　分析 3 2 9例非体外循环冠状动脉旁路移植术 (OPCAB)的临床效果。方法2 0 0 1年 1月至 2 0 0 2年 5月完成OPCAB手术 3 2 9例 ,男 2 50例 ,女 79例 ;平均年龄 (63 6± 9 1)岁。研究对象分为三组 :陈旧性心肌梗死 95例 (2 8 9% ) ,急性心肌梗死 54例 (16 4% ) ,单纯心绞痛 180例 (54 7% )。对各组手术的近期临床效果进行统计分析。结果　全部 3 2 9例采用OPCAB手术方式 ,无一例中转至体外循环。平均旁路移植 (3 0 9± 0 77)支。旁路材料选用乳内动脉 2 66例(80 9% ) ,桡动脉 159例 (48 3 % ) ;全动脉化 2 1例 (10 1% )。术中同时行激光打孔 2 2例 (6 69% ) ;非体外循环下行室壁瘤缝缩术 1例。应用主动脉内球囊反搏 2 7例 (8 2 % )。手术死亡 4例 ,病死率1 2 %。术后严重并发症 17例 (5 2 % )。除在主动脉内球囊反搏使用方面陈旧及急性心肌梗死组明显高于心绞痛组外 ,其余各指标无组间显著性差异。结论　OPCAB可同样安全有效地应用于心肌梗死及心绞痛患者