Initial experience with off-pump coronary artery bypass grafting

Off-pump coronary artery bypass grafting (OPCAB) is clearly preferable for patients with extracardiac complications. The aim of this study was to evaluate the initial outcome of OPCAB, and its validity for patients with extracardiac complications. One hundred and fifty-seven consecutive coronary artery bypass graft (CABG) patients were divided into two groups: 30 OPCAB patients and 127 on-pump CABG patients. The early outcomes of the two groups were compared. Preoperatively, OPCAB patients had more extracardiac risk factors than on-pump CABG patients. There were no differences in age or cardiac function between the groups, but the off-pump group had a higher incidence of previous surgery, cerebrovascular disease, and renal failure. There were no differences in graft patency, stroke, or mortality between the two groups, even though the OPCAB patients had more risk factors than the on-pump patients. Our initial experience with OPCAB showed that it is acceptable for high-risk patients in view of the serious nature of their extracardiac condition. Received: April 12, 2001 / Accepted: August 17, 2001     

非体外循环和体外循环冠状动脉旁路移植术生活质量比较

目的:用一个普适生活质量量表和一个疾病特异量表随机对照研究非体外循环和体外循环冠状动脉旁路移植术患者生活质量改变的情况。方法:应用健康标准化量表简短表格36(SF-36),西雅图心绞痛调查问卷(SAQ)分析研究2006-01-2010-10这5年间147例冠状动脉旁路移植术患者资料,其中非体外循环冠状动脉旁路移植术组96例、体外循环组51例。调查时间是术前1周,术后6～12个月。结果:术前两组患者问卷结果相似。术后6～12个月,SF-36问卷显示在生理职能、社会功能、精神健康等方面,非体外循环组优于体外循环组;SAQ问卷在心绞痛程度、心绞痛频率、生活质量方面,非体外循环组优于体外循环组。结论:术后6～12个月非体外循环较体外循环冠状动脉旁路移植术对患者生活质量改善更明显。     

Off-pump coronary artery bypass grafting in India

Off-pump Coronary Artery Bypass Grafting (OPCAB) is the latest innovation in cardiac surgery. However OPCAB is not adopted universally. Even there have been suggestions of abandoning OPCAB in a special report. In India, OPCAB has been successfully adopted across the board. There are various evidences which favor OPCAB and are discussed in this review. The purpose of this review is to put forward the perspective of the OPCAB surgeons of our country and critically look at the suggestion of abandoning OPCAB.     

体外循环与非体外循环冠状动脉旁路移植术早期疗效分析

目的:探讨体外循环冠状动脉旁路移植术(CCABG)和非体外循环冠状动脉旁路移植术（OPCABG）早期疗效的差异。方法: 采集自2003年10月~2008年1月我院单纯冠状动脉旁路移植术5325例临床资料,分为CCABG组（343例）与OPCABG组（4 982例）。对两组患者各项术前因素、术中因素、手术死亡率及并发症进行比较。结果: OPCABG组实际手术死亡率（1.7％）明显低于CCABG组（6.7％）,P<0.01;术后二次开胸止血、肾功能不全等并发症的发生率及ICU停留时间、呼吸机辅助时间、术后住院时间都低于CCABG组（P<0.05,P<0.01）。风险调整后CCABG组手术死亡率仍高于OPCABG组6个百分点,术后并发症的发生率均略高于OPCABG组（P<0.05）。结论: CCABG与OPCABG早期临床疗效均令人满意,后者更好一些。     

冠状动脉旁路移植术中骨骼肌化胸廓内动脉的应用

目的 探讨骨骼肌化胸廓内动脉（ITA）用于冠状动脉旁路移植术的优越性。方法采用剪刀和钛夹将骨骼肌化的ITA游离,并将其用于冠状动脉旁路移植术。结果共游离ITA 61根,并顺利用于60例冠状动脉旁路移植术患者,平均获取时间为26．8min。骨骼肌化ITA平均血流量吻合前为86．5ml／min,吻合后为26.4ml／min。随访1～31个月,无心脏相关性死亡和事件发生。结论在冠状动脉旁路移植术中应用骨骼肌化的ITA和带蒂ITA一样安全、有效。     

冠状动脉多层螺旋CT成像及冠脉造影对冠脉搭桥术后桥血管的评价

目的观察冠状动脉多层螺旋CT成像及冠脉造影对冠脉搭桥手术后桥血管的评价作用。方法33例冠脉搭桥手术患者,术前常规冠脉造影检查,手术行不停跳冠脉搭桥术,手术后1 a行冠状动脉多层螺旋CT成像,并于冠状动脉多层螺旋CT成像复查后1周内行冠脉造影检查。结果33例患者共行冠脉搭桥101支,冠状动脉多层螺旋CT成像能够成功显示99支,显示率为98.02%。冠状动脉多层螺旋CT成像与冠脉造影结果对比,其对冠脉搭桥手术后桥血管狭窄和阻塞评价敏感度达100%。结论应用冠状动脉多层螺旋CT成像对冠脉搭桥术后桥血管评价简便、无创,具有较好的可信性和可行性。     

既往经皮冠状动脉介入对冠状动脉旁路移植术效果的影响

随着经皮冠状动脉介入（percutaneous coronary intervention，PCI）治疗的发展，接受PCI治疗的冠心病患者不断增加。由于支架内再狭窄、未处理节段冠状动脉粥样硬化进展，既往接受PCI治疗行冠状动脉旁路移植术（coronary artery bypass grafting，CABG）的患者亦不断增加。既往PCI对CABG手术效果是否存在影响仍有争议，本文对此作一综述。     

Robot-assisted coronary artery bypass grafting improves short-term outcomes compared with minimally invasive direct coronary artery bypass grafting

Background

Robot-assisted coronary artery bypass grafts (RACAB) utilizing the da Vinci surgical system are increasingly used and allow the surgeon to conveniently harvest internal mammary arteries (IMAs). The aim of this study was to compare the outcomes of off-pump RACAB and minimally invasive direct coronary artery bypass grafting (MIDCAB) in the short and medium term.

Methods

We performed a retrospective review of 132 patients with single- or multiple-vessel coronary artery disease who underwent minimally invasive off-pump CABG (OPCAB) between May 2009 and May 2014. The patients were divided into two groups based on the surgical approach, MIDCAB and RACAB group. The anastomosis of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) was performed as regular OPCAB through the incision on the beating heart using regular stabilization devices (Genzyme Corporation). The preoperative, intraoperative, postoperative, and follow-up data, including major adverse cardiac and cerebrovascular events (MACCE), were compared.

Results

The preoperative data were similar. RACAB significantly shorten the intensive care unit (ICU) stay and postoperative compared with the MIDCAB group (P<0.05). There were 12 (19.7%) patients treated with a two-stage hybrid procedure in the MIDCAB group and 34 (47.9%) patients in the RACAB group (P=0.001). Thirty-day mortality was 1.6% in the MIDCAB group. There were 9 (14.7%) MIDCAB patients and 2 (2.8%) RACAB patients (P=0.013) that developed new arrhythmia. The two groups showed comparable mid-term survival (P=0.246), but the MACCEs were significantly different (P=0.038).

Conclusions

RACAB may be a valuable alternative for patients requiring single or simple multi-vessel coronary artery bypass grafting (CABG). Although the mid-term mortality outcomes are similar, RACAB improves short-term outcomes and mid-term MACCE-free survival compared with MIDCAB.     

冠状动脉旁路移植术中体外循环对肾功能的影响

目的:了解冠状动脉旁路移植术中体外循环对病人肾功能损伤的影响。方法:689例行冠状动脉搭桥术患者按施行体外循环与否及体外循环时间进行分组。分析术前及术后的肾功能指标水平。结果:冠状动脉旁路移植术后肾功能指标:血肌酐(Cr)、尿素氮(BUN),尿α-微量蛋白(MG)各指标水平较术前均有明显升高(P<0.01).体外循环组较非体外循环组升高更明显(P<0.05～<0.01);体外循环时间超过150 min者的升高最明显(P<0.01)。结论:非体外循环CABG术对病人肾功能损害影响的小于有体外循环的CABG术,过长时间的体外循环时间对肾功能损害的影响更大。     

Effects of residual coronary artery disease on results of coronary artery bypass grafting

To assess the effects of residual coronary artery disease (non-revascularized coronary vessels) after coronary artery bypass grafting on symptoms and exercise left ventricular function, we categorized 77 patients into 3 groups according to the extent of residual coronary artery disease: group I (n = 17) had no residual coronary artery disease (residual score = 0); group II (n = 30) had light residual coronary artery disease (score of 1 to 9, mean 4.7); and group III (n = 30) had moderate residual coronary artery disease (score greater than or equal to 10, mean 23). Sixty patients were asymptomatic after coronary artery bypass grafting (14 in group I, 24 in group II, and 22 in group III), but the remaining patients had occasional angina pectoris. The resting left ventricular ejection fraction was significantly higher in group I than in the remaining 2 groups (56 +/- 18% in group I, 47 +/- 19% in group II, and 43 +/- 16% in group III, P less than 0.05). The exercise left ventricular ejection fraction was also significantly higher in group I (61 +/- 16% in group I, 51 +/- 18% in group II and 45 +/- 18% in group III, P less than 0.01). The ejection fraction response to exercise was abnormal in 5 patients in group I, 15 patients in group II, and 19 patients in group III. Thus, coronary artery bypass grafting results in symptomatic improvement, even in patients with residual coronary artery disease. The presence of residual coronary artery disease, however, may be a determinant of exercise left ventricular function in these patients.     

Redo off-pump coronary artery bypass grafting via a left thoracotomy

Re-operative coronary artery bypass graft (CABG) surgery is more complicated than the initial CABG and it may also be more hazardous because of risk factors related to median resternotomy, such as cardiac injury and damage to the patent grafts due to sternal adhesion.1 Deciding on the appropriate treatment for recurrent coronary artery disease (CAD), especially conditions such as non-left anterior descending coronary artery (LAD) ischaemic lesions during the existence of patent left internal thoracic artery-to-left anterior descending coronary artery (LITA–LAD) anastomosis is a dilemma.2If the patient is unresponsive to medical therapy, and percutaneous transluminal coronary angioplasty (PTCA) and/or stenting is not appropriate for revascularisation, alternative surgical strategies, excluding resternotomy and cardiopulmonary bypass (CPB), may be the most appropriate way of revascularising the branches of the circumflex artery (Cx) or right coronary arteries (RCA) (non-LAD territories).3-5 In selected patients, off-pump redo CABG for the branches of the Cx via a posterolateral thoracotomy may reduce the risks due to median resternotomy and dissection of the heart.This procedure to avoid resternotomy and CPB has become an established and popular way of revascularising recurrent coronary artery disease in the lateral aspect of the heart. In this article, we share our experience of 32 patients who underwent redo CABG for the Cx and its branches via a left posterolateral thoracotomy.     

冠状动脉搭桥术后呼吸衰竭的预防

目的探讨冠状动脉搭桥术后呼吸衰竭的预防策略。方法本组35例冠状动脉搭桥术,其中体外循环下冠状动脉搭桥术28例,非体外循环下冠状动脉搭桥术7例。主要呼吸功能保护策略包括：术前的呼吸肌锻炼,术中的呼吸功能保护,术后的呼吸机辅助呼吸和呼吸道管理。结果本组无一例呼吸衰竭发生。结论围术期有多种因素影响冠状动脉搭桥术患者的呼吸功能。积极的呼吸功能保护策略能有较好的临床效果。     

Preoperative frailty and adverse outcomes following coronary artery bypass grafting surgery in US veterans

Background

Contemporary guidelines emphasize the value of incorporating frailty into clinical decision-making regarding revascularization strategies for coronary artery disease. Yet, there are limited data describing the association between frailty and longer-term mortality among coronary artery bypass grafting (CABG) patients.

Methods

We conducted a retrospective cohort study (2016–2020, 40 VA medical centers) of US veterans nationwide that underwent coronary artery bypass grafting (CABG). Frailty was quantified by the Veterans Administration Frailty Index (VA-FI), which applies the cumulative deficit method to render a proportion of 30 pertinent diagnosis codes. Patients were classified as non-frail (VA-FI ≤ 0.1), pre-frail (0.1 < VA-FI ≤ 0.2), or frail (VA-FI > 0.2). We used Cox proportional hazards models to ascertain the association of frailty with all-cause mortality. Our primary study outcome was 5-year all-cause mortality; the co-primary outcome was days alive and out of the hospital within the first postoperative year.

Results

There were 13,554 CABG patients (median 69 years, 79% White, 1.5% women). The mean pre-operative VA-FI was 0.21 (SD: 0.11); 31% were pre-frail (VA-FI: 0.17) and 47% were frail (VA-FI: 0.31). Frail patients were older and had higher co-morbidity burdens than pre-frail and non-frail patients. Compared with non-frail patients (13.0% [11.4, 14.7]), there was a significant association between frail and pre-frail patients and increased cumulative 5-year all-cause mortality (frail: 24.8% [23.3, 26.1]; HR: 1.75 [95% CI 1.54, 2.00]; pre-frail 16.8% [95% CI 15.3, 18.4]; HR 1.2 [1.08,1.34]). Compared with non-frail patients (mean 362[SD 12]), pre-frail (mean 361 [SD 14]; p < 0.01) and frail patients (mean 358[SD 18]; p < 0.01) spent fewer days alive and out of the hospital in the first postoperative year.

Conclusions

Pre-frailty and frailty were prevalent among US veterans undergoing CABG and associated with worse mid-term outcomes. Given the high prevalence of frailty with attendant adverse outcomes, there may be an opportunity to improve outcomes by identifying and mitigating frailty before surgery.     

老年冠心病患者冠状动脉旁路移植术后神经系统并发症

目的探讨非体外循环下冠状动脉旁路移植术（OPCAB）后患者神经系统并发症（NC）的种类、发生率、危险因素和防治方法。方法收集北京安贞医院2010年6～10月入院行OPCAB的82例老年患者进行前瞻性研究。术前收集NC危险因素,手术前后进行神经系统查体和头颅320排CT脑灌注检查,术后进行神经系统查体确认有无NC的发生。根据术后是否发生NC分为NC组和非NC组,组间进行危险因素单因素分析。结果NC总发生率为17．01％（14／82）,无死亡病例,其中术后认知功能障碍（POCD）发生率为14．63％（12／82）,焦虑、抑郁的发生率为6．10％（5／82）,缺血缺氧性脑病发生率为3．66％（3／82）,缺血性脑血管病发生率为1．22％（1／82）;NC组与非NC组间进行既往史单因素分析显示,术后NC组脑卒中病史、CT平扫示病灶、糖尿病病史与非NC组相比,有统计学差异;CT脑灌注检查提示,两组脑灌注达峰时间有统计学差异。结论对于行OPCAB患者,应重视术前筛查,完善实验室检查、脑灌注检查等,有助于术前筛查出术后发生NC的高危患者,以给予相应的预防治疗;OPCAB对神经系统而言相对安全但仍需要更多资料进一步研究。     

Beating-heart on-pump coronary artery bypass grafting vs. off-pump coronary artery bypass grafting: a systematic review and meta-analysis

BackgroundBeating-heart on-pump coronary artery bypass grafting (CABG), otherwise known as BH-ONCAB, can reduce myocardial injury by preserving native coronary blood flow while maintaining hemodynamic stability by the effective support of cardiopulmonary bypass (CPB). This study aimed to identify whether BH-ONCAB confers a survival, mortality, or morbidity benefit over off-pump CABG (OPCAB).MethodsA systematic literature review identified 18 studies incorporating 5,615 patients (1,548 BH-ONCAB and 4,067 OPCAB cases) who satisfied the inclusion criteria. Outcome measures were meta-analyzed using random-effects modeling. Between-study heterogeneity was investigated through quality assessment and risk of bias analysis.ResultsThe results demonstrated comparable early mortality and long-term survival between BH-ONCAB and OPCAB coronary revascularization with no significant statistical differences. The incidences of stroke, renal failure, blood loss, and arrhythmias were significantly higher in patients who underwent BH-ONCAB than patients who underwent OPCAB. However, BH-ONCAB conferred lower rates of incomplete revascularization and greater numbers of distal anastomoses.ConclusionsBH-ONCAB is a safe and comparable alternative to OPCAB in terms of early mortality and late survival. BH-ONCAB may confer particular advantages in preventing incomplete revascularization and allowing more distal anastomoses compared to OPCAB. However, BH-ONCAB was associated with more postoperative complications due to the use of CPB. Future work should focus on larger matched studies and multicenter randomized controlled trials to optimize our surgical revascularization strategies.     

Spontaneous coronary artery dissection and associated CT coronary angiographic findings: a case report and review

We report a case of an acute coronary syndrome in a 21-year-old male with invasive coronary angiography and computed tomography (CT) coronary angiography showing a spontaneous dissection of the left anterior descending artery. To our knowledge the CT coronary angiographic appearance of spontaneous coronary artery dissection has been reported only once before. We describe the role CT coronary angiography may have in the evaluation of coronary dissection as well as potential treatment options.     

189例重症冠心病的冠状动脉旁路移植术临床分析

目的:提高重症冠心病人冠状动脉旁路移植术的手术疗效。方法:回顾性分析189例重症冠心病的冠状动脉旁路移植术资料。其中应用体外循环157例,非体外循环32例;搭桥数1～6(平均3.49±1.04)支/人。对手术方法、主要并发症和术后处理进行分析总结。结果:二次开胸4例(2.1％),低心排综合征9例(4.8％),应用主动脉内球囊反搏(IABP)4例(2.1％),反复发作房颤17例(9.0％),胸腔积液27例(14.3％),肺功能不全6例(3.2％),脑合并症3例(1.6％),肝功能不全5例(2.6％),肾功能不全6例(3.2％),死亡7例(3.7％),其余病人康复出院。结论:合理的选择病人,成熟的手术技术,良好的心肌保护,停机困难者IABP的尽早应用及术后处理的加强是提高重症冠心病人冠状动脉旁路移植术疗效的重要措施。