非体外循环下的冠状动脉旁路移植术--101例临床经验体会

目的 :探讨非体外循环下冠状动脉旁路移植术的手术方法及手术适应证 ,并评价其初步临床结果。　　方法 :阜外心血管病医院 1996年 5月～ 1999年 12月完成非体外循环下的冠状动脉旁路移植术 10 1例 ,包括经正中切口非体外循环下的冠状动脉旁路移植术 (OPCAB)组 76例和经胸壁小切口非体外循环下的冠状动脉旁路移植术(MIDCAB)组 2 5例 ,其中 7例在胸腔镜辅助下获取内乳动脉。　　结果 :OPCAB组 76例 ,旁路移植支数平均 2 .5 9支 ,无手术死亡 ,术后并发症包括 :心室颤动并使用主动脉球囊反搏1例 ,出血二次开胸 3例 ,胸部切口感染 2例 ,肺部并发症 2例 ,肾部并发症 1例 ;MIDCAB组 2 5例 ,旁路移植支数平均1.10支 ,无手术死亡 ,围术期心肌梗塞行再次旁路移植手术 1例 ,出血二次开胸 1例 ,胸部切口感染 1例。　　结论 :对于选择的患者 ,非体外循环下 ,不停跳冠状动脉旁路移植术是一项安全、有效的术式。     

12年连续冠脉搭桥手术后无胸骨哆开的临床经验

目的：回顾性分析我院完成的2243例冠状动脉旁路移植术术后伤口并发症情况,总结冠脉搭桥正中手术切口术中及术后处理要点。方法：自1997年4月－2015年12月,排除围术期死亡患者,连续完成冠状动脉旁路移植手术2243例,年龄33－87岁,所有患者均以胸骨正中切口入路,心脏旁路手术完成后采用常规方法关胸,但结合患者情况确定个体化关胸策略。对比分析不同时段术后切口并发症包括胸骨哆开情况。结果：全组患者共发生术后胸骨哆开4例（0.54%）,均发生于2003年前（730例）,经二次固定后痊愈。自2003年后完成的1513例患者无一例发生胸骨哆开。其中单一手术组完成的1130例正中开胸冠脉搭桥手术,胸部切口局部脂肪液化15例,给予减张缝合局部酒精湿敷后干燥愈合。伤口胸骨皮下组织裂开8例（0.7％）,均经换药并二期缝合痊愈。3例患者因无菌性骨髓炎,给予胸骨坏死组织清除、胸大肌填埋成形术后痊愈。结论：心脏手术胸部正中切口并发症重在预防：开胸时注意切口保护、采用个体化胸骨固定技术、术后严格控制血糖水平、使用胸部固定带等综合措施的合理应用,可以使冠状动脉旁路移植手术后切口并发症发生率大大降低。     

左胸小切口冠状动脉旁路移植术30例分析

目的:探讨左胸小切口冠状动脉旁路移植术(MIDCAB)的临床效果。方法:2013年10月至2014年10月,采用左胸小切口取左乳内动脉(LIMA)心脏不停跳冠状动脉旁路移植术30例。采用全麻、双腔气管插管,平卧位左胸抬高30°,左前外侧第4或第5肋切口,用特制牵开器(德国Fehling公司)牵开肋骨,游离乳内动脉,使用心脏固定器下行冠状动脉吻合。结果:全组患者无围术期死亡。术中出血量40~150m L,平均(85±32)m L。术后24h引流量0~1 325(285±262)m L。术后呼吸机辅助时间4~17h,平均(9.5±5.7)h。二次开胸2例。无切口感染。30例随访0.5~1年,心绞痛症状消失27例,明显减轻3例。结论:胸部小切口冠状动脉旁路移植术主要适用于心脏前壁冠状动脉尤其是前降支的再血管化,安全可靠,中期疗效好。使用特制牵开器行MIDCAB手术安全可行。     

二次冠状动脉旁路移植术的临床应用

目的 分析探讨二次冠状动脉旁路移植术的临床应用.方法 回顾性分析22例二次冠状动脉旁路移植术患者的临床资料.结果 围手术期死亡3例.生存病例随访6～60个月,多数患者心功能改善,运动耐量增加,生活质量提高.结论 二次冠状动脉旁路移植术手术风险较大,手术效果较好.     

胸骨下段正中较小切口非体外循环下冠状动脉旁路移植术

目的介绍并探讨经胸骨下段正中较小切口非体外循环下冠状动脉旁路移植术的外科技术和临床经验.方法经胸骨下段正中较小切口游离左侧乳内动脉,用于冠状动脉前降支旁路移植术.对冠状动脉多支病变患者同时游离大隐静脉,用于冠状动脉其它分支旁路移植术.在非体外循环,心脏跳动下,完成冠状动脉单支或多支病变血管的旁路移植术.观察术后恢复情况.结果全组22例患者采用该手术方法,其中5例为前降支单支病变,17例为多支病变.22例患者前降支旁路移植术均采用左乳内动脉.平均冠状动脉旁路移植支数2.40±1.04(1～4)支/人.冠状动脉旁路移植的靶血管包括前降支、对角支、右冠状动脉或后降支和高位边缘支.全组患者术后恢复顺利,无严重术后并发症和死亡.患者术后平均8.1±1.6天痊愈出院.结论该手术方法创伤较小,安全易行,对有手术适应证的多支病变患者是一种较好的微创冠状动脉旁路移植手术方法.     

冠状动脉旁路移植术治疗冠心病32例体会

目的 总结冠状动脉旁路移植术（CABG）治疗冠心病的临床经验。方法 收集2012年1月到2015年1月期间32例行冠状动脉旁路移植术的冠心病患者临床资料,其中行常规体外循环下冠状动脉旁路移植术（CCABG）19例,非体外循环下冠状动脉旁路移植术（OPCAB）13例。对患者手术方法、桥血管的选择及住院时间等资料进行分析。结果 所有患者平均搭桥3.5根,患者术后均无严重并发症,无手术死亡。29例患者术后心绞痛症状完全消失,3例症状较术前减轻,住院一段时间后均痊愈出院。结论 冠状动脉旁路移植术疗效显著,手术安全性较高,近期临床效果满意。     

高龄病人冠状动脉旁路移植术的临床分析——附32例报道

目的 总结高龄病人行冠状动脉旁路移植术病人的特点.方法 对近8年来32例75岁以上冠心病病人行冠状动脉旁路移植术(coronary artery bypass grafting,CABG),其中行不停搏冠状动脉旁路移植术25例,体外循环下冠状动脉旁路移植术4例(占12%),体外循环下冠状动脉旁路移植术加二尖瓣置换3例(占9%).结果 32例高龄冠状动脉旁路移植术病人无院内死亡,平均术后气管插管时间12 h,重症监护病房停留时间4 d,术后住院时间18 d,术后引流量831 ml.共有29例次术后发生各种不同的并发症.20例随访3～88个月,晚期死亡3例(占9%),其中因心脏病死亡2例(占6%).结论 高龄冠心病病人只要一般情况好,无严重肺、肝、肾和脑疾病,选择合适的手术方式,加强围手术期处理,可获得良好的手术效果.不停搏冠状动脉旁路移植术可显著降低术后并发症的发生率及院内病死率,为高龄冠状动脉旁路移植术病人首选术式.     

不停跳冠状动脉旁路移植术对糖尿病患者术后早期结果的影响

目的探讨糖尿病对冠状动脉旁路移植术的手术病死率和并发症发生率的影响作用.方法回顾分析1995年10月-2004年1月958例择期行冠状动脉旁路移植术的患者,其中191例并发糖尿病.糖尿病和无糖尿病患者按是否应用体外循环进一步分为四组,对四组患者术前、术后资料进行对比分析.结果糖尿病组应用体外循环患者手术病死率为5.6%,糖尿病组不停跳冠状动脉旁路移植术患者为2.1%.结论糖尿病是影响冠状动脉旁路移植术预后的危险因素,不停跳冠状动脉旁路移植术能显著减少糖尿病患者的手术病死率和并发症发生率.     

高龄病人冠状动脉旁路移植术的临床分析——附32例报道

目的 总结高龄病人行冠状动脉旁路移植术病人的特点.方法 对近8年来32例75岁以上冠心病病人行冠状动脉旁路移植术（coronary artery bypass grafting,CABG）,其中行不停搏冠状动脉旁路移植术25例,体外循环下冠状动脉旁路移植术4例（占12%）,体外循环下冠状动脉旁路移植术加二尖瓣置换3例（占9%）.结果 32例高龄冠状动脉旁路移植术病人无院内死亡,平均术后气管插管时间12 h,重症监护病房停留时间4 d,术后住院时间18 d,术后引流量831 ml.共有29例次术后发生各种不同的并发症.20例随访3～88个月,晚期死亡3例（占9%）,其中因心脏病死亡2例（占6%）.结论 高龄冠心病病人只要一般情况好,无严重肺、肝、肾和脑疾病,选择合适的手术方式,加强围手术期处理,可获得良好的手术效果.不停搏冠状动脉旁路移植术可显著降低术后并发症的发生率及院内病死率,为高龄冠状动脉旁路移植术病人首选术式.     

小切口肌桥松解术治疗冠状动脉肌桥的临床研究

目的:探讨小切口肌桥松解术治疗冠状动脉肌桥(myocardial bridging,MB)的手术方法及中短期手术效果。方法:2009年9月至2013年11月间,我们对11例MB患者施行了小切口肌桥松解术,其中10例为孤立MB,1例合并前降支—肺动脉瘘。11例患者均有胸痛或胸闷病史,并经过系统的药物治疗,症状仍间断发作。术前均由冠状动脉造影检查明确诊断,肌桥均位于左前降支,长度为2~4cm,收缩期狭窄均60%。结果:11例患者均行胸骨中下段小切口,10例孤立MB患者顺利在非体外下行肌桥松解术,1例行松解时损伤冠状动脉,改行非体外冠状动脉旁路移植术;合并前降支—肺动脉瘘的患者在非体外下行肌桥松解术同时行瘘修补术。无患者死亡,也无心室破裂、肺部感染、肾衰竭等围手术期并发症。术后均顺利出院。术后11例患者均被随访,随访时间2~51个月,10例行肌桥松解术患者中有1例患者术后再次发作胸痛症状,行冠状动脉造影检查未见明显收缩期狭窄,给予药物可控制症状。1例行冠状动脉旁路移植术患者9个月后再发胸痛症状,内科行支架置入治疗。结论:小切口肌桥松解术创伤小、安全性高、疗效可靠,可作为药物控制不佳MB患者的治疗选择。     

Radial artery conduit for coronary revascularization: as good as an internal thoracic artery?

PURPOSE OF REVIEW: Multiple arterial grafting has been proposed to improve outcomes after coronary bypass surgery. We sought to define the emerging role of the radial artery as an alternative second arterial graft. RECENT FINDINGS: Despite significant evidence suggesting superiority of bilateral internal thoracic artery grafting, utilization in current clinical practice remains low due to concerns about sternal wound infection and conduit length. Recent clinical trials have started to clarify the role of the radial artery in coronary surgery. This conduit provides superior patency to saphenous vein grafts in the setting of high-grade stenosis regardless of the target territory and with minimal harvest site complications. SUMMARY: The radial artery is a versatile conduit that provides clinical benefit in a large variety of patients undergoing coronary bypass surgery. Outcomes from ongoing longitudinal clinical trials will further clarify optimal conduit selection strategies.     

血清BNP水平与冠状动脉旁路移植术术后并发房颤的关系

目的 探讨血清B型利钠肽（BNP）水平与冠状动脉旁路移植术后并发房颤的关系。方法 收集2016年3月至2017年9月我院收治的98例行冠状动脉旁路移植手术的患者为研究对象，根据术后是否并发房颤将其分为房颤组（n=37）和窦律组（n=61），收集患者的临床病历资料，包括人口学资料、疾病史、心功能检查、实验室检查等，采用多因素Logistic回归分析血清BNP与房颤的关系。结果 房颤组患者年龄、术后24h LVEF大于窦律组，术后24h血清BNP、hs-CRP水平高于窦律组，差异均有统计学意义（P<0.05）。多因素Logistic回归结果显示，年龄、术后24h LVEF、术后24h BNP、术后24h hs-CRP为冠状动脉旁路移植术后并发房颤的独立危险因素，OR分别为1.868、1.285、1.784、1.436，差异均有统计学意义（P<0.05）。术后24h血清BNP对冠状动脉旁路移植术后并发房颤预测的ROC曲线下面积为0.855（95%CI：0.794，0.915），血清BNP最佳临界值为107.28 pg/mL，灵敏度、特异性分别为76.35%、82.11%，准确性为75.29%。结论 血清BNP水平是冠状动脉旁路移植术后并发房颤的独立危险因素，术后24h内及时检测可作为预测房颤的重要指标。     

Continuous insulin infusion improves postoperative glucose control in patients with diabetes mellitus undergoing coronary artery bypass surgery

Postoperative glucose control directly affects the incidence of deep sternal wound infection and death after patients with diabetes have undergone coronary artery bypass grafting. We compared the effect upon glucose control of continuous insulin infusion with that of glucometer-guided insulin injection after coronary artery bypass. Our prospective, randomized, controlled study involved patients with diabetes mellitus who underwent coronary artery bypass grafting in our hospital from January 2001 through January 2003. Immediately after surgery, patients were randomly assigned to receive continuous insulin infusion or conventional glucometer-guided injection to maintain blood glucose at a level between 150 and 200 mg/dL. The adequacy of postoperative blood glucose control and clinical outcome were evaluated.Of 93 patients studied, the incidence of sternal wound infection was 3.9% among infusion patients and 4.8% among injection patients (P=0.587). There was no significant difference in mortality rates (infusion, 3.9%; injection, 2.4%; P=0.573). Satisfactory blood glucose levels were achieved in significantly more patients undergoing infusion than injection (64.7% vs 28.6%, P <0.001). In the injection group, significantly more blood glucose measurements were required to achieve control (23.4 vs 16.5, P=0.001), and good control was attained much sooner in the infusion group (21.4 vs 30.5 hr, P=0.013). We conclude that continuous insulin infusion provides better control of postoperative blood glucose levels after coronary artery bypass grafting in patients with diabetes than does glucometer-guided insulin injection.     

胸廓内动脉行冠脉搭桥术的应用解剖学研究

目的了解胸廓内动脉的解剖结构,为临床进行冠状动脉搭桥术提供解剖学资料。方法选取甲醛固定的成人尸体标本40具,胸廓内动脉保留完好。观察记录胸廓内动脉的起始部位和终末分支,以及胸廓内动脉与胸横肌的关系。测量胸廓内动脉的长度和各肋间隙距胸骨侧缘的距离。结果多数胸廓内动脉起自锁骨下动脉第1段,沿胸骨侧缘外侧下行;多数胸廓内动脉在第6肋间隙形成终末分支;多数胸横肌上缘与胸廓内动脉相交在第3肋软骨处。左、右侧胸廓内动脉的长度分别为（19．34±1．69）cm和（18．86±1．73）cm,平均外径为（2．81±0．39）mm和（3．08±0．44）mm。结论胸廓内动脉行冠脉搭桥术是一种可行的搭桥方式,根据解剖学数据,在术中应取用第6肋软骨以上的血管进行吻合。     

Bilateral internal mammary artery mobilization and sternal healing.

Four instances of mediastinal wound infection occurred in 100 patients who underwent bilateral internal mammary artery (IMA) mobilization for coronary bypass. Debridement of 3--5 mm of the sternal edges was performed 6--18 days after the primary operation, and 2 patients required additional, anatomically limited debridement. Wounds were allowed to heal by secondary intention. The wounds of 3 patients healed by 4, 7, and 16 months; they had patent grafts at the postoperative or 1-year catheterization; and they returned to work and are free of angina. The fourth patient died of renal and respiratory failure 3 months after the operation; his wound was healing and had not required additional debridement. These observations indicate that bilateral IMA mobilization does not result in avascularity of the sternum, which required only limited debridement and quickly formed granulation tissue from the periosteum and marrow.     

两种冠状动脉旁路移植术对老年患者血浆肾上腺髓质素和内皮素-1的影响

目的 探讨体外循环和非体外循环下冠状动脉旁路移植术式对老年患者手术后血浆肾上腺髓质素(ADM)及内皮素-1(ET-1)的影响.方法 选择体外循环和非体外循环冠状动脉旁路移植术老年患者各20例,于术前、术后即刻、术后6 h、24 h和术后3 d抽取静脉血,采用放射免疫法测定血浆ADM及ET-1的浓度.结果 体外组和非体外组患者术后即刻ET-1及ADM浓度均明显升高,ET-1分别为(67.59±10.18)ng/L和(58.73±9.64)ng/L,ADM分别为(284.90±36.24)ng/L和(243.25±25.70)ng/L,且体外组升高更明显(P＜0.05);体外组和非体外组术后6 h ET-1及ADM浓度开始下降,并延续至24 h后,术后3 d非体外组基本恢复至术前水平,体外组尚处于较高水平.结论 体外循环和非体外循环冠状动脉旁路移植术均可引起血管内皮功能紊乱,导致血浆ET-1及ADM水平升高,但非体外循环冠状动脉旁路移植术对其影响较小.     

Comparison of recovery patterns for patients undergoing coronary artery bypass grafting and minimally invasive direct coronary artery bypass in the early discharge period

The purpose of this pilot study was to compare the postoperative problems, evaluation and response of symptoms, and functional status (physiologic and psychosocial functioning) during the early recovery period (2, 4, and 6 weeks after surgery) in 35 individuals who underwent coronary artery bypass grafting (n=24) or minimally invasive direct coronary artery bypass (n=11). The most frequent postoperative problem reported by the coronary artery bypass grafting group was an incisional infection (either sternal or leg); 26% reported infection at 2 and 4 weeks, and 21% at 6 weeks after surgery. Respiratory problems (pleural effusion, pneumonia) were the second most frequently reported problem, reported by 10% of the subjects at 2 and 4 weeks and by 16% at 6 weeks. Other, less frequent problems were severe nervousness, rhythm problems, and pericarditis. Minimally invasive direct coronary artery bypass patients reported fewer postoperative or cardiac-related problems, as only 5% indicated a problem with heart failure at both 2 and 4 weeks, and 36% reported being very nervous or having emotional problems at 4 weeks. Unlike postoperative problems, there were numerous similarities in postprocedural symptoms between these two groups. Fatigue, shortness of breath, and pain were the major symptoms reported postdischarge by both groups in this study. In addition, sleeping problems were also fairly prevalent in the coronary artery bypass grafting group, which is understandable, considering the fatigue ratings. Physiologic and psychosocial functioning varied minimally between the two procedures. While there were many similarities in the recovery patterns of both groups, the occurrence of postprocedural problems and symptoms of these two patient groups should be considered by clinicians to further tailor patient education.     

冠状动脉旁路移植手术后低氧血症及相关因素分析

目的：通过对冠状动脉旁路移植手术前后诸因素的分析，了解导致冠状动脉旁路移植手术后出现低氧血症的原因及处理对策。材料及方法：回顾性分析1996年10月-1999年2月共23l例冠状动脉旁路移植手术患者。男205例，女26例，年龄32—76岁。以患者术后出现动脉血氧饱和度〈90％为界，分为低氧组和正常组。两组计量资料行T检验，计数资料行卡方或Fisher精确计算法检验，并进行多因素Logistic回归分析。结果：231例患者术后动脉血氧饱和度低于90％有53例，低氧发生率约23％。术后动脉血氧分压呈下降趋势，术后第三天达最低水平，术后第四天氧分压呈上升趋势。单因素分析，术前左室射血功能（EF）小于45％、合并慢性阻塞性肺疾病、既往手术史及术前氧分压降低与术后低氧密切相关。多因素分析显示术前EF小于45％、既往手术、吸烟、主动脉阻断时间、第一秒时间肺活量（FEV1）减低和一氧化碳弥散量减低为术后低氧血症独立影响因素。结论：术前EF小于45％、合并慢性阻塞性肺疾病、再次手术、术前氧分压降低、吸烟、主动脉阻断时间、FEV1和一氧化碳弥散量减低是术后低氧血症发生的相关因素。     

Double coronary revascularization using the internal mammary arteries. Mid-term results of 74 cases

This study reports our experience of 74 multiple coronary artery bypass, using either the two internal mammary arteries (IMA) (43 cases), or the left internal mammary artery (LIMA), alone for sequential bypass (31 cases). Comparison with a series of 200 patients operated upon in a previous period (1981-83), when the LIMA was used alone for single bypass, showed that post-operative mortality, post-operative infarction and mediastinitis were significantly more frequent with double bypass using the two IMA; similarly, the mid-term results seemed to be less satisfactory with the double IMA bypass technique. This difference was due to the fact that using the right and left IMA means longer dissection time, greater problems of haemostasis, stronger surgical trauma and prolonged exposure of the sternum, which is a source of infection. In addition, the right internal mammary artery (RIMA) being further away from the sites of coronary grafting lends itself less readily than the LIMA to this type of bypass, and it is often used for the right and marginal coronary artery which is less suitable for surgery. Using the LIMA alone for sequential bypass does not seem to produce more complications than using that vessel for single bypass. On the basis of the results obtained, we consider that the double IMA bypass should only be used when the internal saphenous vein bypass is contraindicated (past history of stripping, varices, fragile aorta forewarning of difficult grafting).(ABSTRACT TRUNCATED AT 250 WORDS)     

严重左心室功能不全冠心病的外科手术治疗

目的总结严重左心室功能不全（LVEF≤35％）冠心病患者行冠状动脉旁路移植术（CABG）的临床经验。方法回顾性研究分析23例有严重左心室功能不全冠心病患者行CABG的临床资料,其中合并左主干病变18例,合并室壁瘤6例,合并室间隔穿孔1例;16例采取非体外循环下冠状动脉旁路移植术,7例在体外循环下行冠状动脉旁路移植术。结果死亡2例,21例患者治愈出院。随诊6～36个月,无死亡．2例患者有心绞痛发作。结论CABG术对有严重左心室功能不全的冠心病是有效的治疗方法,手术效果取决于存活心肌的多少和可再血管化血管的数量。