非体外循环冠状动脉旁路移植术中血流动力学和氧供需变化及麻醉处理

目的 观察非体外循环冠状动脉旁路移植术中处理三支主要冠状动脉分支引起的血流动力学和氧供需改变，并对原因作初步分析，为麻醉处理提供依据。方法 选择我院2004年1月-2005年12月择期行非体外循环冠状动脉旁路秽植术符合标准的60倒病人。手术开始后，记录以下5点的血流动力学数值：（1）开胸始；（2）暴露和固定前降支后；（3）暴露和固定左回旋支冠状动脉后；（4）暴露和固定右冠状动脉后；（5）术毕。记录（1），（4），（5）点血气。结果 血流动力学发生了明显的改变，平均动脉血压、心指数下降，而心率、中心静脉压升高，平均肺动昧压、肺动脉楔压升高。动脉血气改变，动脉血乳酸水平升高。结论 本组病人行非体外循环冠状动脉旁路移植时，血流动力学发生了变化，经及时处理完成手术。氧供逐渐减少，氧耗量没有明显的改变，氧代谢紊乱及缺氧程度较轻。     

酒石酸布托啡诺对冠状动脉旁路移植术丙泊酚麻醉诱导期血流动力学的影响

目的 探讨酒石酸布托啡诺对冠状动脉旁路移植术（CABG）患者丙泊酚麻醉诱导期血流动力学的影响。方法 将纳入的94例行CABG治疗的患者随机分为观察组和对照组,各47例。观察组患者麻醉诱导前给予40μg/kg酒石酸布托啡诺,对照组患者麻醉诱导前给予等量生理盐水,2组麻醉诱导及维持方法相同。于给予酒石酸布托啡诺或生理盐水前（T0）、插管即刻（T1）、插管后1 min(T2)、插管后3 min(T3)、插管后5 min(T4)记录2组患者平均动脉压（MAP）、心率（HR）,同时检测血清皮质醇（Cor）、促肾上腺皮质激素（ACTH）、去甲肾上腺素（NE）水平。统计2组患者麻醉诱导期不良反应发生情况。结果 2组患者T1时MAP、HR均明显低于T0时（P<0.05）;对照组T2～T4时MAP、HR较T0时明显升高（P<0.05）,观察组T2～T4时MAP、HR较T0时明显降低（P<0.05）;T1时观察组MAP、HR明显较对照组高（P<0.05）,T2～T4时观察组MAP、HR明显较对照组低（P<0.05）。观察组T2时血清Cor、ACTH、NE水平较T0时明显升高（...     

冠状动脉旁路移植术后静脉桥再狭窄的基因治疗研究进展

冠状动脉旁路移植术是治疗缺血性心脏病安全、有效的方法.自体大隐静脉是术中最常用的移植血管材料.但是血栓形成、内膜增厚和粥样硬化导致的静脉桥再狭窄严重影响了其通畅率,而且至今尚无有效的治疗药物.分子生物学技术理论的发展为冠状动脉旁路移植术后静脉桥再狭窄的防治提供了新思路,基因治疗静脉桥再狭窄已成为目前研究的热点.本文主要从静脉桥再狭窄防治的目的基因、基因导入方式、基因载体等方面,对静脉桥再狭窄基因治疗的研究进展进行综述.     

冠状动脉移植管的血流动力学数值模拟

采用有限元数值计算的方法，模拟了冠状动脉搭桥术中移植管内的生理流动。计算模型包括了冠状动脉狭窄，并考虑了由于移植管直径大于冠状动脉直径而在两者缝合时移植管的变形。计算结果分析了缝合区附近的流场、二次流、壁面切应力在心动周期内的时空分布情况。计算结果表明，在缝合前端下游，存在一个低切应力、高切应力梯度的区域，在缝合区底部存在一个高切应力、高切应力梯度的区域。这两个区域都是内皮细胞增生并造成移植管术后再阻塞的危险部位。     

胸骨下端正中小切口冠状动脉旁路移植术围手术期护理

随着微创小切口冠状动脉旁路移植术（minimally invasive direct coronary artery bypass grafting,MIDCAB）在临床上的逐步推广,冠状动脉旁路移植术可以在心脏不停跳的情况下通过一个小的胸部切口进行。MIDCAB手术住院时间短、术后并发症少、切口小、康复快、费用低,具有良好的社会效益。我院于2008年3月至2009年10月共计开展8例MIDCAB手术,效果较好,现将围手术期护理体会报告如下。     

冠状动脉搭桥血流动力学数值模拟

目的深入研究缝合区附近的血流动力学特性,这对于了解内膜增生的发生机制以及提高冠状动脉搭桥畅通率有重要的指导与临床意义。方法通过运用三维重建软件和逆向工程软件从CT医学图像中重建出弯曲冠状动脉模型,并考虑移植管缝合到冠状动脉上时端口的变形。采用有限体积法数值研究的方法,模拟冠状动脉搭桥术中下游缝合区附近的血液流动的流场。结果临床上常出现内膜增生的位置都存在不正常的血流动力学现象,缝合前端和缝合后端都出现了严重的回流现象。结论在冠状动脉旁路移植术中,移值管远端应缝合到曲率较小的冠状动脉上。     

冠状动脉旁路移植治疗冠状动脉肌桥9例分析

目的回顾冠状动脉旁路移植术治疗症状性肌桥的外科治疗经验及结果。方法选取2004年3月至2011年1月因冠状动脉肌桥导致冠状幼脉血流堵塞需行冠状动脉旁路移植术的患者资料9例,采用胸廊内动脉到前降支进行旁路移植,2例取大隐静脉与其他病变冠状动脉进行旁路移植。结果全组无患者死亡,无术中相关并发症发生。所有患者随访4个月至7年,临床症状均明显改善,无心绞痛发生,无心肌梗死及其他主要心血管不良事件（再血管化或死亡等）发生。结论冠状动脉旁路移植治疗有症状的肌桥安全、有效。     

冠状动脉旁路移植术后急性肾损伤的危险因素分析

目的 对比冠状动脉旁路移植术(coronary artery bypass grafting,CABG)后急性肾损伤(acute kidney injury,AKI)诊断标志物的表达水平,分析CABG后AKI的危险因素.方法 选取73例CABG患者作为研究对象,以CABG是否发生AKI分组为AKI组与对照组;对比两组患者术后24h血清肌酐(serum creatinine,Scr)、血清尿素氮(serum urea nitrogen,BUN)、尿液胱抑素C(urine cystatin C,Cys C)及肾损伤分子-1(kidney injury molecule-1,KIM-1)的表达水平;以AKI为作因变量,而患者的临床资料作为自变量,分析CABG后AKI的危险因素,并进行多因素及单因素Logistic回归分析,为CABG后AKI的预防策略提供依据.结果 AKI组与对照组术前Scr、BUN、Cys C及KIM-1的表达水平对比,差异均无统计学意义(P ＞0.05);AKI组术后Scr、BUN、Cys C及KIM-1的表达水平均显著高于对照组,两组数据差异具有统计学意义(t分别为3.586、3.728、4.325、3.089,P均小于0.05);单因素Logistic回归分析显示,年龄、高血压、移植血管桥数量、机械通气时间及术后低心排作为CABG后AKI的危险因素;多因素Logistic回归分析显示,年龄、移植血管桥数量及术后低心排作为CABG后AKI的独立危险因素,具有统计学意义(P＜0.05).结论 CABG后应密切监测患者的Scr、BUN、Cys C及KIM-1的表达水平,作为AKI的诊断标志物;年龄、移植血管桥数量及术后低心排作为CABG后AKI的独立危险因素,应严格进行术前评估、降低手术风险、围术期保护及改善肾功能,降低CABG后AKI发生的风险.     

395例体外循环下冠状动脉旁路移植术临床分析

目的总结分析冠状动脉旁路移植术(CABG)治疗冠心病的疗效和经验。方法 2002年1月至2012年12月我们完成CABG有395例,其中男299例,女96例,平均年龄62.3岁,均在中低温体外循环下完成手术,其中18例同期行室壁瘤切除术。结果本组平均搭桥3.2支。体外循环时间62~170 min,平均88 min,主动脉阻断时间25~102 min,平均68 min。术后机械通气时间12~72 h,平均18 h。围手术期死亡8例,死亡率2.0%,其中多器官功能衰竭6例,术后发生室颤抢救无效死亡1例,围术期急性心肌梗死1例。心功能均明显改善,195例心绞痛症状完全缓解,85例症状较前减轻。随访280例,随访时间8个月至11年,远期死亡5例,死亡原因不明。结论常规中低温体外循环下CABG是治疗冠心病安全、有效的方法。     

颅内动脉瘤径颈比对瘤体与分支血管血流动力学影响的数值模拟研究

动脉瘤的血流动力学是影响其生长与破裂的重要因素,尤其是形态学参数径颈比(aspect ratio,AR,瘤体长径/瘤颈宽度)对其血流动力学影响较大。本研究使用基于计算流体力学(computational fluid dynamics,CFD)技术的ANSYS 16.0软件包,数值仿真分析了不同径颈比对颅内动脉瘤瘤体与分支血管血流动力学的影响,为临床上制定合理的形态学与血流动力学指标来筛选高危的动脉瘤患者,并进行积极的干预治疗提供一定的理论依据。通过使用空间直角坐标系建立径颈比为3.33、2.5、2、1.67、1.43、1.25的理想颅内动脉瘤几何模型,分析和比较了包括血液流场与涡量分布、流速与流量、壁面压力、壁面切应力(wall shear stress,WSS)、瘤颈近远侧端与分支血管剪切应变率(shear strain rate,SSR)在内的血流动力学参数。数值模拟结果给出了动脉瘤与分支血管内的流线图、涡核图、压力分布云图、WSS分布云图以及随X轴变化的流速与压力峰值分布曲线。分析得出,径颈比决定瘤内血流模式,径颈比减小,瘤顶的流速与SSR增大,瘤壁上的压力与WSS增大,分支血管壁上的压力增大,且WSS/SSR瘤颈远侧端>WSS/SSR瘤颈近侧端>WSS/SSR分支血管中心,涡核区域由瘤体远侧壁增大至覆盖整个动脉瘤,但对分支血管内血流的阻碍作用减小。     

A numerical study of blood flow in coronary artery bypass graft side-to-side anastomoses

Purpose: When sequential grafts are used in multivessel coronary artery bypass grafting, the graft first supplies blood to one or more coronary arteries via a side-to-side anastomosis. We studied hemodynamics in idealized models of parallel and diamond side-to-side anastomoses, identifying features that might promote restenosis. Methods: Blood flow was computed in three representative anastomosis configurations: parallel side-to-side, diamond side-to-side, and end-to-side. We compared configurations and the effect of host-graft diameter ratio. Results:Hemodynamic patterns depended strongly on anastomosis geometry and graft/host diameter ratio. In the distal graft, the diamond configuration had large areas of low wall shear stress (WSS) and high spatial WSS gradients. In the proximal graft the unfavorable WSS patterns were comparable for all models, while the distal portion of the host artery the diamond model was best. Models with smaller host arteries had smaller regions of low WSS. Conclusions: The parallel configuration was preferred over the diamond for maintaining graft patency, while the diamond configuration appeared best for maintaining host artery patency. Since graft patency is critical, parallel configurations seem hemodynamically advantageous. Larger graft/host ratios have better hemodynamic performance than smaller ones. © 2002 Biomedical Engineering Society. PAC2002: 8719Uv, 8710+e     

Induction of anesthesia in coronary artery bypass graft surgery: the hemodynamic and analgesic effects of ketamine

OBJECTIVE

The aim of this prospective, randomized study was to evaluate the hemodynamic and analgesic effects of ketamine by comparing it with propofol starting at the induction of anesthesia until the end of sternotomy in patients undergoing coronary artery bypass grafting surgery.

INTRODUCTION

Anesthetic induction and maintenance may induce myocardial ischemia in patients with coronary artery disease. A primary goal in the anesthesia of patients undergoing coronary artery bypass grafting surgery is both the attenuation of sympathetic responses to noxious stimuli and the prevention of hypotension.

METHODS

Thirty patients undergoing coronary artery bypass grafting surgery were randomized to receive either ketamine 2 mg.kg⁻¹ (Group K) or propofol 0.5 mg.kg⁻¹ (Group P) during induction of anesthesia. Patients also received standardized doses of midazolam, fentanyl, and rocuronium in the induction sequence. The duration of anesthesia from induction to skin incision and sternotomy, as well as the supplemental doses of fentanyl and sevoflurane, were recorded. Heart rate, mean arterial pressure, central venous pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, cardiac index, systemic and pulmonary vascular resistance indices, stroke work index, and left and right ventricular stroke work indices were obtained before induction of anesthesia; one minute after induction; one, three, five, and ten minutes after intubation; one minute after skin incision; and at one minute after sternotomy.

RESULTS

There were significant changes in the measured and calculated hemodynamic variables when compared to their values before induction. One minute after induction, mean arterial pressure and the systemic vascular resistance index decreased significantly in group P (p<0.01).

CONCLUSION

There were no differences between groups in the consumption of sevoflurane or in the use of additional fentanyl. The combination of ketamine, midazolam, and fentanyl for the induction of anesthesia provided better hemodynamic stability during induction and until the end of sternotomy in patients undergoing coronary artery bypass grafting surgery.     

左侧肋间后动脉用于冠状动脉搭桥术的应用解剖

目的：为左侧肋间后动脉冠状动脉搭桥术提供解剖学基础。方法：在３０具成人尸体标本上,对左侧肋间后动脉及心脏冠状动脉的后降支和左缘支进行了观察。结果：左侧第８、９、１０肋间动脉到后降支（房窒交点下方１ｃｍ处＿平均外径分别为２．５、２．６、２．８ｍｍ,与冠状动脉后降支此点处外径（２．５ｍｍ）较为接近;到左缘支点处的平均外径为２．７、２．８、２．６ｍｍ,与左缘地此点处外径（２．１ｍｍ）较为接近;到后降支中     

旋股外侧动脉降支用于冠状动脉旁路术的可行性研究

目的 为旋股外侧动脉降支用于冠状动脉旁路术提供解剖学依据,并对其手术切取方法进行初步设计。方法 对19具福尔马林保存成年尸体38侧旋股外侧动脉起始部及其降支的走行、分支及周围结构进行详细的观察,测定旋股外侧动脉降支主干的长度、起点和止点处的外径,以及髂前上棘至髌骨中点连线的中点到股外侧肌与股直肌间沟的水平距离。结果 旋股外侧动脉降支位置较为恒定,位于股中间肌、股直肌、股外侧肌之间的肌间隙内。主干长度为12.0±2.36cm,起点处外径为2.7±0.35mm,止点处外径为2.2±0.28mm,髂前上棘至髌骨中点连线的中点到股外侧肌、股直肌间隙前外侧缘的水平距离为0.4±0.18cm。结论 旋股外侧动脉降支的解剖特点符合冠状动脉旁路术的要求,可以用于该手术,经股直肌和股外侧肌间隙可方便切取该动脉。     

Effect of a flow-streamlining implant at the distal anastomosis of a coronary artery bypass graft

Intimal thickening in the coronary artery bypass graft (CABG) distal anastomosis has been implicated as the major cause of restenosis and long-term graft failure. Several studies point to the interplay between nonuniform hemodynamics including disturbed flows and recirculation zones, wall shear stress, and long particle residence time as possible etiologies. The hemodynamic features of two anatomic models of saphenous-vein CABGs were studied and compared. One simulated an anastomosis with both diameter and compliance mismatch and a curvature at the connection, analogous to the geometry observed in a conventional cardiothoracic procedure. The other, simulated an anastomosis with a flow stabilizing anastomotic implant connector which improves current cardiothoracic procedures by eliminating the distal vein bulging and curvature. Physiologic flow conditions were imposed on both models and qualitative analysis of the flow was performed with dye injection and a digital camera. Quantitative analysis was performed with laser Doppler velocimetry. Results showed that the presence of the bulge at the veno-arterial junction, contributed to the formation of accentuated secondary structures (helices), which progress into the flow divider and significantly affect radial velocity components at the host vessel up to four diameters downstream of the junction. The model with the implant, achieved more hemodynamically efficient conditions on the host vessel with higher mean and maximum axial velocities and lower radial velocities than the conventional model. The presence of the sinus may also affect the magnitude and shape of the shear stress at locations where intimal thickening occurs. Thus, the presence of the implant creates a more streamlined environment with more primary and less secondary flow components which may then inhibit the development of intimal thickening, restenosis, and ultimate failure of the saphenous vein graft. © 2002 Biomedical Engineering Society. PAC2002: 8780Rb, 8719Rr, 8719Uv, 8763Lk, 8719Xx, 4262Be, 4780+v, 8710+e     

Short-term response of metabolic hormones to coronary artery bypass surgery

PurposeTo explore the response pattern of plasma adipokine and ghrelin levels to coronary artery bypass graft (CABG) surgery in patients with (on-pump) and without (off-pump) cardiopulmonary bypass (CPB).Material/methodsSixteen consecutive patients (age: 62 ± 10 years, male: 10) with obstructive coronary artery disease (CAD) who underwent elective CABG surgery with CPB and intraoperative GIK infusion were selected for on-pump group and 19 CAD patients (age: 63 ± 10 years, male: 16) were included in the off-pump group. Blood samples were taken before, during and after surgery. Intraoperative samples were withdrawn simultaneously for peripheral vein and sinus coronarius (SC). Plasma adipokine concentrations were measured by ELISA, those of ghrelin by RIA kits.ResultsIn response to surgical intervention there was an early, transient fall in plasma levels of adiponectin (p < 0.0001) and resistin (p = 0.002) followed by an increase to approach their initial values. Plasma ghrelin also increased (p = 0.045), this increase, however, was confined to the period of GIK supported CPB. Plasma insulin (p = 0.003) and resistin (p = 0.009) was significantly higher in the peripheral vein than in SC. The perioperative hormone profile of patients without CPB (off-pump) proved to be comparable to that of on-pump patients in spite of the insulin administration and greater oxidative and inflammatory stress.ConclusionsAdipose tissue-derived factors appear to mediate the metabolic and vascular changes that occur in patients with CABG surgery. Epicardial adipose tissue is unlikely to have major contribution to the development of CAD as adipokines are not elevated in SC independent of the mode of intervention.     

血嗜酸性粒细胞计数与冠状动脉旁路移植手术后肺炎风险（英文）

目的:研究血嗜酸性粒细胞计数与冠状动脉旁路移植手术患者术后肺炎风险的关系。方法:收集2008年~2017年在我院进行冠状动脉旁路移植手术的613例患者资料进行分析,比较不同血嗜酸性粒细胞计数患者术后肺炎发生率及住院死亡率,采用多因素回归分析明确患者术后肺炎的危险因素。结果:研究共纳入582例患者,其中220例患者血嗜酸性粒细胞比例2%(低血嗜酸性粒细胞组),362例患者血嗜酸性粒细胞比例≥2%(高血嗜酸性粒细胞组)。低血嗜酸性粒细胞组术后肺炎发生率(14.1%,31/220)明显高于高血嗜酸性粒细胞组(6.4%,23/362,P=0.002),而2组患者住院死亡率无明显差异。多因素回归分析结果显示低血嗜酸性粒细胞计数(OR=3.521,95%CI:1.213~10.223,P=0.021)、鼻胃管(OR=6.490,95%CI:2.757~15.280,P0.001)和机械通气时间≥24 h(OR=3.496,95%CI:1.156~10.178,P=0.035)为术后发生肺炎的独立危险因素。结论:低血嗜酸性粒细胞计数患者冠状动脉旁路移植手术后发生肺炎的风险升高。     

Adherence to lifestyle changes after coronary artery bypass graft: Outcome of preoperative peer education

ObjectiveThis study was done to investigate the effect of preoperative peer education on patients' adherence to medication and lifestyle changes after Coronary Artery Bypass Graft (CABG).MethodsIn this randomized clinical trial, the peers of CABG patients conducted preoperative educational sessions at the ward in groups of 4–5 (n = 36) while the control group (n = 34) received routine education by a nurse. Adherence of both groups to medication and recommendations for lifestyle modification including physical activity, smoking, and diet was measured one and two months after discharge.ResultsA multivariate analysis of co-variance showed the significant effect of peer education on adherence (F = 32.586, p < 0.001; η² = 0.671). Univariate ANCOVA revealed a significant difference in adherence to diet between the two groups (F = 62.316, p = 0 0.0001; η² = 0.482). Based on the repeated measures ANOVA, peer education significantly improved the CABG patients' adherence to diet (F = 55.373, p = 0.0001) and their total adherence (F = 9.911, p = 0.002) compared to the control group.ConclusionPreoperative peer education had a significant effect on improving CABG patients' adherence to lifestyle changes after hospital discharge.Practice implicationPeer education can be used as an effective method to improve the CABG patients ' adherence to lifestyle changes.     

Risk factors for ventilator dependency following coronary artery bypass grafting

Background: Ventilator dependency following coronary artery bypass grafting (CABG) is often associated with significant morbidity and mortality. However, few reports have focused on the independent risk factors for ventilator dependency following CABG. This study aimed to evaluate the independent risk factors for ventilator dependency following coronary artery bypass grafting (CABG). Methods: The relevant pre-, intra- and post-operative data of patients without a history of chronic obstructive pulmonary disease undergoing isolated CABG from January 2003 to December 2008 in our center were retrospectively analyzed. Elapsed time between CABG and extubation of more than 48 hours was defined as postoperative ventilator dependency (PVD). Results: The incidence of PVD was 13.8% (81/588). The in-hospital mortality in the PVD group was significantly higher than that in the non-PVD group (8.6% versus 2.4%, p=0.0092). Besides the length of ICU and hospital stay, PVD correlated with negative respiratory outcomes. The independent risk factors for PVD were preoperative congestive heart failure (OR=2.456, 95%CI 1.426-6.879), preoperative hypoalbuminemia (OR=1.353, 95%CI 1.125-3.232), preoperative arterial oxygen partial pressure (PO₂) (OR=0.462, 95%CI 0.235-0.783) and postoperative anaemia (OR=1.541, 95%CI 1.231-3.783). Conclusions: Preoperative congestive heart failure, preoperative hypoalbuminemia, low preoperative PO₂ and postoperative anaemia were identified as four independent risk factors for ventilator dependency following CABG.     

Metal allergy to stainless steel wire after coronary artery bypass grafting

 To our knowledge, this is the first reported case of a manganese metal allergy to stainless steel wire. A 51-year-old man suffered from a refractory pruritic erythematous wheal after the insertion of a stainless steel wire. The patch test showed strong reactions to manganese, one of the constituents of stainless steel wire. After the removal of all stainless steel wires, the symptoms were much improved, except for mild pruritus on his face. Received: March 28, 2002 / Accepted: October 16, 2002 Correspondence to:K. Takazawa