Vasodilator properties of prostacyclin after coronary artery bypass surgery

The vasodilatory properties of prostacyclin were studied in 12 intubated patients who underwent coronary artery bypass surgery. When infused in doses of 2.5, 5, 10, and 20 ng/kg/min, prostacyclin produced a dose-dependent decrease in systemic vascular resistance from 2,702 +/- 143 to 1,654 +/- 106 dynes/cm5/m2 (p less than 0.05). Heart rate, right atrial pressure, and pulmonary arterial and capillary wedge pressures did not change. Cardiac function was improved, since stroke volume index increased from 29.5 +/- 1.4 to 35.5 +/- 2.0 ml/min/m2 (p less than 0.05) and the rate pressure product decreased from 13.3 +/- 1.3 to 10.9 +/- 0.9 X 10(3) mm Hg/beats/min (p less than 0.05), while stroke work index remained unchanged. These hemodynamic changes were associated with a dose-dependent decrease in arterial oxygen tension which occurred from 278 +/- 25 to 133 +/- 22 mm Hg; however, oxygen transport increased as a result of the prostacyclin-induced increase in cardiac index. This study demonstrates that prostacyclin is a potent arterial vasodilator that may be of interest in the treatment of postoperative vasoconstriction occurring after coronary artery bypass surgery.     

Usefulness of fasudil, a Rho-kinase inhibitor, to treat intractable severe coronary spasm after coronary artery bypass surgery

We have recently demonstrated that fasudil, a Rho-kinase inhibitor, is effective in suppressing coronary artery spasm in patients with vasospastic angina. Thus, blockade of Rho-kinase may provide a novel therapeutic strategy to treat ischemic coronary syndrome caused by the spasm. Severe coronary artery spasm still remains a life-threatening serious complication of coronary artery bypass grafting (CABG). In this study, we examined the inhibitory effect of fasudil in patients with intractable severe coronary spasm after CABG. Three patients who underwent CABG showed severe myocardial ischemia resistant to intensive therapy with intravenous conventional vasodilators, including isosorbide dinitrate (ISDN), diltiazem, and nicorandil. Coronary angiography revealed severe coronary spasm in native coronary arteries and/or bypass arterial grafts in all patients. Since intracoronary and/or intragraft administration of ISDN was ineffective to resolve the spasm, we then administered fasudil (1.5 mg/min for 15 minutes) into the spastic arteries. Fasudil successfully resolved the spasm and improved myocardial ischemia in all patients without any systemic adverse effects. In conclusion, the treatment with fasudil may be useful to treat intractable and otherwise fatal coronary spasm resistant to intensive conventional vasodilator therapy after CABG.     

Smooth muscle and endothelial function of arterial grafts for coronary artery bypass surgery

1. Various small/mid-sized conductance arteries have been used for coronary artery bypass grafting as arterial grafts, but unanimous opinion to the best use of these grafts has not been formed. 2. Arterial grafts are not uniform in their biological characteristics. 3. The differences among the arteries may involve the contractility of the vessel. Based on studies of the contractility of arterial grafts, a clinical classification was formed to describe the tendency of vasospasm in the arterial grafts. 4. The differences among arterial grafts also involve endothelial function. This refers to both nitric oxide release from the endothelium, as well as endothelium-derived hyperpolarizing factor-mediated hyperpolarization and relaxation. 5. The difference in the peri-operative behaviour of the grafts and in their long-term patency may be related to different characteristics. These should be taken into account in the use of arterial grafts, some of which are subject to more active pharmacological intervention during and after operation to obtain satisfactory results. The clinical choice of grafts must be based on the general condition of the patient, the biological characteristics of the graft, the anatomy of the coronary artery, the match between the coronary artery and the graft and the technical considerations, including antispastic management.     

Pericardial constriction following coronary artery bypass surgery: case reports

Two patients with the rare complication of pericardial constriction following coronary artery bypass surgery are presented. Management was with prednisone but one patient needed a pericardectomy.     

血清C反应蛋白对非体外循环下冠状动脉旁路移植术临床疗效的影响

目的探讨术前血清C反应蛋白水平对非体外循环下冠状动脉旁路移植术临床疗效的影响。方法将734例行非体外循环下冠状动脉旁路移植术的冠心病患者根据术前C反应蛋白水平分为CRP≥3．0mg／L组（386例）和CRP〈3．0mg／L组（348例）,记录术后心血管事件发生情况,Logistic回归分析影响预后的相关因素。结果术后30d内CRP≥3．0mg／L组心血管事件发生率[4．9％（19例）]高于CRP〈3．0mg／L组[4．0％（14例）],但差异无统计学意义（P〉0．05）;平均随访（5．2±1．8）年,CRP≥3．0mg／L组心血管事件发生率[22．0％（78例）]明显高于CRP〈3．0mg／L组[12．2％（40例）],差异有统计学意义（P〈0．05）,Logistic回归分析示：CRP≥3．0mg／L不能预测术后30d心血管事件发生情况,但是预测术后远期心血管事件最强因子,COX分析术前CRP≥3．0mg／L是影响患者预后的危险因素,其次左心室射血分数〈45％。CRP≥．0mg／L组5年实际生存率明显低于CRP〈3．0mg／L组[（90．0±1．2）％比（94．0±0．8）％,P〈0．05]。CRP≥3．0mg／L和左心室射血分数〈45％二者合并的患者5年生存率明显降低（88．0±0．4）％。结论血清C反应蛋白水平可以预测非体外循环下冠状动脉旁路移植术的远期临床疗效,提示血管壁的炎症程度与远期疗效相关。     

Beneficial effect of sodium nitroprusside after coronary artery bypass surgery: pump function correlates inversely with cardiac release of proinflammatory cytokines

The authors studied the relationship between cardiac cytokine release and pump function and whether low-dose application of sodium nitroprusside (SNP) improves cardiac performance during coronary artery bypass graft (CABG) creation. Cardiac reperfusion and application of nitric oxide have an influence on cytokine release. However, the functional consequences are unclear. Patients with CABGs (n = 30) with severely compromised left ventricular ejection fraction (<40%) were treated with either SNP (0.5 microg/kg/min) or placebo for the first 60 minutes of reperfusion after cardiac arrest. Interleukin (IL)-6, IL-8, and tumor necrosis factor (TNF)-alpha were determined in blood samples from the radial artery and coronary sinus during reperfusion (5, 35, and 75 minutes). Hemodynamic measurements were performed before and after cardiopulmonary bypass and at the end of surgery. In all patients, the cardiac index at the end of surgery correlated negatively with levels of TNF-alpha at 5 minutes (r = 0.398; P < 0.05), IL-8 at 35 minutes (r = 0.394; P < 0.05), and IL-6 at 75 minutes of reperfusion (r = 0.421; P < 0.025). Sodium nitroprusside improved the cardiac index immediately after reperfusion (4.4 L/min/m2 +/- 0.3 vs. 3.7 L/min/m2 +/- 0.1; P = 0.014) and at the end of surgery (3.8 L/min/m2 +/- 0.3 vs. 3.0 L/min/m2 +/- 0.2; P = 0.023). The negative correlation between cardiac index and transcardiac cytokines suggests that reducing cardiac inflammatory reaction improves postischemic cardiac function. This was achieved by treating CABG patients with the nitric oxide donor SNP at a dosage without vasodilatory action.     

Rationale for administering beta-blocker therapy to patients undergoing coronary artery bypass surgery: a systematic review

Introduction: Secondary preventative therapies are essential for patients undergoing coronary artery bypass graft (CABG) surgery to optimize perioperative and long-term outcomes. Beta-blockers are commonly used to treat patients with coronary artery disease and congestive heart failure (CHF), but their role for CABG patients remains unclear. The goal of this systematic review was to evaluate the rationale for administering beta-blockers to the CABG population and to assess their efficacy before and after coronary surgical revascularization.

Areas covered: A systematic literature review was performed to retrieve relevant articles from the PubMed database published between 1985 and 2017.

Expert opinion: Outside of the surgical field, strong evidence supports the use of beta-blockers for patients with a history of previous myocardial infarction (MI) or CHF. For the CABG population, studies have suggested that perioperative beta-blocker therapy is beneficial, with an associated reduction in mortality, particularly among those with a history of previous MI or CHF. Beta-blocker administration has also clearly been shown to lower the rate of new-onset postoperative atrial fibrillation after CABG. Among the different types of beta-blockers, perioperative carvedilol appears to be the most beneficial. In the absence of contraindications, nearly all CABG patients are candidates for perioperative beta-blocker therapy.     

微创左胸小切口冠脉搭桥术的临床研究

目的 总结微创左胸小切口冠脉搭桥术(MIDCAB)的临床经验,并与常规非体外循环心脏不停跳冠脉搭桥术(OPCAB)进行比较.方法 选取合适病例共施行MIDCAB 21例,随机抽取同期OPCAB 30例进行对比研究,比较术前基本情况,观察术后引流量、呼吸机辅助时间、ICU时间、术后住院天数、二次开胸止血、围术期心梗、死亡率等,并随访3~24个月,观察有无心肌梗死或心绞痛发作.结果 MIDCAB组无1例死亡,术后呼吸机辅助时间、ICU时间、术后引流量、输红细胞量、胸腔积液例数、穿刺或引流处理例数、低心排例数、主动脉内球囊反搏(IABP)例数、肾功能不全例数、二次开胸止血例数、感染等发生率低于OPCAB组;随访3~24个月,乳内动脉(LIMA)桥均通畅,无1例发生心绞痛或心肌梗死.结论 MIDCAB创伤小,安全,效果可靠,适用于单纯前降支开口病变,或合并回旋支、右冠轻度狭窄(TIMI分级Ⅲ级),或回旋支、右冠病变可以支架处理的病例,值得推广.     

Levosimendan in off-pump coronary artery bypass: a four-times masked controlled study

We tested the hypothesis that levosimendan produced beneficial hemodynamic effects during and after off-pump coronary artery bypass grafting in patients with good preoperative left ventricular function. Levosimendan at low dose (12 microg/kg), high dose (24 microg/kg), or placebo were administered in thirty-one patients in a randomized and four-times masked controlled study. Heart rate was not significantly different between experimental groups. Significant increases in cardiac output and left ventricular ejection fraction occurred after high-dose (P < 0.001; P = 0.006) and low-dose levosimendan (P = 0.001; P = 0.002). Both doses of levosimendan produced significant increased stroke volume and decreased systemic vascular resistance. Mean arterial pressure, pulmonary capillary wedge pressure, and left ventricular end-systolic volume were not significantly different between groups.The low-dose levosimendan produced better hemodynamic response than high-dose and may be preferable in patients undergoing off-pump coronary artery bypass grafting.     

Massage therapy to improve sleep quality post coronary artery bypass graft surgery

Nerbass FB, Feltrim MIZ, de Souza SA, Ykeda DS, Lorenzi‐Filho G. Effects of massage therapy on sleep quality after coronary artery bypass graft surgery. Clinics 2010; 65: 1105–10.     

Study of levosimendan during off-pump coronary artery bypass grafting in patients with LV dysfunction: A double-blind randomized study

Objectives:

Levosimendan is a calcium sensitizer drug which has been used in cardiac surgery for the prevention of postoperative low cardiac output syndrome (LCOS) and in difficult weaning from cardiopulmonary bypass (CPB). This study aims to evaluate perioperative hemodynamic effects of levosimendan pretreatment in patients for off-pump coronary artery bypass graft (OPCABG) surgery with low left ventricular ejection fractions (LVEF < 30%).

Materials and Methods:

Fifty patients undergoing OPCABG surgery with low LVEF (<30%) were enrolled in the study. Patients were randomly divided in two groups: Levosimendan pretreatment (Group L) and placebo pretreatment (Group C) of 25 each. Group L, patients received levosimendan infusion 200 μg/kg over 24 h and in Group C Patients received placebo. The clinical parameters measured before and after the drug administration up to 48 h were heart rate (HR; for the hour after drug infusion), cardiac index (CI), and pulmonary capillary wedge pressure (PCWP). The requirement of inotropes, intraaortic balloon pump (IABP), CPB, intensive care unit (ICU) stay, and hospital stay were also measured.

Results:

The patients in group L exhibited higher CI and PCWP during operative in early postoperative period as compared to control group C. Group L also had a less requirement for inotropes, CPB support and IABP with shorter ICU stay as well as hospital stay.

Conclusion:

Levosimendan pretreatment (24 h infusion) in patient for OPCABG with poor LVEF shows better outcomes and hemodynamics in terms of inotropes, CPB and IABP requirements. It also reduces ICU stay.KEY WORDS: Cardiac index, CPB, hemodynamic optimization, inotropic agents, LCOS, levosimendan, off-pump coronary artery bypass graft, OPCABG surgery, pulmonary capillary wedge pressure     

非体外循环冠状动脉旁路移植术后急性肾损伤的危险因素分析

目的:探讨非体外循环冠状动脉旁路移植术(OPCABG)后急性肾功能损伤(AKI)的发生情况及危险因素.方法:回顾性分析我院2009年6月-2009年12月完成的537例OPCABG手术患者的临床资料.将患者是否发生AKI分为AKI组79例(14.7％)和对照组458例,比较2组相关因素的差异,统计术后AKI的发生率,应用Logistic回归分析AKI危险因素.结果:2组间年龄≥70岁、高血压、术前肌酐水平、移植血管桥数量、机械通气时间、监护室停留时间及术后低心排比较差异有统计学意义(P＜0.01).Logistic多因素回归分析提示,年龄≥70岁、高血压、术前肌酐水平、移植血管桥数量、机械通气时间及术后低心排是OPCABG后AKI发生的危险因素.结论:年龄≥70岁、高血压、术前肌酐水平、移植血管桥数、机械通气时间及术后低心排是OPCABG术后AKI的危险因素.     

吸烟对冠状动脉旁路移植术后生存质量的影响

目的研究吸烟对冠状动脉旁路移植术（CABG）后早期生存质量的影响。方法随机入选2011年1月-2013年1月接受冠状动脉旁路移植术,并符合纳入标准的连续患者共120例。根据术前是否有吸烟史,分为吸烟组（60例）和未吸烟组（60例）,分别在术后3、6、12个月向患者发放SF-36（shortform-36）生存质量调查量表,对患者生存质量予以评定,分析吸烟对患者术后生存质量的影响。结果与未吸烟组比较,吸烟组患者冠状动脉旁路移植术后3、6、12个月躯体健康评分（PCS）和精神健康评分（MCS）以及生存质量总评分QOL均降低,差异有统计学意义（P〈0．01）。结论与未吸烟组比较,吸烟组患者冠状动脉旁路移植术后早期生存质量降低,吸烟是影响冠状动脉旁路移植术后早期生存质量恢复不佳的危险因素。     

乌司他丁在非体外循环冠脉搭桥术中的作用

目的:观察非体外循环冠脉搭桥术(OPCAB)中应用不同剂量乌司他丁对炎性反应和器官功能的影响.方法:30例进行OPCAB的患者随机单盲分为三组,每组10例.对照组(C组)未用药,乌司他丁10万U组(U组)和乌司他丁20万U组(T组)分别于麻醉诱导前缓慢静推.麻醉诱导用依托咪酯0.3mg·kg -1 、咪达唑仑0.05～0.1mg·kg -1 、派库溴铵0.1mg·kg -1 和芬太尼15～20μg·kg -1 静注,维持采用吸入0.2%～1%异氟醚,间断静注芬太尼、咪唑安定和派库溴铵.于诱导前、术毕和术后24h抽血测定谷丙转氨酶(ALT)、谷草转氨酶(AST)、血尿素氮(BUN)、肌酐(Cr)、心肌型肌酸激酶同工酶(CK-MB),并用放免法测定肿瘤坏死因子-α(TNF-α)和白介素-2(IL-2).结果:三组患者术前术后血流动力学无显著差异(P>0.05).AST术后T组24h比C组明显降低(P<0.05).BUN和Cr三组术后均有升高趋势,但无显著性差异.TNF-α在术后24hU组和T组与C组比较有显著下降(P<0.05).IL-2在术后24hU组和T组较C组明显下降(P<0.05),而且T组比U组更低(P<0.01).结论:OPCAB对机体的侵袭作用较弱,诱导前应用乌司他丁可以促进术后器官功能的恢复,并有一定的抗炎作用.     

不同旁路材料在冠状动脉旁路移植术中的应用

目的总结冠状动脉旁路移植术中目前几种常用旁路材料的临床应用。方法2001-10～2006-10连续106例行冠状动脉旁路移植术,旁路材料包括左乳内动脉(106根)、游离右乳内动脉(42根)、桡动脉(46根)和大隐静脉(86根),回顾分析不同旁路材料的手术结果。结果全组无手术死亡,桡动脉移植后旁路血管“线样征”1例;无胸骨、前臂并发症;下肢切口感染2例,均为糖尿病、大体重患者,治疗后痊愈。结论注意旁路材料的取制技巧,针对不同病变冠脉血管选取应用不同旁路血管,以及术后及时监护处理是保证良好手术结果的关键。