冠脉搭桥手术后患者不适症状与焦虑抑郁关系的研究

目的：研究冠状动脉旁路移植手术后患者不适症状与心理状态的关系。方法：采用问卷调查的方法（症状调查表，焦虑自评量表及抑郁自评量表对65例接受了冠状动脉旁路移植手术的患者进行调查。结果：不适症状量表总得分与心理状态SAS及SDS量表总标准分呈正相关。症状调查表分数越高，则心理问题越严重。结论：对CABG术后患者采取健康宣教、心理辅导甚至适当的使用药物能减轻患者的不适症状。     

Native Coronary Artery and Grafted Artery Spasm Just after Coronary Artery Bypass Grafting: A Case Report

Native coronary artery spasm after coronary artery bypass grafting (CABG) is scarce. It frequently causes disastrous circulatory collapse. We report a 72-yr-old male, who experienced native coronary artery spasm and grafted artery spasm following CABG, which was successfully treated with coronary angiography and intracoronary injection of nitroglycerine.     

冠状动脉旁路移植围手术期抑郁、焦虑状况调查

目的调查行冠状动脉旁路移植术(CABG)的患者围术期抑郁、焦虑的发生率及相关因素.方法2005年7月至2006年5月,以连续行择期CABG术的73例患者为研究对象,分别在术前1周内和术后出院前1天使用ZUNG氏抑郁自评量表和焦虑自评量表进行评分.结果手术前共有21例(28.8%)阳性患者,其中11例患者存在抑郁状态,7例患者同时存在抑郁和焦虑状态,3例存在焦虑状态.手术后共有34例(46.6%)阳性患者,其中18例患者存在抑郁状态,13例患者同时存在抑郁和焦虑状态,3例存在焦虑状态.SDS标准分术后(47.9±10.0)高于术前(43.7±10.0, t=3.55,P=0.001), 焦虑评分术后(41.6±8.5)高于术前(39.3±7.4, t=2.20,P=0.031).术前发生抑郁焦虑的患者受教育少(8±3/10±3年, t=2.18,P=0.032),术后焦虑抑郁组中术前就存在抑郁焦虑的比例高(16/34对5/39,χ2＝10.391, P=0.001),术前多次心肌梗死的4例都在术后抑郁焦虑组(4/34比0/39,P=0.043);术前抑郁焦虑情绪对术后围手术期恢复没有影响.术后是否发生抑郁焦虑者住院时间没有显著差别.结论CABG患者围术期抑郁焦虑状态有较高的发生率,术后情绪更差.受教育程度低是术前情绪不良的危险因素,病情重是术后情绪不良的危险因素.     

术前抑郁、焦虑状况与冠状动脉旁路移植术后心血管事件发生的关系

目的:前瞻、序列、对比研究我科行冠状动脉旁路移植术(coronary artery bypass grafting,CABG)的患者术后1年抑郁、焦虑的状况以及心血管事件的发生率.方法:2005年10月至2006年8月,以我科连续行择期CABG术的69例患者为对象,分别在术前1周内、术后出院前1天、术后1年使用ZUNG氏抑郁自评量表和焦虑自评量表进行抑郁、焦虑状态评分,同时随访术后1年的心血管事件的发生率.结果:术前24例(34.8%)存在抑郁焦虑状态,出院前33例(47.8%)存在抑郁焦虑状态,术后1年随访时10例(14.5%)存在抑郁焦虑状态.术后1年随访时共有6例(8.7%)患者发生心血管病事件,其中5例再次入院.术前存在抑郁焦虑的患者与不存在抑郁焦虑的患者相比:术后住院时间延长[(19±8)d vs.(16±6)d, P=0.003],容易出现伤口并发症(3/24 vs. 0/45, P=0.039),出院前和术后12月随访时不良情绪的发生率较高(分别为75% vs. 33%, P=0.001; 29% vs. 7%, P=0.017);随访时存在抑郁焦虑的患者与不存在抑郁焦虑的患者相比:术前和术后发生心律失常更多见 (3/10 vs. 2/59, P=0.019;6/10 vs. 2/59,P=0.000),术中移植血管桥数量较多[(3.5±0.5) vs.(3.0±0.9),P=0.049],术后住院时间较长[(24±11)天 vs. (16±6)天,P=0.001],术前存在抑郁焦虑状态比例较高(7/10 vs.3/59,P=0.026),发生心血管事件较多 (3/10 vs. 3/59,P=0.036).结论:行冠状动脉旁路移植术术前不良情绪会导致术后恢复减慢,而术前不良情绪、病情重、术后随访发生心血管事件可能与术后1年的抑郁焦虑状态有关系,需要引起重视.     

高压氧预处理对冠状动脉搭桥手术后早期认知功能的影响

目的分析高压氧(HBO)预处理对冠状动脉搭桥(CABG)手术后早期认知功能的影响。方法选取82例行CABG患者临床资料,将其分为对照组(41例)、观察组(41例)。对照组术前不给予HBO治疗,观察组术前行HBO治疗,观察比较两组术后认知功能及生活质量情况。结果对照组术后Newman各指标均较术前下降(P0.05),评分较观察组低(P0.05),生理机能、精神状态、社会功能评分较观察组低(P0.05)。结论对CABG手术患者术前给予HBO治疗能有效保护患者神经系统,减少术后认知功能障碍情况发生,提高生活质量。     

冠状动脉旁路移植术临床应用45例

目的:探讨冠状动脉旁路移植术(CABG)治疗冠心病的临床疗效.方法:采用CABG手术治疗冠心病患者45例,其中冠脉3支及以上病变35例,2支病变6例,1支病变4例.常规体外循环下手术(cCABG)30例,非体外循环下手术(OPCAB)15例.共行远端吻合口139个,其中动脉旁路远端吻合口36个,静脉旁路远端吻合口103个,包括心中静脉原位动脉化吻合口1个.结果:完成手术44例(97.78%),术中死亡1例(2.22%).术后并发低心排血综合征、严重心律失常各1例,肺部及胸骨感染各2例,均治愈出院.随访2～84个月,平均(32±7.6)月.1例术后高血糖酸中毒6h突发室颤,植物生存6个月后死亡,另1例术后6年脑血管意外死亡.术后1年心绞痛复发2例,服药控制;其余40例心绞痛消失.结论:应用cCABG和OPCAB手术方法治疗冠心病患者是安全、可靠的技术,效果良好.OPCAB手术虽具有一定的优势,但仍不能完全替代cCABG手术.     

冠状动脉搭桥术后谵妄的研究现状

冠状动脉搭桥手术越来越普遍,术后谵妄成为影响冠状动脉搭桥手术预后的一大难题。术后谵妄不仅影响患者心肺功能恢复,延长术后ICU滞留时间及住院时间,增加医疗负担,并且与术后并发症发生率及死亡率的增加密切相关。本文从谵妄的定义、易感因素、发病机制、术后评估、治疗几个方面做一综述,旨在总结以往研究经验,发掘围手术期实际有效的干预措施,提高临床医生对冠状动脉搭桥术后谵妄的认识和管理水平。     

体外循环不停跳冠脉搭桥术治疗重症冠心病的应用

目的 观察体外循环辅助心脏不停跳冠脉搭桥术(OPCABG)治疗重症冠心痛的效果.方法 选择42例左室射血分数(LVEF)<0.30的重症冠心病患者,采用体外循环辅助心脏不停跳冠脉搭桥术.其中男性36例,女性6例;术前超声心动图检查提示:LVRF在0.18～0.30,平均(0.26±0.03)之间.左心室舒张末期内径(LVDD)52～76(61.3±4.2)mm.观察手术情况、比较术前与术后早期的心功能情况.结果 42例患者平均远端吻合口数目为(3.5±1.3)个,使用主动脉内球囊反搏泵(IABP)6例;住院死亡2例;术后2周、3个月的LVEF、LVDD较术前显著改善.结论 重症冠心病患者(EF<0.30)实施体外循环辅助心脏不停跳冠脉搭桥术能避免缺血损害,能完全再血管化,降低手术风险,有良好的近期效果.     

他汀类药物联合抗血小板药物降低冠状动脉搭桥术后血管再狭窄的研究

冠状动脉旁路移植术（CABG）是治疗冠心病有效手段之一,但是其术后易发生桥静脉再狭窄甚至闭塞,发生复发性心绞痛、心肌梗死以及再次血运重建的风险增加。抗血小板药物和他汀类药物是临床提高桥血管通畅率的常用药物,抗血小板药物能减少早期的血栓形成,他汀类药物能够延缓中期的内膜增厚和晚期的粥样斑块的形成。本文就联合使用抗血小板药物和他汀类药物降低CABG术后血管再狭窄的研究作一综述,并对综合治疗CABG术后血管再狭窄的方法进行展望。     

Retraumatization Mediates the Effect of Adverse Childhood Experiences on Clinical Training-Related Secondary Traumatic Stress Symptoms

Previous research (Butler, Carello, & Maguin, 2016) has found that exposure to trauma-related material in graduate clinical coursework and field training can put students at risk for reactivations of feelings/memories from negative past experiences (retraumatization) and for secondary traumatic stress (STS) symptoms. The present report sought to examine the role, if any, of adverse childhood experiences (ACEs) in these outcomes. Using the Butler et al. (2016) sample, we examined: (1) rates of ACEs in 195 graduate social work students, (2) whether the total number of ACEs was associated with training-related retraumatization (TRT) and/or STS symptoms, and (3) if TRT mediated the relationship between ACEs and STS symptoms. The results indicate that more than three quarters of the sample had experienced one or more ACEs before age 18 and almost one third endorsed 4 or more. The most commonly reported ACEs were household mental illness, parental separation/divorce, household alcohol/substance abuse, and emotional abuse or neglect by a parent or household member. Higher ACE scores were associated with increased likelihood of TRT experiences and STS symptoms during training. A mediation analysis confirmed that TRT mediated the effect of ACE scores on STS symptoms; this finding also provides support for the role of proximal emotional reactions in mediating the effects of distal adverse experiences on the development of trauma symptoms. In summary, despite the evident resilience of this graduate student sample, those with ACE histories were at heightened risk for training-related distress. These results underscore the need for a trauma-informed approach to clinical training.     

主动脉球囊反搏术在再次冠状动脉旁路移植术中的应用

观察主动脉球囊反搏术(IABP)在再次冠状动脉旁路移植术中的应用价值.收集再次冠状动脉旁路移植术应用IABP的患者21例,观察其IABP前后的连续心输出量(CCO)、混合静脉血氧饱和度(SVO2)、有创动脉收缩压(SABP)、有创平均动脉压(MABP)、心指数(CI)、肺毛细血管楔压(PCWP)等血流动力学指标和临床恢复情况.并行统计学分析.在21例IABP中.术前使用3例,术中使用6例,术后使用12例;15例患者恢复良好,死亡6例.死者中有3例因经济原因放弃治疗,2例死于围术期心肌梗死.1例是死于肺功能衰竭.3例出现球囊破裂,1例出现感染.平均IABP时间(98.4±43.7)h,在使用IABP期间,升压药单纯用多巴胺即可,剂量平均(5.2±3.6)μg/kg·min-1,在6例症状改善不明显的患者中,合用了肾上腺素或者间羟胺.平均呼吸机辅助时间(33.6±12.9)h,ICU监护时间(5.7±1.6)d,辅助用药时间(48.7±23.8)h.血流动力学指标:术后CCO、CI、SABP、MABP、SVO2较术前明显升高(P<0.05),而PCWP较术前明显降低(P<0.05).在再次冠状动脉旁路移植术中应用主动脉球囊反搏能明显改善患者心功能,降低死亡率.     

坠楼自杀事件目击者创伤性应激障碍

目的:调查某高校自杀坠楼事件目击者急性应激障碍(ASD)和创伤后应激障碍(PTSD)状况。方法:使用一般情况及事件主观体验问卷和创伤性应激障碍临床访谈问卷,对58名事件现场目击者,分别在事件发生后第三周和第五周进行调查。结果:在事件发生后第三周,符合DSM-Ⅳ诊断标准的ASD检出率为6.9%,符合PTSD症状标准和社会功能损害标准的目击受害者共6人,检出率为10.3%。事件后三周受害人出现创伤性应激症状和功能损害的比例较高,分别为强烈恐惧害怕65.5%、创伤性分离51.0%、警觉性增高53.4%、再体验84.5%、回避70.7%、和社会功能障碍25.9%。创伤性事件发生后第三周出现分离症状的目击者比没有出现分离症状的目击者在事件后第五周时表现出了更加严重的ASD和PTSD的各组症状(如分离症状严重程度17.9vs29.7,U=128.5,P=0.001)。结论:1、创伤性事件发生后早期,受害人心理应激反应具有一定的普遍性,其中一部分受害人出现社会功能变化。2、提示对事件后早期那些不符合ASD诊断标准,但符合PTSD症状标准和社会功能变化标准的受害者应该给与心理干预。3、创伤时分离症状可能是预测受害人出现远期严重应激障碍的一个因素。     

远端侧-侧吻合冠脉搭桥术后血栓形成的数值模拟

目的 研究桥血管远端不同处理方式对其血栓生成的不同影响。方法 针对远端侧-侧吻合(distal-end side-side anastomosis, DESSA)冠脉搭桥术,构建桥血管远端裁剪和不裁剪两种模型。使用生化反应的血液物质传输扩散模型,同时考虑血流动力学的切变率、流体滞留时间和血小板分布参数,评估血栓形成的可能性,使用数值模拟方法探讨DESSA冠脉搭桥中血栓生长。结果 对于桥血管远端无裁剪处理的模型,血栓首先在桥血管远端内壁面上形成,随后向其内部生长,直至血栓占满大部分桥血管远端区域,血栓进入稳定状态,体积不再变化,生成血栓体积为15.051 mm³。对于桥血管远端裁剪处理模型,生成血栓体积为7.352 mm³,同远端无裁剪模型相比,生成血栓体积减小51.2%。桥血管远端裁剪处理后,吻合口上方桥血管内壁上有血栓生成,壁厚约为0.16 mm,为桥血管半径的10.65%。上述两种术式中,桥血管远端区域形成多个漩涡流(流速小于10 mm/s),促进桥血管远端血栓形成;计算结果和临床报道的血栓形成区域相一致。结论 临床DESSA冠脉搭桥术时...     

Outcomes of Off-Pump Coronary Bypass Grafting with the Bilateral Internal Thoracic Artery for Left Ventricular Dysfunction

This study evaluated the outcomes of off-pump coronary artery bypass surgery (OPCAB) with severe left ventricular dysfunction using composite bilateral internal thoracic artery grafting. From January 2001 to December 2008, 1,842 patients underwent primary isolated OPCAB with composite bilateral internal thoracic artery grafting. A total of 131 of these patients were diagnosed with a severely depressed preoperative left ventricle ejection fraction (LVEF) (≤0.35). These patient outcomes were compared with the outcomes of 830 patients that had mildly or moderately depressed LVEF (0.36 to 0.59) and 881 patients with normal LVEF (>0.6). The early mortality for patients with severe LVEF was 2.3%. The 3-yr and 7-yr survival rate for patients with severe LV dysfunction was 86.0% and 82.8%, respectively. Multivariate analysis showed that severe LV dysfunction EF increased the risk of all-cause death (P=0.012; hazard ratio [HR],2.14; 95% confidence interval [CI],1.19-3.88) and the risk of cardiac-related death (P=0.008; HR,3.38; 95% CI, 1.37-8.341). The study identified positive surgical outcomes of OPCAB, although severe LVEF was associated with two-fold increase in mortality risk compared with patients who had normal LVEF.     

Therapeutic Hypothermia Following Emergent Coronary Artery Bypass Grafting After Failed Percutaneous Coronary Intervention in a Comatose Post-Cardiac Arrest Patient

We report the case of 60-yr-old female in which therapeutic hypothermia (TH) was successfully induced maintaining the target temperature of 34℃ for 12 hr despite a risk of hypothermia-induced coagulation abnormalities following an emergent coronary artery bypass grafting (CABG) due to failed percutaneous coronary intervention, who suffered a cardiac arrest. Emergent CABG may be a relative contraindication for TH in post-cardiac arrest patients because hypothermia may increase the risk of infection and bleeding. However, the possibility of an improved neurologic outcome outweighs the risk of bleeding, although major surgery may be a relative contraindication for TH.     

Myocardial Function Prediction After Coronary Artery Bypass Grafting Using MRI Radiomic Features and Machine Learning Algorithms

The main aim of the present study was to predict myocardial function improvement in cardiac MR (LGE-CMR) images in patients after coronary artery bypass grafting (CABG) using radiomics and machine learning algorithms. Altogether, 43 patients who had visible scars on short-axis LGE-CMR images and were candidates for CABG surgery were selected and enrolled in this study. MR imaging was performed preoperatively using a 1.5-T MRI scanner. All images were segmented by two expert radiologists (in consensus). Prior to extraction of radiomics features, all MR images were resampled to an isotropic voxel size of 1.8 × 1.8 × 1.8 mm³. Subsequently, intensities were quantized to 64 discretized gray levels and a total of 93 features were extracted. The applied algorithms included a smoothly clipped absolute deviation (SCAD)–penalized support vector machine (SVM) and the recursive partitioning (RP) algorithm as a robust classifier for binary classification in this high-dimensional and non-sparse data. All models were validated with repeated fivefold cross-validation and 10,000 bootstrapping resamples. Ten and seven features were selected with SCAD-penalized SVM and RP algorithm, respectively, for CABG responder/non-responder classification. Considering univariate analysis, the GLSZM gray-level non-uniformity-normalized feature achieved the best performance (AUC: 0.62, 95% CI: 0.53–0.76) with SCAD-penalized SVM. Regarding multivariable modeling, SCAD-penalized SVM obtained an AUC of 0.784 (95% CI: 0.64–0.92), whereas the RP algorithm achieved an AUC of 0.654 (95% CI: 0.50–0.82). In conclusion, different radiomics texture features alone or combined in multivariate analysis using machine learning algorithms provide prognostic information regarding myocardial function in patients after CABG.     

非吻合口狭窄致冠状动脉旁路移植物慢血流危险因素分析

目的:探讨非吻合口狭窄致冠状动脉旁路移植物血流减慢的危险因素。方法:选取2008-06—2018-06本院心血管外科行冠状动脉旁路移植手术(CABG)患者病历资料,90例CABG术后经瞬时血流仪测定移植物血流减慢(移植物静脉桥15ml/min或动脉桥10ml/min)患者为慢血流组,130例移植物血流量正常患者为对照组,对比分析两组患者围手术期资料各变量差异。结果:单因素方差分析显示两组患者年龄、使用乳内动脉材料、复合手术、心功能Ⅲ-Ⅳ级、测流量时平均动脉压、术前等待时间、不稳定性心绞痛、术前心包积液及低氧血症等因素差异无统计学意义(P0.05);两组男性、饮酒、心肌梗死时间(AMI)7天、高血压、糖尿病、高尿酸血症(HUA)、高脂血症、C反应蛋白(CRP)、体重指数(BMI)28kg/m~2、肾功能不全、红细胞分布宽度(RDW)、血小板计数(PLT)200×109/L、血红蛋白(HGB)120g/L、脑血管病史、移植物内径等指标差异有统计学意义(P0.05);Logistic回归分析结果显示吸烟史、AMI7天、HUA、高脂血症、糖尿病、CRP、RDW、PLT200×109/L、HGB120g/L、肾功能不全、BMI28kg/m~2、脑血管病史为冠状动脉移植物慢血流高危因素(P0.05)。结论:吸烟史、CRP、BMI28kg/m~2及肾脏损伤等因素是冠状动脉移植物慢血流的危险因素。     

非体外循环冠状动脉搭桥术临床分析——附21例报告

目的评价非体外循环心脏不停跳冠状动脉搭桥术的临床价值及意义。方法回顾分析21例非体外循环冠状动脉搭桥术的临床资料,对手术方法及围手术期治疗进行分析总结。结果全组无术中需转体外循环,无围手术期急性心肌梗死,无死亡病例。术后心绞痛全部缓解,住院天数12~21d,平均14.53d。结论非体外循环冠状动脉搭桥术安全可行,且可减少输血,减轻手术创伤与并发症。远期效果有待观察。     

The Performance of the Current Risk Prediction Scoring Systems in Patients Undergoing Anaortic Off-pump Coronary Artery Bypass Grafting

BackgroundThis study aimed to evaluate the performance of the Society of Thoracic Surgeons (STS) risk model and European System for Cardiac Operative Risk Evaluation (EuroSCORE) II for patients undergoing anaortic off-pump coronary artery bypass grafting (OPCAB).MethodsFrom January 2010 to June 2017, 1,048 patients (isolated anaortic OPCAB: 1,043, on-pump conversion:5) undergoing isolated anaortic OPCAB were enrolled. The STS risk score and EuroSCORE II were calculated with dedicated online software. Calibration of the models were performed by the risk-adjusted event ratio that was defined as observed events divided by expected events (O/E ratio) and Hosmer-Lemeshow test. The discrimination powers were evaluated by the area under the receiver operating characteristic curve (AUC).ResultsOperative mortality occurred in 10 patients (0.95%). The predicted mortality rates by the EuroSCORE II and STS risk model were 2.58 ± 4.15% and 1.72 ± 2.92%, respectively. The O/E ratio of the EuroSCORE II was 0.370 with significant overprediction of operative mortality (confidence interval [CI], 0.157–0.652; P = 0.003). The STS score also overpredicted the operative mortality (O/E ratio, 0.556) with marginal significance (CI, 0.266–1.023; P = 0.052). Permanent stroke occurred in 6 patients (0.53%). The predicted permanent stroke occurrence rate was 1.73 ± 1.48%. The O/E ratio was 0.332 with significant overprediction of permanent stroke (CI, 0.121–0.722; P = 0.011). Regarding discrimination power for the STS risk model, the operative mortality was excellent (AUC, 0.876) and permanent stroke was acceptable (AUC, 0.740). The EuroSCORE II showed good discrimination power (AUC, 0.784). There was a significant difference in discrimination power for mortality between STS and EuroSCORE II risk models (P = 0.007).ConclusionPreexisting risk predicting scoring systems, STS risk model and EuroSCORE II, overpredict the risk of mortality and stroke rate for anaortic OPCAB. These findings suggest the possibility that anaortic OPCAB can lower the operative mortality and occurrence of postoperative stroke than conventional coronary artery bypass grafting.