OPCAB与CABG术后患者ICU监护的对比观察

目的探讨非体外循环心脏跳动下冠状动脉搭桥术（OPCAB）与体外循环下冠状动脉搭桥术（CCABG）术后ICU监护工作特点及临床意义。方法随机抽取甲组（n=32）OPCAB组；乙组（n=48）CABG组。通过对两组病人术后ICU内监护时间、辅助呼吸时间、住院总天数、术后引流量及术后并发症等方面作统计学处理和对比分析。结果两组患者术后ICU内监护时间、辅助呼吸时间、住院总天数、术后引流量均有显著性差异（P〈0．05）。结论非体外循环心脏跳动下冠状动脉搭桥术心功能稳定，并发症少，明显减少了药品使用和护理工作量，能为监护室的排班提供合理依据。     

左房-主动脉转流辅助循环在心脏手术中的应用

为评估左房主动脉转流作为左心辅助循环在心内直视术后顽固性左心衰竭的应用效果，为２７例术后出现顽固性左心衰竭的病人，经左心房辅助泵主动脉建立左心辅助循环，结果２３例脱离人工心肺机，２０例痊愈出院。死亡原因主要为顽固性心衰、心律失常、出血、多器官功能衰竭等。结果：左心辅助疗效肯定，具有良好的临床使用价值     

自制左心辅助引流管道行左心辅助2例

左心辅助循环是治疗术后严重低心排的最有力措施之一。１９９５年９月至１９９６年９月我们使用自制左心辅助引流管道进行床旁左心辅助循环，对２例冠状动脉搭桥术后低心排病人进行左心辅助，现报道如下。临床资料２例重症冠心病病人均为男性，年龄分别为５８、５５岁。均...     

微创伤切取大隐静脉方法在冠状动脉搭桥术中的应用

目的：探讨腔镜辅助的微创伤方法切取大隐静脉在冠状动脉搭桥术（CABG）病人应用的可行性，安全性及能否减少腿部的并发症。方法：29例应用大隐静脉CABG的病人中，采用传统方法切取大隐静脉16例，腔镜辅助的微创伤方法取材大隐静脉13例，比较两种方法在手术时间，所取大隐静脉的长度，有无损伤及术后腿部并发症等方面的差异。结果：两种方法对大隐静脉均无损伤，在单位时间取材大隐静脉长度无明显区别，但微创伤方法术后腿部并发症明显减少（P＜0．05），从25％降至7．6％，结论：采用腔镜辅助的微创伤方法切取大隐静脉是安全可行的，并能明显减少传统方法的腿部并发症。     

左心辅助循环应用初探

探讨左心辅助循环于心脏术后顽固性左心衰竭的应用效果。５例术后顽固性左心衰竭病人，经左心房－辅助泵－右髂外动脉，建立左心辅肋循环。结果见５例病人均脱离人工心肺机，２例存活出院。并发症有出血、感染及多器官功能衰竭。作者认为，左心辅助循环疗效肯定，关键在于及时果断应用。     

机械辅助循环（二）

4临床应用 临床上除了有一部分血泵用于人工心肺机之外，主要应用于心衰患者。需要机械辅助循环的心衰患者大约有90％是左心衰患者，只用左心辅助；只有20％-30％的患者由于应用左心辅助后，导致右室的收缩力降低，而且对药物的反应不良，导致右室失功，需要双心室辅助。对于一开始就为全心衰竭的患者，应采取全人工心脏支持较好。根据辅助时间长短，可应用于：     

护理本科生实习期间惧怕否定心理及相关因素调查

目的 降低老年心脏病患者体外循环术后机械辅助通气并发症发生率和使患者顺利脱机。方法 将42例老年心脏病体外循环术后患者随机分为两组各21例，对照组采用单纯有创机械通气，观察组采用有创一无创序贯机械通气。结果 观察组拔管后呼吸频率及收缩压波动显著低于对照组（均P〈0．01），机械辅助通气时间相对短于对照组，而术后肺部感染率低于对照组，但差异无显著性意义（均P〉0．05）。结论 老年心脏病患者体外循环术后行序贯机械通气可减少机械通气并发症，有助于患者顺利脱机。     

心脏机械瓣替换术后126例抗凝治疗随访

对１２６例心脏机械瓣膜替换术后病人抗凝治疗进行了随访，旨在了解病人术后服用抗凝剂种类、剂量，抗凝监测及并发症情况。随访时间４１０．３７病人－年（９～７６个月）。结果表明：总的抗凝治疗出血率７．６％病人－年，栓塞率０．４９％病人－年，出血病人平均凝血酶原时间比值（ＰＴＲ）ｌ．８０±０．５８，非出血病人为１．４３±０．１７（Ｐ＜０．０５）。抗凝监测７５６份血标本平均ＰＴＲ值为１．４９±０．１８。作者认为：（ｌ）长期抗凝以单用香豆素类药较好；（２）国人ＰＴＲ值１．５左右较理想。并推荐使用标准化的凝血激酶试剂。     

成人体外膜肺氧合循环支持19例

目的总结成人临床应用体外膜肺氧合（ECMO）的经验、教训。方法2004年12月至2006年4月对19例成人实施ECMO，男14例，女5例；年龄19～72岁，平均48．8岁；体重37～100kg，平均69．2kg。内科急性心肺衰竭4例，术后心肺衰竭15例。使用Medtmnic成人ECMO配套系统，经股动、静脉插管行心肺辅助。结果10例（52．6％）顺利出院，9例（47．4％）死亡，其中6例未能脱机，EC2V10成功脱机13例（68．4％），其中3例脱机后未能得到进一步有效治疗而死亡。EC2V10支持11～196h，平均83．3h。单一膜肺使用寿命40～134h。结论EC2V10可以作为临床难治性心肺衰竭的有效辅助手段，使危重症病人度过危险期，为进一步治疗争取宝贵的时间。     

胰十二指肠切除术治疗胰头和壶部癌230例分析

目的：了解胰十二指肠切除术治疗胰头和壶腹部癌的效果和影响病人生存的因素。方法：分析２３０例胰头和壶腹部癌的主要表现、辅助检查、手术并发症、手术死亡率，调查术后生存情况及影响病人长期生存的因素。结果：本组病人出现黄疸９０．９％，腹痛５６．１％。手术并发症７２例（３１．３％），死亡２０例（８．７％）。术后１、３、５年存活率分别为４６．７％，１７．４％和５２％。肿瘤直径、淋巴结转移和切缘状态是影响病人术     

Myocardial revascularization in patients with severe ischemic left ventricular dysfunction. Long term follow-up in 141 patients

Objectives: The present study evaluates our experience with coronary bypass grafting in patients with EF ≤25%. Myocardial revascularization in this setting remains controversial because of concerns over operative mortality and morbidity and lack of functional and survival benefit. Materials and methods: One hundred and forty-one patients with coronary artery disease and left ventricular ejection fraction ≤25% underwent coronary artery bypass graft between January 1988 and December 1998. Mean age at operation was 63.3 years and 81.4% were male. The major indication for surgery was angina (114 patients, 80.8%). Ejection fraction (EF), left ventricular end diastolic pressure (LVEDP) and cardiac index (CI) were used to assess left ventricular function. The number of graft was 2.7±1.6/patient. Internal mammary artery was used in 119 patients (84.3%). Intra aortic balloon pump was placed preoperatively in 25 patients (17.7%). Five operative risk factors were associated with a higher mortality: emergency, female sex, LVEDP, CI and NYHA class IV. Results: The operative mortality was 7% (10 patients). Left ventricular ejection fraction (assessed post operatively in 83 patients) improved from 22.2% preoperatively to 33.5% post operatively (P<0.001), mean end diastolic volume index fell from 98 to 83 ml/m² following surgery. Survival at 2, 5 and 7 years was respectively 84±3%, 70±4% and 50±5%. Two variables were associated with increased long term survival: congestive heart failure (NYHA class lower than IV (P=0.035) and cardiomegaly (P=0.04) Conclusion: In patients with left ventricular dysfunction, myocardial revascularization can be performed relatively safely with good medium term survival and improvement in quality of life and in left ventricular function. Coronary artery bypass graft may be offered to patients with impaired ventricular function, but careful patient selection and management when considering these patients for operation should assess potentially reversible dysfunction.     

700例冠状动脉旁路移植术的临床回顾

作者对阜外医院７００例冠状动脉旁路移植术（ＣＡＢＧ）患者的临床资料和手术结果，按时间分Ａ、Ｂ两组进行对比分析，结果显示合并糖尿病、高血脂症、心功能Ⅲ～Ⅳ级、左主干病变、广泛三支病变等在患者中所占比例近三年有显著的增高（Ｐ＜０．０５）；合并高血压病（４１．３％）、陈旧性心肌梗塞（６５．０％）、有左室室壁瘤（２４．３％）、术后需使用ＩＡＢＰ（９．４％）发生率高，但两组间无显著性差异。心肌保护方法的改进、冠状动脉充分再血管化技术的提高和内乳动脉的广泛采用，使术后早期死亡率（Ｂ组９．６％，Ａ组２．７％）及围术期心梗发生率（Ｂ组９．０％、Ａ组３．２％，Ｐ＜０．００５）明显下降。     

冠状动脉内膜剥脱联合旁路移植治疗弥漫性冠状动脉狭窄病变的近中期效果

目的探讨冠状动脉内膜剥脱术(CE)联合冠状动脉旁路移植术(CABG)治疗弥漫性冠状动脉狭窄病变的近中期效果。方法回顾性分析2010年1月至2019年1月在南京市第一医院心胸血管外科接受CE+CABG的248例弥漫性冠状动脉狭窄病变患者的临床资料。男性201例,女性47例;年龄(65.6±8.5)岁(范围:43~79岁)。体外循环手术156例,非体外循环手术92例。共对269根病变血管完成CE,包括前降支108根,右冠状动脉140根,钝缘支21根。共完成旁路移植872支,包括左胸廓内动脉248支,桡动脉48支,大隐静脉576支,每例患者移植(3.5±0.8)支(范围:2~6支)。CE后平均血流量为(26±8)ml/min(范围:13~59 ml/min),血流指数为3.1±0.8(范围:2.0~6.7)。采用t检验或χ²检验比较体外循环和非体外循环患者的手术结果及术后通畅率。结果全组围手术期病死率为1.2%(3/248),2例死于肾功能衰竭,1例死于术后顽固性低心排血量。9例发生围手术期心肌梗死。随访(41.8±21.4)个月(范围:1~68个月)。旁路血管术后1年通畅率为78.4%(182/232),3年通畅率为69.8%(162/232)。左冠状动脉系统通畅率明显高于右冠状动脉系统(1年:87.4%比73.1%,χ²=6.533,P=0.011;3年:78.2%比64.8%,χ²=4.588,P=0.032)。体外循环组和非体外循环组旁路血管通畅率无差异(1年:80.0%比76.9%,χ²=0.277,P=0.599;3年:71.5%比67.9%,χ²=0.300,P=0.584)。结论CE+CABG治疗弥漫性冠状动脉狭窄病变可以获得较满意的完全再血管化,有较好的早、中期效果和旁路血管通畅率。体外循环和非体外循环手术具有相似的早中期结果。     

Safe evolution towards routine off-pump coronary artery bypass: negotiating the learning curve

Objective: Off-pump coronary artery bypass (OPCAB) hopes to avoid morbidity associated with cardiopulmonary bypass, improving clinical outcomes. Yet its technical difficulty and unfamiliarity raise concern that adoption of OPCAB might be associated with poorer outcomes during each surgeon's ‘learning curve’. We examined trends in patient selection over time as a single surgeon's practice evolved to routine OPCAB. Methods: Between 10-1-96 and 12-31-01, 1479 consecutive patients had isolated coronary artery bypass grafting (CABG). Clinical data were gathered prospectively and reviewed retrospectively. Trends in adoption of OPCAB and clinical outcomes were examined. Results: There were 756 OPCAB and 723 CABG/cardiopulmonary bypass patients. The practice evolved from 90% conventional CABG to 93% OPCAB. An abrupt transition coincided with evolution of techniques to expose the obtuse marginal arteries, and improvements in suction-based coronary stabilizers. Mortality was 1.0% for the off-pump group and 2.1% for the on-pump group. Careful patient selection helped maintain acceptable outcomes during the ‘learning curve’. Patients with depressed left ventricular ejection fraction, left main disease, and complex three vessel disease were excluded from OPCAB until significant experience (>200 cases) was attained. Presently, all isolated coronary bypass cases are candidates for OPCAB except patients with ischemic ventricular arrhythmias, those in cardiac arrest, and those for whom previous left pneumonectomy or deep pectus excavatum prevent rightward mobilization of heart. Conclusions: Despite a significant learning curve, evolution to routine OPCAB can be achieved while maintaining good patient outcomes. The development of specialized techniques, coronary stabilizers, and apical suction devices allows the application of OPCAB to virtually all coronary bypass patients, as surgeon experience matures.     

Centrifugal Pumps as Left Ventricular Assist for Coronary Revascularization on a Beating Heart

During recent years, coronary bypass surgery has progressed toward minimizing invasiveness. One important feature of this approach is performing surgery on a beating heart. During the crucial phase of such surgery, the mechanical support of the heart with a left ventricular assist device (LVAD) is a possible option. During the period from October 1, 1994 until June 30, 1997, we employed a centrifugal pump system in 118 cases of coronary artery bypass graft (CABG) procedures with LVAD support (mechanically supported CABG [SUPPCAB]). A total of 179 distal anastomoses with an average of 1.5 ± 0.5 coronary anastomoses per patient was performed. Three types of pumps were used: 23 BioPump, 87 Isoflow, and 8 Capiox systems. The median time on mechanical support was 44 min (range, 16–116 min). The mean flow rate during support time was 3.5 ± 0.8 L/min, which results in a calculated flow of 1.7 ± 0.6 L/min/m² body surface area (BSA). The average flow was 3.2 ± 0.8 L/min with the BioPump and 3.7 ± 0.8 L/min with the Isoflow pump, respectively (p < 0.01). The mean arterial pressure during mechanical support was 75 ± 12 mm Hg. In 2 patients, the pump system was kept running postoperatively in the ICU. Eight of the patients received operations under resuscitation or in cardiogenic shock. Nine (7.9%) of the patients did not survive the early postoperative phase. For coronary revascularization of the anterolateral and diaphragmatic parts of the heart, the SUPPCAB procedure is feasible with excellent mechanical support of the heart by centrifugal pumps. Especially in high risk cases, this procedure can be recommended.     

Report of a case successfully weaned from long left ventricular assist with complete recovery after coronary artery bypass grafting

A 45-year-old female underwent coronary artery bypass grafting (CABG) due to medically uncontrollable unstable angina. After completion of CABG, left ventricular contraction was remarkably diminished to maintain systemic circulation. Because intraaortic balloon pumping and veno-arterial bypass with large amount of catecholamines could not improve left ventricular wall function, we decided to use left ventricular assist device (LVAD). After application of LVAD, the patient could easily be weaned from cardio-pulmonary bypass. LVAD was used for 25 days and the patient was successfully weaned from LVAD too, and are now living 6 months postoperatively. As far as we know, this case is the first survival patient after the longest cardiac assist in our country.     

Venticular arrhythmia following successful myocardial revascularization: incidence, predictors and prevention

Objectives: We estimated the risk of sudden cardiac death (SCD), from a spontaneous episode of ventricular arrhythmia (VT/VF), after a successful surgical myocardial revascularization (coronary artery bypass grafting; CABG) procedure. Predictors of these events were identified, and long term benefits of the prophylactic regimes, that were used to control these events, were evaluated. Methods: We selected 8642 consecutive patients, who had undergone an isolated and first time CABG procedure, between 1/3/1980 and 1/3/1995. A standard hazard function model (1) was used for statistical analysis. Efficacy of the prophylactic regimes, was examined in a group of 350 high risk patients, with a preoperative left ventricular ejection fraction 30% or less, who were recently operated since 1/1/1988. Electrophysiologic (EP) guided prophylaxis was used in 92 (26%) patients, who had survived a documented episode of SCD, and remaining 258 patients were maintained on antiarrhythmic medication on an empirical basis. A sequential EP evaluation was performed, when indicated. Results: During an early phase of hazard, which mainly lasted for up to 3 months after CABG, incremental risk factors were preoperative LVEF 30% or less (P=0.0007) and preoperative episodes of VT/VF (P=0.04). This phase was followed by a constant phase with a low risk of the events, which merged into a slowly rising late phase after 6 years. EP guided prophylaxis, reduced the risk of SCD in high risk patients (P=0.03). A sequential EP evaluation, helped to detect the problems of drug resistance and a cross over from non-sustained to sustained runs of VT/VF. Conclusions: Despite a successful CABG surgery, risk of VT/VF persists. A routine EP evaluation before and after a CABG procedure is recommended in all patients with a poor left ventricular function.     

Significance and management of early graft failure after coronary artery bypass grafting: Feasibility and results of acute angiography and re-re-vascularization

Perioperative ischaemia and infarction after CABG are associated with increased morbidity and mortality. Objective: To study causes of perioperative ischaemia and infarction by acute re-angiography and to treat incomplete re-vascularization caused by graft failure or any other cause. Methods: Between 1990 and 1995, 2003 patients underwent an isolated CABG operation. Myocardial ischaemia was suspected if one or more of the following criteria were present: New changes in the ST-segment in the ECG; a CKMB value greater than 80 U/L; new Q-waves in the ECG; recurrent episodes of, or sustained ventricular tachyarrhythmia; ventricular fibrillation; haemodynamic deterioration and left ventricular failure. Acute coronary angiography was performed in stable patients, while haemodynamically severely compromised patients were rushed to the operating room. Results: A total of 71 (3.5%) patients of all CABGs with suspected graft failure were identified and included in the study. Patients were grouped according to whether they had an acute re-angiography (n=59; group 1) or an immediate re-operation (n=12; group 2) performed. In group 1, the acute re-angiography demonstrated graft failure/incomplete re-vascularization in 43 patients (73%). The angiographic findings were: Occluded vein graft(s) in 19 (32%); poor distal run-off to the grafted coronary artery in ten (17%); internal mammary artery stenosis in four (7%); internal mammary artery occlusion in three (5%); vein graft stenoses in three (5%); left mammary artery subclavian artery steal in two (3%); and the wrong coronary artery grafted in one (2%). Based on the angiography findings, 27 patients were re-operated and re-grafted. At the time of re-operation, 18 patients (67%) had evolving infarction documented by ECG or CKMB. Two patients (3%) experienced stroke in immediate relation to the re-angiography. The 30-day mortality was three (7%). In group 2, graft occlusions were found in 11 patients (92%). The 30-day mortality was six (50%). Conclusion: An acute re-angiography demonstrated graft failure or incomplete re-vascularization in the majority of patients with myocardial ischaemia early after CABG. Re-operation for re-re-vascularization was performed with low risk. Few patients with circulatory collapse could be saved by an immediate re-operation without preceding angiography.     

Minimally invasive coronary artery bypass grafting via a small thoracotomy versus off-pump: a case-matched study

Objective: The minimally invasive coronary artery bypass grafting (MICS CABG) operation performed via a small thoracotomy has not previously been examined in a direct comparison to sternotomy off-pump coronary artery bypass grafting (OPCAB). Methods: We matched, according to age, gender, left ventricular function, and median number of distal anastomoses, 150 patients who underwent MICS CABG via small left thoracotomy, and 150 patients who received sternotomy OPCAB. All operations were performed by the same surgeon. Results: There was no perioperative mortality (0/300). In the MICS CABG group, pump assistance was used in 28/150 (19%) patients, and conversion to sternotomy occurred in 10/150 (6.7%) patients. In the OPCAB group, conversion to on-pump occurred in 3/150 (2.0%) patients. There were four (2.7%) reoperations for bleeding and one (0.7%) for anastomotic revision in each group. The median hospital length of stay was 5 days for MICS CABG (average 5.4), and 6 days for OPCAB (average 7.2) (P = 0.02). New-onset atrial fibrillation occurred in 35 (23%) MICS CABG patients and in 42 (28%) OPCAB patients (P = 0.3). No wound infection occurred with MICS CABG versus six (4.0%) with OPCAB (P = 0.03). A self-limiting left pleural effusion developed in 22 (15%) MICS CABG patients and in six (4.0%) OPCAB patients (P = 0.002). The median time to return to full physical activity was 12 days in MICS CABG patients versus >5 weeks in OPCAB patients (P < 0.001). Conclusions: MICS CABG is a valuable alternative for patients in need of multivessel CABG. The operation appears at least as safe as OPCAB, and associated with shorter hospital length of stay, less wound infections, and faster postoperative recovery than OPCAB.     

Coronary artery bypass grafting in 105 patients with hemodialysis-dependent renal failure

This study was proposed to define early and long-term results of coronary artery bypass grafting (CABG) in dialysis-dependent renal failure (RF) patients, and preoperative patient characteristics. This study included 105 patients (87 males and 18 females; mean age 60.0 +/- 9.0 years, range 39-79) with RF on maintenance dialysis (hemodialysis 100, peritoneal dialysis 5) who underwent isolated CABG between August 1985 and April 2000. Postoperative follow-up was completed in 100% and averaged 3.1 years. There were 22 emergency and 2 re-CABG cases. Previous myocardial infarction (MI) was found in 55 patients (52%), and unstable angina was noted in 53 patients (50%). Diabetes mellitus was the cause of RF in 50 patients (48%; 24 patients required insulin). There was 1 case of single vessel disease, 31 cases of double vessel disease, 54 cases of triple vessel disease, and 19 cases of left main disease. Preoperative left ventriculography was performed in 92 patients (88%). Left ventricular ejection fraction (LVEF) was 48.3 +/- 15.8% (range 11-74%) and was 40% or less in 25 patients (27%). The mean number of distal anastomoses was 2.5 (range 1-5). Three patients received only vein grafts, but all were cases of emergency CABG. The remaining 102 patients (97%) received at least 1 arterial conduit. Among them, 64 patients received only arterial conduits, and 72 patients received 2 or more distal anastomoses with arterial conduits. Five patients (4.8%) died within 30 days after CABG (2 cardiac deaths and 3 noncardiac deaths), and 8 patients (7.6%) died beyond 30 days after CABG before discharge (all noncardiac deaths). The cause of 2 cardiac deaths was abrupt circulatory collapse during or after hemodialysis in patients with severe left ventricular dysfunction (LVEF; 11% and 28%) in the early postoperative period. The causes of 8 noncardiac deaths included infection in 4 and rupture of aortic aneurysm, stroke, sleep apnea syndrome, and mesenteric infarction. During the follow-up period, there were 29 late deaths (8 cardiac, 13 noncardiac, and 8 sudden death), 6 MIs, 13 percutaneous transluminal coronary angioplasty, and 1 re-CABG. The 5-year actuarial survival rate was 59.8%, the cardiac death-free rate was 83.0%, and the cardiac event-free rate was 62.4%. Although CABG in patients on hemodialysis is associated with high early and long-term mortality in terms of both cardiac and noncardiac deaths in proportion to the severity of the preoperative condition, long-term survival was still better than that of general dialysis patients. Meticulous perioperative management may be the key factor in the improvement of early results.