Outcome of renal insufficiency patients undergoing coronary artery bypass graft surgery

Renal insufficiency (RI) is a prognostic marker in patients with cardiovascular disease. In this study, the latest standard of glomerular filtration rate (GFR) calculation, that is the modification of diet in renal disease (MDRD) study equation, is used to measure the difference in the outcome of coronary artery bypass graft (CABG) surgery in various GFR groups. Between 2000 and 2005, 1,055 patients underwent CABG surgery and were categorized into 5 groups according to the National Kidney Foundation guidelines: stage 1 = normal renal function; stage 2 = mild RI; stage 3 = moderate RI; stage 4 = severe RI; stage 5 = end-stage renal failure (excluded). Precautions were taken in RI patients to avoid perioperative hypotension, fluid overload and limited cardioplegia; cardiopulmonary bypass time was kept at a minimum by performing an essential number of grafts only. Thirty-day mortality occurred in 5 of 1,052 patients (0.48%) with no statistical difference in stages 1-4. There was increase in bleed requiring reoperation and total complications from stages 1 to 4, but it was not statistically significant. Preoperative renal dysfunction in CABG surgery patients is an important predictor of outcome. Patients undergoing CABG surgery can have acceptable results without significant increase in complications and mortality provided that risk factors are minimized perioperatively.     

Efficacy of reiki on patients undergoing coronary artery bypass graft surgery

Reiki was administered to 50 patients out of 100 patients with normal left ventricular function scheduled for elective coronary artery bypass grafting. Blood components and inflammatory markers were estimated at various time points. Haemodynamic parameters, psychological analysis, intensive care unit stay,incidence of infection, chest tube drainage and mortality were recorded. Haemodynamic parameters and use of blood components were similar in both groups. Interleukin-6 were significantly lower in the preoperative period in the Reiki group, but showed similar trends in both the groups in the post-operative period. The psychological analysis assessed by World Health Organisation quality of life and General Health Questionnaire revealed that social relationships improve once patient is in his own surroundings and with his own people in both the groups. Psychological domain showed significant difference, six day after surgery in the Reiki group. This study concludes that Reiki is a time consuming process with no significant clinical benefit.     

零平衡超滤对老年冠状动脉搭桥围术期心肺功能的影响

目的评估体外循环（ECC）中采用零平衡超滤对老年冠状动脉搭桥围术期心肺功能的影响。方法选取拟行冠状动脉搭桥术患者20例，随机分为两组，超滤组和对照组。分别在术前0．5h（T1）、主动脉阻断后30min（T2）、ECC结束后1h（T3）、8h（T4）、24h（T5）、48h（T6）抽取静脉血，测定血浆肌酸肌酶同工酶（CK-MB）、心肌肌钙蛋白I（cTnI）、肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）的水平．监测并记录T1～T6各时间的肺泡-动脉血氧分压差P（A-a）O2，并记录患者心脏自动复跳率及术后恢复情况。结果超滤组患者心脏自动复跳率明显高于对照组；超滤组术后机械通气时间及ICU停留时间显著短于对照组（P〈0．05）；两组患者ECC后CK-MB、cTnI、TNF-α、IL-6血浆浓度均有不同程度升高，但超滤组患者血浆CK—MB、IL-6浓度在T2～T6均低于对照组（P〈0．01或P〈0．05）．超滤组cTnI浓度在T2～T5、TNF-α浓度在T3～T5低于对照组（P〈0.05）；超滤组肺泡-动脉血氧分压差在T3低于对照组（P〈0．05）。结论ECC中采用零平衡超滤对老年冠状动脉粥样硬化性心脏病患者的心肺功能有一定程度的保护作用。     

非体外循环下冠状动脉旁路移植术中应用正性肌力药物的相关因素

目的:观察和分析冠状动脉旁路移植手术(coronary artery bypass graft,CABG)中应用正性肌力药物的相关因素。方法:以2012年1月~2013年12月在北京市大兴区人民医院心脏中心接受非体外循环下CABG的患者630(男351,女279)例为研究对象。按术中是否应用正性肌力药物分为应用组(n=330)和未应用组(n=300)。通过回顾原始病历收集临床资料。需要应用正性肌力药物被定义为使用多巴胺剂量超过5μg/(kg·min)、任何剂量的肾上腺素或去甲肾上腺素、米力农。结果:确定了3个应用正性肌力药物的独立的相关因素:1心脏指数(CI)≤2.5 L/(min·m2);2左室射血分数(LVEF)≤35%;3左室舒张末压(LVEDP)≥25 mm Hg。结论:CI≤2.5 L/(min·m2)、LVEF≤35%和LVEDP≥25 mm Hg是增加非体外循环下CABG中应用正性肌力药物风险的独立相关因素。     

Abdominal perfusion pressure and coronary arterial perfusion pressure in patients undergoing coronary artery bypass graft surgery

Abdominal perfusion pressure (APP) is defined as the difference between the mean arterial pressure and the intra-abdominal pressure (IAP). IAP elevation results in various side effects, including a decrease in coronary arterial perfusion pressure (CoPP). The present study analyzed the relationship between APP and CoPP in patients undergoing extracorporeal circulation (ECC). The patient population selected for the present study comprised 45 adult patients with a mean (± SD) age of 65.9±7.21 years (range 42 to 80 years), undergoing coronary artery bypass grafting with ECC and normovolemic hemodilution under general anesthesia. CoPP was measured as the difference between mean arterial pressure and pulmonary capillary wedge pressure. APP and CoPP were measured at seven time points (TPs): before surgery after the induction of anesthesia (TP1), during internal mammary artery preparation (TP2), 10 min after the heart-lung machine disconnection (TP3), after completion of the procedure but before sending the patient to the postoperative intensive care unit (TP4), 1 h after surgery (TP5), 6 h after surgery (TP6) and 18 h after the procedure (TP7). TP1 was considered to be the baseline value. IAP increased from TP3 to TP7; APP decreased at TP3 and TP4; there were no significant changes in CoPP. Significant correlations between APP and CoPP were observed at all TPs. Moreover, IAP correlated with CoPP at TP2 and TP4. Additionally, there was a strong overall correlation between APP and CoPP (P<0.001, r=0.9598). The present study arrived at two major conclusions: that ECC resulted in IAP elevation and that APP was strongly correlated with CoPP.     

Myocardial oxygen balance and cardiopulmonary bypass in patients undergoing coronary artery bypass grafting

The frequency of anaerobic myocardial metabolism was studied in 14 patients undergoing coronary artery bypass surgery during enflurane-supplemented high-dose fentanyl anesthesia and compared with other clinical monitors of myocardial ischemia including the configuration of the pulmonary capillary wedge pressure (PCWP) and electrocardiographic findings. Hemodynamic parameters, coronary sinus blood flow, myocardial oxygen and lactate extractions, and a seven-lead ECG were recorded before and after cannulation of the aorta and vena cava, during total cardiopulmonary bypass (CPB) in a vented heart, during rewarming after global myocardial ischemia and cold cardioplegia, and 15 minutes after coming off bypass. The cannulation for CPB induced no changes in the central or coronary hemodynamics, but four patients had abnormal lactate metabolism. Two of these also had ST segment depression, and two had prominent AC waves on the PCWP tracing. Coronary sinus blood flow and myocardial oxygen extraction were maintained at the beginning of CPB, but lactate extraction decreased markedly or turned to lactate production, and ECG changes indicating myocardial ischemia were seen in five patients. During rewarming and after CPB, all patients had abnormal lactate metabolism despite decreased myocardial oxygen extraction, adequate coronary perfusion pressure, and adequate coronary sinus blood flow. During these periods most patients also had cardiac conduction disturbances that made the interpretation of the ST segment impossible. Only one patient had clearly abnormal AC and V waves on the PCWP tracing after CPB. Two patients had ECG evidence of a perioperative myocardial infarction, but they had no significant clinical consequences. Four patients had a fascicular block at discharge. These results indicate that anaerobic myocardial metabolism is common during and after CPB, and that associated myocardial ischemia cannot always be reliably detected by changes in the ECG or the PCWP tracings.     

Management of patients undergoing coronary artery bypass graft surgery with mild to moderate aortic stenosis

BACKGROUND AND AIM OF THE STUDY: The management of patients undergoing coronary artery bypass graft (CABG) surgery with mild to moderate aortic stenosis (AS) remains controversial. The study aim was to examine the outcome in patients with mild to moderate AS undergoing CABG. METHODS: A retrospective analysis was carried out of 200 patients with coronary artery disease requiring CABG and with a peak AS gradient < 40 mmHg measured by Doppler echocardiography, between 1990 and 2000. Among patients, 154 underwent isolated CABG (group A) and 46 CABG + aortic valve replacement (AVR) (group B). RESULTS: Mortality was 2.6% (n = 4) in group A and 6.5% (n = 3) in group B (p = NS). The median AS gradients were 34 and 40 mmHg, respectively. Thirty patients (20%) in group A were in NYHA class III-IV compared to 20 (44%) in group B (p = 0.002). There was no significant difference in postoperative complications. The mean intensive care unit stay was 2.3 and 2.2 days, respectively (p = NS); median postoperative stay was 6 and 8 days, respectively (p = 0.02). During the median follow up period of 4.2 years no patient in group A required AVR. Nine late deaths occurred in group B, none of which was cardiac-related. CONCLUSION: Morbidity and mortality in patients who underwent combined surgery was comparable with that in patients who had isolated CABG. However, none of the patients who underwent only CABG required AVR during the follow up period. It is concluded that patients with mild AS at the time of CABG should not undergo AVR. It is possible that a cut-off AS gradient > 40 mmHg should be considered for combined surgery.     

Effect of hypothermia in patients undergoing simultaneous carotid endarterectomy and coronary artery bypass graft surgery

The co-existence of coronary, carotid, peripheral and renal atherosclerotic diseases is not infrequent and it was reported that 24% of patients with coronary artery disease have at least one additional atherosclerotic lesion.1 In previous studies, 4.6 to 8.0% of patients with coronary artery disease (CAD) had severe coronary artery stenosis (CAS), the extent of the atherosclerotic involvement being significantly correlated with the carotid and coronary arteries.2,3 Simultaneous surgical management of concomitant coronary and carotid artery disease has been the focus of interest in the past two decades since success rates of coronary artery bypass grafting (CABG) has substantially increased while a preventive approach for adverse neurological outcomes has gained popularity.4 Carotid stenosis and previous history of cerebrovascular disease were reported to be among the most prominent risk factors for peri-operative stroke and neurocognitive decline in patients undergoing CABG.5The optimal decision for the timing of carotid endarterectomy (CEA) is controversial in patients submitted for CABG since data focusing on establishing the best strategy of practice are limited.6 There have been numerous cross-sectional studies reporting favourable outcomes for both simultaneous and staged CEA and CABG procedures,7-9 and some authors have suggested that the decision to perform the two procedures simultaneously should be made based on strict patient selection criteria.10 Nevertheless, delaying the CEA was found to be an independent predictor of early stroke and death in one recent randomised trial.11 This uncertainty led to an increasing trend towards individualisation of the treatment in patients with concomitant disease.Some earlier studies implied the potential role of hypothermia as a preventative measure against adverse postoperative outcomes in patients undergoing single-stage on-pump CABG and CEA.12,13 However, these studies fell short of their goal of determining whether hypothermia provides protection, because none of them involved a control group of patients undergoing CEA under normothermic conditions. In this study we sought to determine whether hypothermia provided any benefit in patients undergoing simultaneous CABG and CEA using one of two different surgical strategies.     

Diabetes mellitus increases short-term mortality and morbidity in patients undergoing coronary artery bypass graft surgery

OBJECTIVES: The aim of this study was to determine the impact of diabetes mellitus (DM) on short-term mortality and morbidity in patients undergoing coronary artery bypass surgery (CABG). BACKGROUND: Diabetes mellitus is present in approximately 20% to 30% of patients undergoing CABG, and the impact of diabetes on short-term outcome is unclear. METHODS: We performed a retrospective cohort study in 434 hospitals from North America. The study population included 146,786 patients undergoing CABG during 1997: 41,663 patients with DM and 105,123 without DM. The primary outcome was 30-day mortality. Secondary outcomes were in-hospital morbidity, infections and composite outcomes of mortality or morbidity and mortality or infection. RESULTS: The 30-day mortality was 3.7% in patients with DM and 2.7% in those without DM; the unadjusted odds ratio was 1.40 (95% confidence interval [CI], 1.31 to 1.49). After adjusting for other baseline risk factors, the overall adjusted odds ratio for diabetics was 1.23 (95% CI, 1.15 to 1.32). Patients treated with oral hypoglycemic medications had adjusted odds ratio 1.13; 95% CI, 1.04 to 1.23, whereas those on insulin had an adjusted odds ratio 1.39; 95% CI, 1.27 to 1.52. Morbidity, infections and the composite outcomes occurred more commonly in diabetic patients and were associated with an adjusted risk about 35% higher in diabetics than nondiabetics, particularly among insulin-treated diabetics (adjusted risk between 1.5 to 1.61). CONCLUSIONS: Diabetes mellitus is an important risk factor for mortality and morbidity among those undergoing CABG. Research is needed to determine if good control of glucose levels during the perioperative time period improves outcome.     

Metabolic and hemodynamic features of elderly patients undergoing beating heart coronary artery bypass graft surgery

AIM: Coronary artery bypass graft (CABG) surgery, nowadays, is increasingly performed in patients who are older and have more comorbidities than subjects operated on a decade ago. In this study, we investigated metabolic and hemodynamic features of elderly patients with single vessel coronary artery disease (CAD), undergoing beating heart coronary artery bypass graft (BHCABG) surgery. METHODS: Twenty-five elderly patients, ages 73-78 years, with isolated left anterior descending artery (LAD) disease, were enrolled and compared to a younger similar group of 25 patients, mean age 48+/-1.2 years. A single vessel left internal mammary artery (LIMA) to LAD BHCABG was performed in all patients. Duration of temporary LAD occlusion was 9.8+/-0.5 min in the elderly group, and 10+/-0.4 min in the younger group. Myocardial arterial-venous differences in glucose, lactate, and creatine phosphokinase (CPK) were performed at different time points: preoperatively in the operating room (T0); at the end of the grafting procedure (T1); and before closing the chest (T2). Left ventricular stroke work index (LVSWI), as an indicator of global function of left ventricle, were recorded at T0, T1, T2, 6 (T3) and 48 (T4) hours postoperatively. RESULTS: Preoperative glucose extraction, observed in both groups, did not augment during and after surgery. In addition, neither lactate nor CPK were released in the coronary sinus during temporary LAD occlusion and following reperfusion in either group. Similarly, no significant changes in LVSWI were observed intra- and perioperatively between the two groups. CONCLUSIONS: Cardiac metabolism, hemodynamic parameters and global left ventricular function were not affected in either group by brief LAD occlusion during BHCABG, suggesting that BHCABG is a well-tolerated surgical approach, which can be safely attempted in patients of any age.     

Blood levels of atrial natriuretic peptide, endothelin, cortisol and ACTH in patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass.

Previous studies demonstrated a biphasic time course with post-operative dissociation of blood levels of cortisol and ACTH in patients undergoing major surgery and critically ill patients. A possible role of endothelin and atrial natriuretic peptide (ANP) in the dissociation of concentrations of cortisol and ACTH in critically ill patients has been suggested. In the present study, we investigated the perioperative course of blood levels of endothelin, ANP, ACTH, and cortisol in 13 male patients undergoing cardiac surgery with cardiopulmonary bypass (CPB): group 1 consisted of 7 patients with an uneventful perioperative period and group 2 consisted of 6 patients with perioperative complications. Blood samples were taken pre-[T1], intra-[T2], post-operatively (on the day of surgery) [T3], as well as on the first [T4] and second [T5] post-operative days. Blood samples of endothelin, ANP, cortisol, and ACTH were measured using commercially available immunoassays. Perioperatively, a biphasic time course with post-operative dissociation of ACTH and cortisol concentrations was observed in all patients studied. Intraoperatively, during CPB, the highest levels of endothelin were found. Perioperatively, ANP and endothelin levels were elevated compared to pre-operative values up to the second post-operative day. On the second post-operative day, ANP concentrations were significantly higher in patients with complications in the perioperative period compared to those with an uneventful perioperative period. Our results suggest that: 1) plasma levels of ANP increased in patients with perioperative complications; 2) plasma levels of ANP may have prognostic value for patients undergoing cardiac surgery; and 3) the dissociation of ACTH and cortisol cannot solely be explained by the increase in endothelin-1 and ANP concentrations observed in patients undergoing major surgery.     

Increase in plasma and surface CD163 levels in patients undergoing coronary artery bypass graft surgery

Although haptoglobin polymorphism has been shown to be a genetic risk factor in coronary artery disease, its mechanisms of action are incompletely defined. Recently, a macrophage scavenger receptor for the uptake of haptoglobin–hemoglobin (Hp–Hb) complexes was cloned and designated CD163. Macrophage expression of CD163 is increased by glucocorticoids, IL-10 and IL-6. To better understand the in vivo response of CD163 to an inflammatory stimulus and glucocorticoid treatment, we studied 18 patients who underwent elective coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB). We report a rapid increase in plasma levels of soluble CD163 by 1 h post-declamping the aorta during CABG surgery with CPB. Furthermore, we demonstrate significant increases in monocyte CD163 on post-operative day 1; 14-fold for patients pre-treated with methylprednisolone and 3-fold for those who did not receive exogenous glucocorticoids. These findings show CD163 to be rapidly mobilized in response to systemic inflammatory stimuli and to be affected significantly by glucocorticoids in vivo. The proposed role of CD163 as a Hp–Hb scavenger and anti-inflammatory molecule, in conjunction with the results of this study, make CD163 an intriguing target for potential manipulation of the acute response to inflammation.     

Coronary angioplasty in patients with prior coronary artery bypass surgery: all prior coronary artery bypass surgery patients and patients more than 5 years after coronary bypass surgery

Percutaneous transluminal coronary angioplasty (PTCA) has been used successfully in patients who have had prior bypass surgery (CABG) as a means of revascularizing the myocardium and avoiding repeat myocardial revascularization. However, angioplasty has been considered inappropriate as a means of dilating old saphenous vein grafts. The first section of this article details the authors' experience with PTCA of prior CABG patients, and the second section discusses the results of PTCA in the subset of patients 5 or more years after their last coronary bypass surgery. These data may make individuals rethink the appropriateness of PTCA in old saphenous vein grafts.     

高压氧预处理对冠状动脉旁路移植手术的心肌保护作用

目的:评估重复高压氧（HBO）预处理对冠状动脉旁路移植（CABG）手术患者的心肌保护效果及临床应用安全性。方法: 49例拟行择期CABG手术的患者,随机分为对照组（n=25）和预处理组（n=24）,对照组包括15例采用体外循环（CPB）手术（On-pump）方式和10例不停跳手术（Off-pump）方式的患者,预处理组CPB手术和Off-pump手术患者分别为14例和10例。预处理组患者于手术前5 d开始给予HBO预处理措施（2.0 ATA,120 min/次,1次/d,连续5 d）,对照组不给予HBO预处理。于诱导前、到达ICU、术后6 、12、24 、48及72 h抽取桡动脉血检测血清肌钙蛋白I（cTnI）浓度,并计算从到达ICU至术后6、12、24和48 h的心血管支持药物用量评分。结果: 两组患者术前一般资料组间比较均无统计学差异。对于CPB手术患者:从到达ICU至术后48 h这5个时间点,预处理组患者的血清cTnI浓度均明显低于对照组（P<0.05）。从术后24 h至36 h,预处理组心血管支持药物用量明显低于对照组（P<0.05）。对于Off-pump手术患者:从诱导前直至术后72 h,预处理组患者的血清cTnI浓度与对照组相比较没有明显差别。术后心血管支持药物用量评分两组间也无统计学差异。结论: 重复HBO预处理可安全用于心脏外科CABG手术患者,减少CPB手术患者术后cTnI的释放和心血管支持药物的用量,具有心肌保护效果,但对Off-pump手术患者无明显的心肌保护效应。