康复运动对冠状动脉搭桥术后患者生存质量的影响研究

目的观察康复运动对冠状动脉搭桥术后患者生活质量(QOL)的影响。方法将我院50例经冠状动脉造影证实存在左冠状动脉所属的前降支、回旋支以及右冠状动脉三支病变的患者,随机分为康复组(n=28)和对照组(n=22),对照组给予常规治疗及护理,康复组给予逐渐递增的运动康复治疗护理。运动方式为有氧运动,以步行为主。康复组及对照组患者分别于术后15天及术后90天均由专人进行左室射血分数(LVEF)、简明健康调查表(SF-36)、6min步行试验测定运动后耗氧量和术后平均住院天数的统计。结果与对照组比较.康复组SF-36量表中躯体功能、一般健康状况、精力、情感职能和心理健康差异有统计学意义(P<0.01),康复组6MWD明显高于对照组(P<0.01),康复组较对照组恢复至运动前水平所需耗氧量低(P<0.01),康复组患者术后平均住院时间较对照组明显缩短(P<0.01)。结论康复运动可以提高冠状动脉搭桥术后患者的生活质量,缩短住院时间。     

冠状动脉搭桥术单病种质量控制标准的解读与运用

缺血性心脏病是多发病并且危害巨大、医疗费用高,有必要对该病种进行质量控制。而冠状动脉搭桥术是治疗缺血性心脏病有效的方法之一,并且对于该手术国内外均有明确的指南,易于选取大家公认的质量控制指标。为此,卫生部和中国医院协会将其列为首批六个单病种质量控制试点之一。冠状动脉搭桥术的单病种控制指标有术前准备、手术适应症、术中使用内乳动脉、抗生素使用、术后并发症和健康教育等7项过程指标和住院花费、21天内出院等3项结果指标。北京市的试点表明：单病种质量控制有助于冠状动脉搭桥术医疗质量和医院医疗管理水平的提高。     

Cognitive and cardiac outcomes 5 years after off-pump vs on-pump coronary artery bypass graft surgery

Context  Conventional coronary artery bypass graft surgery with use of cardiopulmonary bypass (on-pump CABG) is associated with excellent long-term cardiac outcomes but also with a high incidence of cognitive decline. The effect of avoiding cardiopulmonary bypass (off-pump CABG) on long-term cognitive and cardiac outcomes is unknown. Objective  To compare the effect of off-pump CABG and on-pump CABG surgery on long-term cognitive and cardiac outcomes. Design, Setting, and Participants  The Octopus Study, a multicenter randomized controlled trial conducted in the Netherlands, which enrolled 281 low-risk CABG patients between 1998 and 2000. Five years after their surgery, surviving patients were invited for a follow-up assessment. Intervention  Patients were randomly assigned to receive either off-pump (n = 142) or on-pump (n = 139) CABG surgery. Main Outcome Measure  The primary measure was cognitive status 5 years after surgery, which was determined by a psychologist blinded to treatment allocation who administered 10 standardized validated neuropsychological tests. Secondary measures were occurrence of cardiovascular events (all-cause mortality, stroke, myocardial infarction, and coronary reintervention), anginal status, and quality of life. Results  After 5 years, 130 patients were alive in each group. Cognitive outcomes could be determined in 123 and 117 patients in the off-pump and on-pump groups, respectively. When using a standard definition of cognitive decline (20% decline in performance in 20% of the neuropsychological test variables), 62 (50.4%) of 123 in the off-pump group and 59 (50.4%) of 117 in the on-pump group had cognitive decline (absolute difference, 0%; 95% confidence interval [CI], –12.7% to 12.6%; P>.99). When a more conservative definition of cognitive decline was used, 41 (33.3%) in the off-pump group and 41 (35.0%) in the on-pump group had cognitive decline (absolute difference, –1.7%; 95% CI, –13.7% to 10.3%; P = .79). Thirty off-pump patients (21.1%) and 25 on-pump patients (18.0%) experienced a cardiovascular event (absolute difference, 3.1%; 95% CI, –6.1% to 12.4%; P = .55). No differences were observed in anginal status or quality of life. Conclusion  In low-risk patients undergoing CABG surgery, avoiding the use of cardiopulmonary bypass had no effect on 5-year cognitive or cardiac outcomes. Trial Registration  isrctn.org Identifier: ISRCTN69438133      

Predictors of atrial fibrillation after coronary artery bypass graft surgery

Objective To identify the clinical predictors of atrial fibrillation (AF) after coronary artery bypass grafting (CABG).Methods 322 consecutive patients who had undergone isolated CABG were reviewed. Preoperative, intraoperative and postoperative data were collected. Patients were grouped according to whether AF appeared postoperatively.Results AF occurred in 75 patients (23.3%). Most cases of AF (85.6%) appeared on or before the third postoperative day. The mean age for patients with AF was 62.5 years compared with 56.7 years for patients without AF ( P &lt;0.05). The mean aortic crossclamp time for patients with AF was 67 min compared with 60.3 min for patients without AF ( P &lt;0.05). The mean duration of cardiopulmonary bypass for patients with AF was 109.6 min compared with 97.3 min for patients without AF ( P &lt;0.05). The mean duration of mechanical ventilation for patients with AF was 19.1 h compared with 15.7h for patients without AF ( P &lt;0.05). Multivariate logistic regression analysis was used to identify the following independent predictors of postoperative AF ( P &lt;0.05): age≥65 years (OR 2.7; 95% CI 1.5 to 5.1), lesions in the right coronary artery (OR 2.5; 95% CI 1.4 to 4.5), and early postoperative withdrawal of β blocker (OR 3.9; 95% CI 2.1 to 7.7).Conclusions AF remains the most common complication after CABG. Age and lesions in the right coronary artery can influence the incidence of AF, and β blocker and magnesium may be the most economical and effective prevention for AF early after CABG.     

Preoperative carotid artery screening in patients undergoing coronary artery bypass graft surgery

BACKGROUND: The incidence of stroke is 2.1-5.2% in bypass surgery patients with a mortality of 0-38%. This study was designed to evaluate the incidence of significant carotid artery stenosis and its related risk factors in candidates for coronary artery bypass graft (CABG) surgery. METHODS: One thousand forty five consecutive candidates for CABG underwent carotid artery Doppler examination in a prospective study. The relation of age, sex, smoking and diabetes history, as well as lipid profile with carotid stenosis, was evaluated. RESULTS: In 1045 CABG candidates with a mean age of 60 years, prevalence of significant carotid stenosis (>60%) was 6.9%. In the patients aged 65 years and older, the rate of significant stenosis was 12.5%. Age >50 years, female gender, hypercholesterolemia and diabetes mellitus are independent risk factors for significant carotid stenosis. CONCLUSIONS: Significant carotid stenosis has an earlier appearance in our study. Cost-effectiveness studies are recommended for revising the previous screening protocols.     

睡眠对老年冠心病患者生活质量的影响

目的了解不同睡眠情况下的老年冠心病（CHD）患者生活质量。方法采用匹兹堡睡眠质量指数（PSQI）、健康调查简表（SF-36）对122例CHD患者进行睡眠情况及生活质量的调查。结果发现PSQI总分≥7分的CHD患者SF-36总分、生理功能（PF）、躯体疼痛（BP）、总体健康感（GH）、社会功能（SF）、情感问题所致的角色受限（RE）标准分均显著低于PSQI总分≤4分的CHD患者（P〈0．05）。结论睡眠紊乱对CHD患者的生理、心理及社会功能等生活质量均有的不良影响,应积极采取睡眠干预措施改善患者生活质量。     

瑞芬太尼预处理对非体外循环冠脉搭桥术患者血浆肌钙蛋白Ⅰ的影响

目的 应用心肌肌钙蛋白I(cTnI)评价瑞芬太尼预处理对非体外循环冠脉搭桥(OPCAB)患者的心肌保护作用.方法 选择24例行OPCAB的冠心病患者,随机分为瑞芬太尼预处理组(R组)和对照组(C组).所有患者术前口服安定10mg,肌肉注射吗啡10mg、东莨菪碱0.3 mg,全麻诱导静脉注射咪唑安定0.08 mg/kg,依托咪酯0.1～0.3 mg/kg,芬太尼5～10 μg/kg,罗库溴铵1 mg/kg诱导,吸人1 MAC异氟醚,持续静脉输注异丙酚0.8~2μ/ml;间断给予芬太尼5～10μg/kg,哌库溴铵0.05 mg/kg.R组:瑞芬太尼5 μg/kg溶于50 ml生理盐水,于麻醉诱导后10 min恒速泵完.C组:泵注同等容量生理盐水.测定术前、术毕及术后1、6、24、48h血浆cTnI水平.结果 各组内术后cTnI水平均明显增高(P<0.05).R组术后cTnI水平显著低于C组(P<0.05).结论 瑞芬太尼预处理可降低OPCAB患者的cTnI水平,减轻心肌损伤.

Abstract：

Objective To investigate the value of cardiac troponin I (cTnI) levels in assessing myocardial protection by remifentanil precondition against myocardial. injury induced by off-pump coronary artery bypass (OPCAB). Methods Twenty-four patients undergoing OPCAB were randomized into control and remifentanil preconditioning group (n=12). All the patients received pretreatment with oral diazepam (10 mg), intramuscular morphine (10 mg) and hyosine (0.3 mg). General anesthesia was induced with midazolam (0.08 mg/kg), etomidate (0.1-0.3 mg/kg), fentanyl (5-10 (μg/kg), and rocuronium (1mg/kg), and maintained with isoflurane inhalation and propofol infusion. Intermittent fentanyl and pipecuronium were given intravenously, In remifentanil preconditioning group, remifentanil (5 μg/kg in 50 ml normal saline) was infused in 10 min after anesthesia induction, and only NS was administered in the control group. Blood samples were obtained before and at 0, 2, 6,24, and 48 h after the operation to determine serum cTnI evels. Results In both of the two groups, the cTnI levels increased significantly at the postoperative time points (0, 2, 6, 24, and 48 h) as compared with those before the operation (P<0.05). The cTnI levels of remifentanil preconditioning group were markedly decreased after the operation in comparison with those of the control group (P<0.05). Conclusion Remifentanil preconditioning decreases the cTnI levels and reduces myocardial injury induced by OPCAB.     

冠状动脉搭桥术后早期新发房颤的相关因素分析

目的探讨冠状动脉搭桥手术后心房颤动的发生率及相关因素.方法对70例冠状动脉搭桥术的病人进行回顾,分析年龄、β阻滞剂的使用、电解质、右冠状动脉、体外循环冠状动脉搭桥术与非体外循环冠状动脉搭桥术等因素与心房颤动的关系.结果70例冠状动脉搭桥手术新发心房颤动15例,发生率21%,其中体外循环冠状动脉搭桥术后发生12例(30%),非体外循环冠状动脉搭桥术后发生3例(10.7%),15例心房颤动病人有4例未用β阻滞剂,体外循环冠状动脉搭桥手术组病人平均年龄62.3岁,非体外循环冠状动脉搭桥手术组病人平均年龄63岁.结论冠状动脉搭桥手术后新发心房颤动原因较多,可能与高龄,心肌缺血,右冠状动脉病变,围手术期停用β阻滞剂有关.     

EuroSCORE与SinoSCORE对冠状动脉旁路移植术后患者早期生命质量的预测价值

目的：探讨欧洲心脏外科手术风险评估系统 (European system for cardiac operative risk evaluation,EuroSCORE) 与中国冠状动脉旁路移植手术评分系统(sino system for coronary operative risk evaluation, SinoSCORE) 对冠状动脉旁路移植术后患者早期生命质量的预测价值。方法：连续选择2010年3月至2013年1月在北京大学第三医院心外科接受冠状动脉旁路移植术的218例患者,术前分别以EuroSCORE和SinoSCORE进行手术风险评价,术前及术后3个月以简明健康调查量表进行生命质量调查,分析不同评分系统对术后早期生命质量的预测价值。校准度采用Hosmer-Lemeshow拟合优度检验评价,分辨力采用ROC曲线下面积(AUC)评价。结果：除疼痛与心理功能两个维度外,患者的手术风险评分与术后早期生命质量存在一定相关性 (r=-0.493～-0.203,P＜0.05)。Logistic回归显示,患者手术风险评分高是术后生命质量低于平均水平的危险因素 (OR＞1.0,P＜0.05),并且 EuroSCORE的OR值高于SinoSCORE。SinoSCORE模型Hosmer-Lemeshow拟合优度检验P=0.628,AUC=0.754;EuroSCORE模型Hosmer-Lemeshowrny拟合优度检验P=0.538,AUC=0.854。结论：EuroSCORE和SinoSCORE对冠状动脉旁路移植术患者术后早期生命质量的某些方面具有一定的预测价值,并且EuroSCORE的预测价值可能更高。     

冠状动脉搭桥术的体外循环管理探讨

目的　探讨冠状动脉搭桥术顺利进行的体外循环的管理要素。方法　选用优质氧合器等体外循环材料 ,体外循环中维持平均动脉压 8.0～ 10 .6kPa ,采用顺灌注晶体停跳液 (加入山莨宕碱 )等心肌保护措施 ,体外循环中监测各项血流动力学指标 ,体外循环在各种条件满意时才停止。结果　全组体外循环时间平均(173 .4± 6 2 .4)min ,主动脉阻断时间平均 (10 5 .5± 42 .5 )min。结论　冠状动脉搭桥手术中 ,体外循环需保持平稳灌注压 ,采用各种有效方法保护心肌 ,停机时间应恰当 ,体外循环设备及辅助循环设备均需充分     

Comparative study of graft flow between on-pump and off-pump coronary bypass surgery for patients with multivessel coronary artery disease

Objective： To Comparatively study grafts flow between on-pump and off-pump coronary bypass surgery for patients with triple coronary artery disease. Methods ： The grafts flow was studied in 100 patients of OPCAB and compared with 100 cases of CCABG by means of Medi-Stim Butterfly Flowmeter measurement intraoperatively. Results： The mean number of the distal anastomosis was 3.78＋ 1.11 in CCABG group, and 3.83 ＋ 0.93 in OPCAB group. The index of completeness of revascularization in CCABG group was 1.01 ＋ 0.08, and 1.10＋ 0.09 in OPCAB group. The flow of grafts was satisfied in all patients. The PI values were all under 5. There was no significant difference in the mean graft flow and PI value between two groups. Conclusion： OPCAB can provide the same grafts flow and similar completeness of revascularization when compared with CCABG which indicates the similar anastomosis quality of grafts in OPCAB and CCABG groups.     

冠状动脉旁路移植术后桡动脉桥血管通畅率的影响因素分析

目的 分析冠状动脉旁路移植术(CABG)后桡动脉(RA)桥通畅率的影响因素。 方法 回顾性分析在CABG术中使用RA桥,并于术后1年复查冠状动脉计算机断层扫描血管造影术(CTA)患者65例。收集患者术前、术中及术后的相关资料,采用多因素logistic回归分析筛选RA桥通畅率的影响因素。 结果 RA桥靶血管近端狭窄程度≥80%(OR=0.212, 95%CI: 0.049~0.912, P=0.037)和靶血管在左前降支区域(OR=0.104, 95%CI: 0.012~0.921, P=0.042)是RA桥术后通畅率的独立保护因素,而术后未规范联用抗痉挛药物(OR=6.825, 95%CI: 1.857~25.083, P=0.004)是RA桥通畅率的独立危险因素。 结论 CABG术中RA桥靶血管的合理选择和术后联用抗痉挛药物是RA桥通畅率的独立影响因素。