Carotid stenosis and peripheral artery disease in Japanese patients with coronary artery disease undergoing coronary artery bypass grafting.

The combination of a change in lifestyle toward Western habits and an aging society, has led to a steady increase in the incidence of atherosclerotic diseases in the Japanese population. Coronary artery disease (CAD), carotid stenosis (CS), and peripheral artery disease (PAD) are major manifestations of generalized atherosclerosis and increase the risk of cardiovascular events. However, the incidence of CS and PAD in Japanese patients with CAD is not well known, so the present study investigated this in 380 consecutive patients with CAD undergoing elective coronary aorta bypass grafting (CABG) at Kishiwada Tokushukai Hospital between October 1999 and October 2001. The coexistence of CS and PAD in all patients was preoperatively evaluated by duplex ultrasonography and the ankle - brachial index (ABI). The average age of the study population was 66.09.1 years (range, 42-87). The number of male patients was 293 (77.1%). The incidence of CS was 13.7% and 15.3% for PAD. Multivariate logistic regression analysis demonstrated that no particular traditional atherosclerotic risk factor, such as hypertension, hyperlipidemia, diabetes mellitus, and smoking, was able to predict either CS or PAD, but CS and PAD were independent predictors of each other. The results of the study suggest that CS and PAD were not only highly prevalent but also strongly associated with each other in this cohort of CAD patients. Accordingly, extracoronary atherosclerotic disease should be assessed in Japanese CAD patients.     

冠状动脉主干重度狭窄搭桥术麻醉处理486例总结

目的:探讨冠心病冠状动脉主干重度狭窄患者,行搭桥术临床特点及围术期治疗措施。方法:我们对2001年1月至2010年10月,486例冠状动脉主干重度狭窄行搭桥术患者的麻醉及围术期治疗进行回顾性分析。结果:442例行非体外循环下冠状动脉搭桥术(OPCABG)。28例在体外循环下行冠状动脉搭桥术(CABG)。16例患者在OPCABG过程中,由于发生严重心肌缺血、心动过速及低血压,改为体外循环下完成手术。113例放置主动脉内球囊反搏(IABP),包括术前、麻醉前放置8例,麻醉后及术中放置78例,术后放置27例。死亡9例,发生在术后72 h内。结论:冠心病冠状动脉主干重度狭窄患者,围术期需要维持心率、血压平稳、合理的血管扩张药和正性肌力药物选用,IABP的积极使用,完备的体外循环和急救药的准备,防治患者围术期冠状动脉痉挛和心肌梗死。     

Associated vascular lesions in patients undergoing coronary artery bypass grafting

Atherosclerotic involvement of extracoronary arteries in patients undergoing myocardial revascularization can cause severe postoperative complications and increase postoperative mortality. Between January and November 1998, routine preoperative echo-Doppler study of carotid vessels, abdominal aorta and iliac-femoral arteries was performed in all patients undergoing coronary artery bypass grafting (CABG) at our institution, in order to assess the prevalence and the degree of associated vascular lesions. Correlations between echo-Doppler findings, angiographic patterns of coronary lesions and atherosclerotic risk factors were analyzed in all cases. Among 302 patients undergoing CABG, 186 (61.6%) had carotid disease, with a haemodynamically significant stenosis (>70%) of internal carotid in 31 (10.2%). Twenty-three patients had asymptomatic severe carotid disease. A significant correlation between severity of coronary disease and prevalence of severe carotid disease was found (p = 0.02). An abdominal aortic dilatation (diameter > 25 mm) was found in 20 cases (6.6%), with a diameter >35 mm in 7 patients (2.3%), 6 with triple-vessel coronary disease, and 1 with double-vessel disease. Atherosclerotic lesions of iliac-femoro-popliteal axis were found in 165 (54.6%) patients, with a strong correlation to the severity of coronary disease (p = 0.02); lesions were haemodynamically significant (> 70%) in 48 (15.8%) cases. Symptoms of carotid and peripheral vascular disease are no reliable predictors of perioperative risk in patients undergoing CABG. Non-invasive complete arterial investigation should be routinely performed in these patients, in order to plan the most suitable operative approach and to prevent perioperative vascular complications.     

非体外循环下冠状动脉搭桥术的麻醉管理

目的 :总结 2 8例非体外循环下多支冠状动脉搭桥术的麻醉管理。方法 :术前依据患者心脏功能及全身状况 ,给予营养心肌、扩冠、降压、利尿等治疗。采用静吸复合麻醉 ,气管插管控制呼吸 ,在非体外循环下行冠状动脉搭桥术。结果 :手术期间 4例血压过低 ,2例 ST段显著抬高伴室性心律失常 ,改为体外循环辅助下手术 ,余 2 2例术中血流动力学平稳。术毕非体外循环组 2 2例 6～ 8h内拔管 ,明显少于体外循环组 （10～ 16h）。 2 8例预后良好 ,无麻醉并发症。结论 :维持血流动力学平稳和心肌氧供需平衡 ,是非体外循环下冠状动脉搭桥术麻醉的关键     

Analysis of mortality in low-risk patients undergoing coronary artery bypass grafting

Aim

The aims of this study were to determine the early mortality rate in low-risk coronary artery bypass graft (CABG) patients and examine the causes of death, to identify problems that could be avoided in future surgeries.

Methods

All low-risk patients (EuroSCORE ≤ 2) who died after CABG were included. Their peri-operative information was meticulously studied by internal and independent external reviewers to identify causes of death, which were classified as: cardiac or non-cardiac; and a further division as: (1) non-preventable, (2) preventable (technical error), and (3) preventable (system error).

Results

Early mortality was 0.93% (24/2 570). Eleven patients (45.8%) were classified as preventable deaths. In six of them the main problem was identified as graft thrombosis, which was secondary to a technical error of either the harvesting or anastomosis of the left internal mammarian artery. There were also five system errors identified as delays in the treatment of an identified and potentially reversible problem.

Conclusions

Correction of technical and system errors, such as harvesting of the left internal mammarian artery, haemostasis during surgery, and establishing standard protocols for the transfer of patients from ward to intensive care units will eventually lead to improvement in both the quality of care and patient outcomes, even in low-risk groups.     

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.     

Efficacy of coronary artery bypass grafting in elderly patients with coronary artery disease

A consecutive series of 121 patients 70 years of age and older who underwent aortocoronary artery saphenous vein bypass grafting without other cardiac procedures during a 5 year period was analyzed and follow-up status ascertained. This group was compared with a consecutive series of 2,850 patients under the age of 70 who underwent aortocoronary bypass during the same period. The patients aged 70 years or greater had a higher incidence of unstable angina pectoris, congestive heart fallure and cardlomegaly on roentgenography. They had more severe coronary obstruction with a 29 percent incidence rate of left main coronary disease versus a 15 percent incidence rate in the patients aged less than 70 years (P < 0.001). The hospital mortality rate for patients aged less than 70 years was 1.1 percent (31 of 2,850) and for those aged 70 years or greater was 1.6 percent (2 of 121). The 119 patients aged 70 years or greater who survived surgery had a significantly greater incidence of postoperative stroke (3 patients), supraventricular tachycardia (28 patients), transient postoperative psychosis (9 patients), heart block requiring permanent pacing (2 patients), intraaortic balloon pumping (5 patients) and pulmonary embolism (4 patients) than patients aged less than 70 years. Both groups had significant symptomatic improvement: More than 95 percent of the survivors in each group were angina-free or in improved condition at late follow-up. Survival at 36 months was 95 percent for the patients in both age groups. A subgroup of patients aged 75 years or greater had comparable symptomatic results and survival. Patients aged 70 years or greater need not be denied the benefits of coronary bypass surgery on the basis of advanced age alone, although these patients have complfcations of surgery more frequently. However, severe calcification of the ascending aorta is a relative contraindication to saphenous vein bypass surgery in this age group.     

70岁及以上冠状动脉旁路移植患者临床特征分析

目的 观察70岁及以上冠状动脉旁路移植术(CABG)患者的手术危险因素特点及手术效果.方法 回顾分析我院2000年1月至2009年4月施行CABG的426例患者的临床资料,其中70～82岁组118例,24～69岁组308例,将两组患者手术危险因素、并发症及手术效果进行对比研究.结果 70～82岁组术前危险因素为女性、慢性阻塞性肺疾病、外周血管病变、心功能Ⅳ级、需静脉硝酸甘油治疗的不稳定心绞痛、左心室射血分数＜30%的比例、术后严重并发症的发生率、手术病死率、移植血管数和在重症监护病房时间均较24～69岁组高(P＜0.05);70～82岁组患者并存瓣膜病变和采用左乳内动脉桥较24～69岁组少,分别为16例(13.6%)和152例(49.4%),差异有统计学意义(P＜0.05).结论 我国70岁及以上患者手术危险因素组成特点与国外有区别,尽管施行CABG严重并发症发生率和手术病死率较高,但并未明显延长患者的手术恢复时间.

Abstract：

Objective To analyze the clinical characters in old patients undergoing coronary artery bypass grafting (CABG). Methods The clinical data of 426 patients undergoing CABG from January 2000 to April 2009 in our hospital were retrospectively analyzed. One hundred eighteen patients were 70-82 years old (older group), 308 patients were 24-69 years old (younger group). The perioperative risk factors, surgical complication and outcomes between the two groups were compared.Results The older group had higher incidences of post-operative complications than younger group.Pre-operative risk factors included the female, chronic obstructive pulmonary disease, peripheral vessel disease, New york heart association(NYHA) class Ⅳ, unstable angina requiring intravenous nitrates until arrival in the anaesthetic room, left ventricular ejection fraction ＜30%. The older group showed higher incidences of postoperative severe complication, operative mortality, and more grafts and longer time in intensive care unit (ICU), and had lower incidents of valve disease and less use of left internal mammary artery [16 patients (13. 6%) vs. 152 patients (49.4%), all P＜0. 05].Conclusions The many CABG risk factors in China are different from those in the western countries.Although the higher incidents of postoperative severe complication and higher operative mortality are found in the older patients, the recovery period after operation isn't obviously prolonged. The operative outcomes are satisfactory.     

Prospective evaluation of glucose metabolism in patients undergoing coronary artery bypass grafting

INTRODUCTION: Disturbances of glucose metabolism are associated with increased risk of ischaemic heart disease (IHD). It is not uncommon that IHD and its complications precede diagnosis of glucose metabolism disturbances. Since publication of the American Diabetes Association's 2004 Guidelines for the assessment of glucose metabolism, no prospective evaluation of prevalence of carbohydrate metabolism disorders in patients referred for coronary artery bypass grafting (CABG) has been performed. AIM: Evaluation of prevalence of glucose balance disturbances in consecutive patients with stable IHD who underwent elective CABG procedures. METHODS: Prospective analysis of glucose metabolism was carried out on a group of 117 consecutive IHD patients (including 31 women) aged below 80 years, selected for elective CABG surgery. In all patients, history assessment and physical examination as well as basic biochemical studies and resting echocardiography were performed. Additionally, in all individuals without previous diagnosis of diabetes mellitus, oral glucose tolerance test (OGTT) was carried out. RESULTS: History analysis revealed glucose balance disturbances in 35 (29.9%) patients, including diabetes mellitus in 33 (28.2%) subjects and impaired glucose tolerance in 2 (1.7%) individuals. Based on OGTT results, among the remaining 82 (70.1%) subjects without previously known glucose metabolism disturbances 4 (3.4%) patients had abnormal fasting glycaemia, 32 (27.4%) subjects had impaired glucose tolerance, and diabetes mellitus was diagnosed in 12 (10.3%) individuals. No impaired glucose balance was found in only 34 (29.1%) examined subjects. CONCLUSIONS: Over 70% of all patients undergoing elective CABG procedure presented various forms of carbohydrate metabolism disturbances that were not diagnosed previously. Thus, it seems that the assessment of glucose regulation should be mandatory in all patients undergoing elective CABG surgery.     

Profile of coronary arterial disease in diabetic patients undergoing coronary arterial bypass grafting

Diabetics are believed to have more extensive and diffuse lesions of the coronary arteries in presence of coronary arterial disease. We studied prospectively 52 diabetics with coronary arterial disease who underwent coronary arterial bypass grafting and evaluated their pre-operative symptomatology, angiographic appearance of coronary arteries, coronary arterial dimensions as assessed at surgery, and the post-operative complications. These were compared to 52 age and sex matched non-diabetic controls undergoing surgery during the same period. There was no statistically significant difference in the incidence of pre-operative symptomatology or frequency of myocardial infarction in the two groups. Left ventricular angiographic findings were also comparable, as was the observation on the extent and severity of coronary arterial disease as assessed by angiography and at surgery. Hence, we recommend coronary arterial bypass grafting to diabetics with the same criteria as are applied to non-diabetics, confident that there will be no added morbidity and mortality.     

Preoperative aspirin administration improves oxygenation in patients undergoing coronary artery bypass grafting

OBJECTIVES: Release of thromboxane (Tx) A(2) by platelets may be one of multiple factors that are responsible for lung injury after cardiopulmonary bypass, leading to pulmonary vasoconstriction and impaired oxygenation. In experimental models, the inhibition of Tx receptor or its production improved lung function. The use of aspirin, which is used widely in the treatment of ischemic heart disease because of its antiplatelet activity, is usually discontinued a week before the patient undergoes the operation to restore normal platelet hemostatic function. The purpose of this study was to determine the relationship between the time of cessation of aspirin before coronary artery bypass surgery, and postoperative oxygenation and bleeding. DESIGN: A prospective clinical study comparing the effect of aspirin on postoperative oxygenation in patients who had been treated or had not been treated with aspirin. SETTING: Tx levels in the pericardial fluid, oxygenation, and bleeding were compared between the two groups. PATIENTS: Thirty-two patients with coronary artery disease who were undergoing coronary artery bypass grafting. Fourteen of these patients received aspirin until the day of the operation, whereas 18 patients stopped receiving aspirin at least 1 week before undergoing the operation.Main results: Mean (+/- SD) Tx levels in the pericardial fluid were significantly lower in the aspirin group (117 +/- 47 pg/mL) compared to those in the control group (1,306 +/- 2,048 pg/mL; p = 0.02). The duration of ventilation after the operation was significantly longer in the nonaspirin group (9.6 +/- 5.6 h vs 3.8 +/- 1.4 h, respectively; p = 0.0004). Po(2) reached a higher level while patients breathed 100% O(2) in the aspirin group (235 +/- 54 mm Hg vs 176 +/- 27 mm Hg, respectively; p = 0.001). The mean amount of bleeding during the first 24 h after surgery was increased in the aspirin group (710 +/- 202 mL) compared with the nonaspirin group (539 +/- 143 mL; p = 0.01), but these patients did not require more transfusions. CONCLUSIONS: The administration of aspirin until the operation may improve oxygenation with only a slight increase in bleeding. This improvement is probably mediated by antiplatelet activity and Tx inhibition by aspirin.     

重症冠心病的非体外循环下冠状动脉旁路移植术

目的 探讨如何提高莺症冠心病患者非体外循环下冠状动脉旁路移植术的手术疗效.方法 Off-Pump coronary artery bypass grafting of severe coronary artery disease回顾性分析268例重症冠心病患者非体外循环下冠状动脉旁路移植术的临床资料,男性131例,女性137例;搭桥数2～6(4.01±0.99)支/人.对手术方法、主要并发症和术后处理进行分析总结.结果 二次开胸3例(1.1%),低心排综合征9例(3.4%),应用IABP 1例(0.4%),反复发作房颤22例(8.2%),肺功能不全13例(4.9%);死亡2例(0.7%),其余患者康复出院.结论 合理地选择患者、成熟的手术技术、主动脉内球囊反搏(IABP)的尽早应用及术后处理的加强是提高重症冠心病患者非体外循环下冠状动脉旁路移植术疗效的重要措施.     

343例体外循环冠状动脉旁路移植术早期疗效分析

目的:探讨体外循环冠状动脉旁路移植术(CCABG)的早期疗效。方法:采集CCABG 343例临床资料,对全组患者术后死亡率、并发症发生率进行统计学分析,死亡危险因素采用logistic多元回归分析。结果:全组实际手术死亡23例(6.7%),2次开胸止血21例(6.1%);新发心房颤动21例(6.1%);新发室性心律失常32例(9.3%);低心排综合征13例(3.1%);围手术期心肌梗死8例(2.3%);呼吸衰竭6例(1.7%);脑血管意外3例(0.9%);肾功能不全9例(2.6%);男性、年龄及术前心源性休克史可能为围手术期死亡的独立危险因素。结论:CCABG安全、可靠,早期疗效令人满意。     

导致冠状动脉旁路移植术后低氧血症的原因分析

目的 总结冠状动脉旁路移植术后出现低氧血症的相关原因,探讨防治措施.方法 选取我院2008-2013年于心外科行冠状动脉旁路移植术（CABG）的100例患者,对其手术资料进行分析.低氧血症的诊断标准为：排除贫血等因素导致的氧分压降低情况后,在机械通气（FiO2＞45％）或面罩联合鼻导管吸氧（氧流量6 L/min）的情况下供氧,冠状动脉旁路移植术后患者的氧分压仍低于[102-（0.33×年龄）mmHg]的患者.结果 100例冠状动脉旁路移植术患者,术后共有30例出现不同程度的低氧血症症状,发生率为30％（30/100）.随着年龄的增大术后低氧血症的发生率不断升高.低氧血症多在术后第1天出现,急诊手术、有吸烟史,以及合并高血压、糖尿病、心梗、肺部疾病是低氧血症发病的危险因素（P＜0.05）.结论 对冠状动脉旁路移植术后的低氧血症要做好充分的预防,发现后及时纠正,可提高手术治疗的效果.     

186例老年冠心病患者是、否体外循环下冠脉旁路移植术的比较

目的:比较老年冠心病患者体外循环与非体外循环下冠状动脉旁路移植术的疗效。方法:A组选择87例65岁以上的老年患者在体外循环下行冠状动脉旁路移植术(CCABG);B组选择79例65岁以上的老年患者在非体外循环下行冠状动脉旁路移植术(OPCABG)。结果:B组死亡率低于A组(P<0.05),术后胸腔引流量明显少于A组(P<0.05)。结论:老年冠心病患者行冠状动脉旁路移植术是安全的。     

Management of asymptomatic aortic stenosis in patients undergoing coronary artery bypass grafting.

This study compared the outcomes of combined coronary artery bypass grafting (CABG)/aortic valve replacement (AVR) and CABG alone in patients with moderate aortic stenosis and determined the possible indications for AVR at the time of CABG. Between December 1988 and January 2001, in Tenri Hospital, 41 patients with aortic stenosis underwent CABG: 26 patients underwent the combined procedure and 15 patients underwent CABG alone. The patients who underwent CABG alone were separated them into 2 groups on the basis of the results of annual echocardiography: the rapid progression group, defined by an increase of deltaP by >/=10 mmHg/year, and the slow progression group. Of the 15 patients who underwent CABG alone, the probability of survival at the end of the study in 2001 was 92% at 5 years and 74% at 10 years, and the respective event-free rates were 65% and 50%. Patients less than 70 years old and who were in the rapid progression group had a greater risk for re-operation. The study suggests that patients younger than 70 years old with risk factors for rapid progression should undergo CABG/AVR, and conversely, those older than 70 years old without the risk factors can undergo CABG only.     

Haemodynamic effects of leg raising in patients undergoing coronary artery bypass grafting.

Twenty patients undergoing elective coronary artery bypass grafting were studied prospectively to evaluate the haemodynamic effects of passive leg raising. The patients were divided into two groups: those having good left ventricular function with ejection fraction of 0.50 or more (group I, n = 10) and those having poor left ventricular function with ejection fraction of upto 0.35 (group II, n = 10). Morphine-based anaesthetic technique was used and standard haemodynamic measurements were obtained at following stages: (1) control--20 to 30 min after induction of anaesthesia; (2) one minute, and (3) five min after raising both the legs; (4) one min, and (5) five min after the legs were repositioned. In group I, heart rate decreased from 71 +/- 9 to 66 +/- 8 beats/min (p < 0.001) at stage 1 and persisted throughout the study period. This was accompanied by a decrease in cardiac index, although, the statistical significance was achieved at stage 3 and 4 only. The haemodynamic changes observed in group II were of more severe magnitude. The heart rate decreased from 90 +/- 13 to 84 +/- 13 beats/min at stage 1 (p < 0.05) and persisted throughout the study with maximum decrease of 14 percent occurring at stage 3. The cardiac index decreased significantly from 2.4 +/- 0.3 to 2.0 +/- 0.5 L/min/m2 (p < 0.05) at stage 1. This persisted throughout the study except that it recovered at stage 4. The maximum decrease in cardiac index (20%) occurred at stage 2. In addition, systemic vascular resistance increased significantly from 1458 +/- 255 to 1830 +/- 420 dyne.sec.cm-5 (p < 0.05) at stage 1 and persisted throughout the study period. We conclude that passive leg raising should be undertaken with caution in patients with coronary artery disease especially in those who have poor left ventricular function.