急诊冠状动脉搭桥术

目的探讨急诊冠状动脉搭桥(CABG)术的手术指征及外科处理要点,提高手术成功率.方法1999年1月至2001年5月18例急诊CABG病人中男15例,女3例.年龄40.0～71.5岁,平均(61.7±8.5)岁.术前急性心肌梗死(AMI)8例[7例直接行冠状动脉造影(冠造)及经皮腔内冠状动脉成形术(PTCA);1例溶栓失败,急诊行冠状动脉造影及PTCA],冠造均提示三支血管病变,急性心肌梗死到急诊CABG手术时间平均(9.4±6.3)?h;不稳定心绞痛不能控制7例;冠状动脉造影术及PTCA时右冠状动脉撕裂、急性心包压塞及室颤各1例.术前放置主动脉气囊反搏泵(IABP)13例.17例在体外循环下行急诊CABG术,平均体外循环时间(78.5±25.2)?min,平均阻断时间(65.3±23.6)?min;平均每例搭桥(3.4±1.1)支;1例小切口行不停跳搭桥.采用左内乳动脉桥14例、右内乳动脉桥1例、桡动脉桥6例.结果1例术中死亡,1例术后死于低心输出量综合征.余16例随访2～25个月,无死亡;亦无明显心绞痛及心肌缺血表现.结论急诊CABG是挽救不能控制的急性心肌缺血的有效方法之一,及时正确的抢救方法是保证手术成功的关键.     

Emergency conversion in off-pump coronary artery bypass grafting

Emergency conversion to cardiopulmonary bypass in off-pump coronary artery bypass grafting is recognized to increase operative mortality and morbidity. We conducted a retrospective review of 616 consecutive patients who were planned for off-pump coronary artery bypass grafting from April 2001 to July 2004. Fourteen patients (2.3%) required emergency conversion to cardiopulmonary bypass. Operative mortality was 13.3% in the conversion group and 1.2% in the non-conversion group (P<0.001). The incidence of reoperation for bleeding was 7.1% and 1.0%, respectively (P=0.032) and that of respiratory failure was 35.7% and 3.3%, respectively (P<0.001). Multivariable analysis showed that mitral regurgitation and chronic obstructive pulmonary disease were predictors of emergency conversion with all causes except for bleeding, and that mitral regurgitation and no use of a heart positioning device were predictors of emergency conversion due to hemodynamic compromise during distal anastomosis of the circumflex artery territory. In conclusion, emergency conversion in off-pump coronary artery bypass grafting increases operative mortality and morbidity. Mitral regurgitation and chronic obstructive pulmonary disease are risk factors for emergency conversion. Use of a heart positioning device decreases hemodynamic compromise during anastomosis of the circumflex artery territory.     

Emergency coronary artery bypass surgery after failed percutaneous transluminal coronary angioplasty

Coronary complications caused by percutaneous transluminal coronary angioplasty (PTCA) may necessitate emergency coronary artery bypass grafting (CABG). In 1994-1998, 132 patients (1.5% of the patients registered in the Danish PTCA registry) underwent CABG within 24 h because of angioplasty complications. We reviewed the files of 86 patients who had emergency operations within 6 h and found that 35% suffered from 1-vessel disease. Fifty-eight percent were taken directly to the operating room from the cardiovascular laboratory, and 13% were given preoperative cardiovascular resuscitation. The vessels most frequently injured were the right coronary artery and the left anterior descending branch (LAD). The patients received a mean of 2.4 coronary bypasses each. Forty-three percent of the patients with lesions of the left main coronary artery and/or the LAD received a vein graft to the LAD. A perioperative Q-wave myocardial infarction developed in 51% of the patients. The in-hospital mortality rate was 12%. These results are inferior to those obtained after elective surgery. Local cardiothoracic backup is vital when PTCA is performed in an unselected patient group.     

Emergency coronary artery bypass graft surgery in abciximab-treated patients

BACKGROUND: Although the platelet antiaggregant abciximab is frequently used with percutaneous coronary interventions, results of emergency coronary artery bypass graft operations in patients recently treated with abciximab are poorly characterized. METHODS: During a 29-month period, 12 patients required emergency coronary artery bypass grafting within 12 hours (mean, 1.9 hours) of abciximab therapy. Our full standard heparin dose regimen was used (mean heparin dose, 53,000 U per patient). Each patient received a single platelet transfusion dose after protamine administration, and further blood products were transfused as necessary. Clinical outcome and transfusion requirements were compared with predicted results based on risk-adjusted historical patients. RESULTS: No patients died and none were returned to the operating room for coagulopathy-related bleeding. Per patient transfusion requirements were as follows: red blood cells, 3.6 units; apheresis platelets, 1.4 units; and fresh frozen plasma, 1.5 units. As compared with predicted values, there was no excessive incidence of mortality, stroke, or red blood cell transfusion requirements. CONCLUSIONS: Emergency coronary artery bypass graft operations using full-dose heparin can be performed successfully in acutely ischemic abciximab-treated patients. Prophylactic transfusion of platelets after protamine administration appears to be useful.     

Emergency coronary artery bypass grafting for failed percutaneous transluminal coronary angioplasty]

There were 1151 patients who underwent PTCA at our facilities from August 1984 to December 1990. The records of 298 patients were reviewed from August 1984 to June 1988 (former period), and were compared with records of 853 patients undergoing treatment after June 1988 (latter period). Of 852 elective PTCA procedures, complete occlusion of the lesion increased from 2.3% in the former period to 17.5% in the latter period, while for partial occlusion there were 60.4% in the former and 60.5% in the latter. Emergency PTCA for acute myocardial infarction decreased from 37.2% in the former to 22% in the latter. The number of patients with multivessel disease increased slightly from 43.6% in the former to 46.8% in the latter. The success rate for patients who underwent elective PTCA for complete occlusion was 42.8% in the former and 49.6% in the latter, while for partial occlusion it was 87.2% in the former and 91.8% in the latter. The success rate for patients requiring emergency PTCA was 73.8% in the former and 90.4% in the latter. Of the patients undergoing elective PTCA, acute coronary closure occurred in 3% of the former and in 1% of the latter, while for patients requiring emergency PTCA, there were 4.4% in the former and 2.7% in the latter. Of the 8 patients who required emergency CABG, elective PTCA was unsuccessful in 4 cases and emergency PTCA was also unsuccessful in the other 4; in other words, 4 of a total 852 elective PTCAs (0.47%) and 4 of 299 emergency PTCAs (1.3%) for an overall figure of 8/1151 (0.7%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Emergency off-pump coronary artery bypass grafting under a beating-heart.

BACKGROUND: Coronary artery bypass grafting (CABG) on a beating heart has been successfully performed for high risk patients, and is known to be less invasive than conventional CABG using cardiopulmonary bypass (CPB). We expanded the indication of beating-heart CABG in patients requiring emergency coronary revascularization. METHODS: A retrospective chart review was performed for patients who had undergone emergency CABG on a beating heart (EM-BH group), elective CABG on a beating heart (Elective-BH group) and emergency CABG under CPB (EM-CPB group), between January 1, 1997 and June 30, 1998. RESULTS: Four cases (1 male and 3 females with a mean age of 67.8 +/- 5.4) in the EM-BH group, 67 cases (48 males and 19 females with mean age of 67.3 +/- 7.8) in the Elective-BH group, and 41 cases (29 males and 12 females with mean age of 63.3 +/- 10.4) in the EM-CPB group were analyzed. The number of the grafts was 1.75 +/- 0.50 in EM-BH group, 1.37 +/- 0.55 in the Elective-BH group, and 2.95 +/- 1.07 in the EM-CPB group. The intubation period, ICU stay, and the postoperative hospital stay were significantly shorter in the EM-BH group (6.0 hours intubation, 1.5 days ICU stay, and 11.5 days postoperative hospital stay) and Elective-BH group (6.8 +/- 11.0 hours intubation, 1.6 +/- 1.5 days ICU stay, and 12.7 +/- 5.2 days postoperative hospital stay) than in the EM-CPB group (20.1 +/- 22.5 hours intubation, 3.6 +/- 2.4 days ICU stay, and 21.8 +/- 14.9 days postoperative hospital stay). CONCLUSION: The postoperative recovery period for EM-BH patients was almost the same as that for elective cases of beating-heart CABG, and was significantly shorter than that of conventional emergency CABG under CPB. Selected patients with coronary ischemia can be safely treated by beating-heart surgery.     

Emergency coronary artery bypass graft surgery for threatened acute myocardial infarction related to coronary artery catheterization

In 20 patients undergoing cardiac catheterization, usually involving balloon-catheter dilation or streptokinase infusion, catheter-induced coronary artery intimal damage resulted in severe chest pain, electrocardiographic evidence of obstruction or dissection of a major coronary artery. These patients were surgically revascularized within 8 hours after the onset of the acute chest pain syndrome. Our experience with pharmacological and catheter-related manipulations to improve coronary blood flow after the ischemic episode but before operation suggested that the additional time spent in the catheterization laboratory was worthwhile. The injured coronary artery was the left anterior descending in 10 patients, the right in 8, the left main in 1 patient, and an obtuse marginal branch of the circumflex in 1. The average number of grafts per patient was 2.5; only 6 patients had single bypass grafts. In 5 patients, intraaortic balloon pumping was used either preoperatively or postoperatively. Inotropic support was used postoperatively in 5 patients, and 7 patients received lidocaine for ventricular irritability. Abnormal elevation of the serum isoenzyme of creatine kinase (CK-MB) was seen in 8 patients, and new Q waves were noted in 4 patients; 3 of these 4 patients with new Q waves also had abnormal serum CK-MB levels. Global ejection fraction obtained by the equilibrium-gated blood pool scan postoperatively was 60 +/- 3%, which was similar to the 62 +/- 3% obtained from the contrast-determined ventriculogram done preoperatively prior to the catheter-related injury. There were no early or late deaths, but morbidity was much higher in the group who had emergency coronary artery bypass grafting (CABG) compared with those who had elective CABG.(ABSTRACT TRUNCATED AT 250 WORDS)     

Off-pump coronary artery bypass

OBJECTIVES: Off-pump coronary artery bypass grafting (CABG) on the beating heart has become popular procedure in cardiac surgery and its initial results appeared favorable. We report our early and mid-term results of off-pump CABG performed at Shin-Tokyo Hospital. METHODS: Medical records of patients undergoing off-pump or conventional on-pump CABG from September 1, 1996, to August 31, 1999 were retrospectively reviewed. Patients underwent off-pump CABG were further classified into 2 groups; MIDCAB (Off-pump CABG for single vessel revascularization via a small skin incision) and OPCAB (off-pump CABG mainly approached via midline sternotomy) group. Their preoperative, perioperative, and follow-up data were collected and analyzed. RESULTS: Among a total of 995 cases of CABG, 194 cases were off-pump CABG (male/female 142/52, mean age 66.9). The mean number of distal anastomoses in off-pump CABG was 1.9 +/- 0.9 (1.0 +/- 0.0 in MIDCAB and 2.3 +/- 0.7 in OPCAB), which was significantly fewer than in on-pump CABG (3.6 +/- 1.1), with p < 0.0001. Intubation time (5.3 +/- 5.7 hours in off-pump CABG vs 13.1 +/- 24.2 hours in on-pump CABG), ICU stay (1.7 +/- 1.1 vs 3.2 +/- 3.0 days), and postoperative hospital stay (14.0 +/- 7.9 vs 18.1 +/- 12.1 days) in off-pump CABG were significantly shorter than in on-pump CABG (p < 0.0001). In the off-pump CABG group, there were no in-hospital deaths and 14 major complications, fewer than in on-pump CABG (8 hospital deaths and 114 major complications). Postoperative angiography before hospital discharge was conducted in 80 patients (41.2%) and showed 2 occlusions, giving a graft patency rate of 98.6% in the off-pump group. During follow-up (0.9 +/- 0.6 year) period, there were 5 non-cardiac deaths and 20 cardiac events in the off-pump group. The actuarial survival rate at 36 months was 94.6% for off-pump CABG, showing no significant difference from the rate for conventional CABG patients (95.2% at 36 month, p = NS) The event-free rate was 84.0% at 36 months in off-pump CABG patients; however, which was less favorable than on-pump CABG patients (88.0% at 36 months, p < 0.05). CONCLUSIONS: Both in-hospital and mid-term results for off-pump CABG patients were acceptable. Isolated CABG can thus be safely performed without cardiopulmonary bypass. Advances in coronary stabilization have contributed to these improved results. The observed long-term cardiac events may be related to incomplete revascularization.     

Emergency coronary artery bypass grafting for failed angioplasty: risk factors and outcome

It has been suggested that coronary artery bypass grafting (CABG) performed in the setting of emergent failure of percutaneous transluminal coronary angioplasty causes minimal increased risk compared with routine CABG. We reviewed the records of 103 patients undergoing emergency CABG for failed percutaneous transluminal coronary angioplasty (group 1) and compared them with an identical number of consecutive CABG patients from 1987 (group 2). Group 1 had a lower risk profile evidenced by lower mean age (p less than 0.01), fewer diseased vessels (p less than 0.0001), better ventricular function (p less than 0.001), fewer left main lesions (p less than 0.0001), and fewer patients with acute ischemia requiring intravenous administration of nitroglycerin (p less than 0.01). Despite these differences, the group 1 patients had a higher mortality rate (11% versus 1%; p less than 0.01) and a higher rate of perioperative infarctions (new Q wave) (22% versus 6%; p less than 0.01). An analysis of risk factors was performed in the group 1 patients using 36 preoperative and operative variables. Multivariate analysis revealed that left ventricular score (p less than 0.0001), preoperative (after percutaneous transluminal coronary angioplasty) need for inotropic support (p less than 0.005), and age (p less than 0.025) were independent predictors of operative mortality. In conclusion, emergency CABG after failed percutaneous transluminal coronary angioplasty carries a significantly greater risk of operative death and perioperative infarction than elective CABG.     

Emergency coronary artery bypass surgery for failed percutaneous coronary angioplasty. A 10-year experience.

Six hundred ninety-nine patients have required emergency coronary artery bypass after failed elective percutaneous coronary angioplasty during the decade September 1980 through December 1990. This represents 4% of 9860 patients having 12,146 elective percutaneous coronary angioplasty procedures during this interval. Emergency coronary artery bypass was required for acute refractory myocardial ischemia in 82%. Hospital mortality rate for all patients was 3.1%; 3.7% in patients with refractory myocardial ischemia but 0.8% in patients without refractory myocardial ischemia, p = 0.08. Postprocedural Q-wave myocardial infarctions were observed in 21% versus 2.4%, p less than 0.0001, and intra-aortic balloon pumping was required in 19% with versus 0.8% without refractory myocardial ischemia, p less than 0.0001. Multivessel disease, p = 0.004, age older than 65 years, p = 0.005, and refractory myocardial ischemia, p = 0.08, interacted to produce the highest risk of in-hospital death. Follow-up shows that there have been 28 additional late deaths, including 23 of cardiac causes for a 91% survival at 5 years. Freedom from both late death and Q-wave myocardial infarction at 5 years was 61%. In the group going to emergency coronary artery bypass with refractory myocardial ischemia, the late cardiac survival was 90%, and in those without ischemia, 92% at 5 years, p = not significant. The MI--free survival in the group with refractory ischemia, however, was 56% versus 83% in the group without ischemia, p less than 0.0001. Multivariate analysis showed the highest late event rates for patients with Q-wave myocardial infarction at the initial emergency coronary artery bypass, age older than 65 years, angina class III or IV, and prior coronary bypass surgery. In spite of a continuing high incidence of early acute myocardial infarction and an increasing operative mortality rate (7%) in the latest 3 years cohort of patients, excellent late survival and low subsequent cardiac event rates demonstrate the lasting effectiveness of prompt, successful emergency coronary bypass surgery for failed percutaneous coronary angioplasty.     

Reoperative coronary artery bypass grafting using a minimally invasive direct coronary artery bypass procedure

OBJECTIVE: Reoperative coronary artery bypass grafting with cardiopulmonary bypass tends to cause a higher mortality and morbidity than the primary operation. The purpose of this study was to discuss the effectiveness and safety of a minimally invasive coronary artery bypass procedure for patients who had previously undergone coronary artery bypass surgery. METHODS: We performed redo single coronary artery bypass grafting to the left anterior descending coronary artery in 9 patients and to the right coronary artery in 3 patients using minimally invasive cardiac surgery. The graft to the left anterior descending coronary artery was taken from the left internal thoracic artery in 5 patients, the right gastroepiploic artery in 3 patients, and from the saphenous vein in the other 1 patient. The graft to the right coronary artery was from the right gastroepiploic artery in all 3 patients. RESULTS: All grafts were patent. There was no major postoperative complication and no surgical or hospital death except one late death. CONCLUSIONS: In selected patients, we could safely and completely perform coronary artery bypass re-grafting to the left descending coronary artery or right coronary artery using a minimally invasive operation.     

Robotic coronary artery bypass grafting

Robotically assisted surgery enables coronary surgery to be performed totally or partially endoscopically. Using the Da Vinci robotic technology allows minimally invasive treatments. We report on our experience with coronary artery surgery in our department: patients requiring single or double vessel surgical revascularization were eligible. The procedure was performed without cardiopulmonary bypass on a beating heart. From April 2004 to May 2008, 55 consecutive patients were enrolled in the study, and were operated on by a single surgical team. Operative outcomes included operative time, estimated blood loss, transfusions, ventilation time, intensive care unit (ICU) and hospital length of stay. Average operative time was 270 ± 101 min with an estimated blood loss of 509 ± 328 ml, a postoperative ventilation time of 6 ± 12 h, ICU stay of 52 ± 23 h, and a hospital stay of 7 ± 3 days. Nine patients (16%) were converted to open techniques, and transfusion was required in four patients (7%). Follow-up was complete for all patients up to 1 year. There was one hospital death (1.7%) and two deaths at follow-up. Coronary anastomosis was controlled in 48 patients by either angiogram or computed tomography scan, revealing occlusion or anastomotic stenoses (>50%) in six patients. Overall permeability was 92%. Major adverse events occurred in 12 patients (21%). One-year survival was 96%. Our initial experience with robotically assisted coronary surgery is promising: it avoids sternotomy and with a methodical approach we were able to implement the procedure safely and effectively in our practice, combining minimal mortality with excellent survival.