Hibernating myocardium: clinical and functional response to revascularisation

Objective: We assessed the effects of coronary bypass grafting on left ventricular (LV) function, exercise capacity and symptom profile in patients with LV impairment and evaluated the role of identifying myocardial hibernation in a prospective non-randomised study. Methods: Of 120 patients screened, 47 patients with LV ejection fraction <35% and three vessel coronary artery disease were studied. All underwent stress/redistribution and separate day rest/redistribution Tl-201 imaging together with cine MRI at enrolment, and cine MRI at follow-up. Group 1, 30 patients undergoing bypass surgery, underwent symptom limited treadmill exercise testing with peak VO₂ measurement, and symptom profile evaluation less than 3 months before, and 3–6 months after operation. Revascularisation was assessed by post-operative Tl-201 imaging and repeat coronary angiography. Group 2, 17 patients treated on medical therapy alone underwent symptom profile assessment at enrolment and follow-up for those who survived. Segmental hibernation was defined as the equivalent of greater than 50% of maximal Tl-201 uptake where wall motion was severely impaired on resting imaging. Patients were considered to be hibernating where two of nine LV segments fulfilled these criteria. Results: In group 1, five patients died (17%), peri-or post-operatively, two defaulted and 23 attended follow-up studies. In group 2, three patients died prior to follow-up (18%). In the surgical group there was an increase in mean LVEF from 24.0±8% to 29.7±11% (P<0.05) while in the medical group there was a fall from 25.7±10% to 20.6±8% (P<0.05). In group 1, the mean NYHA dyspnoea grade improved from 2.7 to 1.4 while in the medical group it was unchanged, 2.6 to 2.5. In patients with myocardial hibernation identified pre-operatively, 18/19 (95%) improved LVEF after CABG compared with 2/4 (50%) of patients without hibernation. 17/19 (86%) patients with hibernation improved NYHA dyspnoea class compared with 2/4 (50%) of patients without. 60/93 (65%) of hibernating segments improved function after revascularisation while 47/53 (89%) hibernating segments showed no improvement on medical therapy alone. Conclusion: In patients with severe LV impairment with myocardial hibernation, coronary artery bypass grafting improves both global and regional systolic LV function, and symptom profile. Medical treatment of patients with LV impairment and myocardial hibernation does not improve LV contractile function or symptoms. Both surgical and medical therapy carry a high mortality rate.     

术前置入主动脉内球囊反搏对高危冠状动脉旁路移植术患者预后的影响

目的比较高危冠心病患者术前预防性置入主动脉内球囊反搏(IABP)和被动紧急置入IABP对临床预后的影响. 方法 35例接受冠状动脉旁路移植手术同时需接受IABP置入的患者,根据置入的时机不同分为两组.术前置入组 接受术前预防性置入IABP;对照组术中或术后接受紧急置入IABP.比较两组围术期死亡率、心肌梗死发生率、术后心功能不全和需要正性肌力药物辅助的程度、IABP使用的时间、术后呼吸机辅助时间和重症监护治疗病房(ICU)停留时间. 结果术前置入组围手术期死亡率和心肌梗死发生率分别为11.1%和0%,较对照组低(65.4%,50%;P＝0.007,0.013);两组呼吸机辅助通气时间、IABP使用时间、术后需正性肌力药物辅助时间以及术后平均住ICU时间差别均有显著性意义(P＜0.05). 结论术前预防性置入IABP能降低围术期死亡率、心肌梗死发生率,减少对正性肌力药物的需要量和缩短住ICU时间.     

Cardio-pulmonary-bypass time has important independent influence on mortality and morbidity

Objective: To determine the influence of cardio-pulmonary-bypass-time on hospital mortality and ICU-morbidity in isolated CABG surgery. Methods: Between 1985 and 1994 perioperative data of 8578 consecutive CABG operations were prospectively collected. Seven variables: gender, redo vs. primary operation, elective vs. urgent surgery, age in 4 categories, use of IMA, number of distal anastomoses (>4 vs. <=4), and cardio-pulmonary-bypass-time in four categories were entered in multivariate logistic regression analysis and odds ratios for respective cardio-pulmonary-bypass-time-categories with regard to mortality, length-of-stay in the ICU and 8 ICU-complications were calculated. Bypass-time up to 90 min was the reference category, the other categories were from 1.5 to 2.5 h, 2.5 to 3.5 h, and longer than 3.5 h. Results: 8337 operations had complete data. Mortality and ICU-morbidity were low. The odds ratios for mortality were 2.3 (P=0.0094), 7.4 (P<0.0001) and 20.7 (P<0.0001) for ascending bypass-time-categories. The odds ratios for prolonged ICU-stay were 1.8 (P=0.0002), 3.3 (P<0.0001) and 7.9 (P<0.0001) for ascending bypass-time-categories. For postoperative complications the same pattern was found: consequently higher odds ratios for longer bypass-time-categories. Conclusion: The highly significant correlation between cardio-pulmonary-bypass-time-category and the occurrence of undesirable postoperative events is demonstrated by the consequent rise in odds ratios. This independent influence of cardio-pulmonary-bypass-time on outcome reflects both problems encountered during revascularisation and time-related influence of cardio-pulmonary-bypass on the human body. When a predictive model was created, CPBT proved to be a good predictor of undesirable postoperative events.     

Cardiac events after combined surgery for coronary and carotid artery disease

Objective: To evaluate serious cardiac events after combined (either single or two stage) coronary artery surgery (CAS) and carotid endarterectomy (CEA) for concomitant coronary and carotid artery disease. Methods: We have analyzed our 15 year experience (January 1981–September 1996) with 201 consecutive patients operated on using both approaches. Group A consisted of 48 patients with the single-stage procedure, while in group B (153 patients), two stage procedure was carried out, either as carotid endarterectomy (CEA), followed by coronary artery bypass surgery (CAS) (group B₁⁻ 103 patients), or as CAS followed by CEA (group B₂⁻ 50 patients). Five patients from B₁ group died after the CEA procedure, but were included, despite the fact they never reached the second stage. Left main coronary artery disease was found in 41 patients (20.4%), poor left ventricular function in 49 (24.4%) previous MI in 133 (66.2%), while 136 (67.7%) were in NYHA functional class III or IV. Bilateral carotid involvement was present in 61 patients (30.3%). Unstable angina was more prevalent in groups A and B₂ (P<0.0001), NYHA class III/IV in group A (versus B₁, P=0.001 and versus B₂, P=0.02), low ejection fraction in groups A and B₂ (P<0.0001), bilateral carotid stenosis in group B₁ (versus A, P=0.003 and versus B₂, P<0.0001), and ulcerated plaque in group B₁ (P<0.0001). These differences dictated the surgical strategy, which resulted in different protocols for clinical and operative management. Results: Early mortality for the entire group was 5.5% (11/201) 6.2% in group A, 7.8% in group B₁ and 0% in group B₂, respectively; (P>0.05). Serious morbidity occurred in 7.5% of patients (8.3% in group A, 7.8% in group B₁ and 6% in group B₂, respectively; P>0.05). Univariate analysis revealed only bilateral carotid stenosis to influence early outcome (P=0.04). Conclusion: Patients with concomitant coronary and carotid artery disease have relatively good immediate operative results, providing all existing lesions are corrected. Despite it did not reach the statistical significance, cardiac events were less frequent in groups A and B₂ indicating possible protective effect of prior CAS in patients with concomitant disease.     

Beta-blocker effects on postoperative atrial fibrillation

Objectives: To determine whether restarting of Beta Blocker following cardiac surgery would reduce the incidence and the severity of post-operative atrial fibrillation (AF). Methods: 210 patients who underwent elective coronary artery bypass grafting were randomized to control (C) (n=105) and Beta Blockers (BB) (n=105) groups. Preoperatively all patients were on one type or another of betablockers. Postoperatively only the (BB) group received the medication. Both groups were well matched and had the same cardioplegic technique. Results: It was found that; (1) post op (AF) developed in 40 patients of group (C) and in 18 patients of group (BB) P value <0.02. (2) 73% of (AF) patients in group (C) and 81% in group (BB) were older than 70 years of age. (3) 76% of the (AF) in (BB) group versus 43% in (C) group were converted to sinus rhythm or to a stable controlled rhythm within 24 h or less. P value <0.01. Conclusions: the results indicate that restarting the Beta Blockers in the post-operative period after coronary bypass grafts significantly control the incidence and the severity of atrial fibrillation. Also it confirms the strong relation between the older age and (AF) occurrence.     

Reoperative MIDCAB grafting: 3-year clinical experience

Objective: Minimally invasive direct coronary artery bypass (MIDCAB) is performed under direct vision without sternotomy or cardiopulmonary bypass. The technique is used in reoperative patients through various incisions to revascularize one or two areas of the heart. The internal mammary artery, gastroepiploic artery, radial artery, or saphenous vein are used as graft conduits. Methods: Anterior coronary targets are grafted with the internal mammary artery via a small anterior thoracotomy. Inferior coronary targets are grafted with the gastroepiploic artery via a small midline epigastric incision. Lateral coronary targets are grafted with radial artery or saphenous vein via a posterior thoracotomy. After partial heparinization, the anastomosis is facilitated by local coronary occlusion and stabilization. Graft follow-up consists of outpatient Doppler examination and selective recatheterization. Results: Between January 1994 and August 1997, 81 patients underwent reoperative MIDCAB grafting. Twenty-one patients (25.9%) had internal mammary grafting, 39 (48.2%) had gastroepiploic grafting, and 21 (25.9%) had lateral grafting with radial artery or saphenous vein. There were nine early deaths (four cardiac, five non-cardiac), five late deaths (three cardiac, two non-cardiac), and nine myocardial infarctions in remaining patients. Sixteen patients underwent recatheterization; there were one graft occlusion, two graft stenoses, and eight anastomotic stenoses. Mean postoperative length of stay was 3.8 days. Ninety percent (55/61) of patients are free of symptoms at a mean follow-up of 7.8 months (range 0–39). Conclusions: Reoperative MIDCAB grafting avoids the risks of resternotomy, aortic manipulation, and cardiopulmonary bypass. The techniques yield an early patency rate of 94%, which includes eight patients who had postoperative catheter-based interventions. Reoperative MIDCAB grafting had lower rates of supraventricular arrhythmia and transfusion when compared with conventional coronary artery bypass grafting, but did not offer an advantage for mortality, stroke or myocardial infarction. This 3-year experience suggests that while reoperative MIDCAB grafting can effectively revascularize focal areas of the heart, patients should be carefully selected to minimize operative risk.     

Mid-term results of the Ross procedure

Methods: Fifty patients underwent a Ross operation between June 1991 and October 1996. Preoperative diagnosis was: congenital aortic valve disease (31 patients), complex left ventricular outflow tract (LVOT) obstruction (11 patients), outgrowth of a small aortic valve prosthesis (five patients) and valve endocarditis (three patients). Half of the interventions were reoperations. All operations were root replacements. A pulmonary homograft was used in 45 patients. An aorticoventriculoplasty was combined with the root replacement in the 16 patients with LVOT obstruction and a too small aortic valve prosthesis. An enlargement or reduction plasty of the ascending aorta was necessary in seven patients. Results: The mean age was 20.9 years (range: 2.5–54 years). The mean follow up was 34.2±21 months and was 94% complete. Two patients died after 8 days (low cardiac output due to myocardial fibrosis) and 17.4 months (sudden death), respectively, resulting in a survival of 95±4% at 4 years. Those two deaths occurred in the group of patients undergoing Ross procedure and aorticoventriculoplasty. Two autografts were replaced after respectively 2 days (technical failure) and 44 months (progressive root dilatation) resulting in a reoperation-free incidence of 93±6% at 4 years. Other postoperative major complications occurred in six patients. All survivors had regular echo-Doppler examination. All autografts except one had a systolic gradient below 10 mmHg at the last examination. Thirty-four autografts had no leak, ten showed grade 1–2 regurgitation. Two patients showed a higher than grade 3 regurgitation: one leak remains stable with normal left ventricular dimensions and function, one autograft was replaced by a mechanical valve. Conclusion: This experience demonstrates that the medium-term results of the Ross procedure are excellent even in complex LVOT obstructions.     

Early results with the minimally invasive thoracotomy for myocardial revascularization

Objective: We report the early results of the left anterior descending artery revascularization through a minimally invasive thoracotomy, examining the main technical aspects of the operation. Methods: From January 1995 to September 1996, 51 patients underwent myocardial revascularization through a mini-thoracotomy on beating heart without cardiopulmonary bypass. The main indication to operation was limited lesions of the left anterior descending artery with contra-indications or high risk of failure of angioplasty. The position of the patient was the same than traditional surgery; the chest was opened on the fourth left intercostal space; the left internal mammary artery harvested under direct vision; temporary occlusion of the left anterior descending was obtained prevalently using 5–0 poliypropilene sutures; the anastomosis was performed with single or double 7–0 or 8–0 suture. In six patients the chest was closed and a conventional open-heart operation was performed due to internal mammary artery or left anterior descending unsuitability for minimally invasive revascularization. All the patients were submitted after operation to early angiographic control and/or a Doppler study of the mammary flow. Results: There was no intra-operative mortality. One patient had a postoperative myocardial infarction of the anterior-lateral wall of the left ventricle, and died after an emergency open-heart operation. In one case the patient was reopened after a few hours for a bleeding. Three patients showed various degrees of anastomotic stenosis at the angiographic control. Conclusions: Several technical difficulties can play an important role in the operative outcome because a single repeated technical error could not fully explain these heterogeneous observed failures. The technique of myocardial revascularization through a left anterior small thoracotomy might present several critical points, particularly: (1) the harvesting of LIMA, meaning the preservation of integrity of the arterial wall and adequacy of the length; (2) the method of the temporary closure of the LAD during of the anastomosis; (3) the stabilization of the LAD and the surgical technique of the anastomosis; (4) the methods for intraoperative control of the patency of the anastomosis. All points mentioned have been thought in our experience to be causes of early failure.     

冠状动脉旁路移植术应用主动脉球囊反搏的预后分析

目的 对冠状动脉旁路移植术应用主动脉球囊反搏的预后进行分析,评估应用效果.方法 回顾性分析2001年12月-2011年12月新疆维吾尔自治区人民医院收治的82例冠心病患者在冠状动脉旁路移植术后应用主动脉球囊反搏的情况,结合术前左心室射血分数,分析术后早期并发症、病死率、左心室射血分数等相关结果.结果 术后早期死亡14例.43例应用主动脉球囊反搏辅助且无严重并发症(恶性心律失常、肾功能不全),术前平均左心室射血分数为(46.0±1.8)％,术后早期为(50.0±2.7)％(P＜0.05);术前平均左心室舒张末径(66.0±4.1) mm,术后早期为(53.0±2.8) mm (P＜0.05).25例应用主动脉球囊反搏出现了严重并发症.结论合理应用主动脉球囊反搏能够降低术后早期病死率,术后呼吸道感染、肾功能不全为主要并发症.冠状动脉旁路移植术术后积极应用主动脉球囊反搏能降低早期病死率及改善心功能.     

Improvement of heart-, lung-, and liver-performance during mechanical circulatory support by the Novacor-system

Objective: Since its clinical introduction, the Novacor left ventricular assist system (LVAS) has proved to be a reliable and safe method for bridging to cardiac transplantation. To find out whether univentricular assistance is sufficient in patients with severe global heart failure, multi organ monitoring using the COLD system was performed. Methods: In seven patients (mean age 38.8 years), the wearable Novacor system N100 was implanted. Preoperatively, during the first 72 h thereafter and before heart transplantation right and left ventricular cardiac output, right ventricular ejection fraction, pulmonary-, intrathoracic-and total blood volume, extravascular lung water and excretory liver function were monitored by means of double indicator dilution technique with the COLD system. Conventional hemodynamic parameters have also been documented. Results: During left ventricular assistance, both pulmonary and systemic arterial cardiac outputs increased significantly (Student's t-test, P<0.05). Right ventricular ejection fraction rose from 17 to 26%, preoperatively elevated pulmonary-and intrathoracic blood volumes and extravascular lung water fell significantly to normal ranges. Total blood volume remained constant, excretory liver function improved markedly. Conclusions: Pulmonary cardiac output improves due to the reduced right ventricular afterload by unloading the impaired left ventricle with the Novacor pump. The drop in pulmonary blood volume, intrathoracic blood volume and extravascular lung water also indicates a decrease of pulmonary congestion. Since total blood volume remains unchanged, a volume shift to the systemic circulation is suggested, resulting in an improved splanchnic perfusion as demonstrated by a better excretory liver function. In the absence of primary pulmonary hypertension, treatment of global heart failure with a left ventricular assist device is possible. The COLD system is a useful tool for managing this patient group during the postoperative period.     

Sternal wound complications-incidence, microbiology and risk factors

Objective: Sternal wound complications, i.e. instability and/or infection (mediastinitis), are important causes of morbidity in patients undergoing cardiac surgery via median sternotomy. Coagulase negative staphylococci, a normal inhabitant of the skin, have evolved as a cause of sternal wound infections. Since these opportunistic pathogens often are multiresistant, they can cause therapeutic problems. Methods: From 1980 through 1995 open heart surgery, was performed on 13,285 adult patients. Reoperation necessitated by sternal wound complications occurerd in 203 patients (1.5%). The incidence was 1.7% (168/9987) after coronary artery bypass grafting (CABG group) and 0.7% (35/3413) after heart valve surgery with or without concomitant CABG (HVR group). Results: Factors independently related to sternal complications in the CABG group (variable odds ratio [95% C.I.]): year of surgery, 1.9 [1.3–2.8] in 1990–1992, 2.0 [1.4–2.9] in 1993–1995; female sex, 0.4 [0.2–0.6]; diabetic disease, 1.8 [1.2–2.5]; bilateral ITA procedure, 3.3 [1.1–7.7]; and postoperative dialysis, 3.1 [1.4–6.9]. In the HVR group they were: use of ITA graft, 3.7 [1.7–7.7]; early re-exploration because of bleeding 3.0 [1.1–8.2]; and postoperative dialysis 3.1, [1.4–9.3]. Multivariate models were used to compute the risk for sternal complications in each patient. However, the prognostic models based on these risk scores provided low sensitivity and low predictive value. Patients with sternal wound complications showed no increased early mortality but worse long-term survival even after adjustment for other factors (relative hazard in CABG group 1.9 [1.2–2.8]; in HVR group 2.1 [1.1–4.3]. Conclusions: The use of ITA grafts seems to be one of the most important factors related to sternal wound complications. However, patients at truly increased risk for this complication could not be identified on the basis of the risk factors considered in this study.     

Surgery for pulmonary aspergillosis

Objective: Surgery of pulmonary aspergillosis followed by higher incidence of post-operative complications. This was the purpose to evaluate our material. Methods: Between January 1983 and December 1995, the operation was carried out on a total of 84 patients for pulmonary aspergillosis. The patients were comprised of 71 males and 13 females, with a mean age of 49 years (range, 24–71). Previous lung disorders were observed in about half of the cases (most frequently tuberculosis), while in the other half aspergillosis was developed on the basis of (sub)-acute infections. Haemoptysis was present in 48% of patients. The diagnosis was suspected in 47 cases by chest X-ray. Aspergilloma was diagnosed in 50 patients pre-operatively (excluding 12 typical aspergillomas for cavernostomies), with the other pre-operative diagnoses being tuberculosis, lung cancer, pyoscelrosis, etc. Results: In 71 cases pulmonary resection was carried out (52 lobectomies, 13 wedge resections and six pulmonectomies). A total of 12 cavities were opened by cavernostomy and one lung biopsy was performed for disseminated lung disease. The post-operative mortality rate was 9.5%. The most common complications were bleeding, empyema, bronchial fistula and wound infection. In 23 patients with developed prolonged air leak and/or residual air space, complications were observed more frequently in patients with greater cavitation near the chest wall. Conclusions: In most cases of pulmonary aspergilloma surgical intervention remains the only effective therapy. The operation has a lower risk factor in asymptomatic patients and in patients without pleural or chest wall involvement. In some cases, cavernostomy may be the only remaining surgical choice.     

Prospective randomized trial of single clamp technique versus intermittent ischaemic arrest: myocardial and neurological outcome

Objective: To explore the hypothesis that intermittent ischaemic arrest (IIA) provides better myocardial preservation but generates a larger number of cerebral microemboli (ME) and consequently a higher incidence of post-operative cerebral dysfunction compared with the single clamp technique (SCT). Methods: Ninety-one patients with stable angina undergoing elective CABG with no clinical evidence of aortic or cerebro-vascular or neurological disease were prospectively randomized to: IIA (n=43) or SCT with intermittent anterograde cold blood cardioplegia (n=48). Myocardial preservation was assessed by measuring serum CK-MB, Troponin-T (TnT) and Troponin-I (TnI) and from pre- and post-operative ECGs and left ventricular (LV) function by echocardiography. Intra-operative cerebral ME were counted by transcranial Doppler of the right middle cerebral artery. All patients completed the Luria Nebraska Neuropsychological Battery (LNNB) tests for motor, visual, reading, memory and intellectual processes the day before surgery and at 1 week and 6 months post-operatively. Serum levels of the neuro-specific protein S-100 were measured. Results: The two groups were comparable for age, sex, extent of coronary disease, previous myocardial infarction, diabetes, hypertension and number of arterial and venous grafts. The median number of ME detected per patient was 34 (range 4–208) and was similar in both groups. Protein S-100 levels remained normal and similar in both groups at all times except in one patient with SCT who had an operative stroke. LNNB scores were similarly depressed at 1 week and recovered in all cases at 6 months. There was no correlation between the number of ME and LNNB scores. Median peak TnI levels were 0.64 μg/l with IIA vs. 0.87 μg/l with SCT (P=NS) and TnT 0.8 μg/l vs. 1.08 μg/l (P<0.03). SCT was however associated with longer mean ischaemic (67.6±16.1 vs. 34.5±16.5 min, P<0.001) and mean bypass time (88.5±18.2 vs. 74.6±26.3min, P<0.004) than IIA. Four patients with SCT and none with IIA had ECG changes suggestive of MI (P=0.04). Conclusion: During elective CABG in patients with no clinical evidence of aortic or cerebro-vascular disease the incidence of peri-operative ME and post-operative neuropsychological disturbances are comparable with both techniques of myocardial preservation. Biochemical analysis suggests that IIA provides more effective myocardial preservation.     

Effects of cardiopulmonary bypass on neonatal and paediatric inflammatory profiles

Objective: Cardiopulmonary bypass (CPB) causes significant morbidity in paediatric patients, yet the mechanisms involved in the related inflammatory processes (resulting in capillary leak and edema) are poorly understood. Moreover, earlier palliative and corrective intervention in neonates and infants has provided the cohorts of patients about whom little is known of their proinflammatory response. Methods: In the present two group study, 14 neonates (age 1–28 days, 2.5–4.5 kg) and 13 infants (2–12 months, 3–7 kg), undergoing CPB for congenital heart disease were consecutively recruited. The two cohorts were well matched in terms of CPB and aortic cross-clamp times (P>0.1). Blood samples were collected on induction of anaesthesia, 5 min following onset of CPB, at the end of CPB, and 30 min, 2 and 24 h post-protamine (PP) administration. Plasma concentration of cytokines interleukin-6 (IL-6) and interleukin-8 (IL-8), terminal complement complex (C5b-9) neutrophil counts and leucocyte elastase were measured. Results: Plasma levels of all inflammatory markers significantly increased in both groups during and following CPB as compared to baseline. During and following CPB the change in IL-8 level was more pronounced in neonates (peak 30 min PP, median(range): 1062 (182–3872) pg/ml) than in infants 568 (172–1368) pg/ml), P=0.01. Changes in IL-6 level were indistinguishable between groups intraoperatively, but remained significantly higher at 24 h in neonates (P=0.02). Peri and postoperative levels of C5b-9 were significantly higher in infants than in neonates (peak 30 min PP, median (range): 984 (118-1142) ng/ml vs 458 (22–1340) ng/ml in neonates respectively, P=0.01) but were similar at 24 h. Despite this, leucocyte elastase profiles did not differ significantly between the respective cohorts. Conclusion: These results indicate that there may be differences between neonates and infants with regard to the inflammatory response to CPB and neonatal patients merit further investigation in order to elucidate whether the pathophysiology of their CPB related inflammatory response and its clinical sequelae differs from their older counterparts.     

主动脉内球囊反搏在高危冠状动脉旁路移植患者围手术期的应用

目的 总结应用主动脉内球囊反搏(intra-aortic balloon pump IABP)治疗重症冠心病患者的经验,比较冠状动脉旁路移植术前、术中及术后放置IABP对于重症冠心病的治疗效果,为重症冠心病患者临床使用IABP提供参考.方法 回顾性分析2008年1月至2011年5月6208例行冠状动脉旁路移植术或冠状动脉旁路移植合并其他心脏手术的患者资料,按置入IABP时间将103例重症并行IABP治疗患者分为IABP术前置入组(组1)38例、术中置入组(组2)31例和术后置入组(组3)34例.组1为术前药物治疗不能控制的不稳定型心绞痛、冠状动脉左主干狭窄＞90％、心功能低下(左心室射血分数＜0.40)、心源性休克行急诊手术及顽固性室性心律失常患者.组2及组3均符合组1的置入指征并且在术中或术后出现血流动力学不稳定、低心排血量综合征、脱离体外循环困难及心功能降低.分析比较3组术后病死率、住院时间、ICU停留时间、呼吸机使用时间、IABP辅助时间、射血分数改善率、其他机械辅助装置使用比例、室颤及胸腔积液发生率等指标.结果 3组术后死亡比例(组1 2.6％、组212.9％、组3 47.1％)、住院时间[组1(23.6±9.8)天、组2(21.5 ±9.7)天、组3(28.9±13.3)天]、ICU停留时间[组1(2.3±1.1)天、组2(3.5±1.5)天、组3(5.2±3.4)天]、气管插管时间[组1 (29.5±23.0)h、组2(38.7 ±20.6)h、组3(84.1±48.0)h]、IABP维持时间[组1(77.0±43.7)h、组2(93.8±44.8)h、组3(121.5 ±71.7)h],EF改善率[(组1(7.5±7.2)、组2(8.5±7.5)、组3(2.0±6.7)]和正性肌力药物维持时间[组1(3.7±4.9)天、组2(6.2±4.6)天、组3(10.8±5.4)天],差异均有显著统计学意义(P＜0.05).结论 重症冠心病患者术前置入IABP可以明显获益.患者有IABP应用指征时,应果断尽早应用.     

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.