心脏不停跳非体外循环冠状动脉旁路移植术的进展

近年来，随着手术器械的发展，心脏不停跳非体外循环下冠状动脉旁路移植术(OPCAB)逐渐被广泛接受和应用。与常规冠状动脉旁路移植术(CCABG)比较，OPCAB的主要优势为血液中多种炎性介质浓度明显降低，避免了体外循环(CPB)带来的全身系统性炎性损害，减少了并发症，降低了手术死亡率。特别对那些不能采用CPB或采用CPB有风险的高危患者优势更明显。CCABG的手术适应证同样适用于OPCAB，但OPCAB具有相对的禁忌证。OPCAB多采用胸骨正中切口，左前外侧切口适用于左前降支单支病变。OPCAB术后早期结果类似CCABG，但中远期结果有待进一步观察。OPCAB大多数旁路移植血管数低于CCABG，有不能完全再血管化的可能，对OPCAB是否会影响吻合的精确性和旁路血管的长期通畅率有不同意见。OPCAB的优势明确，但仍不能完全替代CCABG，手术的同时应作好CPB准备，必要时改行CCABG。     

部分冠状静脉动脉化在不停跳冠状动脉旁路移植术中的应用

冠状动脉旁路移植(冠脉搭桥术)目前已成为治疗冠心病的一种有效并被广泛接受的方法。但晚期冠状动脉弥漫性病变尤其是合并有糖尿病的病人，病人靶血管条件普遍较差，冠状动脉远端直径明显变细，血管内膜不光滑，流出阻力高，冠脉搭桥术后极易再堵塞并因此造成围术期心肌梗死。以往对于这类病人多采用冠脉搭桥加激光打孔术或单独行激光打孔术，但效果并不理想。     

心脏不停跳下多支冠状动脉旁路移植术20例

1997年 10月至 1999年 11月 ,我们在心脏不停跳下行多支冠状动脉旁路移植术 2 0例 ,现报道如下。临床资料　 2 0例中男 13例 ,女 7例 ;年龄 41～ 70岁 ,平均 5 5 2岁。合并高血压 14例、糖尿病 8例 ,伴陈旧性心肌梗死 9例 ,ＰＴＣＡ术后再狭窄 1例。射血分数 0 38～ 0 5 2。术前冠状动脉造影显示 3支病变 15例 ,2支病变 4例 ,单支左主干 90 %狭窄 1例。手术采用胸骨正中切口 ,体外循环下心脏不停跳手术 12例 ,非体外循环下手术 8例。游离内乳动脉及大隐静脉备用。体外循环组常规建立体外循环 ,术中鼻咽温 2 8 6～31 7℃ ,必要时应用局部…     

非体外循环心脏不停跳冠状动脉旁路移植术中氧动力学的变化

非体外循环下不停跳冠状动脉旁路移植术 (ＣＣＡＢＧ)中 ,如何维护氧动力学的稳定成为麻醉医师必须解决的问题。我们对 32例ＣＣＡＢＧ病人进行了围术期氧动力学变化的观察 ,以求寻找出规律 ,更好地指导临床麻醉。资料和方法　本组中男 2 6例 ,女 6例 ;年龄 51～ 78岁 ,平均 (62 0± 5 5)岁 ;体重 54～ 90ｋｇ,平均 (70 5± 1 4 3)ｋｇ。左室射血分数 (ＥＦ)为 0 58± 0 0 1。心胸比率 0 51± 0 0 5 ,心功能ＩＩ～ＩＩＩ级。合并高血压 2 2例、糖尿病 9例、术前心肌梗死 (心梗 ) 1 3例、2次心梗 3例。全组均采用静吸复合麻醉。每例平…     

心脏停跳与不停跳冠状动脉旁路移植术在高危病人中应用的比较

不停跳冠状动脉旁路移植手术（OPCAB）由于避免了应用体外循环以及由此引起的全身性炎症反应,与体外循环（CPB）停跳冠状动脉旁路移植手术（CABG）相比,OPCAB具有较低的病死率和并发症发生率.特别对于具高危因素病人,OPCAB的优越性更为明显.我们统计141例高危病人手术资料,比较CABG及OPCAB对其术后病死率、并发症发生率等的影响.     

非体外循环与常规体外循环冠状动脉旁路移植术比较

1999年12月至2003年7月，我们对410例冠心病病人施行了心脏不停跳冠状动脉旁路移植手术(冠脉搭桥，OPCAB)，对318例施行传统体外循环冠脉搭桥手术(CCAB)，现对两种术式进行比较，报道如下。     

曲马多在不停跳冠状动脉旁路移植术后镇痛中的应用

目的 探讨曲马多用于不停跳冠状动脉旁路移植术(OPCABG)后镇痛的有效性与安全性.方法 OPCABG患者64例,随机均分为两组,术中均吸入1％七氟醚和静注舒芬太尼维持麻醉,关闭胸骨前分别采用曲马多(T组)和舒芬太尼(S组)自控镇痛.记录患者疼痛VAS评分、镇静评分及不良反应.结果 T组静息VAS评分显著低于S组(P＜0.05).两组术后清醒时间和机械通气时间差异无统计学意义.结论 曲马多用于OPCABG术后镇痛具有良好的镇痛效果.     

非体外循环心脏不停跳冠状动脉旁路移植术中护理

<正>非体外循环心脏不停跳冠状动脉旁路移植术(OPCABG) 即是在没有体外循环支持下,在病人跳动的心脏表面完成冠状动脉搭桥手术,与传统的体外循环冠状动脉搭桥术(CABG)相比,它具有创伤小、费用低、并发症少、术后恢复快等诸多优点。我院2002年4月-2005年9月开展OPCABG73例,手术过程顺利,取得了良好的效果。现将手术配合和体会介绍如下:     

体质量指数对不停跳冠状动脉旁路移植术的早期影响CSCD

目的 探讨体质量指数对不停跳冠状动脉旁路移植术（OPCABG）后早期的影响.方法 2015年1月到2015年5月,连续记录在北京安贞医院完成的1062例OPCABG患者,根据体质量指数（BMI）分为体质量正常组（360例）,超重组（527例）和肥胖组（175例）,比较3组间手术死亡比例,房颤发生比例、主动脉内球囊反搏（IABP）使用比例,多器官衰竭评分系统（MODS）、心脏外科术后评分系统（PSCS）和序贯衰竭评分系统（SOFA）以及呼吸指数（PaO2/FiO2）,心率×中心静脉压/平均动脉压（pres-sure-adjusted heart rate,PAHR）.结果 超重组的手术死亡比例最低,为0.6％,显著低于体质量正常组（2.2％）和肥胖组（1.1％）,P〈0.01.肥胖组的房颤发生比例最低,为20.1％,显著低于体质量正常组（22.1％）和超重组（20.7％）,P〈0.01.IABP使用比例,体质量正常组最高,为8.1％,其次为超重组（6.0％）和肥胖组（2.9％）,P〈0.01.在手术当日和手术后第1天,肥胖组的MODS,SOFA和PSCS评分显著高于体质量正常组,P〈0.01.肥胖组的PaO2/FiO2显著低于体质量正常组,P〈0.01.肥胖组的PAHR显著高于体质量正常组,P〈0.01.结论 随着BMI的增加,肥胖组OPCABG术后死亡比例、房颤发生比例和IABP使用比例低于BMI正常组,其中超重组的死亡比例最低.     

非体外循环心脏不停跳冠状动脉旁路移植术加左心室室壁瘤折叠术的临床效果

目的评价非体外循环冠状动脉旁路移植术(OPCAB)同期行左心室室壁瘤折叠术的临床效果。方法选择2007年1月至2011年1月期间北京安贞医院资料完整的冠状动脉旁路移植术(CABG)同期行室壁瘤手术患者114例进行对比研究,其中在体外循环心脏停搏下行CABG加室壁瘤切除术76例(Ⅰ组),男57例、女19例,年龄(63.4±7.8)岁;在非体外循环心脏不停跳下行CABG加室壁瘤折叠术38例(Ⅱ组),男32例、女6例,年龄(60.6±8.9)岁。除Ⅰ组患者室壁瘤占左心室较Ⅱ组大外(42.2%±13.6%vs.26.5%±12.3%,t=5.499,P=0.000),其余临床资料相比差异无统计学意义。比较两组患者手术效果及并发症发生情况,并进行随访6个月。结果Ⅰ组中死亡2例,其中1例死于术后恶性心律失常,1例死于肺部感染;Ⅱ组1例死于围术期心肌梗死。两组患者术后胸腔引流量、二次开胸止血、呼吸机辅助时间和放置主动脉内球囊反搏(IABP)例数等差异无统计学意义(P>0.05)。两组患者术后早期及术后6个月复查心脏超声心动图,左心室舒张期末内径(LVEDD)均较术前明显减小[Ⅰ组:(54.0±7.8)mm&(56.0±8.1)mm vs.(59.6±6.6)mm,Ⅱ组:(52.0±7.2)mm&(53.6±5.3)mm vs.(57.9±5.4)mm];左心室射血分数(LVEF)显著增加(Ⅰ组:43.5%±3.2%&55.7%±3.7%vs.38.0%±7.4%,Ⅱ组:44.7%±2.8%&57.0%±3.5%vs.41.0%±6.6%),但两组间比较差异无统计学意义(P>0.05)。结论非体外循环心脏不停跳CABG同期行室壁瘤折叠术安全有效,可能更适用于室壁瘤较小的患者。     

Off-pump coronary artery bypass grafting: A single center experience

Background Coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) is gaining popularity as an effective alternative to conventional CABG using cardiopulmonary bypass. With the advent of mechanical tissue stabilization systems and intra coronary shunts the technique of off-pump CABG (OPCAB) is now applicable to revascularize the patients with multi-vessel disease. Methods A total of 293 patients underwent surgical myocardial revascularization without cardiopulmonary bypass between July 1996 and October 2000 at our hospital. Of these, 245 patients received 2 or more grafts: two in 193 patients, 3 in 46 patients and 4 in 7 patients. A mechnical tissue stabilization system (CTS or Octopus II/III) was used in all patients. In majority of the patients intra coronary shunts were also used. A total of 550 distal anastomoses were made and the vessels grafted were LAD (n=245), diagonal (n=90), ramus intermedius (n=16), obtuse marginal branches (n=58), distal right coronary artery (n=88) and posterior descending artery (n=52). Results There was no incidence of perioperative myocardial infarction. Three patients had transient ST segment elevation postoperatively which was normalized in the first few hours. Hospital mortality was 0.4%. No patient needed reexploration for bleeding. No patient had neurological event or pulmonary problems. All these patients except one were discharged from the hospital between 6 and 9 days. Conclusion In selected patients multi vessel OPCAB is a safe and reproducible technique and the mechanical tissue stabilization systems have made the procedure less difficult to perform. Its usefulness is more pronounced in high risk patients with comorbidities and the patients who undergo this procedure are free from major complications.     

Risk-adjusted analysis of long-term outcomes after on- versus off-pump coronary artery bypass grafting

 Open in a separate windowOBJECTIVESRecent data suggested that off-pump coronary artery bypass (OPCAB) may carry a higher risk for mortality in the long term when compared to on-pump coronary artery bypass (ONCAB). We, therefore, compared long-term survival and morbidity in patients undergoing ONCAB versus OPCAB in a large single-centre cohort.METHODSA total of 8981 patients undergoing isolated elective/urgent coronary artery bypass grafting between January 2009 and December 2019 were analysed. Patients were stratified into 2 groups (OPCAB n = 6649/ONCAB n = 2332). The primary end point was all-cause mortality. Secondary endpoints included repeat revascularization, stroke and myocardial infarction. To adjust for potential selection bias, 1:1 nearest neighbour propensity score (PS) matching was performed resulting in 1857 matched pairs. Moreover, sensitivity analysis was applied in the entire study cohort using multivariable- and PS-adjusted Cox regression analysis.RESULTSIn the PS-matched cohort, 10-year mortality was similar between study groups [OPCAB 36.4% vs ONCAB 35.8%: hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.87–1.12; P = 0.84]. While 10-year outcomes of secondary endpoints did not differ significantly, risk of stroke (OPCAB 1.50% vs ONCAB 2.8%: HR 0.51, 95% CI 0.32–0.83; P = 0.006) and mortality (OPCAB 3.1% vs ONCAB 4.8%: HR 0.65, 95% CI 0.47–0.91; P = 0.011) at 1 year was lower in the OPCAB group. In the multivariable- and the PS-adjusted model, mortality at 10 years was not significantly different (OPCAB 34.1% vs ONCAB 35.7%: HR 0.97, 95% CI 0.87–1.08; P = 0.59 and HR 1.01, 95% CI 0.90–1.13; P = 0.91, respectively).CONCLUSIONSData do not provide evidence that elective/urgent OPCAB is associated with significantly higher risks of mortality, repeat revascularization, or myocardial infarction during late follow-up when compared to ONCAB. Patients undergoing OPCAB may benefit from reduced risks of stroke and mortality within the first year postoperatively.     

Surgical considerations in off-pump coronary artery bypass grafting

Off pump coronary artery bypass grafting remains an important technique particularly in the care of high-risk patients. Consistently successful adoption of this technique requires a cooperative team approach and standardization across all phases of patient care. This review describes our approach to off pump coronary surgery.     

非体外循环冠脉搭桥术中抗纤溶药物的应用

非体外循环冠脉旁路移植术使心脏手术后出血并发症的发生率明显低于借助体外循环进行的冠脉旁路移植术，但仍无法完全避免。降低这一并发症的重要方法是采用药物来保护血小板、凝血因子等血液成分，并抑制机体的一些不不良反应，保护包括凝血功能在内的血液正常功能。其中抗纤溶药物的应用最为广泛。本文主要综述各种抗纤溶药物的优缺点，并对其临床应用情况进行展望。     

非体外循环冠状动脉旁路移植术治疗重症冠状动脉粥样硬化性心脏病

目的探讨非体外循环冠状动脉旁路移植术治疗重症冠状动脉粥样硬化性心脏病(冠心病)的可行性. 方法回顾分析2002年1月～12月37例重症冠心病的临床资料.均采用全麻,胸骨正中切口,游离左乳内动脉及大隐静脉.心脏稳定器局部固定心肌,显露目标冠状动脉,切开后置入冠状动脉内血液分流器.一般先做左乳内动脉与左冠状动脉前降支的吻合,其余血管桥先做桥血管与主动脉的近心端吻合,然后再做桥血管与冠状动脉的吻合. 结果全组病例均在非体外循环下完成手术,搭桥1～6支,(3.2±0.5)支.术后10 d死亡1例,其余36例未发生围术期心肌梗死,无呼吸功能不全、肾功能不全、脑血管意外等严重并发症. 结论在成熟的手术技术和严格的围手术期管理的条件下,非体外循环冠状动脉旁路移植术治疗重症冠心病可行.     

Does multi-vessel off-pump coronary artery bypass grafting reduce post operative morbidity compared to on-pump CABG?

Background Cardiopulmonary bypass (CPB) may contribute to the complications and it is assumed that eliminating cardiopulmonary bypass has the potential of reducing post operative morbidity after coronary artery bypass grafting (CABG). The study was carried out to compare mortality and morbidity in the off-pump and on-pump CABG groups. Methods We prospectively analysed 200 patients undergoing CABG. Group A consists of 100 patients underwent multi-vessel off-pump CABG and group B consists of 100 patients underwent CABG with CPB. The incidence of complications (mortality, re-exploration for bleeding, myocardial infarction, atrial fibrillation, neurological events, new onset renal failure (s. creatinine>1.6 mg/dL) pulmonary complications, length of ICU stay and hospital stay were recorded, analysed and compared. Results OPCAB patients received 2.73±0.61 grafts/patient and on-pump CABG patients received 3.39±0.75 grafts/patient (p value<0.00001). There was no significant statistical difference in mortality, incidence of stroke between OPCAB and CABG with CPB patients. Length of ICU stay was 32.84±4.22 vs 44.85±7.18 hrs (p value<0.00001) and hospital stay was 6.52±0.69 vs 7.94±0.92 days (p value<0.00001) between group A and group B respectively. Incidence of atrial fibrillation was less in OPCAB group 7% vs 12% although it was statistically not significant (p value 0.33). It was observed in our study that there was no significant deference in worsening of existing renal failure between on-pump CABG and OPCAB 6% vs 2% (P value 0.28). Blood utilization was significantly less in OPCAB group (p value<0.001). Conclusion There was no statistically significant difference in terms of mortality, incidence of stroke and new onset renal failure in both groups. But there was lesser incidence of post operative atrial fibrillation, worsening of existing renal failure in off-pump group though statistically not significant. There was significant reduction in blood utilization, length of ICU and hospital stay in OPCAB group.     

雷米芬太尼在非体外循环冠状动脉搭桥术"快通道"麻醉中的应用

目的 研究雷米芬太尼用于非体外循环下冠状动脉搭桥术"快通道"麻醉的临床效果.方法 48例行非体外循环下冠状动脉搭桥术患者随机均分为雷米芬太尼组(R组)和芬太尼组(F组).记录两组诱导前(T0)、插管后2 min(T1)、切皮后2 min(T2)、锯胸骨后2 min(T3)、关胸时(T4)、手术结束后30min(T5)的HR,MAP、CVP,肺小动脉楔压(PAWP)、肺毛细血管楔压(PCWP)、术后拔管时间、ICU停留时间和住院时间.结果 R组与F组比较血流动力学和住院时间差异无统计学意义.R组在拔管时间和ICU停留时间上显著短于F组(P<0.01).结论 雷米芬太尼用于非体外循环下冠状动脉搭桥术"快通道"麻醉安全性高、效果明显.     

冠心病患者非体外循环冠状动脉旁路移植术后新发房颤与血清微小RNA-146a、微小RNA-499的关系

目的:探讨血清微小RNA(miR)-146a、miR-499与冠心病患者非体外循环冠状动脉旁路移植术(OPCABG)后新发房颤的关系。方法:选取郑州大学第一附属医院2019年8月至2021年8月收治的118例冠心病患者作为研究对象,所有患者均行OPCABG术治疗,术后接受为期7 d观察,将观察期间发生房颤患者纳入发生组...