老年冠状动脉搭桥手术体外循环总结

2002年5月～2002年12月我科共行CABG术20例，现对老年人体外循环方法、特点做一回顾性总结。     

糖尿病对非体外循环冠状动脉搭桥手术的影响

目的 探讨糖尿病对非体外循环冠状动脉搭桥手术的影响.方法 以我院心脏血管外科从2003年1月至2009年12月所实施的483例冠状动脉搭桥手术患者作为研究对象,其中糖尿病（DM）组197例,非糖尿病（non DM）组286例.结果 两组的年龄、性别、糖尿病以外的冠脉危险因子、左室射血分数差异无统计学意义.既往合并肾功能衰竭（22.3%比9.0%,P=0.011）及脑梗塞（25.4%比11.5%,P=0.012）病史两组比较差异有统计学意义.DM组的冠脉病变支数三支以上患者所占比例比non DM组大（67.0%比50.7%,p=0.024）,差异有统计学意义.在手术时间及移植血管种类上两组比较差异无统计学意义.但DM组的远端吻合口数比non DM组多[（3.2±0.9）个比（2.8±0.7）个,P=0.031],有统计学意义.两组患者的术后气管捕管时间及ICU留置时间比较无统计学意义.DM组的住院时间比non DM组长[（33.2±14.1）h比（24.7±9.5）h,p=0.001）],差异有统计学意义.两组都各有2例表层切口感染,没有胸骨纵隔感染.围手术期死亡率及平均（38.8±16.2）个月电话随访心衰、心梗及心源性死亡率两组之间比较差异无统计学意义.结论 糖尿病对非体外循环冠状动脉搭桥手术的影响很小.     

非体外循环冠状动脉搭桥手术后血糖控制水平分析

目的:探讨非体外循环下冠状动脉搭桥术后患者的血糖控制水平对手术后主要并发症的影响。方法:2年共观察患者83例,对住院准备手术的患者进行随机分组,术前将血糖控制在正常水平。实验组手术后48h内血糖控制在(4·4~7·1)mmol/L,对照组血糖控制在(7·1~11)mmol/L。观察术后呼吸机辅助呼吸时间、平均住院时间、术后7d内心房颤动的发生率、围手术期心脏事件发生率、伤口并发症情况。结果:实验组术后7d内心房颤动的发生率12%,较对照组低,差异有显著性。其余指标差异无显著性。结论:非体外循环下冠状动脉搭桥手术后血糖控制在较低水平对患者术后恢复有利。     

非体外循环冠状动脉搭桥157例术后护理体会

2005年7月-2007年7月，我们共在非体外循环下行冠状动脉搭桥术157例，效果良好。现将术后护理体会报告如下。     

非体外循环下冠脉搭桥围手术期护理

非体外循环（以下简称OFF-PUMP）冠脉搭桥术（CABG）是微创伤手术,是冠心外科的新技术。它可大大缩短住院日和减少术后并发症。我院在OFF-PUMP下行112例CABG,取得了满意的疗效,现将围手术期护理总结如下。     

非体外循环下冠状动脉搭桥术的手术配合

非体外循环冠状动脉搭桥术较体外循环下冠状动脉搭桥手术具有减少手术创伤、避免体外循环相关并发症的发生、缩短手术时间及住院时间等优点。2006年12月～2008年12月,我院共完成非体外循环下冠状动脉搭桥手术134例。现将手术配合方法介绍如下。     

合并升主动脉钙化的冠心病患者不用主动脉侧壁钳非体外循环冠状动脉多支搭桥

目的:总结不用主动脉侧壁钳的非体外循环冠状动脉多支搭桥治疗合并升主动脉钙化的冠心病病人的临床经验。方法:不用主动脉侧壁钳的非体外循环冠状动脉搭桥(OPCAB)30例,男23例,女7例,年龄53～83岁,平均69.1岁。有脑中风史13例。双支和三支系统病变为2例和28例,同时有左主干病变11例。左心室射血分数0.52±0.19。30例病人均可以摸到明显的升主动脉片状或弥漫性钙化斑块,21例病人手术中食道超声心动图提示主动脉明显钙化。9例以左乳内动脉(LIMA)为唯一供血来源(in-flow),其余静脉桥吻合到LIMA,1例静脉桥吻合到无名动脉,其余静脉～静脉"Y"吻合,6例使用主动脉隔离装置(Enclose)行主动脉上的近端吻合,14例采用双侧乳内动脉。术中用血流仪定量测定桥血流。结果:本组30例人均远端吻合3.40(3～5)处。术后8例需多巴胺>5ng/(kg·min)支持16～45小时。手术后2～12小时病人完全清醒,人均带气管插管时间(8.9±3.7)小时。手术中实时桥血流测定显示桥血流均满意(17～110ml/ min),9例以LIMA为唯一in-flow,LIMA总血流量基本是各分支桥血流量之数学和。无围手术期心肌梗死、无出血再开胸、无脑中风,无手术后急性肾衰。下肢切口感染1例,8例(26.7%)术后一过性房颤。全组无围手术期死亡。术后心绞痛均消失,术后(12.7±4.6)天出院。结论:在升主动脉有明显钙化的冠心病病人,采用OPCAB结合主动脉不接触(no-touch)技术或主动脉近端吻合装置,安全可行,临床效果满意。     

盐酸戊乙奎醚对非体外循环冠状动脉搭桥手术患者微循环功能的影响

目前,体外循环(CPB)虽广泛用于临床,但其可影响患者的微循环.2005年1月～2007年11月,我们观察了盐酸戊乙奎醚对行非体外循环冠状动脉桥手术(OPCAB)患者微循环功能的影响.现报告如下.     

搭桥手术用与不用体外循环的现状

冠状动脉狭窄时，应用外科搭桥是十分成熟的手术。但由于这项手术创伤性毕竟是较大．且术后仍有一定的并发症，因而近年来一些外科医生在以往应用体外循环常规搭桥方法之外，而采用另一种新方法进行搭桥手术，即是采用不让心脏停跳，     

冠状动脉搭桥的手术配合

20 0 0年 11月以来 ,我院对 3例冠状动脉粥样硬化性心脏病患者施行冠状动脉搭桥术。 3例均为男性 ,年龄 5 0～ 6 2岁。均有频发心绞痛病史 ,1例合并陈旧性心肌梗死。冠状动脉造影显示单支病变 1例 ,多支病变 2例。行内乳动脉吻合搭桥 1例 ,内乳动脉搭桥加 2支大隐静脉搭桥 2例。现将手术配合体会介绍如下。术前准备 :术前一日参加病例讨论 ,了解病情及手术方案并拟订护理计划 ,充分估计术中可能出现的问题并做好准备。访视患者 ,介绍手术过程 ,有针对性地做好解释和安慰工作。做好器械准备 ,检查手术房间电路有无故障 ,确保术中用电 ,做好房…     

Off-pump coronary artery bypass grafting using continuous heparin infusion

ObjectivesLevels of anticoagulation during off-pump coronary artery bypass grafting (OPCAB) remain controversial. Prolonged activated clotting time (ACT) during OPCAB increases blood loss during surgery and can also cause paradoxical increase in postoperative myocardial infarction. Shorter ACT can increase thrombotic complication. Maintaining a steady ACT level is challenging. We have used continuous heparin infusion after initial bolus during OPCAB to maintain a steady low target ACT. The objective of the present study was to assess the effectiveness and safety of heparin infusion in maintaining a steady target ACT level.MethodsThis was a prospective study of consecutive OPCAB patients. ACT was measured after initial bolus dose of heparin. Once ACT of more than 200 seconds was achieved, heparin infusion was started to maintain the required level of anticoagulation. CPK-MB was measured in operation room, 6 and 24 hours postoperatively to rule out ischemic complication.ResultsACT could be maintained in target range with heparin infusion in 80.1% patients (161/201). Of the 40 patients with one or more ACT reading less than 200 seconds, 38 patients were managed by increasing the dose of heparin infusion and only 2 patients required additional bolus dose of heparin.ConclusionsHeparin infusion maintains a steady target ACT level and avoids peaks and troughs associated with bolus doses. Lower level of anticoagulation using continuous heparin infusion does not increase ischemic complications. This is the first ever study of use of heparin infusion during OPCAB. We may conclude that heparin infusion is a safe anticoagulation strategy for OPCAB.     

Off-pump coronary artery bypass grafting in India

Off-pump Coronary Artery Bypass Grafting (OPCAB) is the latest innovation in cardiac surgery. However OPCAB is not adopted universally. Even there have been suggestions of abandoning OPCAB in a special report. In India, OPCAB has been successfully adopted across the board. There are various evidences which favor OPCAB and are discussed in this review. The purpose of this review is to put forward the perspective of the OPCAB surgeons of our country and critically look at the suggestion of abandoning OPCAB.     

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。     

高龄冠心病患者冠状动脉搭桥术

目的比较冠脉搭桥术（CABG）的术式选择对高龄冠心病患者的影响,讨论高龄冠心病患者的围手术期管理方法。方法以我院心脏血管外科2003年1月至2009年12月所实施的514例CABG患者为研究对象,其中75岁以上患者49例,为高龄患者组,占同期CABG的9．5％;75岁以下患者465例,为非高龄患者组,占同期CABG的90．5％。结果患者的年龄、不稳定型心绞痛、有无急性心梗、冠脉危险因子、术前血红蛋白含量比例两组相比差异无统计学意义;左室射血分数〈30％,既往合并肾功能异常、脑梗塞及患有三支冠状动脉病变的患者比例两组相比差异有统计学意义。主动脉内气囊反搏（IABP）、移植血管种类、手术时间两组相比差异无统计学意义,但远心端吻合口数及完全性血运再建例数比例、跳动下冠状动脉搭桥手术（OPCAB）比例两组之间比较差异有统计学意义。术后气管插管时间、留置ICU时间两组之间比较差异无统计学意义,患者住院天数两组之间比较差异有统计学意义。术后肺部感染、肾衰、并发症脑梗塞发生率两组之间比较差异无统计学意义。围手术期死亡率两组之间比较差异无统计学意义。术后平均39个月的电话随访,心衰、心梗发生率及心源性死亡率两组之间比较差异无统计学意义。结论对于高龄患者的CABG要多考虑采用OPCAB方式及动、静脉移植血管相组合等低侵袭性手术方法,术后应早期下床进行康复训练。     

185例冠状动脉搭桥手术危险因素分析

目的 探讨冠状动脉搭桥手术的效果及危险因素。方法 回顾性分析我院冠状动脉搭桥手术185例患的手术死亡率及其中相关危险因素。手术效果。结果 本组患手术死亡率4.86%，全组患心绞痛症状在出现时均缓解。结论 冠状动脉搭桥手术的成功率在逐年上升。手术效果满意。与手术相关的危险因素有年龄。心功能，EF值，心肌缺血时间，有无合并症及其是否处理恰当以及再血管化的完全性。     

并行循环冠状动脉旁路移植16例分析

目的探讨并行循环下冠状动脉旁路移植术的疗效。方法比较并行循环冠状动脉旁路移植术16例和非体外循环冠状动脉旁路移植术33例的临床资料。结果两组术后旁路通畅率为100%。住院时间并行循环冠状动脉旁路移植术(18±7)d,非体外循环冠状动脉旁路移植术(18±8))d;入住重症监护病房时间:并行循环冠状动脉旁路移植术(48±14)h,非体外循环冠状动脉旁路移植术(57±32)h;心房颤动发生率:并行循环冠状动脉旁路移植术1/16(6%),非体外循环冠状动脉旁路移植术为4/33(12%)。结论并行循环冠状动脉旁路移植术也是一种合理和安全的术式。     

非体外循环下多支冠状动脉病变的旁路移植术

目的：探讨非体外循环冠状动脉旁路移植术的手术技巧和术中处理方法。方法：连续57例患接受非体外循环冠状动脉旁路移植术。术中予以适量扩容、小剂量α受体兴奋剂以维持血流动力学平稳，采用心脏稳定器控制局部心肌运动幅度，阻断冠状动脉或在置入血管塞控制冠状动脉出血情况下进行血管吻合。全组吻合前降支57例，对角支21例，右冠状动脉27例，钝缘支42例，后降支20例。结果：术后1例死于并发感染和急性肾功能衰竭，余患痊愈出院。随访所有患心绞痛症状均消失，冠状动脉造影示桥路和吻合口通畅。结论：选择合适的病例进行非体外循环冠状动脉旁路移植术可获得满意的临床效果。术中血流动力学稳定极为重要。弹力线阻断靶血管近远端或腔内置入血管塞法均能有效地控制切开的冠状动脉出血。冠状动脉吻合的顺序应是先行前降支和右冠系统的吻合。     

冠状动脉旁路手术中动脉材料的选择与应用

目的 在冠状动脉旁路手术(CABG)中寻求动脉材料作旁路移植，减少因大隐静脉桥(SVG)阻塞对远期通畅率的影响。方法 34例冠心病患者以乳内动脉(IMA)和桡动脉(RA)作为血管桥行CABG，采用不接触血管技术制备动脉桥，应用药物防止动脉痉挛。结果 取乳内动脉35根，桡动脉20根，大隐静脉11根，平均移植血管1．94支，死亡1例，手术死亡率2．9％。结论 使用动脉材料行旁路移植术安全有效，预计能保持移植血管长期通畅。     

Clinical outcomes of off-pump coronary artery bypass graft in patients with diabetes and non-diabetics: A systematic review and meta-analysis

Background and aimDiabetes mellitus is a prevalent risk factor for developing coronary artery disease which worsens the clinical outcomes of patients undergoing coronary artery bypass grafting (CABG). This study aimed to determine the clinical outcomes of patients with diabetes and non-diabetic patients who underwent off-pump CABG surgery.MethodMedline, Scopus, Proquest, Embase, Web of Science, and Google scholar were searched until September 10, 2021. The effect sizes including unstandardized mean difference and odds ratio with 95% confidence interval were calculated using “Metan” package. The Cochran's Q-test and I² statistic were used to assess heterogeneity, a random-effects model was applied to estimate the pooled effect sizes, and meta-regression was used to investigate the factors affecting heterogeneity between studies.Results10 studies with 6200 sample sizes were included in the study. In groups with diabetes, Summary odds ratio (SOR) and 95% confidence interval of infection was 2.18 more than non-diabetic groups. Also, odds renal complication was 1.74 more than non-diabetic groups, and the odds cardiovascular complication in groups with diabetes was 1.30 more than non-diabetics. There were no differences in mortality, neurologic, respiratory and surgical complications between groups with diabetes and non-diabetics. Based on meta-regression results, age (Coefficient: 0.942; p = 0.009) had a significant direct relationship and sample size (Coefficient: 0.001; p = 0.009) had an indirect significant relationship with heterogeneity of neurologic outcomes. There was no significant publication bias in our results.ConclusionOur study revealed that off-pump CABG led to some significant outcomes in patients with diabetes compared to non-diabetics. Renal and infection complications were higher in patients with diabetes but no significant differences were seen in most of other postoperative outcomes between the two groups.     

Protective effect of silymarin during coronary artery bypass grafting surgery

BACKGROUND:

An inflammatory response and systemic oxidative stress are directly caused by coronary artery bypass grafting (CABG) surgery. Cytokines, such as interleukin (IL) 1β, IL-6 and tumour necrosis factor-α (TNF-α), can also be stimulated. Reducing the release of pro-inflammatory cytokines plays an important role in limiting the postoperative inflammatory response. Silymarin has strong anti-inflammatory, antioxidant and cytoprotective properties.

OBJECTIVE:

To investigate the protective anti-inflammatory and antioxidant properties of silymarin against the inflammation and oxidative stresss inherent to CABG surgery.

METHODS:

Of the 102 patients undergoing elective first-time CABG surgery that were recruited, 50 (49.02%) received silymarin treatment and 52 (50.9%) were controls. Plasma cytokine levels (IL-1β, IL-6 and TNF-α) were measured preoperatively, 6 h and 24 h after CABG surgery. C-reactive protein (CRP) levels, trolox equivalent antioxidant capacity (TEAC) and glutathione (GSH) and malondialdehyde (MDA) levels were analyzed.

RESULTS:

Postoperative cytokine levels in the silymarin group were significantly lower compared with preoperative levels, and were significantly lower compared with postoperative control group levels. The area under the curve for cytokines and CRP for the silymarin group were significantly lower compared with preoperative levels, and were significantly lower compared with postoperative control group levels. Postoperative levels of TEAC and MDA in the silymarin-treated group were significantly lower than in the control group. GSH levels were significantly elevated in the silymarin group compared with control. No side effects or mortality were associated with the use of silymarin.

CONCLUSION:

The anti-inflammatory and antioxidant effects of silymarin treatment provided protection against reperfusion injury and inflammation after CABG surgery.