Eleven-year outcomes of U-clips in totally robotic coronary artery bypass grafting versus standard hand-sewn running suture in robotic-assisted coronary artery bypass grafting

 Open in a separate windowOBJECTIVESThe aim of this study was to evaluate the clinical outcomes of patients undergoing off-pump robotic coronary artery bypass grafting (CABG) with either interrupted nitinol U-Clips in totally endoscopic coronary artery bypass (TECAB) or standard running suture anastomosis in robotically assisted direct coronary artery bypass (RADCAB) over a decade.METHODSFrom January 2007 to December 2017, 280 patients underwent robotic off-pump CABG using the da Vinci S/Si Surgical System in our centre. TECAB with interrupted nitinol U-Clips anastomosis was performed in the left internal mammary artery (LIMA) to LAD grafting in 126 patients and RADCAB (n = 154) of the LIMA to LAD was completed with standard running suture. After discharge, patients were contacted through telephone interview and were invited to attend the outpatient clinic every 6 months or 1 year. The graft patency was assessed by coronary angiography or computed tomography angiography.RESULTSAll cases were completed without conversion to median sternotomy or cardiopulmonary bypass. A total of 275 single internal mammary artery (IMA) grafts (271 LIMAs, 4 right internal mammary arteries) and 5 bilateral IMA grafts were used as single graft or composite grafts. All the patients were discharged without in-hospital mortality or adverse outcomes. The average follow-up was 89.7 ± 30.4 months (range, 14–143 months). The cumulative survival rates (P = 0.53), the cumulative IMA patency rates (P = 0.83), and the rates of freedom from major adverse cerebrovascular and cardiovascular events (P = 0.41) between TECAB and RADCAB all showed no significant difference in the follow-up.CONCLUSIONSRobotic off-pump CABG using IMA grafts is safe and can provide reliable long-term outcomes. Compared with the standard hand-sewn running suture technique in RADCAB, interrupted suture with the nitinol U-Clips in TECAB showed similar long-term clinical results and graft patency in LIMA to LAD bypass grafting.     

Mid-term outcomes of coronary endarterectomy combined with coronary artery bypass grafting

Open in a separate window OBJECTIVESThe aim of this study was to evaluate the mid-term outcome of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) and explore the potential risk factors for adverse events.METHODSA total of 208 consecutive patients underwent CE between 2008 and 2018 in our centre, of which 198 were included in this retrospective cohort study. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCEs). Kaplan–Meier analysis was performed to evaluate event-free survival, whereas subgroup analysis and Cox regression were used to explore risk factors for the outcomes.RESULTSThe median follow-up time was 34.7 months. CE + CABG was performed mainly on the left anterior descending artery (42.3%) or right coronary artery (42.3%). Both operative mortality and incidence of perioperative myocardial infarction were 1.5%. The overall survival at 3 and 5 years was 98.0% and 95.9%, whereas the MACCE-free survival was 93.7% and 89.4%, respectively. No significant difference in the incidence of MACCE was observed between on-pump and off-pump CE (P = 0.256) or between left anterior descending artery and non-left anterior descending artery endarterectomy (P = 0.540). Advanced age (>65 years) was associated with a higher risk of MACCE both in univariate [hazard ratio (HR) 3.62, 95% confidence interval (CI) 1.37–9.62; P = 0.010] and multivariate analysis (HR 3.59, 95% CI 1.32–9.77; P = 0.013).CONCLUSIONSWhen performed by experienced surgeons, CE + CABG could be an acceptable approach to achieve complete revascularization of diffusely diseased coronary arteries with satisfactory outcomes, although advanced age might increase the risk of MACCE.     

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。     

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.     

Impact of gender on 10-year outcome after coronary artery bypass grafting

Open in a separate window OBJECTIVESOur goal was to evaluate the impact of gender on the 10-year outcome of patients after isolated coronary artery bypass grafting (CABG) included in the Italian nationwide PRedictIng long-term Outcomes afteR Isolated coronary arTery bypass surgery (PRIORITY) study.METHODSThe PRIORITY project was designed to evaluate the long-term outcomes of patients who underwent CABG and were included in 2 prospective multicentre cohort studies. The primary end point of this analysis was major adverse cardiac and cerebrovascular events. Baseline differences between the study groups were balanced with propensity score matching and inverse probability of treatment. Time to events was analysed using Cox regression and competing risk analysis.RESULTSThe study population comprised 10 989 patients who underwent isolated CABG (women 19.6%). Propensity score matching produced 1898 well-balanced pairs. The hazard of major adverse cardiac and cerebrovascular event was higher in women compared to men [adjusted hazard ratio (HR) 1.13, 95% confidence interval (CI) 1.03–1.23; P = 0.009]. The incidence of major adverse cardiac and cerebrovascular event in women was significantly higher at 1 year (HR 1.31, 95% CI 1.11–1.55; P < 0.001) and after 1 year (HR 1.11, 95% CI 1.00–1.24; P = 0.05). Mortality at 10 years in the matched groups was comparable (HR 1.04, 95% CI 0.93–1.16; P = 0.531). Women have significantly a higher 10-year risk of myocardial infarction (adjusted HR 1.40, 95% CI 1.17–1.68; P = 0.002) and percutaneous coronary intervention (adjusted HR 1.32, 95% CI 1.10–1.59; P = 0.003).CONCLUSIONSThe present study documented an excess of non-fatal cardiac events after CABG among women despite comparable 10-year survival with men. These findings suggest that studies investigating measures of tertiary prevention are needed to decrease the risk of adverse cardiovascular events among women.     

二次冠状动脉旁路移植术的临床疗效

目的 评价二次冠状动脉旁路移植术的临床疗效.方法 51例病人(占医院同期进行冠状动脉旁路移植术病人的2.5%)进行二次冠状动脉旁路移植术,距首次手术(15.1±5.8)年.10例采用非体外循环冠状动脉旁路移植术(OPCABG),41例采用体外循环冠状动脉旁路移植术(CABG).正中切口43例,左胸侧切口8例.结果 3例行CABG病人手术后呼吸衰竭,需呼吸机辅助.所有病人住ICU(2.2±0.7)天,住院(9.2±2.4)天.术后死亡2例(3.9%),采用OPCABG和CABG者各1例,死亡原因分别为急性心肌梗死、低心排血量综合征和呼吸功能衰竭、重症肺炎.完全再血管化44例,其中行OPCABG者6例,CABG者38例.部分再血管化7例,行OPCABG者4例,CABG者3例.结论 CABG和OPCABG行二次冠状动脉旁路移植术均安全,疗效满意,能达到完全再血管化的目的.     

非体外循环下冠状动脉旁路移植术

目的 报告微创非体外循环冠状动脉旁路移植术(OPCABG),探讨其手术指征及外科处理要点。方法 回顾性总结5例OPCABG的临床资料。结果 5例顺利完成非体外循环冠状动脉旁路移植术。随访3～4个月,无死亡,无明显心绞痛及心肌缺血表现。结论 对于选择的患者,OPCABG安全、经济、有效,是一种值得推广的微创心脏手术方法。     

肺动脉漂浮导管在冠状动脉旁路术中的应用

目的　评价肺动脉漂浮导管连续监测心排血量 (CO)、混合静脉血氧饱和度 (S VO2 )在冠状动脉旁路移植术 (CABG)中的应用。方法　CABG术者 32例 ,年龄 (6 1 31± 6 92 )岁 ,平均搭桥(3 19± 1 12 )支。麻醉诱导用芬太尼 2 0～ 30 μg/kg、维库溴铵 0 3mg/kg、咪唑安定 (3 5 8± 2 0 0 )mg ;术中以芬太尼、异氟醚维持。经右颈内静脉置CCO S VO2 肺动脉漂浮导管 ,连续监测CO、S VO2 、平均动脉压 (MAP)、肺动脉压 (PAP)、肺毛细血管楔压 (PCWP)和中心静脉压 (CVP)等 ,记录诱导前、插管后、心肺转流 (CPB)前、停CPB及关胸时的数据。结果　心排指数 (CI)、MAP和S VO2 在插管后各时段较诱导前明显下降 (P <0 0 5 ) ,CVP、PCWP及PAP停CPB后较插管后升高 (P <0 0 5 )。HR在插管后下降 (P <0 0 5 ) ,停CPB后升高 (P <0 0 5 )。结论　在CABG术中 ,利用肺动脉漂浮导管连续监测CO、S VO2 及各项相关指标 ,及时了解心脏功能、全身及心肌的氧供需平衡状况 ,并调整用药 ,以利于围手术期意外的处理 ,防止心肌缺血的发生     

吸入麻醉药对冠脉搭桥术心肌保护作用的Meta分析

目的 评价吸入麻醉药对冠状动脉搭桥术(CABG)心肌缺血-再灌注损伤的保护作用.方法 检索Medline和中国期刊全文数据库,收集各研究中的心脏指数、使用正性肌力药的例数和术后24 h内心肌肌钙蛋白I(cTnI)的最高数值.计数资料采用优势比(OR)和95%可信区间(CI)表示.计量资料用加权平均差(WMD)和95%可信区间表示,统计分析用Revman 4.2.10软件完成.结果 符合标准的文献共23篇,1398例患者.分析显示,吸入麻醉约都能使CABG患者术后的心脏指数增加[WMD=0.41;95%CI(0.17,0.64)],使cTnI明显降低[WMD=-1.61;95%CI(-2.25,-0.96)],需用正性肌力药的患者数减少[OR=0.45;95%CI(0.35,0.58)].结论 七氟醚等吸入麻醉药用于CABG具有明显的心肌保护作用.     

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.     

急性心肌梗死后冠状动脉旁路移植术时机选择

目的确定急性心肌梗死（AMI）后行冠状动脉旁路移植术（CABG）时机对术后30d死亡率的影响。方法233病例分为心肌梗死和心绞痛两组，对多个风险因素通过单因素、多因素分析，以确定AMI后不同时段手术是否为死亡的独立风险因素。结果233例中男176例（75．4％），女57例（24．5％）。年龄34～86岁，平均（65．6±9．2）岁。平均移植血管（3．46±0．89）支，137例（58．8％）应用乳内动脉137根。总死亡率4．3％（10／233例）。AMI距手术时间≤3d者，手术死亡6例（14．6％，6／41例），较心绞痛组3例（2．3％，3／130例）显著增高（P=0．033）；4～10d者1例（2．7％，1／37例）与心绞痛组相比差异无统计学意义（P=0．67），11～30d者无手术死亡。结论急性心肌梗死3d后行冠脉旁路移植术较为安全。     

Breast necrosis following coronary artery bypass grafting

We present a case of left breast necrosis following coronary artery bypass grafting which was misdiagnosed as a breast cancer. Breast necrosis after myocardial revascularization is an extremely rare complication of the surgical procedure using the most conventional graft which is the left internal mammary artery. The left internal mammary artery is the main blood supplying artery of the left breast.     

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.     

Off-pump coronary artery bypass grafting in patients with significant left ventricular dysfunction

Objective  Off-pump coronary artery bypass grafting (OPCAB) is known to preserve left ventricular function better than conventional coronary artery bypass grafting (CCAB). This study was carried out to investigate the safety, feasibility and efficacy of off-pump coronary artery bypass grafting in patients with significant left ventricular dysfunction. Methods  Three hundred and eighty eight consecutive patients with preoperative left ventricular ejection fraction ≤ 39% who underwent CABG between January 2001 through October 2007 were included in this retrospective study. Two hundred and eleven patients were operated by off-pump technique (group 1) and 178 patients were operated by on-pump technique (CCAB) (group 2). The postoperative outcomes were analyzed. Of these, 204 (52.57%) patients were diabetics, 355 (91.49%) patients had documented prior myocardial infarction, 316 (81.44%) patients were in canadian cardiovascular society(CCS) class III and 47 (12.11%) patients were in CCS class IV. Results  There was no significant difference in the number of grafts per patient between the two groups [group 1 3.02 ± 0.76 vs group 2 3.18 ± 0.72 (P=0.07) and the index of completeness of revascularization was comparable [1.08 ± 0.08) (OPCAB) vs 1.04 ± 0.06 (CCAB) (p=0.52)] The left internal thoracic artery was anastomosed to left anterior descending artery in 98% of patients. Operative mortality was 2.8% (6 deaths) following OPCAB and 3.93% (7 deaths) following CCAB (p=0746). Postoperative usage of IABP support was higher in CCAB group (12 patients vs 4 patients: P<0.03) and usage of moderate or higher doses of inotropic support was also higher in the conventional group (p<0.0006). More worsening of preexisting renal insufficiency was observed in CCAB group (p=0.01) and no significant difference in the incidence of atrial fibrillation was observed between the groups. Conclusions  Off-pump coronary artery bypass grafting is feasible and safe in patients with depressed left ventricular function and the postoperative morbidity was less in OPCAB group compared to on-pump group.     

非体外循环下冠状动脉旁路移植术

目的 总结110例非体外循环心脏跳动下冠状动脉旁路移植术经验，探讨其手术适应证、优缺点及手术方法。方法 常温、全身麻醉，胸正中切口，非体外循环心脏跳动下，应用特殊心表固定器行冠状动脉旁路移植术，平均搭桥3．9支，血管桥为乳内动脉、大隐静脉及桡动脉。结果 全组无手术死亡，术后心绞痛症状消失。手术时间平均为210min，术后气管插管时间平均为4．8h。术后住院时间平均为10d，住院费用平均为4．4万元。其中3例术中出现不可逆血压过低、室颤而转为体外循环冠状动脉旁路移植术。结论 非体外循环心脏跳动下冠状动脉旁路移植术是一种安全、有效的治疗方法。特别适合于老年及心功能差的患者，可减少体外循环并发症，缩短术后住院时间，降低住院费用，但不能完全替代体外循环旁路移植术。     

Early angiographic control of perioperative ischemia after coronary artery bypass grafting

Objective: To assess the impact of immediate angiography in patients with defined clinical and laboratory criteria of perioperative myocardial infarction after coronary artery bypass operation. Patients and methods: Between January 1999 and December 1999 2052 patients underwent coronary artery bypass grafting in our institution. Out of this cohort 131 (6.4%) patients met the criteria of perioperative myocardial ischemia, which was defined as: (a) increase in the isoenzyme ratio of creatinine phosphokinase (CK/CK-MB] above 10%; (b) ischemic electrocardiographic episodes (defined as a new onset of elevated ST-segment change lasting at least 1 min and involving a shift from baseline of greater than or equal to 0.1 mV of ST-depression and a new association of a postoperative Q; (c) recurrent episodes of, or sustained ventricular tachyarrhythmia as well as ventricular fibrillation; (d) hemodynamic deterioration despite adequate inotropic support. Results: Angiography was performed in 108 patients (5.3%, group A) whereas 23 patients (1.1%, group B) were immediately re-operated due to severely compromised hemodynamics. Angiographic results in group A showed regular grafts in 45 patients (2.2%); 63 patients (3.1%) had either an occlusion (n=41), incorrect anastomosis (n=29), graft stenosis (n=14), graft spasm (n=6), displaced graft (n=6), poor distal run-off (n=5) or incomplete revascularization (n=2). In group A 43 patients underwent a re-operation (34 patients) or an early angioplasty (nine patients). Due to poor coronary artery status no intervention was performed in the remaining 20 patients with angiographic findings. Operative findings in group B showed graft occlusion in ten patients (43.5%), incorrect anastomosis in five patients (21.7%), bleeding, stretched graft, venous graft spasm and displaced graft in one patient (4.3%) each, and no patho-morphological finding in 4 patients (17.4%). Thirty-day mortality rate was ten patients in group A (9.3%), all of them with angiographic findings, as opposed to nine patients (39.1%) in group B. Conclusion: ST-change and elevated CK/CK-MB enzyme ratio is highly indicative for possible graft failure and should be followed early angiographic control to assess the need for reintervention.     

胸骨下段正中小切口在冠状动脉旁路移植术中的应用

目的总结162例胸骨正中下段小切口行冠状动脉旁路移植手术的经验. 方法 1998年4月～2003年6月,经胸骨下段正中小切口行冠状动脉旁路移植手术162例,包括体外循环下冠状动脉旁路移植术(coronary artery bypass grafting, CABG)77例,CABG联合心内手术13例,非体外循环CABG(off-pump coronary artery bypass grafting, OPCABG)72例. 结果手术死亡1例(0.6%),再手术1例(0.6%),术后并发症9例(5.6%).体外循环手术的主动脉阻断、体外循环及手术时间分别为(74.8±23.1) min、(113.6±31.3) min及(255.5±54.5) min.非体外循环手术时间(195.6±50.6) min.吻合口数目1～5个,(2.4±0.7) 个.术后气管插管时间0～364 h,中位数11 h;恢复室时间1～28 d,中位数3 d;术后住院5～60 d,中位数10 d.胸腔引流量(607.2±443.0) ml,按体重计算为(8.6±6.0) ml/kg.38例输血,输血量(1 161.3±741.2) ml. 结论胸骨正中下段小切口行冠状动脉旁路移植手术创伤小,安全可靠;皮肤切口小;无须特殊器械,操作简单,可获得冠状动脉多支病变充分再血管化的效果,可同时进行其他心内手术.     

应用Port-Access系统行微创冠状动脉旁路移植术21例体会

目的　介绍应用Port-Access系统进行微创冠状动脉旁路移植术的体会。　方法　采用左胸小切口 (6～ 7)cm ,经股静脉插静脉管 ,经升主动脉或股动脉插动脉管 ,主动脉内球囊阻断的方法 ,行微创冠状动脉旁路移植术。　结果　本组 2 1例无手术死亡 ,无重大并发症。　结论　应用Port-Access系统进行微创冠脉搭桥手术是一种安全可靠的手术方法 ,可以避免胸骨切开 ,减轻疼痛 ,利于患者后恢复。     

39例非体外循环下冠状动脉搭桥术的经验

目的总结我院4年来非体外循环冠状动脉搭桥术的临床结果与经验。方法2000年7月_2004年7月,在我科收治2例严重冠心病中,成功的施行非体外循环冠状动脉搭桥术39例,其中青年例术前使用主动脉球囊反搏（IABP）,术中均采用Octopus稳定器。另外3例患者因术中血流动力学不稳定的转体外循环下完成手术。结果全组无1例围手术期死亡,术后心绞痛症状均消失,心功能得到不同程度改善。结论非体外循环冠状动脉搭桥术是一种安全可行,是治疗冠心病的良好方法。