糖尿病病人行OPCAB与CCABG的早期结果对比

目的 比较糖尿病病人非体外循环和经典体外循环冠状动脉旁路移植(OPCAB和CCABG)的术后早期临床结果.方法 1999年4月至2008年1月,318例糖尿病病人行冠状动脉旁路移植术(CABG).OPCAB 210例,CCABG 108例.两组术前总体情况差异无统计学意义.OPCAB在非体外循环、心脏跳动下完成,CCABG在体外循环、心脏停跳下完成.正中开胸,胸膜外游离带蒂左乳内动脉(LIMA),与左前降支(LAD)吻合,大隐静脉(GSV)与其他靶血管吻合,吻合口超过2个采用序贯吻合.术前口服降糖药或皮下注射胰岛素将血糖控制在6 mmol/L以下,术后早期在ICU时持续泵入胰岛素,将血糖控制在6～8mmol/L.结果 两组共5例(1.57%)死亡,7例(2.20%)发生并发症.两组均达到完全再血管化,平均移植旁路血管OPCAB组(2.6±1.1)支,低于CCABG组的(3.1±1.3)支,P＜0.05.OWCAB组死亡1例(0.48%),明显低于CCABG组4例(3.70%),P＜0.05.OPCAB组发生并发症5例(2.30%),CCABG组2例(1.85%),组间差异无统计学意义,P＞0.05.结论 糖尿病者冠状动脉旁路移植手术围术期严格控制血糖至接近正常水平,住院病死率和并发症率低.OWAB术后早期病死率明显低于CCABG.

Comparison of OPCAB and CCABG in patients with diabetes mellitus

Objective Coronary artery bypass grafting (CABG) is typically performed with on-pump cardiopulmonary bypass (CPB) or extracorporeal circulation,which is safe and effective.However,CPB may cause systemic inflammation with resultant damage to the heart,brain,liver,lung and kidney,as well as blood coagulation and immune system.Off pump coronary artery bypass (OPCAB) is superior to the on-pump CABG (conventional coronary artery bypass grafting,CCABG) in avoiding adverse effects associated with CABG.We described the early outcomes with OPCAB in comparison with CCABG in patients with diabetes mellitus.Methods From April of 1999 to January 2008,three hundred eighteen CABGs were performed in patients with diabetes,including 210 cases of OPCAB and 108 cases of CCABG.After full stemotomy,left internal mammary artery (LIMA) was harvested and anastomosed to left anterior descending artery (LAD).Other target vessels were revascularized with great saphenous vein (CSV) and sequential anastomosis was used if more than two anastomotic stoma were required.OPCAB was performed on the beating heart without cardiopulmonary bypass (CPB) and CCABG performed on the arrested heart under CPB.Blood glucose (BG) was controlled preoperatively at less then 6 mmol/L with oral medication or subcutaneous insulin,and was controlled with insulin infusion post-operatively while patients were remaining at ICU,with target level of glucose at 6 to 8 mmol/L.Results Overall,no difference was observed between two groups at baseline.Five in-hospital deaths (1.57%) and 7 complications (2.20%) occurred.Complete revascularization was achieved in both groups.The mean grafts (2.6±1.1) in the OPCAB group was less than that (3.1 ±1.3) in the CCABG group (P＜0.05).Mortality in the OPCAB group (one case,0.48%) was significantly lower than that in the CCABG group (4 cases,3.70%).No significant difference in the incidence of complications was observed between the two groups (5cases,2.3% with OPCAB versus 2 cases,1.85% with CCABG).Conclusion OPCAB was associated with significant lower in-hospital mortality than CCABG in patients with diabetes while they were undergoing CABG.The excellent early outcomes of patients in the OPCAB group indicated that off-pump CABG be the choice of option when possible.Low rates of in-hospital death and complications could be achieved with strict control of the blood glucose peri-operatively,and maintaining the blood glucose near euglycemic range.