影响不停跳冠状动脉旁路移植术效果的因素探讨
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摘要
目的探讨影响不停跳冠状动脉旁路移植术的因素,提高不停跳手术的效果。方法回顾性分析2012年1月至2016年6月吉林大学第二医院心血管外科898例冠状动脉粥样硬化性心脏病患者的临床资料。所有患者均单纯行冠状动脉旁路移植术,均在心脏不停跳下进行搭桥。按是否并行体外循环将患者分为两组:非体外循环心脏不停跳下冠状动脉旁路移植术组(OPCABG组) 797例,其中男592例、女205例,平均年龄(60.5±8.4)岁;体外循环心脏不停跳下冠状动脉旁路移植术组(OPBH组)101例,其中男77例、女24例,平均年龄(61.5±8.2)岁。结果 OPCABG组患者平均搭桥数(3.36±0.74)支,OPBH组患者平均搭桥数(3.71±0.69)支,两组差异有统计学意义(P<0.05)。OPCABG组和OPBH组术后呼吸机辅助通气时间[(10.8±9.5)h vs.(20.6±12.3)h]、住ICU时间[(28.8±15.5)h vs.(37.4±30.8)h]、住院时间[(10.9±4.8)d vs.(14.8±8.6)d]、死亡率(1.1%vs. 3.0%)、主动脉内球囊反搏使用率(2.4%vs. 8.9%)及体外膜肺氧合使用率(0.5%vs. 5.0%)差异有统计学意义(P均<0.05)。898例患者死亡12例,总体无输血率为91.3%。结论研究结果显示,通过心尖及心肌固定器的引入、手术技术和方法的改进、良好的麻醉管理、血管活性药物的灵活精确运用,绝大多数手术患者取得良好效果,但对于那些心脏显著扩大,心功能差,术中搬运心脏导致循环不稳定的患者,需要体外循环的引入。
Objective To explore the factors affecting the operation of coronary artery bypass grafting with heart beating and improve the effect of the operation. Methods From January 2012 to June 2016, 898 patients with coronary heart disease who received cardiovascular surgery in the Second Affiliated Hospital of Jilin University were analyzed retrospectively. All patients only underwent coronary artery bypass grafting with beating heart. Among them, 797 patients underwent the off-pump coronary artery bypass grafting(an OPCABG group, 592 males and 205 females, with an average age of 60.5±8.4 years); another 101 patients received on-pump beating heart coronary artery bypass grafting(an OPBH group, 77 males and 24 females, with an average age of 61.5±8.2 years). Results The average number of grafts in the OPCABG group was 3.36±0.74, and in the OPBH group was 3.71±0.69(P<0.05). The postoperative ventilation time(10.8±9.5 h vs. 20.6±12.3 h), ICU stay(28.8±15.5 h vs. 37.4±30.8 h), hospital stay(10.9±4.8 d vs. 14.8±8.6 d), mortality(1.1% vs. 3.0%), the utilization rate of intra-aortic balloon pump(2.4% vs. 8.9%) and extracorporeal membrane oxygenation(0.5% vs. 5.0%) were significantly different between the OPCABG group and OPBH group(all P<0.05).Twelve patients died after surgery, and the total bloodless operation ratio was 91.3%. Conclusion The results show that most patients can achieve good results with the help of apical fixation and myocardial fixator, improved surgical techniques and methods, good anesthesia management as well as flexible and accurate use of vasoactive drugs. But extracorporeal circulation is necessary in the patients with large left ventricle, low ejection fraction and hemodynamic instability after intraoperatively moving the heart.
Objective To explore the factors affecting the operation of coronary artery bypass grafting with heart beating and improve the effect of the operation. Methods From January 2012 to June 2016, 898 patients with coronary heart disease who received cardiovascular surgery in the Second Affiliated Hospital of Jilin University were analyzed retrospectively. All patients only underwent coronary artery bypass grafting with beating heart. Among them, 797 patients underwent the off-pump coronary artery bypass grafting(an OPCABG group, 592 males and 205 females, with an average age of 60.5±8.4 years); another 101 patients received on-pump beating heart coronary artery bypass grafting(an OPBH group, 77 males and 24 females, with an average age of 61.5±8.2 years). Results The average number of grafts in the OPCABG group was 3.36±0.74, and in the OPBH group was 3.71±0.69(P<0.05). The postoperative ventilation time(10.8±9.5 h vs. 20.6±12.3 h), ICU stay(28.8±15.5 h vs. 37.4±30.8 h), hospital stay(10.9±4.8 d vs. 14.8±8.6 d), mortality(1.1% vs. 3.0%), the utilization rate of intra-aortic balloon pump(2.4% vs. 8.9%) and extracorporeal membrane oxygenation(0.5% vs. 5.0%) were significantly different between the OPCABG group and OPBH group(all P<0.05).Twelve patients died after surgery, and the total bloodless operation ratio was 91.3%. Conclusion The results show that most patients can achieve good results with the help of apical fixation and myocardial fixator, improved surgical techniques and methods, good anesthesia management as well as flexible and accurate use of vasoactive drugs. But extracorporeal circulation is necessary in the patients with large left ventricle, low ejection fraction and hemodynamic instability after intraoperatively moving the heart.
引文
1 Jansen EW, Borst C, Lahpor JR, et al. Coronary artery bypass grafting without cardiopulmonary bypass using the octopus method:results in the first one hundred patients. J Thorac Cardiovasc Surg, 1998,116(1):60-67.
2 Athanasiou T, Al-Ruzzeh S, Kumar P, et al. Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients. Ann Thorac Surg, 2004, 77(2):745-753.
3 Kshettry VR, Flavin TF, Emery RW, et al. Does multivessel, offpump coronary artery bypass reduce postoperative morbidity? Ann Thorac Surg,2000, 69(6):1725-1730.
4 Lee JD, Dang CR, Taoka S, et al. Coronary artery bypass grafting performed with or without a bypass pump:early results. Hawaii Med J, 2000, 59(2):54-56.
5 Arom KV, Emery RW, Flavin TF, et al. Cost-effectiveness of minimally invasive coronary artery bypass surgery. Ann Thorac Surg, 1999, 68(4):1562-1566.
6 Boyd WD, Desai ND, Del Rizzo DF, et al. Off-pump surgery decreases postoperative complications and resource utilization in the elderly. Ann Thorac Surg, 1999, 68(4):1490-1493.
7 Buffolo E, de Andrade CS, Branco JN, et al. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg, 1996,61(1):63-66.
8 Reichenspurner H, Boehm D, Detter C, et al. Economic evaluation of different minimally invasive procedures for the treatment of coronary artery disease. Eur J Cardiothorac Surg, 1999, 16(Suppl2):S76-S79.
9陈长城,尤斌,王盛宇,等.非体外循环冠状动脉旁路移植术中转体外循环后的临床转归.心肺血管病杂志,2013, 32(6):738-741.
10喻磊,谷天祥,师恩祎,等.70岁以下多支冠状动脉病变患者体外与非体外循环冠状动脉旁路移植术的比较.中国胸心血管外科临床杂志,2010, 17(4):292-296.
11 Cheng DC, Bainbridge D, Martin JE, et al. Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials. Anesthesiology, 2005, 102(1):188-203.
12 Athanasiou T, Aziz O, Mangoush O, et al. Do off-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass grafting? Ann Thorac Surg, 2004, 77(5):1567-1574.
13伍育旗,张郁林,周波,等.92例非体外循环冠状动脉旁路移植术的临床分析.中国胸心血管外科临床杂志,2013,20(6):725-727.
14 Wang J, Xiao F, Ren J, et al. Risk factors for mortality after coronary artery bypass grafting in patients with low left ventricular ejection fraction. Chin Med J(Engl), 2007,120(4):317-322.
15顾松,苏丕雄,刘岩,等.左心室射血分数与缩短分数对冠状动脉旁路移植术后室性心律失常的预测.中国胸心血管外科临床杂志,2002, 9(3):168-171.
16 Bouchart F, Tabley A, Litzler PY, et al. Myocardialrevascularization in patients with severe ischemic left ventricular dysfunction. Long term follow-up in 141 patients. Eur J Cardiothorac Surg, 2001, 20(6):1157-1162.
17 Reston JT, Tregear SJ, Turkelson CM. Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting. Ann Thorac Surg, 2003, 76(5):1510-1515.
18 Ezhov MV, Safarova MS, Afanasieva OI, et al. Lipoprotein(a)level and apolipoprotein(a)phenotype as predictors of long-term cardiovascular outcomes after coronary artery bypass grafting.Atherosclerosis, 2014, 235(2):477-482.
2 Athanasiou T, Al-Ruzzeh S, Kumar P, et al. Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients. Ann Thorac Surg, 2004, 77(2):745-753.
3 Kshettry VR, Flavin TF, Emery RW, et al. Does multivessel, offpump coronary artery bypass reduce postoperative morbidity? Ann Thorac Surg,2000, 69(6):1725-1730.
4 Lee JD, Dang CR, Taoka S, et al. Coronary artery bypass grafting performed with or without a bypass pump:early results. Hawaii Med J, 2000, 59(2):54-56.
5 Arom KV, Emery RW, Flavin TF, et al. Cost-effectiveness of minimally invasive coronary artery bypass surgery. Ann Thorac Surg, 1999, 68(4):1562-1566.
6 Boyd WD, Desai ND, Del Rizzo DF, et al. Off-pump surgery decreases postoperative complications and resource utilization in the elderly. Ann Thorac Surg, 1999, 68(4):1490-1493.
7 Buffolo E, de Andrade CS, Branco JN, et al. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg, 1996,61(1):63-66.
8 Reichenspurner H, Boehm D, Detter C, et al. Economic evaluation of different minimally invasive procedures for the treatment of coronary artery disease. Eur J Cardiothorac Surg, 1999, 16(Suppl2):S76-S79.
9陈长城,尤斌,王盛宇,等.非体外循环冠状动脉旁路移植术中转体外循环后的临床转归.心肺血管病杂志,2013, 32(6):738-741.
10喻磊,谷天祥,师恩祎,等.70岁以下多支冠状动脉病变患者体外与非体外循环冠状动脉旁路移植术的比较.中国胸心血管外科临床杂志,2010, 17(4):292-296.
11 Cheng DC, Bainbridge D, Martin JE, et al. Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials. Anesthesiology, 2005, 102(1):188-203.
12 Athanasiou T, Aziz O, Mangoush O, et al. Do off-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass grafting? Ann Thorac Surg, 2004, 77(5):1567-1574.
13伍育旗,张郁林,周波,等.92例非体外循环冠状动脉旁路移植术的临床分析.中国胸心血管外科临床杂志,2013,20(6):725-727.
14 Wang J, Xiao F, Ren J, et al. Risk factors for mortality after coronary artery bypass grafting in patients with low left ventricular ejection fraction. Chin Med J(Engl), 2007,120(4):317-322.
15顾松,苏丕雄,刘岩,等.左心室射血分数与缩短分数对冠状动脉旁路移植术后室性心律失常的预测.中国胸心血管外科临床杂志,2002, 9(3):168-171.
16 Bouchart F, Tabley A, Litzler PY, et al. Myocardialrevascularization in patients with severe ischemic left ventricular dysfunction. Long term follow-up in 141 patients. Eur J Cardiothorac Surg, 2001, 20(6):1157-1162.
17 Reston JT, Tregear SJ, Turkelson CM. Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting. Ann Thorac Surg, 2003, 76(5):1510-1515.
18 Ezhov MV, Safarova MS, Afanasieva OI, et al. Lipoprotein(a)level and apolipoprotein(a)phenotype as predictors of long-term cardiovascular outcomes after coronary artery bypass grafting.Atherosclerosis, 2014, 235(2):477-482.