ObjectiveTo investigate the technique and efficacy of left atrial appendage (LAA) occlusion during off-pump coronary artery bypass grafting (OPCABG) in elderly patients with coronary artery disease (CAD) and atrial fibrillation (AF).MethodsFrom 2013 to 2018, 84 elderly patients with CAD and AF with reduced left ventricular ejection fraction (LVEF< 50%) underwent OPCABG in our department. There were 54 males and 30 females at age of 70-82 years. They were divided into a left atrial appendage (LAA) occlusion group (n=56) and a non-LAA occlusion group (n=28). Postoperative antithrombotic therapy: the LAA occlusion group was given warfarin + aspirin + clopidogrel “triple antithrombotic therapy” for 3 months after operation, then was changed to aspirin + clopidogrel “dual antiplatelet” for long-term antithrombotic; the non-LAA occlusion group was given warfarin + aspirin + clopidogrel “triple antithrombotic” for long-term antithrombotic after operation. The clinical effectiveness of the two groups was compared.ResultsAll patients underwent the surgery successfully. There were 56 patients in the LAA occlusion group, including 44 patients of LAA exclusion and 12 patients of LAA clip. The time of LAA occlusion was 3 to 8 minutes. There was no injury of graft vessels and anastomotic stoma. Early postoperative death occurred in 2 patients (2.4%). There was no statistical difference between the two groups in postoperative hospital stay (P=0.115). Postoperative LVEF of the two groups significantly improved compared with that before operation (P<0.05). There was no stroke or bleeding in important organs during hospitalization. During follow-up of 1 year, no cerebral infarction occurred in both groups, but the incidence of bleeding related complications in the LAA occlusion group was significantly lower than that in the non-LAA occlusion group (3.6% vs. 18.5%, P=0.036).ConclusionFor elderly patients with CAD and AF with reduced LVEF, LAA occlusion during OPCABG can effectively reduce the risk of stroke and bleeding related complications, and without increasing the risk of surgery.
In order to study the clinical efficacy of facial artery musculocutaneous flap on repairing the defect of the floor of mouth, 21 patients had received this type of treatment from 1991 to 1997. The size of the flaps ranged from 8.0 x 3.4 cm to 12.1 x 5.4 cm and the average age of these patients was 59.5 years old. The donor site was closed directly. Nineteen flaps survived completely, while necrosis occurred at the apex of the other 2 flaps, which healed by ordinary management. The applied anatomy of the flap and the design and the main points of the operation were reported in details. The advantage of the flap and the prevention of facial malformation following operation were discussed. The conclusion was that this type of flap was ideal for reconstruction of the defects of floor of the mouth.
This paper discusses a female patient with severe aortic stenosis, who was preoperatively assessed to be at high risk of left coronary artery occlusion, but developed complete occlusion of the right coronary artery during the procedure of transcatheter aortic valve replacement, leading to hemodynamic disorder. Surgical treatment under emergency cardiopulmonary bypass played a critical role in rescuing the patient.
Objective To investigate the distribution of the perforating branches artery of distally-based flap of sural nerve nutrient vessels and its clinical application. Methods The origins and distribution of perforating branchesartery of distally-based flap were observed on specimens of 30 adult cadavericlow limbs by perfusing red gelatin to dissect the artery.Among the 36 cases, there were 21 males, 15 females. Their ages ranged from 6 to 66, 35.2 in average. The defect area was 3.5 cm×2.5 cm to 17.0 cm×11.0 cm. The flap taken ranged from 4 cm×3 cm to 18 cm×12 cm. Results The perforating branches artery of distally-based flap had 2 to 5 branches and originated from the heel lateral artery, the terminal perforating branches of peroneal artery(diameters were 0.6±0.2 mm and 0.8±0.2 mm, 1.0±1.3 cm and 2.8±1.0 cm to the level of cusp lateral malleolus cusp).The intermuscular septum perforating branches of peroneal artery had 0 to 3 branches. Their rate of presence was 96.7%,66.7% and 20.0% respectively(the diameters were 0.9±0.3, 1.0±0.2 and 0.8±0.4 mm, andtheir distances to the level of cusp of lateral malleolus were 5.3±2.1, 6.8±2.8 and 7.0±4.0 cm). Those perforating branches included fascia branches, cutaneous branches, nerve and vein nutrient branches. Those nutrient vessels formed longitudinal vessel chain of sural nerve shaft, vessel chain of vein side and vessel network of deep superficial fascia. The distally-based superficial sural artery island flap was used in 18 cases, all flaps survived. Conclusion Distally-based sural nerve, small saphenous vein, and nutrient vessels of fascia skin have the same origin. Rotation point of flap is 3.0 cm to the cusp of lateral malleolus, when the distally-based flap is pedicled with the terminal branch of peroneal artery.Rotation point of flap is close to the cusp of lateral malleolus, when the distally-based flap is pedicled with the heel lateral artery.
Transit time flow measurement (TTFM),which is independent of vessel size and shape, has been considered to be an easy, reproducible and non-invasive method to assess the hemodynamic characteristics. Moreover, current studies have shown that TTFM has clinical application in identifying the function of grafted vessel and prognosis. Researchers have proved some reliable indicators for the function of grafted vessel as follows: mean graft flow (MGF) > 15 ml/min, diastolic flow (DF) >50% and pulsatility index (PI)<3 or 5. This article focuses on the review of clinical application and research progress of TTFM in CABG.
Abstract: Coronary artery bypass grafting (CABG) has become more and more popular, but how to decrease the thrombotic stenosis of saphenous vein grafts remains a tough problem clinically. Some researchers raised that aspirin resistance (AR) may be one of the most principal causes of graft thrombus and many correlative studies have been reported in recent years．In this article, we reviewed and analyzed the concept and evaluation criterion, incidence rate, mechanisms, clinic significance, and preventing strategy of AR, expecting to deepen the understanding of AR and help to optimize the antiplatelet therapy for postCABG patients with AR.
摘要:目的: 探讨非体外循环冠状动脉旁路移植术(offpump coronary artery bypass grafting,OPCABG)患者的围术期管理。 方法 : 回顾分析2005 年7 月至2008 年6 月的200 例择期非体外循环下冠状动脉旁路移植术患者200例,诱导用咪唑安定005～01 mg/kg,依托咪酯03 mg/kg,芬太尼5～15 μg／kg,罗库溴铵05～10 mg／kg,麻醉维持采用持续泵注异丙酚1～4 mg/kg·h,,间断辅以05%～20%异氟烷吸入,术中随手术操作时出现的血流动力学变化,用血管活性药物调整。 结果 : 麻醉效果满意,术中血压心率基本满意。本组患者苏醒时间,拔管时间和ICU停留时间为(178±42) min、(105±40)h、(18±63)h。术毕180例患者在12 h内拔管。180例预后良好,无麻醉并发症。 结论 :非体外循环下冠状动脉旁路移植术麻醉管理的关键是合理的应用麻醉药和血管活性药来维持血流动力学平稳。Abstract: Objective: To summarize the technique and evaluate the effect of anesthesia for offpump coronary artery bypass surgery (OPCAB). Methods :From July of 2005 through June of 2008,two hundred consecutive patients undergoing OPCAB were retrospectively studied. Anesthesia was induced with midazolam 00501mg/kg, or etomidate 03mg/kg and fentanyl 515μg/kg. Anesthesia was maintained with isoflurane 05%20% and oxygen, combined with propofol 14mg/(kg·h). Intraoperative hypotension resulting from either surgical procedure or anesthetics should be dealt with inotropes immediately. Results :Intraoperative hemodynamics deviation was tolerated with the support of inotropics. The mean of patients of consciousness recovery time, tracheal extubation time and stay in ICU time were 178±42 min,105±40 hours and 18±63 hours. The patients were discharged in 80±12 days. Racheal intubation were remained 12 hours in 180 patients after operation, 180 patients had good recovery without any anesthesia complications. Conclusion : Rational use of anesthetics and inotropics to stabilize hemodynamics during operation plays a key role in successful OPCAB.
ObjectiveTo compare clinical outcomes between coronary artery bypass grafting (CABG)and off-pump coronary artery bypass grafting (OPCAB)for high-risk coronary artery disease (CAD)patients with high European System for Cardiac Operative Risk Evaluation (EuroSCORE). MethodsA total of 211 CAD patients undergoing surgical treatment in the Department of Cardiovascular Surgery, Anhui Provincial Hospital Affiliated to Anhui Medical University from June 2007 to July 2013 were enrolled into this study, including 52 patients receiving CABG and 159 patients receiving OPCAB. Predicted risk of operative mortality (PROM)of each patient was calculated by EuroSCORE. Patients with PROM≥6 were stratified into high-risk subgroups. Clinical outcomes were compared between CABG and OPCAB patients, as well as incidence of cardiovascular events, angina and stroke within 30 postoperative days in high-risk subgroup patients. ResultsOPCAB and CABG group patients had similar left main disease. There was no statistical difference in the number of distal anastomosis between OPCAB (2.75±0.82)and CABG group patients (2.83±0.58) (P > 0.05). Operation time[ (3.92±0.79)hour vs. (6.83±1.53)hour], thoracic drainage[ (983.14±802.39)ml vs. (1 620.40±879.32)ml], blood transfusion[ (1 289.30±668.08)ml vs. (2 325.30±491.98)ml], length of ICU stay[ (3.90±1.33)days vs. (5.08±1.78)days], and mechanical ventilation time[ (9.63±3.32)h vs. (13.76±3.79)h] of OPCAB group patients were significantly shorter or lower than those of CABG group patients (P < 0.05). There was no statistical difference in 30-day mortality between OPCAB and CABG group patients (1.26% vs. 3.85%, P > 0.05). Among high-risk subgroup patients, the odds ratio of stroke within 30 postoperative days in CABG was 5.7 (95%CI 1.28-25.09, P < 0.05)compared with OPCAB group patients, and the incidence of cardiovascular events and angina within 30 postoperative days were similar between the 2 subgroups. ConclusionsPostoperative mortality and number of distal anastomosis are not significantly different between CABG and OPCAB patients, but OPCAB can significantly reduce operation time, thoracic drainage, blood transfusion, length of ICU stay and mechanical ventilation time compared with CABG. For high-risk patients with high EuroSCORE, OPCAB can better reduce the incidence of postoperative stroke compared with CABG.
摘要:目的:了解血肌酐清除率受损是否与冠心病患病率存在联系。方法:纳入2006年7月至2008年2月期间经冠状动脉造影证实的冠心病患者及年龄、性别匹配的对照组,按血肌酐清除率值将患者分为正常［≥90 mg/（mL·173 m2)］,轻度受损［≥60 mg/（mL·1.73 m2）,lt;90 mg/（mL·1.73 m2)］和明显受损［lt;60 mg/（mL·1.73 m2)］。比较冠心病组与对照组各组人群的比例有无差异。结果:研究期间共纳入冠心病组和对照组患者各116例。在冠心病组中,血肌酐清除率正常患者82例、轻度受损29例、重度受损5例,对照组中,正常患者98例、轻度受损13例、重度受损5例,〖JP3〗两组比较分布有统计学差异(χ2值7.517,P=0.023)。与对照组比较,冠心病组的血清肌酐值无明显差异（Pgt;005)，〖JP〗冠心病组（103.29±51.08） μmol/L,对照组（102.67±41.21）μmol/L。结论:血肌酐清除率降低是冠心病的危险因素。Abstract: Objective: To disclose the relation of the estimated glomerular filtration rate (eGFR) and coronary artery disease. Methods：We analyzed eGFR in the patients with coronary artery disease confirmed by coronary angiography and the control, and compared the proportion of patients with reduced renal function in the different groups. Results: A total 116 cases were included in each group. Among these patients, normal renal function, mildly and severe reduced renal function was documented in 82, 29 and 5 in coronary artery disease group, and in 98, 13 and 5 in the control group, respectively. In comparison to the control, more patients with reduced eGFR were found in coronary artery disease group (χ2 value 7.517,P=0.023), although no significant difference was observed between both groups（Pgt;0.05). Conclusion: Reduced eGFR, even if mildly, could be regarded as the risk factor of coronary artery disease.
ObjectiveTo compare the short- and long-term efficacy of artery-first approach pancreatico-duodenectomy (AF-PD) and standard approach pancreaticoduodenectomy (S-PD).MethodsThe PubMed, EMbase, The Cochrane Library, Web of Science, CBM, WanFang, and CNKI databases were searched, relevant literatures were included, and relevant data were extracted for meta-analysis.ResultsA total of 30 articles were included, including 2 750 cases underwent pancreaticoduodenectomy. The results of meta-analysis showed that in terms of short-term efficacy when compared with S-PD group, the AF-PD group had less intraoperative blood loss (WMD=–175.87, P<0.001), lower intraoperative blood transfusion rate (OR=0.36, P=0.002), higher R0 resection rate (OR=1.83, P<0.001), lower postoperative pancreatic leakage rate (OR=0.71, P=0.005), and shorter postoperative hospital stay (WMD=–2.69, P=0.007). However, there were no statistically significant differences in the operation time and overall postoperative complication rate between the two groups (P>0.05). In terms of long-term efficacy when compared with S-PD group, the AF-PD group had lower tumor local recurrence rate (OR=0.43, P=0.004) and tumor liver metastasis rate (OR=0.60, P=0.010), but had higher 1-year (OR=1.95, P=0.007), 2-year (OR=2.04, P<0.001), 3-year (OR=2.09, P=0.001), and 5-year (OR=2.06, P=0.003) overall survival rates, and there were no significant differences in the rates of lung metastasis and peritoneal metastasis between the two groups (P>0.05).ConclusionsAF-PD is better than S-PD in some short-term and long-term outcome indicators such as R0 resection rate, pancreatic leakage rate, overall survival rate, and so on. However, due to the limited quality of the included literatures, more high-quality studies are still needed to verify in the future.