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.
Objective To evaluate the clinical efficacy of coronary artery bypass grafting in the treatment of coronary artery disease patients aged over 70 years. Methods A total of 160 patients with coronary atherosclerotic heart disease underwent off-pump coronary artery bypass grafting from January 2013 to December 2017. There were 94 males and 66 females at age of 70–85 (76.67±2.33) years. Operations were performed by using sternal median incision with the assistance of local myocardial surface fixator and shunt plug, and the saphenous vein and internal mammary arterywere used as grafted vessels. Results All the patients were received successful off-pump coronary artery bypass grafting without death, and the cardiac function improved significantly. There were 62 patients with the internal mammary artery bridge and 98 patients with the whole vein bridge. All the patients were followed-up for 1 to 4 years. All the patients had obvious relief of angina pectoris. Conclusion Off-pump coronary artery bypass grafting for the treatment of elderly patients with coronary heart disease is an effective and safe operation, especially for patients with renal insufficiency, cerebrovascular disease, respiratory disease and severe left ventricular dysfunction.
Minimally invasive cardiac surgeries are the trend in the future. Among them, robotic cardiac surgery is the latest iteration with several key-hole incision, 3-dimentional visualization, and articulated instrumentation of 7 degree of ergonomic freedom for those complex procedures in the heart. In particular, robotic mitral valve surgery, as well as coronary artery bypass grafting, has evolved over the last decade and become the preferred method at certain specialized centers worldwide because of excellent results. Other cardiac procedures are in various stages of evolution. Stepwise innovation of robotic technology will continue to make robotic operations simpler, more efficient, and less invasive, which will encourage more surgeons to take up this technology and extend the benefits of robotic surgery to a larger patient population.
Patients undergoing coronary artery bypass grafting (CABG) belong to the very high-risk group of atherosclerotic cardiovascular disease. Although CABG gets advantages in relieving symptoms and improving long-term outcomes, a significant risk of cardiovascular adverse events after surgery still exists and standardized secondary prevention is needed. Lipid management plays a critical role as a secondary preventive strategy in CABG. However, lipid management of CABG patients in real clinical setting is inadequate, including lack of standardized lipid-lowering strategy, low goal attainment rate, as well as poor long-term medication adherence. In recent years, a series of clinical trials have provided a lot of groundbreaking new evidence for lipid management in patients with cardiovascular diseases which offers new strategies together with objectives of lipid-lowering and comprehensive management for patients undergoing CABG. This article reviews the strategy and research progress of lipid management after CABG, aiming to provide objective reference for clinical treatment.
Objective To summarize the treatment outcomes of antegrade sequential anastomosis of great saphenous veins in off-pump coronary artery bypass grafting for coronary atherosclerotic heart disease. Methods A total of 116 patients with coronary atherosclerotic heart diseases underwent off-pump coronary artery bypass grafting from January 2013 to June 2015 in our hospital. There were 63 males and 53 females with a mean age of 42–80 (64.26±9.67) years. Left internal mammary artery was anastomosed to left anterior descending artery. The rest of the target vessels received antegrade sequential anastomosis of great saphenous veins with the order of proximal ascending aorta, diagonal branch, circumflex branch, obtuse marginal branch, left ventricular branch and posterior descending artery. Results All patients were performed off-pump coronary artery bypass grafting successfully without death or perioperative myocardial infarction. A total of 436 grafts were adopted with 3.75±0.53 in each patient. Three patients suffered low cardiac output syndrome, and were cured after administration of vasoactive drugs combined with the intra-aortic balloon pump. One patient suffered tardive pericardial tamponade and one acute renal failure, who were cured with disappearance of angina symptoms and increase of activities without discomfort. Conclusion Antegrade sequential anastomosis, as a safe and effective method, can reduce aortic stoma, save the length of grafts, shorten operative time and quickly restorate blood supply of myocardium in off-pump coronary artery bypass grafting.
ObjectiveTo study the learning curve of minimal invasive coronary artery bypass grafting (MICS CABG) and the influence on the perioperative clinical effects by analyzing operation time.MethodsFrom March 2012 to November 2020, 212 patients underwent MICS CABG by the same surgeon. Among them, 59 patients (52 males and average age of 62.89±8.27 years) with single vessel bypass grafting were as a single-vessel group and 153 patients (138 males, average age of 59.80±9.22 years) with multi-vessel bypass grafting were as a multi-vessel group. Two sets of operation time-operation sequence scatter plots were made and learning curve was analyzed by cumulative summation (CUSUM) and regression method of operation time. The surgical data of each group before and after the inflection point of the learning curve were compared with the main clinical outcome events within 30 days after surgery.ResultsThere was no death, perioperative myocardial infarction and stroke in 212 MICS CABG patients and no transfer to cardiopulmonary bypass or redo thoracotomy. The learning curve conformed to the cubic fitting formula. In the single-vessel group, CUSUM (x operation number)=–1.93+93.45×x–2.33×x2+0.01×x3, P=0.000, R2=0.986, the tipping point was 27 patients. In the multi-vessel group, CUSUM (x)=y=2.87+1.15×x–1.29× x2+3.463×x3, P=0.000, R2=0.993, and the tipping point was 59 patients. The two sets of case data were compared before and after the learning curve and there was no statistical difference in main clinical outcomes within 30 days (mortality, acute myocardial infarction, stroke, perioperative blood transfusion rate), ventilator tube, and intensive care unit retention.ConclusionThe learning curve of MICS CABG conforms to the cubic formula, and the process transitions from single to multiple vessels bypass. To enter the mature stage of the learning phase, a certain number of patients need to be done. Reasonable surgical procedures and quality control measures can ensure the safety during the learning phase.
ObjectiveTo analyze the risk factors of new-onset postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG).MethodsFrom September 2011 to October 2013, 1 614 consecutive patients underwent elective coronary artery bypass grafting in Fuwai Hospital. There were 1 281 males and 333 females at average age of 60.3±8.4 years. Holter data recorded for 5 days after operation were collected and analyzed. The risk factors associated with POAF were assessed according to the baseline and intraoperative data, and the positive variables were stratified.ResultsA total of 314 patients (19.5%) developed new-onset POAF. The rate of POAF was elevating with the increase of age (P<0.001).ConclusionAge was an independent risk factor for POAF in patients undergoing elective CABG alone.
The choice of the graft conduit for coronary artery bypass grafting (CABG) has significant implications both in the short-and long-term. The patency of a coronary conduit is closely associated with an uneventful postoperative course, better long-term patient survival and superior freedom from re-intervention. The internal mammary artery is regarded as the primary conduit for CABG patients, given its association with long-term patency and survival. However, long saphenous vein (LSV) continues to be utilized universally as patients presenting for CABG often have multiple coronary territories requiring revascularization. Traditionally, the LSV has been harvested by creating incisions from the ankle up to the groin termed open vein harvesting (OVH). However, such harvesting methods are associated with incisional pain and leg wound infections. In addition, patients find such large incisions to be cosmetically unappealing. These concerns regarding wound morbidity and patient satisfaction led to the emergence of endoscopic vein harvesting (EVH). Published experience comparing OVH with EVH suggests decreased wound related complications, improved patient satisfaction, shorter hospital stay, and reduced postoperative pain at the harvest site following EVH. Despite these reported advantages concerns regarding risk of injury at the time of harvest with its potential detrimental effect on vein graft patency and clinical outcomes have prevented universal adoption of EVH. This review article provides a detailed insight into the technical aspects, outcomes, concerns, and controversies associated with EVH.
ObjectiveTo investigate the factors associated with unplanned readmission within 30 days after discharge in adult patients who underwent coronary artery bypass grafting (CABG) and to develop and validate a risk prediction model. MethodsA retrospective analysis was conducted on the clinical data of patients who underwent isolated CABG at the Nanjing First Hospital between January 2020 and June 2024. Data from January 2020 to August 2023 were used as a training set, and data from September 2023 to June 2024 were used as a validation set. In the training set, patients were divided into a readmission group and a non-readmission group based on whether they had unplanned readmission within 30 days post-discharge. Clinical data between the two groups were compared, and logistic regression was performed to identify independent risk factors for unplanned readmission. A risk prediction model and a nomogram were constructed, and internal validation was performed to assess the model’s performance. The validation set was used for validation. ResultsA total of 2 460 patients were included, comprising 1 787 males and 673 females, with a median age of 70 (34, 89) years. The training set included 1 932 patients, and the validation set included 528 patients. In the training set, there were statistically significant differences between the readmission group (79 patients) and the non-readmission group (1 853 patients) in terms of gender, age, carotid artery stenosis, history of myocardial infarction, preoperative anemia, and heart failure classification (P<0.05). The main causes of readmission were poor wound healing, postoperative pulmonary infections, and new-onset atrial fibrillation. Multivariable logistic regression analysis revealed that females [OR=1.659, 95%CI (1.022, 2.692), P=0.041], age [OR=1.042, 95%CI (1.011, 1.075), P=0.008], carotid artery stenosis [OR=1.680, 95%CI (1.130, 2.496), P=0.010], duration of first ICU stay [OR=1.359, 95%CI (1.195, 1.545), P<0.001], and the second ICU admission [OR=4.142, 95%CI (1.507, 11.383), P=0.006] were independent risk factors for unplanned readmission. In the internal validation, the area under the curve (AUC) was 0.806, and the net benefit rate of the clinical decision curve analysis (DCA) was >3%. In the validation set, the AUC was 0.732, and the DCA net benefit rate ranged from 3% to 48%. ConclusionFemales, age, carotid artery stenosis, duration of first ICU stay, and second ICU admission are independent risk factors for unplanned readmission within 30 days after isolated CABG. The constructed nomogram demonstrates good predictive power.
ObjectiveTo explore the incidence of total occlusion of right coronary artery (RCA)and its treatment strategy during off-pump coronary artery bypass grafting (OPCAB). MethodsA total of 1 153 patients with total RCA occlusion were chosen from 6 206 patients who underwent OPCAB in Beijing Anzhen Hospital from January 1, 2005 to December 31, 2012. There were 889 male (77.1%)and 264 female (22.9%)patients with their age of 45-78 years. The incidence of total RCA occlusion was calculated, and its treatment strategies were discussed. ResultsAmong 6 206 OPCAB patients, 1 153 patients (18.6%)had total RCA occlusion. All the 1 153 patients successfully received OPCAB, but 13 patients (1.1%)died postoperatively. Thirty-four patients (2.9%)had postoperative complications including cerebral infarction, mild to moderate pleural effusion and poor wound healing, all of whom were cured or improved, and all the other patients were discharged uneventfully. A total of 1 110 patients (97.4%)were followed up for 1 month to 7 years, and 30 patients were lost during follow-up. Angina symptoms disappeared in 758 patients and were relieved in 352 patients. During follow-up, 64-row helical CT of 586 patients with preoperative total RCA occlusion showed good graft patency, and echocardiography and nuclear myocardial scan showed improved left ventricular systolic function and myocardial blood flow. ConclusionThe incidence of total RCA occlusion is 18.6% in our study. Appropriate surgical strategies are needed according to individualized patient conditions to get satisfactory clinical outcomes.