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影响不停跳冠状动脉搭桥手术效果的诸因素探讨
Discussion on the Factors of Beating Heart Coronary-artery Bypass Grafting
【作者】 刘云；
【导师】 柳克祥；
【作者基本信息】 吉林大学 ， 临床医学硕士（专业学位）， 2018， 硕士
【摘要】 目的:探讨影响不停跳冠状动脉搭桥手术的因素,提高不停跳手术的效果。方法:回顾分析2012年1月到2016年6月,我院心血管外科收治的898例冠心病患者,均单纯行冠状动脉旁路移植术,所有患者均在心脏不停跳下进行搭桥。其中非体外循环心脏跳动下冠状动脉搭桥术(off-pump coronary-artery bypass grafting,OPCABG)组797例;体外循环心脏不停跳下冠状动脉搭桥术(on-pump beating heart coronary-artery bypass grafting,OPBH)组101例。手术方法:全身肝素化(1mg/kg,体外组3mg/kg)后,运用心尖固定器和心肌固定器保持心脏和心肌位置,首先吻合乳内动脉-左前降支,然后用大隐静脉,按照右冠-回旋-对角-主动脉的顺序,采用序贯-平行的吻合方法搭桥。结果:OPCABG组患者平均搭桥数3.36±0.74个。OPBH组患者平均搭桥数3.71±0.69个。术后呼吸机辅助通气时间,ICU时间,住院时间,死亡率,IABP使用率,ECMO使用率有明显差异。全部898例总体死亡率为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。
【Abstract】 Objective:To explore the factors affecting the operation of coronary artery bypass grafting 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 underwent coronary artery bypass grafting only.All patients were cabled under beating heart.The off-pump coronary artery bypass grafting(off-pump coronary-artery bypass grafting,OPCABG)group concluded 797 cases;Another 101 cases were beating heart coronary artery bypass grafting(on-pump beating heart coronary-artery bypass grafting,OPBH)group.Operation method: After heparin(1mg/kg,3mg/kg,in OPBH),we used apical fixation and myocardial fixator to keep the heart and the location of the myocardium,anastomosis of the internal mammary artery with the anterior descending branch at first,and then we performed the bypasses: Great saphenous vein-RCA-LCX-Diagonal branch in sequential method.Results:The average number of bypasses in group OPCABG were 3.36±0.74.And the group OPBH were 3.71±0.69,and there was no significant difference between them.The postoperative ventilator ventilation time,ICU time,hospitalization time,mortality,the utilization rate of IABP and ECMO were significantly different.The total mortality of all 898 cases was 1.68%(12 cases),and the total bloodless operation ratio was 91.3%.Conclusion:The results showed that most patients achieved good results with the help of apical fixation and myocardial fixator,surgical techniques and methods,good anesthesia management,flexible and accurate use of vasoactive drugs.But extracorporeal circuIation are necessary in the cases of large left ventricle,low EF and hypotension after moving heart.