Zehr K J, Handa N, Bonilla L F, Abel M D, Holmes D R
Division of Cardiovascular Surgery, Mayo Foundation, Rochester, MN 55905, USA.
Heart Surg Forum. 2000;3(4):293-9.
We sought to determine the feasibility of off-pump coronary artery bypass grafting (OPCAB) in a consecutive series and prospectively assess the value of immediate post-operative coronary angiography.
All patients referred for coronary artery bypass grafting, within a four-month period, were approached as candidates for OPCAB. All 50 OPCAB patients were studied by immediate post-operative coronary angiography.
The OPCAB procedure was feasible in 67% of patients (50/75). Five of 55 patients (9.1%) were converted to on-pump procedures, three for hemodynamic instability, and two because of deeply intramyocardial vessels. The other 20 underwent on-pump revascularization for anatomical and physiological reasons. The average age of OPCAB patients was 68.1 +/- 9.6 years; 26% were female, 74% male. Two (4%) were redo operations. Mean number of grafts was 2.9 +/- 0.8, 51 internal thoracic artery grafts (ITA), 17 radial artery grafts (RA), and 76 saphenous vein grafts (SVG). Angiographic graft patency was 90.2% for ITA, 88.2% for RA, and 96.1% for SVG. Interpretation of catheterization results was confounded by significant native and arterial graft spasm. Six of seven occluded arterial grafts and one of three SVG were probe patent at immediate reoperation (all had adequate flow by intra-operative doppler at the initial operation). Only two graft occlusions were noted in the 18 patients who did not receive protamine. The patency rate was 95.6% (131/137) when the probe patent anastomoses were excluded. Seven patients (14%) returned to the OR as a result of the catheterization findings; five to revise occluded grafts, one to improve the lie of a kinked SVG, and one to graft an intramyocardial intermediate ramus when an adjacent high diagonal was grafted instead (two of seven on-pump). All graft problems were found in the absence of hemodynamic instability or electrocardiogram changes. In-hospital mortality was 2% (1). Complications in survivors were atrial fibrillation in 12 patients (24.5%), permanent pacemaker in one (2%), endotracheal bleeding in one (2%), and take-back for bleeding in one (2%).
There were a significant number of unexpected arterial graft occlusions. The reversal of heparin and ITA spasm appeared to be contributory. All patients with occluded grafts had no signs of trouble. Interpretation of immediate post-operative catherization is difficult because of significant native vessel and graft spasm. It reliably determines patency but it's value is suspect for determination of long-term graft adequacy.
我们试图确定连续系列非体外循环冠状动脉搭桥术（OPCAB）的可行性，并前瞻性评估术后即刻冠状动脉造影的价值。
在四个月期间，所有被推荐进行冠状动脉搭桥术的患者均被视为OPCAB的候选者。所有50例OPCAB患者均接受了术后即刻冠状动脉造影检查。
OPCAB手术在67%的患者（50/75）中可行。55例患者中有5例（9.1%）转为体外循环手术，3例因血流动力学不稳定，2例因心肌内血管过深。另外20例因解剖和生理原因接受了体外循环血运重建。OPCAB患者的平均年龄为68.1±9.6岁；26%为女性，74%为男性。2例（4%）为再次手术。平均移植血管数为2.9±0.8，其中51支胸廓内动脉移植血管（ITA），17支桡动脉移植血管（RA），76支大隐静脉移植血管（SVG）。ITA的血管造影通畅率为90.2%，RA为88.2%，SVG为96.1%。由于显著的自身血管和动脉移植血管痉挛，导管检查结果的解读受到干扰。7支闭塞的动脉移植血管中有6支以及3支SVG中有1支在即刻再次手术时探查通畅（所有在初次手术时术中多普勒显示血流充足）。在未接受鱼精蛋白的18例患者中仅发现2例移植血管闭塞。排除探查通畅的吻合口后，通畅率为95.6%（131/137）。7例患者（14%）因导管检查结果返回手术室；5例是为了修正闭塞的移植血管，1例是为了改善扭曲的SVG的走行，1例是在相邻高位对角支被移植时为心肌内中间分支进行移植（7例体外循环患者中的2例）。所有移植血管问题均在无血流动力学不稳定或心电图改变的情况下被发现。住院死亡率为2%（1例）。存活患者的并发症包括12例（24.5%）房颤，1例（2%）永久起搏器植入，1例（2%）气管内出血，1例（2%）因出血返回手术室。结论：存在大量意外的动脉移植血管闭塞。肝素和ITA痉挛的逆转似乎是其原因。所有移植血管闭塞的患者均无问题迹象。由于显著的自身血管和移植血管痉挛，术后即刻导管检查的解读困难。它能可靠地确定通畅情况，但对于确定长期移植血管的充足性其价值存疑。
