Roy A, Stanbridge R L, O'Regan D, Salerno G, Saldanha C, Griselli M, Cherian A
Cardiothoracic Unit, St. Mary's Hospital, Praed Street, London, United Kingdom.
Heart Surg Forum. 2001;4(2):174-8.
Can off-pump coronary artery bypass grafting become the routine standard in all elective primary coronary artery bypass grafting (CABG) operations? This paper shows how this aim has been achieved during one year in 130 off-pump cases performed through a sternotomy. This strategy allows for full revascularization (up to six grafts) without the disadvantage of cardiopulmonary bypass. The study introduces a variant of the Octopus stabilizer, a single Octopus 1 arm (Medtronic, Inc., Minneapolis, MN) with a dual holder.
From November 1998 through February 2000, 130 patients underwent coronary artery bypass grafting through a sternotomy off-pump utilizing a stabilizer and CO2 blower. The stabilizer most frequently used to achieve this was a single Octopus 1 arm equipped with a dual holder to accommodate two straight suction pods. The holder allowed increased flexibility and manipulation of the suction pods with an equivalent of seven degrees' freedom of motion at the dual holder junction. Techniques for carrying out total revascularization are discussed. The progress of proportion of elective primary CABG revascularization performed off-pump is shown and results are compared with published reviews of the literature for off-pump coronary revascularization.
Patient demographics included: age range 32 to 87, mean 61.3; female sex: 17%; ejection fraction < 50%: 54%; presence of left main stem disease: 17%. Overall Parsonnet risk score ranged 0-31, with a mean of 8.8. Graft numbers carried out were: 34 x 2, 34 x 3, 32 x 4, 25 x 5 and 5 x 6 anastomoses respectively. The mean number of distal anastomoses was 3.6 +/- 1.0. There was extensive coverage of the lateral aspect of the heart (153 circumflex territory grafts, 33%). Radial artery, left internal mammary artery or saphenous vein sequential (jump) grafts were used in 26 cases (20%). Apart from general experience, the use of the dual holder and wide opening of the right pleura were the two important factors allowing freedom for multi-vessel lateral and posterior wall grafting. Thirteen Genzyme (Genzyme Surgical Products, Inc., Cambridge, MA) and ten Octopus 2 (or 2+) stabilizers were used, mostly for two or three grafts. The remainder were carried out using the Octopus 1 (dual holder: 83). In the first three-month period, 31% of cases were off-pump compared to the last three-month period, when 96% were off-pump. In the last two months we performed 100% of all 27 cases referred off-pump. There were no deaths, strokes or myocardial infarctions. Ventricular arrhythmia occurred in two cases. Conversions to bypass were undertaken twice. Two unexpected renal failures occurred, neither of which were from the 13 patients with preoperative incipient renal failure, of whom none suffered a rise in postoperative creatinine of greater than 30%. The results compare favorably with published results despite having a large mean number of grafts of 3.6.
Off-pump surgery with full revascularization has now become feasible for all primary elective coronary artery graft operations.
非体外循环冠状动脉旁路移植术能否成为所有择期原发性冠状动脉旁路移植术（CABG）手术的常规标准？本文展示了在通过胸骨切开术进行的130例非体外循环手术中，这一目标是如何在一年内实现的。该策略可实现完全血运重建（最多六个移植血管），且无体外循环的弊端。本研究介绍了章鱼稳定器的一种变体，即带有双固定器的单臂章鱼1（美敦力公司，明尼阿波利斯，明尼苏达州）。
从1998年11月至2000年2月，130例患者通过胸骨切开术，在非体外循环下使用稳定器和二氧化碳吹入器进行冠状动脉旁路移植术。最常用于此目的的稳定器是配备双固定器的单臂章鱼1，该双固定器可容纳两个直吸头。该固定器增加了吸头的灵活性和可操作性，在双固定器连接处相当于有七个自由度的运动。讨论了进行完全血运重建的技术。展示了非体外循环下择期原发性CABG血运重建比例的进展情况，并将结果与已发表的非体外循环冠状动脉血运重建文献综述进行了比较。
患者人口统计学特征包括：年龄范围32至87岁，平均61.3岁；女性：17%；射血分数<50%：54%；存在左主干病变：17%。总体帕森内特风险评分范围为0 - 31，平均为8.8。进行的移植血管数量分别为：34例2个吻合口、34例3个吻合口、32例4个吻合口、25例5个吻合口和5例6个吻合口。远端吻合口的平均数量为3.6±1.0。心脏侧面有广泛覆盖（153例旋支区域移植血管，占33%）·26例（20%）使用了桡动脉、左乳内动脉或大隐静脉序贯（跳跃）移植血管。除了一般经验外，双固定器的使用和右胸膜的广泛打开是允许在多支血管的侧面和后壁进行移植的两个重要因素。使用了13个Genzyme（Genzyme Surgical Products公司，剑桥，马萨诸塞州）和10个章鱼2（或2 +）稳定器，主要用于两个或三个移植血管。其余使用章鱼1（双固定器：83例）进行。在第一个三个月期间，31%的病例为非体外循环，而在最后一个三个月期间，96%为非体外循环。在最后两个月，我们对所有转诊的27例非体外循环病例均进行了100%的非体外循环手术。无死亡、中风或心肌梗死发生。两例发生室性心律失常。转为体外循环手术两次。发生两例意外肾衰竭，均非来自术前已有早期肾衰竭昀13例患者，这些患者术后肌酐升高均未超过30%。尽管平均移植血管数量较多，为3.6个，但结果与已发表结果相比仍较为理想。
对于所有原发性择期冠状动脉移植手术，完全血运重建的非体外循环手术现已变得可行。
