Edgerton James R., Herbert Morley A., Jones Katherine K., Prince Syma L., Acuff Tea, Carter David, Dewey Todd, Magee Mitchell, Mack Michael
Cardiopulmonary Research Science and Technology Institute, Dallas.
Heart Surg Forum. 2004 Jan 1;7(1):8-15.
Abstract Background: Cardiac surgery has expanded the available approaches to aortocoronary artery bypass grafting to include approaches from minimally invasive surgery to full sternotomy. The heart can be arrested, left beating, or assisted with a right ventricular assist device or cardiopulmonary bypass pump. We have examined the 4 surgical modes that we use routinely in our large multisurgeon practice to determine our selection biases and the outcomes of the different techniques. Methods: Of the 4733 coronary artery bypass grafting (CABG) patients we studied from January 2000 through December 2002, 2332 (49.3%) operations were done on-pump on the arrested heart, 1908 (40.3%) were performed off-pump, 364 (7.7%) were performed on-pump on the beating heart, and 129 (2.7%) were performed with right heart assist. The preoperative risk factors, operative variables, and postoperative outcomes of the groups were analyzed. Results: Patients selected for on-pump beating heart procedures tended to be sicker with the highest predicted risk of death. We also selected patients who were in cardiogenic shock, in resuscitation, in emergent or salvage status, on dialysis, and with preoperative intra-aortic balloon pump (IABP) use for on-pump beating heart procedures at higher than expected rates. Patients with renal failure with or without dialysis, and those having a history of cerebrovascular accident tended not to be chosen for on-pump arrested heart procedures. Off-pump beating heart procedures were avoided for patients with cardiogenic shock or resuscitation, in emergent or salvage status, and with preoperative IABP use. The mortality rate in these patients was slightly worse in the on-pump beating heart group (4.4%) than in the on-pump arrested heart (3.5%) and off-pump (2.3%) groups (analysis of variance [ANOVA], P =.04). Atrial fibrillation occurred more frequently in both the on-pump beating heart (20.1%) and on-pump arrested heart (23.8%) groups (ANOVA, P <.001). The on-pump groups had higher rates of blood product use and reoperation for bleeding and a prolonged ventilation rate, compared with the other procedures. On-pump patients had a statistically longer length of stay than either off-pump or right heart-assisted patients ( P <.05) and required longer times on the ventilator and in the intensive care unit. Conclusions: Normothermic cardiopulmonary bypass with a beating heart is safe and efficacious and may be the method of choice for patients in cardiogenic shock, requiring resuscitation, or with previous CABG surgery, recent myocardial infarction, a low ejection fraction, or unstable arrhythmias.
摘要 背景：心脏外科手术已拓展了主动脉冠状动脉搭桥术的可用方法，涵盖了从微创手术到全胸骨切开术等多种术式。心脏可以停跳、保持跳动，或者借助右心室辅助装置或体外循环泵进行辅助。我们研究了在我们大型多外科医生的实践中常规使用的4种手术模式，以确定我们的选择偏倚和不同技术的结果。方法：在我们于2000年1月至2002年12月期间研究的4733例冠状动脉搭桥术（CABG）患者中，2332例（49.3%）手术是在心脏停跳下进行体外循环，1908例（40.3%）是在非体外循环下进行，364例（7.7%）是在心脏跳动下进行体外循环，129例（2.7%）是在右心辅助下进行。分析了各组的术前危险因素、手术变量和术后结果。结果：被选进行体外循环心脏跳动下手术的患者往往病情更重，预测死亡风险最高。我们还以高于预期的比例选择处于心源性休克、正在复苏、处于紧急或挽救状态、正在透析以及术前使用主动脉内球囊反搏（IABP）的患者进行体外循环心脏跳动下手术。有或无透析的肾衰竭患者以及有脑血管意外病史的患者往往不被选进行体外循环心脏停跳手术。对于心源性休克或正在复苏、处于紧急或挽救状态以及术前使用IABP的患者，避免进行非体外循环心脏跳动下手术。这些患者中，体外循环心脏跳动下手术组的死亡率（4.4%）略高于体外循环心脏停跳组（3.5%）和非体外循环组（2.3%）（方差分析[ANOVA]，P = 0.04）。心房颤动在体外循环心脏跳动下手术组（20.1%）和体外循环心脏停跳手术组（23.8%）中均更频繁发生（ANOVA，P < 0.001）。与其他手术相比，体外循环组血液制品使用、因出血再次手术以及通气时间延长的发生率更高。体外循环患者的住院时间在统计学上比非体外循环或右心辅助患者更长（P < 0.05），且呼吸机使用时间和重症监护病房停留时间更长。结论：常温体外循环下心脏跳动是安全有效的，对于心源性休克、需要复苏、或有既往CABG手术史、近期心肌梗死、低射血分数或不稳定心律失常的患者可能是首选方法。
