Gold Jeffrey P, Torres Kaila E, Maldarelli William, Zhuravlev Ilya, Condit Douglas, Wasnick John
Department of Cardiovascular and Thoracic Surgery, Albert Einstein College of Medicine, Bronx, New York 10467, USA.
Ann Thorac Surg. 2004 Nov;78(5):1579-85. doi: 10.1016/j.athoracsur.2004.05.051.
Stroke and death continue to occur perioperatively associated with on-pump and off-pump coronary artery bypass grafting surgery (CABG) procedures. We report on a prospectively implemented multifaceted strategy to improve short-term outcomes associated with on-pump CABG.
Five hundred consecutive patients from a single teaching institution undergoing standardized on-pump nonreoperative CABG between June 1996 and July 2003 were entered into the New York State Cardiac Surgery database, a verified comprehensive clinical registry. Risk factors and outcomes were analyzed and compared with the statewide New York State CABG registry. All patients underwent intraoperative transesophageal echocardiography to guide distal aortic cannulation and high flow-high pressure cardiopulmonary bypass perfusion, arterial filtration, centrifugal pump perfusion, and membrane oxygenation. Intraoperative and early postoperative blood pressures were continuously targeted to match the patient's preoperative range.
The mean patient age was 63.5 years, 335 (67%) were male, and 320 (64%) were deemed to be of elective surgical priority. The mean ejection fraction was 0.434, with 255 (51%) having sustained a prior myocardial infarction. The mean cardiopulmonary bypass time was 95 minutes with an ischemic time of 51 minutes to accomplish a mean of 3.19 grafts/patient. The predicted group mortality was 2.28%, which was greater than the simultaneously measured 1.98% New York statewide CABG mortality during the same period for comparable patients (p < 0.05). There was no in-hospital or 30-day mortality nor were there any perioperative strokes in this group (p < 0.05). The mean postoperative hospital length of stay was 3.61 days with a 5.1% 30-day readmission rate.
A standardized approach to CABG using echocardiographic guided aortic cannulation and perioperative hemodynamic management reduces perioperative stroke and death associated with on-pump coronary surgery.
在体外循环和非体外循环冠状动脉搭桥手术（CABG）过程中，围手术期仍会发生中风和死亡。我们报告了一项前瞻性实施的多方面策略，以改善与体外循环CABG相关的短期结局。
1996年6月至2003年7月期间，来自单一教学机构的500例连续接受标准化体外循环非手术CABG的患者被纳入纽约州心脏外科数据库，这是一个经过验证的综合临床登记系统。分析危险因素和结局，并与全州范围的纽约州CABG登记系统进行比较。所有患者均接受术中经食管超声心动图检查，以指导远端主动脉插管以及高流量-高压体外循环灌注、动脉滤过、离心泵灌注和膜肺氧合。术中及术后早期血压持续维持在与患者术前范围相匹配的水平。
患者平均年龄为63.5岁，335例（67%）为男性，320例（64%）被认为具有择期手术优先权。平均射血分数为0.434，255例（51%）曾发生过心肌梗死。平均体外循环时间为95分钟，缺血时间为51分钟，平均每位患者完成3.19支移植血管吻合。预测的组死亡率为2.28%，高于同期纽约州全州范围内可比患者同时测量的1.98%的CABG死亡率（p<0.05）。该组患者无住院或30天死亡率，围手术期也无中风发生（p<0.05）。术后平均住院时间为3.61天，30天再入院率为5.1%。
采用超声心动图引导主动脉插管和围手术期血流动力学管理的标准化CABG方法可降低与体外循环冠状动脉手术相关的围手术期中风和死亡。
