Karhunen Janne P, Sihvo Eero I T, Suojaranta-Ylinen Raili T, Rämö O Juhani, Salminen Ulla-Stina
Department of Cardiothoracic Surgery, Helsinki University Hospital, Helsinki, Finland.
J Cardiothorac Vasc Anesth. 2006 Apr;20(2):143-8. doi: 10.1053/j.jvca.2005.11.005. Epub 2006 Feb 21.
Sudden hemodynamic collapse after coronary artery bypass graft (CABG) surgery is a complication with high morbidity and mortality. The aim of this study was to explore factors possibly predictive of this major complication.
Retrospective case-control study.
University hospital, department of cardiothoracic surgery.
Between 1988 and 1999, of 8,807 CABG patients, a total of 76 (0.9%) suffered hemodynamic collapse after CABG surgery unrelated to pericardial tamponade or bleeding. Preoperatively matched patients (by age, sex, New York Heart Association classification, number of diseased vessels, left ventricular ejection fraction, and diabetes) served as a control group (n = 76).
Patients with sudden cardiovascular collapse underwent emergency reopening of the sternotomy and open cardiac massage (OCM group). Several pre-, intra-, and postoperative variables were compared, and significant parameters in match-pair analysis were further tested with regression techniques.
Of the 76 OCMs, 57 (75%) occurred during the first 5 postoperative hours. In-hospital mortality was 46% (35 of 76) versus 0% in controls; 5-year survival was 49% versus 95%. In the OCM group, cardiopulmonary bypass (CPB) time was significantly prolonged (p = 0.0024), and cardiac index (p = 0.05) and the first acid-base values after CPB were lower (pH, p = 0.0057; BE, p = 0.0014). Postoperative myocardial ischemia appeared in 33% of patients in the OCM group and in 8% of controls (p < 0.0001). OCM-group patients more frequently required postoperative inotropic (epinephrine, p = 0.0002) and mechanical support (intra-aortic balloon pump, p = 0.005). Regression analysis revealed a correlation between cardiopulmonary resuscitation risk and low cardiac index, postoperative ischemia, and low pH level.
Inadequate tissue perfusion, postoperative myocardial ischemia, and increased need for inotropic and mechanical support preceded hemodynamic collapse. Interventions to improve tissue perfusion and to prevent and treat myocardial ischemia may result in a more favorable outcome.
冠状动脉旁路移植术（CABG）后突然发生的血流动力学崩溃是一种发病率和死亡率都很高的并发症。本研究的目的是探索可能预测这一主要并发症的因素。
回顾性病例对照研究。
大学医院心胸外科。
1988年至1999年间，在8807例CABG患者中，共有76例（0.9%）在CABG术后发生了与心包填塞或出血无关的血流动力学崩溃。术前通过年龄、性别、纽约心脏协会分级、病变血管数量、左心室射血分数和糖尿病进行匹配的患者作为对照组（n = 76）。
发生突然心血管崩溃的患者接受紧急胸骨切开术重新打开并进行开胸心脏按压（OCM组）。比较了几个术前、术中和术后变量，并使用回归技术对配对分析中的显著参数进行了进一步测试。
在76例OCM患者中，57例（75%）发生在术后最初5小时内。住院死亡率为46%（76例中的35例），而对照组为0%；5年生存率分别为49%和95%。在OCM组中，体外循环（CPB）时间显著延长（p = 0.0024），心脏指数（p = 0.05）以及CPB后的首个酸碱值较低（pH，p = 0.0057；碱剩余，p = 0.0014）。OCM组33%的患者出现术后心肌缺血，而对照组为8%（p < 0.0001）。OCM组患者术后更频繁地需要使用血管活性药物（肾上腺素，p = 0.0002）和机械支持（主动脉内球囊反搏，p = 0.005）。回归分析显示心肺复苏风险与低心脏指数、术后缺血和低pH水平之间存在相关性。
血流动力学崩溃之前存在组织灌注不足、术后心肌缺血以及对血管活性药物和机械支持需求增加的情况。改善组织灌注以及预防和治疗心肌缺血的干预措施可能会带来更有利的结果。
