Ramponi Fabio, Seco Michael, Brereton Russel John Legay, Gaudino Mario F L, Puskas John D, Calafiore Antonio M, Vallely Michael P
Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.
J Card Surg. 2021 Apr;36(4):1499-1510. doi: 10.1111/jocs.15372. Epub 2021 Jan 27.
Surgical coronary revascularization remains the preferred strategy in a significant portion of patients with coronary artery disease due to superior long-term outcomes. However, there is a significant risk of perioperative neurologic injury that has influenced guideline recommendations. These complications occur in 1%-5% of patients, ranging from overt neurologic deficits with permanent disability, to subtle cerebral defects noted on neuroimaging that may result in slow cognitive and functional decline. The primary mechanism by which these events occur is thromboembolism from manipulation of the ascending aorta. This occurs during cardiopulmonary bypass, aortic cross-clamping, and partial occlusion clamping (side clamp). Elderly patients and patients with aortic atheroma are, therefore, at significantly increased risk. Initial surgical techniques addressed this by aggressively debriding or replacing the ascending aorta during coronary artery bypass grafting (CABG). Strategies then moved toward minimizing aortic manipulation through pump-assisted beating heart surgery and off-pump surgery with partial occlusion clamping or proximal anastomosis devices. Finally, anaortic off-pump CABG aims to avoid all manipulation of the ascending aorta through advanced off-pump grafting techniques combined with in situ and composite grafts. This has been demonstrated to result in the greatest reduction in risk. Establishing successful anaortic off-pump CABG programs requires subspecialization and focused interest groups dedicated to advancing CABG outcomes.
由于长期效果更佳，外科冠状动脉血运重建仍是很大一部分冠心病患者的首选治疗策略。然而，围手术期神经损伤风险较高，这影响了相关指南建议。这些并发症在1%至5%的患者中出现，范围从导致永久性残疾的明显神经功能缺损，到神经影像学检查发现的细微脑损伤，后者可能导致认知和功能缓慢衰退。这些事件发生的主要机制是升主动脉操作引发的血栓栓塞。这发生在体外循环、主动脉交叉钳夹和部分闭塞钳夹（侧钳夹）过程中。因此，老年患者和有主动脉粥样硬化的患者风险显著增加。最初的外科技术通过在冠状动脉旁路移植术（CABG）期间积极清创或置换升主动脉来解决这一问题。随后策略转向通过泵辅助心脏跳动手术以及使用部分闭塞钳夹或近端吻合装置的非体外循环手术来尽量减少主动脉操作。最后，无主动脉非体外循环CABG旨在通过先进的非体外循环移植技术结合原位和复合移植物来避免对升主动脉的所有操作。这已被证明能最大程度降低风险。建立成功的无主动脉非体外循环CABG项目需要亚专业划分和专注的兴趣小组，致力于提高CABG的治疗效果。
