Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
Division of Cardiothoracic Transplantation and Circulatory Support, Texas Heart Institute, Houston, TX, USA.
J Cardiovasc Surg (Torino). 2022 Dec;63(6):742-748. doi: 10.23736/S0021-9509.22.12337-2. Epub 2022 Sep 28.
Ascending aorta manipulation during on-pump coronary artery bypass grafting (CABG) surgery can release embolic matter and may cause stroke. Strategies for lowering the stroke rate associated with coronary artery bypass grafting surgery include off-pump surgery without cardiopulmonary bypass and pump-assisted surgery with minimal aortic manipulation (i.e., without aortic cross-clamping). We examined whether one approach is superior to the other in reducing stroke and perioperative mortality rates.
We reviewed consecutive elective, urgent, and emergency off-pump/no-bypass and pump-assisted/no-clamp coronary artery bypass grafting procedures performed by a single surgeon at our institution from June 2011 through October 2017.
Of 570 patients analyzed, 395 (69.3%) underwent off-pump/no-bypass surgery, 43 (7.5%) underwent pump-assisted/no-clamp surgery, and 132 (23.2%) transitioned mid-procedure from off-pump/no-bypass to pump-assisted/no-clamp surgery. Patients who were >70 years old, were female, or had diabetes, cardiomegaly, or a history of myocardial infarction or congestive heart failure were more likely to undergo pump-assisted/no-clamp surgery or the combined technique. None of the pump-assisted/no-clamp patients had a stroke, versus 0.3% of the off-pump/no-bypass patients and 0.8% of the combination patients. Stroke and in-hospital mortality rates did not differ by technique.
A hybrid strategy incorporating off-pump, pump-assisted, and combined off-pump/pump-assisted techniques achieved very low stroke rates in patients undergoing coronary revascularization. Perioperative mortality was similar for all three techniques. Avoiding aortic clamping may be crucial for decreasing CABG-related stroke rates. Off-pump/no-bypass surgery had no significant advantage over the pump-assisted/no-clamp or combined techniques in reducing the stroke rate after coronary artery bypass grafting surgery.
在体外循环冠状动脉旁路移植术（CABG）期间对升主动脉进行操作可能会释放栓子，从而导致中风。降低与冠状动脉旁路移植术相关的中风发生率的策略包括不停跳手术（无体外循环）和泵辅助手术（主动脉最小操作，即无主动脉阻断）。我们研究了一种方法是否优于另一种方法来降低中风和围手术期死亡率。
我们回顾了 2011 年 6 月至 2017 年 10 月期间，由一位外科医生在我们机构进行的连续择期、紧急和急诊不停跳/无旁路和泵辅助/无阻断的冠状动脉旁路移植术。
在分析的 570 例患者中，395 例（69.3%）接受了不停跳/无旁路手术，43 例（7.5%）接受了泵辅助/无阻断手术，132 例（23.2%）在手术过程中从不停跳/无旁路转为泵辅助/无阻断手术。年龄>70 岁、女性、患有糖尿病、心腔扩大或有心肌梗死或充血性心力衰竭病史的患者更可能接受泵辅助/无阻断手术或联合技术。泵辅助/无阻断组无中风患者，而不停跳/无旁路组和联合组的中风发生率分别为 0.3%和 0.8%。三种技术的中风和院内死亡率没有差异。
在接受冠状动脉血运重建的患者中，结合不停跳、泵辅助和联合不停跳/泵辅助技术的混合策略实现了非常低的中风发生率。所有三种技术的围手术期死亡率相似。避免主动脉阻断可能是降低 CABG 相关中风发生率的关键。与泵辅助/无阻断或联合技术相比，不停跳/无旁路手术在降低冠状动脉旁路移植术后中风发生率方面没有显著优势。
