非体外循环冠状动脉旁路移植术的手术策略对术中血流动力学的影响

Clinical studies in the effect of operative strategies on the hemodynamics in off-pump coronary artery bypass grafting

目的研究非体外循环冠状动脉旁路移植术（CABG）的术中手术策略在吻合不同部位靶血管时对血流动力学的影响，探讨非体外循环CABG术中稳定血流动力学的措施。方法2005年3月至2007年3月进行手术治疗的67例冠状动脉粥样硬化性心脏病患者，男性45例，女性22例，年龄44—81岁，均为严重三支病变。所有患者均先作左胸廓内动脉．前降支（LIMA-LAD）吻合，再作钝缘支（OM）及后降支（PDA）的序贯吻合。根据吻合的顺序不同将患者分为三组：组Ⅰ吻合顺序为PDA-OM-主动脉（Ao），共22例；组Ⅱ吻合顺序为Ao-PDA-OM，共14例；组Ⅲ为Ao-OM-PDA，共31例。以LIMA-LAD吻合前的血流动力学指标为基础值，在LAD吻合时及吻合后、PDA吻合时、OM吻合时各时间点测定血流动力学指标，并与基础值相比较。结果67例患者均顺利施行了非体外循环CABG，无手术死亡。行LIMA-LAD吻合时，各项血流动力学指标变化不显著。HMA-LAD完成后，各项指标显著改善。吻合OM时，组Ⅰ、组Ⅲ的心率（HR）、中心静脉压（CVP）显著升高（P〈0．05），平均动脉压（MAP）、心指数（CI）、左室做功指数（LVSWI）及右室做功指数（RVSWI）均显著降低（P〈0．05），但组Ⅱ上述指标变化均不显著（P〉0．05）。吻合PDA时，组Ⅰ、组Ⅱ的HR、CVP均显著升高（P〈0．05），MAP、CI、LVSWI及RVSWI均显著降低（P〈0．05），但组Ⅲ上述指标变化不显著（P〉0．05）。结论先吻合桥血管的近端，再序贯吻合靶血管，这样的手术策略有利于非体外循环CABG时完成显露、吻合困难的OM、PDA部位的手术。

Objective To study the influence of anastomoses sequence on the hemodynamics in off-pump coronary artery bypass grafting （CABG）, and to investigate the strategy to stabilize the hemodynamics. Methods From March 2005 to March 2007, 67 patients with serious triple-vessel coronary artery lesions （male 45, female 22） with a age range from 44 to 81 years old were enrolled for off-pump CABG. All the patients underwent left internal mammary artery-left anterior descending branch （LIMA- LAD） anastomese firstly, followed by the foreword anastomose of the other two vessels. According to the anastomese sequence of posterior descending braneh （PDA） and obtuse marginal branch （ OM）, the patients were divided into three groups. Group Ⅰ （n=22） did the sequence of PDA-OM-aortic root （Ao）. Group Ⅱ （n= 14） did the sequence of Ao-PDA-OM. Group Ⅲ （ n = 31 ） did the sequence of Ao-OM-PDA. The hemedynamics markers, including heart rate （HR）, central venous pressure （CVP）, mean artery pressure （MAP）, cardiac index （CI）, left ventricular-stroke work index （LVSWI） and right ventricular stroke work index （RVSWI）, were analyzed before LIMA-LAD anastomose to serve as baseline. And these markers were re-measured at LIMA-LAD anastomose, immediately after LIMA-LAD anastomese, at PDA anastomese and at OM anastomose. Results All the patients survived after off-pump CABG. Compared with the baseline, there were no significant hemodynamic changes when doing LIMA-LAD anastomose. When the anastomose finished, the hemndynamic indices improved significantly. When performing OM anastomose, HR and CVP increased significantly, and MAP, CI, LVSWI and RVSWI decreased remarkably in group Ⅰ and group Ⅲ, while there were no signiticant changes of MAP , CI and RVSWI in group Ⅱ. When performing PDA anastomose, HR and CVP increased significantly, and MAP, CI, LVSWI and RVSWI decreased remarkably in group Ⅰ and group Ⅱ, while there were no significant hemodynamic changes in group Ⅲ except HR. Conclusion Proximal anastomose first when performing off-pump CABG, followed by distal anastomoses of target vessels is beneficial to those who have hard exposure and difficult anastomose of OM and PDA.