非停跳冠状动脉搭桥术病生理改变及临床监测

Off-pump coronary artery bypass grafting： pathophysiology and anesthetic monitoring

非停跳冠状动脉搭桥术（OPCABG）因其避免了体外循环的不良反应，在临床上得到了广泛应用。术中心脏位置的变化和应用心脏固定器，会引起显著的血流动力学波动、心肌缺血等病生理改变，进而导致心室功能障碍。近年的研究表明，心室舒张功能障碍和右心功能不全是引起血流动力学变化的重要因素。临床上多采用肺动脉导管（PAC）和经食道超声心动图（TEE）来监测术中血流动力学和心功能的变化。新型的PAC能够将容量监测和压力监测结合起来，拓展了其监测范围和功能；而TEE在术中辅助诊断和监测的可靠性、有效性得到了广泛认可。心室压力一容量环作为一种非容量依赖性的方法，在监测心功能方面越来越受到重视。

Off- pump coronary artery bypass grafting （OPCABG） might reduce perioperative morbidity and improve outcome because of avoidance of cardiopulmonary bypass （CPB）. Therefore, OPCABG is performed widely now. However, displacement of the heart and positioning the stabilizer device can result in particular pathophysiologic changes during beating - heart surgery, which make the anesthetic management more difficult. Moreover, these pathophysiologic changes may lead to myocardial ischemia and cardiac dysfunction. Especially, ventricular diastolic function and right ventricular function get more attentions recently. Anesthetist must know well the intraoperative monitoring in which the new type Swan -Ganz catheter and transesophageal echocardiography（TEE） have more important effects on hemodynamic and cardiac performance monitoring. In addition, ventricular pressure - volume loop is an attractive index to assess cardiac function.