不同近端吻合方式在非体外循环冠状动脉搭桥术中的临床应用研究

Different surgical modalities of proximal anastomosis in off-pump coronary artery bypass

目的了解非体外循环冠状动脉搭桥术(OPCAB)中采用不同近端吻合方式时血流动力学改变特点及临床效果,为不同手术方式的临床应用提供依据。方法对68例行OPCAB术的患者,按照是否具有术后神经系统并发症的高危因素分为A(n=38)、B(n=30)两组。对两组患者的围术期情况进行对比,并比较两组近端吻合前后血流动力学变化和经食道超声观察主动脉形态结构改变情况。结果两组患者术后均无脑卒中、围手术期心肌梗死及二次开胸止血,在移植血管支数、呼吸机辅助时间、ICU停留时间、术后住院时间、手术输血率等两组间差异无统计学意义。A组近端吻合前后血流动力学及主动脉形态结构无明显改变;B组应用侧壁钳部分钳夹升主动脉后心率(HR)、平均动脉压(MAP)、外周血管阻力指数(SVRI)较前明显升高、左心室每搏功指数(LVSWI)增加(P<0.05),经食道超声心动图观察升主动脉内径较前明显减小、升主动脉血流速度、左室流出道血流速度较前增快、左心室舒张末期容积(LVEDV)较前增大(P<0.05)。结论在OPCAB术中采用辅助装置吻合近端吻合口或上侧壁钳吻合近端吻合口时,前者对血流动力学影响小,后者影响大;对伴有升主动脉硬化、高龄、脑梗死病史等易并发神经系统并发症及术中血流动力学不稳定者,宜采用辅助装置吻合近端吻合口的方法,减少并发症的发生,提高手术疗效。

Objective To investigate the hemodynamic changes and the clinical effects of two different surgical modalities of proximal anastomosis. Methods Sixty eight patients who underwent off-pump coronary artery bypass （OPCAB）, were sub-grouped into Group A（using proximal anastomosis assistant device, n=38） and Group B （using aortic side-biting clamp, n =30） according to the risk of neurological complication after operation. The hemodynamic changes and aortic configuration were examined by transesophageal echocardiography before and after the proximal anastomosis. Results There were no events of stroke, perioperation myocardial infarction or thoracic bleeding in both groups. There were no statistical differences in graft numbers, the time of mechanical ventilation, the length of stay after operation, the rate of blood transfusion between two groups. There were no differences in the hemodynamics and aortic configuration before and after the proximal anastomosis in group A. However in group B through the transesophageal echocardiography examination after partial clamp of ascending aorta, it was revealed that the HR, MAP and SVRI increased, LVSWl and the inside diameter of arota decreased （P〈0.05）, blood flow rate of the ascending aorta and left ventricular outflow tract and LVEDV increased （P〈0. 05）. Conclusion The study shows that the impact on the hemodynamic changes is less by using proximal anastomosis assistant device than that of aortic side-biting clamp during OPCAB, which suggests that the proximal anastomosis assistant device should be applied for patients with sclerosis of ascending aorta, older age, cerebral infarction and other neurologic complication and instable hemodynamics.