非体外循环冠状动脉旁路移植术中转体外循环后的临床转归

Patient's outcomes after conversion from off-pump coronary artery bypass to on-pump coronary artery bypass grafting

目的:总结非体外循环冠状动脉旁路移植术(OPCABG)中转为体外循环冠状动脉旁路移植手术(ONCABG)对临床转归的影响,为合理选择术式,改善外科疗效提供依据。方法:自2010年4月至2013年5月,93例患者在我院接受OPCABG手术治疗过程中未能顺利实施,而中转为ONCABG手术。其中80例为紧急中转,13例为选择性中转。回顾分析中转手术病死率、严重并发症发生率、循环辅助手段应用情况、住院时间等指标,判断中转手术方式对疗效的影响。结果:与选择性中转对比,OPCABG紧急中转为ONCABG,延长了呼吸机治疗时间[18(13.5,33.5)vs.40.5(19,120.3)h,P<0.05]、呼吸机通气>48 h患者的比例明显升高(7.7%vs.46.3%,P<0.05),监护室时间增加[48(21.5,49)vs.76(27,142.3)h,P<0.05],住院时间延长[18(14.5,21.5)vs.8(11,23.8)d,P<0.05],围术期心肌梗死发生率高(7.7%vs.38.8%,P<0.05),增加了主动脉内球囊反搏(IABP)(15.4%vs.87.5%,P<0.01)及体外人工肺支持系统(ECMO)使用率(零vs.26.3%,P<0.05),手术病死率增高显著(零vs.37.5%,P<0.01)。结论:OPCABG术中紧急中转术式对临床转归有不良影响,应采取综合措施预防和避免。

Objective： analyse the outcomes and safety of conversion in off-pump coronary artery by- pass（OPCABG） , and propose prevention strategies for achieving better surgical results. Methods： 93 conver- sion patients from April 2010 to May 2013 were studied. Among them 80 cases were emergent conversion, 13 cases were selective conversion. Data of mechanical ventilation time, ICU and hospital stay, utilization of circu- latory assisted device, operative mortality and morbidity rates were reviewed. Results： compare to selective conversion group, emergent converted patients have long mechanical ventilation time 18 （13.5,33.5） vs. 40. 5 （ 19,120. 3 ） hours, P 〈 0. 05, more ICU treatment time [ 48 （21.5,49） vs. 76 （ 27,142. 3 ） hours, P 〈 0. 05 ） ~ and hospital stay [ 18 （ 14. 5,21.5 ） vs. 18 （ 11,23.8 ） days, P 〈 0. 01 ） ], increased peri-operative myo- cardial infarction rates （7.7% vs. 38.8% , P 〈 0. 05 ） , higher rates of intra aortic balloon counter pulsation （IABP） （ 15.4% vs. 87.5% , P 〈0. 01 ） and extracorporeal membrane oxygenator （ECMO） supporting（ zero vs. 26. 3% , P 〈 0. 05 ）. Operative mortality was significantly higher in emergent conversion group （zero vs. 37.5% , P 〈0. 01 ）. Conclusion： emergent OPCABG conversion are associated with worse adverse outcomes and higher operative mortalities, a prevention protocol including OPCABG surgeon training, preoperative risk factors evaluation, intraoperative decision making and surgical team cooperation should be emphasized duringdaily OPCABG practice.