近端优先序贯吻合技术在非体外循环冠状动脉搭桥术中的应用

Application of proximal-anastomosis-first sequential anastomosis technique in OPCAB surgical practice

目的探讨非体外循环冠状动脉搭桥术(OPCAB)中应用近端优先序贯吻合技术的安全性。方法选择2013年1月至2017年4月首次行OPCAB的多支冠状动脉血管病变患者共2 516例,根据手术方式分为近端优先序贯吻合组(A组)1 323例和远端优先序贯吻合组(B组)1 193例。比较两组患者的围术期相关指标,其中术中心功能改善指标包括心排量(CO)、心指数(CI)、体循环阻力(SVR)、肺循环阻力(PVR);并记录两组患者术后24h心肌酶同工酶(CK-MB)及氨基末端B型钠尿肽原(NT-proBNP)水平。结果两组患者年龄、性别及高血压、糖尿病等合并症和桥血管支数比较,差异均无统计学意义(P>0.05);B组因术中发生恶性心律失常及血流动力学不稳定而中转体外循环的发生率高于A组(2.77%vs.1.21%,P<0.05)。A、B组术中监测指标CO(0.27±0.08 vs.0.13±0.04)、CI(0.15±0.03 vs.0.07±0.03)、SVR(108.32±9.58 vs.56.75±11.15)、PVR(10.52±2.24 vs.15.90±4.65)比较,差异均有统计学意义(P<0.05)。术后24hCKMB[(48.20±9.15)U/L vs.(58.40±10.16)U/L]及NT-proBNP[(1 950.80±298.56)pg/mL vs.(2 789.60±786.43)pg/mL]A组低于B组(P<0.05)。ICU停留时间(26.00±4.75 vs.29.25±4.50)及住院时间(14.10±1.54 vs.16.30±1.65)A组短于B组(P<0.05)。结论近端优先序贯吻合技术应用于OPCAB中较传统的远端优先序贯吻合技术更安全、有效。

Objective To evaluate the safety of proximal-anastomosis-first sequential technique in off-pump coronary artery bypass grafting(OPCAB).Methods Retrospectively analyzed 2 516 patients with multi-vessel disease(MVD)underwent primary isolated OPCAB procedure between January 2013 to April 2017.They were divided into the proximal-anastomosis-first sequential technique group(group A,n=1 323)and the conventional distal-anastomosis-first sequential fashion group(group B,n=1 193)group.Perioperative parameters of the two groups were compared.The heart performance parameters including cardiac output(CO),cardiac index(CI),systemic vascular resistance(SVR)and pulmonary vascular resistance(PVR).The levels of myocardial enzyme isoenzyme(CK-MB)and N-terminal pro-brain B-type natriuretic peptides(NT-proBNP)were recorded at 24 h after surgery.Results There were no significant differences in age,gender,hypertension,diabetes mellitus,and number of grafts between the two groups(P>0.05).Conversion from off-pump to on-pump because of malignant arrhythmia and unstable hemodynamics occurred less in group A(1.21%vs.2.77%,P<0.05).The parameters including CO(0.27±0.08 vs.0.13±0.04),CI(0.15±0.03 vs.0.07±0.03),SVR(108.32±9.58 vs.56.75±11.15),PVR(10.52±2.24 vs.15.90±4.65)improved more significantly in group A(P<0.05).CK-MB[(48.20±9.15)U/L vs.(58.40±10.16)U/L]and NT-proBNP[(1 950.80±298.56)pg/mL vs.(2 789.60±786.43)pg/mL]at the point of postoperative 24 hours were lower in group A(P<0.05).The length of staying in ICU(26.00±4.75 vs.29.25±4.50)and hospital stay(14.10±1.54 vs.16.30±1.65)were shorter in group A(P<0.05).Conclusion The proximal-anastomosis-first sequential bypass grafting technique is more safe and effective than the traditional technique in OPCAB.