心脏不停跳非体外循环冠状动脉旁路移植术的进展

The advances in off-pump coronary artery bypass grafting

近年来 ,随着手术器械的发展 ,心脏不停跳非体外循环下冠状动脉旁路移植术 (OPCAB)逐渐被广泛接受和应用。与常规冠状动脉旁路移植术 (CCABG)比较 ,OPCAB的主要优势为血液中多种炎性介质浓度明显降低 ,避免了体外循环 (CPB)带来的全身系统性炎性损害 ,减少了并发症 ,降低了手术死亡率。特别对那些不能采用 CPB或采用CPB有风险的高危患者优势更明显。 CCABG的手术适应证同样适用于 OPCAB,但 OPCAB具有相对的禁忌证。 OP-CAB多采用胸骨正中切口 ,左前外侧切口适用于左前降支单支病变。OPCAB术后早期结果类似 CCABG,但中远期结果有待进一步观察。OPCAB大多数旁路移植血管数低于 CCABG,有不能完全再血管化的可能 ,对 OPCAB是否会影响吻合的精确性和旁路血管的长期通畅率有不同意见。 OPCAB的优势明确 ,但仍不能完全替代 CCABG,手术的同时应作好 CPB准备 ,必要时改行 CCABG。

Thanks to the improvement of surgical instruments, off-pump coronary artery bypass grafting (OPCAB) has become popular and been widely accepted in recent years. Compared with conventional coronary artery bypass grafting (CCABG), OPCAB has the most prominent advantages of avoiding the maneuver to establish cardiopulmonary bypass (CPB) and its usage, which significantly decrease systemic inflammatory reaction. Complications may be significantly decreased and hospital mortality no more than CCABG. The advantages are more prominent in those patients with high risk factors. In general, OPCAB has the same indications as those for CCABG with the exception of some contraindications. The median sternotomy are usually used in OPCAB, left anterior lateral incision is only suitable for left anterior descending coronary artery disease. Literatures have demonstrated better early result of OPCAB, but the superiority of mid and long term result has not been established. Probability of incomplete revascularization exists and the accuracy and long term patency of anastomosis of OPCAB may be controversial. In spite of its advantages, OPCAB can't replace CCABG completely. Standby of CPB is necessary for OPCAB. In summary, the short term superiority of OPCAB to CCABG has been set up, but long term follow up is needed.