乌司他丁对体外循环术后肺损伤保护作用的临床分析

目的:探讨乌司他丁对体外循环心脏手术后肺功能的保护作用。方法:根据入选标准选择先天性心脏病患儿42例,随机分成对照组(n=20)和乌司他丁组(n=22),观察比较术前、术后1h、24h两组的肺泡-动脉血氧分压差(PA-aO2)、动脉血氧含量(CaO2)、动脉血氧分压(PaO2)、动脉血氧饱和度(SaO2)、X胸片、术后带机时间的变化。结果:术前两组各指标基本一致,差别没有统计学意义(P>0.05);乌司他丁组在术后1h及24hPA-aO2较对照组明显降低(P<0.05);乌司他丁组术后1h及24hCaO2,SaO2,PaO2与对照组比较,均较对照组高,差别具有统计学意义(P<0.05);对照组术后胸片渗出较乌司他丁组多;对照组比乌司他丁组带机时间长,差别具有统计学意义(P<0.05)。结论:体外循环过程造成肺损伤,乌司他丁对肺功能具有保护作用。

Redo Coronary Artery Bypass Grafting: On-Pump and Off-Pump Coronary Artery Bypass Grafting Revascularization Techniques

Objective To analyze the short-term outcomes of redo coronary artery bypass grafting(CABG) using on-pump and off-pump CABG techniques. Methods From January 2003 to August 2013, non-randomized 80 patients were treated with redo CABG in the Department of Cardiac Surgery, Peking University Third Hospital. Among these patients, 40 underwent on-pump CABG technique(redo-ONCAB group) and 40 underwent off-pump CABG technique(redo-OPCAB group). Furthermore, transmyocardial laser revascularization was performed in high-risk patients who were not suitable to conventional grafting. Clinical data of the two groups were recorded and analyzed including operation time, coronary grafts, incomplete revascularization, postoperative ventilation, perioperative stroke, and low output syndrome, etc. Results There were no significantly differences in age, gender distribution, incidences of hypertension, stroke, and other clinical characteristics between redo-OPCAB group and redo-ONCAB group(all P>0.05), except for incidences of renal dysfunction and pulmonary disease(all P<0.05). The number of grafting vessels in the redo-ONCAB and redo-OPCAB groups was 2.1 ± 0.74 and 1.4 ±0.52 respectively. There was significant difference between the two groups(P=0.0243). Compared with the redo-ONCAB group, there was shorter operation time(P=0.0045), postoperative ventilation(P=0.0211) and intensive care unit stay(P=0.0400), as well as fewer use of platelet(P=0.0338) and blood transfusion(P=0.0034) in the redo-OPCAB group. The incidence of incomplete revascularization(P=0.0253) and the use of transmyocardial laser revascularization(P=0.0052) were higher in the redo-OPCAB group than those in the redo-ONCAB group(all P<0.05). However, no significant differences were showed for the incidence of the use of intra aortic balloon pump and continuous renal replacement therapy, perioperative stroke, low output syndrome, and in-hospital mortality between the two groups(all P>0.05). Conclusion Redo CABG is the safety and efficacy surgical procedure, and redo-OPCAB technique with better outcomes is commended especially in high-risk patients.

Risk factors for prolonged intensive care unit stays in patients after cardiac surgery with cardiopulmonary bypass:A retrospective observational study

Objectives:Patients after cardiac surgery with cardiopulmonary bypass(CPB)require a stay in the ICU postoperatively.This study aimed to investigate the incidence of prolonged length of stay(LOS)in the ICU after cardiac surgery with CPB and identify associated risk factors.Methods:The current investigation was an observational,retrospective study that included 395 ICU patients who underwent cardiac surgery with CPB at a tertiary hospital in Guangzhou from June 2015 to June 2017.Data were obtained from the hospital database.Binary logistic regression modeling was used to analyze risk factors for prolonged ICU LOS.Results:Of 395 patients,137(34.7%)had a prolonged ICU LOS(>72.0 h),and the median ICU LOS was 50.9 h.Several variables were found associated with prolonged ICU LOS:duration of CPB,prolonged mechanical ventilation and non-invasive assisted ventilation use,PaO2/FiO2 ratios within 6 h after surgery,type of surgery,red blood cell infusion during surgery,postoperative atrial arrhythmia,postoperative ventricular arrhythmia(all P<0.05).Conclusions:These findings are clinically relevant for identifying patients with an estimated prolonged ICU LOS,enabling clinicians to facilitate earlier intervention to reduce the risk and prevent resulting delayed recovery.

Jejunoileal bypass:A surgery of the past and a review of its complications

Jejunoileal bypass(JIB),popular in the 1960s and 1970s,had remarkable success in achieving weight loss by creating a surgical short bowel syndrome.Our patient had an unusual case of liver disease and provided no history of prior bariatric surgery.Later,it was recognized that he had a JIB in the 1970s,which was also responsible for the gamut of his illnesses.Patients with JIB are often not recognized,as they died of complications,or underwent reversal of their surgery or a liver-kidney transplant.Early identification with prompt reversal,and the recognition and treatment of the life-threatening consequences play a critical role in the management of such patients.

Transcatheter aortic valve replacement in elderly patients

Aortic stenosis is the most common native valve disease, affecting up to 5% of the elderly population. Surgical aortic valve replacement reduces symptoms and improves survival, and is the definitive therapy in patients with symptomatic severe aortic stenosis. However, despite the good results of classic surgery, risk is markedly increased in elderly patients with co-morbidities. Transcatheter aortic valve replacement （TAVR） allows implantation of a prosthetic heart valve within the diseased native aortic valve without the need for open heart surgery and cardiopulmonary bypass, offering a new therapeutic option to elderly patients considered at high surgical risk or with contraindications to surgery. To date, several multicenter registries and a randomized trial have confirmed the safety and efficacy of TAVR in those patients. In this chapter, we review the background and clinical applications of TAVR in elderly patients.

Effects of pH management during deep hypothermic bypass on cerebral oxygenation： alpha-stat versus pH-stat

Objective: There is a remarkable lack of scientific evidence to support the option to use alpha-stat or pH-stat management, as to which is more beneficial to brain protection during deep hypothermic CPB. This study examined cortical blood flow (CBF), cerebral oxygenation, and brain oxygen consumption in relation to deep hypothermic CPB with alpha-stat or pH-stat management. Methods: Twenty-two pigs were cooled with alpha-stat or pH-stat during CPB to 15℃ esophageal temperature. CBF and cerebral oxygenation were measured continuously with a laser flowmeter and near-infrared spec-troscopy, respectively. Brain oxygen consumption was measured with standard laboratory techniques. Results: During CPB cooling, CBF was significantly decreased, about 52,2%±6.3% (P<0.01 vs 92.6%±6.5% of pH-stat) at 15℃ in alpha-stat, whereas there were no significant changes in CBF in pH-stat. While cooling down, brain oxygen extraction (OER) progressively decreased, about 9.5%±0.9% and 10.9%±1.5% at 15℃ in alpha-stat and pH-stat, respectively. At 31℃ the decreased value in pH-stat was lower than in alpha-stat (29.9%±2.7% vs 22.5%±1.9%; P<0.05). The ratio of CBF/OER were 2.0±0.3 in alpha-stat and pH-stat, respectively; it was kept in constant level in alpha-stat, and significantly increased by 19 ℃ to 15℃ in pH-stat (4.9±0.9 vs 2.3±0.4; P<0.01). In mild hypothermia, cerebral oxyhemoglobin and oxygen saturation in alpha-stat were greater than that in pH-stat (102.5%±1.4% vs 99.1%±0.7%; P<0.05). In deep hypothermia, brain oxygen saturation in pH-stat was greater than that in alpha-stat (99.2%±1.0% vs 93.8%±1.0%; P<0.01), and deoxyhemoglobin in pH-stat decreased more greatly than that in alpha-stat (28.7%±6.8% vs 54.1%±4.7%; P<0.05). Conclusions: In mild hypothermic CPB, brain tissue oxygen saturation was greater in alpha-stat than in pH-stat. However, cerebral oxygenation and brain tissue oxygen saturation were better in pH-stat than in alpha-stat during profound hypothermia. PH-stat strategy provided much more oxygen to brain tissue before deep hypothermic circulatory arrest.