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Comparative Study between Offpump and Onpump Coronary Artery Bypass Grafting in the Patients of Multivessel Coronary Disease Below 70 Years Old

Abstract: Objective To compare the therapeutic effects between offpump coronary artery bypass grafting (off-pump CABG) and onpump coronary artery bypass grafting (on-pump CABG) in the patients of multivessel coronary disease below 70 years old, in order to decide on the best surgery method. Methods From June 2007 to June 2009, 196 patients below the age of 70 underwent coronary artery bypass grafting (CABG), including 152 male patients and 44 female patients. The average age was 55.00 years old, ranging from 46 to 69 years. The patients were divided into two groups according to the methods of operation. There were 94 patients in the off-pump CABG group including 2 patients who were converted to the onpump CABG surgery because of the unstable hemodynamics. The other 102 patients were in the onpump CABG group. The type and number of the vessel grafts, the quantity of blood transfusion, intubation duration, length of stay in hospital, complications during perioperative period and mortality were compared between the two groups. Results In the offpump CABG group, 2 patients were converted to onpump CABG surgery because of the unstable hemodynamics, and 1 of them died from multiple organ failure. In the onpump CABG group, 2 patients died from severe low output syndrome and sudden heart arrest respectively. No significant difference was found in the vessel grafting materials, perioperative complications and mortality between the two groups (Pgt;0.05), while the number of anastomosis (3.22±0.65 vs. 4.52±1.11, t=9.807, P=0.000), the [CM(159mm]quantity of blood transfusion (312.57±305.26 ml vs. 744.86±279.37 ml, t=10.317, P=0.000),the intubation duration (10.71±5.32 h vs.17.12±4.67 h, t=8.683, P=0.000) and the length of stay in hospital (17.75±3.04 d vs. 21.24±6.46 d, t=4.782,P=0.000) in the off-pump CABG group were significantly lower or shorter than those in the on-pump CABG group. A total of 93 patients in the off-pump CABG group and 100 patients in the on-pump CABG group were followed up with the time periods ranging from 2 to 26 months. All patients survived without angina. Conclusion There is no significant difference in the early clinical therapeutic effects between off-pump CABG and onpump CABG in the patients of multivessel coronary disease below 70 years old, but revascularization in the on-pump CABG patients is better. So far, offpump CABG cannot replace on-pump CABG and more clinical trails are needed for evaluation of the longterm prognosis.

Minimally Invasive Mitral Valve Replacement Combined with Atrial Fibrillation Radiofrequency Ablation via Right Minithoracotomy

ObjectiveTo summarize clinical advantages and outcomes of minimally invasive mitral valve replacement (MVR) combined with atrial fibrillation (AF) radiofrequency ablation via right minithoracotomy. MethodsEight patients with mitral valve disease and AF who received surgical therapy in the First Hospital of China Medical University between October 2009 and October 2012 were included in the study. There were 4 males and 4 females with their age of 34-67 (52.4±17.5) years. All the patients underwent minimally invasive MVR combined with AF radiofrequency ablation via right minithoracotomy. Clinical outcomes were summarized. ResultsThere was no in-hospital death or conversion to conventional sternotomy in this group. Two patients received biological valve replacement and 6 patients received mechanical prosthesis. Operation time was 207.9±18.1 minutes, cardiopulmonary bypass time was 81.7±23.9 minutes, and chest drainage amount was 126.7±34.5 ml. AF recurred in 1 patient on the 3rd postoperative day. All the patients were in sinus rhythm at discharge. These patients were followed up for 18.3±7.4 months. During follow-up, 1 patient had AF recurrence. Seven patients were in NYHA class Ⅰ, and 1 patients was in NYHA class Ⅱ. ConclusionMinimally invasive MVR combined with AF radiofrequency ablation via right minithoracotomy can achieve satisfactory clinical results and esthetic appearance, and is a good choice for patients with mitral valve disease and AF.

主動脈縮窄合并冠心病一例

原發性心臟腫瘤的外科治療

目的 總結原發性心臟腫瘤的外科治療經驗，以提高手術療效。 方法 回顧性分析1980年6月至2008年12月中國醫科大學附屬第一醫院收治的263例原發性心臟腫瘤患者的臨床資料，其中男90例，女173例；年齡10～79歲（41±13歲）。良性腫瘤241例，其中良性粘液瘤240例，纖維瘤1例；惡性腫瘤22例，其中惡性粘液瘤7例，惡性間皮瘤4例，血管肉瘤5例，橫紋肌肉瘤1例，肺動脈內膜肉瘤1例，平滑肌肉瘤1例，炎癥性惡性纖維組織細胞瘤1例，惡性淋巴瘤1例，滑膜肉瘤1例。手術完整摘除腫瘤252例（惡性腫瘤11例），局部切除腫瘤5例（均為惡性腫瘤），開胸探查取病理活組織檢查6例（均為惡性腫瘤）。同期行冠狀動脈旁路移植術（CABG）5例，二尖瓣置換術5例，二尖瓣成形術4例，三尖瓣成形術9例，三尖瓣生物瓣置換術1例，主動脈根部及肺動脈成形術1例，肺動脈瓣置換術1例，肺動脈主干及左右肺動脈人工血管加肺動脈瓣置換術1例，肺動脈切開取栓術1例，經股動脈取瘤栓術5例。 結果 圍術期死亡7例（良性粘液瘤6例、惡性粘液瘤1例），其中術中不能停體外循環2例，術后發生低心排血量、心室顫動3例，呼吸、循環衰竭1例，大面積腦出血1例；其余患者無并發癥發生。隨訪247例（良性腫瘤229例，惡性腫瘤18例），隨訪時間3個月～28年，失訪9例（良性腫瘤6例、惡性腫瘤3例）。隨訪期間良性粘液瘤復發4例，均再次手術治療；良性腫瘤患者死亡13例（心源性猝死6例、腦卒中2例、肺癌1例、不明原因4例），其余216例均生存。隨訪期間惡性腫瘤患者死亡15例，術后生存時間為1～4年，死于腫瘤復發或轉移11例，心力衰竭和惡病質各2例。 結論 原發性心臟腫瘤一經確診應盡早手術治療，良性腫瘤手術效果好，惡性腫瘤術中應盡量切除腫瘤。

Surgical Treatment for Chronic Total Occlusion of Coronary Artery with Offpump Coronary Artery Bypass Grafting

Objective To investigate the surgical therapy for chronic total occlusion (CTO) of coronary artery with offpump coronary artery bypass grafting (OPCAB). Methods From Aug. 1999 to Oct. 2007, 696 patients with 853 totally occluded coronary arteries (127 coronary arteries lack of opacification while the other 726 arteries with reverse flow showed by coronary angiography) underwent OPCAB. A total of 2 231 grafts were constructed including 136 placed to coronary endarterectomy (CE) targets and 28 arterialized middle cardiac veins. Blood flow was detected during operation in 26 coronary arteries with no opacification in preoperative angiography, while no blood flow was detected in 63 coronary arteries with opacification in preoperative angiography. Cardiopulmonary bypass was applied in 15 cases because of a poor hemodynamics and 6 of which were assisted with intraaortic balloon pump(IABP). Results All patients survived the operation. 6 died in hospital because of low cardiac output (2 cases), renal failure (2 cases), perioperative cardiac infarction (1 case) or cerebrovascular accident (1 case). Stress ulceration occurred in one case, mediastinal infection occurred in another case after operation. Both were treated medically and recovered. 692 patients were followed up and the rate of flup was 99.42%(685/686)， with 4 withdrawal. Freedom from cardiac angina was 99.85%(685/686) and cardiac functional grading (NYHA) was Ⅰ-Ⅱ. Conclusion OPCAB can be well performed in patients with chronic total occlusion of coronary arteries. The ralue of coronary angiography for evaluating totally occluded coronary artery is limited, and endoscope or intravascular ultrasound techniques may be helpful.

Surgical Therapy for Valve Diseases Combined with Coronary Heart Diseases in Patients Over or Below 70 Years Old

Surgical Therapy for Valve Diseases Combined with Coronary Heart Diseases in Patients Over or Below 70 Years Old YU Lei, GU Tianxiang, SHI Enyi, XIU Zongyi, FANG Qin, ZHANG Yuhai. (Department of Cardiac Surgery, The No. 1 Hospital of China Medical University, Shenyang 110001, P.R. China)Corresponding author: GU Tianxiang, Email: cmugtx@sina.comAbstract： Objective To summarize the experiences of valve replacement combined with coronary artery bypass grafting (CABG) in senile patients by comparing clinical outcomes of valve diseases combined with coronary heart diseases in patients over or below 70 years old. Methods We retrospectively analyzed the clinical data of 49 patients who received valve replacement combined with CABG in our department from May 1999 to December 2007. Based on the age, the patients were divided into ≥70 years group (17 cases) with its patients at or above 70 years old and lt;70 years group (32 cases) with its patients younger than 70. The percentage of chronic obstructive pulmonary diseases (COPD) before surgery in ≥70 years group was higher than that in lt;70 years group(Plt;0.05). No significant difference was found in the other relevant factors between the two groups. The clinical index of patients in the two groups were compared and analyzed. Results There were significant differences between the two groups in such factors as the percentage of biovalve use (82.4% vs. 12.5%, χ2=23.311, P=0.000), the time of mechanic ventilation (34.5±29.3 h vs. 18.0±16.1 h, t=-2.542,P=0.014), the time of ICU stay (4.4±1.5 d vs. 3.3±0.7 d, t=-3.522, P=0.001), the time of hospital stay (21.4±7.7 d vs. 18.1±1.8 d, t=-2.319, P=0.025), the percentage of IABP use (29.4% vs. 6.3%, χ2=4.862, P=0.037), the percentage of pulmonary function failure (35.3% vs. 6.3%, χ2=6.859, P=0.009), the percentage of acute renal failure (23.5% vs. 3.1%, χ2=5.051, P=0.025), and the percentage of cerebrovascular accident (11.8% vs. 0.0%, χ2=3.933, P=0.048). There was no significant difference between the two groups in factors like the anastomosis of distal graft (2.5±3.1 vs. 2.4±14, t=0.301, P=0.758), the time of aortic occlusion (89.3±25.4 min vs. 88.5±31.0 min, t=0.108,P=0.913), the time of cardiopulmonary bypass (144.6±44.8 min vs. 138.3±52.9 min, t=0.164, P=0.871) and the mortality (5.9% vs. 6.3%, χ2=0.002,P=0.959). The perioperative myocardial infarction rate was zero in both groups. ≥70 years group patients were followed up for 2 months to 9 years with only 1 case missing. One patient who had undergone mechanic valve replacement died of cerebral hemorrhage 1.5 years after operation. Two died of heart failure and lung cancer 3 months and 6 years after operation respectively. For all the others, the cardiac function was at class Ⅰ to Ⅱ and their life quality was significantly improved. The follow up time of lt;70 years group was 1 month to 6 years and 5 cases were missing. Four patients who had undergone mechanic valve replacement died of complications in relation to anticoagulation treatment. One died of severe low cardiac output. Another died of traffic accident. Conclusion Surgery operation and effective perioperative treatment are key elements in improving surgery successful rate and decreasing mortality in patients with valve and coronary artery diseases. Valve replacement combined with CABG is safe for patients older than 70 years old.

Hypothermia Continuous Renal Replacement Therapy for Severe Heart Failure after Cardiac Surgery

目的探討亞低溫聯合持續腎臟替代治療（CRRT）對心臟外科術后重癥心力衰竭的臨床效果 方法回顧性分析我中心2009年2月至2013年12月行心臟外科術后重癥心力衰竭38例患者的臨床資料，其中男18例、女20例，年齡55～74歲，雖應用大劑量血管活性藥物及主動脈內球囊反搏（IABP）輔助循環，心力衰竭無改善，采用CRRT及亞低溫聯合治療。監測患者在聯合治療前后心臟指數（CI）值、混合靜脈血氧飽和度（SvO2）、尿量、肌酐（Cr）及乳酸（Lac）的變化。 結果亞低溫聯合CRRT治療后，患者CI較治療前明顯改善[（2.3± 0.7）L/（min· m2）vs.（1.8± 0.2）L/（min· m2）]，SvO2升高（62%± 5%vs.50%± 4%），乳酸明顯降低[（8.6± 2.3）mmol/L vs.（3.0± 1.1）mmol/L]，尿量明顯增加[（2.5± 0.9）ml/h vs.（1.0± 0.7）ml/h]，Cr明顯下降[（140± 19）mmol/L vs.（292± 24）mmol/L]。 結論亞低溫聯合CRRT治療心臟外科術后重癥心力衰竭能有效改善循環功能，且操作簡單易行。

Extracorporeal Membrane Oxygenation after Cardiac Surgery: A Clinical Analysis of 27 Adult Patients

ObjectiveTo summarize the experience of applying extracorporeal membrane oxygenation (ECMO) after cardiac surgery in adult patient. MethodsWe retrospectively analyzed the clinical data of 27 patients underwent ECMO from December 2011 to October 2013. There were 15 males and 12 females at the mean age of 51±11 years ranging from 41 to 73 years. Vein-artery perfusion was performed in all 27 patients. ResultsAll 27 patients underwent ECMO. The mean time of using ECMO was 81.2±36.4 hours ranging from 48.0-192.0 hours. The mean time of hospital stay was 307.8±97.0 hours ranging from 168.0-480.0 hours. The rate of weaning from ECMO was 77.8% (21/27). The rate of discharge was 51.9% (14/27). The rate of perioperative mortality was 44.4% (12/27). ConclusionEffective monitoring with other supportive equipments is helpful to promote the result of ECMO.

冠狀動脈旁路移植術治療左主干分叉病變

目的 探討冠狀動脈左主干分叉病變的外科治療方法，總結其臨床經驗。 方法 1999年3月至2008年4月我院共收治29例冠狀動脈左主干分叉病變患者，在體外循環心臟不停跳下行冠狀動脈旁路移植術(CABG)，觀察體外循環時間、術后呼吸機輔助時間、 ICU時間、住院時間、圍術期以及隨訪情況。 結果 體外循環時間為482±15.5 min，術后呼吸機輔助時間14.2±4.6 h，住ICU時間3.3±0.8 d，住院時間18.0±2.7 d，無圍術期心肌梗死發生。本組患者隨訪7～98個月 (29.0±19.2個月)，25例心絞痛癥狀完全消失，2例心絞痛癥狀緩解，3例于術后3年、4年和8年分別死于腦血管病變、心臟驟停及肺癌。超聲心動圖檢查提示:左心室收縮功能獲得不同程度的改善。 結論 冠狀動脈左主干分叉病變應用體外循環心臟不停跳CABG可以取得良好的治療效果。

80歲以上老年患者行非體外循環冠狀動脈旁路移植術16例