Abstract： Objective?To summarize our experience of redo coronary artery bypass grafting（CABG） and explore appropriate redo CABG strategy for Chinese patients. Methods We retrospectively analyzed clinical data of 27 patients who underwent redo CABG in People’s Hospital of Peking University from January 2000 to January 2010. There were 15 male patients and 12 female patients with their age of 41-84 （63±8） years. The mean time between the first CABG and the redo CABG was 45 （4-168） months. Preoperatively all the patients had unstable angina pectoris. Twenty-one patients were in New York Heart Association （NYHA） functional classⅠ-Ⅱ， and 6 patients were in NYHA functional classⅢ-Ⅳ. Preoperatively， their left ventricular end-diastolic dimension （LVEDD） was 41-69 （51.0±0.7） mm， and their left ventricular ejection fraction （LVEF） was 32%-78% （58%±12%）. At the time of redo CABG for the 27 patients， there were 6 new coronary artery lesions， 7 left internal mammary artery （LIMA） lesions， 3 radial artery lesions （including 1 proximal anastomosis lesion alone） and 49 saphenous vein graft （SVG） lesions （including 3 proximal lesions alone and 3 distal lesions alone）.?Results?The surgical approach of redo CABG included median sternotomy in 18 patients， left lateral thoracotomy in 8 patients， upper midline abdomen and subxiphoid incision in 1 patient. Off-pump coronary artery bypass grafting （OPCAB） surgery was performed in 25 patients， but intra-operatively 2 patients underwent conversion to CABG under cardiopulmonary bypass. A total of 65 distal anastomoses and 41 proximal anastomoses were performed during redo CABG. A total of 10 LIMA， 3 right internal mammary artery (RIMA)， 16 left radial artery， 2 right radial artery and 17 SVG were used in redo CABG . There were 1-4 （2.4±0.8） distal anastomoses for each patients. The operation time was 170-530 （304±86）min. Postoperative transfusion was 0-10 （4.3±3.5） U packed red blood cells and 0-1 600 (685±549) ml fresh frozen plasma for each patient. Postoperative mechanical ventilation time was 6-156 （24±32） h and postoperative hospital stay was 7-35 （14±6） d . There was no in-hospital death. All the patients were discharged without any angina symptoms. A total of 26 patients were followed up and 1 patient was lost with the mean follow-up time of 80 （13-133） months. During follow-up， 16 patients were alive without angina symptoms， 4 patients died， and 6 patients had recurrent angina symptoms or heart failure. Conclusions OPCAB is an effective surgical strategy of redo CABG， but cardiopulmonary bypass should also be prepared. Arterial graft should be use as long as possible in redo CABG and the surgical strategy should be individualized.
Objective To identify clinical significance of high level cardiac troponin I （cTnI） in the early postoperative period of off-pump coronary artery bypass grafting （OPCAB） and its predictive value for early clinical outcomes. Methods A total of 240 patients undergoing isolated OPCAB in the Department of Cardiac Surgery of People’s Hospitalof Peking University during 2011 were recruited in the study. There were 164 males and 76 females with their age of 36-83（62.07±8.24） years. Serum cTnI levels in 4-6 hours and 12-18 hours after OPCAB were monitored. Influential factors and its predictive value for early clinical outcomes of OPCAB were analyzed. Binary logistic regression analysis，correlation analysis and receiver operating characteristic （ROC） curve were performed for statistic analysis. Results Serum cTnI level in 4-6 hours after OPCAB （TNI0） was 1.28±0.40 ng/ml，and serum cTnI level in 12-18 hours after OPCAB （TNI1） was 3.60±0.74 ng/ml. Binary logistic regression analysis revealed that graft number was significant influential factors of TNI0 （P=0.000） and TNI1 （P=0.010）. Serum cTnI level in 12-18 hours after OPCAB was significantly correlated with early clinicaloutcomes of OPCAB （P＜0.05），but the correlational relationship was not b （correlation coefficient＜0.5）. ROC curveanalysis showed that serum cTnI level in 12-18 h after OPCAB had higher predictive value for patient prognosis （P＜0.05）. Serum cTnI level higher than 1.49 ng/ml in 12-18 h after OPCAB had good predictive value for postoperative ECG changes，use of intra-aortic balloon pump （IABP） and in-hospital mortality. Conclusions Serum cTnI level increases in varying degrees in the early postoperative period of OPCAB. Together with ECG changes，serum cTnI level can be used for early diagnosis of perioperative myocardial infarction with significant predictive value for early clinical outcomes of OPCAB.
Coronary artery bypass grafting has made great progress in recent years. Off-pump coronary artery bypass grafting （off-pump） can escape from many complications resulting from cardiopulmonary bypass which powered the interest of more and more surgeons, but it is more technically demanding. Conventional coronary artery bypass grafting aided by cardiopulmonary bypass （on-pump） can provide with good condition for anastomosis, and is still applied widely. The comparation of the two surgical techniques were reviewed, including graft patency, mortality, inflammatory response, influence on coagulation and anticoagulation, injury to important organs, hospital length of stay and cost, technical convertion, et al.
ObjectiveTo investigate the influence of 6% hydroxyethyl starch (HES, 130/0.4)on blood coagulation of patients after off-pump coronary artery bypass grafting (opCAB)by thromboelastography (TEG). MethodsOne hundred patients undergoing elective opCAB in Department of Cardiovascular Surgery, General Hospital of Shenyang Military Area Command between May and July 2013 were enrolled in this study. All the patients were randomly divided into 2 groups using random number table method with 50 patients in each group. In the experimental group (G1 group), there were 27 males and 23 females with their age of 64.9±4.4 years, who received intravenous 6% HES (130/0.4)20 ml/kg in 4 hours postoperatively. In the control group (G2 group), there were 31 males and 19 females with their age of 63.1±5.8 years, who received intravenous lactated ringers 20 ml/kg in 4 hours postoperatively. After postoperative ICU admission, full blood count, coagulation tests and TEG were examined. Chest and mediastinal drainage was recorded at 6 hours and 24 hours postoperatively. ResultsThere was no statistical difference in chest and mediastinal drainage 24 hours postoperatively between the 2 groups (591.7±171.7 ml vs. 542.4±174.0 ml, P > 0.05). None of the patients received reexploration for bleeding. There was no statistical difference in hemoglobin, hematocrit, platelet count or traditional coagulation index between the 2 groups (P > 0.05). TEG showed no significant change in coagulation time after intravenous fluid infusion in either group. Reaction time was slightly extended in both groups, but there was no statistical difference in reaction time between the 2 groups (P > 0.05). Maximum amplitude (MA)of G1 group was significantly decreased after intravenous fluid infusion (55.9±10.0 mm vs. 62.8±7.9 mm, P < 0.05), but still within the normal range. There was no significant change in MA after intravenous fluid infusion in G2 group. ConclusionIntravenous infusion of 6% HES (130/0.4)20 ml/kg can reduce platelet function and clot strength, but does not significantly increase postoperative chest or mediastinal drainage, or the incidence of postoperative reexploration for bleeding. It's safe to administer 6% HES (130/0.4)for patients after OPCAB.
Objective To investigate surgical outcomes and prognostic factors for patients with coronary heart disease and low left ventricular ejection fraction （LVEF≤40%） undergoing off-pump coronary artery bypass grafting （OPCAB）. Methods We retrospectively analyzed clinical records of 63 discharged patients with coronary heart disease and low LVEF who underwent OPCAB in Peking University People’s Hospital from 2001 to 2004 year. There were 48 males and 15 females with mean age of 65.1±9.2 years and mean LVEF of 33.8%±5.0%. Regular follow-up evaluation was completed. We investigated risk factors for long-term survival of the patients by Kapalan-Meier survival curve, log-rank test and Cox regression model.?Results?Follow-up time was 3-107 （71.3±24.4） months, and six patients were lost during the follow-up. Nineteen patients （30.2%） died during follow-up including 10 patients （15.9%） who had cardiac-related death. The survival rate at 1, 3, 5 and 8 year was 96.7% （61）, 94.9% （60）, 85.9% （55）, 77.2% （53） respectively. Univariate analysis shows LVEF≤30% and acute myocardial infarction within 30 days are risk factors for long-term survival（P＜0.05）. Cox regression analysis showed that LVEF≤30%（RR=4.662, P＜0.05）and acute myocardial infarction within 30 days（RR=5.544, P＜0.05）were two independent risk factors for cardiac-related death after discharge. Conclusion Patients with coronary heart disease and low LVEF can have satisfactory surgical outcomes after OPCAB. LVEF≤30% and acute myocardial infarction within 30 days are the two independent risk factors for cardiac-related death after discharge.
Objective To introduce the results and strategy of perioperative management undergo coronary artery bypass grafting (CABG) for patients older than 70. Methods One hundred and twenty one patients, 93.4%(113/121) of whom was complicated with other diseases, were retrospectively studied. Off-pump CABG (OPCAB) was used in 80 cases (66.1%). For the rest patients with severely compromised heart function or small target vessel with diffuse lesion, conventional CABG (CCABG) was selected. Left internal mammary artery (LIMA) was harvested leaving pleural cavity intact and grafted to left anterior descending artery (LAD). Saphenous vein(SV) was utilized for other anastomoses. Transit-time flowmeter (TTFM) was utilized to make sure that grafts were patent with satisfactory blood flow. Procedure of sternotomy and chest closure was carefully performed to decrease the complication of mediastinitis. Adequate nutrition and gradually increased physical activity were encouraged for "fast-track". Results Grafts were 3.08±0.75 for CCABG and 2.24±0.82 for OPCAB . LIMA was used in 90.9%(110/121) patients. One patient receiving emergency operation died of multiple organ failure syndrome resulting in mortality of 0.8%. The incidence of complication was 3.3%(4/121). The others recovered smoothly without any complication. Intubation time of OPCAB(10.04±5.68 h) was significantly shorter than that of CCABG(21.46±14.54 h). Patients were discharged within 12.22±5.56 days after operation. Conclusion Good short term result, namely low incidence of mortality and complication, could be obtained in patients older than 70 who underwent CABG through meticulous perioperative management.
Objective To compare the clinical early results of on-pump and off-pump coronary artery bypass grafting re-operations (re-CABG)and introduce our experience. Methods From April 2000 to June 2006, 21 cases with coronary artery diease of re-CABG were performed in this hospital. 10 patients received off-pump CABG (off-pump group), and 11 underwent CABG re-operations with cardiopulmonary bypass CABG(on-pump group). There were no significant difference regarding gender, age, weight, diabetes, hypertension, left ventricular end-diastolic dimension (LVEDD) and left ventricular ejection fraction (LVEF) between two groups before operation. On-pump CABG procedures were performed on hypothermia cardiopulmonary bypass. Standard methods were used to finish off-pump CABG. Flow meters were utilized to measure the flow of grafts in both groups. Results No one in off-pump group needed to conver to on-pump CABG. There was no operative or late mortality. The operation time, respiratory support time, the volume of chest tube drainage, blood transfusion and postoperative hospital stay were less in off-pump group than those in on-pump group after operation. Early death occurred in 1 patient in on-pump group. The number of distal anastomosis were more in on-pump group than that in off-pump group. Conclusions Both off-pump CABG and on-pump CABG can be applied to CABG re-operations and achieved similar completeness of revascularization, similar early surgical results.
ObjectiveTo explore the difference between minimally invasive direct and conventional thoracotomy off-pump coronary artery bypass surgery (CABG). MethodsWe selected 276 patients underwent off-pump CABG surgery in our hospital from June 2005 through June 2014. There were 55 patients with minimally invasive off-pump CABG surgery and 221 patients conventional thoracotomy surgery. By using the method of peopensity score matching, we selected 55 conventional thoracotomy patients as a control group in our study. There were 41 males and 14 females at age of 60.8±10.5 years with minimally invasive off-pump CABG surgery, 44 males and 11 females at age of 60.6±12.5 years with conventional thoracotomy. ResultsThere was no statistical difference in surgery time, stay in the intensive care unit (ICU) time between conventional thoracotomy surgery and minimally invasive off-pump CABG. Compared with conventional thoracotomy surgery, minimally invasive off-pump CABG patients had statistical improvement in post-operative hospital stay time (7.3±3.1 d vs. 8.8±3.9 d, P=0.01), postoperative drainage (684(0-2 790)ml vs. 739(50-4 460)ml, P=0.03), perioperative blood transfusion (1.91(0-20)U vs. 6.62(0-20)U, P=0.00), surgery incision length (5.6±1.1 cm vs. 26.3±4.5 cm, P=0.00). ConclusionOverlooking the learning curve, minimally invasive direct off-pump CABG surgery has more advantages than conventional thoracotomy surgery. It is a safe and effective procedure.
Objective To explore the factors affecting the operation of coronary artery bypass grafting with heart beating and improve the effect of the operation. MethodsFrom January 2012 to June 2016, 898 patients with coronary heart disease who received cardiovascular surgery in the Second Affiliated Hospital of Jilin University were analyzed retrospectively. All patients only underwent coronary artery bypass grafting with beating heart. Among them, 797 patients underwent the off-pump coronary artery bypass grafting (an OPCABG group, 592 males and 205 females, with an average age of 60.5±8.4 years); another 101 patients received on-pump beating heart coronary artery bypass grafting (an OPBH group, 77 males and 24 females, with an average age of 61.5±8.2 years). ResultsThe average number of grafts in the OPCABG group was 3.36±0.74, and in the OPBH group was 3.71±0.69 (P<0.05). The postoperative ventilation time (10.8±9.5 h vs. 20.6±12.3 h), ICU stay (28.8±15.5 h vs. 37.4±30.8 h), hospital stay (10.9±4.8 d vs. 14.8±8.6 d), mortality (1.1% vs. 3.0%), the utilization rate of intra-aortic balloon pump (2.4% vs. 8.9%) and extracorporeal membrane oxygenation (0.5% vs. 5.0%) were significantly different between the OPCABG group and OPBH group (all P<0.05). Twelve patients died after surgery, and the total bloodless operation ratio was 91.3%. ConclusionThe results show that most patients can achieve good results with the help of apical fixation and myocardial fixator, improved surgical techniques and methods, good anesthesia management as well as flexible and accurate use of vasoactive drugs. But extracorporeal circulation is necessary in the patients with large left ventricle, low ejection fraction and hemodynamic instability after intraoperatively moving the heart.
Objective To investigate the impact of edaravone on serum reactive oxygen species during the perioperative period of off-pump coronary artery bypass grafting （OPCAB）. Methods A total of 40 patients who underwent selective OPCAB in the First Hospital of Hebei Medical University between June 2011 and November 2012 were prospectively enrolled in this study. All the patients were randomly divided into a trial group and a control group by a random digitaltable method with 20 patients in each group. There were 13 males and 7 females in the trial group with their age of 40-67（51.8±11.5） years， and 9 males and 11 females in the control group with their age of 42-70 （53.5±13.1） years. Afteranesthesia induction， patients in the trial group received continuous intravenous infusion of edaravone 60 mg （diluted in 100 ml saline）， while patients in the control group received continuous intravenous infusion of saline 100 ml， both of whichwere finished within 30 minutes. Venous blood samples were taken 24 hours preoperatively （T1）， 1 hour after skin incision（T2）， at the end of the surgery （T3） and 24 hours postoperatively （T4） to examine the concentration of superoxide dismutase（SOD） and malondialdehyde （MDA）. The data of the two groups were compared. Results All the patients successfully underwent their surgery and were included in the analysis. At the T2， T3 and T4 time point， SOD concentration was 80.3±21.3 U/ml， 78.5±17.4 U/ml and 81.4±17.5 U/ml， and MDA concentration was 10.2±1.8 nmol/ml， 11.3±1.9 nmol/ml，14.8±2.1 nmol/ml respectively in the control group；SOD concentration was 92.8±18.4 U/ml，90.0±18.1 U/ml，and 88.7±18.7 U/ml，and MDA concentration was 7.2±1.7 nmol/ml，8.2±1.2 nmol/ml，10.2±1.3 nmol/ml respectively in the trial group. At each above time point， SOD activity was significantly higher in the trial group than the control group （F=2.90，P=0.003；F=2.80，P=0.003；F=2.80，P=0.001）， and MDA concentration was significantly lower in the trial group than the control group （F=2.79，P=0.001；F=2.80，P=0.001；F=2.90，P=0.000）. Conclusion Edaravone can decrease serum reactive oxygen species caused by OPCAB and reduce myocardial injury.