Hybrid coronary revascularization (HCR) combines the advantages of minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous coronary intervention (PCI), and avoids its relative shortcomings, which has received particular attention in recent years. HCR seems to have become the third revascularization strategy for multi-vessel disease in coronary heart diseases. However, the clinical researches on HCR are still limited. This article will systematically review the comparison of HCR with coronary artery bypass grafting (CABG) and PCI, the results of HCR in specific patients, and the clinical results of different HCR strategies.
ObjectiveTo summarize the experience of 4 patients with a great saphenous venous graft patency after 15 years of postoperitive great saphenous venous sequential aortic coronary artery bypass grafting. MethodWe retrospectively analyzed the clinical data of 4 patients accepted great saphenous vein aortic coronary artery bypass graft under moderate hypothermia cardiopulmonary bypass from November 1989 to December 1992 year. There were 3 males and 1 female with a mean age of 48.3 years ranging from 40-58 years. We harvested great saphenous vein under groin 45-50 cm. The proximal and distal anastomoses were performed with parachute technique under two clamps technique. Coronary artery bypass graft was performed by two sequential grafts routinely. Aspirin was given through nasal tube 6 hours after operation. The risk factors of arteriosclerosis were controlled by patients themselves after discharge. ResultFour patients received coronary angiography in 15, 16, 18, and 21 years after surgery and the grafts and both proximal and distal anastomoses were patent. The patients lived about 20 years without angina. Conclusioncarefully dealing with the vein graft, taking sequential bypass grafting to guarantee parabolic curve and meticulous anastomosis are preconditional and necessary for long-term patency.
Objective To investigate the function of a self-designed bilayered negative pressure wound therapy (b-NPWT) in reducing the occurrence of these complications through a clinical randomized controlled trial. Methods We included 72 coronary heart disease patients in our hospital from December 2013 through March 2014. There were 48 males and 24 females aged 38.4±18.6 years undergoing coronary artery bypass graft(CABG) surgery, and great saphenous veins were chosen as grafts. Patients were equally randomized into a trial group and a control group. The patients in the trial group underwent 5 d of b-NPWT for thigh incision and interrupted suture for shank incision after the harvesting of great saphenous veins. Patients in the control group received an interrupted suture for both thigh incision and shank incision after the harvesting of great saphenous veins. We evaluated the function of b-NPWT by reducing the complications arising from the harvesting of great saphenous veins in CABG patients. Results The incidences of early complications, such as lymphedema, incision infection, non-union, and skin flap necrosis of the vascular zone in the trial group were significantly lower than those of the control group. There was no death or new problem in heart or deep venous thrombosis in both groups. No complication occurred in long term. The incidence of lower limb edema was lower in the trial group than that in the control group at the end of 3 months follow-up. Conclusion B-NPWT can effectively prevent lymphorrhagia in CABG patients who underwent the harvesting of great saphenous veins. It can also reduce the incidence of complications and discomfort of the patients.
ObjectiveTo evaluate the relationship between four classic inflammatory biomarkers, including C-reactive protein (CRP), white blood cell (WBC), IL (interleukin family), tumor necrosis factor-α (TNF-α), and postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) and valve replacement (VR) surgeries.MethodsWe searched PubMed, EMBase, the Cochrane Library, Ovid, Chinese Journal Full-text Database, Chinese Biomedical Literature Database, VIP database and WanFang database from the inception to April 2020. Studies on the relationship between POAF and the above four inflammatory biomarkers were analyzed. Two researchers independently reviewed the literature, extracted data and evaluated the quality of the literature. RevMan 5.3 software was used for meta-analysis.ResultsA total of 47 articles were included, covering 10 711 patients. The levels of preoperative CRP (SMD=0.38, 95%CI 0.14-0.62, Z=3.12, P=0.002) and postoperative CRP (SMD=0.40, 95%CI 0.06-0.74, Z=2.33, P=0.02), IL-6 (SMD=1.34, 95%CI 0.98-1.70, Z=7.26, P<0.001) and TNF-α (SMD=?0.33, 95%CI ?0.65-?0.01, Z=2.02, P=0.040) were related to POAF, while preoperative IL-8 (SMD=?0.05, 95%CI ?0.28-0.18, Z=0.42, P=0.68) and TNF-α (SMD=?0.43, 95%CI ?1.22-0.36, Z=1.07, P=0.28), postoperative WBC (WMD=1.16, 95%CI ?0.09-2.42, Z=1.82, P=0.07) and IL-10 (SMD=0.21, 95%CI ?0.35-0.77, Z=0.73, P=0.46) were not related to POAF. The relationships between preoperative WBC and IL-10, postoperative IL-8 and POAF were inclusive, which needed further verification. Furthermore, the relationship between postoperative CRP and POAF were not consistent, as they were not significantly correlated in sub-group analysis.ConclusionThe inflammatory substrate before the surgery and inflammatory reaction induced by the operation is related to the occurrence and maintenance of POAF. Compared with preoperative inflammatory status, postoperative inflammatory factors may have a greater predictive value for POAF. Preoperative CRP, postoperative IL-6 and TNF-α levels are reliable biomarkers of POAF.
ObjectiveTo introduce the method and preliminary experience of robot-assisted bilateral internal mammary arteries (BIMA) harvesting for off-pump coronary artery bypass grafting (OPCAB) with 5 grafts via left anterolateral minithoracotomy.MethodsBIMA were harvested using the da Vinci robotic surgical system, and the right internal mammary artery (RIMA) was pulled out of the thoracic cavity through right second intercostal space. Intercepting the distal part of the RIMA for the BIMA composite Lima-Rima Y graft and anastomosing the great saphenous vein with remaining RIMA end to end. The Y graft anastomosed with left anterior descending (LAD) branch and diagonal branches (DIAG), artery-vein graft sequentially anastomosed with blunt round branch, left ventricular posterior branch and posterior descending branch.ResultsThe operation succeeded without hemodynamic instability and intra aortic balloon pump (IABP) implantation or cardiopulmonary bypass. The blood flow of Y graft was 24 mL/min, and the blood flow of artery-vein graft was 30 mL/min. Ventilator assistance time was 35 hours, ICU staying time was 62 hours, and postoperative myocardial enzymes increased temporarily. Postoperative coronary CTA showed that all the grafts were patency, and cardiac ultrasound indicated that the heart function was normal. The patient cured and discharged from hospital 7 days after operation.ConclusionRobot-assisted bilateral internal mammary artery harvesting for OPCAB with 5 grafts via left anterolateral minithoracotomy is feasible, which can achieve complete revascularization.
ObjectiveTo explore the relationship between myocardial viability in patients with coronary artery disease who underwent elective coronary artery bypass grafting (CABG) and early application of intra-aortic balloon pump (IABP) after coronary revascularization, and to provide relevant clinical reference for the pre-implantation of 16G single-lumen catheter in the femoral artery of high-risk patients to facilitate the addition of IABP after operation.MethodsThis retrospective study included 521 patients (414 males and 107 females, aged 62.50±8.82 years) who underwent positron emission tomography (PET)-computed tomography (CT) perfusion-metabolism imaging prior to CABG surgery in our institution from December 2015 to August 2020. The myocardial viability information and left ventricular functional parameters were measured, including the proportion of non-viable myocardium (perfusion-metabolic imaging match), hibernating myocardium (perfusion-metabolic imaging mismatch) and dysfunctional myocardium (non-viable+viable myocardium), left ventricular ejection fraction, left ventricular end-diastolic volume and left ventricular end-systolic volume (LVESV). The patients were divided into an IABP group and a non-IABP group according to whether they received IABP treatment after revascularization. The clinical data were reviewed and compared to explore significant impact factors between the two groups. And the multivariate logistic regression analysis was performed to investigate the correlation between preoperative myocardial viability and early use of IABP after CABG.ResultsIn multivariate logistic regression analysis, the amount of non-viable, dysfunctional myocardium and LVESV value were identified as the independent predictors for the probability of IABP use in the initial postoperative period. Receiver operating characteristic analysis showed that 9.5% non-viable myocardium, 19.5% dysfunctional myocardium, and LVESV of 114.5 mL were the optimal cutoff for predicting early IABP implantation during CABG.ConclusionThe myocardial survival status displayed by preoperative PET-CT myocardial perfusion-metabolism imaging can predict the possibility of applying IABP in CABG perioperative period. In addition to routine pre-anesthesia assessment, anesthesiologists can conduct risk stratification assessment for patients with CABG according to the results of preoperative myocardial viability imaging, which is of great significance to ensure the perioperative safety of high-risk patients with CABG.
Abstract: Objective To compare the midterm patency rates of individual and sequential saphenous vein grafts (SVG) as coronary bypass conduits of offpump coronary artery bypass grafting (OPCAB) and evaluate the impact of the grafting techniques (individual or sequential grafts) on the graft patencyafter OPCAB. Methods The clinical data of 398 patients in General Hospital of the People’s Liberation Army receiving OPCAB with individual and sequential grafts from June 2005 to March 2009 were retrospectively analyzed. There were 301 males and 97 females with their age ranged from 53 to 82 years (63.6±10.3 years). A total of 714 distal coronary anastomoses on 448 SVG were assessed by using 64multislice computed tomography (64MSCTA) at an average of 19.8±23.6 months (3 months to 5 years) after OPCAB procedure. The blood flow of grafts in the proximal segment of individual and sequential SVG and the patency rates of grafts and anastomoses were compared, and the effect of different locations on the patency rate of the anastomoses was analyzed. Results The mean blood flow in double SVG (37.11±16.70 ml/min vs. 25.15±14.24 ml/min, P0.042) and in triple SVG (37.56±19.58 ml/min vs. 25.15±14.24 ml/min, P=0.048) were both significantly higher than the flow in single SVG. The anastomoses on the sequential conduits had better patency (95.1％ vs. 90.1％, P=0.013). The patency of sideto side anastomoses was better than that of endtoside anastomoses (97.0% vs. 93.1%, P=0.002) and that of the individual endtoside anastomoses (97.0% vs. 90.1%, P=0.041). There was no significant difference between distal anastomoses in sequential and those in single grafts (P=0.253). No significant difference was observed between the two methods in regard to the three major coronary systems (including the anterior descending branch, the right coronary artery, and the circumflex branch). However, anastomoses on sequential grafts had superior patency to those on individual grafts in the right coronary system (P=0.008). Conclusion The midterm patency of a sequential SVG conduit after OPCAB is excellent and generally superior to that of an individual one. The best runoff coronary artery should be placed at the distal end and the poor coronary vessels should be arranged in the middle of the grafts.
ObjectiveTo evaluate the clinical efficacy of preoperative intra-aortic balloon pump (IABP) insertion in patients with off-pump coronary artery bypass grafting (OPCABG) surgery.MethodsThe clinical data of 130 patients who underwent OPCABG with IABP from 2015 to 2019 in our hospital were retrospectively analyzed. The patients were divided into two groups, including a group A (preoperative IABP insertion, n=72) and a group B (emergent IABP insertion, n=58). There were 42 males and 30 females in the group A with an average age of 60-72 (65.0±5.2) years. There were 32 males and 26 females in the group B with an average age of 56-73 (62.3±7.6) years. The in-hospital mortality rate and prognosis were compared between the two groups.ResultsThe in-hospital mortality rate in the group A (4.2%) was significantly lower than that in the group B (12.1%, P=0.002). The IABP time (40.8±10.3 min vs. 65.3±15.6 min), mechanical ventilation time (18.7±6.1 min vs. 48.7±10.5 min) and ICU stay time (48.1±7.8 min vs. 90.2±21.3 min) of the group A were shorter than those of the group B (P<0.05). The number of bypass grafts was not significantly different between the two groups (3.6±1.2 vs. 3.8±1.0, P=0.387). Multivariable logistic regression analysis indicated that independent risk factors for in-hospital mortality included age [OR=1.04, 95%CI (1.01, 1.10), P=0.030], female [OR=2.56, 95%CI (1.53, 6.12), P=0.000] and left ventricular end-diastolic diameter [OR=1.05, 95%CI (1.01, 1.13), P=0.030]. Preoperative IABP support was the protective factor [OR=0.17, 95%CI (0.01, 0.78), P=0.005].ConclusionPatients undergoing OPCABG with preoperative IABP insertion may reduce in-hospital mortality rate and improve outcomes.
ObjectiveTo explore the relationship between glycated hemoglobin (HbA1c) level and blood glucose fluctuations after coronary artery bypass grafting (CABG) and adverse events in non-diabetic patients, thus providing theoretical support for intensive preoperative blood glucose management in patients undergoing CABG surgery.MethodsA total of 304 patients undergoing CABG with or without valvular surgery from October 2013 to December 2017 were enrolled in this prospective, single-center, observational cohort study. We classified them into two different groups which were a low-level group and a high-level group according to the HbA1c level. There were 102 males and 37 females, aged 36–85 (61.5±9.5) years in the low-level group, and 118 males and 47 females aged 34–85 (63.1±9.4) years in the high-level group. The main results were different in hospital mortality and perioperative complications including in-hospital death, myocardial infarction, sternal incision infection, new stroke, new-onset renal failure and multiple organ failure. To assess the effects of confounding factors, multivariate logistic regression analysis was used.Results Postoperative blood glucose fluctuation was more pronounced in the high-level group than that in the low-level group before admission [0.8 (0.6, 1.2) mmol/L vs. 1.0 (0.8, 1.8) mmol/L, P<0.01]. This study also suggested that the incidence of major adverse events was significantly lower in the low-level group compared with the high-level group (P=0.001). Multivariate logistic regression analyses to correct the influence of other confounding factors showed that HbA1c (OR=2.773, P=0.002) and postoperative blood glucose fluctuations (OR=3.091, P<0.001) could still predict the occurrence of postoperative adverse events.ConclusionHbA1c on admission can effectively predict blood glucose fluctuations in 24 hours after surgery. Secondly, HbA1c on admission and postoperative blood glucose fluctuations can further predict postoperative adverse events. It is suggested that we control the patient's preoperative HbA1c at a low level, which is beneficial to control postoperative blood glucose fluctuation and postoperative adverse events.
ObjectiveTo compare the perioperative results of hybrid coronary revascularization (HCR), off-pump coronary artery bypass (OPCAB) and percutaneous coronary intervention (PCI) in elderly patients with three-vessel coronary artery disease involving left anterior descending (LAD) branch and explores the safety of surgery.MethodsWe prospectively enrolled patients with coronary heart disease over 65 years who were admitted to General Hospital of People’s Liberation Army from January 2018 to September 2019. Coronary angiography results were all three-vessel lesions involving the anterior descending artery. After preoperative examination and assessment by the cardiovascular team, all patients were suitable for OPCAB or PCI treatment. According to the patient’s preference, HCR, OPCAB or PCI were performed. The preoperative baseline data and perioperative results were collected, and SPSS 22.0 was used for statistical analysis.ResultsA total of 110 patients met the criteria and were included in the study, 28 in the HCR group, 45 in the OPCAB group, and 37 in the PCI group, with an average age of 71.4±5.6 years. There was no statistical difference in the preoperative baseline data of patients among the three groups. The intubation time (P=0.039), perioperative drainage volume (P<0.001), blood transfusion (P=0.021) in the HCR group were lower than those in the OPCAB group. There was no statistical difference in the main organ adverse events (MOAE, P=0.096) and in-hospital mortality (P=0.784) among the three groups of patients. The use of antibiotics in the PCI group was significantly lower than the other two groups (P<0.001).ConclusionHCR combines the advantage of CABG and PCI including proved long-term patency rate with left internal mammary artery-LAD grafting, less trauma and superior long-term patency with PCI in non-LAD territory. Compared with OPCAB and PCI, there is no increase in perioperative major organ adverse events and in-hospital mortality. It is a safe and reliable minimally invasive myocardial revascularization technique for elderly patients with three-vessel coronary artery disease involving the anterior descending artery.