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1、不停跳非体外循环冠状动脉旁路术的进展高长青中国人民解放军总医院心血管外科,100853摘要近年来,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。临床研究表明,OPCAB的主要优势是血液中多种炎症介质浓度明显降低,避免了CPB所带来的全身系统性炎症损害,也避免了建立体外循环造成的并发症,全身反应轻,恢复快,呼吸机辅助时间短,心肌缺血再灌注损伤减轻,输血可能性降低,并发症减少,手术死亡率不高于或低于CCABG,特别对那些不能或采用体外循环有风险的高危患者
2、优势更明显。CCABG的手术适应症同样适用于OPCAB,但OPCAB具有相对禁绝对忌症。良好的麻醉是OPCAB成功的基本条件,麻醉医师必须与术者密切配合,在手术的全程维持循环稳定。OPCAB采用正中胸骨切口,采用牵引线,使心脏抬高并右旋,结合Trendlenburg体位,显露靶血管,借助Octupus心脏稳定器和吹雾器,固定和显露吻合部位,以完全血管化。左前外侧切口(MIDCAB)适用于LAD单支病变,应慎重选择病例。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
3、旁路血管数低于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。手术的同时应作体外循环准备,必要时改行CCABG。ThecurrentstatusofOffPumpCoronaryArteryBypassGaoChangqingMDDepartmentofCardiovascularSurgery,PLAGeneralHospital,Beijing,100853Thankstotheimprove
4、mentofsurgicalinstrument,OffPumpCoronaryArteryBypass(OPCAB)hasbecomepopularandbeenwidelyacceptedinrecentyears.Accordingtoclinicalinvestigations,comparedwithConventionalCoronaryArteryBypassGrafting(CCABG),OPCABhasthemostprominentadvantagesofavoidingthem
5、aneuvertoestablishCardiopulmonaryBypass(CPB)anditsusage,whichsignificantlydecreasesystemicinflammatoryreactionandthedetrimentalconsequences,resultinginlessischemiaandreperfusioninjury,shortermechanicalventilation,lessbloodinfusion,fasterresuscitationan
6、dshortertimetostayinhospital.ComplicationsmaybesignificantlydecreasedandhospitalmortalitynomorethanCCABG.Theadvantagesaremoreprominentinthosepatientswithhighriskfactors.Ingeneral,OPCABhasthesameindicationsasthatforCCABGwiththeexceptionofsomecontraindic
7、ations.Anesthesiologistisimperativetocloselycooperatewithsurgeontomaintainhemodynamicstability.Aftermediansternotomy,thesuturesareplacedinobliquesinustoelevateanddexterlyrotatetheheart,WithcombineduseofTrendlenburgmaneuverandOctupusstabilizer,toexposet
8、hetargetvesselsforcompleterevascularization.MinimallyInvasiveCoronaryArteryBypass(MIDCAB)isonlysuitableforLADdisease,accordingly,thecaseshouldbecarefullyselected.LiteratureshavedemonstratedbetterearlyresultofOPCAB,butthesuperiorityofmid