冠狀動脈搭橋術(shù)CABG課件

CoronaryArteryBypassGrafting1CoronaryArteryBypassGraftinDefinitionIndicationContraindicationCABGTypesGraftchooseComplications2DefinitionIndicationContrainWhatisCABG?Coronaryarterybypassgraftsurgery(CABG)isaprocedurethatusespatient’sownveins(usuallyfromthelegs)orarteriestobypassnarrowedareasandrestorebloodflowtoheartmuscle.Bypasssurgerycanmarkedlyreduceorrelievechestpainformostpatients,andimprovesurvivalandminimizecomplicationsofcardiacischemiaMorethan300,000patientsundergoCABGsurgeryannuallyintheUS3WhatisCABG?CoronaryarterybCoronaryArteries4CoronaryArteries4AHAGuidelineforCABGSurgeryLeftmaincoronaryarterydisease(LMCA)orsignificantdiseaseoftheLADwithanothervesselinvolvedorallthreecoronaryarteries(LAD,LCXandRCA).DiffusediseasenotsuitabletotreatmentwithaPCIorstentplacementisnotsuccessfulinopeningtheblockedbloodvesselsSurvivorsofsuddendeathwhohavecoronaryarterydiseaseOtherhigh-riskpatientssuchasthosewithsevereventriculardysfunction(i.e.lowejectionfraction),ordiabetesmellitus.CABGissuperiortoPCIforsomepatientswithmultivesselCADAHAGuidelineforCABGSurgeryCABGisnotrecommendedforpatientswhodonothaveadequatenativevesselstouseasgraft.Patientswithverysmallcoronaryarteries(<1

mmor<1.5

mm)andatherosclerosisoftheaorta,heavilycalcified,orlocatedwithintheheartmuscleratherthanonthesurfacearechallengesinCABG.CABGContraindicationCABGisnotrecommendedforpaCABGTraditionalCABGNontraditionalCABGOffPumpCoronaryArteryBypassGraftingMinimallyInvasiveDirectCoronaryArteryBypassGraftingTypesofCABGCABGTraditionalCABGNontraditiOffPumpCoronaryArteryBypassGraftingOffPumpCoronaryArteryBypasOffPumpCoronaryArteryBypassGrafting

Advantages:AdecreasedneedforbloodtransfusionLessmyocardialenzymereleaseLessrenaldysfunctionLessearlyneurologicaldysfunctionDisadvantage:Decreasedgraftpatencyduetoproblemswithanastomoses9OffPumpCoronaryArteryBypasChoiceofGraft

Internalthoracicarteries(alsocalledinternalmammaryarteries)RadialarteriesSaphenousveinsRightgastroepiploicarteryChoiceofGraft

InternalthoraSaphenousveingraftpatencydeclinessignificantlystartingatthetimeofsurgery.Ratesbelow90percentarecommonatoneyear.Long-termgraftpatencyisexcellentwithinternalthoracicarteryandradialarterybypassgrafts.Ratesexceeding90percentat5to10yearsarecommon.Graftpatencyisdependentonanumberoffactors,includingthetypeofgraftused,thesizeofthecoronaryarterythatthegraftisanastomosedwith,andtheskillofthesurgeon(s)performingtheprocedure.

Bloodflowbeginstodiminishwitharounda70percentstenosisinthegraft.SaphenousveingraftpatencydBleedingthatmayrequireareturntotheoperatingroomHeartattackorheartfailureorarrhythmiaStrokeorchangesincognitivefunctionPulmonaryproblems;WoundinfectionRenalfailure;Death.BypassSurgeryComplicationsBleedingthatmayrequireareCardiaccomplicationsAtrialfibrillation：40%Sustainedventriculartachycardiaorventricularfibrillation:2to3%Postoperativebradycardia：0.8to4%PericarditisorCardiactamponadeBypassComplications:Cardiaccomplications

CardiaccomplicationsAtrialfiApproximately30%ofpatientsrequireabloodtransfusionafterCABG.Onlyabout2percentofpeoplerequiresurgerytostopexcessivebleeding.Medicationshoulddiscontinuedpriortosurgery:Aspirin:2-3daysPlavix:5-7daysTirofiban:4to6hoursWarfarin:FourdaysUnfractionatedHeparin:D/CatthetimeofsurgeryLowmolecularweightheparin12to24hourspriortosurgeryBypassSurgeryComplications:BleedingApproximately30%ofpatientsStrokeorDepressionPost-opdeliriumShort-andlong-termcognitivechangesBypassComplications:NeurologiccomplicationsTheincidenceofneurologicproblemsfollowingCABG:2to4%Olderpatientsandwomenareaffectedmorefrequently.StrokeorDepressionPost-opdeSternalwoundinfection:1%.Itusuallydevelopsbyseventoninedaysaftersurgery.Legwoundsinfection:5%,dermatitis,cellulitis,nervedamage,andnon-healingulcers;mostareminoranddonotrequiresurgicalintervention.Catheterrelatedinfection:CVC,Swan-ganzcatheter,A-line,Endotrachealtube,FoleycatheterBypassComplications:Infection

Sternalwoundinfection:LegwoRenalfailure

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Atemporarydecreaseinkidneyfunctionoccursinapproximately5to10%.Pleuraleffusions:occurringinupto90%.Theyareusuallysmallanddonotrequiretreatment.Phreni