CAJ | 학술논문

目的冠状动脉再血管化杂交手术(Hybrid手术)特殊抗凝方案对患者术后出血的影响及其临床转归.方法 Hybrid手术患者141例(Hybrid组),年龄35～ 82岁,体重45 ～ 105 kg,ASA分级Ⅱ或Ⅲ级,性别不限.采用倾向性评分法在本院电子手术数据库中选取同期非体外循环冠状动脉旁路移植术(OPCAB)患者141例(OPCAB组)作为对照,年龄43～ 80岁,体重47～ 110 kg,性别不限,ASAⅡ或Ⅲ级.Hybrid组游离左乳内动脉后静脉注射肝素100～ 120 U/kg,必要时补充肝素,维持ACT250 ～ 300 s.乳内动脉至前降支血管吻合后静脉注射鱼精蛋白1 mg/kg拮抗肝素,支架植入前再次前经中心静脉注射肝素6000～ 8000 U,并经胃管给予氯吡格雷300 mg,维持ACT 200 ～ 250 s直至术毕.术后服用氯吡格雷75 mg/d,至少12个月.记录术后胸腔引流量,机械通气时间、ICU停留时间、术后输血、再次气管插管、心肌损伤、急性肾损伤、肺不张、胸腔积液和支架内血栓栓塞的发生情况.结果患者术后住院期间未发生支架内血栓栓塞.与OPCAB组比较,Hybrid组患者术后胸腔引流量减少,机械通气时间和ICU停留时间缩短,胸腔积液、肺不张发生率及住院期间输血率降低(P＜0.05),2组再次气管插管、心肌损伤和急性肾损伤发生率差异无统计学意义(P＞0.05).结论 Hybrid手术特殊抗凝方案未增加患者术后出血量,早期临床转归较好.
목적 관상동맥재혈관화잡교수술(Hybrid수술)특수항응방안대환자술후출혈적영향급기림상전귀.방법 Hybrid수술환자141례(Hybrid조),년령35～ 82세,체중45 ～ 105 kg,ASA분급Ⅱ혹Ⅲ급,성별불한.채용경향성평분법재본원전자수술수거고중선취동기비체외순배관상동맥방로이식술(OPCAB)환자141례(OPCAB조)작위대조,년령43～ 80세,체중47～ 110 kg,성별불한,ASAⅡ혹Ⅲ급.Hybrid조유리좌유내동맥후정맥주사간소100～ 120 U/kg,필요시보충간소,유지ACT250 ～ 300 s.유내동맥지전강지혈관문합후정맥주사어정단백1 mg/kg길항간소,지가식입전재차전경중심정맥주사간소6000～ 8000 U,병경위관급여록필격뢰300 mg,유지ACT 200 ～ 250 s직지술필.술후복용록필격뢰75 mg/d,지소12개월.기록술후흉강인류량,궤계통기시간、ICU정류시간、술후수혈、재차기관삽관、심기손상、급성신손상、폐불장、흉강적액화지가내혈전전새적발생정황.결과 환자술후주원기간미발생지가내혈전전새.여OPCAB조비교,Hybrid조환자술후흉강인류량감소,궤계통기시간화ICU정류시간축단,흉강적액、폐불장발생솔급주원기간수혈솔강저(P＜0.05),2조재차기관삽관、심기손상화급성신손상발생솔차이무통계학의의(P＞0.05).결론 Hybrid수술특수항응방안미증가환자술후출혈량,조기림상전귀교호.
Objective To investigate the effects of special anticoagulation method of hybrid coronary revascularization procedure on postoperative bleeding and clinical outcomes.Methods One hundred and forty-one ASA Ⅱ or Ⅲ consecutive patients,aged 35-82 yr,weighing 45-105 kg,undergoing "one-stop" hybrid coronary revascularization procedure from June 2007 to January 2011 in Fuwai cardiovascular hospital were enrolled and served as Hybrid group.Using propensity score methodology,these patients were matched with another 141 patients who had undergone off-pump coronary artery bypass grafting (OPCAB group) during the same period,selecting from the surgical database.These ASAⅡ or Ⅲ 141 patients,aged 43-80 yr,weighing 47-110 kg,who underwent OPCAB,were served as control subjects.In group Hybrid,the left internal mammary artery was isolated and then 100-120 U/kg heparin was administrated to maintain activated clotting time between 250-300 s,and additional heparin was given if needed.Protamine 1 mg/kg was used to reverse the effect of heparin after anastomosis between left internal mammary artery and left anterior descending branch.Before stent implantation,6000-8000 U heparin and 300 mg clopidogrel were administrated.Activated clotting time was maintained between 200-250 s until the end of operation.Clopidogrel 75 mg/d was taken for at least 12 months after operation.The volume of postoperative chest tube drainage,mechanical ventilation time,length of stay in intensive care unit,postoperative transfusion of allogeneic blood,re-intubation,myocardial damage,acute kidney injury,atelectasis,hydrothorax and thromboembolism were recorded.Results No thromboembolism was observed within the stent during stay in hospital after operation in patients.The volume of chest tube drainage was significantly less,mechanical ventilation time and length of stay in intensive care unit were shorter,the incidence of atelectasis and hydrothorax and transfusion of allogeneic blood requirement were lower in Hybrid group than in OPCAB group (P ＜ 0.05).There was no significant difference in the incidences of re-intubation,myocardio damage,and acute kidney injury between the two groups (P ＞0.05).Conclusion Special anticoagulation method of hybrid coronary revascularization procedure does not increase postoperative bleeding and has a better clinical outcomes during the early period.