冠状动脉搭桥术CABG课件.ppt

CoronaryArteryBypassGrafting1Definition Indication ContraindicationCABG Types Graft chooseComplications2医者仁心 一路相随 WithYouAllTheWayWhatisCABG?pCoronaryarterybypassgraftsurgery(CABG)isaprocedurethatusespatients own veins(usuallyfromthelegs)orarteriestobypassnarrowedareasandrestorebloodflowtoheartmuscle.pBypasssurgerycanmarkedlyreduceorrelieve chest pain formostpatients,andimprove survival andminimizecomplicationsofcardiacischemiapMorethan300,000 patientsundergoCABGsurgeryannuallyintheUS3医者仁心 一路相随 WithYouAllTheWayCoronary Arteries4医者仁心 一路相随 WithYouAllTheWayAHAGuidelineforCABGSurgeryLeftmaincoronaryarterydisease(LMCA)orsignificantdiseaseoftheLADwithanothervesselinvolvedorallthreecoronaryarteries(LAD,LCXandRCA).DiffusediseasenotsuitabletotreatmentwithaPCIorstentplacementisnotsuccessfulinopeningtheblockedbloodvesselsSurvivorsofsuddendeathwhohavecoronaryarterydiseaseOtherhigh-riskpatientssuchasthosewithsevereventriculardysfunction(i.e.lowejectionfraction),ordiabetesmellitus.CABGissuperiortoPCIforsomepatientswithmultivesselCAD医者仁心 一路相随 WithYouAllTheWayCABGisnotrecommendedforpatientswhodonothaveadequatenativevesselstouseasgraft.Patientswithverysmallcoronaryarteries(1mmor1.5mm)andatherosclerosisoftheaorta,heavilycalcified,orlocatedwithintheheartmuscleratherthanonthesurfacearechallengesinCABG.CABGContraindication医者仁心 一路相随 WithYouAllTheWayCABGTraditionalCABGNontraditionalCABGOffPumpCoronaryArteryBypassGraftingMinimallyInvasiveDirectCoronaryArteryBypassGraftingTypesofCABG医者仁心 一路相随 WithYouAllTheWayOffPumpCoronaryArteryBypassGrafting医者仁心 一路相随 WithYouAllTheWayOff Pump Coronary Artery Bypass GraftingAdvantages:AdecreasedneedforbloodtransfusionLessmyocardialenzymereleaseLessrenaldysfunctionLessearlyneurologicaldysfunctionDisadvantage:Decreasedgraftpatencyduetoproblemswithanastomoses9医者仁心 一路相随 WithYouAllTheWayChoiceofGraftInternalthoracicarteries(alsocalledinternalmammaryarteries)RadialarteriesSaphenousveinsRightgastroepiploicartery医者仁心 一路相随 WithYouAllTheWaylSaphenousveingraftpatencydeclinessignificantlystartingatthetimeofsurgery.Ratesbelow90percentarecommonatoneyear.lLong-termgraftpatencyisexcellentwithinternal thoracic artery andradial artery bypassgrafts.Ratesexceeding90percentat5to10yearsarecommon.lGraftpatencyisdependentonanumberoffactors,includingthetypeofgraftused,thesizeofthecoronaryarterythatthegraftisanastomosedwith,andtheskillofthesurgeon(s)performingtheprocedure.Bloodflowbeginstodiminishwitharounda70percentstenosisinthegraft.医者仁心 一路相随 WithYouAllTheWayBleedingthatmayrequireareturntotheoperatingroomHeartattackorheartfailureorarrhythmiaStrokeorchangesincognitivefunctionPulmonaryproblems;WoundinfectionRenalfailure;Death.BypassSurgeryComplications医者仁心 一路相随 WithYouAllTheWayCardiaccomplicationsAtrialfibrillation：40%Sustainedventriculartachycardiaorventricularfibrillation:2to3%Postoperativebradycardia：0.8to4%PericarditisorCardiactamponadeBypassComplications:Cardiaccomplications医者仁心 一路相随 WithYouAllTheWayApproximately30%ofpatientsrequireabloodtransfusionafterCABG.Onlyabout2percentofpeoplerequiresurgerytostopexcessivebleeding.Medicationshoulddiscontinuedpriortosurgery:Aspirin:2-3daysPlavix:5-7daysTirofiban:4to6hoursWarfarin:FourdaysUnfractionatedHeparin:D/CatthetimeofsurgeryLowmolecularweightheparin12to24hourspriortosurgeryBypassSurgeryComplications:Bleeding医者仁心 一路相随 WithYouAllTheWayStrokeorDepressionPost-opdeliriumShort-andlong-termcognitivechangesBypassComplications:NeurologiccomplicationsTheincidenceofneurologicproblemsfollowingCABG:2 to 4%Olderpatientsandwomenareaffectedmorefrequently.医者仁心 一路相随 WithYouAllTheWaySternal wound infection:1%.Itusuallydevelopsbyseventoninedaysaftersurgery.Leg wounds infection:5%,dermatitis,cellulitis,nervedamage,andnon-healingulcers;mostareminoranddonotrequiresurgicalintervention.Catheter related infection:CVC,Swan-ganzcatheter,A-line,Endotrachealtube,FoleycatheterBypassComplications:Infection医者仁心 一路相随 WithYouAllTheWayRenalfailureAtemporarydecreaseinkidneyfunctionoccursinapproximately5to10%.Pleuraleffusions:occurringinupto90%.Theyareusuallysmallanddonotrequiretreatment.Phrenicnervedamage:Numbness,tenderness,orburningdiscomfortoverthesternumandleftanterolateralchestwall.Painusuallysubsidesbyfourmonths.AorticdissectionThrombocytopeniaOthercomplications医者仁心 一路相随 WithYouAllTheWay