Vural ÖZCAN, Sabit SARIKAYA, Onursal BUĞRA, Cengiz KÖKSAL, Mustafa ZENGİN

Çalışan kalpte koroner by-pass cerrahisinin çok damar hastalarında kullanımı

Koroner kalp hastalıklarının tedavisinde kardiyopulmoner by-pass (KPBP) kullanmaksızın koroner revaskülarizasyon ameliyatları yaygınlaşmış olup, amaç kardiopulmoner by-passın olumsuz etkilerinden korunmaktır. İlk dönemlerde bu yöntem sadece tek damar hastaları ve düşük riskli hastalarda kullanılır iken, günümüzde çok damar hastaları ve yüksek riskli hastalara da kolayca uygulanabilir hale gelmiştir. Kliniğimizde 2002-2004 yılları arasında 149 hastaya koroner by-pass ameliyatı yapılmış olup bunların 40’ı yüksek riskli hastalardı. Bu yüksek riskli hasta grubundan, 3 veya daha çok damar hastalığı olan 14 hastaya çalışan kalpte koroner by-pass (ÇKKB) ameliyatı planlanmıştır. 11 hastaya ÇKKB yapılmış olup bir hasta erken dönemde kaybedilmiştir. Bir hastanın da hastane kalış süresi sternal ayrılma nedeniyle uzamıştır. 14 adet ÇKKB planlanan hastaların üçünde ise hemodinamik sorunlar nedeniyle kardiopulmoner by-passa geçilmek zorunda kalınmıştır. Yüksek risk grubunda yer alan hastalarda koroner revaskülarizasyon işleminin KPB kullanmadan yapılması erken dönem mortaliteyi belirgin azaltmaktadır. Kardiyak stabilizasyon için yeni teknolojilerin gelişmesi ile çalışan kalpte koroner by-pass ameliyatları daha fazla koroner arter hastasına uygulanabilir hale gelecektir.

Off-pump coronary revascularization for treatment of multivessel coronary artery disease

Background and Desing.- Coronary artery bypass grafting (CABG) with off-pump technique is a widely used treatment modality for coronary artery disease, which avoids the disadvantages of cardiopulmonary bypass (CPB). At the early periods, it was only used for single vessel disease and for patients with low risk. However, currently it became easily applicable to multi-vessel disease and high-risk patients. Material and Methods.- In our clinic, between 2002-2004, 149 patients were underwent CABG, in which 40 of them were high risk. In the high-risk group, 14 patients were diagnosed to have triple or more vessel disease and scheduled for coronary artery bypass grafting with off-pump technique (OPCAB). 11 of them had OPCAB for multi-vessel coronary artery disease. One patient was died in the early postoperative period and one patient had prolonged hospitalization period due to sternal dehiscence. In 3 patients from the OPCAB scheduled group, the operation technique had to be converted to on-pump from off-pump due to hemodynamic problems. Result.- CABG with off-pump technique decreases early postoperative mortality in high-risk patient groups. With the advent of new technologies for cardiac stabilization and positioning, OPCAB technique will be more and more applicable to all patients for myocardial revascularization.

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1. Cheng W, Denton TA, Fontana GP, Raissi S, Blanche C, Kass RM, Magliato KE, Mirocha J, Trento A: Off-pump coronary surgery: effect on early mortality and stroke. J Thorac Cardiovasc Surg. 2002; 124: 313-318.
2. Kilger E, Weis FC, Goetz AE, Frey L, Kesel K, Schutz A, Lamm P, Uberfuhr P, Knoll A, Felbinger TW, Peter K: Intensive care after minimally invasive and conventional coronary surgery: a prospective comparison. Intensive Care Med, 2001; 27: 534-538.
3. Kavarana MN, Asher AS, Barbone A, Williams MR, Faber JM, Weinberg AD, Isidro AB, Oz MC, Esrig BC: A comparison consecutive off-pump versus conventional coronary artery bypass. Heart Surg Forum 2001; 4: 160- 165.
4. Machnaughton PD, Braude S, Hunter DN, Denison DM, Evans TW: Changes in lung function and pulmonary capilllary permeability after cardiopulmonary bypass. Crit Care Med 1992; 20: 1289-95.
5. Chen X, Xu M, Shi H, Mu X, Chen Z, Qiu Z: Comparative study of on-pump and off-pump coronary bypass surgery in patients with triple-vessel coronary artery disease. Chin Med J 2004; 117: 342-346
6. Göksu S, Koçoğlu H, Dağlar B, Üstünsoy H, Celkan MA, Kazaz H, Uyar A, Öner Ü: Koroner revaskülarizasyon olgularında postoperatif erken dönem; pompalı ve pompasız yöntemlerin karşılaştırılması. GKD Anest. Yoğ. Bak. Dern. Derg., 2003; 9: 162-166.
7. Gormley SM, Young IS, Armstrong MA, McMurray TJ, McGowan SW, Campalani G, McBride WT: Noncardiopulmanary (CPB) cardiac surgery leads to significant proximal tubular dysfunction. Br J Anesth 1999; 83: 176-183.
8. Loef BG, Epema AH, Navis G, Ebels T, vanQuaveren W, Henning RH: Off-pump coronary revascularization attenuates transient renal damage compared with on-pump coronary revascularization. Chest, 2002; 121: 1190-94.
9. Nader ND, Khadra WZ, Reish NT, Bacon DR, Salerno TA, Panos AL: Blood product use in cardiac revascularization: comparison of on- and off-pump techniques. Ann Thorac Surg. 1999; 68: 1640-45.
10. Benetti FJ. Direct coronary surgery with saphenous bypass without either cardiopulmonary bypass or cardiac rest. J Cardiovas Surg. 1985; 26: 217-222.
11. Buffolo E, de Andrade JC, Branco JN, et al. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg. 1996; 61: 63-66.
12. Nathoe HM, Van Dijk D, Jansen EWL, et al. Acomparison of on-pump and off-pump coronary bypass surgery in low-risk patients. N Engl J Med 2003; 348: 394-402.
13. Plomondon ME, Cleveland JC, Ludwig ST, et al. Off- pump coronary artery bypass is associated with improved risk-adjusted outcomes. Ann Thorac Surg. 2001; 72: 114-119
14. Stamou SC, Jablonski KA, Pfister AJ, et al. Stroke after conventional versus minimally invasive coronary artery bypass. Ann Thorac Surg. 2002; 74: 394-399.
15. Arom KV, Flavin TF, Emery RW, et al. Safety and efficacy of off-pump coronary artery bypass grafting. Ann Thorac Surg. 2000; 69: 704-710
16. Stamou SC, Corso PJ. Coronary revascularization without cardiopulmonary bypass in high risk patients: a route to the future. An Thorac Surg. 2001; 71: 1056-1061.
17. Chamberlain MH, Ascione R, Reeves BC, Angelini GD. Evaluation of effectiveness of off-pump coronary artery bypass grafting in high risk patients: An observational study. Ann Thorac Surg. 2002; 73: 1866-1873.
18. Akpınar B, Guden M, Sanisoğlu I, Sagbas E, Caynak B, Bayramoğlu Z, Bayındır O. Does off-pump coronary bypass surgery reduce mortality in high risk patiens. Heart Surg Forum, 2001; 4: 231-237.
19. Calafiore AM, Maure M, Canosa C, Giammarco G, Iaco AL, Contini M. Early and late outcome of myocardial revascularization with and without cardiopulmonary bypass in high risk patients (EuroSCORE>6). Eur J Cardiothorac Surg. 2003; 23: 360-367.
20. Stamou SC, Pfister AJ, Dangas G, Dullum MK, Boyce SW, Bafi AS, Garcia JM, Corso PJ. Beating Heart versus conventional single vessel reoperative coronary artery bypass surgery. Ann Thorac Surg. 2000; 69: 1383-1387.
21. Riha M, Danzmayr M, Nagele G, Mueller L, Hoefer D, Ott H, Laufer G, Bonatti J. Off-pump coronary artery bypass grafting in EuroSCORE high and low risk patients. Eur J Cardiothorac Surg. 2002; 21: 193-198.
22. Czerny M, Baumer H, Kilo J, et al. Complete revascularization in coronary artery bypass grafting with or without cardiopulmonary bypass. Ann Thorac Surg. 2001; 71: 165-169.
23. Hu S, Wang X, Song Y, Lu F. Graft patency in off-pump and conventional coronary artery bypass grafting for treatment of triple vessel coronary disease. Chin Med J 2003; 116: 436-439.