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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,停跳与不停跳搭桥手术,西方的观点,Michael Mack,M.D.,Dallas,Texas,US,观点之争,科学顾问委员会,-Maquet,我们的标准,CABG-2008,正中胸骨切口,不停跳,一支以上的动脉移植,内窥镜下取静脉,(EVH),内镜下取桡动脉,主动脉扫描,如果并存主动脉疾病则不上主动脉钳,手术部位固定,小引流管,离开手术室前拔气管导管,OPCAB,不停跳搭桥问题,对于,OPCAB,的接受度?为什么接受度不能更高,?,OPCAB,更好吗,?,是否有特定的病人群能从中受益,?,关于未来的发展,?,CABG,在美国,任意技术的接受过程都存在阻碍,术者(而非病人)的态度,价值的体现,可传授性,为何,OPCAB,仅占搭桥手术的,20-25%?,术者不太接受,其优势没有明确的体现,不容易传授,OPCAB,与传统的冠脉搭桥之间的比较,对,37,篇,RCTs,研究进行荟萃分析,3,369,例病人,死亡率、中风、心梗、肾衰的发生率并未减少,某些短期和中期的临床转归得到了改善,OPCAB vs.CCAB,30,天的死亡率分析,OPCAB vs CCAB,术后,30,天中风的分析,OPCAB vs.CCAB,术后,30,天房颤的数据分析,OPCAB vs.CCAB,术后,30,天需要输血病人的数据分析,OPCAB,问题,What is the adoption rate of OPCAB and why is it not higher?,Is OPCAB better?,是否对特定的病人群特别有好处,?,0.10 1.00 10.00,Favors Favors,OPCAB CCAB,死亡率,随机化,观察,高风险,中风,随机化,观察,高风险,急性心梗,随机化,观察,高风险,肾衰,随机化,观察,高风险,OPCAB v CCAB:RCT,NRCT,High-Risk Pt Studies,Cheng 2004(35 RCTs;3305 pts),-,Beattie 2004(16 NRCTs;250k)or,Reston 2003(53 trials;39k),-,ISMICS Consensus 2004(45 NRCTs;26k),0.10 1.00 10.00,Favors Favors,OPCAB CCAB,输血 随机化,观察,高风险,AF,随机化,观察,高风险,正性肌力药的应用,随机化,观察,高风险,呼吸道感染,随机化 观察,高风险,OPCAB v CCAB:RCT,NRCT,针对高风险病人的研究,Cheng 2004(35 RCTs;3305 pts),-,Beattie 2004(16 NRCTs;250k)or,Reston 2003(53 trials;39k),-,ISMICS Consensus 2004(45 NRCTs;26k),CABG in U.S.,那么,将来会有哪些改变呢,?,吻合装置,MECC-,微创体外循环,Cardica,远端吻合装置,输送系统,xA,FlexA,C-Port,临床先导性研究,J Thorac Cardiovasc Surg 2005;130:1645-52,Angiographic Patency,出院时,103/104 99.1%,6,月后,94/98 95.9%,12,个月临床随访,No MACE with 98%followup,大隐静脉桥的通畅度,6-12 Months,MECC(,微创体外循环,),闭合系统,整合的泵,/,氧合器,没有血气接触面,少量预充液,无直接的心脏切开吸引,提供血流动力学支持和手术期间的体外循环支持,降低血液稀释程度,将体外循环相关的炎性反应降低至,OPCAB,的程度,OPCAB,答案,OPCAB,的接受度,为什么没有更高,?,20-25%-,不讨术者喜欢,OPCAB,更好吗,?,是的,对于特定的病人群是否特别有益,?,高危病人,女性病人,将来的发展,?,更先进的吻合装置,微创体外泵,
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