Аннотация
Изобретение и внедрение в клиническую практику искусственного кровообращения (ИК) является революционным достижением прошлого века, давшим основы для дальнейшего прогрессивного развития кардиохирургии. На современном этапе коронарное шунтирование в условиях ИК и кардиоплегической остановки сердца остается «золотым стандартом» и составляет около 80% от общего количества операций, выполняемых на коронарных сосудах. Как известно, ИК обеспечивает простоту технического выполнения хирургических манипуляций на внутренних структурах сердца, особенно на его поверхностных сосудах, способствуя качественному выполнению коронарного анастомоза.
Коронарное шунтирование на работающем сердце приобрело популярность за последние 15–20 лет из-за возможности уменьшить риск повреждения мозга и миокарда, развития почечной недостаточности, респираторных осложнений и синдрома системного воспалительного ответа, связанного с ИК. Коронарное шунтирование на работающем сердце выполняется с целью устранения побочного действия ИК и там самым снижает частоту осложнений, связанных с ИК. Однако в некоторых случаях при операциях коронарного шунтирования на работающем сердце для более безопасного завершения операции требуется подключение ИК. Наличие в операционной аппарата ИК и перфузиолога является обязательным условием для проведения операции на работающем сердце. Несмотря на многочисленные преимущества off-pump coronary artery bypass (ОРСАВ), его долгосрочные результаты, связанные с проходимостью шунтов, спорные. Кроме того, у некоторых пациентов, которые изначально оперируются на работающем сердце, затем происходит конверсия, то есть переход, на ИК, что ведет к повышению риска смертности и послеоперационных осложнений и сводит на нет все достоинства реваскуляризации миокарда по методике OPCAB.
Литература
1. Колесов Е.В. Маммарокоронарный анастомоз
в современной кардиохирургии. Хирургия. Журнал
им. Н.И. Пирогова. 1990; 5: 20–4. [Kolesov E.V. Mammarocoronary
anastomosis in a modern heart surgery.
Khirurgiya. Zhurnal imeni N.I. Pirogova (Journal Surgery
named after N.I. Pirogov, Russian journal). 1990; 5:
20–4 (in Russ.).]
2. Calafiore A.M., Di Giammarco G., Teodori G. et al.
Left anterior descending coronary artery grafting via left
anterior small thoracotomy without cardiopulmonary
bypass. Ann. Thorac. Surg. 1996; 61: 1658–65.
3. Subramanian V.A., McCabe J.C., Geller C.M. Minimally
invasive direct coronary artery bypass grafting:
two-year clinical experience. Ann. Thorac. Surg. 1997;
64: 1648–53.
4. Бокерия Л.А., Беришвили И.И., Сигаев И.Ю. Ре-
васкуляризация миокарда: меняющиеся подходы и
пути развития. Грудная и сердечно-сосудистая хи-
рургия. 1999; 6: 102–12. [Bockeria L.A., Berishvili I.I.,
Sigaev I.Yu. Revaskularization of a myocardium:
the changing approaches and ways of development.
Grudnaya i Serdechno-Sosudistaya Khirurgiya (Russian
Journal of Thoracic and Cardiovascular Surgery). 1999;
6: 102–12 (in Russ.).]
5. Шабалкин Б.В. Становление и развитие коронар-
ной хирургии. Грудная и сердечно-сосудистая хирур-
гия. 2001; 2: 4–7. [Shabalkin B.V. Formation and
development of coronary surgery. Grudnaya i Serdechno-
Sosudistaya Khirurgiya (Russian Journal of
Thoracic and Cardiovascular Surgery). 2001; 2: 4–7
(in Russ.).]
6. Houlind K., Kjeldsen B.J., Madsen S.N., Rasmussen B.S.,
Holme S.J., Nielsen P.H., Mortensen P.E.; DOORS
Study Group. On-pump versus off-pump coronary
artery bypass surgery in elderly patients: results from the
Danish on-pump versus off-pump randomization study.
Circulation. 2012; 125 (20): 2431–9.
7. Diegeler A., Börgermann J., Kappert U., Breuer M.,
Böning A., Ursulescu A. et al. Off-pump versus onpump
coronary-artery bypass grafting in elderly
patients. N. Engl. J. Med. 2013; 368: 1189–98.
8. Lamy A., Devereaux P.J., Prabhakaran D., Taggart D.P.,
Hu S., Paolasso E. et al. Effects of off-pump and onpump
coronary artery bypass grafting at 1 year. N. Engl.
J. Med. 2013; 368: 1179–88.
9. Kowalewski M., Pawliszak W., Malvindi P.G.,
Bokszanski M.P., Perlinski D., Raffa G.M. et al. Offpump
CABG improves short-term outcomes in high
risk patients as compared to on-pump CABG: metaanalysis.
J. Thorac. Cardiovasc. Surg. 2015; 2: 143–7.
10. Bojar R.M. Manual of perioperative care in adult cardiac
surgery. Hoboken: Wiley-Blackwell; 2011: 155–6.
11. Cavallaro P., Itagaki S., Seigerman M., Chikwe J.
Operative mortality and stroke after on-pump vs offpump
surgery in high-risk patients: an analysis of
83,914 coronary bypass operations. Eur. J. Cardiothorac.
Surg. 2014; 45: 159–64.
12. Marui A., Okabayashi H., Komiya T., Tanaka S.,
Furukawa Y., Kita T. et al. CREDO-Kyoto Investigators.
Benefits of off-pump coronary artery bypass
grafting in high-risk patients. Circulation. 2012; 126:
S151–7.
13. Shroyer A.L., Grover F.L., Hattler B., Collins J.F.,
McDonald G.O., Kozora E. et al. Veterans affairs
Randomized On/Off Bypass (ROOBY) study group onpump
versus off-pump coronary-artery bypass surgery.
N. Engl. J. Med. 2009; 361: 1827–37.
14. Straka Z., Widimsky P., Jirasek K., Stros P., Votava J.,
Vanek T. et al. Off-pump versus on-pump coronary surgery:
final results from a prospective randomized study
PRAGUE-4. Ann. Thorac. Surg. 2004; 77: 789–93.
15. Légaré J.F., Buth K.J., Hirsch G.M. Conversion to on
pump from OPCAB is associated with increased mortality:
results from a randomized controlled trial. Eur. J.
Cardiothorac. Surg. 2005; 27: 296–301.
16. Maroto Castellanos L.C., Carnero M., Cobiella F.J.,
Alswies A., Ayaon A., Reguillo F.J. et al. Off-pump to
on-pump emergency conversion: Incidence, risk factors,
and impact on short- and long-term results. J. Card.
Surg. 2015; 30: 735–45.
17. Mukherjee D., Ashrafian H., Kourliouros A., Ahmed K.,
Darzi A., Athanasiou T. Intra-operative conversion is a
cause of masked mortality in off-pump coronary artery
bypass: a meta-analysis. Eur. J. Cardiothorac. Surg.
2012; 41: 291–9.
18. Borde D.P., Asegaonkar B., Apsingekar P., Khade S.,
Futane S., Khodve B. et al. Intraoperative conversion to
on-pump coronary artery bypass grafting is independently
associated with higher mortality in patients undergoing
off-pump coronary artery bypass grafting: a
propensity-matched analysis. Ann. Card. Anaesth. 2016;
19 (3): 475–80.
19. Edgerton J.R., Dewey T.M., Magee M.J. et al.
Conversion in off-pump coronary artery bypass grafting:
an analysis of predictors and outcomes. Ann.
Thorac. Surg. 2003; 76: 1138–43.
20. Patel N.C., Patel N.U., Loulmet D.F. et al. Emergency
conversion to cardiopulmonary bypass during attempted
off-pump revascularization results in increased morbidity
and mortality. J. Thorac. Cardiovasc. Surg. 2004;
128: 655–61.
21. Soltoski P., Salerno T., Levinsky L. et al. Conversion to
cardiopulmonary bypass in off-pump coronary artery
bypass grafting: its effect on outcome. J. Card. Surg.
1998; 13: 328–34.
22. Tabata M., Takanashi S., Horai T. et al. Emergency
conversion in off-pump coronary artery bypass grafting.
Interact. Cardiovasc. Thorac. Surg. 2006; 5: 555–9.
23. Hovakimyan A., Manukyan V., Ghazaryan S. et al.
Predictors of emergency conversion to on-pump during
off-pump coronary surgery. Asian Cardiovasc. Thorac.
Ann. 2008; 16: 226–30.
24. Landoni G., Pappalardo F., Crescenzi G. et al. The outcome
of patients requiring emergency conversion from
off-pump to on-pump coronary artery bypass grafting.
Eur. J. Anaesthesiol. 2007; 24: 317–22.
25. Jin R., Hiratzka L.F., Grunkemeier G.L. et al. Aborted
off-pump coronary artery bypass patients have much
worse outcomes than on-pump or successful off-pump
patients. Circulation. 2005; 112: I332–7.
26. Mishra M., Shrivastava S., Dhar A. et al. A prospective
evaluation of hemodynamic instability during off-pump
coronary artery bypass surgery. J. Cardiothorac. Vasc.
Anesth. 2003; 17: 452–8.
27. Lim J., Lee W.Y., Ra Y.J., Jeong J.H., Ko H.H. Analysis
of risk factors for conversion from off-pump to onpump
coronary artery bypass graft. Korean J. Thorac.
Cardiovasc. Surg. 2017; 50 (1): 14–21.
28. Junghyeon Lim, Won Yong Lee, Yong Joon Ra, Jae Han
Jeong, Ho Hyun Ko. Analysis of risk factors for conversion
from off-pump to on-pump coronary artery bypass
graft. Korean J. Thorac. Cardiovasc. Surg. 2017; 50 (1):
14–21.
29. Vassiliades T.A., Nielsen J.L., Lonquist J.L. Hemodynamic
collapse during off-pump coronary artery
grafting bypass. Ann. Thorac. Surg. 2002; 73: 1874–9.
30. Меликулов А.А. Непосредственные результаты ма-
лоинвазивной реваскуляризации миокарда в слу-
чаях, завершившихся переходом на искусственное
кровообращение: Дис. ... канд. мед. наук. М.; 2009.
[Melikulov A.A. Immediate results of minimally invasive
myocardial revascularization in cases of switching
at on-pump: Cand. Med. Sc. Diss. Moscow; 2009
(in Russ.).]
31. Reeves B.C., Ascione R., Caputo M. et al. Morbidity
and mortality following acute conversion from offpump
to on-pump coronary surgery. Eur. J. Cardiothorac.
Surg. 2006; 29: 941–7.
32. Hangler H., Mueller L., Ruttmann E. et al. Shunt or
snare: coronary endothelial damage due to hemostatic
devices for beating heart coronary surgery. Ann. Thorac.
Surg. 2008; 86: 1873–7.
33. Мерзляков В.Ю., Меликулов А.А., Ключни-
ков И.В., Жалилов А.К. Острая окклюзия коронар-
ной артерии после использования интракоронар-
ного шунта при операции на работающем сердце.
Бюллетень НЦССХ им. А.Н. Бакулева РАМН. 2013;
14 (1): 72–5. [Merzlyakov V.Yu., Melikulov A.A.,
Klyuchnikov I.V., Zhalilov A.K. Acute occlusion of
coronary artery after usage of intracoronary bypass at
off-pump surgery. Byulleten’ Nauchnogo Tsentra
Serdechno-Sosudistoy Khirurgii imeni A.N. Bakuleva
Rossiyskoy Academii Meditsinskikh Nauk (Bulletin of
A.N. Bakoulev Scientific Center for Cardiovascular
Surgery of Russian Academy of Medical Sciences, Russian
journal). 2013; 14 (1): 72–5 (in Russ.).]
34. Sorm Z., Vojacek J., Cermakova E., Pudil R., Stock U.A.,
Harrer J. Elective minimally invasive coronary artery
bypass: shunt or tournique occlusion? Assessment of a
protective role of perioperative left anterior descending
shunting on myocardial damage. A prospective randomized
study. J. Cardiothorac. Surg. 2012; 7: 69.
35. Lucchetti V., Capasso F., Caputo M., Grimaldi G.,
Capece M., Brando G. et al. Intracoronary shunt prevents
left ventricular function impairment during beating
heart coronary revascularization. Eur. J. Cardiothorac.
Surg. 1999; 15: 255–9.
36. Ergle K., Parto P., Krim S.R. Percutaneous ventricular
assist devices: a novel approach in the management of
patients with acute cardiogenic shock. Ochsner. J. 2016;
16 (3): 243–9.
37. Mao C.T., Wang J.L., Chen D.Y., Tsai M.L., Lin Y.S.,
Cherng W.J. et al. Benefits of intraaortic balloon support
for myocardial infarction patients in severe cardiogenic
shock undergoing coronary revascularization.
PLoS One. 2016; 11 (8): e0160070.
38. Craver M.J., Murrah C.P. Elective intraaortic balloon
counterpulsation for high-risk off-pump coronary artery
bypass operations. Ann. Thorac. Surg. 2001; 71: 1220–3.
39. Gregoric I.D., Poglajen G., Matjaz S. et al. Percutaneous
ventricular assist device support during offpump
surgical coronary revascularization. Ann. Thorac.
Surg. 2008; 86: 637–9.
40. Strecker T., Fischlein T., Pfeiffer S. Impella recover 100:
successful perioperative support for off pump coronary
artery bypass grafting surgery in a patient with end-stage
ischemic cardiomyopathy. J. Cardiovasc. Surg. (Torino).
2004; 45: 381–4.
41. Angelini G.D., Taylor F.C., Reeves B.C., Ascione R. Early
and midterm outcome after off-pump and on-pump surgery
in Beating Heart Against Cardioplegic Arrest Studies
(BHACAS 1 and 2): a pooled analysis of two randomised
controlled trials. Lancet. 2002; 359: 1194–9.
42. Puskas J.D., Williams W.H., Duke P.G., Staples J.R.,
Glas K.E., Marshall J.J. et al. Off-pump coronary
artery bypass grafting provides complete revascularization
with reduced myocardial injury, transfusion
requirements, and length of stay: a prospective randomized
comparison of two hundred unselected patients
undergoing off-pump versus conventional coronary
artery bypass grafting. J. Thorac. Cardiovasc. Surg.
2003; 125: 797–808.
43. Hueb W., Lopes N.H., Pereira A.C., Hueb A.C.,
Soares P.R., Favarato D. et al. Five-year follow-up of
a randomized comparison between off-pump and onpump
stable multivessel coronary artery bypass grafting.
The MASS III Trial. Circulation. 2010; 122: S48–52.
44. Fattouch K., Guccione F., Dioguardi P., Sampognaro R.,
Corrado E., Caruso M. et al. Off-pump versus on-pump
myocardial revascularization in patients with ST-segment
elevation myocardial infarction: a randomized
trial. J. Thorac. Cardiovasc. Surg. 2009; 137: 650–7.
45. Hernandez F. Jr, Brown J.R., Likosky D.S., Clough R.A.,
Hess A.L., Roth R.M. et al. Neurocognitive outcomes
of off-pump versus on-pump coronary artery bypass:
a prospective randomized controlled trial. Ann. Thorac.
Surg. 2007; 84: 1897–903.
46. Muneretto C., Bisleri G., Negri A., Manfredi J., Metra M.,
Nodari S. et al. Off-pump coronary artery bypass surgery
technique for total arterial myocardial revascularization:
a prospective randomized study. Ann. Thorac.
Surg. 2003; 76: 778–82.
47. Lingaas P.S., Hol P.K., Lundblad R., Rein K.A.,
Mathisen L., Smith H.J. et al. Clinical and radiologic
outcome of off-pump coronary surgery at 12 months
follow-up: a prospective randomized trial. Ann. Thorac.
Surg. 2006; 81: 2089–95.
48. Moller C.H., Penninga L., Wetterslev J., Steinbruchel
D.A., Gluud C. Clinical outcomes in randomized
trials of off- vs. on-pump coronary artery bypass surgery:
systematic review with meta-analyses and trial
sequential analyses. Eur. Heart J. 2008; 29: 2601–16.
49. Nathoe H.M., van Dijk D., Jansen E.W., Suyker W.J.,
Diephuis J.C., van Boven W.J. et al. A comparison of
on-pump and off-pump coronary bypass surgery in
low-risk patients. N. Engl. J. Med. 2003; 348: 394–402.
50. Masoumi M., Saidi M.R., Rostami F., Sepahi H.,
Roushani D. Off-pump coronary artery bypass grafting
in left ventricular dysfunction. Asian Cardiovasc.
Thorac. Ann. 2008; 16: 16–20.
Об авторах
- Меликулов Алишер Алмардонович, канд. мед. наук, сердечно-сосудистый хирург; orcid.org/0000-0002-5164-9702
- Мерзляков Вадим Юрьевич, доктор мед. наук, заведующий отделением хирургического лечения ишемической болезни сердца и малоинвазивной коронарной хирургии; orcid.org/0000-0001-5638-3723
- Ахмедова Мадина Фатхуллаевна, канд. мед. наук, кардиолог; orcid.org/0000-0002-6184-6742