CABG

冠動脈バイパス術、coronary aortic bypass graft

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1. California
2. Civil Aeronautics Board民間航空委員会

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2014/02/19 16:31:58」(JST)

wiki ja

[Wiki ja表示]

冠動脈大動脈バイパス移植術（かんどうみゃくだいどうみゃくバイパスいしょくじゅつ）は、虚血性心疾患に対し行われる手術的治療法である。

英名のcoronary artery bypass graft（またはgrafting）を略し、CABGとも呼ばれる。

概要

虚血性心疾患は、心臓の筋肉（心筋）への酸素供給量が低下し、需要量を下回ることによって起こる。心筋への酸素供給量が低下する原因の一つに冠動脈の狭窄、閉塞による血流量の低下が挙げられる。冠動脈大動脈バイパス移植術は狭窄した冠動脈の遠位側に大動脈（または内胸動脈）から血管をつなぎ、狭窄部をバイパスすることで血流量の回復をはかる手術である。

術式

虚血性心疾患の治療方法としてはカテーテルを用いた経皮的冠動脈形成術(PCI)もあり、こちらは血管内治療と呼ばれ、いわゆる一般に考えられるような「皮膚を切開する手術」の必要がなく侵襲が低い（患者の体力的負担が軽い）。しかし、PCIが不可能な（もしくは危険で出来ない）病変があり治療に限界がある。 治療の流れとしてはまず血管造影を行い、PCIが可能な病変であればPCIを行い、不可能なものはCABGへと移行していくことになる。 手術は日本においては基本的に全身麻酔下で行われる。施設によっては硬膜外麻酔で行うところもあるが日本では一般的ではない（国情によって異なる）。手術の手順としては以下の通り。

• 開胸（胸骨正中切開）
• 心膜切開、心臓露出、（オンポンプの場合は）カニュレーションの準備
• 上記と並行してバイパスに使う血管（グラフトと呼ぶ）の採取
• グラフトの末梢側（冠動脈）への吻合
• グラフトの中枢側（大動脈）への吻合（トップエンドが大動脈の場合のみ）
• グラフトの血流をダイレクトエコーで確認
• 止血、ドレーン挿入、ペースメーカーリード装着、閉胸、閉創

このうちグラフトに用いられる血管と、グラフトの冠動脈への縫合に関しては何通りかの方法があるため後述する。

人工心肺装置を使用する方法

人工心肺による体外循環を使用し心臓を停止させて縫合を行う黎明期から施されている術式。

人工心肺装置を使用しない方法

従来、常に動いている心臓に太さ数ミリメートルの血管を縫いつけるのは非常に困難であった。しかし、近年スタビライザーという器具が開発され、縫合する部位のみ動きを止めることで心臓が動いている状態のまま手術することが可能となった。この術式を選択する医師も増えてきている。なおこの方法はオフポンプCABG(OPCAB＝オプキャブ)と呼ばれている。

OPCABの利点・欠点

人工心肺を使用しないことで人工心肺使用時のリスクを回避できることである。また、動脈硬化がひどく人工心肺を使用できないような場合でも手術が行える。欠点としては心臓の動きを抑えることで心臓の働きが低下してしまうため、心臓の機能に余裕がない場合手術が行えないことや手術操作中に一時的に冠動脈の血流が減少し不整脈が生じる可能性があること、術者の技量が要求されることなどである。

意見が分かれる項目

CABGに関して、現時点で明確に定まっていない事柄に関して解説する。現在根拠となるデータを集めるべく各国で研究、調査が行われており、標準的な治療方法が確立するまでは時間を要する。

• 人工心肺の必要が無いことから悪影響が少ない（低侵襲）手術方法として期待されたOPCABであったが、確実性に疑問を持たれていることも事実である。人工心肺を使用した方が手術の合併症が少ない、グラフトの開存性が勝っているなど、優れた結果が出ているという報告もある。

グラフトに用いられる血管

静脈を使う場合（静脈グラフト）と動脈を使う場合（動脈グラフト）に大別される。静脈グラフトは古くから用いられていたが、長期間追跡調査によれば静脈グラフトは動脈グラフトよりも開存率が低い。動脈グラフトは、橈骨動脈など使用部位によりグラフトの攣縮（れんしゅく）による血流の低下が問題とされてきたが、塩酸ジルチアゼム製剤など血管拡張薬の進歩により治療成績は改善してきている。

• 静脈グラフト

大伏在静脈

• 動脈グラフト

内胸動脈、橈骨動脈、胃大網動脈

内胸動脈にグラフトをつなぐ（延長する）場合もある。

関連項目

• 静脈血栓塞栓症

外部リンク

wiki en

[Wiki en表示]

"Heart bypass" redirects here. For the technique to take over the function of the heart and lungs during surgery, see Cardiopulmonary bypass.

Coronary artery bypass surgery
Intervention
Early in a coronary artery bypass surgery during vein harvesting from the legs (left of image) and the establishment of bypass (placement of the aortic cannula) (bottom of image). The perfusionist and heart-lung machine (HLM) are on the upper right. The patient's head (not seen) is at the bottom.
ICD-10-PCS	021209W
ICD-9-CM	36.1
MeSH	D001026
MedlinePlus	002946

Coronary artery bypass surgery, also coronary artery bypass graft (CABG, pronounced "cabbage") surgery, and colloquially heart bypass or bypass surgery is a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease. Arteries or veins from elsewhere in the patient's body are grafted to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass; techniques are available to perform CABG on a beating heart, so-called "off-pump" surgery.

Terminology

Three coronary artery bypass grafts, a LIMA to LAD and two saphenous vein grafts – one to the right coronary artery (RCA) system and one to the obtuse marginal (OM) system.

There are many variations on terminology, in which one or more of "artery", "bypass" or "graft" is left out. The most frequently used acronym for this type of surgery is CABG (pronounced 'cabbage'), pluralized as CABGs (pronounced 'cabbages'). More recently the term aortocoronary bypass (ACB) has come into popular use. CAGS (Coronary Artery Graft Surgery, pronounced phonetically) should not be confused with coronary angiography (CAG).

Arteriosclerosis is a common arterial disorder characterized by thickening, loss of elasticity, and calcification of arterial walls, resulting in a decreased blood supply.

Atherosclerosis is a common arterial disorder characterized by yellowish plaques of cholesterol, lipids, and cellular debris in the inner layer of the walls of large and medium-sized arteries.

Number of bypasses

Illustration depicting single, double, triple, and quadruple bypass

The terms single bypass, double bypass, triple bypass, quadruple bypass and quintuple bypass refer to the number of coronary arteries bypassed in the procedure. In other words, a double bypass means two coronary arteries are bypassed (e.g. the left anterior descending (LAD) coronary artery and right coronary artery (RCA)); a triple bypass means three vessels are bypassed (e.g. LAD, RCA, left circumflex artery (LCX)); a quadruple bypass means four vessels are bypassed (e.g. LAD, RCA, LCX, first diagonal artery of the LAD) while quintuple means five. Bypass of more than four coronary arteries is uncommon.

A greater number of bypasses does not imply a person is "more sick", nor does a lesser number imply a person is "healthier." A person with a large amount of coronary artery disease (CAD) may receive fewer bypass grafts owing to the lack of suitable "target" vessels. A coronary artery may be unsuitable for bypass grafting if it is small (< 1 mm or < 1.5 mm depending on surgeon preference), heavily calcified (meaning the artery does not have a section free of CAD) or intramyocardial (the coronary artery is located within the heart muscle rather than on the surface of the heart). Similarly, a person with a single stenosis ("narrowing") of the left main coronary artery requires only two bypasses (to the LAD and the LCX). However, a left main lesion places a person at the highest risk for death from a cardiac cause.^{[citation needed]}

The surgeon reviews the coronary angiogram prior to surgery and identifies the lesions (or "blockages") in the coronary arteries. The surgeon will estimate the number of bypass grafts prior to surgery, but the final decision is made in the operating room upon examination of the heart.

Indications

Several alternative treatments for coronary artery disease exist. They include:

• Medical management (anti-anginal medications plus statins, antihypertensives, smoking cessation, tight blood sugar control in diabetics)
• Percutaneous coronary intervention (PCI)

Both PCI and CABG are more effective than medical management at relieving symptoms, (e.g. angina, dyspnea, fatigue). CABG is superior to PCI for some patients with multivessel CAD

The Surgery or Stent (SoS) trial was a randomized controlled trial that compared CABG to PCI with bare-metal stents. The SoS trial demonstrated CABG is superior to PCI in multivessel coronary disease.

The SYNTAX trial was a randomized controlled trial of 1800 patients with multivessel coronary disease, comparing CABG versus PCI using drug-eluting stents (DES). The study found that rates of major adverse cardiac or cerebrovascular events at 12 months were significantly higher in the DES group (17.8% versus 12.4% for CABG; P=0.002). This was primarily driven by higher need for repeat revascularization procedures in the PCI group with no difference in repeat infarctions or survival. Higher rates of strokes were seen in the CABG group.

The FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus—Optimal Management of Multivessel Disease) trial will compare CABG and DES in patients with diabetes. The registries of the nonrandomized patients screened for these trials may provide as much robust data regarding revascularization outcomes as the randomized analysis.

A study comparing the outcomes of all patients in New York state treated with CABG or percutaneous coronary intervention (PCI) demonstrated CABG was superior to PCI with DES in multivessel (more than one diseased artery) coronary artery disease (CAD). Patients treated with CABG had lower rates of death and of death or myocardial infarction than treatment with a coronary stent. Patients undergoing CABG also had lower rates of repeat revascularization. The New York State registry included all patients undergoing revascularization for coronary artery disease, but was not a randomized trial, and so may have reflected other factors besides the method of coronary revascularization.

A meta-analysis with over 6000 patients showed that coronary artery bypass was associated with lower risk for major adverse cardiac events compared to drug-eluting stenting. However, patients had a higher risk of stroke events.

The 2004 ACC/AHA CABG guidelines state CABG is the preferred treatment for:

• Disease of the left main coronary artery (LMCA).
• Disease of all three coronary vessels (LAD, LCX and RCA).
• Diffuse disease not amenable to treatment with a PCI.

The 2005 ACC/AHA guidelines further state: CABG is the preferred treatment with other high-risk patients such as those with severe ventricular dysfunction (i.e. low ejection fraction), or diabetes mellitus.

Prognosis

Prognosis following CABG depends on a variety of factors, and successful grafts typically last 8–15 years. In general, CABG improves the chances of survival of patients who are at high risk (generally triple or higher bypass), though statistically after about five years the difference in survival rate between those who have had surgery and those treated by drug therapy diminishes. Age at the time of CABG is critical to the prognosis, younger patients with no complicating diseases doing better, while older patients can usually be expected to suffer further blockage of the coronary arteries.^{[citation needed]}

Controversy

The value of coronary artery bypass surgery in rescuing someone having a heart attack (by immediately alleviating an obstruction) is clearly defined in multiple studies, but studies have failed to find benefit for bypass surgery vs. medical therapy in stable angina patients. The artery bypass can temporarily alleviate chest pain, but does not increase longevity. The "vast majority of heart attacks do not originate with obstructions that narrow arteries".

Loss of mental function is a complication of bypass surgery in elderly people, and might influence procedure cost benefit considerations.

Several factors may contribute to immediate cognitive decline. The heart-lung blood circulation system and the surgery itself release a variety of debris, including bits of blood cells, tubing, and plaques. For example, when surgeons clamp and connect the aorta to tubing, resulting emboli block blood flow and cause mini strokes. Other heart surgery factors related to mental damage may be events of hypoxia, high or low body temperature, abnormal blood pressure, irregular heart rhythms, and fever after surgery.

A safer and more permanent and successful way to prevent heart attacks in patients at high risk is to exercise, give up smoking, take "drugs to get blood pressure under control and drive cholesterol levels down to prevent blood clotting". Longer term, behavioral and medication treatment may be the only way to avoid vascular related loss of mental function.

Procedure (simplified)

Illustration of a typical coronary artery bypass surgery. A vein from the leg is removed and grafted to the coronary artery to bypass a blockage.

Coronary artery bypass surgery during mobilization (freeing) of the right coronary artery from its surrounding tissue, adipose tissue (yellow). The tube visible at the bottom is the aortic cannula (returns blood from the HLM). The tube above it (obscured by the surgeon on the right) is the venous cannula (receives blood from the body). The patient's heart is stopped and the aorta is cross-clamped. The patient's head (not seen) is at the bottom.

1. The patient is brought to the operating room and moved on to the operating table.
2. An anaesthetist places a variety of intravenous lines and injects a painkilling agent (usually fentanyl) followed within minutes by an induction agent (usually propofol) to render the patient unconscious.
3. An endotracheal tube is inserted and secured by the anaesthetist and mechanical ventilation is started. General anaesthesia is maintained by a continuous very slow injection of Propofol.
4. The chest is opened via a median sternotomy and the heart is examined by the surgeon.
5. The bypass grafts are harvested – frequent conduits are the internal thoracic arteries, radial arteries and saphenous veins. When harvesting is done, the patient is given heparin to prevent the blood from clotting.
6. In the case of "off-pump" surgery, the surgeon places devices to stabilize the heart.
7. If the case is "on-pump", the surgeon sutures cannulae into the heart and instructs the perfusionist to start cardiopulmonary bypass (CPB). Once CPB is established, the surgeon places the aortic cross-clamp across the aorta and instructs the perfusionist to deliver cardioplegia (a special potassium-mixture, cooled) to stop the heart and slow its metabolism. Usually the patient's machine-circulated blood is cooled to around 84 °F (29 °C)
8. One end of each graft is sewn on to the coronary arteries beyond the blockages and the other end is attached to the aorta.
9. The heart is restarted; or in "off-pump" surgery, the stabilizing devices are removed. In cases where the aorta is partially occluded by a C-shaped clamp, the heart is restarted and suturing of the grafts to the aorta is done in this partially occluded section of the aorta while the heart is beating.
10. Protamine is given to reverse the effects of heparin.
11. Chest tubes are placed in the mediastinal and pleural space to drain blood from around the heart and lungs.
12. The sternum is wired together and the incisions are sutured closed.
13. The patient is moved to the intensive care unit (ICU) to recover.
14. Nurses in the ICU focus on recovering the patient by monitoring blood pressure, urine output and respiratory status as the patient is monitored for bleeding through the chest tubes. If there is chest tube clogging, complications such as cardiac tamponade, pneumothorax or death can ensue. Thus nurses closely monitor the chest tubes and under take methods to prevent clogging so bleeding can be monitored and complications can be prevented.
15. After awakening and stabilizing in the ICU (approximately one day), the person is transferred to the cardiac surgery ward until ready to go home (approximately four days).

Minimally invasive CABG

Alternate methods of minimally invasive coronary artery bypass surgery have been developed. Off-pump coronary artery bypass (OPCAB) is a technique of performing bypass surgery without the use of cardiopulmonary bypass (the heart-lung machine). Further refinements to OPCAB have resulted in minimally invasive direct coronary artery bypass surgery (MIDCAB), a technique of performing bypass surgery through a 5 to 10 cm incision.

Conduits used for bypass

Heart bypass patient with almost invisible residual scarring

The choice of conduits is highly dependent upon the particular surgeon and institution. Typically, the left internal thoracic artery (LITA) (previously referred to as left internal mammary artery or LIMA) is grafted to the left anterior descending artery and a combination of other arteries and veins is used for other coronary arteries. The right internal thoracic artery (RITA), the great saphenous vein from the leg and the radial artery from the forearm are frequently used; in the U.S., these vessels are usually harvested endoscopically, using a technique known as endoscopic vessel harvesting (EVH). The right gastroepiploic artery from the stomach is infrequently used given the difficult mobilization from the abdomen.

Graft patency

Grafts can become diseased and may occlude in the months to years after bypass surgery is performed. Patency is the chance that a graft remains open. A graft is considered patent if there is flow through the graft without any significant (>70% diameter) stenosis in the graft.

Graft patency is dependent on a number of factors, including the type of graft used (internal thoracic artery, radial artery, or great saphenous vein), the size or the coronary artery that the graft is anastomosed with, and, of course, the skill of the surgeon(s) performing the procedure. Arterial grafts (e.g. LITA, radial) are far more sensitive to rough handling than the saphenous veins and may go into spasm if handled improperly.

Generally the best patency rates are achieved with the in-situ left internal thoracic artery (the proximal end is left connected to the subclavian artery) with the distal end being anastomosed with the coronary artery (typically the left anterior descending artery or a diagonal branch artery). Lesser patency rates can be expected with radial artery grafts and "free" internal thoracic artery grafts (where the proximal end of the thoracic artery is excised from its origin from the subclavian artery and re-anastomosed with the ascending aorta). Saphenous vein grafts have worse patency rates, but are more available, as the patients can have multiple segments of the saphenous vein used to bypass different arteries.

Veins that are used either have their valves removed or are turned around so that the valves in them do not occlude blood flow in the graft. LITA grafts are longer-lasting than vein grafts, both because the artery is more robust than a vein and because, being already connected to the arterial tree, the LITA need only be grafted at one end. The LITA is usually grafted to the left anterior descending coronary artery (LAD) because of its superior long-term patency when compared to saphenous vein grafts.

Sternal precautions

Patients undergoing coronary artery bypass surgery will have to avoid certain things for eight to 12 weeks to reduce the risk of opening the incision. These are called sternal precautions. First, patients need to avoid using their arms excessively, such as pushing themselves out of a chair or reaching back before sitting down. To avoid this, patients are encouraged to build up momentum by rocking several times in their chair before standing up. Second, patients should avoid lifting anything in excess of 5–10 pounds. A gallon (U.S.) of milk weighs approximately 8.5 pounds, and is a good reference point for weight limitations. Finally, patients should avoid overhead activities with their hands, such as reaching for sweaters from the top shelf of a closet or reaching for plates or cups from the cupboard.

Complications

People undergoing coronary artery bypass are at risk for the same complications as any surgery, plus some risks more common with or unique to CABG.

CABG associated

• Postperfusion syndrome (pumphead), a transient neurocognitive impairment associated with cardiopulmonary bypass. Some research shows the incidence is initially decreased by off-pump coronary artery bypass, but with no difference beyond three months after surgery. A neurocognitive decline over time has been demonstrated in people with coronary artery disease regardless of treatment (OPCAB, conventional CABG or medical management). However, a 2009 research study suggests that longer term (over 5 years) cognitive decline is not caused by CABG but is rather a consequence of vascular disease.
• Nonunion of the sternum; internal thoracic artery harvesting devascularizes the sternum increasing risk.
• Myocardial infarction due to embolism, hypoperfusion, or graft failure.
• Late graft stenosis, particularly of saphenous vein grafts due to atherosclerosis causing recurrent angina or myocardial infarction.
• Acute renal failure due to embolism or hypoperfusion.
• Stroke, secondary to embolism or hypoperfusion.
• Vasoplegic syndrome, secondary to cardiopulmonary bypass and hypothermia
• Grafts last 8 – 15 years, and then need to be replaced.
• Pneumothorax: An air collection around the lung that compresses the lung
• Hemothorax: Blood in the space around the lungs
• Pericardial tamponade: Blood collection around the heart that compresses the heart and causes poor body and brain perfusion. Chest tubes are placed around the heart and lung to prevent this. If the chest tubes become clogged in the early post operative period when bleeding is ongoing this can lead to Pericardial tamponade, pneumothorax or hemothorax.
• Pleural effusion: Fluid in the space around the lungs. This can lead to hypoxia which can slow recovery.

General cardiac surgery

• Post-operative atrial fibrillation: An arrhythmia that sometimes occurs after cardiac surgery.

General surgical

• Infection at incision sites or sepsis.
• Deep vein thrombosis (DVT)
• Anesthetic complications such as malignant hyperthermia.
• Keloid scarring
• Chronic pain at incision sites
• Chronic stress related illnesses
• Death

Follow up

Patients who have a coronary artery bypass surgery need regular monitoring from a physician. Among the changes in monitoring are five years after the surgery the addition of a regular cardiac stress test even when there is no change in the patient's status.

History

The first coronary artery bypass surgery was performed in the United States on May 2, 1960, at the Albert Einstein College of Medicine-Bronx Municipal Hospital Center by a team led by Dr. Robert Goetz and the thoracic surgeon, Dr. Michael Rohman with the assistance of Dr. Jordan Haller and Dr. Ronald Dee. In this technique the vessels are held together with circumferential ligatures over an inserted metal ring. The internal mammary artery was used as the donor vessel and was anastomosed to the right coronary artery. The actual anastomosis with the Rosenbach ring took fifteen seconds and did not require cardiopulmonary bypass. The disadvantage of using the internal mammary artery was that, at autopsy nine months later, the anastomosis was open, but an atheromatous plaque had occluded the origin of the internal mammary that was used for the bypass.^{[citation needed]}

Soviet cardiac surgeon, Dr. Vasilii Kolesov, performed the first successful internal mammary artery–coronary artery anastomosis in 1964.

However, Goetz's has been cited by others, including Kolesov, as the first successful human coronary artery bypass. Goetz's case has frequently been overlooked. Confusion has persisted for over 40 years and seems to be due to the absence of a full report and to misunderstanding about the type of anastomosis that was created. The anastomosis was intima-to-intima, with the vessels held together with circumferential ligatures over a specially designed metal ring. Kolesov did the first successful coronary bypass using a standard suture technique in 1964, and over the next five years he performed 33 sutured and mechanically stapled anastomoses in Leningrad (now St. Petersburg), USSR.

Dr. René Favaloro, an Argentine surgeon, achieved a physiologic approach in the surgical management of coronary artery disease—the bypass grafting procedure—at the Cleveland Clinic in May 1967. His new technique used a saphenous vein autograft to replace a stenotic segment of the right coronary artery. Later, he successfully used the saphenous vein as a bypassing channel, which has become the typical bypass graft technique we know today; in the U.S., this vessel is typically harvested endoscopically, using a technique known as endoscopic vessel harvesting (EVH). Soon Dr. Dudley Johnson extended the bypass to include left coronary arterial systems. In 1968, Doctors Charles Bailey, Teruo Hirose and George Green used the internal mammary artery instead of the saphenous vein for the grafting.

Additional images

• Illustration depicting Coronary Artery Bypass Surgery (Double Bypass)

• Illustration of Single Bypass

• Illustration of Double Bypass

• Illustration of Triple Bypass

• Illustration of Quadruple Bypass

See also

• Angioplasty
• Cardiothoracic surgery
• Dressler's syndrome
• Hybrid bypass
• Totally endoscopic coronary artery bypass surgery
• Chest tube

References

External links

• A BBC film showing a patient undergoing a double bypass operation.
• Ischemic Heart Disease section in Cardiac Surgey in the Adult
• Coronary Artery Bypass Surgery at NYU Langone Medical Center's Cardiac and Vascular Institute
• Cleveland Clinic page on coronary artery bypass surgery

UpToDate Contents

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• 1. 冠動脈バイパス術：長期的臨床転帰 coronary artery bypass graft surgery long term clinical outcomes
• 2. 冠動脈バイパス術後の合併症予防のための内科的治療 medical therapy to prevent complications after coronary artery bypass graft surgery
• 3. 低侵襲冠動脈バイパス術：定義および技術的な問題 minimally invasive coronary artery bypass graft surgery definitions and technical issues
• 4. ST上昇型心筋梗塞後の冠動脈バイパス術 coronary artery bypass graft surgery after acute st elevation myocardial infarction
• 5. 冠動脈バイパス術の心臓以外の早期合併症 early noncardiac complications of coronary artery bypass graft surgery

English Journal

• Cardiac outcome after sevoflurane versus propofol sedation following coronary bypass surgery: a pilot study.

• Hellstrom J, Owall A, Bergstrom J, Sackey PV.
• Acta anaesthesiologica Scandinavica.2011 Apr;55(4):460-7. doi: 10.1111/j.1399-6576.2011.02405.x. Epub 2011 Feb 22.
• PMID 21342154

• Increased Peak Postoperative B-type Natriuretic Peptide Predicts Decreased Longer-term Physical Function after Primary Coronary Artery Bypass Graft Surgery.

• Fox AA, Marcantonio ER, Collard CD, Thoma M, Perry TE, Shernan SK, Muehlschlegel JD, Body SC.
• Anesthesiology.2011 Apr;114(4):807-816.
• PMID 21427536

• Acquired type 2A von Willebrand syndrome caused by aortic valve disease corrects during valve surgery.

• Solomon C, Budde U, Schneppenheim S, Czaja E, Hagl C, Schoechl H, von Depka M, Rahe-Meyer N.
• British journal of anaesthesia.2011 Apr;106(4):494-500. Epub 2011 Jan 28.
• PMID 21278152

Japanese Journal

• 冠動脈バイパス術を受ける患者の回復に対する認識と術後回復との関連

• 町本 実保,佐藤 まゆみ,佐藤 禮子,Machimoto Mio,Sato Mayumi,Sato Reiko
• 三重看護学誌 13, 103-116, 2011-03-15
• … 的な看護援助は，1）術前患者が個々の術後経過や回復状態を理解し，術後回復のイメージが現実的で無理のない認識によって描かれるよう介入する，2）術後合併症を予防・早期発見し，順調な回復を目指して介入する，である．This study aimed to clarify the relationship between the preoperative expectations of recovery of patients undergoing CABG（coronary artery bypass grafting）and their actual postoperative recovery, so as to gain insight into their effective nursing …
• NAID 120003025360

• 冠動脈バイパス術(CABG)の術式と術後合併症 (特集 要点でつかむ! 心臓血管外科手術と看護ケア--術式と術後合併症編)

• 鈴木 友彰,浅井 徹
• ハートナーシング 24(7), 682-689,672, 2011-07
• NAID 40018912032

Related Links

• 冠動脈バイパス術 （CABG） ｜冠動脈ステント

治療選択肢：冠動脈バイパス術. 冠動脈バイパス術（以下、バイパス術）は、一般的に行 われている開胸心臓手術です。手術医はあなたの脚、胸、腕または腹部から健康な 血管の一部を採取します。この血管を冠動脈の閉塞部分に繋ぎ（移植し）ます。こうする ...

• 冠動脈バイパス術（CABG） - YouTube

2012年8月22日 ... このアニメが好きなら、Facebook上で私たちのように：http://www.nucleusinc.com/ facebook この3D メディカルアニメーションは、冠動脈疾患の治療に使用される、 冠動脈バイパス術、CABGと略されますが、それを描いています。胸腺の正中 ...

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★リンクテーブル★

リンク元	「冠動脈バイパス術」「異型狭心症」「coronary bypass」「coronary artery bypass graft」「冠動脈バイパス移植」
拡張検索	「off pump CABG」「off-pump CABG」
関連記事	「CA」「CAB」

「冠動脈バイパス術」

　　[★]

英

coronary artery bypass grafting, CABG

coronary artery bypass CAB, coronary artery bypass graft surgery, coronary artery bypass surgery

同

A-Cバイパス術 A-C bypass grafting、ACバイパス術 AC bypass grafting

大動脈冠状動脈バイパス術 coronary aortic bypass graft aortocoronary bypass grafting ACBG

関

冠動脈バイパス、冠動脈バイパス手術、冠状動脈バイパス術、冠状動脈バイパス手術

[show details]

冠動脈バイパス術 : 約 42,000 件
冠動脈バイパス手術 : 約 19,700 件
冠状動脈バイパス術 : 約 68,200 件
冠状動脈バイパス手術 : 約 38,800 件

• 冠血行再建術
• 冠状動脈の閉塞、狭窄に対して行われる外科的血行再建術。

適応

• 冠状動脈に75%以上の狭窄がある場合　→　この狭窄で運動すると心筋虚血に陥る
• 左冠状動脈主幹部(LMT)に50%以上の狭窄が認められる
• 責任冠状動脈に心筋虚血が認められる。

YN.C-78

• 1. 左冠状動脈主幹部が50%以上の狭窄例　[show details]
  failpicload@./t_image/097A013.jpg
• 2. 高度な3枝病変や病変の長さが1cm以上等PCI困難例。
• 3. 冠動脈末梢枝のrun-offが良好(径>1.5mm)であること(狭窄・不整なし)
• 4. 左心機能として、駆出率(EF)20%以上、LVEDP20mmHg以下であるもの。
• 5. PCI後の再狭窄。

• 異型狭心症はCABGの対象ではない
• DM合併例の多枝病変ではPCIよりもCABGが推奨される。

標準循環器

• 1. 左冠状動脈主幹部病変例
• 2. 心筋虚血のある3枝病変例
• 3. CCSCのclass III及びIVの狭心症で前下行枝近位部病変を伴った1枝または2枝病変例
• 4. 内科治療抵抗性の不安定狭心症例
• 5. 内科治療抵抗性の心原性ショックを伴った急性心筋梗塞例
• 6. PTCA後の急性冠閉塞により心原性ショックとなった例

ガイドライン1.より引用

• 冠動脈造影上75％以上の狭窄があり、その灌流域の心筋虚血に対し手術効果が大きく、手術の危険性が少ない場合はよい適応となる。

• I 適応決定に必要な項目

• 1. 冠動脈造影による狭窄度、形態評価
• 2. 心筋虚血の証明：方法として負荷心電図、負荷心筋シンチ、負荷心エコー図、症状などがある。

• II 罹患枝数による適応

• 1. 一枝病変

• 大きな左前下行枝の近位部病変、PTCAの困難な病変形態の場合。PTCA不成功例

• 2. 二枝病変

• 左前下行枝近位部病変を含む場合。左前下行枝近位部病変がPTCA困難な病変形態の場合。(特に慢性閉塞性病変）危険にさらされた側副血行路の場合。

• 3. 三枝病変

• 原則的にはCABGの適応。

• 4. 左主幹部病変

• 原則的にはCABGの適応。

• 5. その他

• PTCA後の再狭窄を繰り返すもの。

ガイドライン

• 1. 冠動脈疾患におけるインターベンション治療の適応ガイドライン（冠動脈バイパス術の適応を含む）―待機的インターベンション―

http://www.j-circ.or.jp/guideline/pdf/JCS2000_fujiwara_h.pdf

• 2. 虚血性心疾患に対するバイパスグラフトと手術術式の選択ガイドライン

http://www.j-circ.or.jp/guideline/pdf/JCS2006_kitamura_h.pdf

「異型狭心症」

　　[★]

英

variant form of angina, variant form of angina pectoris, variant angina pectoris, VAP

同

プリンツメタル型狭心症 Prinzmetal angina Prinzmetal's variant angina Prinzmetal's angina

関

狭心症

定義

• 安静時の狭心発作に可逆性一過性のST上昇を伴う狭心症
• 冠攣縮性狭心症のうち発作時の心電図でST上昇を伴うもの(YN.C-68)

特徴

• 発作は安静時、とくに夜間から早朝にかけての睡眠中に出現し(早朝睡眠中)、大体決まった時刻に起こる。
• 心電図上、ST上昇がみられる　←　労作時狭心症では発作中のSTは低下するのじゃが。

疫学

HIM.1531

• 一般的には不安定狭心症患者より若く、リスクファクターは少ない。

成因

• 冠状動脈の攣縮

may involve increased sympathetic activity in combination with endothelial dysfunction.

心外膜の冠動脈における巣状攣縮 focal spasm of an epicardial coronary artery (HIM.1531)

病態

• 冠攣縮：粥状班は冠動脈の完全閉塞をきたさないが、多くの患者で冠動脈の近位部に少なくとも一ヵ所見いだされる。この粥状班から1cmのところで攣縮が起こる。大抵、右冠動脈でfocal spasmがおこるのが一般的である。1本の動脈に単発or多発することもあるし、多枝同時におこるこももある。(HIM.1531)

症候

HIM.1531

• ST上昇を伴う安静時狭心痛

検査

• 心電図
• exercise testing：ST segmentの評価ができないため有用ではない。
• 冠動脈造影検査 coronary angiohraphy：(diagnostic hallmark)一過性の冠攣縮

診断

• 臨床診断はST上昇、安静時狭心痛で行う(HUM.1531)
• エルゴノビン、アセチルコリン、あるいはその他の血管収縮薬の服用、または過呼吸は冠攣縮を誘発するの使われ、またこれらで診断をつけることができるfocal coronary stenosisがはっきりと示される。(HUM.1531)

治療

• nitrates, calcium blocker がメインである。舌下錠は発作に対して、長期作用薬 long-acting nitrate は発作の再発予防に有用。calcium channel blockerは冠攣縮の予防に非常に有用でできるだけ多く処方すべき。
• β blockerは禁忌である　→　冠攣縮を誘発するおそれ。β2Rをblockするから？？？

• 経皮的冠動脈形成術 PTCAや冠動脈バイパス術 CABGの適応はない

参考

• 1. wiki en

http://en.wikipedia.org/wiki/Prinzmetal's_angina

ガイドライン

• 1. 冠攣縮性狭心症の診断と治療に関するガイドライン

http://www.j-circ.or.jp/guideline/pdf/JCS2008_ogawah_h.pdf

「coronary bypass」

　　[★]

• 冠動脈バイパス

関

CABG、coronary artery bypass、coronary artery bypass graft、coronary artery bypass graft surgery、coronary artery bypass grafting

「coronary artery bypass graft」

　　[★]

• 冠動脈バイパス

関

CABG、coronary artery bypass、coronary artery bypass graft surgery、coronary artery bypass grafting、coronary bypass

「冠動脈バイパス移植」

　　[★]

英

coronary artery bypass grafting、CABG

関

冠動脈バイパス術、冠動脈バイパス手術、冠動脈バイパス

「off pump CABG」

　　[★] 心拍動下冠動脈バイパス術, off-pump coronary artery bypass

「off-pump CABG」

　　[★] 心拍動下冠動脈バイパス術, off-pump coronary artery bypass

「CA」

　　[★]

• カテコールアミン catecholamine
• 癌 cancer carcinoma
• 炭酸脱水酵素 carbonic anhydrase
• 生活年齢 chronological age
• 糖鎖抗原 carbohydrate antigen

　

「CAB」

　　[★]

• 冠動脈バイパス術, coronary artery bypass
• 完全アンドロゲン遮断療法 complete androgen blockade