| Objective: Obstructive sleep apnea(OSA)is a common disorder characterised by episodes of upper airway obstruction during sleep that lead to repeated episodes of apnoea or hypopnoea, it can affect all age groups. Among the general population of adults 4% of men and 2% of women are estimated to have OSA. the mechanism may involve OSA initiating and/ or propagating vascular endothelial dysfunction through diverse pathways such as hypoxemia, reactive oxygen species(ROS)production and sympathetic activation. Endothelial dysfunction may lead to vasoconstriction, vascular smooth muscle proliferation, hypercoagulability, thrombosis, and eventually adverse cardiovascular. It has been acknowledged that OSA is an independent risk factor for cardiovascular diseases. Several studies have found far higher prevalences, as much as 30–50%, in patients with systemic hypertension or coronary artery disease(CAD). Patients with OSA are predisposed to the development of upper airway obstruction during sleep. Similarly upper airway obstruction is likely to occur when sedative or anesthetic agents depress consciousness. Thus, OSA susceptible to a variety of serious complications in the perioperative period. Several investigators have reported that perioperative patients with OSA are predisposed to cardiac arrhythmias, freintubation, cardiac events, longer hospital stay, nearly fatal respiratory complications and even unexpected deaths have been reported after surgery in patients with serious OSA that has been unrecognized or inadequately treated in the perioperative and postoperative periods. Thus, the role of sleep apnea as a risk factor for development of postoperative complications needs greater emphasis. clinical symptoms of OSA had been reported is improved by nasal continuous positive airway pressure(nCPAP), nCPAP decreased the risk of cardiovascular diseases with OSA, reducing complication of perioperative patient with OSA. As many as 80-95% of persons with OSA are undiagnosed. Often a definite diagnosis of OSA is not made because of unrecognition difficulty in obtaining polysomnography study and delay surgery until a study is performed is generally unreasonable. Disease progress of CAD with OSA is serious, Patients of CAD with OSA are predisposed to the development of heart failure and sudden death in the perioperation. However, it is rarely reported that perioperative management was performed in perioperitive patients of CAD with OSA. thus, Our experiment observed the clinical characteristics of OSA undergoing off-pump coronary arteries bypass grafting and evaluated the effectiveness of perioperative management in the OSA undergoing off pump coronary arteries bypass grafting(OPCABG).Increased awareness of the risk posed by OSA and appropriate perioperative management are important to optimize. We aim to improving the success rate of coronary artery bypass graft surgery and reducing the incidence of perioperative complications.Methods:1 Between January 2008 and January 2010, 30 patients with moderate or severe degree(apnea hypopnea index AHI 20-65 events / hour)OSAS has been evaluated by means of an overnight polysomnogram, all patients underwent isolated coronary artery bypass grafting(CABG). the patients were divided into treatment group(12 patients)and control group(18 patients)according to differences of perioperative management. Clinical characteristics and cardiovascular features of two groups were similar at baseline in age, gender, ejection fraction, body mass index(BMI), low nocturnal oxygen saturation, diabetes mellitus, hypertension, hypercholesterolemia, current smoking and smoking history, unstable angina, history of myocardial infarction, left main disease and triple vessel disease. plasma concentration of serum soluble intercellular adhesion molecule-1(sICAM-1)and endothelin-1(ET-1)and vascular cell adhesion molecule-1(VCAM-1)did not differ significantly between the two groups, tested and compared the two groups.2 The patients of control group were started on nasal continuous positive airway pressure(nCPAP)before surgery and resumed immediately after extubation for all sleep periods. A thorough airway assessment should be performed before the induction of anesthesia. This evaluation should include temporomandibular joint function, mallampati classification, atlanto-occipital joint mobility. Premedication with respiratory depressant drugs must be avoided because of the possibility of airway obstruction and hypoxemia. Selection of the intubation technique should be based on findings of physical examination and history in relation to general anesthesia. This may include conventional induction and intubation with laryngoscopy and awake tracheal intubation utilizing a fiberoptic bronchoscope may be recommended and incision of trachea. intraoperative anesthetics maintenance doses should be administered less frequently and based on ideal body weight to avoid overdosing. All patients performed off pump coronary arteries bypass grafting, auto-controlled analgesic pump was applied in pain treatment, the time of tracheal extubation, stay in ICU, postoperative hospital stay and the incidence of postoperative atrial fibrillation were recorded.3 Throughout follow-up, data were gathered at 6 months, during visits to the cardiologist or by phone calls to the patient, relatives and local attending physician. All patients were evaluated the rate of vein graft stenosis with the CT angiography or coronary angiography, meanwhile, the plasma levels of sICAM-1 and ET-1 and VCAM-1 were accumulated and studied. the prevalence of the major adverse cardiovascular events(MACE)was recorded, included:cardiovascular death(sudden cardiac death or death due to myocardial infarction, unstable angina, heart failure, or cardiac arrhythmia), acute coronary syndrome (ischemic symptoms and development of abnormal Q waves on the EKG, or EKG changes indicating ischemia, or total creatine kinase elevation to more than twice the upper limit of normal), hospitalisation for heart failureand revascularisation procedures.Result:1 The success rate of operation was 100%. all patients cured and leaved hospital. tracheal extubation time (7.50±4.79 vs. 33.00±15.53), stay in ICU (46.75±1.60 vs. 64.11±14.55)and postoperative hospital stay(11.83±1.94 vs. 17.94±3.84)were significant differences in two groups, and significantly shorter in treatment ground than in control group. The postoperative incidence of the atrial fibrillation no significantly different between the two groups.2 The follow-up period for all the patients was in the range of 6 months to 11 months, mean(9.07±1.82) months and the follow-up rate was 96.7% (29/30)The levels of serum soluble ICAM-1(211.20±38.30 vs. 297.41±40.19), VCAM-1(20.95±3.36 vs. 36.64±5.39)and ET-1(57.58±6.02 vs. 78.32±7.13)were significantly lower in treatment ground, the data of the incidence rates of major adverse cardiac events(MACE)(8.33% vs. 29.4%) and stenosis and occlusion of vein graft(16.7% vs. 38.9%)showed no significantly different between the two groups.3 In treatment ground, the postoperative levels of ICAM-1(211.20±38.30), VCAM-1(20.95±3.36))and ET-1(57.58±6.02)were significantly lower than the preoperative levels(306.37±26.95, 37.62±4.49, 85.20±11.20), while no significant difference in the control groups.Conclusions:Perioperative management for CAD patients with moderate or severe degree of OSAS undergoing OPCABG can reduce tracheal extubation time, stay in ICU and The interval between post-operation and hospital discharge, improve the endothelial function, decrease plasma concentration of adhesion molecule, but perioperative management cannot improve occurrence of the atrial fibrillation and the incidence rates of MACE and stenosis and occlusion of vein graft during the follow-up. |
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