本文選題：冠脈搭橋術(shù)　切入點(diǎn)：非體外循環(huán)下冠狀動(dòng)脈旁路移植術(shù)　出處：《河北醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：目的:本研究旨在應(yīng)用血栓彈力圖(Thrombelastograghy,TEG)測(cè)量在非體外循環(huán)下冠狀動(dòng)脈旁路移植術(shù)(Off-pump coronary artery bypass grafting,OPCABG)圍手術(shù)期糖尿病患者與非糖尿病患者的凝血功能變化,分析比較兩組患者圍手術(shù)期的TEG各參數(shù)值變化,探討OPCABG對(duì)患者凝血功能的影響及糖尿病對(duì)OPCABG術(shù)后凝血功能的影響;通過(guò)對(duì)比兩組花生四烯酸(Arachidonic acid,AA)抑制率及阿司匹林抵抗(Aspirin resistance,AR)的發(fā)生率異同,來(lái)評(píng)價(jià)糖尿病對(duì)OPCABG術(shù)后AR的影響,將其應(yīng)用于臨床上為冠心病合并糖尿病患者在OPCABG圍術(shù)期的合理抗血小板治療提供重要的指導(dǎo)依據(jù)。方法:收集2015年12月至2017年1月就診于我院心外科的冠心病患者,并首次行OPCABG治療。符合納入和排除標(biāo)準(zhǔn),依據(jù)WHO的2型糖尿病診斷標(biāo)準(zhǔn)分為糖尿病組(DM組)及非糖尿病組(NDM組)。兩組患者入院后術(shù)前均口服阿司匹林100mg/d+氯吡格雷75mg/d達(dá)五天以上。術(shù)后2天開(kāi)始口服阿司匹林100mg/d+氯吡格雷75mg/d。兩組患者均于術(shù)前口服阿司匹林100mg/d+氯吡格雷75mg/d達(dá)五天后(T0)、術(shù)后返回監(jiān)護(hù)室后(T1)、術(shù)后口服阿司匹林100mg/d+氯吡格雷75mg/d達(dá)5天(T2)采集靜脈血,行TEG檢測(cè),得出R值,K值,α角,MA值,LY30等指標(biāo),觀察分析各指標(biāo)的變化情況。比較DM組及NDM組患者圍手術(shù)期TEG各項(xiàng)凝血功能參數(shù)變化,分析討論OPCABG對(duì)患者凝血功能的影響及糖尿病對(duì)OPCABG患者術(shù)后凝血功能的影響。兩組所有患者均于術(shù)前口服阿司匹林100mg/d+氯吡格雷75mg/d達(dá)五天后(T0)采集靜脈血行TEG血小板檢測(cè)。選擇其中TEG檢測(cè)阿司匹林反應(yīng)正常(AA50%)的患者,于術(shù)后口服阿司匹林100mg/d+氯吡格雷75mg/d達(dá)5天(T2)再次復(fù)查TEG血小板檢測(cè),比較DM組和NDM組術(shù)后AA抑制率及AR的發(fā)生率,探討糖尿病是否與AR相關(guān)。1本研究共納入56例患者,DM組30例,男性,19例;NDM組26例,男性17例。兩組OPCABG術(shù)后均無(wú)死亡病例,無(wú)術(shù)后早期血栓事件及異常出血等。分析比較兩組患者的主要臨床資料,均無(wú)統(tǒng)計(jì)學(xué)差異(P0.05)。2組內(nèi)比較:DM組:與術(shù)前T0相比,術(shù)后T1及T2時(shí)間點(diǎn)R值、K值均減小,α角、MA值增加,差異有統(tǒng)計(jì)學(xué)意義,且三個(gè)時(shí)間點(diǎn)兩兩比較均有統(tǒng)計(jì)學(xué)差異(P0.05)。NDM組:與術(shù)前T0相比,術(shù)后T1及T2時(shí)間點(diǎn)R值、K值均減小,α角、MA值增加,差異有統(tǒng)計(jì)學(xué)意義,且三個(gè)時(shí)間點(diǎn)兩兩比較均有統(tǒng)計(jì)學(xué)差異(P0.05)。兩組參數(shù)變化規(guī)律:R值T1時(shí)間點(diǎn)下降,T2時(shí)間點(diǎn)上升,但仍然小于術(shù)前T0時(shí)間點(diǎn);K值術(shù)后逐漸減小,MA值、α角術(shù)后逐漸增大。DM組LY30各時(shí)間點(diǎn)均為0;NDM組LY30各時(shí)間點(diǎn)比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(F=0.227,P=0.797)。組間比較:術(shù)后返回監(jiān)護(hù)室時(shí)(T1時(shí)間點(diǎn)):R值在DM組明顯低于NDM組,且差別有統(tǒng)計(jì)學(xué)意義(t=3.611,P=0.001);MA值、K值、α角,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。而術(shù)前(T0時(shí)間點(diǎn))、術(shù)后口服阿司匹林100mg/d+氯吡格雷75mg/d達(dá)5天(T2時(shí)間點(diǎn))時(shí)DM組與NDM組患者R值、MA值、K值、α角以及LY30,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。3從上述病例中選擇術(shù)前T0時(shí)間點(diǎn)TEG血小板檢測(cè)阿司匹林反應(yīng)正常(AA50%)的患者,其中NDM組21例,DM組27例。在OPCABG術(shù)后口服阿司匹林100mg/d+氯吡格雷75mg/d達(dá)5天(T2時(shí)間點(diǎn))DM組AA抑制率顯著低于NDM組(t=3.277,P=0.002)。DM組術(shù)后口服阿司匹林100mg/d+氯吡格雷75mg/d達(dá)5天(T2時(shí)間點(diǎn))AA抑制率明顯低于術(shù)前T0時(shí)間點(diǎn),差異有統(tǒng)計(jì)學(xué)意義(t=5.216,P=0.000)。NDM組術(shù)后口服阿司匹林100mg/d+氯吡格雷75mg/d達(dá)5天(T2時(shí)間點(diǎn))AA抑制率較術(shù)前(T0時(shí)間點(diǎn))雖有所減低,但差異無(wú)統(tǒng)計(jì)學(xué)意義(t=1.016,P=0.322)。DM組27例中AR者12例,NDM組21例中AR者3例,提示OPCABG術(shù)后早期存在AR,且在DM組AR發(fā)生率較NDM組高(χ~2=5.001,P=0.025)。結(jié)論:1 OPCABG患者術(shù)后早期凝血功能呈現(xiàn)高凝狀態(tài)。2糖尿病影響OPCABG患者術(shù)后當(dāng)天凝血功能,合并糖尿病的冠心病結(jié)果:患者OPCABG術(shù)后當(dāng)天的血液高凝狀態(tài)程度要高于單純冠心病患者。但是術(shù)后口服阿司匹林及氯吡格雷達(dá)5天后兩組間凝血功能無(wú)明顯差異。3合并糖尿病的冠心病患者OPCABG術(shù)后血小板聚集抑制率(AA抑制率)明顯減低,且較單純冠心病患者更低、AR發(fā)生率更高。4 TEG可及時(shí)準(zhǔn)確反映體內(nèi)凝血功能狀態(tài),提供較為全面的凝血纖溶功能信息,有助于輔助臨床篩查血栓事件高�；颊�,幫助評(píng)價(jià)抗血小板治療的療效及安全性,對(duì)臨床個(gè)體化治療有重要的指導(dǎo)意義,并提供合理的診斷依據(jù)。
[Abstract]:Objective: This study aims to use the Thrombelastogram (Thrombelastograghy, TEG) measured in off-pump coronary artery bypass grafting (Off-pump coronary artery bypass grafting, OPCABG) in the changes of coagulation function in patients with diabetes mellitus perioperative and non diabetes patients, analysis of perioperative period were compared between the two groups of TEG parameters change, explore effect of OPCABG on coagulation function in patients with diabetes and the influence on blood coagulation function after OPCABG; by comparing the two groups of four arachidonic acid (Arachidonic, acid, AA) and the inhibition rate of aspirin resistance (Aspirin, resistance, AR) the incidence of similarities and differences, to evaluate the influence of diabetes on AR after OPCABG, its application in clinic for patients with coronary heart disease and diabetes in a reasonable perioperative antiplatelet OPCABG treatment provides an important basis for guidance. Methods: from December 2015 to January 2017 in our hospital Heart surgery in patients with coronary heart disease, and treatment of OPCABG. For the first time met the inclusion and exclusion criteria, according to the diagnostic standard of WHO type 2 diabetes were divided into diabetic group (DM group) and non diabetes group (NDM group). Two groups of patients before surgery were given aspirin clopidogrel 100mg/d+ 75mg/ d more than five days after the operation. 2 day oral aspirin clopidogrel 100mg/d+ 75mg/d. two groups of patients in the preoperative aspirin clopidogrel 100mg/d+ 75mg/d up to five days (T0), postoperative ICU after return (T1), postoperative oral aspirin clopidogrel 100mg/d+ 75mg/d for 5 days (T2) collected venous blood detected by TEG. The result showed that R value, K value alpha, angle, MA value, LY30 index, and analyze the changes of each index were observed between DM group and NDM group. The patients with changes of TEG parameters of coagulation operation period, analyze the influence of OPCABG on blood coagulation function in patients suffering from diabetes mellitus and discussion of OPCABG Effect of coagulation function after surgery. All patients in two groups were preoperative aspirin clopidogrel 100mg/d+ 75mg/d up to five days (T0) venous blood collection TEG platelet detection. In TEG detection of aspirin (AA50%) response of normal patients in the postoperative oral aspirin 100mg/d+ and clopidogrel 75mg/d for 5 days (T2) check TEG platelet, DM group and NDM group after AA inhibition rate and the incidence of AR, to investigate whether diabetes is associated with the AR.1 this study included 56 patients, 30 cases of group DM, male, 19 cases; 26 cases in group NDM, 17 cases were male. Two groups after operation were not OPCABG early death, no postoperative thromboembolic events and abnormal bleeding. Analysis of clinical data of the two groups were compared, there was no significant difference (P0.05) of.2 group: DM group: compared with the preoperative T0, T1 and T2 time point R after operation, the K values were decreased, the angle alpha, MA the value increased, the difference was statistically 璁″鎰忎箟,涓斾笁涓椂闂寸偣涓や袱姣旇緝鍧囨湁緇熻瀛﹀樊寮，

本文編號(hào)：1646841