| Coronary atherosclerotic heart disease,namely coronary heart disease,has become one of the major diseases threatening human health in today’s society.In developed countries such as Europe and the United States,coronary heart disease is the leading cause of death.In our country,the incidence and mortality of coronary heart disease are increasing year by year,and it has also become one of the main causes of death.Since Sabiston performed the world’s first coronary artery bypass grafting(coronaryarterybypassgrafting,CABG)in 1962,this operation has become the most effective and long-lasting method for the treatment of ischemic heart disease.In recent decades,with the gradual improvement of the technical level of coronary artery bypass grafting in cardiac surgery and the gradual improvement of medical equipment,off-pump coronary artery bypass grafting has been adopted by more and more doctors due to its many advantages.As a result,many patients benefited from this.One of the many advantages of off-pump coronary artery bypass grafting is to avoid blood coagulation dysfunction caused by hemodilution,blood cell destruction and inflammation caused by cardiopulmonary bypass.Antiplatelet drugs are one of the most important drugs in perioperative period of coronary artery bypass grafting(CABG).The application of antiplatelet therapy can effectively reduce the incidence of short-and long-term restenosis and perioperative myocardial infarction after coronary artery bypass grafting.In particular,the highly respected and widely used dual antiplatelet therapy(dualantiplatelettherapy,DAPT),aspirin combined with a P2Y12 inhibitor,plays a positive role in significantly reducing cardiovascular death,stroke and non-fatal myocardial infarction.Clinically,numerous large-sample,multi-center,prospective,randomized controlled trials have been carried out,all of which show that antiplatelet drugs can significantly reduce the occurrence of non-fatal myocardial infarction and stroke,and significantly improve the clinical prognosis of patients with coronary heart disease.Moreover,the standardized use of antiplatelet drugs for secondary prevention can significantly reduce the occurrence of adverse cardiovascular events.Therefore,dual antiplatelet therapy is not only the standard treatment for coronary heart disease after percutaneous coronary intervention,but also widely used in the perioperative treatment of coronary artery bypass grafting.However,because antiplatelet drug treatment can increase the potential risk of perioperative bleeding complications,for patients who are critically ill and require emergency off-pump coronary artery bypass grafting,dual antiplatelet therapy can significantly increase the risk of perioperative bleeding.Bleeding is one of the main complications that seriously affect the clinical prognosis of patients during cardiac surgery.Severe bleeding during the perioperative period will significantly increase the risk of postoperative myocardial infarction and adversely affect the prognosis.Surgeons attach great importance to the evaluation of coagulation function and risk during OPCABG perioperative period.Therefore,based on the trade-off between perioperative bleeding risk and safety,the strategy of preoperative dual antiplatelet therapy has been discussed and controversial for a long time.Therefore,based on the previous research of our center,this series of studies focused on the risk assessment and functional detection of severe bleeding after coronary artery bypass grafting.There are three parts,part one is designed to predict and evaluate the risk of severe bleeding after coronary artery bypass grafting by developing and validating the prediction model.The second part is aimed to to examine the platelet function during the perioperative period with thromboelastography,observe the changes of platelet function during the perioperative period of off-pump coronary artery bypass grafting,and explore the correlation between platelet function and severe bleeding.The third part is designed to explore the complex relationship between inflammatory factors and coagulation function by analyzing the correlation between cytokines(interleukin-6 and tumor necrosis factor-α)and severe bleeding after off-pump coronary artery bypass grafting,and then combines with basic research.Part One Severe bleeding Following Off-Pump Coronary Artery Bypass Grafting(OPCABG):Predictive Factors and Risk ModelObjective:Severe bleeding following cardiac surgery is still a trouble-some complication,but so far,there is lacking comprehensive predictive models for the risk of severe bleeding following off-pump coronary artery bypass grafting(OPCABG).The purpose of this study is to analyze relevant indicators of severe bleeding after the isolated OPCABG and establish a risk assessment model.Method:The clinical data of 584 patients who underwent OPCABG from January 2018 to April 2020 were retrospectively analyzed.We gathered the preoperative baseline data(T1)and the postoperative data immediate in ICU(T2)and used multi-factor Logistic regression to screen the potential predictors,based on which we established a predictive model.Using consistency index,calibration curve,decision curve,and clinical impact curve,we evaluated the performance of the model.Results:This study was the first to establish a risk assessing and prediction model for severe bleeding following isolated OPCABG.Eight risk factors were identified-female,aspirin/clopidogrel discont-inuation time,immediate postoperative platelet count,fibrinogen level,C-reactive protein,creatinine,and total bilirubin.Among the 483 patients of the modeling group,138 patients(28.6%)had severe bleeding;among 101 patients in the verification group,25 patients(24.8%)had severe bleeding.The internal receiver operating characteristic curve(ROC)had a convincing performance with C-index of 0.859,while external validation area under curve was 0.807.Decision curve analysis showed that the model was useful in both groups.Summary:1.The patient’s gender,preoperative aspirin and clopidogrel withdrawal time are independent risk factors for severe bleeding after coronary artery bypass grafting.2.Platelet count,fibrinogen,total bilirubin,serum creatinine and c-reactive protein immediately after operation(entering ICU)are also independent risk factors for severe hemorrhage.3.This model can accurately predict the probability of severe bleeding after off-pump coronary artery bypass grafting,which is worthy of further exploration and verification.Part Two Prediction of Severe Bleeding after Off-pump Coronary Art-ery Bypass Grafting by ThromboelastographyObjective:The present study aims to investigate the value of thromboelastography(TEG)in predicting blood loss,and its relationship with blood transfusion demand during the perioperative period in off-pump coronary artery bypass grafting(OPCABG).Methods:The data of 398 patients undergoing OPCABG were retrospectively analyzed.Blood was drawn before anesthesia induction(T1)and at 10 minutes after heparin neutralization(T2)for further TEG detection.These patients were divided into two groups,according to the results at T2:TEG normal group and TEG abnormal group.The logistic regression analysis was used to predict the related factors that contributed to the significant increase in perioperative blood loss(more than 20%of the estimated blood volume).Results:There were 277(69.6%)patients in the TEG normal group and 121(30.4%)patients in the TEG abnormal group.Compared to the TEG normal group,the amount of blood loss in another group significantly increased within 24 hours postoperatively,and the volume of red blood cell and plasma transfusion increased.The logistic regression analysis results revealed that age,the use of clopidogrel,platelet count at T2,fibrinogen level at T2 and abnormality in TEG value were independent predictors for the significant increase in perioperative blood loss(P<0.001).Summary:1.After intraoperative heparin neutralization,the abnormality of TEG parameters is an independent risk factor for increased blood loss and blood transfusion during off-pump coronary artery bypass grafting.2.The detection of thromboelastography may play a guiding role in the strategy of blood transfusion after off-pump coronary artery bypass grafting.3.The application of clopidogrel within three days before surgery can lead to increased blood loss and blood transfusion,but does not increase mortality.This provides clinical evidence for the safety of patients undergoing emergency off-pump coronary artery bypass grafting.Part Three Study on the Correlation Between Interleukin-6 and Severe Bleeding after Off-pump Coronary Artery Bypass GraftingObjective:Bleeding after coronary artery bypass grafting is still a major clinical issue.Studies have shown that there is a complex relationship between inflammation and blood coagulation.The purpose of this study was to investigate the relationship between preoperative interleukin-6 levels and severe bleeding after off-pump coronary artery bypass grafting.Methods:The clinical data of 348 patients who underwent off-pump coronary artery bypass grafting in the Department of Cardiac surgery of the second Hospital of Hebei Medical University from January 2017 to February 2018 were analyzed retrospectively.Data such as preoperative interleukin-6 levels and blood loss within 24 hours after surgery were recorded.The main outcome index was the amount of bleeding within 24 hours after operation.Logistic regression was used to analyze the correlation between the amount of bleeding within 24 hours after operation and the preoperative data.Results:Among the preoperative indicators,gender,age,and levels of interleukin-6,tumor necrosis factor-α and fibrinogen,and dual antiplatelet drugs were related to postoperative bleeding.By logistic regression analysis,male(β=-0.137),preoperative IL-6(β=-0.087),tumor necrosis factor-α(β=-0.243)and fibrinogen(β=-0.720)were negatively correlated with postope-rative bleeding volume,which were protective factors of severe bleeding.Summary:1.The preoperative IL-6 concentration is correlated with the amount of bleeding within 24 hours after operation,which can be used as a potential new coagulation marker for patients undergoing coronary artery bypass grafting.2.The increase of preoperative IL-6 concentration can reduce the bleeding of coronary artery bypass grafting and reduce the incidence of severe bleeding;3.There is a complex connection between inflammatory response and coagulation function.Effective intervention on inflammatory response may help reduce postoperative bleeding,which is worthy of further study.Conclusions:1.Patient’s gender,withdrawal time of aspirin and clopidogrel before operation,platelet count,fibrinogen level,total bilirubin level,serum creatinine and c-reactive protein level were independent risk factors for severe bleeding.The model established by the above factors can accurately predict the probability of severe bleeding after off-pump coronary artery bypass grafting.2.The application of clopidogrel within three days before surgery can lead to increased blood loss and blood transfusion,but does not increase mortality.This provides clinical evidence for the safety of patients undergoing emergency off-pump coronary artery bypass grafting.3.After intraoperative heparin neutralization,the abnormality of TEG parameters is an independent risk factor for increased blood loss and blood transfusion during off-pump coronary artery bypass grafting.The detection of thromboelastography may play a guiding role in the strategy of blood transfusion after off-pump coronary artery bypass grafting.4.The preoperative IL-6 concentration is correlated with the amount of bleeding within 24 hours after operation,and more attention should be paid to the complex relationship between inflammatory reaction and blood coag-ulation function... 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