两种心脏灌注方案对心内直视术患者心肌的保护效应

Myocardial protective effect of warm vs cold blood cardioptegia in patients undergoing open heart surgery with cardiopulmonary bypass

目的比较温血心脏灌注液诱导心脏停搏、冷血灌注液维持心脏静止及终末温血灌注方案与单纯冷血灌注液灌注方案对心内直视手术患者的心肌保护效应。方法拟行心内直视术患者30例,随机分为2组,温血组:温血高钾停搏液诱导心脏停跳+冷血维持+终末温血灌注,冷血组:冷血高钾停搏液灌注。分别于术前0.5h、术毕、术后3h、24h、72h、6d时抽取静脉血,测定血浆肌酸肌酶同工酶(CK-MB)、心肌肌钙蛋白I(cTnI)、肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)、白细胞介素-10(IL-10)的水平,并记录患者心脏自动复跳率及患者术后恢复情况。结果温血组患者心脏自动复跳率明显高于冷血组;温血组术后机械通气时间及ICU停留时间显著性短于冷血组(P<0.05)。两组患者术后血浆CK-MB、cTnI、TNF-α、IL-6、IL-10血浆浓度均有不同程度升高(P<0.01或0.05),但温血组患者血浆CK-MB和IL-6浓度在T1-5均低于冷血组(P<0.01或0.05),温血组cTnI浓度在T1-4、TNF-α浓度在T1-3、IL-10浓度在T2-4各时点低于冷血组(P<0.01或0.05)。结论温血灌注液诱导心脏停搏,冷血灌注液维持术中心脏静止的灌注方案能提高对患者的心肌保护效应,并有利于减轻全身炎症反应程度。

Objective To compare the myocardial protective effect of warm and cold blood cardioplegia during open heart surgery with cardiopulmonary bypass ( CPB) . Methods Thirty patients with congenital heart disease undergoing open heart surgery under CPB were randomly divided into warm and cold blood cardioplegia groups. In both groups the ratio between oxygenated blood and cardioplegic solution was 4 : 1. In warm blood cardioplegia group the heart was perfused with warm blood (35℃) mixed with high-potassium cardioplegic solution as soon as the aorta was cross-clamped until cardiac arrest developed (flat baseline on ECG). Then the heart was perfused with cold blood (4-81) mixed with low-potassium cardioplegic solution 10 ml·kg-1 every 20 min during ischemic period. At the end of CPB warm blood without potassium was again used to perfuse the heart. Venous blood samples were taken 0.5 h before operation, at the end of operation (T1) and 3 h, 1, 3 and 6 days (T2-5) after surgery for determination of plasma concentrations of CK-MB, cTnI, TNF-α, IL-6 and IL-10. The rate of spontaneous recovery of heart beating was compared between the two groups. Results The two groups were comparable with respect to the demographic data and CPB time. The rate of spontaneous recovery of heart beating was significantly higher and the duration of postoperative mechanical ventilation and ICU stay were significantly shorter in the warm blood cardioplegia group than in cold blood group. The plasma levels of CK-MB, cTnl, TNF-α, IL-6 and IL-10 increased significantly after operation as compared to the baseline (T0) in both groups. The plasma concentrations of cTnl, CK-MB, TNF-α and IL-6 were significantly lower after operation while plasma IL-10 level was significantly higher at T3-4 in warm than in cold blood cardioplegia group ( P < 0.05 or 0.01 ) . Conclusion The regimen of warm-cold-warm blood cardioplegia provides better myocardial protection and reduce general inflammatory response during and after CPB.