不同剂量参附注射液对体外循环二尖瓣置换术患者的心肌保护作用

Myocardial protective effect of Shenfu injectio in patients undergoing mitral valve replacement with cardiopulmonary bypass

目的 评价不同剂量参附注射液（SFI）对体外循环二尖瓣置换术（MVR）患者围术期的心肌保护作用，探讨其临床应用的适宜剂量。方法 40例MVR患者，年龄46～75岁，ASAⅡ或Ⅲ级，心功能Ⅱ或Ⅲ级，随机分为4组（n=10）：对照组（C组）体外循环（CPB）全过程不用SFI；SFI1组、SFI2组、SFI3组分别在预充时及开放主动脉后经CPB泵入SFI1．0、1．5、2ml／kg。于CPB前（t1）、前并行循环（t2）、后并行循环（t3）及转流结束时（t4）监测平均动脉压（MAP）、复跳时心律、恢复窦性心律时HR。采集中心静脉血，于切皮前（T1）、术毕（T2）、术后3h（L）、24h（T4）测定血浆神经肽Y（NPY）、肌钙蛋白I（cTnI）浓度及谷胱甘肽过氧化物酶（GSH-PX）活性。结果 与C组和SFI1组比较，SFI2组、SFI3组t2～t4时MAP升高，心脏自动复跳率较高，复跳后HR较高，复跳后房室传导阻滞、房颤及室性心律失常的发生率较低，T2～T4时血浆NPY、cTnI浓度降低，GSH-PX活性升高（P〈0．05或0．01），心肌超微结构破坏减轻，C组心肌超微结构破坏最严重。结论参附注射液对体外循环二尖瓣置换术患者具有心肌保护作用，能减轻心肌缺血再灌注损伤，临床适宜剂量为1．5ml／kg。

Objective To evaluate the protective effects of different doses of Shenfu injectio （SFI） on myocardium in patients undergoing mitral valve replacement （MVR） under cardiopulmonary bypass （CPB）. Methods Forty ASA Ⅱ or Ⅲ , NYHA Ⅱ or Ⅲ patients （15 male, 25 female） aged 46-75yr scheduled for MVR under CPB were randomly divided into 4 groups （n = 10 each） ： group Ⅰ control; groupⅡ, Ⅲ and Ⅳ received SFI 1.0, 1.5 and 2.0 ml/kg which were added to the priming fluid and injected after release of aortic cross-clamp respectively. The patients were premedicated with intramuscular morphine 10 mg and scopolamine 0.3 mg. Anesthesia was induced with midazolam 0.1 mg/kg, fentanyl 5-10μg/kg and vecuronium 0.1 mg/kg and maintained with infusion of propofol 2-4 mg·kg^- 1· h^- 1, inhalation of 0.8 % -2.0 % isoflurane and intermittent IV boluses of fentanyl and vecuronium. MAP was recorded before CPB （t1）, at the beginning of parallel circulation （t2）, immediately after removal of the aortic clamp （t3） and at the end of CPB （t4）. The rate of spontaneous recovery of heart beat and cardiac rhythm after restoration of heart beat were recorded. Blood samples were taken from central vein for determination of plasma concentrations of cardiac neuropeptide Y （NPY）, cardiac troponin Ⅰ （cTnI） and the activity of glutathione peroxidase （GSH-PX） before operation （T1, baseline）, at the end of operation （T2）, and 3 and 4 h after operation （T3, T4 ） Results MAP was significantly higher at t3 and t4 in group Ⅲ and Ⅳ than in group Ⅰ and Ⅱ . Plasma NPY and cTnI concentrations were significantly lower while the activity of GSH-PX was significantly higher in group Ⅲand Ⅳ than in group Ⅰ and Ⅱ （ P 〈 0.05 or 0.01 ）. The percentage of spontaneous recovery of heart beat after removal of aortic clamp was significantly higher in group m and Ⅳ than in group Ⅰ and Ⅱ . Uhrastructural damage was most serious in control group （ Ⅰ ）. Myocardial injury was significantly attenuated in group m and Ⅳ. Conclusion SFI can protect myocardium during CPB and 1.5 mg/kg is the appropriate dose.