异丙酚或咪达唑仑复合麻醉下心脏手术患者心肌细胞凋亡及术后早期恢复的比较

Comparison of cardiomyocyte apoptosis and early postoperative recovery between propofol-and midazolamcombined anesthesia in patients undergoing cardiac valve replacement

目的比较异丙酚或咪达唑仑复合麻醉下心脏瓣膜置换术患者心肌细胞凋亡及术后早期恢复情况。方法择期体外循环下心脏瓣膜置换术患者40例，随机分为2组（n=20）：异丙酚复合麻醉组（P组）和咪达唑仑复合麻醉组（M组）。采用异丙酚或咪达唑仑复合芬太尼、维库溴铵全凭静脉麻醉，分别于上腔静脉插管前（CPB前）、撤机后取右心耳组织，检测caspase-9、caspase-3表达，计算细胞凋亡指数（AI），并观察术中MAP、HR及术后早期恢复情况。结果与M组比较，P组多巴酚丁胺的输注速率减慢，清醒时间、拔管时间以及ICU停留时间缩短（P〈0．05）。P组心脏自动复跳率高于M组（P〈0．05）。与CPB前相比，撤机后M组心肌AI升高，caspase-9、caspase-3表达上调（P〈0．05），P组各指标差异无统计学意义（P〉0．05）；撤机后M组心肌AI及caspase-9、caspase-3表达高于P组（P〈0．05）。结论与咪达唑仑复合麻醉比较，异丙酚复合麻醉可抑制心脏瓣膜置换术中患者心肌细胞凋亡，术后早期恢复快，更适用于心脏手术麻醉。

Objective To compare the cardiomyocyte apoptosis and early postoperative recovery in patients undergoing cardiac valve replacement under propofol or midazolam combined anesthesia. Methods Forty NYHA class Ⅱ or Ⅲ patients aged 48-64 yrs weighing 45-78 kg undergoing cardiac valve replacement with cardiopulmonary bypass （CPB） were randomly divided into midazolam group （M） and propofol group （P） （n = 20 each）. The patients were premedicated with morphine 0.1 mg/kg i.v. and scopolamine 0.3 mg i.v. Anesthesia was induced with midazolam 0.2 mg/kg （group M） or propofol 2 mg/kg （group P） combined with fentanyl 10 μg/kg and vecuronium 0.1 mg/kg, and maintained with propofol 5 mg·kg^-1·h^- 1 （ group P） or midazolam 0.1 mg·kg^-1·h^-1 （group M） and intermittent i.v. boluses of fentanyl and vecuronium after tracheal intubation. The patients were mechanically ventilated, PETCO2 was maintained at 35-45 mm Hg. Myocardial tissue was obtained from right atrium before and after CPB for determination of apoptosis in cardiomyocytes （by TUNEL）. Apoptotic index was calculated. The expression of caspase-3 and caspase-9 was determined by immuno-histochemistry-ABC staining. MAP and HR were monitored. Aortic cross-clamping time, surgical and CPB times, spontaneous recovery of normal heart beat, emergence from anesthesia, extubation time and duration of ICU stay were recorded and compared between the two groups. Results The percentage of spontaneous recovery of normal heart beat after release of aortic cross clamp was significantly higher and the need for dobutamine support was significantly less in group P than in group M （P 〈 0.05）. The emergence from anesthesia was significantly more rapid, the extubation time and the ICU stay were significantly shorter in group P than in group M （P 〈 0.05）. There were no significant differences in apoptosis index and expression of caspase-3 and caspase-9 before CPB between the two groups. The apoptosis index and expression of caspase-3 and caspase-9 were significantly increased after CPB in group M and significantly higher than those after CPB in group P （ P 〈 0.05）. Conclusion Cardiomyocyte apoptosis in patients undergoing CPB can be inhibited and the postoperative recovery is more rapid under propofol combined anesthesia.