依赖人工心肺机不停跳冠状动脉旁路移植围术期炎症因子和肌钙蛋白Ⅰ的变化

Inflammatory factor and troponin I changes during coronary artery bypass grafting under an artificial heart lung machine

背景:目前缺乏人工心肺机独立诱导心肌损伤直接的外科证据。目的:观察保持正常冠状动脉血流不依赖人工心肺机冠状动脉旁路移植和依赖人工心肺机不停跳冠状动脉旁路移植围术期心肌损伤和炎症因子的变化情况。设计、时间及地点:随机对照试验生化水平观察,于2007-07/2008-02在解放军沈阳军区总医院心血管外科进行。对象:选择40例具有正常射血分数值和3支血管病变的择期冠状动脉旁路移植患者,随机分成依赖人工心肺机不停跳组20例和不依赖人工心肺机组20例。方法:按常规方法建立体外循环;左乳内动脉-前降支是第一个吻合,顺次吻合大隐静脉-回旋支和大隐静脉-右冠状动脉。主要观察指标:移植前和前降支开放即刻,移植后4,24,48h中心静脉血中白细胞介素6、白细胞介素8、肿瘤坏死因子α、肌酸激酶同工酶、肌钙蛋白I水平。结果:40例患者均进入结果分析。依赖人工心肺机组患者移植后各时间点白细胞介素6、白细胞介素8、肿瘤坏死因子α、肌酸激酶同工酶和肌钙蛋白I明显高于移植前(P<0.05)。移植后早期,依赖人工心肺机不停跳组患者白细胞介素6,白细胞介素8和肿瘤坏死因子α水平高于不依赖人工心肺机组(P<0.05)。肌酸激酶同工酶和肌钙蛋白I水平从左乳内动脉-前降支血流开放到移植后48h均保持有意义的增高(P<0.05)。结论:人工心肺机能独立诱导心肌损伤和炎症反应。

BACKGROUND： At present, there are no coronary artery bypass grafting surgery-evidence of artificial heart lung machine-induced independently myocardial injury. OBJECTIVE： To observe the perioperative inflammatory response and myocardial tissue injury in both on-pump beating heart surgery and off-pump coronary artery bypass that maintains native coronary blood flow. DESIGN, TIME AND SETTING： The randomised controlled trial was performed at Department of Cardiovascular Surgery in the General Hospital of Shenyang Military Area Command from July 2007 to February 2008. PARTICIPANTS： Forty patients with normal ejection fraction and coronary artery disease involving three vessels undergoing elective coronary artery bypass graft were randomly divided into on-pump beating heart group （n=20） and coronary artery bypass graft without artificial heart lung machine group （n=20）. METHODS： Cardopulmonary bypass was established by standard method in the on-pump beating heart group. The left internal mammary artery to left anterior descending was the first anastomosis in all patients. The great saphenous vein to left circumflex coronary artery and next to right coronary artery was the other anastomosis. MAIN OUTCOME MEASURES： Blood samples were collected from central vein to assay interleukin-6 （IL-6）, IL-8, tumor necrosis factor-α （TNF-α ）, MB isoenzyme of creatine kinase （CK-MB） and troponin I before operation, immediately after reperfusion with the left internal mammary artery graft and 4, 24, as well as 48 hours after operation. RESULTS： Forty patients were included in final analysis. After operation, the contents of IL-6, IL-8, TNF-α, CK-MB and troponin I were significantly higher in the on-pump beating heart group than those before operation （P 〈 0.05）. There was significant elevation in the levels of IL-6, IL-8, and TNF-α during and immediately after the operations in the on-pump beating heart group compared with the off-pump group （P 〈 0.05）. Significantly higher CK-MB and troponin I levels were found from left internal mammary artery to left anterior descending flow release to 48h postoperatively in the on-PBH group （P 〈 0.05）. CONCLUSION： Artificial heart lung machine independently induces myocardial injury and inflammatory reaction.