心脏瓣膜置换术中冠状动脉阻力及心肌酶变化的研究

The effects of aprotinin on the changes of coronary artery resistance and myocardial enzymes during cardiac valve replacement operation

目的观察体外循环(CPB)心脏瓣膜置换术中抑肽酶对冠状动脉阻力(CAR)及心肌酶学变化的影响。方法随机选取风湿性心脏瓣膜病(RHVD)的二尖瓣替换(MVR)患者40例。随机分为A组:RHVD瓣膜替换术,B组:RHVD瓣膜替换术+CPB中使用抑肽酶,每组20例。所有患者于阻断前、主动脉开放1 h、术后12 h、24h、48 h、72 h晨静脉抽血,检测血清磷酸肌酸激酶(CK)、磷酸肌酸激酶同功酶(CK-MB)、心肌肌钙蛋白(cTnI)。阻断开始、阻断30 m in、阻断60 m in、开放前温血灌注末,记录每次灌注的压力及流量,测算出CAR。结果B组在阻断60 m in和开放前温血灌注末中CAR明显低于A组,尤其在开放前温血灌注末差异更明显(P<0.01)。2组CK、CK-MB、cTnI在主动脉开放各时点较术前均有不同程度的升高(P<0.05或P<0.01),B组升高幅度小于A组,2组在CPB后各对应时点的差异显著(P<0.01);B组心脏自动复跳率、窦性心率恢复率高于A组,电除颤率、心律失常发生率低于A组(P均<0.05)。结论在心脏停搏下手术时,抑肽酶在主动脉阻断温血灌注中可降低冠状动脉血管的张力,且具有心肌保护作用。

Objective To observe the variation of coronary artery resistance （CAR） and myocardial enzymes during cardiac valve replacement （MVR） operation with or without aprotlnin added with CPB. Methods 40 patients with rheu- matic heart disease were randomly divided into a group A for control and a test group B to have aprotinin administered with CPB （n = 20 each ）. Central venous blood samples were taken at various times during the perioperative period to measure the serum levels of cTnI, CK and CK - MB. The perfusion pressure and flux were recorded during warm blood cardioplegia to calculate the CAR. Results CAR was lower in group B than in group A, with significant difference apparent 60 rain after aortic crossclamp. After CPB, the plasma concentration of cTnI was increased in both groups, but the increment was smaller in group B than in group A （ P 〈 0.01 ）. CK and CK - MB were apparently increased after CPB,and retuned to the original values 72 h after opening the ascending aorta; the increments in group B were smaller than that in group A （P 〈 O. O1 ）. The rate of heart spontaneous re - beating and sinus rhythm recovery were higher, while the rate of defibrillation and incidence of arrhythmia were lower in group B than in group A （ P 〈 O. 05 ）, Conelusion During the MVR.surgery under CPB, administration of aprotinin can reduce the vascular tension of coronary artery and protect the myoeardium.