冠心病患者围术期内皮素变化的临床研究

The Clinical Study of Endothelin during Perioperative Coronary Artery Disease

目的研究冠心病患者围术期内皮素(ET)及血流动力学的改变,总结冠心病围术期的一些变化规律,为临床治疗提供参考。方法将37例冠心病患者及10例心瓣膜疾病患者依据不同的手术方式分为5组,冠状动脉旁路移植术+室壁瘤切除术(CABG+LVAN组),体外循环冠状动脉旁路移植术(CABG组),非体外循环冠状动脉旁路移植术(OPCAB组),激光心肌打孔术(TMLR组),对照组为风湿性心脏病行二尖瓣置换术患者。使用放射免疫分析法分别测定术前,主动脉阻断前(血管移植前或打孔前),主动脉开放时(血管移植结束时或打孔后),心肌再灌注后3h、6h、24h血ET值;并于术前、心肌再灌注后3h、6h、24h测定心排血指数(CI)。结果ET值组内比较:CABG+LVAN组主动脉开放时(69.93±7.20pg/ml),心肌再灌注后3h(89.99±5.76pg/ml)、6h(60.94±8.69pg/ml)、24h(68.99±10.30pg/ml)时ET值显著高于术前(40.17±13.37pg/ml,P<0.05);CABG组主动脉开放时(66.59±4.86pg/ml),心肌再灌注后3h(95.97±10.72pg/ml)、6h(61.51±7.65pg/ml)、24h(57.85±6.34pg/ml)均显著高于术前(43.22±9.13pg/ml,P<0.05);OPCAB组血管移植结束时(66.47±5.90pg/ml)显著高于术前(44.80±6.51pg/ml,P<0.05);TMLR组打孔术后无显著升高;对照组主动脉开放时(69.92±10.80pg/ml),心肌再灌注后3h(77.99±7.49pg/ml)、6h(46.76±7.61pg/ml)、24h(52.07±6.94pg/ml)显著高于术前(35.14±8.10pg/ml,P<0.05)。组间比较:CABG组心肌再灌注后3h显著高于OPCAB组(95.97±10.72pg/mlvs.59.72±4.81pg/ml,P<0.05)。心肌再灌注后各组CI均较术前明显增加,CABG组心肌再灌注后3hCI明显低于OPCAB组(2.17±0.46L/min.m2vs.3.25±0.05L/min.m2,P<0.05)。结论冠心病患者术后ET值均有升高,但各组升高的程度不同。OPCAB患者术后ET变化较轻,心功能恢复快,对有适应证的患者应尽量选用之;CABG患者ET值变化较明显,术后心功能恢复较OPCAB患者慢,但多在24h以内恢复正常;TMLR是冠心病患者外科治疗的有益补充。

Objective To study the characteristics of endothelin（ET） and hemodynamics parameters in patients with coronary artery disease （CAD） in perioperative period and aim to find out some rules and useful suggestions for clinical trial. Methods Forty-seven patients were divided into 5 groups： patients undergoing coronary artery bypass grafting （CABG） and resection of left ventrieular aneurysm（CABG＋ LVAN group）, patients undergoing classical CABG（CABG group）, patients undergoing off-pump coronary artery bypass grafting （OPCAB group）, patients undergoing transmyocardial laser revascularization （TMLR group）, and group control, patients undergoing mitral valve replacement because of rheumatic heart disease（RHD）. The ET was measured in the following time： before operation, before aortic clamping （or before revascularization or before TMLR）, aortic deelamping （or just after revaseularization or just TMLR）, 3 h, 6 h, 24 h after reperfusion. CI was measured before operation, 3 h, 6 h and 24 h after reperfusion, respectively. Results ET Compared in each group： in CABG＋ LVAN group, it significantly increased when aortic deNamping （69.93±7.20 pg/ml）,at 3 h （89.99±5.76 pg/ml）,6 h （60. 94±8.69 pg/ml） and, 24 h （68.99±10.30 pg/ml） after reperfusion than that before-operation （40. 17±13.37 pg/ml,P〈0.05）; in CABG group, ET significantly increased when reperfusion（66. 59 ± 4. 86 pg/ml）, at 3 h （95. 97 ± 10. 72 pg/ml）, 6 h （61. 51±7.65 pg/ml） and, 24 h （57.85±6.34 pg/ml） after reperfusion than that before-operation（43.22±9.13 pg/ ml,P〈0.05） ; in OPCAB group, ET increased significantly when reperfusion（66.47 ± 5.90 pg/ml） than that before operation（44.80±6.51 pg/ml,P〈0.05）, and then returned to normal level; in TMLR group,there is no difference before and after operation; in control group, ET increased significantly after operation. ET compared between different groups： ET level was higher in CABG group than that in OPCAB group at 3 h after reperfusion（95.97± 10.72 pg/ml vs. 59. 72±4.81 pg/ml,P〈0.05）. Although CI significantly increased after myocardial reperfusion in all groups, the CI was significantly higher in OPCAB group than that in CABG group at 3 h after reperfusion（3. 25±0.05 pg/ml vs. 2. 17±0.46 L/min · m^2 ,P〈0.05）. Conclusions In patients with CAD, the ET increases after operation, but the increasing levels are different among the different groups. In patients with OPCAB, the changes of ET and hemodynamics are mild, and heart function recovers quickly, so OPCAB is a very good choice for CAD surgical therapy if the indications are suitable; In patients with classical CABG, the changes of ET are obvious, and the heart function recovers a little bit slowly, but they all can return to normal level at 24 h after operation; TMLR is a good supplement for CAD therapy