心脏不停跳修补室缺后肌钙蛋白T分泌变化

Changes in cTnT secretion after repair of ventricular septal defect on the beating heart

目的 观察心脏不停跳修补室缺后肌钙蛋白T（cTnT）分泌变化.方法 共施行单纯室间隔缺损（VSD）合并轻、中度肺动脉高压患者202例.VSD（0.7 ±0.2）cm;膜部185例,干下型15例,肌部2例.心胸比例0.49 ±0.18.随机分为3组：A组（晶体组）86例;B组（血灌组）51例;C组（不停跳组）65例.术中切取右心耳行电镜观察.术后24 h和72 h抽血监测cTnT.结果 无气栓、死亡、严重低心排、肾功能或呼吸功能衰竭等严重并发症发生.术后1～2 d轻度血红蛋白尿5例.术后1～3 d暂时性房室分离7例.直径＜2 mm残余漏2例.C组2例术中室颤.手术后24 h的cTnT：A组（0.75±0.25）μg/L与B组（0.69 ±0.20）μg/L,P＞0.05,C组（0.55 ±0.18）μg/L与A、B组差异有统计学意义（P＜0.01）.术后72 h的cTnT：A组（0.53 ±0.19）μg/L与C组（0.55±0.13）μg/L,P＞0.05,A组与B组（0.43±0.13）μg/L,P＜0.01.电镜发现3组之间,以C组损害略轻,A组相对较重.结论 心脏跳动下修补可明显减少手术时间,由此可以减少由手术对全身造成的创伤,并且方法安全、可行.心脏不停跳修补的cTnT分泌变化反映了心肌保护效果：并不优于血灌组,两者皆优于晶体停跳组.

Objective To estimate the myocardial protective effect of the operation.Methods From January 2004 to June 2009,we implemented ventricular septal defect （VSD） repairs in 202 patients with simple VSD and mild and moderate pulmonary hypertension,including 98 males and 104 females.Theaverage size of VSD was （0.7 ±0.2） cm.There were 185 patients with perimenbranous VSD,15 patients with lower trunk VSD,and 2 patients with muscular VSD.The average cardiothoracic ratio （CTR） was 0.49 ±0.18.202 patients were randomly divided into 3 groups：group A （crystalloid group） with 86 cases;group B （hemoperfusion group） with 51 cases;group C （beating heart group） with 65 cases.During the operation,right atrial appendage muscle was cut off and observed under the electron microscopy.The blood cardiac Troponin T （cTnT） was examined 24 and 72 h postoperation.Results There was no air embolism,death,severe low cardiac output,renal or respiratory failure or other serious complications.One to2 days after surgery,5 cases had mild hemoglobinuria.One-3 days after surgery,7 cases had a temporary atrioventricular separation.There were 2 cases of residual leakage with the diameters both below 2 mm.Two cases in group C suffered from ventricular fibrillation during operation.At 24th h after surgery,there was no significant difference in cTnT （ P 〉 0.05 ） between group A （0.75 ± 0.25 ） μg/L and group B （0.69 ±0.20） μg/L,and there was statistically great significant difference between group C （0.55 ±0.18） μg/L and groups A or B （P〈0.01）.At tge 72nd h after surgery,there was no significant difference in the cTnT level （ P 〉 0.05 ） between group A （0.53 ± 0.19 ） μg/L and group C （ 0.55 ± 0.13 ）μg/L,but there was statistically great significant difference between group A and group B （0.43 ±0.13）μg/L （P 〈0.01 ）.The damage in group C was milder,and that in group A was severer.Conclusion Beating heart surgery can significantly reduce the operative duration of VSD repair,thereby it can limit the surgical trauma on the body.Moreover,the method is conservative and practical.In terms of changes of cTnT secretion or myocardial protective effect for repair of VSD,the beating heart surgery was not superior to the hemoperfusion group while both of the groups were superior to the crystalloid group.