远程缺血预适应与心脏缺血后处理对心脏瓣膜置换患者的心肌保护作用

Protective effects of remote ischemic preconditioning and ischemia postconditioning on myocardium in patients undergoing heart valvular replacement

目的:探究远程缺血预适应(RPC)及心脏缺血后处理(IPO)对重症心脏瓣膜置换患者体外循环(CPB)后心肌缺血再灌注损伤(IRI)的心肌保护作用。方法:将择期行心脏瓣膜置换术的80例重症患者随机分为实验组1(实施RPC操作)、实验组2(实施IPO操作)、实验组3(叠加实施RPC和IPO操作)和对照组(空白对照组,不实施任何干预),每组各20例。比较各组主动脉阻断时间、CPB时间、手术时间、心脏自动复跳率、心脏除颤次数;记录术前和术后48 h内各组中心静脉压(CVP)、肺动脉压(PAP)、肺毛细血管压(PCWP)、心脏指数(CI)等血流动力学指标以及肌钙蛋白-T(cTnI)、肌酸激酶同工酶(CKMB)、B型利钠肽(BNP)水平;比较各组重症监护室(ICU)住院时间、脱离呼吸机支持时间、主要并发症发生率、平均住院日及平均住院费用。结果:各实验组心脏自动复跳率均高于对照组、心脏除颤次数均少于对照组、术后各时间点PAP、PCWP、CI、CTnI、CKMB、BNP水平均低于对照组(P<0.05);各实验组之间上述指标比较,差异无统计学意义(P>0.05);实验组ICU停留时间、脱离呼吸机支持时间及平均住院日均短于对照组(P<0.05);主要并发症发生率低于对照组、平均住院费用少于对照组(P<0.05)。结论:在成人重症瓣膜置换术中,RPC和IPO均可明显减轻心肌损伤,改善患者预后,降低手术并发症风险,且二者心肌保护作用无明显差别,无叠加效应。

Objective:To investigate the protective effect of remote ischemic preconditioning(RPC)and ischemia postconditioning(IPO)on myocardial ischemia-reperfusion injury(IRI)in patients undergoing severe heart valve replacement after cardiopulmonary bypass(CPB).Methods:80 critically ill patients undergoing elective heart valve replacement were randomly divided into experiment 1 group(undergoing RPC operation),experiment 2 group(undergoing IPO operation),experiment 3 group(undergoing RPC and IPO operation),and control group(blank control group,no intervention),20 cases in each group.The aortic cross-clamp time,CPB time,operation time,auto-rebeat rate of heart,and number of cardiac defibrillation were compared among all groups.The hemodynamic indexes[central venous pressure(CVP),pulmonary arterial pressure(PAP),pulmonary capillary wedge pressure(PCWP)and cardiac index(CI)],and troponin-T(cTnI),creatine kinase isoenzyme(CKMB),and B-type natriuretic peptide(BNP)levels of each group were recorded before and within 48 hours after surgery.The hospital stay in intensive care unit(ICU),off ventilator support time,incidence of major complications,average hospital stay,and average hospitalization costs were compared among all groups.Results:The auto-rebeat rate of heart in all the experiment groups was significantly higher than that in the control group,while the number of defibrillation was significantly less than that in the control group.The PAP,PCWP,CI,CTnI,CKMB and BNP levels in all the experiment groups were significantly lower than those in the control group at each time point after surgery(P<0.05).There were no significant difference among all the experiment groups(P>0.05).And the ICU staying time,off ventilator support time and average hospital stay in all the experiment groups were significantly shorter than those in the control group,while incidence of major complications was significantly lower than that in the control group,and the average hospitalization cost was significantly less than that in the control group(P<0.05).Conclusion:In severe valve replacement for adult,both RPC and IPO can significantly reduce myocardial injury,improve the prognosis of patients,and reduce the risk of surgical complications.And there is no significant difference in myocardial protection effect between the two,no superimposed effect.