顺逆灌结合+开放前温血灌注技术在瓣膜置换术中的心肌保护作用

The myocardial protection effect of combined antegrade and retrograde perfusion plus warm blood perfusion in valve replacement surgery

目的探讨使用顺逆灌结合+开放前温血灌注对瓣膜置换术患者的心肌保护作用。方法选择2010年1月—2020年12月在本院行瓣膜置换手术患者的462例作为研究对象,随机分为研究组(242例)和对照组(220例)两组,另根据重症瓣膜病诊断标准[4],87例诊断为重症心脏瓣膜患者,其中研究组43例,对照组44例。研究组患者心肌保护方法采用顺逆灌结合+开放前温血灌注,对照组患者心肌保护方法采用冷血间断灌注。比较两组患者治疗各项指标评价及心肌酶学心肌肌钙蛋白T(cT-nT)、心肌肌酸激酶(CK)、肌酸激酶同工酶(ck-MB)指标,比较两组重症心脏瓣膜患者治疗情况及心肌酶学cT-nT、CK、ck-MB指标。结果两组患者的体外循环时间,主动脉阻断时间,呼吸机支持时间,ICU治疗时间及平均住院时间比较,差异无统计学意义(P>0.05);术后2 h、4 h、24 h,研究组患者心肌酶cT-nT(ng/mL)、CK(U/L)、CK-MB(U/L)指标明显低于对照组,差异有统计学意义(P<0.05);研究组重症心脏瓣膜病合并冠心病患者心脏自动复跳率(76.70%)明显高于对照组心脏自动复跳率(47.7%),差异有统计学意义(P<0.05);研究组重症心脏瓣膜患者的呼吸机支持时间,ICU治疗时间及平均住院时间明显低于对照组。差异有统计学意义(P<0.05);术后2 h、4 h、24 h,研究组重症心脏瓣膜患者心肌酶学cT-nT(ng/ml)、CK(U/L)、CK-MB(U/L)指标明显低于对照组,差异有统计学意义(P<0.05)。结论两组心肌保护方法均适应临床瓣膜置换术中心肌保护工作;研究组综合性心肌保护较传统冷氧合血灌注能更好减少术中心肌损伤;对长时间复杂瓣膜置换手术或瓣膜置换合并冠脉搭桥患者,顺逆灌结合+开放前温血灌注技术较传统冷血灌注能起到更好的心肌保护作用,术后恢复更快。

Objective To investigate the myocardial protection effect on patients undergoing valve replacement surgery with combined antegrade and retrograde perfusion and warm blood perfusion before releasing aortic cross-clamp.Methods A total of 462 patients ever underwent valve replacement procedures in our hospital from January 2010 to December 2020 were selected as study objects.They were randomly divided into experimental group(n=242)and control group(n=220).According the diagnostic criteria of severe valvular heart disease,the 87 cases of patients diagnosed with severe valvular heart disease were divided into study group(n=43)and control group(n=44).The combined antegrade and retrograde perfusion plus warm blood perfusion before releasing aortic cross-clamp was used as the method of myocardial protection in the experimental group,and cold blood intermittent perfusion was applied in the control group.The various therapeutic indexes and cardiac troponin T(cT-nT),cardiac creatine kinase(CK),and creatine kinase isoenzyme(CK-MB)of cardiac enzymology were compared between the two groups.The treatment status and cT-nT,CK,CK-MB indexes of cardiac enzymology were compared between the two groups of patients with severe heart valve.Results There were no significant differences in extracorporeal circulation time,aorta blocking time,ventilator support time,ICU treatment time and average length of hospital stay between the two groups(P>0.05).At 2h,4h and 24h after surgery,the indexes of cardiac enzymes cT-nT(ng/mL),CK(U/L)and CK-MB(U/L)in study group were significantly lower than those in control group,and the differences were statistically significant(P<0.05).The rate of automatic heart rebeat in patients with severe valvular disease complicated with coronary heart disease in study group(76.70%)was significantly higher than that in control group(47.7%),and the difference was statistically significant(P<0.05).Ventilator support time,ICU treatment time and average length of hospital stay of patients with severe valvular disease in the study group were shorter than those in the control group,the differences were statistically significant(P<0.05).At 2 h,4 h and 24 h after surgery,the indexes of cardiac enzymes cT-nT(ng/mL),CK(U/L)and CK-MB(U/L)in patients with severe valvular disease study group were significantly lower than those in control group,and the differences were statistically significant(P<0.05).Conclusions The myocardial protection methods of both groups are suitable for myocardial protection in clinical valve replacement surgery.The comprehensive myocardial protection method in the experimental group could better reduce intraoperative myocardial injury compared with the cold blood intermittent perfusion.For patients underwent long-term complex valve replacement surgery or valve replacement combined with coronary artery bypass grafting,the perfusion method of combined antegrade and retrograde perfusion plus warm blood perfusion before releasing aortic cross-clamp could play a better myocardial protection effect than traditional cold blood perfusion,and the postoperative recovery is faster.