米力农和罂粟碱解除非体外循环冠状动脉旁路移植术中乳内动脉痉挛的效果对比

Efficacy comparison between Milrinone and Papaverine on the spasm of internal mammary artery during off-pump coronary artery bypass grafting

目的比较米力农和罂粟碱解除非体外循环冠状动脉旁路移植术中乳内动脉痉挛的效果,评价其临床意义。方法连续观察2018年4月至2018年12月在首都医科大学附属北京安贞医院行非体外循环冠状动脉旁路移植术200例患者,其中男103例,女97例;年龄46~74岁,平均(59.12±0.49)岁。全部患者存在明显心绞痛症状,冠状动脉造影结果均显示三支病变,均使用左乳内动脉(LIMA)与左前降支(LAD)吻合。依据解除乳内动脉痉挛方式随机分为4组,每组50例,分别为罂粟碱表面浸润组(Ⅰ组)、罂粟碱腔内注射组(Ⅱ组)、米力农表面浸润组(Ⅲ组)和米力农腔内注射组(Ⅳ组)。比较各组术中离断LIMA流量、旁路移植后LIMA-LAD旁路血管流量、大隐静脉-钝缘支吻合时间和血管活性药物使用情况,以及围手术期和术后1年随访结果。结果术中离断LIMA流量和LIMA-LAD旁路血管流量组间比较,Ⅲ组和Ⅰ组差异无统计学意义[(45.50±1.43)ml/min对(47.42±1.61)ml/min、(28.60±0.89)ml/min对(28.40±0.96)ml/min,均P>0.05];Ⅱ组明显高于Ⅰ组[(60.36±1.28)ml/min对(47.42±1.61)ml/min、(42.40±1.25)ml/min对(28.40±0.96)ml/min],Ⅳ组明显高于Ⅲ组[(70.86±2.00)ml/min对(45.50±1.43)ml/min、(59.46±1.25)ml/min对(28.60±0.89)ml/min],Ⅳ组明显高于Ⅱ组[(70.86±2.00)ml/min对(60.36±1.28)ml/min,(59.46±1.25)ml/min对(42.40±l.25)ml/min],差异均有统计学意义(均P<0.05)。Ⅳ组钝缘支吻合时间[(7.14±0.72)min对(8.30±0.93)min、(8.10±0.89)min、(8.14±0.90)min]、使用多巴胺剂量[(3.76±0.40)μg·kg^(-1)·min^(-1)对(5.02±0.52)μg·kg^(-1)·min^(-1)、(4.84±0.48)μg·kg^(-1)·min^(-1)(4.90±0.49)μg·kg^(-1)·min^(-1)]和艾司洛尔使用率(32%对60%、58%、58%)较其余三组明显减少,差异均有统计学意义(均P<0.05)。Ⅳ组术后第1天V3导联ST压低水平[(0.34±0.18)mv对(0.71±0.22)mv,(0.68±0.20)mv,(0.69±0.22)mv]和术后第3天肌钙蛋白Ⅰ[(0.24±0.08)ng/ml对(0.56±0.15)ng/ml、(O.54±0.11)ng/ml、(0.53±0.12)ng/ml]较其余三组显著下降,差异均有统计学意义(均P<0.05)。四组患者1年乳内动脉旁路血管通畅率未见明显统计学差异(P>0.05)。结论米力农腔内注射解除乳内动脉痉挛效果优于罂粟碱。米力农腔内注射解除乳内动脉痉挛可使非体外循环冠状动脉旁路移植术中钝缘支吻合时间更短,血流动力学更稳定,心肌损伤更轻。

Objective To compare the efficacy of Milrinone and Papaverine in relieving the spasm of internal mammary artery(LIMA)during off-pump coronary artery bypass grafting(OPCABG).Methods Between April 2018 to December 2018,200 patients who suffered obvious angina pectoris and three-vessel disease documented by coronary angiography,undergoing OPCABG at Beijing Anzhen Hospital,Capital Medical University were recruited in this study,including 103 males and 97 females,aged 46-74 years,with an average of(59.12±0.49)years old.For all patients,the LIMA was anastomosed to left anterior descending artery(LAD).According to different methods relieving LIMA spasm,all patients randomly divided into 4 groups(n=50):Papaverine surface infiltration group(group Ⅰ),Papaverine injection group(group Ⅱ),Milrinone surface infiltration group(group Ⅲ)and Milrinone injection group(group Ⅳ).The blood flow(ml/min)of the free LIMA,the blood flow of the LIMA-LAD after bypass,anastomotic time of obtuse marginal artery,the use of vasoactive drugs,the outcomes of perioperative period and 1 year after operation were compared in the four groups.Results There was no significant difference between group Ⅲ and group Ⅰ in the blood flow of free LIMA and LIMA-LAD[(45.50±1.43)ml/min vs.(47.42±1.61)ml/min、(28.60±0.89)ml/min vs.(28.40±0.96)ml/min,all P>0.05].The blood flow of free LIMA and the LIMA-LAD in group Ⅱ were significantly higher than those in group Ⅰ[(60.36±1.28)ml/min vs.(47.42±1.61)ml/min,(42.40±1.25)ml/min vs.(28.40±0.96)ml/min,all P<0.05].The blood flow of free LIMA and LIMA-LAD in group Ⅳ were significantly higher than those in group Ⅲ[(70.86±2.00)ml/min vs.(45.50±1.43)ml/min,(59.46±1.25)ml/min vs.(28.60±0.89)ml/min,all P<0.05].The blood flow of free LIMA and LIMA-LAD in group Ⅳ were significantly higher than those in group Ⅱ[(70.86±2.00)ml/min vs.(60.36±1.28)ml/min,(59.46±1.25)ml/min vs.(42.40±1.25)ml/min,all P<0.05].The anastomotic time of obtuse marginal artery[(7.14±0.72)min vs.(8.30±0.93)min,(8.10±0.89)min,(8.14±0.90)min,P<0.05],the dopamine close[(3.76±0.40)μg·kg^(-1)·min^(-1) vs.(5.02±0.52)μg·kg^(-1)·min^(-1),(4.84±0.48)μg·kg^(-1)·min^(-1),(4.90±0.49)μg·kg^(-1)·min^(-1),P<0.05]and the esmolol usage(32%vs.60%,58%,58%,P<0.05)during the operation in group Ⅳ were significantly reduced compared with the other three groups.The V3 ST depression on the postoperative first day[(0.34±0.18)mv vs.(0.71±0.22)mv,(0.68±0.20)mv,(0.69±0.22)mv,P<0.05],and the TNI on the postoperative third day[(0.24±0.08)ng/ml vs.(0.56±0.15)ng/ml,(0-54±0.11)ng/ml,(0.53±0.12)ng/ml,P<0.05]were significantly lower in group Ⅳ than those in the other three groups.However,there was no significant difference about the first-year patency of LIMA-LAD among four groups.Conclusion For relieving spasm of LIMA,the Milrinone injection was better than that of Papaverine,which could shorten the anastomotic time of obtuse marginal artery,maintain intraoperative hemodynamics stability,reduce myocardial damage during OPCABG.