摘要
目的探讨双瓣膜置换术中更有效的心肌保护措施。方法纳入第三军医大学新桥医院2005年6～12月32例以主动脉瓣狭窄为主行二尖瓣和主动脉瓣双瓣膜置换术(DVR)患者进行心肌保护研究,根据入院顺序将患者分为4组,每组8例。顺行性灌注组(顺灌组):主动脉根部顺行性灌注冷血心脏停搏液,完成二尖瓣置换术(MVR),再经左、右冠状动脉开口,灌注冷血心脏停搏液,进行主动脉瓣置换术(AVR);逆行灌注组(逆灌组):经冠状静脉窦间断逆行灌注冷血心脏停搏液,完成DVR;顺灌+逆灌组:按顺行性灌注方法先完成MVR,再采用逆行灌注方法完成AVR;心脏不停跳组:经冠状静脉窦持续逆行灌注体外循环机氧合血,心脏不停跳下完成DVR。观察4组术后早期临床疗效;采用酶联免疫吸附测定(ELISA)法检测血清心肌肌钙蛋白Ⅰ(cTnI),Hitachi7150型全自动生化分析仪检测磷酸肌酸激酶同工酶(CK-MB)、心肌乳酸释放率,硫代巴比妥酸法检测心肌线粒体丙二醛(MDA)的含量变化。结果32例患者无手术死亡,均痊愈出院。心脏不停跳组主动脉阻断80 min时心肌乳酸释放率,术后第1 d血清cTnI,CK-MB含量,缝闭右心房时心肌线粒体MDA的含量分别为13.59%±6.27%、(1.17±0.25)ng/ml、(56.43±16.50)U/L、(2.18±1.23)nmol(/ng.prot),均明显低于逆灌组[33.49%±8.29%、(1.82±0.58)ng/ml、(78.31±21.27)U/L、(5.07±2.35)nmol/(ng.prot),P<0.05]和逆灌+顺灌组[20.87%±7.22%(、1.49±0.23)ng/ml(、66.67±19.13)U/L、(4.34±1.73)nmol(/ng.prot),P<0.05];与顺灌组[18.83%±5.97%、(1.41±0.32)ng/ml、(63.21±37.52)U/L、(3.46±1.62)nmol(/ng.prot)]比较差异无统计学意义(P>0.05)。结论在DVR中,以上4种心肌保护方法均有效,但心脏不停跳组和顺灌组效果最好,应优先选择;顺行性灌注+逆行灌注操作方便,不影响手术,逆行灌注时间短,也是一种有效的选择。
Objective To evaluate myocardial protection effect of different myocardial protective strategies for patients undergoing double valve replacement （DVR）. Methods From Jun. 2005 to Dec. 2005, 32 patients with predominant aortic valve stenosis undergoing DVR in Xinqiao Hospital were included in this study. These patients were randomly divided into four groups with 8 patients in each group ： （ 1 ） antegrade perfusion group： Cold-blood cardioplegia was delivered antegradely through aortic root, and mitral valve replacement （MVR） was performed. Then cold-blood cardioplegia was delivered antegradely through left and right coronary ostia, and aortic valve replacement （AVR）was performed; （2）retrograde perfusion group： Cold-blood cardioplegia was delivered retrogradely and intermittently through coronary sinus, and DVR was performed; （3） antegrade ＋ retrograde perfusion group： The route of cold-blood cardioplegic infusion was antegrade during MVR procedure first and then retrograde during AVR procedure; and （4）beating heart group： Oxygenated blood from cardio- pulmonary bypass machine was delivered retrogradely and continuously through coronary sinus, and DVR was performed with beating heart. Early clinical outcomes were observed. Serum cardiac troponin I （cTnI） was measured by enzymelinked immunosorbent assay （ELISA）. Serum creatine kinase-MB （CK-MB） and myocardial lactic acid release rate were measured by Hitachi7150 Automatic Chemistry Analyzer. Myocardial mitochondria malondialdehyde （MDA） level was measured through thiobarbituric acid reagent species analysis. Results All the 32 patients survived their surgery and were discharged successfully. Myocardial lactic acid release rate at 80 min after aortic cross-clamping, serum cTnI and CK-MB on the first postoperative day, myocardial mitochondria MDA levels of beating heart group were 13.59% ± 6. 27%, （ 1.17 ± 0.25 ） ng/ml, （56.43 ± 16.50） U/L and （2. 18 ± 1.23 ） nmol/（ng, prot） respectively, all significantly lower than those of retrograde perfusion group [（33.49%±8.29%, （1.82 ± 0.58） ng/ml, （78.31 ±21.27） U/L （5. 07±2.35） nmol/（ng, prot）, P 〈 0. 053 and antegrade ＋ retrograde perfusion group [20.87%±7.22%, （ 1. 49±0.23） ng/ml, （66. 67 ± 19. 13 ） U/L, （4. 34 ±1.73 ） nmol/ （ng. prot）, P 〈 0. 05 ], but not statistically different from those of antegrade perfusion group [ 18.83%±5.97%, （ 1.41 ±0.32） ng/ml, （63.21 ±37.52） U/L, （3.46± 1.62） nmol/（ng, prot）, P 〉 0. 05 ]. Conclusion All the four myocardial protective strategies are effective myocardial protection methods for DVR patients. Continuous retrograde perfusion with beating heart and intermittent antegrade perfusion can provide better myocardial protection, and therefore are preferred for DVR patients. The combination of antegrade and retrograde perfusion is easy to administer and does not negatively influence surgical procedures. Retrograde perfusion is also effective as it takes only a short time.
出处
《中国胸心血管外科临床杂志》
CAS
2012年第4期371-375,共5页
Chinese Journal of Clinical Thoracic and Cardiovascular Surgery
关键词
联合心脏瓣膜疾病
双瓣膜置换术
假体置入手术
心肌保护
Valvular heart disease
Double valve replacement
Prosthesis implantation
Myocardial protection
