康斯特保护液与含血停搏液在瓣膜置换并Cox迷宫Ⅲ型手术中心肌保护的临床效果
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摘要
目的总结康斯特保护液(HTK液)与含血停搏液在心脏瓣膜置换合并Cox迷宫Ⅲ型手术中心肌保护及临床效果。方法回顾2015年7月至2018年1月心脏瓣膜病合并心房纤颤患者同期行Cox迷宫Ⅲ型手术治疗的42例患者,按其术中心肌保护时采用不同的灌注液分为两组:4∶1含血心脏停搏液组(n=21)和HTK液组(n=21)。分别收集术前(T1)、开放升主动脉后10 min(T2)、术后24 h(T3)、术后48 h(T4)心肌酶谱肌酸激酶(CK)、心肌型肌酸激酶同工酶(CKMB)、血清肌钙蛋白I(cTnI)浓度,以及围术期心律失常发生率、机械通气、ICU时间、开放升主动脉后、出院前窦性心律恢复情况、术后并发症及预后等情况。结果全组患者围术期无死亡,平均主动脉阻断时间HTK液组比含血停搏液组为(107.7±10.7)min vs(111.7±11.4)min,平均体外转流时间(171.5±16.3)min vs(169.1±15.5)min。HTK液组患者平均灌注量(1 905±255.9)ml,含血停搏液组患者平均灌注(5.09±0.62)次,平均灌注(3 081±369.6)ml。两组患者血液中CK、CKMB、cTnI浓度在升主动脉开放后均显著升高(P<0.01),术后24 h仍然处于较高水平(P<0.01),术后48 h开始呈下降趋势。HTK液组cTnI浓度在术后24 h时间点显著低于含血停搏液组(P<0.01),在费用上明显高于含血停搏液组为(1.45±0.21)万元vs(0.82±0.12)万元(P<0.01)。两组术中均无左房出血等并发症,含血停搏液组术后除1例出现缺氧性脑功能障碍,经呼吸机支持治疗1周及高压氧治疗2周后恢复,其余均在术后24 h内拔除气管插管。随访两组患者术后生活质量无明显差异。结论 HTK液与4∶1含血停搏液在心脏瓣膜病合并心房纤颤患者Cox迷宫Ⅲ型手术治疗中都具有较好的心肌保护效果;HTK液组围术期心肌酶谱指标cTnI浓度在术后24 h显著低于含血停搏液组,其心肌保护效果优于含血停搏液组。
Objective To compare the cardioprotective effects and clinical outcomes of HTK solution and conventional blood cardioplegia in patients with atrial fibrillation undergoing valvular replacement and Cox maze Ⅲ procedure. Methods From Jan 2015 to Jan 2018,42 patients in our department undergoing valvular replacement or valvular plasty and Cox maze Ⅲ procedure were reviewed. Patients were divided into two groups according to different cardioplegia and myocardial perfusion methods: 4 ∶ 1 conventional blood cardioplegia group and HTK group. Serial blood samples were obtained for detecting serum concentrations of creatine kinase( CK),MB isoenzyme of creatine kinase( CKMB),and cardiac troponin I( cTnI). Data of clinical outcomes,such as postoperative mortality,the incidence of arrhythmia and ICU stay,the recovery of sinus rhythm,postoperative complications and prognosis,were also recorded. Results There were no deaths in both groups. The volume of blood cardioplegia was 3081±369.6 ml,and the frequency was5.09±0.62,the volume of HTK solution was 1905±255.9 ml.There were no significant differences according to postoperative ventilation time,ICU stay and early postoperative life quality between the two groups.The cardiopulmonary bypass cost was significantly higher in HTK group than in blood cadioplegia group( 1.45±0,21 vs 0.82±0.12 ten thousand yuan). HTK group had lower cTnI at 24 h after operation compared to blood cardioplegia group. Conclusion Both blood cardioplegia and HTK solution have the same clinical outcomes in patients with atrial fibrillation undergoing valvular replacement and Cox maze Ⅲ procedure,but HTK may be superior for the recovery of heart function compared to blood cardioplegia.
Objective To compare the cardioprotective effects and clinical outcomes of HTK solution and conventional blood cardioplegia in patients with atrial fibrillation undergoing valvular replacement and Cox maze Ⅲ procedure. Methods From Jan 2015 to Jan 2018,42 patients in our department undergoing valvular replacement or valvular plasty and Cox maze Ⅲ procedure were reviewed. Patients were divided into two groups according to different cardioplegia and myocardial perfusion methods: 4 ∶ 1 conventional blood cardioplegia group and HTK group. Serial blood samples were obtained for detecting serum concentrations of creatine kinase( CK),MB isoenzyme of creatine kinase( CKMB),and cardiac troponin I( cTnI). Data of clinical outcomes,such as postoperative mortality,the incidence of arrhythmia and ICU stay,the recovery of sinus rhythm,postoperative complications and prognosis,were also recorded. Results There were no deaths in both groups. The volume of blood cardioplegia was 3081±369.6 ml,and the frequency was5.09±0.62,the volume of HTK solution was 1905±255.9 ml.There were no significant differences according to postoperative ventilation time,ICU stay and early postoperative life quality between the two groups.The cardiopulmonary bypass cost was significantly higher in HTK group than in blood cadioplegia group( 1.45±0,21 vs 0.82±0.12 ten thousand yuan). HTK group had lower cTnI at 24 h after operation compared to blood cardioplegia group. Conclusion Both blood cardioplegia and HTK solution have the same clinical outcomes in patients with atrial fibrillation undergoing valvular replacement and Cox maze Ⅲ procedure,but HTK may be superior for the recovery of heart function compared to blood cardioplegia.
引文
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[3]Stulak JM,Suri RM,Burkhart HM,et al.Surgical ablation for atrial fibrillation for two decades:Are the results of new techniques equivalent to the Cox mazeⅢprocedure[J]?J Thorac Cardiovasc Surg,2014,147(5):1478-1486.
[4]韩劲松,王辉山,汪曾炜,等.Cox迷宫Ⅲ型手术治疗风湿性二尖瓣病变伴发心房颤动的安全性和有效性[J].中华医学杂志,2016,96(13):1011-1015.
[5]Saposnik G,Gladstone D,Raptis R,et al.Atrial fibrillation in ischemic stroke;predicting response to thrombolysis and clinical outcomes[J].Stroke,2013,44(1):99-104.
[6]Stulak JM,Schaff HV.The cardiac surgeon as electrophysiologist[J].J Thorac Cardiovasc Surg,2016,151(2):298-299.
[7]January CT,Wann LS,Alpert JS,et al.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation:executive summary:a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society[J].Circulation,2014,130(23):2071-2104.
[8]Lawrance CP,Henn MC,Miller JR,et al.Comparison of the stand-alone Cox-Maze IV procedure to the concomitant Cox-Maze IV and mitral valve procedure for atrial fibrillation[J].Ann Cardiothorac Surg,2014,3(1):55-61.
[9]Preusse CJ,Gebhard MM,Bretschneider HJ.Myocardial"equilibration processes"and myocardial energy turnover during initiation of artificial cardiac arrest with cardioplegic solution-reasons for a sufficiently long cardioplegic perfusion[J].Thorac Cardiovasc Surg,1981,29(2):71-76.
[10]Sakata J,Morishita K,Ito T,et al.Comparison of Clinical Outcome Between HTK solution and Cold Blood Cardioplegic Solution in Mitral Valve Replacement[J].J Card Surg,1998,13(1):43-47.
[11]李佳春,王加利,高长青,等.机器人体外循环下心脏手术的心肌灌注方法及效果[J].中国体外循环杂志,2011,9(4):193-195
[12]Caputo M,Dihmis W,Birdi I,et al.Cardiac troponin T and troponin I release during coronary artery surgery using cold crystalloid and cold blood cardioplegia[J].Eur J Cardiothorac Surg,1997,12(2):254-260.
[13]Christakis CT,Koch JP,Deemar KA,et al.A randomized study of the systemic effects of warm heart surgery[J].Ann Thorac Surg,1992,54(3):449-459.
[2]Lawrance CP,Henn MC,Damiano RJ Jr.Surgical ablation for atrial fibrillation:techniques,indications,and results[J].Curr Opin Cardiol,2015,30(1):58-64.
[3]Stulak JM,Suri RM,Burkhart HM,et al.Surgical ablation for atrial fibrillation for two decades:Are the results of new techniques equivalent to the Cox mazeⅢprocedure[J]?J Thorac Cardiovasc Surg,2014,147(5):1478-1486.
[4]韩劲松,王辉山,汪曾炜,等.Cox迷宫Ⅲ型手术治疗风湿性二尖瓣病变伴发心房颤动的安全性和有效性[J].中华医学杂志,2016,96(13):1011-1015.
[5]Saposnik G,Gladstone D,Raptis R,et al.Atrial fibrillation in ischemic stroke;predicting response to thrombolysis and clinical outcomes[J].Stroke,2013,44(1):99-104.
[6]Stulak JM,Schaff HV.The cardiac surgeon as electrophysiologist[J].J Thorac Cardiovasc Surg,2016,151(2):298-299.
[7]January CT,Wann LS,Alpert JS,et al.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation:executive summary:a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society[J].Circulation,2014,130(23):2071-2104.
[8]Lawrance CP,Henn MC,Miller JR,et al.Comparison of the stand-alone Cox-Maze IV procedure to the concomitant Cox-Maze IV and mitral valve procedure for atrial fibrillation[J].Ann Cardiothorac Surg,2014,3(1):55-61.
[9]Preusse CJ,Gebhard MM,Bretschneider HJ.Myocardial"equilibration processes"and myocardial energy turnover during initiation of artificial cardiac arrest with cardioplegic solution-reasons for a sufficiently long cardioplegic perfusion[J].Thorac Cardiovasc Surg,1981,29(2):71-76.
[10]Sakata J,Morishita K,Ito T,et al.Comparison of Clinical Outcome Between HTK solution and Cold Blood Cardioplegic Solution in Mitral Valve Replacement[J].J Card Surg,1998,13(1):43-47.
[11]李佳春,王加利,高长青,等.机器人体外循环下心脏手术的心肌灌注方法及效果[J].中国体外循环杂志,2011,9(4):193-195
[12]Caputo M,Dihmis W,Birdi I,et al.Cardiac troponin T and troponin I release during coronary artery surgery using cold crystalloid and cold blood cardioplegia[J].Eur J Cardiothorac Surg,1997,12(2):254-260.
[13]Christakis CT,Koch JP,Deemar KA,et al.A randomized study of the systemic effects of warm heart surgery[J].Ann Thorac Surg,1992,54(3):449-459.