康斯特保护液与含血停搏液在David及全弓置换支架象鼻手术中心肌保护的临床效果
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摘要
目的探讨康斯特保护液(HTK液)与含血停搏液在深低温停循环(DHCA)下行David手术及全弓置换支架象鼻手术中心肌保护的临床效果。方法回顾性分析2016年1月至2018年11月在本院行该手术的38例患者,按其心肌保护时采用不同的灌注液分为两组:HTK液组(n=19)和4∶1含血心脏停搏液组(n=19)。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)、血清肌钙蛋白I(c Tn I)、心肌型肌酸激酶同工酶(CKMB)浓度,术后机械通气时间、ICU时间,术后并发症及预后等情况。结果两组围术期各2例患者出现死亡,其中2例死于多脏器功能衰竭,1例死于神经系统并发症,1例死于继发腹主动脉破裂出血。含血停搏液和HTK液两组转机时间、阻断时间、停循环时间无统计学差异,停搏液用量两组有差异。两组患者血液心肌酶谱浓度在升主动脉开放后及术后24 h均显著升高(P <0.01),术后48 h开始呈下降趋势,CK浓度在T2、T4时间点HTK液组显著低于含血停搏液组(P <0.05),CKMB浓度在T3时间点HTK液组显著低于含血停搏液组(P <0.05),cTnI浓度在T3、T4时间点HTK液组显著低于含血停搏液组(P <0.01,P <0.05),两组患者费用有差异(P <0.01)。结论两种心肌保护液都具有较好的心肌保护作用,CK浓度在T2、T4时间点、CKMB浓度在T3时间点、c Tn I浓度在T3、T4时间点HTK液组显著低于含血停搏液组(P <0.05),从心肌酶谱数值上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 aortic dissection undergoing David and total arch replacement combined with stented elephant trunk implantation under DHCA. Methods From January 2016 to November 2018,data of 38 patients in our department undergoing the surgery were reviewed. Patients were divided into HTK group( n = 19) and 4: 1 conventional blood cardioplegia group( n = 19) according to different cardioplegia and myocardial perfusion methods. Serial blood samples were collected for detection of serum concentrations of creatine kinase( CK),cardiac troponin I( c Tn I),MB isoenzyme of creatine kinase( CKMB). Data of clinical outcomes including postoperative mortality,complications,ICU stay,postoperative complications and prognosis were also recorded. Results There were two deaths in each group during perioperative period. Among them,two patients died of multiple organ failure,one patient died of neurological complications,one died of secondary abdominal aotic rupture hemorrhage. There was no statistical difference in the duration of CPB time,aortic cross clamp time,and deep hypothermic circulatory arrest time. The solusion volume and perfusion frequency of cardioplegia in two groups showed significant difference. Serum myocardial enzymes in both groups increased significantly after opening of the aorta and 24 hours after the operation( P <0.01),but began to decrease at 48 hours postoperatively. The concentration of CK in HTK group was significantly lower than that in blood cardioplegia group at T2 and T4( P <0.05),and the concentration of CKMB in HTK group was significantly lower than that in blood cardioplegia group at T3( P <0.05). At T3 and T4,the concentration of c Tn I in HTK group was significantly lower than that in blood cardioplegia group( P <0.01,P <0.05). Costs of the two groups were significantly different( P <0.01). There was no significant difference in quality of life between the two groups after hospital discharge. Conclusion Both cardioprotective solutions have good myocardial protective effects. Myocardial protective effect of HTK solution group is better than that of blood cardioplegia group in myocardial zymogram values.
Objective To compare the cardioprotective effects and clinical outcomes of HTK solution and conventional blood cardioplegia in patients with aortic dissection undergoing David and total arch replacement combined with stented elephant trunk implantation under DHCA. Methods From January 2016 to November 2018,data of 38 patients in our department undergoing the surgery were reviewed. Patients were divided into HTK group( n = 19) and 4: 1 conventional blood cardioplegia group( n = 19) according to different cardioplegia and myocardial perfusion methods. Serial blood samples were collected for detection of serum concentrations of creatine kinase( CK),cardiac troponin I( c Tn I),MB isoenzyme of creatine kinase( CKMB). Data of clinical outcomes including postoperative mortality,complications,ICU stay,postoperative complications and prognosis were also recorded. Results There were two deaths in each group during perioperative period. Among them,two patients died of multiple organ failure,one patient died of neurological complications,one died of secondary abdominal aotic rupture hemorrhage. There was no statistical difference in the duration of CPB time,aortic cross clamp time,and deep hypothermic circulatory arrest time. The solusion volume and perfusion frequency of cardioplegia in two groups showed significant difference. Serum myocardial enzymes in both groups increased significantly after opening of the aorta and 24 hours after the operation( P <0.01),but began to decrease at 48 hours postoperatively. The concentration of CK in HTK group was significantly lower than that in blood cardioplegia group at T2 and T4( P <0.05),and the concentration of CKMB in HTK group was significantly lower than that in blood cardioplegia group at T3( P <0.05). At T3 and T4,the concentration of c Tn I in HTK group was significantly lower than that in blood cardioplegia group( P <0.01,P <0.05). Costs of the two groups were significantly different( P <0.01). There was no significant difference in quality of life between the two groups after hospital discharge. Conclusion Both cardioprotective solutions have good myocardial protective effects. Myocardial protective effect of HTK solution group is better than that of blood cardioplegia group in myocardial zymogram values.
引文
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[8] Viana FF,Shi WY,Hayward PA,et al. Custodiol versus blood cardioplegia in complex cardiac operations:an australian experience[J]. Eur J Cardiothorac Surg,2013,43(3):526-531.
[9]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.
[10]张蔚,于新迪,沈佳,等.三种心肌保护液在儿童心脏手术中的应用观察[J].中国体外循环杂志,2016,14(1):12-15.
[11]康邦国.经皮冠状动脉介入治疗联合依达拉奉治疗ST段抬高型急性心肌梗死再灌注损伤的临床观察[J].实用医学杂志,2014,30(11):1729-1731.
[2] Liu W,Wang B,Wang T,et al. Ursodeoxycholic acid attenuates acute aortic dissection formation in angiotensinⅡ-infused apolipoprotein e-deficient mice associated with reduced ros and increased nrf2 levels[J]. Cell Physiol Biochem,2016,38(4):1391-1405.
[3] Camarda JA,Harris SE,Hambrook J,et al. Abnormal mitral valve anatomy in d-transposition of the great arteries:anatomic characterization and surgical outcomes[J]. Pediatr Cardiol,2013,34(1):70-74.
[4]汪源,周璞,周曼玲,等. HTK液与高钾停搏液在成人心脏手术中心肌保护效果的荟萃分析[J].华中科技大学学报(医学版),2017,46(4):484-488.
[5] Matzelle SJ,Murphy MJ,Weightman WM,et al. Minimally invasive mitral valve surgery using single dose antegrade custodiol cardioplegia[J]. Heart Lung Cire,2014,23(9):863-868.
[6] Patel N,Delaney E,Turi G,et al. Custodiol HTK cardioplegia use in robotic mitral valve[J]. J Extra Corpor Technol,2013,45(2):139-142.
[7] Wiedemann D,Schachner T,Bonaros N,et al. Impact of cold ischemia on mitochondrial function in porcine hearts and blood vessels[J]. Int J Mol Sci,2013,14(11):22042-22051.
[8] Viana FF,Shi WY,Hayward PA,et al. Custodiol versus blood cardioplegia in complex cardiac operations:an australian experience[J]. Eur J Cardiothorac Surg,2013,43(3):526-531.
[9]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.
[10]张蔚,于新迪,沈佳,等.三种心肌保护液在儿童心脏手术中的应用观察[J].中国体外循环杂志,2016,14(1):12-15.
[11]康邦国.经皮冠状动脉介入治疗联合依达拉奉治疗ST段抬高型急性心肌梗死再灌注损伤的临床观察[J].实用医学杂志,2014,30(11):1729-1731.
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