远端缺血预处理对心脏瓣膜术患者预后影响及危险因素分析
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摘要
目的探讨远端缺血预处理(RIPC)对心脏瓣膜术患者心、肾功能和预后的影响,并分析影响预后的危险因素。方法筛选2016年1月至2018年6月在河南省胸科医院住院治疗的心脏瓣膜术患者113例,按照随机数字表法分为RIPC组(56例)和对照组(57例)。麻醉诱导后,RIPC组患者行3轮无创左下肢RIPC。比较两组患者围术期的血流动力学、心、肾功能。随访6个月,比较两组的不良心肾事件。单因素和多因素logistic回归分析影响不良心肾事件的危险因素。结果入选的113例患者中,男性77例(68.1%),平均年龄(53.1±15.4)岁。两组患者的年龄、男性比例、体质指数等均无明显差异(均为P>0.05)。瓣膜置换术后,两组的血肌酐、尿素氮和肌钙蛋白I持续升高,但RIPC组的上述指标明显低于对照组(均为P<0.05)。RIPC组的体外循环时间、主动脉阻断时间、ICU住院时间和总住院时间均少于对照组,但差异均无统计学意义(均为P>0.05)。平均随访(6.2±1.1)个月,11例(9.7%)患者失访。两组的急性肾损伤和心肾不良事件发生率无明显差异(均为P>0.05)。多因素logistic回归分析发现老年(≥60岁)、左室射血分数低(<45%)和体外循环时间长(≥135 min)是发生不良心肾事件的危险因素。结论 RIPC可改善瓣膜置换术患者的心、肾功能,但对短期不良心肾事件发生率无显著影响。老年、左室射血分数低和体外循环时间长是发生不良心肾事件的危险因素。
引文
[1] Zarbock A,Schmidt C,Van Aken H,et al;RenalRIPC Investigators.Effect of remote ischemic preconditioning on kidney injury among high-risk patients undergoing cardiac surgery:a randomized clinical trial [J].JAMA,2015,313(21):2133-2141.DOI:10.1001/jama.2015.4189.
[2] Thielmann M,Kottenberg E,Kleinbongard P,et al.Cardioprotective and prognostic effects of remote ischaemic preconditioning in patients undergoing coronary artery bypass surgery:a single-centre randomised,double-blind,controlled trial [J].Lancet,2013,382(9892):597-604.DOI:10.1016/S0140-6736(13)61450-6.
[3] 陈云宪,唐良秋,陈兆基,等.远端肢体缺血预适应对冠心病患者血浆miRNA-21的影响和意义[J].中国心血管杂志,2018,23(3):242-246.DOI:10.3969/j.issn.1007-5410.2018.03.014.Chen YX,Tang LQ,Chen ZJ,et al.Effect of remote ischemic preconditioning on plasma miRNA-21 in patients with coronary heart disease [J].Chin J Cardiovasc Med,2018,23(3):242-246.DOI:10.3969/j.issn.1007-5410.2018.03.014.
[4] Hausenloy DJ,Candilio L,Evans R,et al;ERICCA Trial Investigators.Remote Ischemic Preconditioning and Outcomes of Cardiac Surgery [J].N Engl J Med,2015,373(15):1408-1417.DOI:10.1056/NEJMoa1413534.
[5] Meybohm P,Bein B,Brosteanu O,et al;RIPHeart Study Collaborators.A Multicenter Trial of Remote Ischemic Preconditioning for Heart Surgery [J].N Engl J Med,2015,373(15):1397-1407.DOI:10.1056/NEJMoa1413579.
[6] 刘建华,蒋伟,石光,等.缺血预处理对心脏瓣膜术中脏器的保护作用[J].天津医科大学学报,2018,24(6):513-516.Liu JH,Jiang W,Shi G,et al.Protective effect of ischemic preconditioning on the viscera during cardiac valve surgery [J].J Tianjin Med Univ,2018,24(6):513-516.
[7] Murry CE,Jennings RB,Reimer KA,et al.Preconditioning with ischemia:a delay of lethal cell injury in ischemic myocardium [J].Circulation,1986,74(5):1124- 1136.
[8] Benstoem C,Stoppe C,Liakopoulos OJ,et al.Remote ischaemic preconditioning for coronary artery bypass grafting (with or without valve surgery) [J].Cochrane Database Syst Rev,2017,5:CD011719.DOI:10.1002/14651858.CD011719.pub3.
[9] Zarbock A,Kellum JA,Van Aken H,et al.Long-term Effects of Remote Ischemic Preconditioning on Kidney Function in High-risk Cardiac Surgery Patients:Follow-up Results from the RenalRIP Trial [J].Anesthesiology,2017,126(5):787-798.DOI:10.1097/ALN.0000000000001598.
[10] Zhou H,Yang L,Wang G,et al.Remote Ischemic Preconditioning Prevents Postoperative Acute Kidney Injury After Open Total Aortic Arch Replacement:A Double-Blind,Randomized,Sham-Controlled Trial [J].Anesth Analg,2019 Mar 20.DOI:10.1213/ANE.0000000000004127.
[11] Walsh M,Whitlock R,Garg AX,et al;Remote IMPACT Investigators.Effects of remote ischemic preconditioning in high-risk patients undergoing cardiac surgery (Remote IMPACT):a randomized controlled trial [J].CMAJ,2016,188(5):329-336.DOI:10.1503/cmaj.150632.
[12] Coverdale NS,Hamilton A,Petsikas D,et al.Remote Ischemic Preconditioning in High-risk Cardiovascular Surgery Patients:A Randomized-controlled Trial [J].Semin Thorac Cardiovasc Surg,2018,30(1):26-33.DOI:10.1053/j.semtcvs.2017.09.001.
[13] Menting TP,Wever KE,Ozdemir-van Brunschot DM,et al.Ischaemic preconditioning for the reduction of renal ischaemia reperfusion injury [J].Cochrane Database Syst Rev,2017,3:CD010777.DOI:10.1002/14651858.CD010777.pub2.
[14] Anttila V,Haapanen H,Yannopoulos F,et al.Review of remote ischemic preconditioning:from laboratory studies to clinical trials [J].Scand Cardiovasc J.2016,50(5-6):355-361.
[2] Thielmann M,Kottenberg E,Kleinbongard P,et al.Cardioprotective and prognostic effects of remote ischaemic preconditioning in patients undergoing coronary artery bypass surgery:a single-centre randomised,double-blind,controlled trial [J].Lancet,2013,382(9892):597-604.DOI:10.1016/S0140-6736(13)61450-6.
[3] 陈云宪,唐良秋,陈兆基,等.远端肢体缺血预适应对冠心病患者血浆miRNA-21的影响和意义[J].中国心血管杂志,2018,23(3):242-246.DOI:10.3969/j.issn.1007-5410.2018.03.014.Chen YX,Tang LQ,Chen ZJ,et al.Effect of remote ischemic preconditioning on plasma miRNA-21 in patients with coronary heart disease [J].Chin J Cardiovasc Med,2018,23(3):242-246.DOI:10.3969/j.issn.1007-5410.2018.03.014.
[4] Hausenloy DJ,Candilio L,Evans R,et al;ERICCA Trial Investigators.Remote Ischemic Preconditioning and Outcomes of Cardiac Surgery [J].N Engl J Med,2015,373(15):1408-1417.DOI:10.1056/NEJMoa1413534.
[5] Meybohm P,Bein B,Brosteanu O,et al;RIPHeart Study Collaborators.A Multicenter Trial of Remote Ischemic Preconditioning for Heart Surgery [J].N Engl J Med,2015,373(15):1397-1407.DOI:10.1056/NEJMoa1413579.
[6] 刘建华,蒋伟,石光,等.缺血预处理对心脏瓣膜术中脏器的保护作用[J].天津医科大学学报,2018,24(6):513-516.Liu JH,Jiang W,Shi G,et al.Protective effect of ischemic preconditioning on the viscera during cardiac valve surgery [J].J Tianjin Med Univ,2018,24(6):513-516.
[7] Murry CE,Jennings RB,Reimer KA,et al.Preconditioning with ischemia:a delay of lethal cell injury in ischemic myocardium [J].Circulation,1986,74(5):1124- 1136.
[8] Benstoem C,Stoppe C,Liakopoulos OJ,et al.Remote ischaemic preconditioning for coronary artery bypass grafting (with or without valve surgery) [J].Cochrane Database Syst Rev,2017,5:CD011719.DOI:10.1002/14651858.CD011719.pub3.
[9] Zarbock A,Kellum JA,Van Aken H,et al.Long-term Effects of Remote Ischemic Preconditioning on Kidney Function in High-risk Cardiac Surgery Patients:Follow-up Results from the RenalRIP Trial [J].Anesthesiology,2017,126(5):787-798.DOI:10.1097/ALN.0000000000001598.
[10] Zhou H,Yang L,Wang G,et al.Remote Ischemic Preconditioning Prevents Postoperative Acute Kidney Injury After Open Total Aortic Arch Replacement:A Double-Blind,Randomized,Sham-Controlled Trial [J].Anesth Analg,2019 Mar 20.DOI:10.1213/ANE.0000000000004127.
[11] Walsh M,Whitlock R,Garg AX,et al;Remote IMPACT Investigators.Effects of remote ischemic preconditioning in high-risk patients undergoing cardiac surgery (Remote IMPACT):a randomized controlled trial [J].CMAJ,2016,188(5):329-336.DOI:10.1503/cmaj.150632.
[12] Coverdale NS,Hamilton A,Petsikas D,et al.Remote Ischemic Preconditioning in High-risk Cardiovascular Surgery Patients:A Randomized-controlled Trial [J].Semin Thorac Cardiovasc Surg,2018,30(1):26-33.DOI:10.1053/j.semtcvs.2017.09.001.
[13] Menting TP,Wever KE,Ozdemir-van Brunschot DM,et al.Ischaemic preconditioning for the reduction of renal ischaemia reperfusion injury [J].Cochrane Database Syst Rev,2017,3:CD010777.DOI:10.1002/14651858.CD010777.pub2.
[14] Anttila V,Haapanen H,Yannopoulos F,et al.Review of remote ischemic preconditioning:from laboratory studies to clinical trials [J].Scand Cardiovasc J.2016,50(5-6):355-361.