血液停跳液与晶体停跳液对冠状动脉搭桥术患者术中心肌保护的比较

目的比较血液停跳液和晶体停跳液对冠心病(CAD)患者冠状动脉搭桥术中心肌保护的效果,探讨损伤心肌恢复的指标。方法将53例择期手术的CAD患者分为两组:血液停跳液组(B-CAD)和晶体停跳液组(C-CAD)。分别于术前1d,术后1、3、5、8d晨取静脉血,测定血清天冬氨酸转氨酶(AST)、磷酸肌酸激酶及同功酶M(BCK,CK-MB)、乳酸脱氢酶及同功酶(1LDH,LDH-1)。结果两组患者术前心肌酶的测定结果均在正常范围,术后1d两组的心肌酶释放达到高峰(P<0.05),术后3d均有不同程度的恢复,两组的CKMB已恢复到正常值,C-CAD组的AST与术前相比已无明显差别(P>0.05),但两组的其他心肌酶仍明显高于术前水平(P<0.05)。术后5d继续恢复,两组的CK也恢复到正常水平,但两组的LDH和LDH-1在术后5d和术后8d仍高于术前水平(P<0.05)。术后1d、3dB-CAD的LDH和LDH-1以及术后5dB-CAD的LDH均明显高于C-CAD的测定值(P<0.05),两组间其他心肌酶值在不同的时间差异无统计学意义。以术前心肌酶的值对术后心肌酶值进行校正后,两组间心肌酶的释放在术后各个测定点差异均无统计学意义。心肌酶的释放与主动脉阻断时间(CCT)和体外循环时间(ECCT)呈良好的正相关。两组患者的年龄、体重、CCT和ECCT差别无统计学意义(P>0.05)。结论从心肌酶的释放来判断,血液停跳液并不优于晶体停跳液对CAD的心肌保护效果。要判断心肌损伤的恢复,应以LDH和LDH-1的恢复为标准。     

还原型谷胱甘肽含血停搏液在心脏瓣膜置换术中的心肌保护作用

目的观察心脏含血停搏液加入还原型谷胱甘肽在心脏瓣膜置换术中的心肌保护作用.方法30例心脏瓣膜置换术患者随机分为两组,实验组(n=15)在心脏含血停搏液中加入还原型谷胱甘肽(剂量600 mg),对照组(n=15)单用心脏含血停搏液,分别经主动脉根部或切开主动脉经冠状动脉窦直接灌注,两组分别于麻醉诱导后、主动脉开放后2 h、6 h、24 h采集患者静脉血,测血清肌酸激酶MB同工酶(CK-MB)、乳酸脱氢酶(LDH)、心肌肌钙蛋白I(cTnI).结果两组主动脉开放后血清CK-MB、LDH、cTnI均较麻醉诱导后显著升高,实验组主动脉开放后的血清CK-MB、LDH、cTnI均较对照组显著降低(P均＜0.05-0.01),差异均具有统计学意义.结论还原型谷胱甘肽加入心脏停搏液中具有良好的心肌保护作用.     

氨基酸盐温血停搏液诱导及末次再灌注对风湿性心脏病瓣膜置换术的心肌保护作用

目的观察天门冬氨酸盐(A)和谷氨酸盐(G)对风湿性心脏病瓣膜置换术心肌的保护作用。方法采用含A,G各13mmol/L的温血停搏液诱导心脏停搏与末次再灌注结合传统冷晶体心停搏液心肌保护法作为观察组,与观察组相同但不含氨基酸盐的温血停搏液组为对照组②,仅用单纯冷晶体心停搏液组为对照组①,对心肌保护法进行比较。结果观察组自动复跳和房颤转窦率明显较对照组①高(P<0.01),心肌释放肌酸磷酸激酶(CPK)少(P<0.01)。结论氨基酸盐温血停搏液诱导及末次再灌注心肌保护法明显优于传统的冷晶体心停搏液心肌保护法。     

冷血停搏液对5岁以下儿童先天性心脏病心肌保护效果的观察

目的本研究通过临床应用探索适用于5岁以下儿童心脏直视手术的心肌保护方法。 方法50例行择期法乐四联症根治术患儿随机分为2组对照组用冷晶体停搏液,实验组用冷血停搏液。阻断前,开放冠状动脉循环后1,3,10min分别由冠状静脉窦和动脉同时取血进行血气分析,并测定乳酸、丙二醛含量。术前、开放升主动脉后2,4,8,24,48h测定心肌酶谱。心脏停跳前,开放升主动脉后5min取右心室心肌观察超微结构改变,同时观察临床恢复情况。 结果实验组心电诱导停搏时间较长,量大,术后多巴酚丁胺及异丙肾上腺素平均最大剂量较高,使用时间较长,但心肌氧、乳酸摄取率恢复优于对照组(P＜0.05)。 结论冷血停搏液对紫绀型先天性心脏病患儿术中心肌保护效果较冷晶体停搏液无显著优越性。     

非体外循环下冠状动脉架桥术患者围术期心肌酶的动态变化

目的了解非体外循环下冠状动脉架桥术(OPCAB)患者围术期心肌酶的动态变化.方法13例OPCAB患者术前1 d,术后1、3、5、8 d晨分别取静脉血,测定血清天冬氨酸转氨酶(AST)、磷酸肌酸激酶及同功酶MB(CK,CK-MB)、乳酸脱氢酶及同功酶1(LDH,LDH-1).结果择期手术的OPCAB患者术前5种心肌酶均在正常范围,术后1 d达到高峰(P＜0.05);术后3 d CK-MB恢复到正常范围,其他心肌酶比术前测定值高,但差异无统计学意义(P＞0.05);术后5 d CK,术后8 d LDH、LDH-1恢复到正常水平,AST在手术后的所有测定值与手术前测定值相比差异均无统计学意义(P＞0.05).结论择期OPCAB患者术前5种心肌酶均在正常范围;术后1 d达最高峰,CK-MB恢复最快,LDH和LDH-1恢复最慢.OPCAB是一种对心肌损伤很小的手术方法.     

HTK液与含血停搏液心肌保护效果比较

目的 比较HTK液和含血停搏液在复杂心脏手术中的心肌保护效果。方法40例重症复杂心脏手术患者分为两组。HTK液组（16例）手术中采用HTK液保护心肌；对照组（24例）术中采用常规1：4含血停搏液保护心肌。测定术前、主动脉开放后8h、24h、48h血中肌钙蛋白I（cTnI）和磷酸激酶同工酶（CK-MB）浓度，并比较两组患者术后心脏自动复跳率、正性肌力药物使用率、机械通气支持时间、ICU监护时间等临床指标。结果HTK组和对照组平均体外循环转流时间和主动脉阻断时间无明显差异，术后心脏自动复跳率分别为87．5％、64．6％（P〈0．05）。主动脉开放后8h、24h对照组cTnI和CK-MB均明显高于HTK组（P〈0．05）。两组其余观察指标无明显差异。结论HTK心脏停搏液对复杂重症心脏手术患者的心肌保护作用略优于1：4含血停搏液。     

氨基酸在长时间心脏停搏中对心肌的保护作用

目的：探讨谷氨酸盐（Ｇ）和天门冬氨酸盐（Ａ）在长时间心脏缺血的心肌保护作用。方法：离体大鼠工作心模型。心脏在１５°Ｃ缺血１５０分钟。４８只Ｗｉｓｔａｒ大鼠分为３组：１组，即对照组（ｎ＝１６），心脏用多剂量４°ＣＳｔ．Ｔｈｏｍａｓ冷晶体心脏停搏液结合温血停搏液诱导及终末再灌注进行心肌保护；２组（ｎ＝１６）同１组，但温血停搏液含Ｇ和Ａ各１３ｍｍｏｌ／Ｌ；３组（ｎ＝１６）同１组，但Ｓｔ．Ｔｈｏｍａｓ冷晶体心脏停搏液和温血停搏液中均含相同浓度的Ｇ和Ａ。结果：温血停搏液中应用Ｇ和Ａ能增加心肌的收缩性和心输出量，使缺血后心肌耗氧量恢复较好（Ｐ＜０．０５）。Ｓｔ．Ｔｈｏｍａｓ冷晶体心脏停搏液和温血停搏液中应用Ｇ和Ａ均明显增加心肌保护，使心功能和心肌耗氧量几乎完全恢复。缺血后心肌酶漏出少，缺血前后心肌高能磷酸盐含量和含水量无明显变化，超微结构改变也不明显。结论：含Ｇ和Ａ温血停搏液诱导及终末再灌注增加冷晶体心脏停搏液对长时间心脏停搏的心肌保护效果，冷晶体心脏停搏液中也应用Ｇ和Ａ能提高心肌对长时间缺血的耐受性     

心脏手术中温血心脏停搏液微流量连灌心肌保护效果的研究

为提高心脏手术中心保护的效果，将20例风湿性心瓣膜病手术患者随机分为温血组与冷血组。温血组术中采用温血心脏停搏液微流量连续灌注，冷血采用冷血心脏停搏液间断灌注行心肌保护。检测两组体外循环主动脉开放后即刻，主动脉开放后6、12、24、72小时血清心肌肌钙蛋白Ⅰ（cTnI）值；术中切取心房肌肉标本，电镜下观察超微结构变化，对比评价心肌保护效果。结果术前及主动脉开放即刻两组血清cTnI无显著性差异（P＞0．05）；主动脉开放后6、12、24、72小时温血组cTnI均显著低于冷血组，P＜0．01；超微结构检测示温血组心肌纤维及线粒体损伤显著轻于冷血组。认为温血心脏停搏液微流量连灌的心肌保护效果优于冷血心脏停搏液间断灌注。     

主动脉夹层手术中Del Nido与传统心脏停搏液心肌保护效果的比较

目的 比较主动脉夹层手术中应用del Nido心脏停搏液和传统心脏停搏液的心肌保护效果。方法 回顾性总结分析2017年7月至2019年12月上海交通大学医学院附属新华医院63例主动脉夹层手术的临床资料,根据应用的心脏停搏液不同分两组,应用del Nido心脏停搏液（DN组）33例,应用传统心脏停搏液（传统组）30例。DN组用del Nido晶体液与氧合血按4：1混合（4份晶体1份血）,灌注量 20ml/kg,最大不超过 1 L。主动脉阻断时间超过90min再次灌注300ml。传统组应用4：1含血冷晶体改良St. Thomas液（4份血1份晶体）,灌注量 15ml/kg。每隔20-30min灌注一次（7.5ml/kg）。结果 两组术前一般资料无差异。术中体外循环时间、主动脉阻断时间传统组较长,但无统计学差异。停搏液灌注次数和灌注耗时传统组显著高于DN组。自动复跳率两组相近,DN组94%,传统组97%。术后早期（30天内）死亡率DN组（6.1%）与传统组（6.7%）无差异。术后第1天血清肌钙蛋白I DN组 (4.10±0.65ng/ml)与传统组（4.25±0.61 ng/ml）无差异。术后低心排发生率、术后1天和出院前LVEF两组之间均无统计学差异。结论 主动脉夹层术中应用del Nido心脏停搏液可以达到满意的心肌保护效果。     

左卡尼汀含血停搏液在心内直视术中的心肌保护作用

20例行心脏瓣膜置换手术患者随机分为对照组（冷血停搏液组）和实验组（冷血停搏液中加入左卡尼汀）各10例，分别于围术期多个时点取桡动脉血，测定血浆心型脂肪酸结合蛋白（HFABP）、肌钙蛋白（cTnI）、肌酸激酶同工酶（CK-MB）的水平，并观察手术前后心肌超微结构的变化。结果显示，两组术后HFABP、cTnI、CK-MB的水平均较术前显著升高，实验组上述指标均明显低于对照组。认为外源性左卡尼汀加入心脏停搏液能显著提高心肌保护效果。     

非体外与体外循环下冠状动脉旁路移植术病人的心肌酶变化

目的 比较患者在非体外循环下冠状动脉旁路移植术(off-pump coronary artery bypass grafting,OPCAB)与体外循环下冠状动脉旁路移植术(on-pump coronary artery bypass grafting,CCABG)围术期心肌酶的变化.方法 择期手术的冠心病患者52例,分为OPCAB组和CCABG组.分别于术前1天,术后1,3,5,8日晨测定血清天冬氨酸转氨酶(glutamic-oxal (o)acetic transaminase,GOT),肌酸激酶(creatine kinase,CK)及心肌型肌酸激酶同工酶MB(MB isoenzyme of creatine kinase,CK-MB),乳酸脱氢酶(lactate dehydrogenase,LDH)及同工酶1(LDH-1).结果 两组择期手术的冠心病患者术前心肌酶的测定结果均在正常范围;术后第1天两组的心肌酶释放达到高峰(P＜0.05),术后第3天均有不同程度的恢复;OPCAB组的所有心肌酶释放量与手术前相比差异无统计学意义(P＞0.05),CCABG组的CK-MB也恢复到手术前水平(P＞0.05),但CCABG组在术后第5天和第8天的LDH和LDH-1仍明显高于术前水平(P＜0.05);两组病人术后第3天的CK-MB恢复到术前水平,但CCABG组其他心肌酶在术后第1天和第3天都明显高于OPCAB组(P＜0.05),CCABG组在术后第5天和第8天的LDH和LDH-1仍明显高于OPCAB的对应值(P＜0.05).结论 OPCAB组的心肌的损伤要轻于CCABG组,表现为心肌酶的释放少而且恢复快.     

心肌酶谱对血停跳液心肌保护作用的评价

在５２例复杂先心病心内矫正术中，应用血停跳液（ＢＣＰ）加强心肌保护，与晶体停跳液（ＣＣＰ）进行比较。记录术前、术后６、１２、２４、４８、７２小时内ＣＰＫ、ＣＫ－ＭＢ、ＡＳＴ、ＬＤＨ的变化。结果显示５：术后７２小时内，ＢＣＰ组ＣＫ－ＭＢ值均低于ＣＣＰ组，其峰值只是ＣＣＰ组的５９．８％（Ｐ＜０．０５），酶的释出量大为减少，并于７２小时降至正常，恢复比ＣＣＰ组早；ＣＰＫ、ＡＳＴ、ＬＤＨ值均显示较ＣＣＰ组低。血停跳液能增加心肌能量储备，提高心肌抗缺血的能力，减轻心肌损伤的程度，在加强复杂先心病的心肌保护中，显示出显著的效果。ＢＣＰ心肌保护的效果优于ＣＣＰ。     

Clinical evaluation of hypothermic ventricular fibrillation, multi-dose blood cardioplegia, and single-dose Bretschneider cardioplegia in coronary surgery

37 patients undergoing coronary revascularization were randomly assigned to three protocols for intraoperative myocardial protection: hypothermic ventricular fibrillation (HF) (n = 13), multi-dose blood cardioplegia (BCP) (n = 12) and single-dose Bretschneider's crystalloid cardioplegia (CCP) (n = 12). As intraoperative markers of ischemic damage myocardial ultrastructure, ATP, and CP contents were determined in left ventricular biopsy specimens taken before and after cardiac arrest. Release of serum enzymes (CK, CK-MB, LDH, SGOT) was determined pre- and postoperatively. Hemodynamic data were assessed before, during, and after operation. The incidence of low cardiac output, positive inotropic support, intraaortic balloon counterpulsation, peri-operative myocardial infarction, rhythm disturbances, and the rate of spontaneous defibrillation was compared between groups. The results show a better preservation of high energy phosphates in the BCP group as compared to the HF and CCP groups. Myocardial ultrastructure showed moderate ischemic damage in the hypothermic fibrillation group; in contrast, only slightly deteriorated cells were seen after cardiac arrest, when cardioplegia was used. The incidence of rhythm disturbances was 25% for HF and 42% for CCP. In contrast, only 17% of new rhythm disturbances were seen in the BCP group. Functional recovery (i.e. CI and SWI) of hearts protected with BCP was generally greater as compared to HF and CCP. Release of MB-creatine-kinase isoenzyme was higher in the HF group as compared to cardioplegia. Clinical outcome in terms of incidence of peri-operative infarction, positive inotropic support and low cardiac output was superior in the BCP group but not significantly different between groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

心肌肌钙蛋白I对体外循环心内直视手术心肌损伤的判定价值

目的探讨心肌肌钙蛋白I（cTnI）对体外循环心内直视手术心肌损伤的判定价值。方法40例心脏瓣膜置换手术病人随机分为两组，冷晶体停跳液组（A组），温血停跳液组（B组），每组20例，分别于围手术期多时点采取中心静脉血，测定血清cTnI、心肌肌酸激酶（CK）及其心肌肌酸激酶同工酶（CK-MB）。结果术前两组的cTnI、CK及CK-MB水平均在正常范围，开放主动脉后1h至术后24h达峰值．其后缓慢下降。术后24h、48hB组cTnI水平明显低于A组（P〈0．05），CK—MB在开放主动脉后1hB组低于A组。cTnI峰值浓度与主动脉阻断时间呈直线正相关。结论cTnI判定心内直视手术围手术期心肌损伤的敏感性及特异性明显优于CK、CK—MB，对围手术期心肌缺血损伤的诊断、预后及心肌保护效果的评价具有重要的临床价值。     

Hyperkalemic blood versus crystalloid cardioplegia in longer clamping times

The 715 patients who had crystalloid cardioplegia were compared with 5419 who had cold hyperkalemic blood cardioplegia for isolated coronary artery grafting from 1996 through 2001. Creatine kinase-MB was measured preoperatively, at 90 min, and 7 hours after the end of extracorporeal circulation. Correlation of post-bypass creatine kinase-MB release with aortic crossclamp time and other variables in the two cardioplegia groups was made using dichotomous encoding of cardioplegia in a multivariate linear regression model. Creatine kinase-MB levels 90 min after bypass were higher in patients who had crystalloid cardioplegia than in those who had blood cardioplegia. There was a linear relationship between aortic crossclamp time and post-bypass creatine kinase-MB release in both cardioplegia groups. Post-bypass creatine kinase-MB release increased with aortic crossclamp time independently of other factors and significantly more with crystalloid cardioplegia than with blood cardioplegia (the slope of the regression line was 0.230 versus 0.106). Intraaortic balloon pumping was used less frequently in the blood cardioplegia group. There was an advantage with blood cardioplegia for myocardial protection in longer aortic crossclamp times for isolated coronary bypass grafting.     

温血停搏液连续灌注对心肌保护作用的实验研究

本实验采用离休鼠心模型，比较并评定了冷晶体停搏液和温血停搏液对心肌保护的效果。结果表明：温血停搏液连续灌注有明显加强心肌保护的作用，对高体鼠心准注能减少心肌细胞CK和CK—MB的漏出，加强心肌细胞内ATP含量的储存，增加心肌细胞内线粒体的比表面，降低线粒体的平均分数，其效果明显优于冷晶体停搏液。     

晶体停跳液和含血停跳液的临床应用研究

目的：观察晶体停跳液和含血停跳液对心肌的保护作用。方法：２０例择期性心脏瓣膜替换术患者分别用晶体停跳液（１０例）和含血停跳液（１０例）灌注的结果进行分析。结果：两组在直视手术中心脏停跳良好。围术期血液动力学指标，平均动脉压、中心静脉压、心率无明显差异。心肌摄氧率大致相同。但晶体停跳液组的冠状动脉乳酸摄取率明显低于含血停跳液组，而含血停跳液组的血浆肌酸激酶及其同功酶的水平明显低于晶体停跳液组。电子显微镜观察可见晶体停跳液组右心房心肌的超微结构（线粒体、肌丝）严重损坏，而含血停跳液组对其有明显保护效果。含血停跳液组自动复跳率（６０．５％）明显高于晶体停跳液组（４４．９％）。结论：含血停跳液有很多优点，如临床安全性、心肌酶释放减少、超微结构损伤轻等。     

Leukocyte-depleted continuous blood cardioplegia for coronary artery bypass grafting

Many cardiac surgeries are performed with blood cardioplegia. However, some studies suggest that activated neutrophils form blood cardioplegia can cause reperfusion injury. In this study we assessed myocardial protection using a leukocyte-depleted cardioplegic solution. Patients undergoing elective coronary artery bypass grafting (CABG) with continuous blood cardioplegia were divided into two groups: the LD group, which received leukocyte-depleted blood cardioplegia (n = 11); and the control group, which received nonfiltered blood cardioplegia (n = 11). IL-6, IL-8, CK-MB, and troponin T were measured in the coronary sinus blood immediately after the release of the aortic cross-clamp. Cytokine concentrations were also measured upon the patient's return to the ICU. The total dopamine and dobutamine doses, hemodynamic measurements after surgery, and the leukocyte filtration rate were also measured. During antegrade cardioplegia infusion, leukocytes were almost completely removed (filtration rate: 85.8+/-4.0%). However, during terminal warm cardioplegia, leukocyte removal decreased (filtration rate: 39.9+/-7.8%). Immediately after the release of the aortic cross-clamp, plasma CK-MB and troponin T concentrations were significantly lower in the LD group (17.7+/-1.9 U/l and 0.017+/-0.002 ng/ml, respectively) than in the control group (30.3+/-3.6 U/l and 0.072+/-0.029 ng/ml, respectively). The IL-6 and IL-8 concentrations were similar in the LD group and the control group. After the return to the ICU, the CK-MB and troponin T concentrations were similar in the two groups. No significant differences were found in the total doses of dopamine or dobutamine after surgery in the two groups (99+/-77 vs 101+/-128 microg/kg/min). No significant differences were found in the hemodynamic parameters after surgery in the two groups. In patients undergoing CABG with continuous blood cardioplegia, leukocyte-depleted blood cardioplegic solution may attenuate reperfusion injury.