老年人工生物瓣膜置换过程中紫外线照射充氧血首次灌注对心肌的保护

背景:动物实验表明将紫外线照射充氧血添加于心停搏液中有一定的心肌保护作用,故推测其对体外循环心内直视手术患者的心肌也有保护作用.目的:课题提出使用紫外线照射充氧血行首次冠状动脉顺行灌注,观察其在老年患者人工生物心脏瓣膜置换体外循环过程中是否对心肌有保护作用.设计、时间及地点:生化水平的随机对照试验,于2006-10/2008-04在贵州省人民医院心脏外科完成.对象:选择贵州省人民医院心脏外科收治需择期行人工生物瓣膜置换的风湿性心脏瓣膜病老年患者46例,按随机数字表法分为2组,每组23例.方法:紫外线照射充氧血组于麻醉后通过锁骨下静脉按10 m/kg放血行紫外线照射充氧(同时经另一静脉途径输入等量生理盐水,术前经过计算,体外循环过程中血红蛋白低于70g/L者,用库血代替自体血行紫外线照射充氧),升主动脉阻断后,将紫外线照射充氧血作为心停搏液组成成分进行首次冠状动脉顺行灌注,之后每30 min常规以4:1冷血/晶体灌注.对照组首次冠状动脉顺行灌注使用不含紫外线照射充氧血的4:1冷血/晶体外,其他处理同治疗组.主要观察指标:于升主动脉阻断前,升主动脉开放后5,10 min从冠状静脉窦取血2 mL,测定超氧化物歧化酶活性及丙二醛浓度.在升主动脉阻断前,停体外循环后4,24,48 h时从中心静脉取血2 mL,测定肌酸激酶同工酶活性及肌钙蛋白I质量浓度.结果:开放升主动脉后,紫外线照射充氧血组冠状静脉窦血清丙二醛浓度低于对照组(P＜0.05),超氧化物歧化酶活性显著高于对照组(P<0.05).紫外线照射充氧血组停体外循环后4-48 的血清肌酸激酶同工酶活性及肌钙蛋白I质量浓度显著低于对照组(P< 0.05).结论:体外循环过程中首次冠状动脉顺行灌注紫外线照射充氧血能提高心肌细胞超氧化物歧化酶活性,减少丙二醛产生,减轻心肌缺血再灌注损伤.降低心肌损伤标志物水平,对老年人工生物心脏瓣膜置换患者具有较好的心肌保护作用.

Myocardial protective effect of ultraviolet blood irradiation and oxygenation cardioplegia solution in old patients undergoing valve replacement

BACKGROUND: Animal experiments demonstrated that adding ultraviolet blood irradiation and oxygenation (UBIO) in cardioplegic solutions has myocardial protection during cardiopulmonary bypass (CPB).OBJECTIVE: To investigate the myocardial protective effect of UBIO as cardiac arresting solution in the process of CPB in old patients undergoing valve replacement.DESIGN, TIME AND SETTING: The randomized controlled trial of biochemistry level was performed at Department of Cardiac Surgery, Guizhou Provincial People's Hospital, from October 2006 to April 2008.PARTICIPANTS: A total of 46 old patients scheduled for heart valve replacement were randomly divided into test group and control group, with 23 patients in each group.METHODS: The test group was infuoed with the UBIO blood as a cardiac arresting solution via the ascending aorta. The UBIO blood accumulated from the subclavian vein (10 mL/kg) was heparinized and dealt with the ultraviolet irradiation (wave length 240-300 nm) and oxygenation. And then it was infused for the first antegrade coronary perfusion when the ascending aorta was cross-clamped, when the UBIO blood was produced, the equivalent quantitative saline was infused from another vein. The 4:1 cold oxygenated blood hyperhalemia cardioplegia was perfused and then maintained for 30 minutes. The control group was the same as the test group except that the cardiac arresting solution presented without the 4:1 cold oxygenated blood.MAIN OUTCOME MEASURES: Blood samples were withdrawn from coronary venous sinus before cross-clamping and at minutes 5 and 10 after aorta declamping, to measure the levels of superoxide dismutase (SOD) and the content of malondialdehyde (MDA). Before the beginning of CPB, and at hours 4, 24, and 48 after the end of CPB, venous blood was drawn to test the serum cardiac troponin I(cTnI) and creatine kinase isozyme (CK-MB).RESULTS: MDA levels of plasma were less in the test group than that of the control group after aorta declamping (P < 0.05),while the SOD activity was obvious greater than the control group (P < 0.05). At hours 4-48 after CPB, CK-MB and cTnl levels were lower in the test group than the control group (P< 0.05).CONCLUSION: Antegrade coronary first perfusion with UBIO during CPB has evident cardiac protective in old patients undergoing valve replacement by elevating SOD activity, decreasing MDA level, relieving myocardial reperfusion injury, as well as decreasing myocardial damage markers levels.