体外循环心脏瓣膜植换患者围术期纤溶系统的改变  

Change of fibrinolytic system during perioperation in patients undergoing mechanical heart valve replacement surgery

作　　者：侯立仁[1] 韩培立[2] 李强[3] 曹淑娥[1] 杨双梅[1] 

机构地区：[1]新乡医学院一附院麻醉科,河南卫辉453100 [2]新乡医学院一附院胸外科,河南卫辉453100 [3]新乡医学院一附院中心实验室,河南卫辉453100

出　　处：《中国现代医学杂志》2008年第15期2196-2198,2201,共4页China Journal of Modern Medicine

基　　金：河南省教育厅资助项目(No:2007320015)

摘　　要：目的探讨体外循环(CPB)下心脏瓣膜植换患者围术期纤维蛋白(原)溶解系统的改变情况,为抗纤溶治疗提供理论依据。方法选择20例ASAⅡ、Ⅲ级,择期行心脏机械瓣膜植换的患者。分别于麻醉前(T1)、肝素化前(T2)、主动脉阻断开放时(T3)、CPB结束鱼精蛋白中和后l0min(T4)、术毕2h(T5)、24h(T6)、48h(T7)等7个时间点抽取中心静脉血测定:血小板计数(PLT)、全血激活凝固时间(ACT)、组织纤溶酶元激活物(t-PA)、纤溶酶元激活物抑制物(PAI)和D-二聚体(D-dimer)。分析围术期纤维蛋白(原)溶解系统的变化规律。结果与麻醉前比较,PLT在术中、术后显蓍减少,术后48h仍未达麻醉前水平(P<0.05);t-PA从转流开始至术后24h显著增高(P<0.01),至术后48h下降至麻醉前水平;PAI在CPB中骤降至最低水平(P<0.01),在此后的各点有所回升,但术后48h仍显著低于麻醉前(P<0.01);D-Dimer从转流开始至术后48h明显升高(P<0.01),术后24h有下降趋势,但在术后48h又显著升高(P<0.01)。结论机械瓣膜植换的围术期存在纤溶系统的激活,CPB后存在纤维蛋白降解产物的增高,从而影响了正常凝血功能。[Objective] To investigate the changes of the fibrinolytic system in patients undergoing mechanical heart valve replacement surgery during cardiopulmonary bypass （CPB） and discuss the measures of its protection. [Methods] To select 20 cases of patients of ASA physical status Ⅱ-Ⅲ undergoing mechanical heart valve replacement surgery. Blood samples were taken from jugular vein to assay platelet count （PLT）, activated coagnlation time （ACT）, tissue-type plasminogen activator（t-PA）, plasminogen activator inhibitor （PAl） and D-dimer before anesthesia （T1）, before heparinization （T2）, before CPB, after arteriae aorta unclamp, 10 min after CPB and 2, 24, 48 h after operation. [Results] Compared with those before anesthesia, PLT and AT-Ⅲ significantly decreased during operation and 2, 24, 48 h after operation（P 〈0.05, P〈0.01）. ACT significantly decreased 48 h after operation （P 〈0.05）. PT and APTT significantly increased at the T4 and T5（P 〈0.01）, but they significantly decreased at the T7（P 〈0.05）. The t-PA significantly increased at the T3-T6（P 〈0.01）, it recovered to the level of pre-anesthesia at the T7. PAl suddenly decreased at the T3,then it elevated progressively after operation but was lower （P 〈0.01） than that at the T7 time point. D - Dimer significandy increased at the T3-T7 （P 〈0.01）, while there were descending tendency at the T6,but it significantly increased at the T7 compared with T6 point （P 〈0.01）. [Conclusions] This study shows that there is an activation of the fibrinolytic system during perioperation in patients undergoing mechanical heart valve replacement surgery and an increase of fibrinogen degradation product after CPB, thus interferes blood coagulation.

关 键 词：心脏瓣膜 心肺转流术 纤维蛋白(原)溶解 

分 类 号：R654.1[医药卫生—外科学]