外科换瓣术中心脏停搏前灌注左西孟旦心肌缺血预处理的疗效分析  

Therapeutic effect of levosimendan infusion to ischemic preconditioning on surgical treatment of cardiac valve replacement before arrested heart

作　　者：杨文聪 彭晓鹏 沈国刚 单飞 林明 柯略森 YANG Wen-cong;PENG Xiao-peng;SHEN Guo-gang;SHAN Fei;LIN Mingz;KE Lue-sen(Department of Cardiology,Seventh Affiliated Hospital of Sun Yat-sen University,Guangdong Shenzhen 518107,China;Department of Cardiac Surgery,Dongguan Kanghua Hospital,Guangdong Dongguan 523000,China;Department of Thoracic Surgery,Dongguan Kanghua Hospital,Guangdong Dongguan 523000,China)

机构地区：[1]中山大学附属第七医院心内科,广东深圳518107 [2]广东省东莞康华医院心外科,广东东莞523000 [3]广东省东莞康华医院胸外科,广东东莞523000

出　　处：《中国医刊》2018年第10期1127-1130,共4页Chinese Journal of Medicine

基　　金：东莞市社会科学发展一般项目(201750715059039)

摘　　要：目的探讨外科换瓣术中心脏停搏前经主动脉根部灌注左西孟旦进行心肌缺血预处理对心肌的保护效果,寻求重症瓣膜病患者外科换瓣术中的心肌保护策略。方法回顾性分析2017年1月至2018年2月于东莞康华医院行外科换瓣治疗的52例重症瓣膜病患者,根据在体外循环辅助下心脏停搏前是否经主动脉根部灌注(应用微量泵持续泵入)左西孟旦进行心肌缺血预处理,将患者分为左西孟旦组(n=26)和对照组(n=26)。左西孟旦组在体外循环辅助下心脏停搏前应用微量泵持续泵入左西孟旦,剂量为6~12μg/kg,总时长约10分钟;对照组在常规体外循环辅助下行外科换瓣处理。观察两组患者术中使用体外循环辅助的时间、心脏自动复跳率、正性肌力药物(如多巴胺、肾上腺素)应用情况,术前及术后6、24、48小时的心肌酸激酶同工酶、肌钙蛋白I、脑利钠肽、血乳酸、肌酐水平,记录两组患者围术期并发症(呼吸功能不全、心律失常、低心排综合征、主动脉内球囊反搏机械辅助及死亡等)发生情况。结果与对照组比较,左西孟旦组患者术中心脏自动复跳率更高,体外循环辅助时间更短,正性肌力药物使用剂量更低。术前心肌酸激酶同工酶、肌钙蛋白I、脑利钠肽、血乳酸及肌酐水平两组比较差异无显著性(P>0.05),左西孟旦组术后6、24小时及对照组术后6、24、48小时心肌酸激酶同工酶、肌钙蛋白I、脑利钠肽、血乳酸及肌酐水平均明显高于术前,且术后6、24、48小时对照组明显高于左西孟旦组,差异有显著性(P<0.05)。左西孟旦组患者围术期出现呼吸衰竭、肾功能不全、严重心律失常、低心排综合征等并发症的发生率明显低于对照组(P<0.05),且无应用动脉内球囊反搏机械辅助及死亡事件。结论重症瓣膜病患者换瓣术中应用左西孟旦进行心肌缺血预处理可明显减轻心肌损伤程度,降低围术期并发症�Objective To explore the protective effect of levosimendan infusion to ischemic preconditioning on surgical treatment of cardiac valve replacement before arrested heart, and to search for an effective strategy for treating severe valvular heart disease. Method 52 patients with severe valvular heart disease underwent cardiac valve replacement in the Cardiac Surgery Department, Dongguan Kanghua Hospital from January 2017 to February 2018 were enrolled in this study. Patients were randomly divided into treatment group and control group, with 26 cases in each group. Patients in treatment group received levosimendan infusion using micro pump through the aortic root during cardiopulmonary bypass. Levosimendan infusion was performed at a dose of 6-12 μg/kg for 10 min. Patients in control group received traditional cardiopulmonary bypass after cardiac valve replacement. Doses of positive inotropic drugs（dopamine, epinephrine） were adjusted based on the duration of cardiopulmonary bypass and spontaneous repeating rate. Meanwhile, levels of myocardial enzymes（CK-MB）, troponin I（cTnI）, brain natriuretic peptide（BNP）, blood lactic acid（BLA） and creatinine（CR） before and 6 h, 24 h, 48 h after surgery between the two groups were detected. Postoperative complications, including respiratory insufficiency, arrhythmia, low cardiac output syndrome, IABP（mechanical assistant circulation） and mortality rate between the two groups were recorded. Result Elevated spontaneous repeating rate, decreased duration of cardiopulmonary bypass and doses of the positive inotropic drugs were observed in the treatment group compared with those of the control group. No significant differences in preoperative levels of CK-MB, cTnI, BNP, BLA and CR between the two groups（P〉0.05）. However, there were significant differences in postoperative levels of CK-MB, c Tn I, BNP, BLA and CR at different time points between the two groups（P〈0.05）. Lower complication rate was found in the treatment group compared with that

关 键 词：左西孟旦 缺血预处理 心肌保护 体外循环 心瓣膜置换术 

分 类 号：R541[医药卫生—心血管疾病]