肢体远隔缺血预处理对CPB下心脏瓣膜置换术后老年病人心肌损伤的影响  

Effect of remote limb ischemic preconditioning on myocardial injury after cardiac valve replacement under cardiopulmonary bypass in elderly patients

作　　者：郎志斌 葛振伟 邱林 徐红党 赵亮 李雪 林洪启 Lang Zhibin;Ge Zhenwei;Qiu Lin;Xu Hongdang;Zhao Liang;Li Xue;Lin Hongqi(Department of Anesthesiology,Fuwai Huazhong Cardiovascular Hospital,Henan Provincial People′s Hospital,Zhengzhou University People′s Hospital,Henan University People′s Hospital,Zhengzhou 450003,China;Cardiovascular Surgery Center,Fuwai Huazhong Cardiovascular Hospital,Henan Provincial People′s Hospital,Zhengzhou University People′s Hospital,Henan University People′s Hospital,Zhengzhou 450003,China)

机构地区：[1]阜外华中心血管病医院,河南省人民医院,郑州大学人民医院,河南大学人民医院麻醉科,450003 [2]阜外华中心血管病医院,河南省人民医院,郑州大学人民医院,河南大学人民医院心血管外科中心,450003

出　　处：《中华麻醉学杂志》2020年第9期1066-1070,共5页Chinese Journal of Anesthesiology

基　　金：河南省医学科技攻关计划联合共建项目(2018020460)。

摘　　要：目的评价肢体远隔缺血预处理(RIPC)对体外循环(CPB)下心脏瓣膜置换术后老年病人心肌损伤的影响。方法择期行全身麻醉CPB下心脏瓣膜置换术老年病人60例,性别不限,年龄65~78岁,体重50~80 kg,身高150~180 cm,ASA分级Ⅱ或Ⅲ级,NYHA分级Ⅱ或Ⅲ级,左室射血分数(LVEF)>40%,按照随机数字表法分为2组:对照组(C组)和RIPC组,每组30例。RIPC组于麻醉诱导后5 min实施RIPC。具体步骤如下:在右上肢上臂放置袖带,充气加压使压力200 mmHg,持续5 min后袖带放气至0 mmHg,5 min后再次充气加压,此为1个周期,如此进行3个周期。C组于麻醉诱导后5 min将袖带绑于病人右上肢,但不进行充气及放气操作。于术前(T0)、主动脉开放后1 h(T1)、术后6 h(T2)、12 h(T3)和24 h(T4)时抽取病人颈内静脉血样,检测血浆氨基末端B型脑钠肽前体(NT-proBNP)、cTnI和CK-MB浓度。术前和术后4周时采用心脏彩色多普勒仪器测定左室舒张末期内径(LVEDD)、左室收缩末期内径(LVESD)和LVEF。记录ICU停留时间和住院时间。结果与C组比较,RIPC组T2~4时血浆NT-proBNP、cTnI、CK-MB浓度、术后4周LVEDD和LVESD降低,LVEF升高(P<0.05)。2组病人ICU停留时间和住院时间差异均无统计学意义(P>0.05)。结论RIPC可减轻CPB下心脏瓣膜置换术后老年病人的心肌损伤,改善心功能。Objective To evaluate the effect of remote limb ischemic preconditioning(RIPC)on myocardial injury after cardiac valve replacement under cardiopulmonary bypass(CPB)in elderly patients.Methods Sixty patients of both sexes,aged 65-78 yr,weighing 50-80 kg,with height 150-180 cm,of American Society of Anesthesiologists physical statusⅡorⅢ,of New York Heart Association classⅡorⅢ,with left ventricular ejection fraction(LVEF)>40%,scheduled for elective cardiac valve replacement with CPB under general anesthesia,were divided into 2 groups according to the random number table method:control group(group C)and RIPC group,with 30 cases in each group.Patients underwent RIPC at 5 min after induction of anesthesia in RIPC group.The specific steps were as follows:the cuff was placed on the upper arm of the right upper limb and inflated to a pressure of 200 mmHg,lasing for 5 min,then the cuff was deflated to 0 mmHg,and 5 min later the cuff was inflated again,which was a cycle,and this cycle was repeated for 3 times.In group C,the cuff was tied to the patient′s right upper limb at 5 min after induction of anesthesia,but no inflation or deflation was performed.Before surgery(T0),at 1 h after aortic opening(T1),and at 6,12 and 24 h after surgery(T2-4),blood samples were taken from the internal jugular vein to detect the concentrations of plasma N-terminal pronatriuretic peptide,cardiac troponin and creatine kinase-MB concentrations.Left ventricular end-diastolic diameter,left ventricular end-systolic diameter,and LVEF were measured by cardiac color Doppler instrument before surgery and at 4 weeks after surgery.Time of intensive care unit stay and length of hospital stay were recorded.Results Compared with group C,the plasma concentrations of N-terminal pronatriuretic peptide,cardiac troponin and creatine kinase-MB at T2-4 and left ventricular end-diastolic diameter and left ventricular end-systolic diameter at 4 weeks after surgery were significantly decreased,and LVEF was increased at 4 weeks after surgery in group RIPC(P

关 键 词：缺血预处理 体外循环 心脏瓣膜假体植入 心肌再灌注损伤 老年人 

分 类 号：R654.2[医药卫生—外科学] R542.2[医药卫生—临床医学]