心脏手术围术期心肌损伤患者冠状动脉循环内NE与MPO的变化  

Prognostic value of perioperative change of neutrophil elastase and myeloperoxidase in coronary circulation on perioperative myocardial injury and clinical outcome of patients underwent surgical valve replacement

作　　者：潘沱 姜晨煜 张海涛 张赫 刘畅[3] 密琳 范阜东[3] 陈祖君 王东进 Pan Tuo;Jiang Chenyu;Zhang Haitao;Zhang He;Liu Chang;Mi Lin;Fan Fudong;Chen Zujun;Wang Dongjin(Department of Cardio-Thoracic Surgery,Nanjing Drum Tower Hospital,Chinese Academy of Medical Sciences&Peking Union Medical College,Nanjing 210008,China;Department of Cardiothoracic Surgery,Shanghai Children′s Medical Center,School of Medicine,Shanghai Jiao Tong University,Shanghai 200120,China;Department of Cardio-Thoracic Surgery,Nanjing Drum Tower Hospital,the Affiliated Hospital of Nanjing University Medical School,Nanjing 210008,China;Department of Intensive Care Unit,Chinese Academy of Medical Sciences&Peking Union Medical College Fuwai Hospital,Beijing 100037,China)

机构地区：[1]中国医学科学院、北京协和医学院、南京鼓楼医院心胸外科,南京210008 [2]上海交通大学医学院附属上海儿童医学中心心胸外科,上海200120 [3]南京大学医学院附属南京鼓楼医院心胸外科,南京210008 [4]中国医学科学院、北京协和医学院、国家心血管病中心、阜外医院术后恢复中心,北京100037

出　　处：《中华心血管病杂志》2023年第4期400-406,共7页Chinese Journal of Cardiology

基　　金：南京市心血管病临床医学中心(CZLB506-2020);国家自然科学基金(82270346,81970401)。

摘　　要：目的研究心脏手术围术期心肌损伤患者冠状动脉循环内髓过氧物酶(MPO)与中性粒细胞弹性蛋白酶(NE)的变化及其临床意义。方法该研究为前瞻性队列研究,入选2021年6月至2022年6月在南京鼓楼医院及北京阜外医院行外科瓣膜置换手术的患者。发生围术期心肌损伤的患者为心肌损伤组。在未发生心肌损伤的患者中依据年龄、性别及术式按1∶1的比例匹配对照组。其中围术期心肌损伤定义为术后第1天心肌肌钙蛋白T(cTnT)>0.8μg/L,且术后第2天的cTnT水平相较于第1天增加10%以上。术中分别于阻断升主动脉前及开放升主动脉后5 min内,从患者冠状静脉窦口采集血标本,测量MPO及NE水平。记录患者住院期间死亡、恶性室性心律失常、肺炎、二次气管插管、二次手术发生情况,术后体外膜肺氧合(ECMO)、主动脉内球囊反搏(IABP)、连续性肾脏替代治疗(CRRT)使用情况及呼吸机使用时间、重症监护室(ICU)滞留时间。比较心肌损伤组与对照组的MPO及NE水平以及临床结局发生率,采用多因素logistic回归分析心肌损伤的影响因素。结果共入选130例患者,年龄(60.6±7.6)岁,男性59例(45.4%),心肌损伤组及对照组各65例。住院期间,两组均无死亡、使用ECMO、IABP及CRRT病例;与对照组比较,心肌损伤组患者恶性室性心律失常[13.8%(9/65)比3.1%(2/65),P=0.03]、肺炎[20.0%(13/65)比3.1%(2/65),P=0.03]、二次气管插管[6.2%(4/65)比0,P=0.04]发生率更高,术后呼吸机使用时间[16.8(10.7,101.7)h比7.5(4.7,15.1)h,P<0.01]、ICU滞留时间[3.7(2.7,18.9)d比2.7(1.8,6.9)d,P<0.01]更长。主动脉阻断前两组冠状静脉窦血中的MPO及NE水平差异均无统计学意义(P均>0.05)。但主动脉开放后5 min心肌损伤组冠状静脉窦血中的MPO[(551.3±124.2)μg/L比(447.2±135.9)μg/L,P<0.01]及NE[(417.0±83.1)μg/L比(341.0±68.3)μg/L,P<0.01]水平明显高于对照组。多因素logistic回归分析结果显示主动脉开�Objective To investigate the clinical value of observing perioperative changes of myeloperoxidase(MPO)and neutrophil elastase(NE)in coronary artery circulation in patients underwent valve replacement surgery.Methods This perspective cohort study was performed in patients who underwent valvular surgery in Nanjing Drum Tower Hospital and Fuwai Hospital from June 2021 to June 2022.Patients were divided into perioperative myocardial injury group and age-,sex-and type of cardiac procedure-matched non-perioperative myocardial injury control group in the ratio of 1∶1.Perioperative myocardial injury was defined as cardiac troponin T(cTnT)>0.8μg/L on the first postoperative day(POD),and the cTnT level on the second POD increased by more than 10%compared with the cTnT level on the first POD.During the operation,blood samples were collected from the coronary sinus before clamping ascending aorta,and within 5 minutes after de-clamping ascending aorta.Then,the levels of MPO and NE on coronary sinus were continuously measured.The death,severe ventricular arrhythmia,pneumonia,re-intubation,repeat cardiac surgery,extracorporeal membrane oxygenation(ECMO),intra-aortic balloon pump(IABP),continuous renal replacement therapy(CRRT),mechanical ventilation time and the duration of intensive care unit(ICU)were recorded.The levels of MPO and NE and the incidence of clinical outcomes were compared between the myocardial injury group and the control group.The independent risk factors of myocardial injury were analyzed by multivariate logistic regression.Results A total of 130 patients were enrolled,aged(60.6±7.6)years old,with 59 males(45.4%).There were 65 patients in the myocardial injury group and 65 patients in the control group.During hospitalization,there was no death,ECMO,IABP and CRRT cases in both groups.Compared with the control group,the incidence of severe ventricular arrhythmia(13.8%(9/65)vs.3.1%(2/65),P=0.03),pneumonia(20.0%(13/65)vs.3.1%(2/65),P=0.03),re-intubation(6.2%(4/65)vs.0,P=0.04)was significantly higher in myocar

关 键 词：白细胞弹性蛋白酶 过氧化物酶 心脏外科手术 心肌再灌注损伤 

分 类 号：R654.2[医药卫生—外科学]