心脏手术中温血心脏停搏液微流量连灌心肌保护效果的研究

为提高心脏手术中心保护的效果，将20例风湿性心瓣膜病手术患者随机分为温血组与冷血组。温血组术中采用温血心脏停搏液微流量连续灌注，冷血采用冷血心脏停搏液间断灌注行心肌保护。检测两组体外循环主动脉开放后即刻，主动脉开放后6、12、24、72小时血清心肌肌钙蛋白Ⅰ（cTnI）值；术中切取心房肌肉标本，电镜下观察超微结构变化，对比评价心肌保护效果。结果术前及主动脉开放即刻两组血清cTnI无显著性差异（P＞0．05）；主动脉开放后6、12、24、72小时温血组cTnI均显著低于冷血组，P＜0．01；超微结构检测示温血组心肌纤维及线粒体损伤显著轻于冷血组。认为温血心脏停搏液微流量连灌的心肌保护效果优于冷血心脏停搏液间断灌注。     

常温体外循环温血心停搏液持续灌注心肌保护的实验研究

目的　为了探讨常温体外循环温血心停搏液持续灌注心肌保护的机理。方法　１５ 条犬随机分成三组,在体外循环下分别灌注三种不同的心停搏液,对三种不同的心肌保护方法进行对比观察。结果　温血心停搏液灌注液（Ｃ组） 的ＣＫ－ ＭＢ、ＬＤＨ、ＭＤＡ 及钙离子含量在心脏再灌注３０ｍｉｎ 时均明显低于冷晶体（Ａ 组） 及冷血心停搏液灌注组（Ｂ组）（ Ｐ＜ ０－０５）;而ＡＴＰ 含量则明显高于Ａ、Ｂ 两组（ Ｐ＜０－０５）。心肌超微结构检查也显示Ｃ组心肌无明显缺血损伤。结论　常温体外循环温血心停搏液持续灌注心肌保护的效果良好。     

紫外线照射充氧自体血心脏停搏液对体外循环中心肌保护作用的研究

目的 研究紫外线照射充氧自体血（UBIO）心脏停搏液冠状动脉间断顺行灌注对体外循环（CPB）中心肌的保护作用。方法 将20只健康成年杂种犬（雌雄不拘）随机分为实验组和对照组，每组10只。CPB中实验组采用紫外线照射充氧自体血心脏停搏液问断灌注;对照组用等量4℃St．Thomas Ⅰ号冷晶体液作为心脏停搏液间断灌注，两组其余操作相同。结果 开放升主动脉后，实验组冠状静脉宴血清cTnI、CK-MB水平和左心室心肌MDA水平低于对照组（P〈0．05），左心室心肌SOD活性和ATP水平高于对照组（P〈0．05）;心脏自动复跳率明显高于对照组（P〈0．01）。心肌超微结构观察显示，实验组左心室心肌纤维结构完整，细胞内线粒体轻度水肿，而对照组心肌纤维部分断裂、溶解，线粒体基质外溢，糖原颗粒减少。结论 UBIO血心脏停搏液有较好的心肌保护作用，且能减少心脏停搏液的灌注次数，延长心脏停搏时间;本研究为UBIO血心脏停搏液的临床应用奠定了基础。     

一体化综合性心肌保护对婴幼儿心肌超微结构的保护

目的：观察一体化综合性心肌保护方法对婴幼儿心肌超微结构的影响以评价其心肌保护效果。方法：30例复杂先天性心脏病患儿随机分成一体化综合性心肌保护组（综合组，含温血停搏液诱导停搏，冷血停搏液间歇灌注和终末温血灌注液复苏）、冷血停搏液间断灌注组（冷血组），及冷晶体停搏液间断灌注组（冷晶组），各10例。于心脏停跳即刻、缝合右心房切口前分别取小块右心房肌肉作光镜及电镜观察，并对线粒体、细胞核、肌纤维进行定量评估。结果：三组心肌均存在不同程度的损伤，冷晶组最重，综合组最轻。心肌超微结构评分在三组之间两两比较较有统计学意义（P〈0．01或P〈0．05）。结论：一体化综合性心肌保护作用优于冷血停搏液和冷晶体停搏液。     

冷血停跳加温血诱导、复苏再灌注的心肌保护价值

目的；评价体外循环间断冷血停跳液加温血诱导复苏再灌注在心脏瓣膜置换术中心肌保护的价值。方法：在90例心脏瓣膜置换术中分别采用冷血停跳液加温血诱导复苏再灌注（Ⅰ组）和冷晶体灌注（Ⅱ组），每组各45例，比较其心肌保护疗效。Ⅰ组先用高钾温血停跳液（35℃）诱导心脏停跳。再用冷血低钾停跳液（4－8℃）每15－20分钟灌注1次，保持心肌低温（10℃－15℃），复跳前再用含低钾温血灌注。Ⅱ组应用4℃冷晶体停跳液灌注，每间隔20分钟灌注1次。结果：Ⅰ组心脏自动自动复跳率明显高于Ⅱ组（P＜0．001）；术后应用正性肌力药物剂量及时间明显于Ⅱ组（P＜0．05）；术后低心排症发生率明显低于Ⅱ组（P＜0．05）；在主动脉开放30分钟后Ⅰ组的cTnT,CK-MB及MDA水平升高明显低于Ⅱ组（P＜0．05）。结论：采用冷血停跳液加温血诱导、复苏再灌注技术，可明显减轻心肌再灌注损伤，使术后心功能恢复加快，具有良好的心肌保护作用。     

HTK液与含血停搏液心肌保护效果比较

目的 比较HTK液和含血停搏液在复杂心脏手术中的心肌保护效果。方法40例重症复杂心脏手术患者分为两组。HTK液组（16例）手术中采用HTK液保护心肌；对照组（24例）术中采用常规1：4含血停搏液保护心肌。测定术前、主动脉开放后8h、24h、48h血中肌钙蛋白I（cTnI）和磷酸激酶同工酶（CK-MB）浓度，并比较两组患者术后心脏自动复跳率、正性肌力药物使用率、机械通气支持时间、ICU监护时间等临床指标。结果HTK组和对照组平均体外循环转流时间和主动脉阻断时间无明显差异，术后心脏自动复跳率分别为87．5％、64．6％（P〈0．05）。主动脉开放后8h、24h对照组cTnI和CK-MB均明显高于HTK组（P〈0．05）。两组其余观察指标无明显差异。结论HTK心脏停搏液对复杂重症心脏手术患者的心肌保护作用略优于1：4含血停搏液。     

温、冷血停搏液间断灌注在瓣膜置换术中的心肌保护作用

目的比较体外循环下温血停搏液间断灌注与冷血停搏液间断灌注在瓣膜置换术中的心肌保护作用.方法36例心脏瓣膜置换术患者被随机分为温血间断灌注组(n=18)和冷血间断灌注组(n=18),分别于体外循环前,主动脉开放后30分钟、6小时、24小时采集动脉血,测血清心肌肌钙蛋白Ⅰ(cTnI)浓度.二尖瓣置换患者在主动脉开放时从冠状静脉窦抽取静脉血,检测乳酸浓度.部分患者于主动脉阻断前,开放后30分钟分别取右心房组织,透射电镜观察心肌超微结构.结果瓣膜置换术中温血停搏液间断灌注的心肌保护作用与冷血停搏液间断灌注近似,具有临床应用价值.两组各时间点血清cTnI浓度组间差异无显著性,温血间断灌注组冠状静脉窦血乳酸浓度高于冷血间断灌注组(P＜0.05),两组心肌超微结构变化近似.结论瓣膜置换术中温血停搏液间断灌注的心肌保护作用与冷血停搏液间断灌注近似,具有临床应用价值.     

氨基酸在长时间心脏停搏中对心肌的保护作用

目的：探讨谷氨酸盐（Ｇ）和天门冬氨酸盐（Ａ）在长时间心脏缺血的心肌保护作用。方法：离体大鼠工作心模型。心脏在１５°Ｃ缺血１５０分钟。４８只Ｗｉｓｔａｒ大鼠分为３组：１组，即对照组（ｎ＝１６），心脏用多剂量４°ＣＳｔ．Ｔｈｏｍａｓ冷晶体心脏停搏液结合温血停搏液诱导及终末再灌注进行心肌保护；２组（ｎ＝１６）同１组，但温血停搏液含Ｇ和Ａ各１３ｍｍｏｌ／Ｌ；３组（ｎ＝１６）同１组，但Ｓｔ．Ｔｈｏｍａｓ冷晶体心脏停搏液和温血停搏液中均含相同浓度的Ｇ和Ａ。结果：温血停搏液中应用Ｇ和Ａ能增加心肌的收缩性和心输出量，使缺血后心肌耗氧量恢复较好（Ｐ＜０．０５）。Ｓｔ．Ｔｈｏｍａｓ冷晶体心脏停搏液和温血停搏液中应用Ｇ和Ａ均明显增加心肌保护，使心功能和心肌耗氧量几乎完全恢复。缺血后心肌酶漏出少，缺血前后心肌高能磷酸盐含量和含水量无明显变化，超微结构改变也不明显。结论：含Ｇ和Ａ温血停搏液诱导及终末再灌注增加冷晶体心脏停搏液对长时间心脏停搏的心肌保护效果，冷晶体心脏停搏液中也应用Ｇ和Ａ能提高心肌对长时间缺血的耐受性     

左旋卡尼汀心脏停搏液对主动脉开放后心脏复跳的临床研究

目的研究心脏手术病人术中应用左旋卡尼汀停搏液对主动脉开放后心脏复跳的影响。方法40倒心脏手术病人随机分为对照组和实验组，对照组术中应用St．ThomasⅡ号冷晶体心脏停搏液，实验组术中予St.ThomasⅡ号冷晶体心脏停搏液加入左旋卡尼汀6g／L。结果实验纽较对照组游离脂肪酸显著减少（P〈0．05），且主动脉开放后心脏复跳时间明显高于对照组（P〈0.05）；主动脉开放后发生心律失常及电除颤的例数明显低于对照组（P〈0．05）；实验组心脏自动复跳率明显高于对照组（P〈0．05）。结论左旋卡尼汀停搏液对缺血再灌注心肌有保护作用，其作用表现在多方面上，可以作为一类新型的抗心律失常药物和心肌保护药物应用于心内在视术中。     

温氧合自体血高钾持续灌注对心肌保护作用的临床观察

为观察全身浅低温 (30～ 32℃ )体外循环 (CPB)下温氧合自体血加高钾经主动脉根部持续灌注对心肌的保护效果 ,用该法对 30例心脏手术患者进行心肌保护 (WBC组 ) ,并与 30例用冷晶体间断灌注行心肌保护者(CCC组 )进行对比 ,观察两组围术期血清心肌酶、心肌超微结构及相关临床变化。结果显示 ,术后各时点 WBC组肌酸磷酸激酶 (CK)、肌酸磷酸激酶同工酶 (CK- MB)均显著低于 CCC组 ,P<0 .0 5 ;WBC组心肌超微结构改变轻微 ,术后自动复跳率高 ,正性肌力药物用量少 ,且未发现术后高血钾。提示浅低温 CPB温氧合血高钾持续灌注对心肌有明显保护作用 ,且晶体液用量较少 ,可避免血液过度稀释     

Effectiveness of continuous warm blood cardioplegia in cardiac valve re-replacement

BACKGROUND AND AIM OF THE STUDY: In order to achieve better operative results, myocardial protection for cardiac valve re-replacement must be further improved. The aim of this study was to compare the efficacy of continuous warm blood cardioplegia (CWBC) with that of intermittent cold potassium cardioplegia (ICPC) in cardiac valve re-replacement. METHODS: A total of 49 consecutive patients underwent elective cardiac valve re-replacement via sternal re-entry; 27 patients received CWBC and 22 ICPC. During surgery, a narrower dissection of the heart was used in the CWBC group. The myocardial protective effects and operative outcome were analyzed in the two groups. RESULTS: Two ICPC patients died in hospital, one from cerebral bleeding and one from low output syndrome. The rate of spontaneous recovery of the heart-beat after aortic declamping was significantly higher in CWBC patients than in the ICPC group (92.3% versus 13.6%, p < 0.001). Postoperatively, maximum serum creatine kinase-MB levels were significantly lower in CWBC patients than in ICPC patients (25.5 +/- 6.0 versus 81.1 +/- 26.0 IU/l, p < 0.02). Left ventricular stroke work index in the CWBC group showed significantly better recovery in the early postoperative period compared with that in the ICPC group. Extraction of myocardial oxygen (range: 0.33 to 0.35) and lactate (range: -0.02 to 0.14) in CWBC patients was maintained within the normal range immediately after aortic declamping and in the early postoperative period. In contrast, in ICPC patients extraction of myocardial oxygen (range: 0.18 to 0.23) and lactate (range: -0.27 to -0.17) was impaired during the same period. Postoperative (24-h) blood loss was significantly less in CWBC patients than in ICPC patients (p < 0.02). CONCLUSION: In cardiac valve re-replacement surgery through sternal re-entry, and without wide exposure of the heart, continuous warm blood cardioplegia provides much greater myocardial protection than does intermittent cold potassium cardioplegia.     

温氧合血连灌与冷晶体液间灌的血清cTnI变化比较

为探索温血连灌的心肌保护机制,对温血连灌与冷晶体液间灌的血清肌钙蛋白I(cTnI)变化进行了对比研究,将风心瓣膜病患者20例,随机分为冷晶体液组(冷晶组)及温血组。冷晶组采用含钾冷晶体液主动脉根部间断灌注,首次剂量15ml/kg,每30分钟重复灌注一次,剂量减半。温血组采用氧合温血含钾停搏液连续灌注,开始剂量为8ml/(kg·min),心脏停搏后按0.2ml/(min·kg)持续灌注。分别于麻醉前、主动脉开放、术后6、12、24、72小时采集静脉血,用双抗体固相夹心放免法测定血清cTnI浓度。结果两组麻醉前cTnI无明显差异(P>0.05),以后各时间点冷晶组均较温血组含量增高(P<0.01)。认为温血组与冷晶组比较,能明显减轻体外循环过程中的心肌损伤,起到保护心肌的作用。     

The effect of glutamate and aspartate on myocardial protection at cardiopulmonary bypass]

OBJECTIVE: To determine whether glutamat and aspartat enriched cold crystalloid cardioplegia which was given in antegrade way has any effect on the myocardial protection during cardiopulmonary bypass. METHODS: Thirty-four patients who were electively undergone open heart surgery at Osmangazi University Faculty of Medicine, thoracic and cardiovascular surgery department, between March 2001 and May 2001 were included in this study. The patients were divided in two groups, each consisting of 17 patients. In group 1 coronary artery bypass surgery (CABG) was performed in 11 patients, mitral valve replacement (MVR) in 3 patients, aortic valve replacement (AVR) in 1 patient and AVR and MVR in 2 patients. While in group 2 CABG was performed in 13 patients and MVR was done in 4 patients. Group 1 patients received antegrade glutamat and aspartat (15 mmol/L) enriched cold crystalloid cardioplegia and group 2 patients were given cold crystalloid cardioplegia by antegrade route. Age, gender, diabetes mellitus, hypertension, preoperative myocardial infarction, smoking, ejection fraction, aortic cross-clamp time, need to defibrillation, inotropic support, and intraaortic balloon pump were recorded. The levels of cardiac troponin I (cTI) and creatine kinase myocardial band fraction (CK-MB) were measured in arterial blood samples at five different times. Statistical analysis was performed using Student's t-test and Chi-square test. RESULTS: There were no statistically significant differences in cTI and CK-MB values in blood samples taken at 5 different times pre and postoperatively between group 1 and group 2. CONCLUSION: It is concluded that glutamat and aspartat enriched cold crystalloid cardioplegia does not have any effect on myocardial protection.     

晶体心脏停搏液优于血液心脏停搏液对风湿性心脏病患者的心肌保护

目的比较血液心脏停搏液和晶体停搏液对风湿性心脏病患者心肌保护的效果,为临床选择提供依据。方法将75例择期手术的风湿性心脏病患者分为两组:血液心脏停搏液组(B-rh)和晶体心脏停搏液组(C-rh)。分别于术前1d,术后1,3,5,8d晨分别取静脉血,测定血清天门冬氨酸氨基转氨酶(AST),肌酸激酶(CK)及同工酶MB(CK-MB),乳酸脱氢酶(LDH)及同工酶1(LDH-1)。结果术前除B-rh的LDH略高于正常水平外其它心肌酶的测定结果均在正常范围;术后1d两组的心肌酶分别升高到术前的3~19倍(P<0.05);术后3d两组的CK-MB虽说已恢复到正常值,但五种心肌酶仍明显高于术前水平(P<0.05);术后5dC-rh的CK和CK-MB,B-rh的CK,CK-MB和AST与术前相比已无明显差别(P>0.05);术后8d两组的LDH与LDH-1仍未恢复正常(P<0.05)。两组间有显著差异的心肌酶释放均是B-rh的高。心肌酶的释放量与主动脉阻断时间(CCT)和体外循环时间(ECCT)呈良好的正相关。两组患者的年龄,体重和ECCT无明显差异(P>0.05),CCT以B-rh为短[(77.2±34.6)min比(61.7±26.7)min,P<0.05]。结论从心肌酶的释放来判断,晶体心脏停搏液优于血液心脏停搏液对风湿性心脏病患者的心肌保护效果。     

温血停搏液连续灌注对心肌保护作用的实验研究

本实验采用离休鼠心模型，比较并评定了冷晶体停搏液和温血停搏液对心肌保护的效果。结果表明：温血停搏液连续灌注有明显加强心肌保护的作用，对高体鼠心准注能减少心肌细胞CK和CK—MB的漏出，加强心肌细胞内ATP含量的储存，增加心肌细胞内线粒体的比表面，降低线粒体的平均分数，其效果明显优于冷晶体停搏液。     

Terminal warm blood cardioplegia in mitral valve replacement: prospective study

Terminal warm blood cardioplegia has had a profound impact on cardiac surgery, especially in coronary artery bypass surgery, but there have been few studies on its use in mitral valve replacement. The purpose of this study was to determine whether terminal warm blood cardioplegia offers any advantages in mitral valve replacement. Forty patients with mitral valve disease were prospectively randomized to one of two groups of 20 with different techniques of myocardial protection: group A had cold blood cardioplegia, and group B had cold blood cardioplegia with terminal warm blood cardioplegia. Intraoperative and postoperative variables were used to assess primary outcomes. Postoperative troponin T release was measured as a secondary outcome. Improved spontaneous recovery of sinus rhythm was observed in group B, but the difference was not significant. The maximum doses of inotropics, duration of inotropic support, intensive care unit stay, and postoperative left ventricular ejection fraction were similar in both groups. Troponin T release at 0 and 6 h postoperatively was not different between the two groups. This study did not find any benefit of terminal warm blood cardioplegia in either clinical outcome or troponin T release after mitral valve replacement.     

心脏病瓣膜置换术心肌保护方法对比(附1215例报告)

目的对比心脏瓣置换手术不同心肌保护方法的效果。方法1215例瓣膜置换术中,男性585例（48．1％）,女性630例（51．9％）,年龄15-69岁,平均45岁。心功能Ⅱ级455例、Ⅲ级600例、Ⅳ级160例。术前均应用强心、利尿、扩血管药物治疗,输入极化液1-2周。手术在全麻体外循环中度低温下进行,全组1215例,其中行二尖瓣置换（MVR）804例,主动脉瓣置换（AVR）162例,二尖瓣及主动脉瓣双瓣置换（DVR）246例,三尖瓣置换（TVR）3例,合并三尖瓣关闭不全（TI）者行Devega或Kay成形术,术中行冠状动脉旁路移植术6例。心肌保护方法共4种：A组159例,应用冷晶高钾停跳液灌注;B组960例,应用温血高钾停跳液灌注;C组54例,采用不停跳心肌保护方法;D组42例,采用不阻断升主动脉低温室颤下手术的方法。结果各组间呼吸机辅助时间和ICU治疗时间差异无统计学意义,但是C组术后恢复时间比A组短。C、D组应用正性肌力药物、心律失常发生率和死亡率均较A、B组低。全组死亡29例,死亡率2．4％,其中MVR死亡21例,AVR死亡5例,DVR死亡3例。A组死亡16例（死亡率10％）,B组死亡13例（死亡率1-3％）,C组、D组无死亡病例。结论传统的冷晶高钾停跳液可以很好地保护心肌,现在应用的温血高钾停跳液心肌保护效果更好,不停跳、不阻断升主动脉方法保护心肌效果确切,可以根据患者情况个性化选择心肌保护方法。     

Continuous tepid blood cardioplegia can preserve coronary endothelium and ameliorate the occurrence of cardiomyocyte apoptosis

OBJECTIVE: In modern cardiac surgery, crystalloid or blood cardioplegic solutions have been used widely for myocardial protection; however, ischemia does occur during protection with intermittent infusion of cold crystalloid or blood cardioplegic solutions. The present study was designed to evaluate the effect of different cardioplegic methods on myocardial apoptosis and coronary endothelial injury after global ischemia, cardiopulmonary bypass (CPB), and reperfusion in anesthetized open-chest dogs. METHODS: The dogs were classified into five groups to identify the injury of myocardium and coronary endothelium: group 1, normothermic CPB without cardiac arrest; group 2, hypothermic CPB with continuous tepid blood cardioplegia, and with cardiac arrest; group 3, hypothermic CPB with intermittent cold blood cardioplegia, and with cardiac arrest; group 4, hypothermic CPB with intermittent cold crystalloid cardioplegia, and with cardiac arrest; and group 5, sham-operated control group. During CPB, cardiac arrest was achieved with different cardioplegia solutions for 60 min, followed by reperfusion for 4 h before the myocardium and coronary arteries were harvested. Coronary arteries were harvested immediately and analyzed by scanning electron microscopy. Cardiomyocytic apoptosis was detected using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end labeling, Western blot, and DNA ladder methods. RESULTS: Regardless of the detection method used, significantly higher percentages of apoptotic cardiomyocytes were found in group 3 and group 4 than in other groups. Expression of caspase-3 correlated with increased apoptosis. Scanning electron microscopy revealed severe endothelial injury of coronary arteries in group 3 and group 4. CONCLUSION: These results point to an important explanation for the difference in cardiac recovery after hypothermic ischemia and arrest with various cardioplegic solutions.     

三种停搏液心肌保护实验研究中心肌结构观察

目的　观察三种方法对体外循环犬心肌在缺血前、缺血中及再灌注后的心肌结构变化,以评价其心肌保护效果。方法　１５ 只犬随机分成３ 组（ ｎ＝ ５） 分别灌注三种停搏液。在心肌缺血前,缺血后１２０ ｍｉｎ 及再灌注３０ ｍｉｎ 于右心室相同部位取心肌作光镜及电镜观察。电镜采用线粒体计数作半定量分析。结果　３ 组在缺血前、中及再灌注后光镜结构无明显改变。电镜结构线粒体半定量分析显示在缺血１２０ ｍｉｎ 及再灌注３０ ｍｉｎ 冷血停搏液间断顺灌组及血利钾停搏液及双向性灌注组心肌线粒体损伤轻于冷晶体停搏液组（Ｐ＜０－０５）。前两组之间无显著差异（ Ｐ＞ ０－０５）。结论三种方法均能提供较好的心肌保护,血利钾停搏液及双向性灌注组心肌保护效果同等于冷血停搏液间断顺灌组,优于冷晶体停搏液间断顺灌组。