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冠状动脉旁路移植手术围术期血清肌钙蛋白T水平的变化   总被引:2,自引:0,他引:2  
目的 探讨肌钙旧白T作为心肌损伤生化樗物的价值。方法 连续选择冠状动脉旁路移植手术(CABG)患者22例,分别于麻醉前、体外循环(CPB)前、CPB结束后即刻和CPB后24小时,抽取静脉血4ml,用于肌酸激酶(CK)、肌酸激酶-MB(CK-MB)和心肌肌钙蛋白T(cTnT)的测定。结果 CPB前CK、CK-MB和cTnT的中位数皆在正常范围内,CPB后即刻和24均显著性增高,CK以术后24小时最为  相似文献   

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目的 探讨右美托咪定对心肺转流(CPB)下行冠状动脉旁路移植术(CABG)患者心脏同步化运动的影响.方法 择期CPB下行CABG患者24例,年龄43~75岁,体表面积1.53~2.00m2,ASAⅡ或Ⅲ级,心功能Ⅱ或Ⅲ级.采用随机数字表法分为两组:右美托咪定组(D组)和对照组(C组),每组12例.两组术中麻醉维持均采用全凭静脉麻醉,D组于主动脉开放后经微量注射泵静注右美托咪定负荷剂量0.5μg/kg(10 min内注射完),然后以0.5 μg·kg-1·h-1维持给药至术毕,C组静注等量生理盐水.分别于开胸前(T1)和CPB停机后30 min(T2)、60 min(T3)记录血流动力学指标:HR、MAP、CVP、心脏指数(CI),左右心室收缩功能指标:左室射血分数(LVEF)、右室射血分数(RVEF)和心脏同步性参数:PR间期、QRS时限、室间机械延迟(IVMD).结果 与T1时比较,T2、T3时两组HR明显增快、CI明显升高(P<0.01);与C组比较,D组T2、T3时PR间期明显延长(P<0.05).两组间QRS时限及IVMD差异无统计学意义.结论 CPB下冠状动脉旁路移植术患者,右美托咪定负荷剂量0.5μg/kg后以0.5μg· kg-1·h-1维持能够延长PR间期,影响房室间同步化运动,但对左右心室间电机械同步化运动无明显影响.  相似文献   

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OBJECTIVE: Cardiac troponin I (cTnI) is a highly sensitive and specific marker for postoperative prediction of patients outcome after coronary artery bypass surgery (CABG). Whether preoperatively elevated cTnI levels similarly predict the outcome in patients scheduled for elective CABG is currently unknown. METHODS: Therefore, a possible correlation between preoperative cTnI levels and perioperative major adverse events and in-hospital mortality after CABG was investigated. CTnI was measured within 24h before surgery in 1405 out of 3124 consecutive elective CABG patients. Out of these patients, 1178 had a preoperative cTnI level below 0.1ng/ml (group 1), 163 patients had a cTnI level between 0.11 and 1.5ng/ml (group 2), and 64 patients had a cTnI level above 1.5ng/ml (group 3). CTnI levels, electrocardiograms, clinical data, adverse events and in-hospital mortality were recorded prospectively. Patients with ST-elevation myocardial infarction less than 7 days before surgery were excluded from the study. RESULTS: Perioperative myocardial infarction (PMI) occurred in 69/1178 patients (5.9%) in group 1, 14/163 patients (8.6%; odds ratio (OR) 1.5, 95% confidence interval (CI): 0.8-2.8) in group 2, and 11/64 patients (17.2%; OR 3.3, CI: 1.6-7.0) in group 3 (overall: P<0.001, Cochran-Armitage trend test). Low cardiac output syndrome (LCOS) occurred in 19/1178 patients (1.6%), 9/163 (5.5%; OR 3.6, CI: 1.5-8.5), and 7/64 patients (10.9%; OR 7.5, CI: 2.7-19.8) (overall: P<0.001, group 1 vs. group 2: P<0.002), respectively. In-hospital mortality was 1.7% in group 1 and 3.1% in group 2, but 6.3% (OR 3.9, CI: 1.1-12.5) in group 3 (overall: P<0.01, group 1 vs. group 2: P=NS). Intensive care and hospital stay were significantly longer in group 3 compared to groups 1 and 2. Univariate and multivariate logistic regression analysis confirmed the statistically significant relationship between cTnI and PMI, LCOS and in-hospital mortality, respectively (P<0.001). CONCLUSIONS: Risk stratification by measurement of cTnI levels within 24h before elective CABG clearly identifies a subgroup of patients with increased risk for postoperative adverse outcome and in-hospital mortality.  相似文献   

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OBJECTIVES: Cardiac Troponin I (cTnI) is a well-known marker for myocardial damage in patients undergoing aorto-coronary bypass grafting (CABG) peaking 6-8 h after aortic declamping. The aim of this study was to evaluate cTnI release in the course of CABG procedures early, i.e. after the cessation of cardiopulmonary bypass (CPB) in order to recognize unstable cardiac function leading to hemodynamic deterioration and resulting in an adverse outcome (AO). AO is defined as the onset of myocardial infarction and/or death peri/postoperatively. METHODS: Five-hundred and forty consecutive patients who underwent CABG were evaluated for cTnI release immediately prior to the induction of anesthesia (IND) and after termination of CPB (END). Standard CPB with ante/retrograde cold blood cardioplegia was used. Patients with any of the following criteria were excluded: (1), CABG within 7 days of myocardial infarction; (2), emergency operation for both unstable angina and for coronary occlusion at angioplasty; (3), CABG with concomitant surgical cardiac procedures; (4), preoperative renal dysfunction requiring hemodialysis; (5), redos. Troponin I was measured with the Stratus CS fluorometric enzyme immunoassay analyzer (Dade-Behring) running on site in the operation room (OR), so values of cTnI could be obtained within 15 min. RESULTS: There were six deaths (1.1%) in the entire series, Q-wave myocardial infarction occurred in 19 patients (3.5%), AO was experienced by 21 patients (3.9%). The mean preoperative cTnI level was 0.04+/-0.17 ng/l (mean+/-standard deviation) for the entire group. The END cTnI level for the AO-group was 0.91+/-0.5 ng/l; for all other patients, this was 0.37+/-0.3 ng/l (P<0.001). Changes in intraoperative cTnI levels relative to time course showed a marked increase for the AO-group (0.0038+/-0.0035 ng/l*min) as compared with non-AO patients (0.0019+/-0.0015 ng/l*min; P=0.028). The receiver operating characteristic curve indicates a cTnI level at CPB-end of higher than 0.495 ng/l with an area under the curve of 0.83 as the optimal cut-off point for predicting AO with a sensitivity and specificity of 76.2%. Stepwise logistic regression analysis revealed END cTnI level (odds ratio, 17.24; P<0.001), CPB time (odds ratio, 1.03; P=0.001), female sex (odds ratio, 3.8; P=0.011) as significant independent predictors for AO. Age of over 70 years (P=0.8), Cleveland Clinic risk score (P=0.65), diabetes (P=0.26), elevated preoperative creatinine level (P=0.77), severe left ventricular dysfunction (P=0.51), the number of grafts performed (P=0.15), and change of intraoperative cTnI level relative to time course (P=0.94) did not reach statistical significance. CONCLUSIONS: cTnI release as determined at the end of CABG procedures represents a strong predictor of an AO after surgery. Analyzing blood samples for cTnI with an automated device on site in the OR provides for immediate results, so specific diagnostic and therapeutic interventions can be performed before hemodynamics deteriorate.  相似文献   

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OBJECTIVE: To study several markers of myocardial injury in relation to aortic cross-clamping and cardiopulmonary bypass (CPB) after coronary artery bypass graft (CABG) surgery. DESIGN: Prospective observational study. SETTING: University hospital. PARTICIPANTS: Thirty adult patients who underwent elective CABG surgery with aortic cross-clamping and CPB. MEASUREMENTS AND MAIN RESULTS: Serum levels of interleukin-6 (IL-6), interleukin-8 (IL-8), troponin-T (TnT), myosin light chain I (MLCI), and MB isoenzyme of creatine kinase (CK-MB), as markers of myocardial injury, were measured after induction of anesthesia for baseline values, then again at the end of surgery and on postoperative days 1, 3, and 5. IL-6, IL-8, and CK-MB levels were significantly elevated in the early postoperative stage. TnT significantly increased from the end of surgery to postoperative day 5. MLCI increased also but later than TnT. Aortic cross-clamping time correlated positively with peak TnT (r = 0.51, p < 0.05), TnT level on postoperative day 1 (r = 0.69, p < 0.01), and MLCI level on postoperative day 5 (r = 0.45, p < 0.05). CPB time was correlated only with peak TnT (r = 0.47, p < 0.05). CONCLUSIONS: The increase in TnT level is strongly related to aortic cross-clamping.  相似文献   

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Nesher N  Zisman E  Wolf T  Sharony R  Bolotin G  David M  Uretzky G  Pizov R 《Anesthesia and analgesia》2003,96(2):328-35, table of contents
We assessed the cardioprotective effects of perioperative maintenance of normothermia by determining the perioperative profile of troponin I, a highly cardiac-specific protein important in risk stratification of patients with acute ischemic events. Candidates for their primary coronary artery bypass grafting (CABG) were randomized into a new thermoregulation system group, Allon( thermoregulation (AT; n = 30), and a routine thermal care (RTC; n = 30) group. Anesthetic and operative techniques were similar in both groups. Intraoperative warming was applied before and after cardiopulmonary bypass (CPB) and up to 4 h after surgery. Perioperative temperature and hemodynamic data were recorded. Blood samples for creatine kinase (CK) and its isoform, MB (CK-MB), and for cardiac-specific troponin I (cTnI) were obtained at predetermined intervals throughout the entire operation. Core and skin temperatures were higher in the AT group at all time points. The systemic vascular resistance was lower and the cardiac index higher in the AT group at all intra- and postoperative time points. Increases in CK, CK-MB, and cTnI levels indicated intraoperative ischemic insult in all patients. The respective CK levels for the AT and RTC groups were 53.3 +/- 22.7 IU/L and 47.9 +/- 17.86 IU/L at the time of anesthesia and 64.7 +/- 45.6 IU/L and 47.8 +/- 19.4 IU/L 30 min after the onset of surgery, demonstrating thereafter a steep increase before the discontinuation of CPB. CK-MB mass concentrations in both groups behaved almost identically. Pre-CPB cTnI levels at anesthesia induction were 0.3 +/- 0 ng/mL in both groups, followed by a distinctive profile observed after separation from CPB: 28.1 +/- 11.4 ng/mL, 26.05 +/- 9.20 ng/mL, and 22.3 +/- 8.9 ng/mL at discontinuation from CPB, chest closure, and 2 h after surgery, respectively, in the RTC group, versus 0.6 +/- 4.6 ng/mL, 6.6 +/- 5.5 ng/mL, and 7.9 +/- 4.76 ng/mL at these three time points, respectively, in the AT group (P < 0.01 between groups at the specified time points). Contrary to conventional thinking about the benefits of hypothermia, maintenance of normothermia throughout the non-CPB phases during CABG was demonstrated to be important in attenuating myocardial ischemic injury. Insofar as troponin I was more sensitive than other tested markers, it may provide important data on possible protection from myocardial insult and on other cardioprotective measures.  相似文献   

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Background: With the evolution of anesthesia and surgical procedures, fast track extubation has gained an increased interest, mainly based on the possibility of reducing health costs seemingly without compromising patient care. Aim: To compare two groups of patients submitted to a non-fast track extubation and a fast track extubation protocol after coronary artery bypass graft surgery with cardiopulmonary bypass, regarding their times of ventilation and intubation and their complication rates in the postoperative period. Methods: During the year of 1998, 323 sequential patients scheduled for isolated coronary artery bypass graft surgery with cardiopulmonary bypass were enrolled in the study. Fifty-nine patients were excluded due to preoperative use of emergent mechanical and/or inotropic hemodynamic support, low body mass index (≤18–20 kg/m2), reoperations for acute surgical complications, off-pump coronary artery bypass graft surgery, severe respiratory disease, recent myocardial infarction (≤7 days) and absence of relevant data. Previous myocardial infarction (≥7 days), prophylactic intraaortic balloon pump and use of postoperative vasoactive drugs were not exclusion criteria. We compared 76 patients sequentially submitted to anesthesia by one of the authors with a fast track extubation protocol and 188 patients sequentially submitted to anesthesia by others in the same period and using a conventional anesthetic protocol. Results: Demographic data, previous medical and cardiac history, preoperative medication and operative data were all similar between the two groups. The mean ventilation and intubation times were significantly shorter in the fast track extubation group than in the non-fast track extubation patients (30 min vs. 7 h and 50 min vs. 8 h, respectively). Forty-two percent of patients in the fast track extubation group were extubated on arrival at the intensive care unit. Morbidity and mortality were similar in both groups. Conclusions: The study shows that a very fast track extubation protocol may be safely implemented in patients submitted to coronary artery bypass graft surgery with cardiopulmonary bypass.  相似文献   

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目的 探讨七氟醚后处理对体外循环(CPB)下冠状动脉旁路移植术病人心肌缺血再灌注损伤的影响.方法 择期行冠状动脉旁路移植术病人40例,性别不限,年龄55~64岁,BMI<30 kg/m2,NYHA心功能分级Ⅰ~Ⅲ级,随机分为2组(n=20):对照组(C组)和七氟醚后处理组(S组).S组于主动脉开放即刻通过体外循环机吸入2%七氟醚,持续15 min,C组不给予任何处理.分别于麻醉诱导后、CPB转流前、停机后10 min、术毕、术后6和24 h时,记录MAP、HR、CVP、平均肺动脉压、肺动脉楔压、CO和S(v)O2,计算CI、SVI、体循环血管阻力指数和肺循环血管阻力指数.分别于主动脉阻断前、复灌6 h和术后24 h时,中心静脉取血样,测定血浆肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)和乳酸脱氢酶(LDH)的活性以及肌钙蛋白I(TnI)浓度.分别于主动脉阻断前和CPB停机时,取右心耳心肌组织,观察心肌细胞超微结构,并对心肌细胞损伤程度进行评分.结果 两组间各时点血液动力学和心功能指标比较差异无统计学意义(P>0.05).与C组比较,S组复灌6 h时血浆CK-MB和LDH活性降低,术后24 h时血浆CK活性和TnI浓度降低,CPB停机后心肌细胞损伤程度评分降低(P<0.05).结论 七氟醚后处理可减轻CPB下冠状动脉旁路移植术病人心肌缺血再灌注损伤.  相似文献   

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BACKGROUND: Renal injury remains a persistent complication of cardiopulmonary bypass (CPB) that, when sufficient to require dialysis, increases mortality eight-fold. The high prevalence of renal failure in sepsis and adult respiratory distress syndrome has been linked to the systemic inflammatory response associated with those disorders. We hypothesized that components of the inflammatory response to CPB may similarly contribute to post-CPB acute renal injury. METHODS: Markers of leukocyte and platelet activation peri-CPB were measured in 75 patients undergoing cardiac operation with CPB and were correlated with acute renal injury, defined as an increase (> or = 50%) in peak serum creatinine post-CPB. RESULTS: Eleven patients sustained post-CPB acute renal injury. This subset of patients demonstrated significantly greater increases in neutrophil CD11b density (p = 0.01), as well as higher total neutrophil counts (p = 0.045), compared with patients with preserved renal function. Hemodynamic instability sufficient to require postoperative hemodynamic support also predicted an increased risk of acute renal injury. However, neutrophil CD11b upregulation did not correlate with this or any other clinical variables associated with renal risk, suggesting that this marker of the neutrophil inflammatory response may independently predict renal injury. By contrast other inflammatory markers, neutrophil myeloperoxidase levels, monocyte CD11b, base line C-reactive protein, and platelet CD62P expression did not differ between the two patient groups. CONCLUSIONS: Upregulation of the neutrophil adhesion receptor CD11b and high circulating neutrophil numbers are associated with acute renal injury after CPB, suggesting a contribution by activated neutrophils to the pathophysiology of this complication.  相似文献   

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Purpose : The present study was undertaken to assess the degree of myocardial injury, using troponin T (TnT), in off‐pump coronary artery surgery (OPCAB) and in a comparable patient group undergoing conventional coronary artery graft surgery (CABG). Methods : Twenty‐seven OPCAB and 27 CABG patients were investigated. Blood samples for TnT were taken at intubation and at 12, 24 and 72 h. Nine patients (five OPCAB, four CABG) underwent 2 h sampling for 12 h for the assessment of the TnT release profile. All patients had an electrocardiogram performed preoperatively and on the mornings of days 1 and 5 postoperatively. Results : The OPCAB group had significantly greater Canadian Heart Classification 3 patients (P = 0.003); however, other demographic data were similar between the two groups. All patients had normal TnT at initial sampling. The mean number of grafts in each group was 1.8 ± 0.6 for OPCAB and 1.9 ± 0.3 for CABG (P = NS). There were two new Q wave myocardial infarctions in the CABG group and none in the OPCAB group. These cases were excluded from biochemical analyses. Troponin T release was significantly less in the OPCAB group at 12 and 24 h (P < 0.001 and P = 0.03, respectively). Peak TnT release occurred at 6–8 h in both groups. Troponin T release was significantly lower in the OPCAB group at 2, 4, 6, 8, 10 and 12 h (P = 0.01, P = 0.03, P = 0.02, P = 0.02, P = 0.03 and P = 0.04, respectively). Postoperatively, the OPCAB group required less blood transfusion (P = 0.02). Conclusions : The OPCAB group demonstrated a significantly reduced TnT release profile compared with the CABG group.  相似文献   

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Abstract Objective: To determine predictors of low intensive care unit (ICU) admission hematocrit, and to determine if low hematocrit is associated with postoperative outcomes for coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass. Methods: We performed a retrospective study of 8417 patients who underwent CABG surgery on cardiopulmonary bypass in New York in 2007. Patients with very low ICU admission hematocrit (≤21.9%) and low ICU admission hematocrit (22.0% to 25.9%) were identified. Significant independent predictors of low and very low ICU admission hematocrit, and the independent impact of each of these states on adverse outcomes were identified. Results: A total of 1.1% had very low hematocrit and 8.3% had low hematocrit. Significant independent predictors for either low or very low hematocrit included older age, females, lower body surface area, lower ventricular function, Hispanic ethnicity, non‐Caucasian race, high creatinine, previous cardiac surgery, absence of left main disease, and emergency transfer to the operating room following catheterization or percutaneous coronary intervention. Patients with hematocrit ≤21.9% had significantly higher risk‐adjusted rates of postoperative bleeding (adjusted OR = 4.37, 95% CI [1.97, 9.68, respiratory failure (adjusted OR = 2.85, 95% CI [1.45, 5.63]), and one or more complications than patients with normal hematocrit. Patients with hematocrit between 22.0% and 25.9% also had higher complication rates. Conclusion: It is important for cardiovascular surgical teams to be aware of risk factors that predispose patients to unacceptable hematocrit values, to monitor values closely, and to treat accordingly in the operating room when low values occur. (J Card Surg 2010;25:638‐646)  相似文献   

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目的 观察心肌肌钙蛋白I(cTnI)和CK -MB在冠状动脉旁路移植术 (CABG)围术期变化 ,以判断心肌损伤状况。方法  19例CABG病人 ,其中 3例同时行左室室壁瘤切除。平均体外循环时间12 1min ,阻断升主动脉 5 6min。灌注冷血停跳液保护心肌 ,平均每例搭桥 3 2支。围术期 2 0个时间点取静脉血标本 ,留血浆测cTnI和CK MB。术前及术后第 7d作标准 12导联心电图 (ECG)。结果 cTnI术前 5例升高者 ,停机后全部升高 ,第 8h达高峰 ,术后第 7d有 7例 (36 8% )仍高于正常 ;CK MB阻断升主动脉前正常 ,停机后升高 ,第 6h达高峰 ,术后第 2d全部恢复正常 ;2例发生围术期心梗 (PMI)者 ,整个围术期cTnI高于无PMI者 ;cTnI阻断升主动脉前已升高者 ,术后升高更显著。结论 cTnI与CK MB在CABG术后变化规律相似 ,但cTnI高于正常的持续时间长于CK MB ,有利于回顾性诊断 ;若阻断升主动脉前cTnI已升高 ,术后水平更高 ;cTnI诊断心肌损伤敏感性高于CK -MB。  相似文献   

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