持续温血停搏液心肌保护方法的改良

在３６例重症患者的心脏手术中,对经典的温血停搏液心肌保护方法进行了改良。根据术中监测的血清钾浓度,以容积输液泵精确控制和灵活调节血停搏液中高钾液入量。本法心肌保护效果满意,与经典法相比,无高血钾倾向和液体潴留,操作简便。     

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。     

温血诱导心脏停搏和主动脉开放前温血灌注的心肌保护作用

将１５只犬随机分为低温心脏停搏（下简称停搏）、主动脉开放前温血灌注、常温停搏十主动脉开放前温血灌注３组。结果发现低温诱导停搏对心肌代谢、心脏收缩及舒张功能的保护均不理想，主动脉开放前温血灌注能改善低温停搏的保护效果，但对冠状循环及舒张功能的保护仍不完善，常温停搏十主动脉开放前温血灌注能较完善的保护心肌代谢、心脏收缩及舒张功能。     

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.     

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。     

温血诱导停搏加末次温血灌注心肌保护在瓣膜置换术中的应用(附50例报告)

在体外循环心内直视手术中,采用温血灌注保护心肌是近十几年来应用于临床的一种心肌保护方法,较之传统的冷晶体液灌注心肌保护有较好的效果。我院自1993年来,采用温血诱导停搏加末次温血灌注心肌,应用于风湿性瓣膜病瓣膜置换术50例,包括各种瓣膜置换。其中心功能Ⅱ级8例,Ⅲ级26例,Ⅳ级16例,停跳液配方为改良托马斯配方,温血灌注液为33℃左右氧合机血加1单位的含钾停跳液。阻断主动脉后,于主动脉根部或冠状动脉窦灌入氧合温血,灌注量为每千克体重10mL,于2～3min内灌完,开放主动脉前再灌入含半量钾的氧合温血,结果全组自动复跳率为86％,无一例复跳失败,均较传统的冷晶体灌注液法高,心率失常为4％,提示温血灌注保护心肌技术较冷晶体灌注保护心肌的效果更好,但强调在灌注过程中严格执行无菌操作,杜绝污染。     

改良式氧合血停搏液对未成熟心肌的保护作用

目的:证实氧合血停搏液对未成熟心肌的保护作用。方法:以18例婴幼儿复杂先心病患者为对象.分为晶体组和氧合血停搏液组,观察转流中及术后各项指标,并进行比较。结果:两组患者术前情况都比较接近,转流时间,阻断时间、复跳情况,术后并发症均未见明显差异,但晶体组预充总量大,停跳液晶体回收量大,转中多应用超滤.利尿剂等,血球压积变化较大和库血用量多(P均<0.05)。结论:氧合血停搏液可为婴幼儿提供良好的心肌保护条件。     

氨基酸盐温血停搏液诱导及末次再灌注对风湿性心脏病瓣膜置换术的心肌保护作用

目的观察天门冬氨酸盐(A)和谷氨酸盐(G)对风湿性心脏病瓣膜置换术心肌的保护作用。方法采用含A,G各13mmol/L的温血停搏液诱导心脏停搏与末次再灌注结合传统冷晶体心停搏液心肌保护法作为观察组,与观察组相同但不含氨基酸盐的温血停搏液组为对照组②,仅用单纯冷晶体心停搏液组为对照组①,对心肌保护法进行比较。结果观察组自动复跳和房颤转窦率明显较对照组①高(P<0.01),心肌释放肌酸磷酸激酶(CPK)少(P<0.01)。结论氨基酸盐温血停搏液诱导及末次再灌注心肌保护法明显优于传统的冷晶体心停搏液心肌保护法。     

温血心脏停搏液中白细胞对心肌损伤的作用机制探讨

2002年7月～2003年9月,我们用白细胞滤器制成脱白细胞温血心脏停搏液．采用微流量连续灌注心肌保护与含白细胞温血心脏停搏液作比较,观察白细胞在心肌缺血-再灌注损伤中的作用。     

心脏瓣膜手术中冷氧合血与冷晶体停跳液保护心肌作用的比较(附20例报告)

将20例行心脏瓣膜置换术的患者随机分为两组,分别在体外循环期间采用冷氧合血停跳液及冷晶体停跳液。通过监测围术期,术后24h的血流动力学变化,心脏自动复跳率及复跳时间,开放主动脉后6h心肌肌钙蛋白T（cTnT)的变化,术后标准Ⅱ导联心电图变化和临床强心药物使用及患者在危重监测病房（ICU）停留时间等,对比观察两组的心肌保护效果。结果：冷氧合血停跳液组（氧合血组）的心脏自动复跳率及自动复跳时间优于冷晶体停跳液组（冷晶体组）;开放主动脉后6h cTnT含量少于冷晶体组,两组术中及术后24h内血流动力学变化无差异。认为冷氧合血停跳液的心肌保护效果优于冷晶体停跳液。     

Comparison between warm blood and crystalloid cardioplegia during open heart surgery

Objective: This study was designed to compare the degree of myocardial protection afforded by warm blood and cold crystalloid cardioplegia in a group of patients undergoing elective coronary artery bypass surgery. Methods: Seventeen patients, were randomly assigned to Group A (n=9), who received crystalloid cardioplegic solution, and Group B who received warm blood cardioplegic solution (n=8). Before the aorta was clamped, and 10 min after reperfusion, blood samples from the coronary sinus were obtained to assay -tocopherol, β-carotene, ubiquinol, and thiobarbituric acid reactive substances (TBARS). At the same intervals, biopsies from the left ventricle were obtained to determine ultrastructural alterations. Results: No significant changes were observed between preischemia and reperfusion values for both blood and crystalloid groups concerning -tocopherol, β-carotene, and ubiquinol, and no differences between groups were detected. Values for TBARS in group A were 3.49±0.3 and 5.27±0.45 μM for presichemia and reperfusion samples, respectively (P<0.01). In group B values were 2.6±0.3 and 3.54±0.3 μM, respectively (P=NS). For electron microscopy studies, semiquantitative analysis showed a significant mitochondrial damage in reperfusion biopsies from group A (grades 0, 3 and 4). In group B, no significant changes were observed in mitochondrial damage between preischemia and repefusion biopsies (except for grade 0). Conclusion: These results indicate that blood cardioplegia affords better protection to the myocyte than crystalloid cardioplegia.     

利多卡因高钾温血停搏液对犬心肌保护的实验研究

目的观察利多卡因高钾温血心停搏液(LHKWBCP)对犬心肌的保护效果。方法12只杂种犬随机分为对照组、利多卡因组(n=6)。常规建立体外循环(CPB),对照组用ST-ThomasⅡ冷晶体心停搏液常规灌注,首次剂量20ml/kg,每隔30min复灌一次,量为10ml/kg,共4次。利多卡因组用LHKWBCP,仅灌注一次(5ml/kg)。心脏停搏120min,辅助30min,停机后30min结束实验。监测围手术期血流动力学指标、血清中肌酸激酶(CPK)、心肌钙蛋白T(cTnT)及心肌三磷酸腺苷(ATP)的含量;并取左心尖心肌组织作电镜检查,称量心室肌干湿比。结果围手术期血流动力学各项指标、血清CPK、cTnT含量、心肌ATP含量、心肌干湿比组间比较差异无统计学意义(P>0.05);电镜检查两组心肌细胞结构无差异,肌纤维无水肿,线粒体、细胞核完整。结论LHKWBCP对犬心肌结构和功能有良好的保护作用。LHKWBCP具有配制简单,使用方便,所需量少,维持心脏电机械活动静止时间长的特点,具有临床推广使用价值。     

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     

Myocardial metabolism studied during warm blood antero-retrograde reperfusion in ischaemic human hearts

We propose modified warm blood antegrade-retrograde reperfusion (WBARR) of arrested hearts as a metabolic model with which to study substrate exchange and energy metabolism during the recovery phase after 90 min of ischaemia in man. Eleven anaesthetized patients undergoing aorto-coronary bypass were studied during WBARR. The protocol was designed as follows: period 1, a warm blood reperfusion with potassium (3 min); period 2, a warm blood reperfusion without potassium (2 min). The perfusion flow rate averaged 250±2 ml/min at the beginning of period 1 and 218±19 ml/min at the beginning and at the end of period 2; the perfusion was performed antegradely and retrogradely in the arrested hearts. Samples were simultaneously taken from the coronary venous sinus (CVS) and from the aortic root needle (AR). At the beginning of WBARR lactate release was 85±44 μmol/min and at the end it had significantly decreased to 21±99 μmol/min (P<0.03). Simultaneously, non-esterified fatty acids (NEFA) and β-hydroxy-butyrate were initially released (71±61 and 22±66 μmol/min, respectively), while at the end of the WBARR there was an uptake of both NEFA (20±22 μmol/min; P<0.01) and β-hydroxy-butyrate (12±35 μmol/min; P=0.290). Alanine, glycerol and branched chain amino acid balance across the heart did not significantly change. In summary after 90 min of ischaemia the heart energy metabolism is mainly anaerobic and based on glucose consumption, with lactate, NEFA and amino acids, which are mainly released. After 5 min of WBARR (recovery from ischaemia), lactate release is significantly reduced and NEFA becomes the energy supply of the heart. In conclusion, (1) WBARR is a valuable method with which to study myocardial metabolism in anaesthetized humans and may be combined with the use of tracers; (2) the study of myocardial metabolism in arrested hearts eliminates the imprecisions arising from the non-continuous coronary blood flow; (3) NEFA become an important source of energy utilized by human hearts in the recovery phase from ischaemia. Received: 11 July 1997 / Accepted in revised form: 30 April 1998     

自体冷血停跳液对未成熟心肌保护机制的研究

目的:研究婴幼儿心内直视手术灌注不同停跳液心肌细胞丙二醛(MDA)和超氧化物歧化酶(SOD)的变化,探讨自体冷血停跳液对婴幼儿心肌保护的作用机制.方法:婴幼儿(体重≤8 Kg)非发绀先天性心脏病30例,随机分为自体冷血(A组)、冷血(B组)和晶体(C组)停跳液组,每组10例.分别于心脏停跳前、复跳后取右心耳心肌,检测心肌MDA和SOD含量.结果:3组术后心肌细胞MDA明显升高,SOD明显降低,与术前比较差异有统计学意义(P＜0.05);其中A组MDA较低,SOD较高,与B、C组比较差异有统计学意义(P＜0.05).结论:自体冷血停跳液通过降低心肌细胞氧自由基的产生对婴幼儿心内直视手术心肌具有保护作用.     

改良迷宫双极射频消融术治疗心房颤动的早期疗效分析

目的:分析瓣膜置换同期行改良迷宫双极射频消融术治疗合并心房颤动的早期疗效。方法:2011年9月至2012年9月,39例患者在瓣膜置换术同期采用双极射频消融系统,取改良迷宫手术路径治疗心房颤动。其中男性16例,女性23例,年龄23～69岁,二尖瓣置换28例,双瓣膜置换11例,同时行三尖瓣成型26例(包括5例使用成型环)。记录术前,术后当日,出院时,出院后1个月、3个月心电图分析早期疗效。并取同期同一医师单纯瓣膜置换手术89例作为对比。结果:同期射频消融术组出院时窦性心律34例,3例仍为心房颤动,房颤消除率为87.1%。术后予胺碘酮治疗3个月。出院后3个月窦性心律35例,心房颤动消除率为89.7%。对比单纯瓣膜置换组在体外循环时间、术后前3 d胸腔积液量增加差异有统计学意义(P<0.05),其余手术并发症无增加。结论:改良迷宫双极射频消融术治疗合并心房颤动安全、简便,早期疗效好。     

Myocardial protection: the rebirth of potassium-based cardioplegia

The introduction of open-heart surgery more than 4 decades ago signaled a new era in medicine. For the 1st time, previously untreatable cardiac anomalies became amenable to surgical therapy. The use of the heart-lung machine seemed to grant the surgeon unlimited time in which to operate inside the heart. Still frustrated by poor operating conditions and the threat of air embolism, Denis Melrose introduced elective cardiac arrest in 1955. His use of a potassium citrate solution seemed to offer a safe method to effect a quiet, bloodless field. However, a few years after its inception, numerous reports began to question the safety of this approach, and the Melrose technique was abandoned in the early 1960s. Nearly 15 years elapsed before potassium-based cardioplegia regained popularity. During this period, topical hypothermia, coronary perfusion with intermittent aortic occlusion, and normothermic ischemia were evaluated and discarded. A few European investigators like Hoelscher, Bretschneider, and Kirsch had maintained their interest in chemical cardioplegia, and it was through their efforts that future researchers like Hearse and Gay spearheaded the return to potassium-based cardioplegia, which today forms the core of the cardiac surgeon's myocardial protective armamentarium and has contributed towards lowering operative mortality rates.