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題 名 | A Generalized Consideration of Myocardial Preservation with Cold Crystalloid Versus Warm Blood Cardioplegia in Heart Valve Replacement=低溫類晶質與常溫血心臟麻痺液在心瓣膜置換術中心肌保護作用的綜合考量 |
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作 者 | 袁師敏; | 書刊名 | The Kaohsiung Journal of Medical Sciences |
卷 期 | 14:5 1998.05[民87.05] |
頁 次 | 頁266-273 |
分類號 | 416.262 |
關鍵詞 | 心瓣膜置換術; 連續常溫血液心臟麻痺液; 心肌保護; 開心術; Cardioplegia; Heart valve replacement; Myocardium; |
語 文 | 英文(English) |
中文摘要 | 連續常溫血液心臟麻痺液作為一種有效的心肌保護方法被廣泛地應用於開心術中。然而,傳統的低溫類晶質與常溫血液心臟麻痺液之間的對照評估,除了考察其臨床效應以外,主要依賴於血行力學、心功能和心肌代謝的指標。本研究則以臨床效應、血清酶活性和心肌細胞化學綜合考量之。 選取20名開心心瓣膜替換手術病人作為本實驗研究對象,第一組接受低溫體外循環併類晶質心臟麻痺液 (St. Thomas Hospital溶液) 間斷灌注的心肌保護方法,第二組接受常溫體外循環併常溫血心臟麻痺液連續灌注的心肌保護方法。兩組病人乃經自由採樣,無論年齡、體重、體表面積大小或術前心功能級,皆無統計學上的差異。手術期間經橈動脈插管或人工肺之動脈端抽取血樣。開放上行主動脈之前即刻(缺血期)和開放上行主動脈之後30分鐘(再灌流期)各從右心房肌取樣。測定血清酶包括谷丙轉氨酶 (ALT)、谷草轉氨酶 (AST)、乳酸去氫酶 (LDH) 及其同功酶、肌酸激酶 ( CK)及其同功酶之活性。心肌之病理學改變著重於三磷酸腺苷酶(ATPase)、琥珀酸去氫酶和細胞色素氧化酶 (CCO) 的細胞化學及其電腦圖像分析的灰度值的分析。並對有關的關聯性進行檢討。 第二組再灌流時間及呼吸器支持時間均有顯著的縮短 ( 333.50 ± 3.78分,25.00 ± 4.46分, p < 0.05;38.98 ± 16.55小時,19.84 ± l.11小時,p < 0.05)。第二組上行主動脈阻斷期問的心房搏動發生率顯著高於第一組(80 % , 20 % , p < 0.05),開放上行主動脈後的心臟自動復甦率亦顯著高於第一組(70 % , 10 % , p < 0.05 ) 。兩組間的醫院內死亡率、併發症發生率均無統計學上的差異。血清AsT、 ALT、LDH和LDH1 + LDH2兩組間比較亦無顯著性的差異。第二組的血清 CK-MB峰值提升,並延遲出現。ATPase的細胞化學活性組間及組內比較無差異,而第一組再灌流期的SDH活性是最高的,第二組的缺血期和再灌流期的CCO活性均有顯著的提升。 在開心術中,連續常溫血液心臟麻痺液可以獲得較高的心臟自動復甦率、較短的再灌流時問和呼吸器支持時間。但是也會發生心肌、骨骼肌和肝臟的損傷。儘管如此,它仍然是一種可行的心肌保護方法。 |
英文摘要 | Continuous warm blood cardiopiegia was widely used, as an effective means of myocardial preservation, In open heart surgery. The comparisons of myocardial protective effects between traditional cold crystalloid and warm blood cardioplegia, however, have been based mainly on hemodynamics, cardiac function and myocardial metabolism, other than clinical outcome. The present study was designed to examine myocardial protective effects by assessing clinical outcome, enzyme levels and myocardial cytochemistry. Twenty patients undergoing heart valve replacement were divided randomly into two groups: Group I was given intermittent perfusion of cold crystalloid (St. Thomas Hospital solution) with hypothermic cardiopulmonary bypass (CPB) and Group II was given continuous administration of warm blood cardioplegia with normothermlc CPB. The groups were similar with respect to sex, age, body surface area and preoperative ventricular function. Blood samples were obtained from an indwelling radial arterial catheter or from the arterial end of the oxygenator. Biopsy specimens from the right atrium were obtained immediately before aortic declamping (ischemic period) and 30 minutes after cross clamp removal (reperfusion period). Serum enzymes, including alanine transaminase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH) and its isoenzymes and creatine phosphokinase (CK) and its isoenzyme, were determined. Myocardial cytochemistry were chiefly assessed by grey-scale image processing of adenosine triphosphatase (ATPase), succinate dehydrogenase (SDH) and cytochrome oxiclase (CCO) examinations. Relations among the results were discussed. Reperfusion time was reduced and ventilation support time decreased in Group II (33.50 ± 3.78 mm vs. 25.00 ± 4.46 mm, p < 0.05; 38.98 ± 16.55 hvs. 19.84 ± 1.11 h, p < 0.05). Rates of aerial beating during aortic cross clamp and spontaneous recovery to normal sinus rhythm were much higher in Group II than in Group 1(80% vs. 20%, p < 0.05; 70% vs. 10%, p < 0.05). Differences in hospital morbidity and mortality between groups were nonsignificant. Serum AST, ALT, LDH and LDH1÷LDH2 all showed no significant intergroup differences. There was a higher serum CK-MB level with a delayed peak in Group II. The cytochemistry activities of ATPase was not different between groups and periods and SDH was the highest during reperfusion period in Group I and of CCO significantly much promoted in Group II in both periods. Continuous warm blood cardioplegia resulted in higher spontaneous recovery to sinus rhythm, shorter reperfusion and ventilation support time. Damage to the myocardium, skeletal muscle and liver always occur in warm blood cardioplegic patients. However, warm blood cardioplegia is still a practical method for myocardial preservation in open heart surgery. |
本系統中英文摘要資訊取自各篇刊載內容。