Benefits and Pitfalls of Warm Blood Cardioplegia in Heart Valve Replacement: Systemic Protective Effects

溫血心臟麻痺液在心瓣膜替換術中所扮演之角色：對全身組織的保護作用

袁師敏(Shi-Min Yuan)

《The Kaohsiung Journal of Medical Sciences》 14卷10期 (1998/10) Pp. 616-624

https://doi.org/10.6452/KJMS.199810.0616

摘要

本文旨在評估持續溫血心臟麻痺液較傳統的冷類晶質心臟麻痺液而言在心瓣膜替換術中所扮演之角色。
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)間斷灌流的心肌保護方法，第二組接受常溫體外循環併常溫血心臟麻痺液連續灌流的心肌保護方法。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。轉流條件及圍手術期併發症作組間比較。術後120小時之內血清酶，乳酸去氫酶(LDH)及其同功酶LDH1+LDH2、肌酸激酶(CK)及其同功酶CK-MB、superoxide dismutase 及malondialdehyde，亦作組間比較。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。兩組各期心肌損害情形予以觀察和評分。
轉流條件中，除灌流流量、機體溫度、中心靜脈壓外，均無組間的統計學差異。圍手術期併發症發生率亦無組間的差異。除CK以外，第一組的血清酶達到峰值的時間先於或與第二組同時出現。除CK以外，血清酶峰值水平無組間的差異(CK:307.44±38.56 U/L, 466.29±52.03 U/L, P=0.039) 。病理評分示，第一組再灌流期心肌損傷最重，且兩組均為再灌流期較缺血期嚴重。
溫血心臟麻痺液技術，雖有許多潛在的危險因子存在，仍是開心術中實用的心肌保護方法。但對心冗以外的組織保護效果略遜。

並列摘要

The purpose of this paper was to assess the role of continuous warm blood cardioplegia in heart valve replacement in comparison with standard intermittent cold crystalloid cardioplegia.
Twenty patients undergoing open heart valve replacement were divided arbitrarily into two groups in this strudy; Group Iwas given intermittent perfusion of cold crystalloid(St. Thomas Hospital solution) with hypothermic cardiopulmonary bypass (CPB)(10 patients) and Group II was given continuous administrationo of warm blood cardioplegia with normothermic CPB(10 patients). The groups were similar with respect to sex, age, body surface area and preoperative ventricular function. Bypass conditions as well as perioperative complications were evaluated in the respective groups. Peak values of the serum enzyme levels within 120 hours of postoperation including alanine transaminase, aspartate aminotransferase, lactate dehydrogenase (LDH) and its isoenzymes LDH1+LDH2, phosphokinase (CK) and its isoenzyme CK-MB, superoxide dismutase, and malondialdehyde in the two groups were also assessed. Biopsies from the right atrium were obtained immediately before aortic cross clamp removal (ischemic period), and 30 minutes after cross clamp removal (reperfusion period). Myocardial structures were observed and scored.
No significant intergroup differences were found in the bypass conditions except for the perfusion flow, systemic temperature and central venous pressure. There were no significant differences in the intergroup perioperative complications, either. Serum enzymes except CK which reached peak values in Group I appeared prior to or consistent with Group II. There were no significant intergroup differences in peak levels of the serum enzymes except CK(307.44 ± 38.56 U/L vs. 466.29 ± 52.03 U/L, p=0.039 for CK). From the pathological assessment, the structural alterations were the most severe during the reperfusion period in group I. Myocardial damage showed more severely in reperfusion than in ischemia in both.
Warm blood cardioplegic technique, raising potential hazards, is still a practicle method for myocardial protection in open hear surgery, but might be less effective in protecting the tissues beyond myocardium.

並列關鍵字

cardioplegia ； heart valve procedure ； reperfusion injury