心肌肌鈣蛋白I對(duì)心內(nèi)直視手術(shù)心肌損傷的判定價(jià)值

1、心肌肌鈣蛋白I對(duì)心內(nèi)直視手術(shù)心肌損傷的判定價(jià)值                       作者：郭訓(xùn)，劉琴湘，岑歡，邵兵，胡寧東，周海波   【摘要】  目的 探討心肌肌鈣蛋白I(cTnI)對(duì)心內(nèi)直視手術(shù)心肌損傷的判定價(jià)值。方法 40例心臟瓣膜置換手術(shù)患者隨機(jī)分為兩組，冷晶體停跳液組(A組)，溫血停跳液組(B組) 每組20例，分別于圍術(shù)期多時(shí)點(diǎn)采

2、取中心靜脈血，測(cè)定血清cTnI、CK及CK-MB的水平。結(jié)果 術(shù)前兩組的cTnl、CK及CK-MB水平均在正常范圍，開放主動(dòng)脈后l h至術(shù)后24 h達(dá)峰值，其后緩慢下降。術(shù)后24 h、48 h溫血停跳液組cTnI水平明顯低于冷晶體停跳液組(P<0.05)，CK-MB在開放主動(dòng)脈后1 h溫血停跳液組低于冷晶體停跳液組。cTnl峰值濃度與主動(dòng)脈阻斷時(shí)間呈直線正相關(guān)。結(jié)論 cTnl判定心內(nèi)直視手術(shù)圍術(shù)期心肌損傷的敏感性及特異性明顯優(yōu)于CK、CK-MB，對(duì)圍術(shù)期心肌缺血損傷的診斷、預(yù)后及心肌保護(hù)效果的評(píng)價(jià)具有重要的臨床價(jià)值。 【關(guān)鍵詞】  心肺轉(zhuǎn)流；心肌損傷；心肌肌鈣蛋白IApplic

3、ation of Cardiac Troponin I to the Diagnosis of Myocardial Injury During Open Heart Surgery Under Cardiopulmonary BypassAbstract: OBJECTIVE  To evaluate the clinical value of cardiac troponin I(cTnI)in the diagnosis of myocardial ischemic injury during open heart surgery.METHODS  Fourty pa

4、tients under-going cardiac valve replacement operation were randomly divided into two groups：group A(cold crystalloid cardioplegia,n=20)and group B(warm blood cardioplegia,n=20). The central venous blood samples were taken at various times during perioperation to measure the serum levels of cTnI,CK-

5、MB and CK.RESULTS  cTnI,CK and CK-MB levels were normal before operation,increased markedly following aortic declamping,reached the peak value at 1 h after aortic declamping to 24 h after operation,and therefter decreased progressively to be normal in two groups.The serum cTnl level was signifi

6、cantly lower in group B than that in group A 24 h and 48 h after operation.The serum CK-MB activity was lower in group B than that in group A 1 h after aortic declamping.There was positive significant correlation between aortic clamping time and cTnI peak leve1CONCLUSION  cTnl can be used to ev

7、aluate the degree of myocardial injury and myocardial protective effect in open heart surgery，the sensitivity and specificity of cTnl are more valuable than those of myocardial enzymes.Key words：Cardiopulmonary bypass；Myocardium injury；Cardiac troponin I心肺轉(zhuǎn)流（Cardiopulmonary bypass，CPB）作為非生理過程和心臟手術(shù)操作

8、都可導(dǎo)致心肌損傷，因此圍術(shù)期心肌損傷的監(jiān)測(cè)非常重要。以往常將肌酸激酶(CK)及其同工酶(CK-MB)作為術(shù)中心肌損傷的監(jiān)測(cè)指標(biāo)，但兩者并非心肌特異性酶，其敏感性和特異性較低。心肌肌鈣蛋白I(cTnI)是一項(xiàng)快速、敏感、能準(zhǔn)確判定心肌損傷的最新診斷指標(biāo)，cTnI在血中出現(xiàn)早，持續(xù)時(shí)間長(zhǎng)，且為心肌細(xì)胞所特有，具有敏感性高、特異性強(qiáng)的特點(diǎn)1。本研究動(dòng)態(tài)觀察心臟手術(shù)圍術(shù)期cTnI、CK、CK-MB的變化，以探討cTnI在評(píng)價(jià)心肌損傷和心肌保護(hù)效果的臨床價(jià)值。1  資料與方法 1.1  一般資料 40例心臟瓣膜置換手術(shù)患者，無(wú)合并冠心病或其它心臟病史，隨機(jī)分為兩組

9、，每組20例，A組為冷晶體停跳液組，B組為溫血停跳液組，見表1。表1  患者一般資料（略）注：MVR(二尖瓣置換) ; DVR(二尖瓣與主動(dòng)脈瓣置換) ; AVR(主動(dòng)脈瓣置換)兩組間比較, P>0.051.2  方法   全部患者術(shù)前肌注嗎啡 0.2 mg/kg,東莨菪堿0.3 mg,均采用咪唑安定0.2 mg/kg、維庫(kù)溴銨0.10.15 mg/kg、芬太尼5 g/kg靜注誘導(dǎo)，經(jīng)口明視氣管插管。鋸胸骨前、CPB前追加芬太尼和維庫(kù)溴銨，間斷吸入異氟烷維持麻醉, 芬太尼總用量40 g/kg。術(shù)中動(dòng)態(tài)監(jiān)測(cè)血壓、中心靜脈壓（CVP）、激活凝

10、血時(shí)間(ACT)、血?dú)?、血生化和尿量、紅細(xì)胞壓積(Hct)等。CPB采用Stockert S型心肺機(jī)，Dideco膜式氧合器行平流灌注。A組：阻斷升主動(dòng)脈后經(jīng)升主動(dòng)脈根部灌注4晶體含鉀停跳液(K+ 20 mmol/L)1015 ml/kg，其后每20 min灌注一次，劑量減半(K+ 10mmol/L)，同時(shí)心包腔內(nèi)放置冰屑以保持心肌全層深低溫，及時(shí)左心引流使心肌在低負(fù)荷下停跳。B組：阻斷升主動(dòng)脈后經(jīng)升主動(dòng)脈根部(AVR者行主動(dòng)脈切開順行灌注)灌注溫血(3032)含鉀停跳液(血：停跳液=41，K+20 mmol/L)，灌注速度為150200 ml/min，首次灌注量為1015 ml/kg，心臟停跳后每20 min30 min灌注一次，劑量減半(K+ 10 mmol/L)。兩組患者分別在術(shù)前、開放主動(dòng)脈后1 h、術(shù)后24 h、術(shù)后48 h、術(shù)后72 h、術(shù)后168 h 6個(gè)時(shí)點(diǎn)從中心靜脈采取血樣測(cè)定血清CK、CK-MB和cTnI水平。CK、CK-MB測(cè)定使用北京九公司提供的試劑盒，采用比色法日立7170自動(dòng)生化分析儀定量測(cè)定，CK標(biāo)準(zhǔn)值為25200 U/L，CK-MB標(biāo)準(zhǔn)值為025 U/L