心肌肌钙蛋白I对心内直视手术心肌损伤的判定价值

1、心肌肌钙蛋白I对心内直视手术心肌损伤的判定价值                       作者：郭训，刘琴湘，岑欢，邵兵，胡宁东，周海波   【摘要】  目的 探讨心肌肌钙蛋白I(cTnI)对心内直视手术心肌损伤的判定价值。方法 40例心脏瓣膜置换手术患者随机分为两组，冷晶体停跳液组(A组)，温血停跳液组(B组) 每组20例，分别于围术期多时点采

2、取中心静脉血，测定血清cTnI、CK及CK-MB的水平。结果 术前两组的cTnl、CK及CK-MB水平均在正常范围，开放主动脉后l h至术后24 h达峰值，其后缓慢下降。术后24 h、48 h温血停跳液组cTnI水平明显低于冷晶体停跳液组(P<0.05)，CK-MB在开放主动脉后1 h温血停跳液组低于冷晶体停跳液组。cTnl峰值浓度与主动脉阻断时间呈直线正相关。结论 cTnl判定心内直视手术围术期心肌损伤的敏感性及特异性明显优于CK、CK-MB，对围术期心肌缺血损伤的诊断、预后及心肌保护效果的评价具有重要的临床价值。 【关键词】  心肺转流；心肌损伤；心肌肌钙蛋白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心肺转流（Cardiopulmonary bypass，CPB）作为非生理过程和心脏手术操作

8、都可导致心肌损伤，因此围术期心肌损伤的监测非常重要。以往常将肌酸激酶(CK)及其同工酶(CK-MB)作为术中心肌损伤的监测指标，但两者并非心肌特异性酶，其敏感性和特异性较低。心肌肌钙蛋白I(cTnI)是一项快速、敏感、能准确判定心肌损伤的最新诊断指标，cTnI在血中出现早，持续时间长，且为心肌细胞所特有，具有敏感性高、特异性强的特点1。本研究动态观察心脏手术围术期cTnI、CK、CK-MB的变化，以探讨cTnI在评价心肌损伤和心肌保护效果的临床价值。1  资料与方法 1.1  一般资料 40例心脏瓣膜置换手术患者，无合并冠心病或其它心脏病史，随机分为两组

9、，每组20例，A组为冷晶体停跳液组，B组为温血停跳液组，见表1。表1  患者一般资料（略）注：MVR(二尖瓣置换) ; DVR(二尖瓣与主动脉瓣置换) ; AVR(主动脉瓣置换)两组间比较, P>0.051.2  方法   全部患者术前肌注吗啡 0.2 mg/kg,东莨菪碱0.3 mg,均采用咪唑安定0.2 mg/kg、维库溴铵0.10.15 mg/kg、芬太尼5 g/kg静注诱导，经口明视气管插管。锯胸骨前、CPB前追加芬太尼和维库溴铵，间断吸入异氟烷维持麻醉, 芬太尼总用量40 g/kg。术中动态监测血压、中心静脉压（CVP）、激活凝

10、血时间(ACT)、血气、血生化和尿量、红细胞压积(Hct)等。CPB采用Stockert S型心肺机，Dideco膜式氧合器行平流灌注。A组：阻断升主动脉后经升主动脉根部灌注4晶体含钾停跳液(K+ 20 mmol/L)1015 ml/kg，其后每20 min灌注一次，剂量减半(K+ 10mmol/L)，同时心包腔内放置冰屑以保持心肌全层深低温，及时左心引流使心肌在低负荷下停跳。B组：阻断升主动脉后经升主动脉根部(AVR者行主动脉切开顺行灌注)灌注温血(3032)含钾停跳液(血：停跳液=41，K+20 mmol/L)，灌注速度为150200 ml/min，首次灌注量为1015 ml/kg，心脏停跳后每20 min30 min灌注一次，剂量减半(K+ 10 mmol/L)。两组患者分别在术前、开放主动脉后1 h、术后24 h、术后48 h、术后72 h、术后168 h 6个时点从中心静脉采取血样测定血清CK、CK-MB和cTnI水平。CK、CK-MB测定使用北京九公司提供的试剂盒，采用比色法日立7170自动生化分析仪定量测定，CK标准值为25200 U/L，CK-MB标准值为025 U/L