Heyer Eric J, Lee Kevin S, Manspeizer Heather E, Mongero Linda, Spanier Talia B, Caliste Xzabia, Esrig Barry, Smith Craig
Departments of Anesthesiology, Surgery, and Neurology, College of Physicians and Surgeons of Columbia University, and Columbia--Presbyterian Medical Center, New York, NY 10032, USA.
J Cardiothorac Vasc Anesth. 2002 Feb;16(1):37-42. doi: 10.1053/jcan.2002.29659.
To determine the incidence of cerebral dysfunction in cardiac surgical patients exposed to heparin-bonded cardiopulmonary bypass (HB-CPB) versus nonheparin-bonded cardiopulmonary bypass (NH-CPB) circuits through neuropsychometric testing and to correlate these findings with markers of the systemic inflammatory response to CPB.
Prospective, randomized, blinded clinical trial.
University hospital.
Sixty-one patients undergoing elective cardiac surgery.
A cohort of 61 patients scheduled for elective coronary artery bypass graft surgery were prospectively randomized to receive either HB-CPB or NH-CPB circuits during surgery. Patients were evaluated for cerebral injury using a battery of neuropsychometric tests at the following 3 time points: (1) before surgery as a baseline examination, (2) postoperative day 5, and (3) postoperative week 6. Blood samples were drawn to measure inflammatory markers at the following time points: (1) preincision, after induction of anesthesia, (2) 15 minutes after onset of CPB, (3) 30 minutes after CPB, (4) 6 hours postoperatively, and (5) 24 hours postoperatively.
Neuropsychometric performance was evaluated by group-rate and event-rate analyses. By group-rate analysis, patients undergoing surgery with HB-CPB performed significantly better at 5 days after surgery on 2 neuropsychometric tests (trails A [p < 0.01] and finger tapping with the dominant hand [p < 0.01]) and at 6 weeks after surgery on one neuropsychometric test (trails A [p < 0.01]). By event-rate analysis, at 5 days, patients undergoing surgery with HB-CPB circuits had less cognitive dysfunction (p < 0.05) compared with patients undergoing surgery with NH-CPB circuits. Serum samples were analyzed to evaluate markers of complement activation (C3a), proinflammatory cytokines (tumor necrosis factor-alpha, interleukin-1 beta, and interleukin-6), and coagulation (thrombin-antithrombin complex [TAT]) using the quantitative sandwich enzyme immunoassay technique. Although there were no significant differences in cytokine activation in either group, C3a was significantly higher in the NH-CPB group intraoperatively at 1 hour after CPB (p < 0.05), and TAT was higher in the HB-CPB group at 24 hours after surgery (p < 0.05).
Patients undergoing cardiac surgery with CPB have less postoperative cognitive dysfunction during CPB when HB-CPB circuits are employed. Although there was a relationship, this finding did not correlate with decreased complement activation intraoperatively and activation of coagulation postoperatively.
通过神经心理测试确定接受肝素涂层体外循环（HB-CPB）与未涂层体外循环（NH-CPB）的心脏手术患者脑功能障碍的发生率，并将这些结果与体外循环全身炎症反应标志物相关联。
前瞻性、随机、盲法临床试验。
大学医院。
61例行择期心脏手术的患者。
将61例计划行择期冠状动脉搭桥手术的患者前瞻性随机分为两组，术中分别接受HB-CPB或NH-CPB。在以下3个时间点使用一系列神经心理测试对患者进行脑损伤评估：（1）术前作为基线检查；（2）术后第5天；（3）术后第6周。在以下时间点采集血样以测量炎症标志物：（1）麻醉诱导后切皮前；（2）体外循环开始后15分钟；（3）体外循环后30分钟；（4）术后6小时；（5）术后24小时。
通过组率分析和事件率分析评估神经心理测试表现。通过组率分析，接受HB-CPB手术的患者在术后5天的两项神经心理测试（A组连线试验[p < 0.01]和优势手手指敲击试验[p < 0.01]）以及术后6周的一项神经心理测试（A组连线试验[p < 0.01]）中表现明显更好。通过事件率分析，术后5天时，接受HB-CPB的患者与接受NH-CPB的患者相比，认知功能障碍更少（p < 0.05）。使用定量夹心酶免疫测定技术分析血清样本，以评估补体激活标志物（C3a）、促炎细胞因子（肿瘤坏死因子-α、白细胞介素-1β和白细胞介素-6）和凝血标志物（凝血酶-抗凝血酶复合物[TAT]）。虽然两组细胞因子激活无显著差异，但NH-CPB组在体外循环后1小时术中C3a显著更高（p < 0.05），而HB-CPB组在术后24小时TAT更高（p < 0.05）。
使用HB-CPB进行心脏手术的患者在体外循环期间术后认知功能障碍较少。虽然存在关联，但这一发现与术中补体激活减少和术后凝血激活无关。
