在体外循环心脏手术中，胸段硬膜外麻醉的心脏保护作用是由血管内皮生长因子和诱导型一氧化氮合酶的表达所诱导的。

The cardioprotective effects of thoracal epidural anestesia are induced by the expression of vascular endothelial growth factor and inducible nitric oxide synthase in cardiopulmonary bypass surgery.

作者信息

Gonca S, Kiliçkan L, Dalçik C, Dalçik H, Bayindir O

机构信息

Department of Histology and Embryology, Kocaeli University School of Medicine, Kocaeli, Turkey.

出版信息

J Cardiovasc Surg (Torino). 2007 Feb;48(1):93-102.

PMID:17308528

Abstract

AIM

The cardioprotective effects of thoracal epidural anesthesia (TEA) are induced by the expression of vascular endothelial growth factor (VEGF) and inducible nitric oxide synthase (i-NOS) in cardiopulmonary bypass (CPB) surgery. When general anaesthesia (GA) is combined with TEA during coronary artery bypass graft, we investigated whether TEA together with GA play a role on VEGF and i-NOS expression in human heart tissue in cardiac ischemia.

METHODS

Right atrial biopsy samples were taken before CPB, before aortic cross clamp (ACC) and at 15 min after ACC release (after ischemia and reperfusion). Human heart tissues were obtained from the TEA+GA and GA groups. Immunocytochemistry was performed using antibodies for VEGF and i-NOS.

RESULTS

Both VEGF and i-NOS immunoreactivity was observed in cardiomyocytes and arteriol walls. Although VEGF and i-NOS immunoreactivity was apparent in both groups,, immunostaining intensity was greater in the TEA+GA group than the GA group. Between groups, at 4 h and at 24 h after the end of CPB, the cardiac index (CI) was significantly higher in the TEA+GA group than GA group (3.4+/-0.8 L/min/m(2) vs 2.5+/-0.8 L/min/m(2); P<0.001), (3.8+/-1.1 L/min/m(2) vs 3.1+/-1.1 L/min/m(2); P<0.008) respectively. Within groups, at 4 and 24 h after the end of CPB, the CI was significantly higher in the TEA+GA group than baseline values, (3.4+/-0.8 L/min/m(2) vs 2.4+/-0.7 L/min/m(2); P<0.001), (3.8 +/-1.1 L/min/m(2) vs 2.4+/-0.7 L/min/m(2); P<0.001) respectively, but no difference was found in the GA group (2.6+/-0.8 L/min/m(2) vs 2.5+/-0.8 L/min/m(2); P>0.05), (2.6+/-0.8 L/min/m(2) vs 3.1+/-1.1 L/min/m(2); P>0.05) respectively. After ACC release, 11/40 (27.5%) patients in the TEA+GA group showed ventricular fibrillation (VF), atrial fibrillation or heart block versus 25/40 (62.5%) of those in the GA group. VF after ACC release in the TEA+GA group (9/20 patients, 22.5%) was significantly lower than in the GA group (21/40 patients, 52.5%); (P<0.006). Sinus rhythm after ACC release in the TEA+GA group (29/40 patients, 72.5%) was significantly higher than in the GA group (15/40 patients, 37.5%); (P<0.002).

CONCLUSIONS

The results of the present study indicate that TEA plus GA in coronary surgery preserve cardiac function via increased expression of VEGF and i-NOS, improved hemodynamic function and reduced arrhythmias after ACC release.

摘要

目的

在体外循环（CPB）手术中，胸段硬膜外麻醉（TEA）的心脏保护作用是由血管内皮生长因子（VEGF）和诱导型一氧化氮合酶（i-NOS）的表达介导的。在冠状动脉搭桥手术中，当全身麻醉（GA）与TEA联合使用时，我们研究了TEA与GA联合使用是否对心脏缺血时人心脏组织中的VEGF和i-NOS表达有影响。

方法

在CPB前、主动脉阻断钳夹（ACC）前以及ACC松开后15分钟（缺血和再灌注后）采集右心房活检样本。人心脏组织取自TEA+GA组和GA组。使用针对VEGF和i-NOS的抗体进行免疫细胞化学检测。

结果

在心肌细胞和小动脉壁中均观察到VEGF和i-NOS免疫反应性。虽然两组中VEGF和i-NOS免疫反应性均明显，但TEA+GA组的免疫染色强度高于GA组。组间比较，在CPB结束后4小时和24小时，TEA+GA组的心脏指数（CI）显著高于GA组（3.4±0.8 L/min/m² 对 2.5±0.8 L/min/m²；P<0.001），（3.8±1.1 L/min/m² 对 3.1±1.1 L/min/m²；P<0.008）。组内比较，在CPB结束后4小时和24小时，TEA+GA组的CI显著高于基线值，（3.4±0.8 L/min/m² 对 2.4±0.7 L/min/m²；P<0.001），（3.8±1.1 L/min/m² 对 2.4±0.7 L/min/m²；P<0.001），但GA组未发现差异（2.6±0.8 L/min/m² 对 2.5±0.8 L/min/m²；P>0.05），（2.6±0.8 L/min/m² 对 3.1±1.1 L/min/m²；P>0.05）。ACC松开后，TEA+GA组40例患者中有11例（27.5%）出现心室颤动（VF）、心房颤动或心脏传导阻滞，而GA组40例患者中有25例（62.5%）出现。TEA+GA组ACC松开后VF发生率（9/20例患者，22.5%）显著低于GA组（21/40例患者，52.5%）；（P<0.006）。TEA+GA组ACC松开后窦性心律发生率（29/40例患者，72.5%）显著高于GA组（15/40例患者，37.5%）；（P<0.002）。