Liakopoulos Oliver J, Schmitto Jan D, Kazmaier Stefan, Bräuer Anselm, Quintel Michael, Schoendube Friedrich A, Dörge Hilmar
Department of Thoracic and Cardiovascular Surgery, University of Göttingen, Göttingen, Germany.
Ann Thorac Surg. 2007 Jul;84(1):110-8; discussion 118-9. doi: 10.1016/j.athoracsur.2007.01.003.
Cardiopulmonary bypass (CPB)-related inflammatory response can be attenuated by glucocorticoid treatment, but its impact on postoperative cardiopulmonary function remains controversial. It was investigated whether the systemic and myocardial antiinflammatory effects of glucocorticoids are associated with improved cardiopulmonary function in cardiac surgery patients.
Eighty patients undergoing elective coronary artery bypass grafting were randomly assigned to receive a single shot of methylprednisolone (15 mg/kg) or placebo before CPB. Variables of myocardial and pulmonary function and systemic hemodynamics were measured before and 1, 4, 10, and 24 hours after CPB. Blood was sampled for measurement of proinflammatory (tumor necrosis factor-alpha, interleukin 6, interleukin 8) and antiinflammatory (interleukin 10) cytokines (by enzyme-linked immunoassay), troponin T, and C-reactive protein. Phosphorylation of inhibitory kappa-B alpha and p38 mitogen-activated protein kinase was determined in right atrial biopsies before and after CPB (phosphoprotein assay).
Preoperative and intraoperative characteristics of patients were not different between groups. Methylprednisolone attenuated postoperative tumor necrosis factor-alpha, interleukin 6, interleukin 8, and C-reactive protein levels while increasing interleukin 10 release. Myocardial inhibitory kappa-B alpha was preserved with methylprednisolone (p < 0.05 versus placebo), but p38 mitogen-activated protein kinase activation occurred in both groups after CPB (p < 0.05 versus before CPB). Methylprednisolone improved postoperative cardiac index and was associated with decreased troponin T when compared with placebo (p < 0.05). Postoperative blood glucose, oxygen delivery index, and pulmonary shunt flow were increased in the methylprednisolone group (p < 0.05). There was no difference in postoperative oxygenation index, ventilation time, and clinical outcome between treatment groups.
Glucocorticoid treatment before CPB attenuates perioperative release of systemic and myocardial inflammatory mediators and improves myocardial function, suggesting potential cardioprotective effects in patients undergoing cardiac surgery.
体外循环（CPB）相关的炎症反应可通过糖皮质激素治疗减轻，但其对术后心肺功能的影响仍存在争议。本研究旨在探讨糖皮质激素的全身和心肌抗炎作用是否与心脏手术患者心肺功能改善相关。
80例行择期冠状动脉搭桥术的患者在CPB前随机分为两组，分别接受单次静脉注射甲泼尼龙（15mg/kg）或安慰剂。在CPB前以及CPB后1、4、10和24小时测量心肌和肺功能以及全身血流动力学指标。采集血样检测促炎细胞因子（肿瘤坏死因子-α、白细胞介素6、白细胞介素8）和抗炎细胞因子（白细胞介素10）（采用酶联免疫吸附测定法）、肌钙蛋白T和C反应蛋白。在CPB前后取右心房组织活检，测定抑制性κBα和p38丝裂原活化蛋白激酶的磷酸化水平（采用磷蛋白测定法）。
两组患者术前和术中特征无差异。甲泼尼龙可减轻术后肿瘤坏死因子-α、白细胞介素6、白细胞介素8和C反应蛋白水平，同时增加白细胞介素10的释放。甲泼尼龙可使心肌抑制性κBα得以保留（与安慰剂组相比，P<0.05），但两组在CPB后均出现p38丝裂原活化蛋白激酶激活（与CPB前相比，P<0.05）。与安慰剂组相比，甲泼尼龙可改善术后心脏指数，并使肌钙蛋白T水平降低（P<0.05）。甲泼尼龙组术后血糖、氧输送指数和肺分流流量增加（P<0.05）。治疗组之间术后氧合指数、通气时间和临床结局无差异。
CPB前应用糖皮质激素可减轻围手术期全身和心肌炎症介质的释放，并改善心肌功能，提示其对心脏手术患者具有潜在的心脏保护作用。
