Drenger Benjamin, Gilon Dan, Chevion Mordechai, Elami Amir, Meroz Yuval, Milgalter Eli, Gozal Yaacov
Department of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University Medical Center Hospital and the Hebrew University School of Medicine, Jerusalem, Israel.
J Cardiothorac Vasc Anesth. 2008 Jun;22(3):369-76. doi: 10.1053/j.jvca.2007.12.023. Epub 2008 Mar 24.
During off-pump coronary artery bypass (OPCAB) surgery, the heart is subjected to ischemia and reperfusion. The authors hypothesized that the volatile anesthetics are as effective as ischemic preconditioning (IPC) in preserving myocardial function during off-pump cardiac surgery, and this effect is because of multiple mechanisms of action. Therefore, the effects of enflurane with its calcium inhibition and antioxidative properties were compared with mechanical IPC in preserving myocardial cellular markers.
A prospective, randomized, controlled, and partly blinded study.
A tertiary care university hospital.
Twenty-five patients undergoing elective single-graft OPCAB surgery.
Patients were randomized into 3 groups: (1) control (n = 8), (2) a single 5-minute ischemia/reperfusion interval of IPC before coronary occlusion (n = 9), and (3) 1.6% enflurane anesthesia 15 minutes before and during graft attachment (n = 8). Arterial and coronary sinus venous blood were analyzed for biochemical indices of ischemia and hydroxyl radical generation.
Although the hemodynamic changes were small, myocardial lactate production in the control group increased by 120%, whereas in the enflurane group it decreased significantly (p < 0.01) compared with the control and IPC groups. Oxygen utilization in the control group was 44% higher (p < 0.03), and there was also a larger release of the hydroxyl radical-dependent adduct 2,3-dihydroxybenzoic acid (225% increase, p < 0.05) compared with both study groups. During reperfusion, initial anterior wall hypokinesis by TEE was observed, with slow recovery during reperfusion compared with early recovery in both study groups.
Coronary occlusion during OPCAB surgery results in increased production of ischemia-related metabolic products. The application of methods such as IPC or volatile anesthesia appears to reduce the metabolic deficit, free-radical production, and physiologic changes.
在非体外循环冠状动脉搭桥术（OPCAB）中，心脏会经历缺血和再灌注过程。作者推测，在非体外循环心脏手术中，挥发性麻醉剂在保护心肌功能方面与缺血预处理（IPC）同样有效，且这种作用是由多种作用机制导致的。因此，将具有钙抑制和抗氧化特性的恩氟烷与机械性IPC在保护心肌细胞标志物方面的效果进行了比较。
一项前瞻性、随机、对照且部分盲法的研究。
一家三级护理大学医院。
25例行择期单支血管OPCAB手术的患者。
患者被随机分为3组：（1）对照组（n = 8），（2）冠状动脉闭塞前进行单次5分钟的IPC缺血/再灌注间隔组（n = 9），（3）在血管吻合前15分钟及吻合过程中采用1.6%恩氟烷麻醉组（n = 8）。分析动脉血和冠状静脉窦血中缺血及羟自由基生成的生化指标。
尽管血流动力学变化较小，但与对照组和IPC组相比，对照组心肌乳酸生成增加了120%，而恩氟烷组显著降低（p < 0.01）。对照组的氧利用率高44%（p < 0.03），与两个研究组相比，羟自由基依赖性加合物2,3 - 二羟基苯甲酸的释放量也更大（增加225%，p < 0.05）。在再灌注期间，经食管超声心动图观察到初始前壁运动减弱，与两个研究组再灌注早期恢复相比，该组再灌注期间恢复缓慢。
OPCAB手术中的冠状动脉闭塞导致与缺血相关的代谢产物生成增加。应用IPC或挥发性麻醉等方法似乎可减少代谢缺陷、自由基生成及生理变化。
