Cardiac Surgery Department, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium.
Eur J Cardiothorac Surg. 2011 Dec;40(6):1384-90. doi: 10.1016/j.ejcts.2011.03.047. Epub 2011 Jul 12.
Although normothermia and warm blood cardioplegia are widely used in adults, cold crystalloids and hypothermia remain routinely used in pediatric cardiac surgery. The superiority of either technique in both brain and myocardial protection remains controversial. We designed a prospective randomized study to compare both approaches in terms of early myocardial protection and late neurodevelopmental status.
From 2004 to 2005, 47 patients were randomly assigned to either mild hypothermia associated to cold crystalloid cardioplegia (CCC, 22 patients) or normothermia with intermittent warm blood cardioplegia (IWBC, 25 patients). Intramyocyte adenosine triphosphate (ATP) was measured before, during and after cardioplegic arrest and results between groups were compared. In addition to their cardiac status, early and late neurologic assessment was performed by psychometric evaluation tests.
Intracellular ATP levels were not significantly different between the two groups. However, intragroup comparison revealed different profiles according to myocardial protection: in the normothermia/warm blood cardioplegia group, ATP concentration increased during cardioplegic arrest and returned to initial values afterward (11 nmol mg(-1) vs 21 nmol mg(-1) vs 10 nmol mg(-1), p < 0.001), such changes did not occur in the cold protocol (17 nmol mg(-1) vs 19 nmol mg(-1) vs 14 nmol mg(-1), p = NS). Early neurological outcome was similar in both groups. At late follow-up (mean = 4 years), no significant difference was observed between the two groups.
This study demonstrates that normothermia/IWBC protocols are not deleterious when compared with more conventional approaches. A more physiologic ATP steady state, reflecting the absence of cellular ischemic insult was observed in the IWBC group. Importantly, no significant difference was found between IWBC and CCC groups in terms of early and late neurodevelopmental status.
尽管在成人心脏手术中，常采用常温及温血停搏液，但低温晶体停搏液和低温仍是儿科心脏手术中的常规方法。在脑和心肌保护方面，这两种技术孰优孰劣，目前仍存在争议。本研究设计了一项前瞻性随机研究，旨在比较这两种方法在早期心肌保护和晚期神经发育方面的差异。
2004 年至 2005 年，将 47 例患者随机分为低温晶体停搏液伴亚低温（CCC）组（22 例）或常温间断温血停搏液（IWBC）组（25 例）。分别于停搏前、停搏中和停搏后测定心肌细胞内三磷酸腺苷（ATP）水平，并对两组间的结果进行比较。除了心脏状况外，还通过心理计量评估测试进行早期和晚期神经评估。
两组间细胞内 ATP 水平无显著差异。然而，组内比较显示，根据心肌保护方式，存在不同的特点：在常温/温血停搏液组，停搏期间 ATP 浓度增加，停搏后恢复至初始值（11 nmol/mg 比 21 nmol/mg 比 10 nmol/mg，p<0.001），而在低温方案中未出现这些变化（17 nmol/mg 比 19 nmol/mg 比 14 nmol/mg，p=NS）。两组的早期神经结局相似。在晚期随访（平均 4 年）时，两组间无显著差异。
本研究表明，与更传统的方法相比，常温/IWBC 方案并无不良影响。IWBC 组观察到更接近生理的 ATP 稳态，反映了细胞无缺血损伤。重要的是，IWBC 组和 CCC 组在早期和晚期神经发育方面无显著差异。
