Zhang Rufang, Shen Li, Xie Yewei, Gen Lin, Li Xiaobing, Ji Qiang
Department of Cardiothoracic Surgery, Shanghai Children's Hospital, Shanghai Jiaotong University, Shanghai, 1400 Western Beijing Rd, Shanghai 200040, PR China.
J Cardiothorac Surg. 2013 Apr 11;8:76. doi: 10.1186/1749-8090-8-76.
Results of previous reports on ischemic postconditioning in animals and humans were very encouraging. Although ischemic postconditioning possessed a wide prospect of clinical application, debates on the precise ischemic postconditioning algorithm to use in clinical settings were ongoing. In this regard, pharmacological strategies were possible alternative methods. Accumulating data demonstrated that pharmacological postconditioning with morphine conferred cardioprotection in animals. This trial aimed to evaluate the effect of morphine-induced postconditioning on protection against myocardial ischemia/reperfusion injury in patients undergoing corrections of Tetralogy of Fallot (TOF).
Eight-nine consecutive children scheduled for corrections of TOF were enrolled and randomly assigned to either a postconditioning group (patients received a dose of morphine (0.1 mg/kg) injected via a cardioplegia needle into the aortic root for direct and focused delivery to the heart within 1 minute starting at 3 min before aorta cross-clamp removal, n=44) or a control group (the same protocol was performed as in the postconditioning group except that patients received the same volume of saline instead, n=45). The peri-operative relevant data were investigated and analyzed, and the cardiac troponin I (cTnI) was assayed preoperatively, and then 4 h, 8 h, 12 h, 24 h and 48 h after reperfusion.
Morphine-induced postconditioning reduced postoperative peak cTnI release as compared to the control group (0.57 ± 0.15 versus 0.75 ± 0.20 ng/mL, p<0.0001). Morphine-induced postconditioned patients had lower peak inotropic score (5.7 ± 2.4 versus 8.4 ± 3.6, p<0.0001) and shorter duration of mechanical ventilation as well as ICU stay (20.6 ± 6.8 versus 28.5 ± 8.3 hours, p<0.0001 and 40.4 ± 10.3 versus 57.8 ± 15.2 hours, p<0.0001, respectively), while higher left ventricular ejection fraction as well as cardiac output (0.57±0.15 versus 0.51±0.13, p=0.0467 and 1.39 ± 0.25 versus 1.24 ± 0.21 L/min, p=0.0029, respectively) as compared to the control group during the first postoperative 24 hours.
Morphine-induced postconditioning may provide enhanced cardioprotection against ischemia/reperfusion injury in children undergoing corrections of TOF.
先前关于动物和人类缺血后适应的报告结果非常令人鼓舞。尽管缺血后适应具有广泛的临床应用前景，但关于在临床环境中使用的精确缺血后适应算法的争论仍在继续。在这方面，药理学策略可能是替代方法。越来越多的数据表明，吗啡进行的药理学后适应在动物中具有心脏保护作用。本试验旨在评估吗啡诱导的后适应对法洛四联症（TOF）矫治患者心肌缺血/再灌注损伤的保护作用。
连续纳入89例计划进行TOF矫治的儿童，并随机分为后适应组（患者在主动脉阻断钳移除前3分钟开始的1分钟内，通过心脏停搏针向主动脉根部注射一剂吗啡（0.1mg/kg），以直接并集中作用于心脏，n = 44）或对照组（除患者接受相同体积的生理盐水外，执行与后适应组相同的方案，n = 45）。对围手术期相关数据进行调查和分析，并在术前、再灌注后4小时、8小时、12小时、24小时和48小时测定心肌肌钙蛋白I（cTnI）。
与对照组相比，吗啡诱导的后适应降低了术后cTnI的峰值释放（0.57±0.15对0.75±0.20ng/mL，p<0.0001）。吗啡诱导后适应的患者具有较低的峰值肌力评分（5.7±2.4对8.4±3.6，p<0.0001），机械通气时间和重症监护病房停留时间较短（分别为20.6±6.8对28.5±8.3小时，p<0.0001和40.4±10.3对57.8±15.2小时，p<0.0001），而术后24小时内左心室射血分数和心输出量较高（分别为0.57±0.15对0.51±0.13，p = 0.0467和1.39±0.25对1.24±0.21L/min，p = 0.0029）。
吗啡诱导的后适应可能为接受TOF矫治的儿童提供增强的抗缺血/再灌注损伤的心脏保护作用。
