老年患者主动脉瓣手术中搏动性体外循环与肾功能†

Pulsatile cardiopulmonary bypass and renal function in elderly patients undergoing aortic valve surgery†.

作者信息

Milano Aldo Domenico, Dodonov Mikhail, Van Oeveren Willem, Onorati Francesco, Gu Y John, Tessari Maddalena, Menon Tiziano, Gottin Leonardo, Faggian Giuseppe

机构信息

Division of Cardiac Surgery, Department of Surgery, University of Verona Medical School, Verona, Italy.

Division of Cardiac Surgery, Department of Surgery, University of Verona Medical School, Verona, Italy

出版信息

Eur J Cardiothorac Surg. 2015 Feb;47(2):291-8; discussion 298. doi: 10.1093/ejcts/ezu136. Epub 2014 Apr 16.

DOI:10.1093/ejcts/ezu136

PMID:24740935

Abstract

OBJECTIVES

To evaluate if pulsatile cardiopulmonary bypass (CPB) has any protective influence on renal function in elderly patients undergoing aortic valve replacement (AVR).

METHODS

Forty-six patients (≥ 75 years old) with aortic valve stenosis underwent AVR with either pulsatile perfusion (PP) or non-pulsatile perfusion (NP) during CPB. Haemodynamic efficacy of the blood pump during either type of perfusion was described in terms of the energy equivalent pressure and the surplus haemodynamic energy. Urine samples were collected before surgery, at sternum closure, and at 2 and 18 h of intensive care unit stay to detect acute kidney injury markers. Perioperative urine levels of N-acetyl-β-D-glucosaminidase (NAG), kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin (NGAL) were assessed together with plasma creatinine, creatinine clearance (CCr) and 24-h haemodynamic monitoring. Normally distributed continuous variables were described as mean ± standard deviation and non-normally distributed data were presented as the median [25th-75th percentiles].

RESULTS

PP was characterized by a significantly higher amount of surplus haemodynamic energy transferred to the patients (P < 0.001), with lower mean systemic vascular resistance during CPB (P = 0.020) and during 18 h postoperatively (group-P = 0.018). No difference was found between pre- and postoperative CCr in the PP group (71 ± 23 vs 60 ± 35 ml/min, P = 0.27), while its statistically significant perioperative decrement was observed in the NP group (67 ± 24 vs 45 ± 15 ml/min, P < 0.001). The PP group showed significantly lower urinary levels of NAG at 18 h postoperatively (P = 0.008), and NGAL at sternum closure (P = 0.010), 2 h (P < 0.001) and 18 h (P = 0.015) postoperatively.

CONCLUSIONS

Short-term PP in elderly patients showed higher safety for renal physiology than NP, resulting in better maintenance of glomerular filtration and lower renal tissue injury.

摘要

目的

评估搏动性体外循环（CPB）对接受主动脉瓣置换术（AVR）的老年患者肾功能是否有任何保护作用。

方法

46例（≥75岁）主动脉瓣狭窄患者在CPB期间接受搏动灌注（PP）或非搏动灌注（NP）下的AVR。根据能量等效压力和剩余血流动力学能量描述两种灌注类型期间血泵的血流动力学效果。在手术前、胸骨闭合时以及重症监护病房停留2小时和18小时时收集尿液样本，以检测急性肾损伤标志物。评估围手术期尿液中N-乙酰-β-D-氨基葡萄糖苷酶（NAG）、肾损伤分子-1和中性粒细胞明胶酶相关脂质运载蛋白（NGAL）的水平，同时评估血浆肌酐、肌酐清除率（CCr）和24小时血流动力学监测。正态分布的连续变量描述为均值±标准差，非正态分布的数据表示为中位数[第25-75百分位数]。

结果

PP的特征是传递给患者的剩余血流动力学能量显著更高（P<0.001），CPB期间（P = 0.020）和术后18小时（组间P = 0.018）平均体循环血管阻力较低。PP组术前和术后CCr无差异（71±23 vs 60±35 ml/min，P = 0.27），而NP组围手术期有统计学意义的下降（67±24 vs 45±15 ml/min，P<0.001）。PP组术后18小时尿液中NAG水平显著较低（P = 0.008），胸骨闭合时、术后2小时（P<0.001）和18小时（P = 0.015）尿液中NGAL水平显著较低。