Chowdhury Ujjwal Kumar, Sheil Avneesh, Kapoor Poonam Malhotra, Narang Rajiv, Gharde Parag, Malik Vishwas, Kalaivani Mani, Chaudhury Arindam
Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.
Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India.
Ann Card Anaesth. 2016 Jul-Sep;19(3):439-53. doi: 10.4103/0971-9784.185526.
To investigate the release pattern of different cardiac metabolites and biomarkers directly from the coronary sinus (CS) and to establish the diagnostic discrimination limits of each marker protein and metabolites to evaluate perioperative myocardial injury in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB).
Sixty-eight patients undergoing first mitral and/or aortic valve replacements with/without coronary artery bypass grafting and Bentall procedure under CPB and blood cardioplegic arrest were studied. All cardiac metabolites and biomarkers were measured in serial CS-derived blood samples at pre-CPB, immediate post aortic declamping, 10 minutes post-CPB and 12 hrs post-CPB.
Receiver operating characteristic curve analysis of cardiac biomarkers indicated lactate-pyruvate ratio as the superior diagnostic discriminator of myocardial injury with an optimal "cut-off" value >10.8 immediately after aortic declamping (AUC, 0.92; 95% CI: 0.85-0.98). Lactate was the second best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >2mmol/l at immediately after aortic declamping (AUC, 0.89; 95% CI: 0.80-0.96). Cardiac troponin-I was the third best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >2.1ng/ml at immediately after aortic declamping (AUC, 0.88; 95% CI: 0.80-0.95). Creatine kinase-MB was the fourth best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >58 log units/ml prior to decanulation (AUC, 0.85; 95% CI: 0.78-0.94).
Measurable cardiac damage exists in all patients undergoing cardiac surgery under cardioplegic arrest. The degree of myocardial injury is more in patients with poor ventricular function and those requiring longer aortic clamp time. CS-derived lactate-pyruvate ratio, lactate, cTn-I served as superior diagnostic discriminators of peri-operative myocardial damage.
直接研究不同心脏代谢产物和生物标志物从冠状窦（CS）的释放模式，并确定每种标记蛋白和代谢产物的诊断鉴别界限，以评估体外循环（CPB）下心内手术患者围手术期心肌损伤情况。
对68例在CPB和冷血心脏停搏下进行首次二尖瓣和/或主动脉瓣置换术（伴或不伴冠状动脉搭桥术及Bentall手术）的患者进行研究。在CPB前、主动脉开放后即刻、CPB后10分钟和CPB后12小时，对一系列源自CS的血样进行所有心脏代谢产物和生物标志物的测量。
心脏生物标志物的受试者工作特征曲线分析表明，乳酸 - 丙酮酸比值是心肌损伤的最佳诊断鉴别指标，在主动脉开放后即刻最佳“截断”值>10.8（AUC，0.92；95%CI：0.85 - 0.98）。乳酸是心肌损伤的第二佳诊断鉴别指标，在主动脉开放后即刻最佳“截断”值>2mmol/l（AUC，0.89；95%CI：0.80 - 0.96）。心肌肌钙蛋白I是心肌损伤的第三佳诊断鉴别指标，在主动脉开放后即刻最佳“截断”值>2.1ng/ml（AUC，0.88；95%CI：0.80 - 0.95）。肌酸激酶 - MB是心肌损伤的第四佳诊断鉴别指标，在拔除插管前最佳“截断”值>58 log单位/ml（AUC，0.85；95%CI：0.78 - 0.94）。
所有在心脏停搏下心内手术的患者均存在可测量的心脏损伤。心室功能差和主动脉阻断时间长的患者心肌损伤程度更重。源自CS的乳酸 - 丙酮酸比值、乳酸、cTn - I是围手术期心肌损伤的最佳诊断鉴别指标。
