Oikawa Fernando Teiichi Costa, Hueb Whady, Nomura Cesar Higa, Hueb Alexandre Ciappina, Villa Alexandre Volney, da Costa Leandro Menezes Alves, de Melo Rodrigo Morel Vieira, Rezende Paulo Cury, Segre Carlos Alexandre Wainrober, Garzillo Cibele Larrosa, Lima Eduardo Gomes, Ramires Jose Antonio Franchini, Filho Roberto Kalil
Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
J Cardiothorac Surg. 2017 Dec 29;12(1):122. doi: 10.1186/s13019-017-0684-3.
The diagnosis of peri-procedural myocardial infarction is complex, especially after the emergence of high-sensitivity markers of myocardial necrosis.
In this study, patients with normal baseline cardiac biomarkers and formal indication for elective on-pump coronary bypass surgery were evaluated. Electrocardiograms, cardiac biomarkers, and cardiac magnetic resonance imaging with late gadolinium enhancement were performed before and after procedures. Myocardial infarction was defined as more than ten times the upper reference limit of the 99th percentile for troponin I and for creatine kinase isoform (CK-MB) and by the findings of new late gadolinium enhancement on cardiac magnetic resonance. We assessed the release of cardiac biomarkers in patients with no evidence of myocardial infarction on cardiac magnetic resonance.
Of 75 patients referred for on-pump coronary bypass surgery, 54 (100%) did not have evidence of myocardial infarction on cardiac magnetic resonance. However, all had a peak troponin I above the 99th percentile; 52 (96%) had an elevation 10 times higher than the 99th percentile. Regarding CK-MB, 54 (100%) patients had a peak CK-MB above the 99th percentile limit, and only 13 (24%) had an elevation greater than 10 times the 99th percentile. The median value of troponin I peak was 3.15 (1.2 to 3.9) ng/mL, which represented 78.7 times the 99th percentile.
In this study, different from CK-MB findings, troponin was significantly increased in the absence of myocardial infarction on cardiac magnetic resonance. Thus, CK-MB was more accurate than troponin I for excluding procedure-related myocardial infarction. These data suggest a higher troponin cutoff for the diagnosis of coronary bypass surgery related myocardial infarction.
http://www.isrctn.com/ISRCTN09454308 . Registered 08 May 2012.
围手术期心肌梗死的诊断较为复杂，尤其是在心肌坏死高敏标志物出现之后。
在本研究中，对基线心脏生物标志物正常且有择期体外循环冠状动脉搭桥手术正式指征的患者进行了评估。在手术前后进行了心电图、心脏生物标志物检测以及延迟钆增强心脏磁共振成像检查。心肌梗死的定义为肌钙蛋白I和肌酸激酶同工酶（CK-MB）超过第99百分位数上限参考值的十倍以上，以及心脏磁共振上出现新的延迟钆增强表现。我们评估了心脏磁共振上无心肌梗死证据的患者心脏生物标志物的释放情况。
在75例接受体外循环冠状动脉搭桥手术的患者中，54例（100%）在心脏磁共振上无心肌梗死证据。然而，所有患者的肌钙蛋白I峰值均高于第99百分位数；52例（96%）升高至高于第99百分位数的10倍以上。关于CK-MB，54例（100%）患者的CK-MB峰值高于第99百分位数上限，只有13例（24%）升高大于第99百分位数的10倍。肌钙蛋白I峰值的中位数为3.15（1.2至3.9）ng/mL，为第99百分位数的78.7倍。
在本研究中，与CK-MB结果不同，心脏磁共振上无心肌梗死时肌钙蛋白显著升高。因此，CK-MB在排除手术相关心肌梗死方面比肌钙蛋白I更准确。这些数据提示在诊断冠状动脉搭桥手术相关心肌梗死时应采用更高的肌钙蛋白临界值。
http://www.isrctn.com/ISRCTN09454308 。2012年5月8日注册。
