局部缺血后外科再灌注与药物再灌注的优越性。

Superiority of surgical versus medical reperfusion after regional ischemia.

作者信息

Vinten-Johansen J, Buckberg G D, Okamoto F, Rosenkranz E R, Bugyi H, Leaf J

出版信息

J Thorac Cardiovasc Surg. 1986 Sep;92(3 Pt 2):525-34.

Abstract

This study tests the hypothesis that surgical revascularization (i.e., simulating coronary artery bypass grafting) with control of reperfusion conditions (total vented bypass) and of reperfusate composition (substrate-enriched blood cardioplegic solution) produces better recovery than is possible in the non-surgical setting (i.e., normal blood in beating, working hearts to simulate streptokinase and angioplasty). Eighteen dogs underwent 2 hours of left anterior descending coronary artery ligation (35% of the left ventricle at risk) followed by 2 hours of reperfusion. In five dogs the ligature was released to simulate streptokinase thrombolysis and angioplasty in working hearts (medical). In 13 dogs, surgical reperfusion was accomplished during total vented bypass, where six dogs received normal blood and seven others received substrate-enriched blood cardioplegic solution with 1 additional hour of aortic clamping (i.e., a total of 3 hours of ischemia). Segmental shortening with ultrasonic crystals, tissue water content, and vital staining (triphenyltetrazolium chloride) were assessed. Ischemia produced severe systolic bulging (-42% of control systolic shortening, p less than 0.05). Medical reperfusion resulted in failure to restore regional contractility (-27% systolic shortening, p less than 0.05), severe edema (82.4% H2O content, p less than 0.05), and extensive transmural nonstaining (44%, p less than 0.05). In contrast, surgical reperfusion with substrate-enriched blood cardioplegic solution during total vented bypass restored regional contraction to 46% of control values (p less than 0.05) and resulted in less edema (80.6% H2O content, p less than 0.05), and only mild nonstaining (21%, p less than 0.05) restricted to the subendocardial region. Surgical revascularization with controlled reperfusion conditions and reperfusate composition produces better myocardial salvage than is possible in the medical setting, despite a longer period of ischemia.

摘要

本研究检验了以下假设

通过控制再灌注条件（全排气旁路）和再灌注液成分（富含底物的血液停搏液）进行手术血运重建（即模拟冠状动脉搭桥术），比在非手术环境下（即跳动、工作的心脏中的正常血液以模拟链激酶和血管成形术）能产生更好的恢复效果。18只狗接受了2小时的左前降支冠状动脉结扎（左心室35%处于危险中），随后进行2小时的再灌注。5只狗松开结扎线以模拟工作心脏中的链激酶溶栓和血管成形术（药物治疗组）。13只狗在全排气旁路期间进行手术再灌注，其中6只狗接受正常血液，另外7只狗接受富含底物的血液停搏液，并额外进行1小时的主动脉钳夹（即总共3小时的缺血）。使用超声晶体评估节段缩短、组织含水量和活体染色（氯化三苯基四氮唑）。缺血导致严重的收缩期膨出（对照收缩期缩短的-42%，p<0.05）。药物再灌注未能恢复局部收缩力（收缩期缩短-27%，p<0.05），出现严重水肿（含水量82.4%，p<0.05），以及广泛的透壁无染色（44%，p<0.05）。相比之下，在全排气旁路期间使用富含底物的血液停搏液进行手术再灌注，使局部收缩恢复到对照值的46%（p<0.05），水肿较轻（含水量80.6%，p<0.05），仅心内膜下区域有轻度无染色（21%，p<0.05）。尽管缺血时间更长，但通过控制再灌注条件和再灌注液成分进行手术血运重建比药物治疗能产生更好的心肌挽救效果。