Fremes S E, Christakis G T, Weisel R D, Mickle D A, Madonik M M, Ivanov J, Harding R, Seawright S J, Houle S, McLaughlin P R
J Thorac Cardiovasc Surg. 1984 Nov;88(5 Pt 1):726-41.
Although experimental studies suggest that blood cardioplegia provides better protection than crystalloid cardioplegia, clinical studies have been inconclusive. Ninety patients undergoing coronary bypass grafting were randomized to receive either blood (n = 43) or crystalloid cardioplegia (n = 47). The incidence of perioperative myocardial infarction was lower with blood cardioplegia (blood, n = 0; crystalloid, n = 5; p = 0.06), and the maximum MB isoenzyme of creatine kinase was significantly less with blood cardioplegia (blood, 26.3 +/- 12.6 U/L; crystalloid, 35.6 +/- 17.0 U/L, mean +/- standard deviation; p less than 0.02.) Sixty patients (blood cardioplegia, n = 28; crystalloid cardioplegia, n = 32) had more sensitive measurements to assess the metabolic response to aortic occlusion and to compare the metabolic and functional recovery from the operation. Coronary sinus blood flow (by the continuous thermodilution technique) was significantly lower after cross-clamp removal with blood cardioplegia (blood, 160 +/- 100 ml/min; crystalloid, 220 +/- 120 ml/min; p less than 0.05), indicating less reactive hyperemia. The cardiac production of lactate was significantly less with blood cardioplegia during aortic occlusion (blood, -0.5 +/- 0.9 mmol/L; crystalloid, -0.9 +/- 0.9 mmol/L; p less than 0.05) and immediately after aortic declamping (blood, -0.2 +/- 0.4 mmol/L; crystalloid, -0.7 +/- 0.7 mmol/L; p less than 0.01). Thermodilution cardiac output measurements permitted calculation of the left ventricular stroke work index, and nuclear ventriculograms permitted calculation of the left ventricular end-diastolic volume index and end-systolic volume index. Myocardial performance, systolic elastance, and diastolic compliance were determined from volume loading studies (250 to 500 ml colloid) performed 2 to 4 hours postoperatively. Myocardial performance (the left ventricular stroke work index-left ventricular end-diastolic volume index relation) and systolic elastance (the systolic blood pressure-left ventricular end-systolic volume index relation) were significantly better with blood cardioplegia (p less than 0.01 by multivariate analysis); diastolic compliance (the left atrial pressure-left ventricular end-diastolic volume index relation) was similar. Blood cardioplegia reduced ischemic injury, decreased anaerobic metabolism during arrest, and permitted better functional recovery. Blood cardioplegia provides superior protection for elective coronary bypass grafting and may improve the clinical results in patients with unstable angina and in other high-risk patients.
尽管实验研究表明血液停搏液比晶体停搏液能提供更好的心肌保护，但临床研究尚无定论。90例行冠状动脉搭桥术的患者被随机分为两组，分别接受血液停搏液（n = 43）或晶体停搏液（n = 47）。血液停搏液组围手术期心肌梗死的发生率较低（血液停搏液组，n = 0；晶体停搏液组，n = 5；p = 0.06），且血液停搏液组肌酸激酶的最大MB同工酶水平显著更低（血液停搏液组，26.3±12.6 U/L；晶体停搏液组，35.6±17.0 U/L，均值±标准差；p < 0.02）。60例患者（血液停搏液组，n = 28；晶体停搏液组，n = 32）接受了更敏感的测量，以评估对主动脉阻断的代谢反应，并比较手术中的代谢和功能恢复情况。血液停搏液组在松开主动脉夹后，冠状窦血流量（采用连续热稀释技术测量）显著更低（血液停搏液组，160±100 ml/min；晶体停搏液组，220±120 ml/min；p < 0.05），表明反应性充血较少。在主动脉阻断期间（血液停搏液组，-0.5±0.9 mmol/L；晶体停搏液组，-0.9±0.9 mmol/L；p < 0.05）以及主动脉夹松开后即刻（血液停搏液组，-0.2±0.4 mmol/L；晶体停搏液组，-0.7±0.7 mmol/L；p < 0.01），血液停搏液组心肌乳酸生成显著更少。热稀释法测量心输出量可用于计算左心室每搏功指数，核素心室造影可用于计算左心室舒张末期容积指数和收缩末期容积指数。通过术后两到四小时进行的容量负荷研究（250至500 ml胶体）来测定心肌性能、收缩弹性和舒张顺应性。血液停搏液组的心肌性能（左心室每搏功指数与左心室舒张末期容积指数的关系）和收缩弹性（收缩压与左心室收缩末期容积指数的关系）显著更好（多因素分析显示p < 0.01）；舒张顺应性（左心房压力与左心室舒张末期容积指数的关系）相似。血液停搏液可减轻缺血损伤，减少心脏停搏期间的无氧代谢，并促进更好的功能恢复。血液停搏液为择期冠状动脉搭桥术提供了更好的心肌保护，可能改善不稳定型心绞痛患者及其他高危患者的临床结局。
