间歇性温血心脏停搏液。温心研究组。

Intermittent warm blood cardioplegia. Warm Heart Investigators.

作者信息

Lichtenstein S V, Naylor C D, Feindel C M, Sykora K, Abel J G, Slutsky A S, Mazer C D, Christakis G T, Goldman B S, Fremes S E

机构信息

Department of Surgery, University of Toronto, Canada.

出版信息

Circulation. 1995 Nov 1;92(9 Suppl):II341-6. doi: 10.1161/01.cir.92.9.341.

DOI:10.1161/01.cir.92.9.341

PMID:7586435

Abstract

BACKGROUND

Warm heart surgery implies continuous perfusion with normothermic blood cardioplegia. Interruption of cardioplegia, however, facilitates construction of distal coronary anastomoses and is the method practiced by many surgeons. To determine whether intermittency is harmful, we present results from 720 coronary bypass patients, protected with intermittent antegrade warm blood cardioplegia, that were derived from a previous study of normothermic versus hypothermic cardioplegia.

METHODS AND RESULTS

Mean +/- SD age was 60.8 +/- 9.0 years; 27% of cases were urgent; 16% of patients had > 50% left main stenosis, and 19% had grade III or IV ventricles. A mean of 3.2 +/- 0.9 grafts was constructed. The average aortic cross-clamp time was 61.8 +/- 22.2 minutes. The longest single time off cardioplegia (LTOC) averaged 11.4 +/- 4.0 minutes per patient. The cumulative time off cardioplegia as a percentage of the cross-clamp time (PTOC) was 48.2 +/- 18.6% per patient. LTOC and PTOC were divided into quartiles (LTOC, < 10, 10 to 11, 12 to 13, and > 13 minutes; PTOC, < 36%, 36% to 49%, 50% to 62%, and > 62%) and related to the prespecified composite outcome of mortality, myocardial infarction according to serial CK-MB sampling, and low-output syndrome (LOS). Longer LTOC was harmful (event rates per quartile, 13.5%, 10.3%, 10.9%, and 19.0%; P = .046), whereas longer PTOC was protective (16.1%, 17.2%, 9.4%, and 10.6%; P = .07). Stepwise logistic regression was performed, controlling for demographic and angiographic predictors. In the multivariate models, LTOC remained detrimental (P = .07) and PTOC remained beneficial (P = .053). Additional modeling after entering surgeon identity (P < .001) into the risk equation eliminated the PTOC effect, whereas LTOC remained predictive of adverse outcomes (P = .053; odds ratio, 1.06; 95% CI, 1.00, 1.13).

CONCLUSIONS

The data indicate that a reasonable margin of safety exists with intermittent, antegrade warm blood cardioplegia. Repeated interruptions of warm blood cardioplegia are unlikely to lead to adverse clinical results if single interruptions are < or = 13 minutes.

摘要

背景

心脏温血手术意味着用常温血液停搏液持续灌注。然而，中断停搏液灌注便于构建远端冠状动脉吻合，这是许多外科医生采用的方法。为了确定间歇性中断是否有害，我们展示了720例接受间歇性顺行温血心脏停搏液保护的冠状动脉搭桥患者的结果，这些结果来自之前一项关于常温与低温心脏停搏液的研究。

方法与结果

平均年龄±标准差为60.8±9.0岁；27%的病例为急诊；16%的患者左主干狭窄>50%，19%的患者有Ⅲ级或Ⅳ级心室。平均构建了3.2±0.9支移植血管。平均主动脉阻断时间为61.8±22.2分钟。每位患者单次停搏液中断最长时间（LTOC）平均为11.4±4.0分钟。停搏液中断累计时间占阻断时间的百分比（PTOC）每位患者为48.2±18.6%。LTOC和PTOC被分为四分位数（LTOC，<10分钟、10至11分钟、12至13分钟和>13分钟；PTOC，<36%、36%至49%、50%至62%和>62%），并与预先设定的死亡、根据连续CK-MB采样诊断的心肌梗死和低心排综合征（LOS）的综合结局相关。较长的LTOC是有害的（每个四分位数的事件发生率分别为13.5%、10.3%、10.9%和19.0%；P = 0.046），而较长的PTOC是有保护作用的（16.1%、17.2%、9.4%和10.6%；P = 0.07）。进行逐步逻辑回归分析，控制人口统计学和血管造影预测因素。在多变量模型中，LTOC仍然有害（P = 0.07），PTOC仍然有益（P = 0.053）。将外科医生身份（P < 0.001）纳入风险方程后进行的额外建模消除了PTOC的影响，而LTOC仍然可预测不良结局（P = 0.053；优势比，1.06；95%可信区间，1.00，1.13）。