一氧化氮在舒芬太尼后处理减轻心脏瓣膜置换术患者心肌缺血再灌注损伤中的作用
role of nitric oxide in reduction of myocardial ischemia-reperfusion injury by sufentanil postconditioning in cardiac valve replacement patients under cardiac pulmonary bypass
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摘要: 目的:评价一氧化氮(NO)在舒芬太尼后处理减轻体外循环(CPB)下心脏瓣膜置换术患者心肌缺血再灌注损伤中的作用。方法:择期行心脏瓣膜置换术患者60例,年龄19~64岁,ASAⅡ~Ⅲ级,心功能Ⅱ~Ⅲ级。随机分为对照组(C组)、舒芬太尼0.5g/kg组(S1组)、1.0g/kg组(S2组)和2.0g/kg组(S3组),每组15例。S1、S2、S3组于主动脉开放前5 min时经主动脉根部分别输注舒芬太尼0.5、1.0和2.0g/kg,稀释容量为2 ml/kg,输注时间2 min,C组用相同方法给予等容量0.9%氯化钠注射液。于麻醉诱导前(T0)、主动脉开放后2 h(T1)、4 h(T2)、8 h(T3)、24 h(T4)、48 h(T5)抽取桡动脉血,测定血浆心肌肌钙蛋白I(cTnI)、NO水平和肌酸磷酸激酶同工酶(CK-MB)、一氧化氮合酶(NOS)活力。记录患者血流动力学参数、CPB时间、主动脉阻断时间、气管导管拔出时间、ICU停留时间、术后24 h心肌收缩力评分、术后24 h引流量及心脏自动复跳率。结果:与C组比较:S1组T1~3时cTnI、CK-MB均降低,NOS、NO均升高(P0.01);S2、S3组T1~5时cTnI、CK-MB均降低,T1~4时NOS、NO均升高(P0.01),气管导管拔出时间、ICU停留时间和术后24 h心肌收缩力评分均降低(P0.05~P0.01)。与S1组比较,S2、S3组T4~5时cTnI和CK-MB均降低,T3~4时NOS、NO均升高,术后24 h心肌收缩力评分均降低(P0.05~P0.01)。S2与S3组差异均无统计学意义(P0.05)。结论:舒芬太尼后处理通过激活NOS/NO信号通路,减轻CPB心脏瓣膜置换患者心肌缺血再灌注损伤,且有剂量依赖性和封顶效应。Abstract: Objective: To investigate the role of nitric oxide(NO) in reduction of myocardial ischemia-reperfusion(I /r) injury by sufentanil postconditioning in cardiac valve replacement patients under cardiac pulmonary bypass(CPB) . Methods: Sixty patients(ASA grade Ⅱ or Ⅲ，NYHA class Ⅱ or Ⅲ) of both sexes, aged 19-64, scheduled for cardiac valve replacement were randomly divided into 4 groups(n = 15 each): control group(group C) , sufentanil 0. 5 g /kg group(group S1 ) , sufentanil 1. 0 g /kg group(group S2 ) and sufentanil 2. 0 g /kg group(group S3 ) . In groups S1 ，S2 and S3 , sufentanil 0. 5，1 . 0 and 2. 0 g /kg were infused over 2 min via aortic root 5 min before aortic unclamping respectively. In group C, the equal volume of normal saline (2 ml /kg) was infused instead of sufentanil. Blood samples were taken from radial artery before induction of anesthesia(T0 ) and at 2 h(T1 ) ，4 h(T2 ) ，8 h(T3 ) , 24 h (T4 ) and 48 h (T5 ) after aortic unclamping for determination of plasma concentrations of cardiac troponin-I (cTnI) and NO and activities of creatine kinase isoenzyme-MB(CK-MB) and nitric oxide synthase(NOS) . The hemodynamic parameters，duration of CPB, time of aortic clamping, extubation time，duration of stay in ICU, and myocardial contractility score and volume of drainage at 24 h after the operation were recorded. The restoration of spontaneous heart beat were observed. results: The plasma cTnI concentrations and CKMB activity were significantly lower，while the plasma NO concentrations and NOS activity were significantly higher at T1-3 in group S1 than that in group C(P ＜ 0. 01) . The plasma cTnI concentration and CK-MB activity were significantly lower at T1-5 , the plasma NO significantly higher at T3-4 , and the myocardial contractility score at 24 h after the operation was significantly lower in groups S2 ，3 than that in group S1 (P ＜ 0. 05 to P ＜ 0. 01) . There was no significant difference between groups S2 and S3 (P ＞ 0. 05) . Conclusions: Sufentanil postconditioning can relieve myocardial I /r injury in patients undergoing cardiac valve replacement under CPB by activating the NOS /NO pathway，which is dose-dependent and ceiling-effective.
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