【作者】 王咏；

【导师】 肖颖彬；

【作者基本信息】 第三军医大学 ， 外科学， 2003， 硕士

【摘要】 目的 观测浅低温体外循环(CPB)心脏不停跳与中浅低温体外循环心脏停跳下心内直视手术患者围手术期血浆中神经元特异性烯醇化酶(NSE)与S-100b蛋白的含量和手术前后脑电图(EEG)的变化，对心脏停跳与心脏不停跳条件下心内直视手术导致的脑损害进行临床对比研究。 方法 选择择期心内直视手术患者40例，其中先天性心脏病20例，风湿性心脏病20例。随机分为A组(n=20)，在中低温体外循环心脏停跳下施行心内直视手术，其中先天性心脏病(A1组)和风湿性心脏病(A2组)各10例；B组(n=20)，在浅低温体外循环心脏不停跳下施行心内直视手术，其中先天性心脏病(B1组)和风湿性心脏病(B2组)各10例。两组患者均在术前、CPB开始后20 min、CPB结束后60 min 和术后24 h采取血标本。运用酶联免疫吸附法(ELISA，单克隆双抗体夹心法)测定血浆中NSE和S-100b蛋白的含量；并在术前与术后7天对全组患者进行脑电图检查。对所得结果进行统计分析处理。 结果 CPB开始 20 min两组患者血浆中的S－100b均明显升高(p<0.01)，而且一直持续到术后第一天仍高于术前水平(p<0.01)；CPB 开始20 min , A组中先心病患者血浆S－100b升高程度高于B组中先心病患者(p<0.05)。在CPB 开始20 min A组患者血浆NSE升高的程度高于B组患者(p<0.05)；血浆NSE水平在CPB 开始20 min先心病组明显升高(p<0.01)，一直持续至CPB 结束后60 min达到最高点，以后NSE浓度逐渐下降，至术后24 h已降至术前水平(p>0.05)；风心病组患者在CPB 开始20 min NSE升高(p<0.05)，在CPB 结束后60 min明显高于术前，一直持续到术后24 h仍较术前高(p<0.01)。 其余各时相点血浆NSE和S－100b的变化两组间无显著差异(p>0.05)。术后两组患者EEG结果较术前明显变差(p<0.01)；但两组间的异常率无显著差别(p>0.05)。 结论 我们的结果表明体外循环心脏停跳与心脏不停跳心内直视手术患者血浆中NSE和S－100b蛋白均有明显升高；EEG较术前明显变差，说明体外循环心内直视手术会导致一定的脑组织损害。心脏不停跳组患者血浆NSE、S－100b蛋白的升高程度和术后EEG的变化并不比心脏停跳组显著，提示浅低温体外循环心脏不停跳心内直视手术导致的脑损伤并不比传统的心脏停跳心内直视手术更严重。更多还原

【Abstract】 Objective The aim of this study was to compare the cerebral injury in on-pump beating-heart intracardiac procedures with that in traditional arrested heart intracardiac procedures. Methods Forty patients, including of twenty patients with congenital heart disease and twenty patients with rheumatic heart valve disease, were randomly divided into two groups: on-pump arrested heart group(Group A, n=20) and on-pump beating-heart group(Group B, n=20). There were ten cases of congenital heart disease and ten cases of rheumatic heart disease in each group. The patients in Group A underwent traditional arrested-heart intracardiac procedures, and the patients in Group B underwent on-pump beating-heart intracardiac procedures. Arterial blood was sampled at preoperation, twenty minutes after the start of CPB, one hour after CPB and twenty-four hours after operation. Levels of plasma neuron specific enolase(NSE) and protein S-100b were measured with ELISA. All the patients’ electroencephalograms(EEGs) were examined before and one week after operations. The perioperative plasma NSE ,protein S-100b and EEG changes of the two groups were compared statistically. Results The levels of plasma protein S-100b increased significantly at twenty minutes after the start of CPB, and maintained high level till twenty four hours after operation(p<0.01). The level of plasma NSE in congenital heart disease group increased more significantly than that did in rheumatic heart disease group at twenty minutes after the start of CPB. The level of plasma NSE in congenital heart disease group returned to the nadir at twenty four hours after operation, but it was still higher than the preoperative level in rheumatic heart disease group at the same time(p<0.01). The level of plasma NSE in group A was significantly higher than that in group B at twenty minutes after the start of CPB. The protein S-100b of the patients with congenital heart disease in group A was significantly higher than that in group B at twenty minutes after the start of CPB (p<0.05).There was no significant difference between the twe groups at other times. The postoperative EEG abnormality rates were 65% in group A and 70% in group B respectively. There was no significant difference between two groups. Conclusion Our preliminary results showed that the levels of plasma NSE and S-100b<WP=5>increased significantly during intracardic procedures both on-pump beating-heart and on traditional arrested heart; postoperative EEG became even worse than that before operation, which implicated that intracardic procedures under CPB might induce some cerebral injury. The increase of NSE and S-100b in the beating-heart group and the abnormality of the postoperative EEG are not more significant than those in the arrested-heart group, which recommend that the cerebral injury induced by on-pump beating heart intracardic procedures was not more severe than that by traditional arrested heart operations.更多还原