Adnan TORGAY, Atilla SEZGİN, Elif A. AKPEK, Gülnaz ARSLAN, Kamer KILINÇ

Timing of cardiopulmonary bypass termination: Effects on biochemical markers of early myocardial injury

Amaç: Kardiyopulmoner bypass (KPB) sırasında temel hedeflerden biri miyokardm korunmasıdır. Bu çalışmada amaç, iki farklı zamanda KPB sonlandırma tekniğinin, erken miyokard hasarında biyokimyasal belirleyiciler üzerine etkisini karşılaştırmaktır. Metod: Üç-dört damar hastalığı olup koroner arter bypass grefî cerrahisi planlanan, 22 erişkin hasta prospektif randomize düzende çalışmaya alındı. Tüm hastalarda distal anastomozlar aortik klemp altında yapıldı. Hastalar KPB'ı sonlandırma aşamasında randomize olarak iki gruba ayrıldı. Birinci grupta (n=10), KPB proksimal anastomozlar tamamlanmadan sonlandırıldı ve ikinci grupta (n=12), KPB proksimal anastomozlar tamamlandıktan sonra sonlandırıldı. Koroner sinüsten kan örnekleri, başlangıçta (tl), aortik klemp kaldırıldıktan hemen sonra (t2), 5 dakika sonra (t3), KPB sonlandırıldıktan 5 dakika (t4), ve 15 dakika sonra (t5) alındı. Bulgular: Plazma laktat, hipoksantin ve malondialdehit (MDA) düzeyleri her iki grupta da zaman içerisinde anlamlı olarak artış gösterdi. İkinci grupta, t4 ve t5'de MDA düzeyleri anlamlı olarak yüksek, t2'de ise pH, baz açığı, ionize kalsiyum ve bikarbonat düzeyleri anlamlı olarak düşük bulundu (p< 0.05). Sonuç: KPB'ı sonlandırma zamanı olarak karşılaştırılan iki farklı teknik arasında, miyokardın durumunun biyokimyasal belirleyicilerinden olan enerji metabolizması ürünleri ve asid-baz analizi bakımından fark bulunmadı.

Kardiyopulmoner bypass sonlandırmasında zamanlama: Erken miyokard hasarındaki biyokimyasal belirleyiciler üzerine etkisi

Purpose: Major concern during cardiopulmonary bypass (CPB) is myocardial protection. The purpose of this study was to compare the effects of two techniques of terminating CPB on the biochemical markers of early myocardial injury. Method': Twenty-two adult patients with three or four vessel diseases undergoing elective coronary artery bypass grafting surgery were studied in a prospective randomized clinical design. All distal anastomoses were performed during a single period of cross clamping. Then, patients were randomized in terms of terminating CPB. In group 1 (n=10), CPB was terminated before the proximal anastomoses were completed and in group 2 (n=12), CPB was terminated after completion of all proximal anastomoses. Blood samples were collected from the coronary sinus as baseline (tl), at the time of 0 (t2) and 5 minutes after (t3) cross-clamp removal, 5 (t4) and 15 minutes (t5) after CPB termination. Results: Plasma lactate, hypoxanthine and malondi aldehyde (MDA) levels significantly increased over time in both groups. MDA levels at t4 and t5 were higher and pH, base excess, ionized calcium and bicarbonate levels at t2 were significantly lower in group 2 when compared to group 1 (p< 0.05). Conclusion: Two techniques of terminating CPB did not differ in terms of end- products of energy metabolism and acid-base analysis as biochemical markers of myocardial status.

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1. Ross S, Foex P. Protective effects of anesthetics in reversible and irreversible ischemia-reperfusion injury. Br J Anaesth 1999; 82: 622-632.
2. Wade CR, Van Rij AM. Plasma thiobarbituric acid reactivity: Reaction conditions and the role of iron, antioxidants and lipid peroxy radicals on the quantitation of plasma lipid peroxides. Life Sciences 1988; 43: 1085- 1093.
3. Jong JW, Goldstein S. Changes in coronary venous inosine concentration and myocardial wall thickening during ischemia in the pig. Circ Res 1974; 35: 111-118.
4. Wan S, LeClerc JL, Vincent JL. Cytokine responses to cardiopulmonary bypass: lessons learned from cardiac transplantation. Ann Thorac Surg 1997; 63: 269-276.
5. Hauser GJ, Chan MM, Casey WF, Midgley FM, Holbrook PR. Immune dysfunction in children after corrective surgery for congenital heart disease. Crit Care Med 1991; 19: 874-881.
6. Manager WM, Frohlich ED, Gifford RW, Dustan HP. Norepinephrine infusion in normal subjects and patients with essential or renal hypertension: effect on blood pressure, heart rate and plasma catecholamine concentrations. J Clin Pharmacol 1976; 16: 129-141.
7. Hayashi H, Prabhu R, Kramer D, Oka Y. Predictors of inotropic support during weaning from cardiopulmonary bypass in coronary artery bypass grafting surgery. J Anesth 1997; 11: 3-9.
8. Chraemmer JB, Hoilund CP, Marving J, Christensen V. Left ventricular ejection fraction during anasthetic induction: comparison of rapid-sequence and elective induction. Can Anaesth Soc J 1986; 33:754-759.
9. Randall CC, Juli W, Stuart RH, John B. Pre-treatment with low-dose fentanyl for rapid-sequence induction. Anesthesiology 1983; 59: A344.
10. Jennings RB, Reimer KA, Hili ML, Mayer SE. Total ischemia in dog hearts, in vitro. Circ Res 1981; 49: 892- 900.
11. Hearse D J, Opie LH, Katzeff IE, Lubbe WF, Van der Werff TJ, Peisach M, Boulle G. Characterization of the "border zone" in acute regional ischemia in the dog. J Cardiol 1977; 40: 716-726.
12. Skinner FP, Scott RF, Morrison ES, Imai H, Jarmolych J, Lee KT. High energy phosphate compounds and mitochondrial function in ischemic myocardium of swine with advanced coronary atherosclerosis. J Mol Cell Cardiol 1973; 5: 515-526.
13. Tyberg JV, Yeatman LA, Parmley WW, Urschel CW, Sonnenblick EH. Effects of hypoxia on mechanics of cardiac contraction. Am J Physiol 1970; 218: 1780-1788.
14. Waters DD, DaLuz P, Wyatt HL, Swan HJC, Forrester JS. Early changes in regional and global left ventricular function induced by graded reductions in regional coronary perfusion. Am J Cardiol 1977; 39: 537-543.
15. Harden W, Barlow CH, Simson MB, Harken AH. Temporal relation between onset of cell anoxia and ischemic contractile failure. Am J Cardiol 1979; 44: 741- 746.
16. Schaper J, Mulch J, Winkler B, Schaper W. Ultrastructural, functional and biochemical criteria for estimation of reversibility of ischemic injury. A study on the effects of global ischemia on the isolated dog heart. J Mol Cell Cardiol 1979; 11: 521-541.
17. Reimer KA, Jennings RB, Hill ML. Total ischemia in dog hearts in vitro. Cir Res 1981; 49: 901-911.
18. DeJong JW, Verdouw PD, Remme WJ. Myocardial nucleotide and carbohydrate metabolism and hemodynamics during partial occlusion and reperfusion of pig coronary artery. J Mol Cell Cardiol 1977; 9: 297- 312.
19. Kannengiesser GJ, Opie LH, Van Der W. Impaired cardiac work and oxygen uptake after reperfusion of regionally ischemic myocardium. J Mol Cell Cardiol 1979: 197-207.
20. Mathur PP, Case RB. Phosphate loss during reversible myocardial ischemia. J Mol Cell Cardiol 1973; 5: 375- 393