心肌缺血再灌注损伤药物干预的临床研究
|
摘要
背景和目的:心脏直视手术需要在体外循环(cardio-pulmonary bypass,CPB)状态下暂时阻断心脏冠状动脉血液循环。CPB可以导致心肌缺血再灌注损伤(myocardial ischemia/reperfusion injury,MI/RI),再灌注损伤表现为心律不齐、可逆性收缩功能障碍——心肌顿抑、内皮功能障碍以及心肌超微结构的改变等,这些关系到心脏手术成败及患者预后。
目前,MI/RI是阻碍缺血心肌从再灌注疗法中获得最佳疗效的主要难题,预防或减轻再灌注损伤已成为抗MI/RI的重要课题。针对I/R损伤的发生,很多研究结果表明药物对MI/RI具有防治作用,可减少心律失常、出血性坏死以及梗塞面积扩大等,但是由于药物本身的一些毒副作用及机体状态的影响,使其很难发挥真正的效能,因此仍然多限于基础研究阶段。
为了进一步了解麻醉药、改善细胞能量代谢、NO合成的特异前体以及传统中药干预以后对心肌缺血再灌注药物的影响,本试验选择132例在CPB下行心内直视手术的心脏病患者,分为四大组,分别用异丙酚、氯胺酮、1.6-二磷酸果糖、左旋精氨酸及活血化瘀药物川芎嗪等不同药物干预,观察心肌组织热休克蛋白72、诱导型一氧化氮合酶和中性粒细胞NF-κB、Bcl-2的表达以及血清心肌肌钙蛋白T的变化。进一步认识不同药物干预对心肌缺血再灌注损伤的保护作用及其作用机理。
方法:132例CPB下行心内直视手术的心脏病患者,根据试验时间分四大组。
组一(G1)28例,随机分为对照组(C组)川芎嗪干预组(M组),每组14例。M组麻醉诱导后经静内静脉滴入川芎嗪3 mg·kg~(-1),30 min内滴完,转流后追加1 mg·kg~(-1)于氧合器中,C组于上述时间给予等量生理盐水。在主动脉阻断(ACC)前后切取右心房心肌标本,半定量逆转录聚合酶链式反应(RT-PCR)测定心肌细胞中HSP72mRNA的相对表达量;分别于转流前、主动脉开放后30min和术后24 h测定外周血天冬酸氨基转移酶(AST)、乳酸脱氢酶(LDH)、肌酸磷酸激酶(CK)和肌酸磷酸激酶同工酶(CK-MB)的变化;分别于转流前和主动脉开放后30min取右心耳心肌组织,透射电镜观察心肌超微结构变化,并采用Flameng线粒体半定量分析法对心肌线粒体进行计分。
组二(G2)24例,随机分为对照组(C组)和氯胺酮干预组(K1组、K2组),每组8例。在劈胸骨时、主动脉插管时和主动脉开放前5min,干预组分别静脉注射氯胺酮0.5 mg·kg~(-1)或1.0 mg·kg~(-1),对照组注射等量生理盐水。于上腔静脉插管时(T1)、主动脉阻断后30min(T2)和主动脉开放后30min(T3)取适量右心耳心肌组织,一步法实时荧光定量RT-PCR技术(采用SYBR Green 1嵌合荧光法)检测心肌中iNOSmRNA和HSP72mRNA的表达量。并分别于T1、T2、T3和主动脉开放后2h(T4)取上腔静脉血4ml,检测血清中肌酸激酶(CK)和肌酸激酶同工酶(CK-MB)含量。
组三(G3)40例,随机分为对照组(C组)、左旋精氨酸组(L组)、1,6-二磷酸果糖组(F组)和联合用药组(D组),每组各10例。根据L-Arg和FDP作用机制的不同,L组于主动脉开放后即刻给予L-Arg200 mg·kg~(-1),F组于主动脉阻断前给予FDP200 mg·kg~(-1),D组联合应用两种药物。分别于主动脉插管时、主动脉开放30min、2h、6h检测血浆心肌肌钙蛋白T(cTnT)、乳酸脱氢酶(LDH)、肌酸激酶同工酶(CK-MB)、丙二醛(MDA)含量,以及超氧化物歧化酶(SOD)活力。
组四(G4)40例,随机分为对照组(C组)和异丙酚组(P组),每组20例。在麻醉诱导后,P组用TCI输注泵以2.5μg·ml~(-1)为初始血浆靶浓度持续输注异丙酚,根据麻醉深度调整异丙酚血浆靶浓度,最大可达3.4μg·ml~(-1)。分别于麻醉诱导后CPB前(T1)、主动脉阻断后30min(T2)、主动脉开放时(T3)、CPB停机后30min(T4)、停机后90min(T5)采集上腔静脉血检测血浆中肿瘤坏死因子-α(TNF-α)、白细胞介素-8(IL-8)、白细胞介素-10(IL-10)、血浆丙二醛(MDA)的浓度及超氧化物歧化酶(SOD)的活性,于T1、T4时间点采集上腔静脉血检测中性粒细胞NF-κB和Bcl-2的表达及中性粒细胞计数。
结果:G1组:与ACC术前比较,ACC术后两组心肌组织HSP72 mRNA表达量、心肌酶含量及线粒体记分均显著增高(P＜0.05或P＜0.01);与C组比较,ACC后M组心肌组织HSP72 mRNA表达量和线粒体记分显著增高,心肌酶AST、LDH、CK、CK-MB的升高幅度明显降低(P＜0.05)。心肌超微结构变化,CPB后对照组线粒体基质颗粒丢失,嵴断裂,肌浆网扩张,肌原纤维明显松弛,部分溶解、断裂。川芎组肌原纤维排列整齐,可见少数线粒体嵴肿胀模糊,嵴断裂,间隙增宽。局部内质网扩张。
G2组:与T1比较,三组T2和T3心肌iNOSmRNA和HSP72mRNA表达量均显著升高(P＜0.05、P＜0.01),CK、CK-MB含量在T2、T3、T4均显著增高(P＜0.01);与T2比较,三组T3心肌iNOSmRNA和HSP72mRNA表达量均显著升高(P＜0.05、P＜0.01),CK、CK-MB含量在T3、T4均显著增高(P＜0.01);与T3比较,CK、CK-MB含量在T4均显著增高(P＜0.01);与C组比较,K1组在T2而K2组在T2、T3心肌iNOSmRNA表达量及CK、CK-MB升高幅度在T2、T3、T4均显著降低(P＜0.05、P＜0.01),K1、K2组HSP72mRNA表达量在T2、T3均显著增高(P＜0.01);与K1组比较,K2组心肌iNOSmRNA表达量在T2、T3及CK、CK-MB升高幅度在T2、T3、T4均显著降低(P＜0.05、P＜0.01),HSP72mRNA表达量差异无显著性(P＞0.05)。
G3组:与T1比较,四组血浆cTnT、LDH、CK-MB、MDA和SOD在T2、T3、T4均显著增高(P＜0.05、P＜0.01);与C组比较,血浆cTnT值L组和F组在T4而D组在T3、T4显著降低(P＜0.01或P＜0.05),LDH升高幅度L组在T3而D组在T2、T3、T4显著降低(P＜0.01或P＜0.05),CK-MB和MDA的升高幅度L、F、D组在T2、T3、T4均有显著降低(P＜0.01或P＜0.05),三组SOD在T3显著升高(P＜0.05);与L组比较,D组血浆cTnT值在T3时显著降低(P＜0.01);与F组比较,D组血浆cTnT值在T3、T4时、LDH在T2时显著降低(P＜0.01或P＜0.05)
G4组:与T1比较,CPB后(T4)两组中性粒细胞NF-κB、Bcl-2表达及中性粒细胞数均显著升高(P＜0.01),T2～T5血清TNF-α、MDA和SOD、T3～T5血清IL-8和IL-10含量显著升高(P＜0.01、P＜0.05);与C组比较,体外循环后P组中性粒细胞NF-κB、Bcl-2的表达及中性粒细胞数明显降低(P＜0.01),P组T2～T5血清TNF-α和MDA、T3～T5血清IL-8含量显著降低(P＜0.05),T3～T5血清IL-10含量、T2～T5血清SOD含量显著升高(P＜0.05)。
结论:HSP72、iNOS、NF-κB和Bcl-2参与了心肌缺血/再灌注损伤的发生和发展。
体外循环期间心内直视手术患者心肌组织中HSP72mRNA的表达增加;川芎嗪干预上调心肌细胞HSP72mRNA的表达,启动内源性心脏保护机制,使患者心肌超微结构损害减轻,使心肌线粒体结构和功能的完整性得到保护,在一定程度上减轻了心肌缺血再灌注损伤。
麻醉(1.0mg·kg~(-1))和亚麻醉(0.5mg·kg~(-1))剂量的氯胺酮通过下调心肌iNOSmRNA的表达和上调心肌HSP72mRNA的表达,减少血清心肌酶的漏出,在一定程度上具有心肌保护作用,且麻醉优于亚麻醉。
左旋精氨酸或1,6-二磷酸果糖由于其不同的作用机制对缺血再灌注损伤心肌有良好的保护作用,联合应用可发挥两种药物的协同作用,对心肌的保护作用更好。
体外循环心内直视手术期间使用异丙酚不仅可以起到满意的麻醉镇静作用,还可通过影响中性粒细胞的效应作用、促/抗炎细胞因子水平、氧自由基等炎性反应的多个环节起到抑制炎症反应,减轻组织损伤的作用。
Backgroud and objective Cardiopulmonary bypass(CPB)is applied in open heart operation to temporary block the blood circulation of the cardiac coronary artery. Myocardial ischemia/reperfusion injury(MI/RI)can be caused by CPB.The main presentations of MI/RI are arrhythmia,reversible contractile dysfunction(myocardial stunning),endothelium dysfunction and myocardial ultrastructure change,which play the important role to success in surgery.
At present,MI/RI is a commonly occurred perioperative cardiac problem that hinders ischemic myocardium to acquire the best curative effect from the reperfusion therapy.The prevention or reduction of MI/RI has become an important subject. Recently,many research results show that MI/RI can be prevented by many drugs which suppressed the acute ischemic arrhythmia,hemorrhagic necrosis and the expansion of the infarcted area.But because of the adverse effects and the effects of drugs to the physiology,it is very difficult for the drugs to play a role.Therefore,most of the drugs are still in the stage of fundamental research.
In order to get a better understanding of the effect of anesthetics,the improvement of energy metabolism of cells,the synthesis of the specific precursor of NO and the intervention of traditional Chinese herbs to the drugs of myocardial ischemia reperfusion(MIR),132 patients undergoing open heart surgery utilizing CPB were divided into four groups.Made intervention with Propofol,Ketamine,1, 6-diphosphate,L-arginine and tetramethylpyrazine and observed the expression of heat shock protein(HSP)72,myocardium induced nitric oxide synthase(iNOS), polymorphonuclear neutrophil(PMN)NF-κB,Bcl-2 and the change of serum cardiac troponin T(cTnT)for further understanding the protecting action and mechanism of different drugs to MI/RI.
Methods A hundred and thirty-two patients undergoing open-heart-surgery by CPB were randomly divided into four groups.
The first group(G1)has twenty-eight patients,which were randomly divided into two groups(n=14 each),control(C)and TMP groups(M).In group M,TMP 3 mg/kg were given for thirty minutes after anesthesia induction and 1 mg/kg were given in oxygenator during CPB.In group C,same volume 0.9%NaCl were given at same time.A piece of right atrium myocardium was obtained before and after aortic cross-cramping(ACC)during cardiopulmonary bypass to measure the levels of HSP72 mRNA by semi-quantitative RT-PCR.Peripheral levels of AST,LDH,CK and CK-MB were measured before the CPB and 30 minutes after opening of aorta clamp and 24 h after cardiosurgery as markers of heart damage.A piece of right auricle myocardium was obtained before the CPB and 30 min after opening aorta to observe myocardial ultrastructure and analyzing mitochondria semiquantatively according to Flameng method.
The second group(G2)has thirty-six patients,which were randomly divided into three groups(n=12 each),control(C)and Ketamine interfered groups(K1 and K2). In group K1 and K2,Ketamine 0.5 mg/kg and 1.0 mg/kg were vein injected before sternum splitted at the time of aorta intubated and 5 minutes before aorta clamped off partly.A piece of right auricle myocardium was obtained at the time of right atria intubated(T1),30 minutes after aorta clamped on(T2)and 30 minutes after aorta clamped off(T3)to measured the levels of iNOSmRNA and HSP72mRNA by one step real time fluorescence quantitative RT-PCR(used SYBR Green 1 fluorescence inosculating method).Blood samples were drawn from superior vena at T1,T2,T3 and two hours after aorta clamped off(T4).The content of creatinekinase(CK)and creatinekinase isozyme(CK-MB)were detected.
The third group(G3)has fourty patients,which were randomly divided into four groups(n=10 each),control(C),L-Arg(L),FDP(F)and L-Arg plus FDP groups(D). In group L,L-Arg 200mg/kg were infused after aorta clamped off.In group F,FDP 200mg/kg were infused before aorta clamped on.In group D,L-Arg 200mg/kg were infused after aorta clamped off and FDP 200mg/kg were infused before aorta clamped on.Blood samples were taken to measure the levels of cardiac Troponin T(cTnT), Lactate dehydrogenase(LDH),MB isoenzyme of creatine kinase(CK-MB), malondialdehyde(MDA)and the activity of superoxide dismutase(SOD)before aortic-clamping on and 30 minutes,2 hours and 6 hours after aorta clamped off.
The fourth group(G4)has fourty patients,which were randomly divided into two groups(n=20 each),control(C)and propofol groups(P).There were no differences between two groups about medication during operation except that the propofol was used for anesthesia maintenance in group P.In group P,the plasma concentration of propofol was targeted and started from 2.5-3.4μg/ml by target-controlled infusion, then adjusted plasma concentration to depend on blood pressure and heart rate.Blood samples were taken from superior vena cava after anesthesia induction and before CPB(T1),30 minutes after aorta clamped on(T2),while aorta clamped off(T3),30 minutes after CPB(T4)and 90 minutes after CPB(T5)to measure following data, NF-kB and Bcl-2 in neutrophil,and plasma levels of tumour necrosis factor-α(TNF-α), interleukin-8(IL-8),interleukin-10(IL-10),malondiadilyde(MDA)and superoxide dismutase(SOD)activity.
Results In the first group(G1),there were no significant differences between the two groups in sex,age,weight,ACC time,CPB time and cardioplegic solution.The expression of HSP72mRNA and the serum concentration of AST,LDH,CK and CK-MB and the scores of myocardial mitochondria were significantly increased after ACC as compared to before ACC in the two groups(P＜0.05 or P＜0.01).The expression of HSP72 mRNA were significantly higher after ACC in the group M than in the control group(P＜0.05).The serum concentration of AST,LDH,CK and CK-MB and the scores of myocardial mitochondria were significantly lower in the group M than in the control group(P＜0.05)after CPB.The myocardial ultrastructure in the group had milder alterations than in the control group after CPB(P＜0.05).
In the second group(G2),there were no significant differences among the three groups in sex,age,weight and time of aorta clamped on and cardiopulmonary bypass (P＞0.05).The expression of iNOSmRNA and HSP72mRNA were significantly increased at T2 and T3 and the serum concentration of CK,CK-MB were significantly increased at T2,T3 and T4 as compared to at T1 in the three groups(P＜0.05 or P＜0.01).The expression of iNOSmRNA and HSP72mRNA were significantly increased at T3 and the serum concentration of CK and CK-MB were significantly increased at T3 and T4 as compared to at T2 in the three groups(P＜0.05 or P＜0.01). The serum concentration of CK and CK-MB were significantly increased at T4 as compared to at T3 in the three groups(P＜0.01).Compared to the control group,the expression of iNOSmRNA significantly decreased in the group K1 at T2 and in the group K2 at T2 and T3(P＜0.01),the serum concentration of CK and CK-MB were significantly lower in the groups K1 and K2 at T2,T3 and T4(P＜0.01),the expression of HSP72mRNA were significantly increased in the group K1 and K2 at T2 and T3.Compared to the group K1,the expression of iNOSmRNA significantly decreased in the group K2 at T2 and T3(P＜0.01),the serum concentration of CK and CK-MB were significantly lower in the group K2 at T2,T3 and T4(P＜0.05 or P＜0.01),the expression of HSP72mRNA were no significant differences in the group K2(P＞0.05).
In the third group(G3),the plasma concentration of cTnT,LDH,CK-MB,MDA and SOD were significantly increased at T2,T3 and T4 as compared to at T1 in the four groups(P＜0.05 or P＜0.01).Compared to the control group,the plasma concentration of cTnT were significantly lower in the group L and F at T4 and in the group D at T3 and T4(P＜0.05),the plasma concentration of LDH were significantly lower in the group L at T3 and in the group D at T2,T3 and T4(P＜0.05 or P＜0.01), the plasma concentration of CK-MB and MDA were significantly lower in the group L,F and D at T2,T3 and T4(P＜0.05 or P＜0.01),the plasma concentration of SOD were significantly higher in the group L,F and D at T3.The plasma concentration of cTnT were significantly lower in the group D than in the group L at T3(P＜0.01)and in the group F at T3 and T4(P＜0.01).The plasma concentration of LDH were significantly lower in the group D than in the group F at T2(P＜0.05).
In the fourth group(G4),there were no significant differences between two groups in sex,age,weight,ascending aorta clamping time,CPB time and operation time(P＞0.05).The expression of NF-kB and Bcl-2 and the count of neutrophil were significantly increased at T4 as compared to at Tl in the two groups(P＜0.01).The serum concentration of TNF-α,MDA and SOD were significantly increased at T2,T3, T4 and T5 as compared to at T1 in the two groups(P＜0.05 or P＜0.01).The serum concentration of IL-8 and L-10 were significantly increased at T3,T4 and T5 as compared to at T1 in the two groups(P＜0.05 or P＜0.01).Compared to the control group,the expression of NF-kB and Bcl-2 and the count of neutrophil were significantly decreased in the group P at T4(P＜0.01),the serum concentration of TNF-αand MDA were significantly lower in the group P at T2,T3,T4 and T5 (P＜0.05 or P＜0.01),the serum concentration of IL-8 were significantly lower in the group P at T3,T4 and T5(P＜0.05),the serum concentration of IL-10 were significantly higher in the group P at T3,T4 and T5(P＜0.05),the serum concentration of SOD were significantly higher in the group P at T2,T3,T4 and T5 (P＜0.05).
Conclusion HSP72,iNOS,NF-kB and Bcl-2 take part in myocardial ischemia -reperfusion injury.
HSP72 gene expression increase in myocardium of patients undergoing open heart surgery during CPB.TMP pre-conditioning can induce HSP72 gene expression and protect myocardial mitochondria from ischemia reperfusion injury and attenuates CPB-induced myocardial ischemia reperfusion injury through a self-protective mechanism.
Ketamine in dose of anesthesia(1.0mg/kg)and subanaesthetic(0.5mg/kg)can decrease iNOSmRNA and increase HSP72mRNA expression in myocardium and reduce leakage of myocardium enzyme.Ketamine acts myocardial protection,and which in anesthesia dose is more effective than in subanaesthetic dose.
The both of L-Arg and FDP can produce protective effects on myocardial ischemia reperfusion injury during open heart surgery with CPB through different protective mechanism.The combined use of L-Arg and FDP shows obvious synergistic effects on myocardial protection.
Propofol is used to the patients undergoing open heart surgery during the CPB not only has the satisfactory actions of anesthesia and sedation but also has the actions of inhibiting Inflammatory reaction and abatement tissue injury by impact the function of neutrophil,the proinflammatory anti-inflammatory cytokines and oxygen free radicals etc.It has the prevention to MI/RI that was induced by infection or uninfection during cardiac surgery.So it has the clinic significance to use propofol in cardiac surgery anaesthesia.
目前,MI/RI是阻碍缺血心肌从再灌注疗法中获得最佳疗效的主要难题,预防或减轻再灌注损伤已成为抗MI/RI的重要课题。针对I/R损伤的发生,很多研究结果表明药物对MI/RI具有防治作用,可减少心律失常、出血性坏死以及梗塞面积扩大等,但是由于药物本身的一些毒副作用及机体状态的影响,使其很难发挥真正的效能,因此仍然多限于基础研究阶段。
为了进一步了解麻醉药、改善细胞能量代谢、NO合成的特异前体以及传统中药干预以后对心肌缺血再灌注药物的影响,本试验选择132例在CPB下行心内直视手术的心脏病患者,分为四大组,分别用异丙酚、氯胺酮、1.6-二磷酸果糖、左旋精氨酸及活血化瘀药物川芎嗪等不同药物干预,观察心肌组织热休克蛋白72、诱导型一氧化氮合酶和中性粒细胞NF-κB、Bcl-2的表达以及血清心肌肌钙蛋白T的变化。进一步认识不同药物干预对心肌缺血再灌注损伤的保护作用及其作用机理。
方法:132例CPB下行心内直视手术的心脏病患者,根据试验时间分四大组。
组一(G1)28例,随机分为对照组(C组)川芎嗪干预组(M组),每组14例。M组麻醉诱导后经静内静脉滴入川芎嗪3 mg·kg~(-1),30 min内滴完,转流后追加1 mg·kg~(-1)于氧合器中,C组于上述时间给予等量生理盐水。在主动脉阻断(ACC)前后切取右心房心肌标本,半定量逆转录聚合酶链式反应(RT-PCR)测定心肌细胞中HSP72mRNA的相对表达量;分别于转流前、主动脉开放后30min和术后24 h测定外周血天冬酸氨基转移酶(AST)、乳酸脱氢酶(LDH)、肌酸磷酸激酶(CK)和肌酸磷酸激酶同工酶(CK-MB)的变化;分别于转流前和主动脉开放后30min取右心耳心肌组织,透射电镜观察心肌超微结构变化,并采用Flameng线粒体半定量分析法对心肌线粒体进行计分。
组二(G2)24例,随机分为对照组(C组)和氯胺酮干预组(K1组、K2组),每组8例。在劈胸骨时、主动脉插管时和主动脉开放前5min,干预组分别静脉注射氯胺酮0.5 mg·kg~(-1)或1.0 mg·kg~(-1),对照组注射等量生理盐水。于上腔静脉插管时(T1)、主动脉阻断后30min(T2)和主动脉开放后30min(T3)取适量右心耳心肌组织,一步法实时荧光定量RT-PCR技术(采用SYBR Green 1嵌合荧光法)检测心肌中iNOSmRNA和HSP72mRNA的表达量。并分别于T1、T2、T3和主动脉开放后2h(T4)取上腔静脉血4ml,检测血清中肌酸激酶(CK)和肌酸激酶同工酶(CK-MB)含量。
组三(G3)40例,随机分为对照组(C组)、左旋精氨酸组(L组)、1,6-二磷酸果糖组(F组)和联合用药组(D组),每组各10例。根据L-Arg和FDP作用机制的不同,L组于主动脉开放后即刻给予L-Arg200 mg·kg~(-1),F组于主动脉阻断前给予FDP200 mg·kg~(-1),D组联合应用两种药物。分别于主动脉插管时、主动脉开放30min、2h、6h检测血浆心肌肌钙蛋白T(cTnT)、乳酸脱氢酶(LDH)、肌酸激酶同工酶(CK-MB)、丙二醛(MDA)含量,以及超氧化物歧化酶(SOD)活力。
组四(G4)40例,随机分为对照组(C组)和异丙酚组(P组),每组20例。在麻醉诱导后,P组用TCI输注泵以2.5μg·ml~(-1)为初始血浆靶浓度持续输注异丙酚,根据麻醉深度调整异丙酚血浆靶浓度,最大可达3.4μg·ml~(-1)。分别于麻醉诱导后CPB前(T1)、主动脉阻断后30min(T2)、主动脉开放时(T3)、CPB停机后30min(T4)、停机后90min(T5)采集上腔静脉血检测血浆中肿瘤坏死因子-α(TNF-α)、白细胞介素-8(IL-8)、白细胞介素-10(IL-10)、血浆丙二醛(MDA)的浓度及超氧化物歧化酶(SOD)的活性,于T1、T4时间点采集上腔静脉血检测中性粒细胞NF-κB和Bcl-2的表达及中性粒细胞计数。
结果:G1组:与ACC术前比较,ACC术后两组心肌组织HSP72 mRNA表达量、心肌酶含量及线粒体记分均显著增高(P＜0.05或P＜0.01);与C组比较,ACC后M组心肌组织HSP72 mRNA表达量和线粒体记分显著增高,心肌酶AST、LDH、CK、CK-MB的升高幅度明显降低(P＜0.05)。心肌超微结构变化,CPB后对照组线粒体基质颗粒丢失,嵴断裂,肌浆网扩张,肌原纤维明显松弛,部分溶解、断裂。川芎组肌原纤维排列整齐,可见少数线粒体嵴肿胀模糊,嵴断裂,间隙增宽。局部内质网扩张。
G2组:与T1比较,三组T2和T3心肌iNOSmRNA和HSP72mRNA表达量均显著升高(P＜0.05、P＜0.01),CK、CK-MB含量在T2、T3、T4均显著增高(P＜0.01);与T2比较,三组T3心肌iNOSmRNA和HSP72mRNA表达量均显著升高(P＜0.05、P＜0.01),CK、CK-MB含量在T3、T4均显著增高(P＜0.01);与T3比较,CK、CK-MB含量在T4均显著增高(P＜0.01);与C组比较,K1组在T2而K2组在T2、T3心肌iNOSmRNA表达量及CK、CK-MB升高幅度在T2、T3、T4均显著降低(P＜0.05、P＜0.01),K1、K2组HSP72mRNA表达量在T2、T3均显著增高(P＜0.01);与K1组比较,K2组心肌iNOSmRNA表达量在T2、T3及CK、CK-MB升高幅度在T2、T3、T4均显著降低(P＜0.05、P＜0.01),HSP72mRNA表达量差异无显著性(P＞0.05)。
G3组:与T1比较,四组血浆cTnT、LDH、CK-MB、MDA和SOD在T2、T3、T4均显著增高(P＜0.05、P＜0.01);与C组比较,血浆cTnT值L组和F组在T4而D组在T3、T4显著降低(P＜0.01或P＜0.05),LDH升高幅度L组在T3而D组在T2、T3、T4显著降低(P＜0.01或P＜0.05),CK-MB和MDA的升高幅度L、F、D组在T2、T3、T4均有显著降低(P＜0.01或P＜0.05),三组SOD在T3显著升高(P＜0.05);与L组比较,D组血浆cTnT值在T3时显著降低(P＜0.01);与F组比较,D组血浆cTnT值在T3、T4时、LDH在T2时显著降低(P＜0.01或P＜0.05)
G4组:与T1比较,CPB后(T4)两组中性粒细胞NF-κB、Bcl-2表达及中性粒细胞数均显著升高(P＜0.01),T2～T5血清TNF-α、MDA和SOD、T3～T5血清IL-8和IL-10含量显著升高(P＜0.01、P＜0.05);与C组比较,体外循环后P组中性粒细胞NF-κB、Bcl-2的表达及中性粒细胞数明显降低(P＜0.01),P组T2～T5血清TNF-α和MDA、T3～T5血清IL-8含量显著降低(P＜0.05),T3～T5血清IL-10含量、T2～T5血清SOD含量显著升高(P＜0.05)。
结论:HSP72、iNOS、NF-κB和Bcl-2参与了心肌缺血/再灌注损伤的发生和发展。
体外循环期间心内直视手术患者心肌组织中HSP72mRNA的表达增加;川芎嗪干预上调心肌细胞HSP72mRNA的表达,启动内源性心脏保护机制,使患者心肌超微结构损害减轻,使心肌线粒体结构和功能的完整性得到保护,在一定程度上减轻了心肌缺血再灌注损伤。
麻醉(1.0mg·kg~(-1))和亚麻醉(0.5mg·kg~(-1))剂量的氯胺酮通过下调心肌iNOSmRNA的表达和上调心肌HSP72mRNA的表达,减少血清心肌酶的漏出,在一定程度上具有心肌保护作用,且麻醉优于亚麻醉。
左旋精氨酸或1,6-二磷酸果糖由于其不同的作用机制对缺血再灌注损伤心肌有良好的保护作用,联合应用可发挥两种药物的协同作用,对心肌的保护作用更好。
体外循环心内直视手术期间使用异丙酚不仅可以起到满意的麻醉镇静作用,还可通过影响中性粒细胞的效应作用、促/抗炎细胞因子水平、氧自由基等炎性反应的多个环节起到抑制炎症反应,减轻组织损伤的作用。
Backgroud and objective Cardiopulmonary bypass(CPB)is applied in open heart operation to temporary block the blood circulation of the cardiac coronary artery. Myocardial ischemia/reperfusion injury(MI/RI)can be caused by CPB.The main presentations of MI/RI are arrhythmia,reversible contractile dysfunction(myocardial stunning),endothelium dysfunction and myocardial ultrastructure change,which play the important role to success in surgery.
At present,MI/RI is a commonly occurred perioperative cardiac problem that hinders ischemic myocardium to acquire the best curative effect from the reperfusion therapy.The prevention or reduction of MI/RI has become an important subject. Recently,many research results show that MI/RI can be prevented by many drugs which suppressed the acute ischemic arrhythmia,hemorrhagic necrosis and the expansion of the infarcted area.But because of the adverse effects and the effects of drugs to the physiology,it is very difficult for the drugs to play a role.Therefore,most of the drugs are still in the stage of fundamental research.
In order to get a better understanding of the effect of anesthetics,the improvement of energy metabolism of cells,the synthesis of the specific precursor of NO and the intervention of traditional Chinese herbs to the drugs of myocardial ischemia reperfusion(MIR),132 patients undergoing open heart surgery utilizing CPB were divided into four groups.Made intervention with Propofol,Ketamine,1, 6-diphosphate,L-arginine and tetramethylpyrazine and observed the expression of heat shock protein(HSP)72,myocardium induced nitric oxide synthase(iNOS), polymorphonuclear neutrophil(PMN)NF-κB,Bcl-2 and the change of serum cardiac troponin T(cTnT)for further understanding the protecting action and mechanism of different drugs to MI/RI.
Methods A hundred and thirty-two patients undergoing open-heart-surgery by CPB were randomly divided into four groups.
The first group(G1)has twenty-eight patients,which were randomly divided into two groups(n=14 each),control(C)and TMP groups(M).In group M,TMP 3 mg/kg were given for thirty minutes after anesthesia induction and 1 mg/kg were given in oxygenator during CPB.In group C,same volume 0.9%NaCl were given at same time.A piece of right atrium myocardium was obtained before and after aortic cross-cramping(ACC)during cardiopulmonary bypass to measure the levels of HSP72 mRNA by semi-quantitative RT-PCR.Peripheral levels of AST,LDH,CK and CK-MB were measured before the CPB and 30 minutes after opening of aorta clamp and 24 h after cardiosurgery as markers of heart damage.A piece of right auricle myocardium was obtained before the CPB and 30 min after opening aorta to observe myocardial ultrastructure and analyzing mitochondria semiquantatively according to Flameng method.
The second group(G2)has thirty-six patients,which were randomly divided into three groups(n=12 each),control(C)and Ketamine interfered groups(K1 and K2). In group K1 and K2,Ketamine 0.5 mg/kg and 1.0 mg/kg were vein injected before sternum splitted at the time of aorta intubated and 5 minutes before aorta clamped off partly.A piece of right auricle myocardium was obtained at the time of right atria intubated(T1),30 minutes after aorta clamped on(T2)and 30 minutes after aorta clamped off(T3)to measured the levels of iNOSmRNA and HSP72mRNA by one step real time fluorescence quantitative RT-PCR(used SYBR Green 1 fluorescence inosculating method).Blood samples were drawn from superior vena at T1,T2,T3 and two hours after aorta clamped off(T4).The content of creatinekinase(CK)and creatinekinase isozyme(CK-MB)were detected.
The third group(G3)has fourty patients,which were randomly divided into four groups(n=10 each),control(C),L-Arg(L),FDP(F)and L-Arg plus FDP groups(D). In group L,L-Arg 200mg/kg were infused after aorta clamped off.In group F,FDP 200mg/kg were infused before aorta clamped on.In group D,L-Arg 200mg/kg were infused after aorta clamped off and FDP 200mg/kg were infused before aorta clamped on.Blood samples were taken to measure the levels of cardiac Troponin T(cTnT), Lactate dehydrogenase(LDH),MB isoenzyme of creatine kinase(CK-MB), malondialdehyde(MDA)and the activity of superoxide dismutase(SOD)before aortic-clamping on and 30 minutes,2 hours and 6 hours after aorta clamped off.
The fourth group(G4)has fourty patients,which were randomly divided into two groups(n=20 each),control(C)and propofol groups(P).There were no differences between two groups about medication during operation except that the propofol was used for anesthesia maintenance in group P.In group P,the plasma concentration of propofol was targeted and started from 2.5-3.4μg/ml by target-controlled infusion, then adjusted plasma concentration to depend on blood pressure and heart rate.Blood samples were taken from superior vena cava after anesthesia induction and before CPB(T1),30 minutes after aorta clamped on(T2),while aorta clamped off(T3),30 minutes after CPB(T4)and 90 minutes after CPB(T5)to measure following data, NF-kB and Bcl-2 in neutrophil,and plasma levels of tumour necrosis factor-α(TNF-α), interleukin-8(IL-8),interleukin-10(IL-10),malondiadilyde(MDA)and superoxide dismutase(SOD)activity.
Results In the first group(G1),there were no significant differences between the two groups in sex,age,weight,ACC time,CPB time and cardioplegic solution.The expression of HSP72mRNA and the serum concentration of AST,LDH,CK and CK-MB and the scores of myocardial mitochondria were significantly increased after ACC as compared to before ACC in the two groups(P＜0.05 or P＜0.01).The expression of HSP72 mRNA were significantly higher after ACC in the group M than in the control group(P＜0.05).The serum concentration of AST,LDH,CK and CK-MB and the scores of myocardial mitochondria were significantly lower in the group M than in the control group(P＜0.05)after CPB.The myocardial ultrastructure in the group had milder alterations than in the control group after CPB(P＜0.05).
In the second group(G2),there were no significant differences among the three groups in sex,age,weight and time of aorta clamped on and cardiopulmonary bypass (P＞0.05).The expression of iNOSmRNA and HSP72mRNA were significantly increased at T2 and T3 and the serum concentration of CK,CK-MB were significantly increased at T2,T3 and T4 as compared to at T1 in the three groups(P＜0.05 or P＜0.01).The expression of iNOSmRNA and HSP72mRNA were significantly increased at T3 and the serum concentration of CK and CK-MB were significantly increased at T3 and T4 as compared to at T2 in the three groups(P＜0.05 or P＜0.01). The serum concentration of CK and CK-MB were significantly increased at T4 as compared to at T3 in the three groups(P＜0.01).Compared to the control group,the expression of iNOSmRNA significantly decreased in the group K1 at T2 and in the group K2 at T2 and T3(P＜0.01),the serum concentration of CK and CK-MB were significantly lower in the groups K1 and K2 at T2,T3 and T4(P＜0.01),the expression of HSP72mRNA were significantly increased in the group K1 and K2 at T2 and T3.Compared to the group K1,the expression of iNOSmRNA significantly decreased in the group K2 at T2 and T3(P＜0.01),the serum concentration of CK and CK-MB were significantly lower in the group K2 at T2,T3 and T4(P＜0.05 or P＜0.01),the expression of HSP72mRNA were no significant differences in the group K2(P＞0.05).
In the third group(G3),the plasma concentration of cTnT,LDH,CK-MB,MDA and SOD were significantly increased at T2,T3 and T4 as compared to at T1 in the four groups(P＜0.05 or P＜0.01).Compared to the control group,the plasma concentration of cTnT were significantly lower in the group L and F at T4 and in the group D at T3 and T4(P＜0.05),the plasma concentration of LDH were significantly lower in the group L at T3 and in the group D at T2,T3 and T4(P＜0.05 or P＜0.01), the plasma concentration of CK-MB and MDA were significantly lower in the group L,F and D at T2,T3 and T4(P＜0.05 or P＜0.01),the plasma concentration of SOD were significantly higher in the group L,F and D at T3.The plasma concentration of cTnT were significantly lower in the group D than in the group L at T3(P＜0.01)and in the group F at T3 and T4(P＜0.01).The plasma concentration of LDH were significantly lower in the group D than in the group F at T2(P＜0.05).
In the fourth group(G4),there were no significant differences between two groups in sex,age,weight,ascending aorta clamping time,CPB time and operation time(P＞0.05).The expression of NF-kB and Bcl-2 and the count of neutrophil were significantly increased at T4 as compared to at Tl in the two groups(P＜0.01).The serum concentration of TNF-α,MDA and SOD were significantly increased at T2,T3, T4 and T5 as compared to at T1 in the two groups(P＜0.05 or P＜0.01).The serum concentration of IL-8 and L-10 were significantly increased at T3,T4 and T5 as compared to at T1 in the two groups(P＜0.05 or P＜0.01).Compared to the control group,the expression of NF-kB and Bcl-2 and the count of neutrophil were significantly decreased in the group P at T4(P＜0.01),the serum concentration of TNF-αand MDA were significantly lower in the group P at T2,T3,T4 and T5 (P＜0.05 or P＜0.01),the serum concentration of IL-8 were significantly lower in the group P at T3,T4 and T5(P＜0.05),the serum concentration of IL-10 were significantly higher in the group P at T3,T4 and T5(P＜0.05),the serum concentration of SOD were significantly higher in the group P at T2,T3,T4 and T5 (P＜0.05).
Conclusion HSP72,iNOS,NF-kB and Bcl-2 take part in myocardial ischemia -reperfusion injury.
HSP72 gene expression increase in myocardium of patients undergoing open heart surgery during CPB.TMP pre-conditioning can induce HSP72 gene expression and protect myocardial mitochondria from ischemia reperfusion injury and attenuates CPB-induced myocardial ischemia reperfusion injury through a self-protective mechanism.
Ketamine in dose of anesthesia(1.0mg/kg)and subanaesthetic(0.5mg/kg)can decrease iNOSmRNA and increase HSP72mRNA expression in myocardium and reduce leakage of myocardium enzyme.Ketamine acts myocardial protection,and which in anesthesia dose is more effective than in subanaesthetic dose.
The both of L-Arg and FDP can produce protective effects on myocardial ischemia reperfusion injury during open heart surgery with CPB through different protective mechanism.The combined use of L-Arg and FDP shows obvious synergistic effects on myocardial protection.
Propofol is used to the patients undergoing open heart surgery during the CPB not only has the satisfactory actions of anesthesia and sedation but also has the actions of inhibiting Inflammatory reaction and abatement tissue injury by impact the function of neutrophil,the proinflammatory anti-inflammatory cytokines and oxygen free radicals etc.It has the prevention to MI/RI that was induced by infection or uninfection during cardiac surgery.So it has the clinic significance to use propofol in cardiac surgery anaesthesia.
引文
1 Jennings RB,Sommers HM,Smyth GA,et al.Myocardial necrosis induced by temporary occlusion of a coronary artery in the dog.Arch Payhol,1960,70:68-78.
2 RobertaA,Gottlieb,Katharine O,et al.Reperfusion induces apoptosis in rabbit cardiomyocytes.J Clin Invest,1996,112:1621-1628.
3 Silverman HS.Ionic basis of ischaemic cardiac injury:insight from cellular studies.Cardiovasc Res,1994,28:581-588.
4 戴瑞鸿,李勇,范维琥,等.保护内皮细胞功能在防治心血管疾病中的重要性.国际心血管杂志,2000,2:328-331.
5 Barry S,Oemar,Marcel R,et al.Reduced endotheial nitric oxide synthase expression and production in human atheroslerosis.Circulation,1998,97:2494-2497.
6 Young DK,Moncada SR,Kuklo TR,et al.Brief ischemia-reperfusion induces stunning of endothelium in canine coronary artery.Circlation,1992,85:1473.
7 王长谦.细胞粘附分子与心肌缺血再灌注损伤.国外医学生理病理科学与临床分册,1996,16(2):82.
8 丁钢,沈景霞.心肌缺血再灌注损伤中一氧化氮与中性粒细胞之间的关系.心血管病学进展,2000,21(5):290-293.
9 Komai H,Rusy BF.Effects of inhibition of transsar colemmal calciam inlux by nickel on force of postrest contraction on contracture induced by rapid colling.Cardiovasc Res,1993,27:801-802.
10 Kark M,Ziemer G,Zoeller M,et al.Protection of the chronic hypoxic immature rat heart during globalischemia.Ann Thorac Surg,1995,59:699-701.
11 Ritossa F.A new puffing induced by temperature shock and DNP in drosophila.Experientia,1962,18:571-573.
12 Buckiov(?) D,Jel(?)nek R.Heat shock proteins and teratogenesis.Reprod Toxicol,1995 Nov-Dec;9(6):501-511.
13 Martindale JL,Holbrook NJ.Cellular response to oxidative stress:signaling for suicide and survival.Cell Physiol,2002,192(1):1-15.
14 Tajima M,Isoyama S,Nitta Y,Abe K.Attenuation of heat shock protein expression by coronary occlusion in hypertrophied hearts.Am J Physiol,1997 Aug;273(2 Pt 2):H526-533.
15 Holownia A,Ledig M,Copin JC,Tholey G.The effect of ethanol on HSP70 in cultured rat glial cells and in brain areas of rat pups exposed to ethanol in utero.Neurochem Res,1995,20:875-878.
16 Knowlton AA,Brecher P,Apstein CS.Rapid expression of heat shock protein in the rabbit after brief cardiac ischemia.J Clin Invest,1991,87:139-147.
17 Tanaka M,Fujiwara H,Yamasaki K,et al.Ischemic preconditioning elevates cardiac stress protein but does not limit infarct size 24 or 48 h later in rabbits.Am J Physiol,1994,267(4 Pt 2):H1476-482.
18 Hutter JJ,Mestril R,Tam EK,et al.Overexpression of heat shock pretein 72 in transgenic mice decreases infarct size in vivo.Circulation,1996,94:1408-1411.
19 Cohen G,Shirai T,Weisel RD,et al.Optimal myocardial preconditioning in a human model of ischemia and reperfusion.Circulation,1998,98:Ⅱ184-196.
20 Nishizawa J,Nakai A.Higashi T,et al.Reperfusion causes significant activation of heat shock transcription factor 1 in ischemic rat heart.Circulation.1996,94:2185-2192.
21 Yahav S,Shamay A,Horev G,et al.Effect of acquisition of improved thermotolerance on the induction of heat shock proteins in broiler chickens.Poult Sci, 1997,76:1428-1434.
22 TanonakaK,Toga W,Takeo S.Induction of heat shock protein 70 in failing heart.Nippon Yakungaku Zasshi.2004,23:71-76.
23 Sharma M,Ganguly NK,ChaturvediG,et al.A possible role of HSP70 in mediating cardioprotection in patients undergoing CABG.Mol Cell Biochem,2003,247:31-36.
24 Patel HH,Hsu A,Gross GJ.Attenuation of heat shock-induced cardioprotection by treatment with the opiate receptor antagonist naloxone._Am J Physiol Heart Circ Physiol.2002,282:H2011-2017.
25 Benedict PE,Benedict MB, Su TP,et al.Opiate drugs and delta-receptor-mediated myocardial protection.Circulation, 1999, 100:11357-1360.
26 Shevchenko IuL,Demidov ON,Tyrenko W,et al.Role of heat-shock proteins in cardioprotection of patients operated on for ischemic heart disease.Vestn Khir Im I I Grek,1999, 158:11-15.
27 Li PL,ChaoYM,ChanSH,Chan JY.Potentiation of baroreceptor reflex response by heat shock protein 70 in nucleus tractus solitarii confers cardiovascular protection during heatstroke.Circulation,2001, 103:2114-2119.
28 陈在嘉．再灌注治疗应当重视心肌微循环的灌注．中国循环杂志,2002,17：163-164．
29 Suzuki K,Sawa Y,Kaneda Y,et al.Overexpressed heat shock protein 70 attenuates hypoxic injury in coronary endothelial cell.Mol Cell Cardiol, 1998,30:1129-1136.)
30 Yellon DM,Latchman DS,Marber MS.Stress proteins—an endogenous route to myocardial protection: fact or fiction?.Cardiovasc Res, 1993,27:158-161.
31 Amrani M,Corbett J,Boateng SY,et al.Kinetics of induction and protective effect of heat-shock proteins after cardioplegic arrest.Ann Thorac Surg, 1996,61:1407-1412.
32 Okubo S,Wildner O,Shah MR,et al.Gene transfer of heat-shock protein 70 reduces infarct size in vivo after ischemia/reperfusion in the rabbit heart.Circulation.2001, 103:877-881.
33 Mestril R,Giordano FJ,Conde AG,et al.Adenovirus-mediated gene transfer of a heat shock protein 70 (hsp 70i) protects against simulated ischemia.J Mol Cell Cardiol, 1996,28:2351-2358.
34 JayakumarJ,Suzuki K,KhanM,et al.Gene therapy for myocardial protection: transfection of donor hearts with heat shock protein 70 gene protects cardiac function against ischemia-reperfusion injury.Circulation,2000, 102:111302-306.
35 Zhu X,Zhao X,et al.Structural analysis of substrate binding by the molecular chaperone DNaK.Science, 1996, 272: 1606-1614.
36 Polla BS,Jacquier-Sarlin MR,Kantengwa S,et al.TNF-a alters mitochondrial melt brad potential in L929 but not in TNF-a resistant L929.12 cells: relationship with the expression of stress proteins,annexin 1 and super-oxide dismuta-activity.Free Radic Res,1996,25:125-131.
37 AseaA,Kraeft SK,Kurt Jones EA,et al.HSP 70 stimulates cytokine production through a CD14-dependent pathway demonstrating its dual role as a chaperone and cytokine .Nat Med,2000, 6:435-442.
38 Mocanu MM,SteareSE,Evans Mc.et al.Heat stress attenuates free radical release in the isolated perfused rat heart.Free Rad Biol Med, 1993, 15: 459-463.
39 Mosser DD,Caron AW,Bourget L,et al.Role of the human heat shock protein HSP70 in protection against stress-induced apoptosis.Mol Cell Biol,1997,17:5317-5327.
40 Katherine A,Buzzard,Amato J.Heat Shock Protein 72 Modulates Pathways of Stress-induced Apoptosis.The journal of biological chemistry,1998,273:17147-17153.
41 Gabai VL,et al.HSP70 prevents activation of stress kinases.A novel pathway of cellular thermo-tolerance,J Biol chem,1997,272:18033-18037.
42 McMillan DR,Xiao X,Shao L.et al.Targeted disruption of heat shock transcription factor 1abolishes thermo-tolerance and protection against heat induced apoptosis.Biol Chem,1998,273:7523-7528.
43 Roigas J,Wallen ES,Loening SA.Heat shock protein(HSP72) surface expression enhances the lysis of a human renal cell carcinoma by IL-2 stimulated NK cells.Adv Exp Med Biol,1998,451:225-229.
44 Meng X,Brown JM,Ao L,et al.Norepinephrine induces cardiac heat shock protein 70 and delayed cardioprotection in the rat through alpha 1 adrenoceptors.Cardiovasc Res,1996,32:374-383.
45 柯琴梅,冯义柏,成蓓,等.去甲肾上腺素预先给药对大鼠缺血再灌注心肌的延迟性保护作用.中国微循环,2004,8:7-9.
46 Katori M,Tamaki T,Takahashi T,et al.Prior induction of heat shock proteins by a nitric oxide donor attenuates cardiac ischemia/reperfusion injury in the rat.Transplantation,2000,69:2530-2537.
47 Oxman T,Shapira M,Diver A,et al.A new method of long-term preventive cardioprotection using Lactobacillus.Am J Physiol Heart Circ Physiol,2000,278:H1717-1724.
48 毛定安,杨于嘉,虞佩兰,等.黄芩甙川芎嗪诱导大鼠脑组织热休克蛋白70合成.中国当代儿科杂志,2001,8:367-369.
49 Fliss H,Gattinger D.Apoptosis in ischemic and reperfused rat myocardium.Cir Res,1996,79:949-956.
50 姚震,焦解歌,冯建章.心肌缺血再灌注损伤与细胞调亡关系的实验研究.海南医学院学报,2000,6:129-133.
51 Saraste A,Pulkki K,Kallajok M,et al.Apoptosis in human acute myocardial infarction.Circulation,1997,95:320-323.
52 Oyama J,Shimokawa H,Momii H,et al.Role of nitric oxide and peroxynitrite in the cytokine induced sustained myocardial dysfunction in dogs in vivo.J Clin Invest,1998,101:2207-2214.
53 Tsao PS,Aoki N,Lefer DJ,et al.Time course ofendothelial dysfunction my-ocar dial injury during myocardial ischemia and reperfusion in the rats.Circulation,1990,82:1402-1405.
54 Maulik N.Nitric oxide signaling in ischemic heart.Cardiovasc Res,1995,30:593-598.
55 Engelman DT,Watanake M,Engelmar RM,et al.Constitutive nitric oxide release is impaired after ischemia and reperfusion.J Thorac Cardiovasc Surg,1995,110:1047-1053.
56 Weyrich AS,Ma XL,Lefer AM.The role of L-arginine in ameliorating reperfusion injury after myocardial ischemia in the cat.Circulation,1992,86:279-288.
57 Gauthier TW,Davenpeck KL,Lefer AM.Nitric oxide attenuates leukocyte-endothelial interaction via P-selectin in splanchnic ischemia-reperfusion.Am J Physiol,1994,267:G562-568.
58 Valen G,Paulsson G,Vaage J.Induction of inflammatory mediators during reperfusion of the human heart.Ann Thorac Surg,2001,71:226-232.
59 Li C,Browder W,Kao RL.Early activation of transcription factor NF-kappa B during ischemia in perfused rat heart.Am j Physiol,1999,276:H543-H552.
60 王云,渠川铮,王莉,等.抑制核转录因子减轻心肌缺血再灌注损伤.中华胸心血管外科杂志,2001,17:105-107.
61 Sun B,Fan H,Honda T,et al.Activation of NF kappa B and expression of ICAM-1 in ischemic-reperfused canine myocardium.J Mol Cell Cardiol,2001,33:109-119.
62 Kupatt C,Habazettl H,Becker BF,et al.Endothelial activation-a strategic event during postischemic myocardial inflammation.Z Kardiol,2000,89:IX/96-100.
63 姜恩平,胡景鑫.一氧化氮与心肌再灌注损伤.北华大学学报,2001,2:314-317.
64 Chandrasekar B,Smith JB,Freeman GL.Ischemia-reperfusion of rat myocardium activates nuclear factor-KappaB and induces neutrophil infiltration via lipopolysaccharide-induced CXC chemokine.Circulation,2001,103:2296-2302.
65 Sasaki H,Galang N,Maulik N.Redox regulation of NF-kappaB and AP-1 in ischemic reperfused heart.Antioxid Redox Signal,1999,1:317-324.
66 Maulik N,Goswami S,Galang N,et al.Differential regulation of Bcl-2,AP-1 and NF-kappa B on cardiomyocyte apoptosis during myocardial ischemic stress adaptation.FEBS Lett,1999,443:331-336.
67 Moissac D,Zheng H,KirshenbaumLA.Linkage of the BH4 domain of Bcl-2 and the nuclear factor kappa B aignaling pathway for suppression of apoptosia.J Biol Chem,1999,274:29505-29509.
68 Li C,Kao RL,Ha T,et al.Early activation of IkBβduring in vivo myocardial ischemia.Am J Physiol Heart Circ Physiol,2001,280:H1264-H1271.
69 Maulik N,Sato M,Price BD,et al.An essential role of NFkappaB in tyrosine kinase signaling of p38 MAP kinase regulation of myocardial adaptation to ischemia.FEBS Lett,1998,429:365-369.
70 Feinastein DL,Galea E,Aquino DA,et al.Heat shock protein 70 suppresses astroglialinducible nitro oxide synthase expression by decreasing NF-kB activation.J Boil Chem,1996,271:17224-17232.
71 Bach FH,Hancock WW,Ferran C.Protective gene expressed in endothelial cells:a regulatory response to injure.Immunol Today,1997,18:483-486.
72 Sergeev P,da Silva R,Lucchinetti E,et al.Trigger-dependent gene expression profiles in cardiac preconditioning:evidence for distinct genetic programs in ischemic and anesthetic preconditioning.Anesthesiology,2004,100:474-488.
73 Patel Y,Collaco Moraes Y,Latchman D,et al.Neuro-protective effects of copper/zinc-dependent superoxide dismutase against a wide variety of death-enduring stimuli and pro-apoptotic effect of familial a myotrophic lateral sclerosis mutations.Brain Res Mol Brain Res,2002,109:189-197.
74 Smart SC,Sagar KB,Warltier DC.Differential roles of,myocardial Ca~(2+) channels and Na~+/Ca~(2+) exchange in myocardial reperfusion injury in open chest dogs:relative roles during ischemia and reperfusion.Cardiovasc Res,1997,36:337-346.
75 Murohara T,Delyani JA,Albelda SM,et al.Blockade of platelet endothelial cell adhesion molecule-1 protects against myocardial ischemia and reperfusion injury in cats.J Immunol,1996,156:3550-3557.
76 Jordan JE,Thourani VH,Auchampach JA,et al.A(3) adenosine receptor activation attenuates neutrophil function and neutrophil-mediated reperfusion injury.Am J physiol.1999,277:1895-1905.
77 Park JL,Lucchessi BR.Mechanisms of myocardial reperfusion injury.Ann Thorac Surg,1999,68:1905-1912.
78 Hannan RL,John MC,Kouretas PC,et al.Deletion of endothelial nitric oxide synthase exacerbates myocardial stunning in an isolated mousse heart model.J Surg Res,2000,93910:127-132.
79 Gonon AT,Gourine AV,Pemow J.Cardio protection from ischemia and reperfusion injury by an endothelin Acceptor antagonist in relation to nitrix oxide production.J Cardiovasc Pharmacol,2000,36930:405-412.
80 Weidenbach R,Schulz R,Gres P,et al.Enhanced reduction of myocardial infarct size by combined ACE inhibition and AT-1 receptor antagonisn.Br J Pharmacol,2000,131(1):138-144.
81 Rohmann S,Weygandt H,Minck KO.Pre-ischemia as well as post-ischemia application of a Na~+/H~+exchange inhibitor reduces infarct size in pigs.Cardiovasc Res,1995,30:946-951.
82 Valeva AP,Agah A,Rollins SA,et al.Myocardial infarction and apoptosis after myocardial ischemia and reperfusion:role of the terminal complement components and inhibition by anti-C5 therapy.Circulation,1998,97:2259-2267.
83 Dieffenbach CW.引物设计.见:黄培堂译.PCR技术实验指南.北京:科学出版社,1998,88-94.
84 Flameng W.Ultrastructural and cytochemical correlates of myocardial protection by cold hypothermia in man.J Thorac Cardivasc Sury,1980,79:413-425
85 法宪恩,董铁立,权晓强,等.冷晶体停搏液间断灌注和温血停搏液连续灌注法对心脏直视手术患者心肌的保护作用.中华麻醉学杂志,2003,23:386-387.
86 陈晓东,张宝仁,朱家麟,等.顺行灌注冷晶体停搏液及温血停搏液对心肌的保护作用.中华实验外科杂志,1999,16:349-351.
87 刘流,陈启智,周英.心内直视手术中血清LPO,LDH同工酶的变化.中华麻醉学志,1996,16:351-352
88 Nowak JR.Heat shock protein 70 and c-fos gene expression after transient ischemia.Stroke,1990,21:107-111.
89 李萍,富青,熊凡.热休克蛋白70在大鼠心肌缺血再灌注过程中的表达及其意义.微循环学杂志,2004,14:3941.
90 Hutter IC,et al.Recent cadiovascular drugs from Chinese medicinal plants.Cardiovasc Res,1993:27:890-891.
91 廖福龙,李斌.川芎嗪抗剪刀应力诱导血小板聚集的实验研究.中国药理学通报,1997,13:47-50.
92 Pang PK.Tetramethylpyrazine,a Calcium antagonist.Planta Med,1996;62:431-435.
93 徐浩.川芎嗪的临床应用和药理作用.中国中西医结合杂志,2003,23:376-377.91
94 王万铁,许正介,林丽娜,等.川芎嗪对实验性缺血—再灌注损伤心肌能量代谢的干预.中国急救医学,2003,23:129-130.
95 文飞,冯义柏,田莉,等.川芎嗪预处理对大鼠心肌缺血/再灌注损伤的保护.中华实用中西医杂志,2005,18:1099-1101.
96 Hutter M M,Sievers R E,Barbosa V,et al.Heat-shock protein induction in rat hearts.A direct correlation between the amount of heat-shock protein induced and the degree of myocardial protection.Circulation,1994,89:355-360.
97 Giannessi D,Caselli C,Vitale RL,et al.A possible cardioprotective effect of heat shock proteins during cardiac surgery in pediatric patients.Pharmacological Research,2003,48:19-29.
98 Dzeja PP,Ekshon,Holmuhamedov.Mitochondria:Gateway for Cytoprotection.Circ.Res,2001,89:744-746.
99 Sammut IA,Jayakumar J,Latif N,et al.Heat Stress Contributes to the Enhancement of Cardiac Mitochondrial Complex Activity.Am J Pathol,2001,158:1821-1831.97
100 Jayakumar J,Suzuki K,Sammut IA,et al.Heat shock protein 70gene transfac tion protects mitochondrial and function against ischemia reperfusion injury.Circ,2001,104:301-303.
101 姜泊,主编.细胞凋亡基础与临床.第1版北京:人民军医出版社,1999,107-108.
102 Wang WJ,Sawicki G,Schulz R.Peroxynitrite induced myocardial injury is mediated through matrix metalloid proteinase-2.Cardiovase Res,2002,53:165-174.
103 Gabbai FB,Hamrnond TC,Thomson SC,et al.Effect of acute iNOS inhibition on glomerulate function in tubulointerstitial nephritis.Kidney Int,2002,61:885
104 Bengoechea.Alonso MT,Pelacho B,et al.Regulation of NF-kB activation by protein phosphatase ZB and NO,via protein Kinase A activity,in human monocytes,Nitric Oxide,2003,8:65-74
105 方育,汪珺,衡新华.氯胺酮的抗炎作用.云南医药,2004,25:410-413.
106 朱同玉,欧阳嘉慧,柯嘉敏,等.肾脏缺血再灌注损伤后一氧化氮合酶的变化.复旦学报(医学版),2004,31:221-224,
107 安立敏,胡健,夏经纲.一氧化氮释放剂对心肌热休克蛋白70诱导的实验研究.中国循环杂志,2005,20:305-308.
108 Masamichi K,Tohru T,Tsuyoshi T,et al.Prior induction of heat shock proteins by a nitric oxide donor attenuates cardiac ischemia reperfusion injury in the rat.Trans platation,2000,69:2530-2537.
109 李伟杰,贾国良,郭文怡.一氧化氮通过诱导热休克蛋白72的表达打开缺血预处理的第二保护窗.中国病理生理杂志,2003,19:1386-1390.
110 Xu Q,Hu Y,Kleindienst R,et al.Nitric oxide induces heat shock protein 70 expression in vascular smooth muscle cells via activation of heat shock factor 1.J Clin Invest,1997,100:1089.
111 黄冰,张运龙,陈庆廉.氯胺酮的研究进展.《国外医学》麻醉学与复苏分册2000,5(21):306-308.
112 彭章龙,杭燕南,孙大金.氯胺酮对培养心肌细胞的直接作用及其机制.中华麻醉学杂志,1999,19:566-568.
113 张铁铮,王凤学,周锦等.氯胺酮对大鼠全心缺血/再灌注时心肌c-fos基因表达的影响.中华麻醉学杂志,2000,20(10):615-617.
114 曹德权,杨荣雪.小剂量氯胺酮对体外循环促炎细胞因子反应及心肌损伤的影响[J].中华麻醉学杂志,2001,21:199-201.
115 肖红,王泉云,张兰,等.氯胺酮-咪唑安定对感染性休克大鼠血清肿瘤坏死因子-α和心肌环磷酸腺苷的影响[J].中华麻醉学杂志,2001,21:113-116.
116 Zilberstein G,Levy R,Rachinsky M,et al.Ketamine attenuates neutrophil activation after cardio pulmonary bypass[J].Anesth Analg,2002,95:531-536.
117 彭章龙,杭燕南,孙大金.氯胺酮对培养心肌细胞的直接作用及其机制[J].中华麻醉学杂志,1999,19:566-568.
118 张铁铮,王凤学,周锦.氯胺酮对大鼠全心缺血/再灌注时心肌c-fos基因表达的影响.中华麻醉学杂志,2000,20:615-617.
119 Li CY,Chou TC,Wong CS,et al.Ketamine inhibits nitric oxide synthase in lipopolysaccharide-treated rat alveolar macrophages.Can J Anaesth,1997,44:989-995.
120 Higuchi K,Abe S,Matsuoka T,et al.Usefulness of rapid quantitative cardiac troponin T and myoglobin assays for the diagnosis of acute myocardial infarction.J Cardiol.2003Feb;41:55-62.
121 Markov AK,Terry J,White TZ,et al.Increasing survival of dogs subjected to hemorrhagic shock by administration of fructose 1,6-diphosphate[J].Suegery,1987,102:515-525.
122 Wabb WR.Metabolic effects of fructose diphosphate in hypoxic and states.J Thorac Cardiovasc Surg,1984,88(5Pt2):863-866.
123 范国辉.1,6二磷酸果糖[J].中华麻醉学杂志,1995,15:45-47.
124 赖平,张洪泉,马郁文等.1,6二磷酸果糖对阿酶素心肌损伤防治的实验研究.山东医科大学学报,1997,35:242 243.
125 Romsi P,Kaakinen T,Kiviluoma K,et al.Fructose-1,6-bisphosphate for improved outcome after hypothermic circulatory arrest in pigs[J].J Thorac Cardiovasc Surg,2003,125:686-398.
126 Ramos RC,de Meis L.Glucose 6-phosphate and fructose 1,6-bisphosphate can be used as ATP-regenerating systems by cerebellum Ca~2+-transport ATPas(J).Neurochem,1999;72(1):81-86.
127 李建雄,刘桥义,张翠清等.缺血再灌注不同时期应用1,6-二磷酸果糖对幼兔心脏的保护作用(J).临床麻醉学杂志,2002,18(9):484-486.
128 卢卫新,戴瑞鸿,1,6-二磷酸果糖对组织缺血与缺氧的保护作用.中国临床医学,2002,9(1):91-92.
129 Oz E,Arsakay G.Role of the nitric oxide pathway on ischemia reperfusion injury in an isolated perfused guinea pig heart[J].Gen Pharmacol,2000,34(1):3-7.147
130 Moens AL,Claeys MJ,Timmermans JP,et al.Myocardial ischemia/reperfusion-injury,a clinical view on a complex pathophysiological process.Int J Cardiol,2005,100(2):179-190.
131 Nonami Y,Rao V,Shiono N,et al.Quenching the effects of L-arginine on free radical injuryin cultured cardiomyocytes(J).Surg Today,1998,28(4):379-84.
132 侯文明,郭兰敏,范全心,等.体外循环中应用L-精氨酸防治心肌再灌注损伤的临床研究.临床麻醉学杂志,2001,17:66-68.
133 Riedel BJ,Gal J,Ellis G,et al,Myocardial protection using fructose-1.6-diphosphate during coronary artery bypass graft surgery:a randomized,placebo-controlled clinical trial.Anesth Analg,2004,98:20-29.
134 吕胜,张慈忱.1,6-二磷酸果糖(FDP)对心脏瓣膜置换手术患者脂质过氧化的影响.中国胸心血管外科临床杂志,1996,3:70-72.
135 Rocke DA,Gaffin SL,Wells MT,et al.Endotoxemia associatied with cardiopulmonary bypass.J Thorac Cardiovasc Surg,1987,93:832-837.
136 Gadaleta D,Fahey AL,Verma M,et al.Neutraphil leukotriene generation increases after cardiopulmonary bypass.J Thorac Cardiovasc Surg,1994,108(4):642-647.
137 夏瑞,杨光,郑利民,等.异丙酚对家兔脑缺血-再灌注损伤的保护作用.中华麻醉学杂志,2000,20:233-235.
138 蔡英民,王美纳,薛荣光,等.麻醉剂量异丙酚对大鼠脑缺血-再灌注损伤的保护作用.中华麻醉学杂志,2001,21:160-162.
139 Taniguchi T,Yamamoto K,Ohmoto N,et al.Effects ofpropofol on hemodynamic and inflammatouy response to endotoxemia in rats.Crit Care Med,2000,28:1101-1106.
140 Heine J,Leuwer M,Scheinichen D,et al.Flow cytometry evaluation of the in vitro influence of four in anaesthetics on respiratory burst ofneutrophils.Br J Anesth,1996,77(3):387-392.
141 Mikawa K,Akamatsu H,Nishina K,et al.apropofol inhibits human neutrophil functions.Anesth Analg,1998,87:695-700.
142 Hofbauer R,Frass M,Salfinger H,et al.Propofol reduces the migration of human leukocytes through endothelial cell monolayers.Crit Care Med,1999,27(9):1843-1847.
143 Chang KS,Davris RF.Propofol produces endothelium independent vasdilation and as a Ca2+channel blocker.Anesth Analg,1993,76:24-32.
144 Murphy PG,Myers PS,Davise MJ,et al.The mantioxidant potential ofpropofol(2,6-Dissopropylphenol).Br J Anesth,1992,68:613-618.
145 Green TR,Bennett SR,Nelson VM,et al.Specificity and properties of propofol as an antioxidant free radical scavenger.Toxicol Appl Pharmacol,1994,129:163-169.
146 张诗海,姚尚龙。异丙酚在成人体外循环中抗氧化效应的研究.中华麻醉学杂志,2000,20:594-596.
147 Galley HF,Dubble AM,Webster NR.The effect of midazolam and propofol on interleukin-8from human polymorphonuclear leukocytes.Anesth Analg,1998,86:1289-1293.
148 Gilliland HE,Armstrong MA,Carabine U,et al.The choice of anesthestic maintenance technique influences the anti-inflammatory cytokine response to abdominal surgery.Anesth Analg,1997,85:1394-1398.
2 RobertaA,Gottlieb,Katharine O,et al.Reperfusion induces apoptosis in rabbit cardiomyocytes.J Clin Invest,1996,112:1621-1628.
3 Silverman HS.Ionic basis of ischaemic cardiac injury:insight from cellular studies.Cardiovasc Res,1994,28:581-588.
4 戴瑞鸿,李勇,范维琥,等.保护内皮细胞功能在防治心血管疾病中的重要性.国际心血管杂志,2000,2:328-331.
5 Barry S,Oemar,Marcel R,et al.Reduced endotheial nitric oxide synthase expression and production in human atheroslerosis.Circulation,1998,97:2494-2497.
6 Young DK,Moncada SR,Kuklo TR,et al.Brief ischemia-reperfusion induces stunning of endothelium in canine coronary artery.Circlation,1992,85:1473.
7 王长谦.细胞粘附分子与心肌缺血再灌注损伤.国外医学生理病理科学与临床分册,1996,16(2):82.
8 丁钢,沈景霞.心肌缺血再灌注损伤中一氧化氮与中性粒细胞之间的关系.心血管病学进展,2000,21(5):290-293.
9 Komai H,Rusy BF.Effects of inhibition of transsar colemmal calciam inlux by nickel on force of postrest contraction on contracture induced by rapid colling.Cardiovasc Res,1993,27:801-802.
10 Kark M,Ziemer G,Zoeller M,et al.Protection of the chronic hypoxic immature rat heart during globalischemia.Ann Thorac Surg,1995,59:699-701.
11 Ritossa F.A new puffing induced by temperature shock and DNP in drosophila.Experientia,1962,18:571-573.
12 Buckiov(?) D,Jel(?)nek R.Heat shock proteins and teratogenesis.Reprod Toxicol,1995 Nov-Dec;9(6):501-511.
13 Martindale JL,Holbrook NJ.Cellular response to oxidative stress:signaling for suicide and survival.Cell Physiol,2002,192(1):1-15.
14 Tajima M,Isoyama S,Nitta Y,Abe K.Attenuation of heat shock protein expression by coronary occlusion in hypertrophied hearts.Am J Physiol,1997 Aug;273(2 Pt 2):H526-533.
15 Holownia A,Ledig M,Copin JC,Tholey G.The effect of ethanol on HSP70 in cultured rat glial cells and in brain areas of rat pups exposed to ethanol in utero.Neurochem Res,1995,20:875-878.
16 Knowlton AA,Brecher P,Apstein CS.Rapid expression of heat shock protein in the rabbit after brief cardiac ischemia.J Clin Invest,1991,87:139-147.
17 Tanaka M,Fujiwara H,Yamasaki K,et al.Ischemic preconditioning elevates cardiac stress protein but does not limit infarct size 24 or 48 h later in rabbits.Am J Physiol,1994,267(4 Pt 2):H1476-482.
18 Hutter JJ,Mestril R,Tam EK,et al.Overexpression of heat shock pretein 72 in transgenic mice decreases infarct size in vivo.Circulation,1996,94:1408-1411.
19 Cohen G,Shirai T,Weisel RD,et al.Optimal myocardial preconditioning in a human model of ischemia and reperfusion.Circulation,1998,98:Ⅱ184-196.
20 Nishizawa J,Nakai A.Higashi T,et al.Reperfusion causes significant activation of heat shock transcription factor 1 in ischemic rat heart.Circulation.1996,94:2185-2192.
21 Yahav S,Shamay A,Horev G,et al.Effect of acquisition of improved thermotolerance on the induction of heat shock proteins in broiler chickens.Poult Sci, 1997,76:1428-1434.
22 TanonakaK,Toga W,Takeo S.Induction of heat shock protein 70 in failing heart.Nippon Yakungaku Zasshi.2004,23:71-76.
23 Sharma M,Ganguly NK,ChaturvediG,et al.A possible role of HSP70 in mediating cardioprotection in patients undergoing CABG.Mol Cell Biochem,2003,247:31-36.
24 Patel HH,Hsu A,Gross GJ.Attenuation of heat shock-induced cardioprotection by treatment with the opiate receptor antagonist naloxone._Am J Physiol Heart Circ Physiol.2002,282:H2011-2017.
25 Benedict PE,Benedict MB, Su TP,et al.Opiate drugs and delta-receptor-mediated myocardial protection.Circulation, 1999, 100:11357-1360.
26 Shevchenko IuL,Demidov ON,Tyrenko W,et al.Role of heat-shock proteins in cardioprotection of patients operated on for ischemic heart disease.Vestn Khir Im I I Grek,1999, 158:11-15.
27 Li PL,ChaoYM,ChanSH,Chan JY.Potentiation of baroreceptor reflex response by heat shock protein 70 in nucleus tractus solitarii confers cardiovascular protection during heatstroke.Circulation,2001, 103:2114-2119.
28 陈在嘉．再灌注治疗应当重视心肌微循环的灌注．中国循环杂志,2002,17：163-164．
29 Suzuki K,Sawa Y,Kaneda Y,et al.Overexpressed heat shock protein 70 attenuates hypoxic injury in coronary endothelial cell.Mol Cell Cardiol, 1998,30:1129-1136.)
30 Yellon DM,Latchman DS,Marber MS.Stress proteins—an endogenous route to myocardial protection: fact or fiction?.Cardiovasc Res, 1993,27:158-161.
31 Amrani M,Corbett J,Boateng SY,et al.Kinetics of induction and protective effect of heat-shock proteins after cardioplegic arrest.Ann Thorac Surg, 1996,61:1407-1412.
32 Okubo S,Wildner O,Shah MR,et al.Gene transfer of heat-shock protein 70 reduces infarct size in vivo after ischemia/reperfusion in the rabbit heart.Circulation.2001, 103:877-881.
33 Mestril R,Giordano FJ,Conde AG,et al.Adenovirus-mediated gene transfer of a heat shock protein 70 (hsp 70i) protects against simulated ischemia.J Mol Cell Cardiol, 1996,28:2351-2358.
34 JayakumarJ,Suzuki K,KhanM,et al.Gene therapy for myocardial protection: transfection of donor hearts with heat shock protein 70 gene protects cardiac function against ischemia-reperfusion injury.Circulation,2000, 102:111302-306.
35 Zhu X,Zhao X,et al.Structural analysis of substrate binding by the molecular chaperone DNaK.Science, 1996, 272: 1606-1614.
36 Polla BS,Jacquier-Sarlin MR,Kantengwa S,et al.TNF-a alters mitochondrial melt brad potential in L929 but not in TNF-a resistant L929.12 cells: relationship with the expression of stress proteins,annexin 1 and super-oxide dismuta-activity.Free Radic Res,1996,25:125-131.
37 AseaA,Kraeft SK,Kurt Jones EA,et al.HSP 70 stimulates cytokine production through a CD14-dependent pathway demonstrating its dual role as a chaperone and cytokine .Nat Med,2000, 6:435-442.
38 Mocanu MM,SteareSE,Evans Mc.et al.Heat stress attenuates free radical release in the isolated perfused rat heart.Free Rad Biol Med, 1993, 15: 459-463.
39 Mosser DD,Caron AW,Bourget L,et al.Role of the human heat shock protein HSP70 in protection against stress-induced apoptosis.Mol Cell Biol,1997,17:5317-5327.
40 Katherine A,Buzzard,Amato J.Heat Shock Protein 72 Modulates Pathways of Stress-induced Apoptosis.The journal of biological chemistry,1998,273:17147-17153.
41 Gabai VL,et al.HSP70 prevents activation of stress kinases.A novel pathway of cellular thermo-tolerance,J Biol chem,1997,272:18033-18037.
42 McMillan DR,Xiao X,Shao L.et al.Targeted disruption of heat shock transcription factor 1abolishes thermo-tolerance and protection against heat induced apoptosis.Biol Chem,1998,273:7523-7528.
43 Roigas J,Wallen ES,Loening SA.Heat shock protein(HSP72) surface expression enhances the lysis of a human renal cell carcinoma by IL-2 stimulated NK cells.Adv Exp Med Biol,1998,451:225-229.
44 Meng X,Brown JM,Ao L,et al.Norepinephrine induces cardiac heat shock protein 70 and delayed cardioprotection in the rat through alpha 1 adrenoceptors.Cardiovasc Res,1996,32:374-383.
45 柯琴梅,冯义柏,成蓓,等.去甲肾上腺素预先给药对大鼠缺血再灌注心肌的延迟性保护作用.中国微循环,2004,8:7-9.
46 Katori M,Tamaki T,Takahashi T,et al.Prior induction of heat shock proteins by a nitric oxide donor attenuates cardiac ischemia/reperfusion injury in the rat.Transplantation,2000,69:2530-2537.
47 Oxman T,Shapira M,Diver A,et al.A new method of long-term preventive cardioprotection using Lactobacillus.Am J Physiol Heart Circ Physiol,2000,278:H1717-1724.
48 毛定安,杨于嘉,虞佩兰,等.黄芩甙川芎嗪诱导大鼠脑组织热休克蛋白70合成.中国当代儿科杂志,2001,8:367-369.
49 Fliss H,Gattinger D.Apoptosis in ischemic and reperfused rat myocardium.Cir Res,1996,79:949-956.
50 姚震,焦解歌,冯建章.心肌缺血再灌注损伤与细胞调亡关系的实验研究.海南医学院学报,2000,6:129-133.
51 Saraste A,Pulkki K,Kallajok M,et al.Apoptosis in human acute myocardial infarction.Circulation,1997,95:320-323.
52 Oyama J,Shimokawa H,Momii H,et al.Role of nitric oxide and peroxynitrite in the cytokine induced sustained myocardial dysfunction in dogs in vivo.J Clin Invest,1998,101:2207-2214.
53 Tsao PS,Aoki N,Lefer DJ,et al.Time course ofendothelial dysfunction my-ocar dial injury during myocardial ischemia and reperfusion in the rats.Circulation,1990,82:1402-1405.
54 Maulik N.Nitric oxide signaling in ischemic heart.Cardiovasc Res,1995,30:593-598.
55 Engelman DT,Watanake M,Engelmar RM,et al.Constitutive nitric oxide release is impaired after ischemia and reperfusion.J Thorac Cardiovasc Surg,1995,110:1047-1053.
56 Weyrich AS,Ma XL,Lefer AM.The role of L-arginine in ameliorating reperfusion injury after myocardial ischemia in the cat.Circulation,1992,86:279-288.
57 Gauthier TW,Davenpeck KL,Lefer AM.Nitric oxide attenuates leukocyte-endothelial interaction via P-selectin in splanchnic ischemia-reperfusion.Am J Physiol,1994,267:G562-568.
58 Valen G,Paulsson G,Vaage J.Induction of inflammatory mediators during reperfusion of the human heart.Ann Thorac Surg,2001,71:226-232.
59 Li C,Browder W,Kao RL.Early activation of transcription factor NF-kappa B during ischemia in perfused rat heart.Am j Physiol,1999,276:H543-H552.
60 王云,渠川铮,王莉,等.抑制核转录因子减轻心肌缺血再灌注损伤.中华胸心血管外科杂志,2001,17:105-107.
61 Sun B,Fan H,Honda T,et al.Activation of NF kappa B and expression of ICAM-1 in ischemic-reperfused canine myocardium.J Mol Cell Cardiol,2001,33:109-119.
62 Kupatt C,Habazettl H,Becker BF,et al.Endothelial activation-a strategic event during postischemic myocardial inflammation.Z Kardiol,2000,89:IX/96-100.
63 姜恩平,胡景鑫.一氧化氮与心肌再灌注损伤.北华大学学报,2001,2:314-317.
64 Chandrasekar B,Smith JB,Freeman GL.Ischemia-reperfusion of rat myocardium activates nuclear factor-KappaB and induces neutrophil infiltration via lipopolysaccharide-induced CXC chemokine.Circulation,2001,103:2296-2302.
65 Sasaki H,Galang N,Maulik N.Redox regulation of NF-kappaB and AP-1 in ischemic reperfused heart.Antioxid Redox Signal,1999,1:317-324.
66 Maulik N,Goswami S,Galang N,et al.Differential regulation of Bcl-2,AP-1 and NF-kappa B on cardiomyocyte apoptosis during myocardial ischemic stress adaptation.FEBS Lett,1999,443:331-336.
67 Moissac D,Zheng H,KirshenbaumLA.Linkage of the BH4 domain of Bcl-2 and the nuclear factor kappa B aignaling pathway for suppression of apoptosia.J Biol Chem,1999,274:29505-29509.
68 Li C,Kao RL,Ha T,et al.Early activation of IkBβduring in vivo myocardial ischemia.Am J Physiol Heart Circ Physiol,2001,280:H1264-H1271.
69 Maulik N,Sato M,Price BD,et al.An essential role of NFkappaB in tyrosine kinase signaling of p38 MAP kinase regulation of myocardial adaptation to ischemia.FEBS Lett,1998,429:365-369.
70 Feinastein DL,Galea E,Aquino DA,et al.Heat shock protein 70 suppresses astroglialinducible nitro oxide synthase expression by decreasing NF-kB activation.J Boil Chem,1996,271:17224-17232.
71 Bach FH,Hancock WW,Ferran C.Protective gene expressed in endothelial cells:a regulatory response to injure.Immunol Today,1997,18:483-486.
72 Sergeev P,da Silva R,Lucchinetti E,et al.Trigger-dependent gene expression profiles in cardiac preconditioning:evidence for distinct genetic programs in ischemic and anesthetic preconditioning.Anesthesiology,2004,100:474-488.
73 Patel Y,Collaco Moraes Y,Latchman D,et al.Neuro-protective effects of copper/zinc-dependent superoxide dismutase against a wide variety of death-enduring stimuli and pro-apoptotic effect of familial a myotrophic lateral sclerosis mutations.Brain Res Mol Brain Res,2002,109:189-197.
74 Smart SC,Sagar KB,Warltier DC.Differential roles of,myocardial Ca~(2+) channels and Na~+/Ca~(2+) exchange in myocardial reperfusion injury in open chest dogs:relative roles during ischemia and reperfusion.Cardiovasc Res,1997,36:337-346.
75 Murohara T,Delyani JA,Albelda SM,et al.Blockade of platelet endothelial cell adhesion molecule-1 protects against myocardial ischemia and reperfusion injury in cats.J Immunol,1996,156:3550-3557.
76 Jordan JE,Thourani VH,Auchampach JA,et al.A(3) adenosine receptor activation attenuates neutrophil function and neutrophil-mediated reperfusion injury.Am J physiol.1999,277:1895-1905.
77 Park JL,Lucchessi BR.Mechanisms of myocardial reperfusion injury.Ann Thorac Surg,1999,68:1905-1912.
78 Hannan RL,John MC,Kouretas PC,et al.Deletion of endothelial nitric oxide synthase exacerbates myocardial stunning in an isolated mousse heart model.J Surg Res,2000,93910:127-132.
79 Gonon AT,Gourine AV,Pemow J.Cardio protection from ischemia and reperfusion injury by an endothelin Acceptor antagonist in relation to nitrix oxide production.J Cardiovasc Pharmacol,2000,36930:405-412.
80 Weidenbach R,Schulz R,Gres P,et al.Enhanced reduction of myocardial infarct size by combined ACE inhibition and AT-1 receptor antagonisn.Br J Pharmacol,2000,131(1):138-144.
81 Rohmann S,Weygandt H,Minck KO.Pre-ischemia as well as post-ischemia application of a Na~+/H~+exchange inhibitor reduces infarct size in pigs.Cardiovasc Res,1995,30:946-951.
82 Valeva AP,Agah A,Rollins SA,et al.Myocardial infarction and apoptosis after myocardial ischemia and reperfusion:role of the terminal complement components and inhibition by anti-C5 therapy.Circulation,1998,97:2259-2267.
83 Dieffenbach CW.引物设计.见:黄培堂译.PCR技术实验指南.北京:科学出版社,1998,88-94.
84 Flameng W.Ultrastructural and cytochemical correlates of myocardial protection by cold hypothermia in man.J Thorac Cardivasc Sury,1980,79:413-425
85 法宪恩,董铁立,权晓强,等.冷晶体停搏液间断灌注和温血停搏液连续灌注法对心脏直视手术患者心肌的保护作用.中华麻醉学杂志,2003,23:386-387.
86 陈晓东,张宝仁,朱家麟,等.顺行灌注冷晶体停搏液及温血停搏液对心肌的保护作用.中华实验外科杂志,1999,16:349-351.
87 刘流,陈启智,周英.心内直视手术中血清LPO,LDH同工酶的变化.中华麻醉学志,1996,16:351-352
88 Nowak JR.Heat shock protein 70 and c-fos gene expression after transient ischemia.Stroke,1990,21:107-111.
89 李萍,富青,熊凡.热休克蛋白70在大鼠心肌缺血再灌注过程中的表达及其意义.微循环学杂志,2004,14:3941.
90 Hutter IC,et al.Recent cadiovascular drugs from Chinese medicinal plants.Cardiovasc Res,1993:27:890-891.
91 廖福龙,李斌.川芎嗪抗剪刀应力诱导血小板聚集的实验研究.中国药理学通报,1997,13:47-50.
92 Pang PK.Tetramethylpyrazine,a Calcium antagonist.Planta Med,1996;62:431-435.
93 徐浩.川芎嗪的临床应用和药理作用.中国中西医结合杂志,2003,23:376-377.91
94 王万铁,许正介,林丽娜,等.川芎嗪对实验性缺血—再灌注损伤心肌能量代谢的干预.中国急救医学,2003,23:129-130.
95 文飞,冯义柏,田莉,等.川芎嗪预处理对大鼠心肌缺血/再灌注损伤的保护.中华实用中西医杂志,2005,18:1099-1101.
96 Hutter M M,Sievers R E,Barbosa V,et al.Heat-shock protein induction in rat hearts.A direct correlation between the amount of heat-shock protein induced and the degree of myocardial protection.Circulation,1994,89:355-360.
97 Giannessi D,Caselli C,Vitale RL,et al.A possible cardioprotective effect of heat shock proteins during cardiac surgery in pediatric patients.Pharmacological Research,2003,48:19-29.
98 Dzeja PP,Ekshon,Holmuhamedov.Mitochondria:Gateway for Cytoprotection.Circ.Res,2001,89:744-746.
99 Sammut IA,Jayakumar J,Latif N,et al.Heat Stress Contributes to the Enhancement of Cardiac Mitochondrial Complex Activity.Am J Pathol,2001,158:1821-1831.97
100 Jayakumar J,Suzuki K,Sammut IA,et al.Heat shock protein 70gene transfac tion protects mitochondrial and function against ischemia reperfusion injury.Circ,2001,104:301-303.
101 姜泊,主编.细胞凋亡基础与临床.第1版北京:人民军医出版社,1999,107-108.
102 Wang WJ,Sawicki G,Schulz R.Peroxynitrite induced myocardial injury is mediated through matrix metalloid proteinase-2.Cardiovase Res,2002,53:165-174.
103 Gabbai FB,Hamrnond TC,Thomson SC,et al.Effect of acute iNOS inhibition on glomerulate function in tubulointerstitial nephritis.Kidney Int,2002,61:885
104 Bengoechea.Alonso MT,Pelacho B,et al.Regulation of NF-kB activation by protein phosphatase ZB and NO,via protein Kinase A activity,in human monocytes,Nitric Oxide,2003,8:65-74
105 方育,汪珺,衡新华.氯胺酮的抗炎作用.云南医药,2004,25:410-413.
106 朱同玉,欧阳嘉慧,柯嘉敏,等.肾脏缺血再灌注损伤后一氧化氮合酶的变化.复旦学报(医学版),2004,31:221-224,
107 安立敏,胡健,夏经纲.一氧化氮释放剂对心肌热休克蛋白70诱导的实验研究.中国循环杂志,2005,20:305-308.
108 Masamichi K,Tohru T,Tsuyoshi T,et al.Prior induction of heat shock proteins by a nitric oxide donor attenuates cardiac ischemia reperfusion injury in the rat.Trans platation,2000,69:2530-2537.
109 李伟杰,贾国良,郭文怡.一氧化氮通过诱导热休克蛋白72的表达打开缺血预处理的第二保护窗.中国病理生理杂志,2003,19:1386-1390.
110 Xu Q,Hu Y,Kleindienst R,et al.Nitric oxide induces heat shock protein 70 expression in vascular smooth muscle cells via activation of heat shock factor 1.J Clin Invest,1997,100:1089.
111 黄冰,张运龙,陈庆廉.氯胺酮的研究进展.《国外医学》麻醉学与复苏分册2000,5(21):306-308.
112 彭章龙,杭燕南,孙大金.氯胺酮对培养心肌细胞的直接作用及其机制.中华麻醉学杂志,1999,19:566-568.
113 张铁铮,王凤学,周锦等.氯胺酮对大鼠全心缺血/再灌注时心肌c-fos基因表达的影响.中华麻醉学杂志,2000,20(10):615-617.
114 曹德权,杨荣雪.小剂量氯胺酮对体外循环促炎细胞因子反应及心肌损伤的影响[J].中华麻醉学杂志,2001,21:199-201.
115 肖红,王泉云,张兰,等.氯胺酮-咪唑安定对感染性休克大鼠血清肿瘤坏死因子-α和心肌环磷酸腺苷的影响[J].中华麻醉学杂志,2001,21:113-116.
116 Zilberstein G,Levy R,Rachinsky M,et al.Ketamine attenuates neutrophil activation after cardio pulmonary bypass[J].Anesth Analg,2002,95:531-536.
117 彭章龙,杭燕南,孙大金.氯胺酮对培养心肌细胞的直接作用及其机制[J].中华麻醉学杂志,1999,19:566-568.
118 张铁铮,王凤学,周锦.氯胺酮对大鼠全心缺血/再灌注时心肌c-fos基因表达的影响.中华麻醉学杂志,2000,20:615-617.
119 Li CY,Chou TC,Wong CS,et al.Ketamine inhibits nitric oxide synthase in lipopolysaccharide-treated rat alveolar macrophages.Can J Anaesth,1997,44:989-995.
120 Higuchi K,Abe S,Matsuoka T,et al.Usefulness of rapid quantitative cardiac troponin T and myoglobin assays for the diagnosis of acute myocardial infarction.J Cardiol.2003Feb;41:55-62.
121 Markov AK,Terry J,White TZ,et al.Increasing survival of dogs subjected to hemorrhagic shock by administration of fructose 1,6-diphosphate[J].Suegery,1987,102:515-525.
122 Wabb WR.Metabolic effects of fructose diphosphate in hypoxic and states.J Thorac Cardiovasc Surg,1984,88(5Pt2):863-866.
123 范国辉.1,6二磷酸果糖[J].中华麻醉学杂志,1995,15:45-47.
124 赖平,张洪泉,马郁文等.1,6二磷酸果糖对阿酶素心肌损伤防治的实验研究.山东医科大学学报,1997,35:242 243.
125 Romsi P,Kaakinen T,Kiviluoma K,et al.Fructose-1,6-bisphosphate for improved outcome after hypothermic circulatory arrest in pigs[J].J Thorac Cardiovasc Surg,2003,125:686-398.
126 Ramos RC,de Meis L.Glucose 6-phosphate and fructose 1,6-bisphosphate can be used as ATP-regenerating systems by cerebellum Ca~2+-transport ATPas(J).Neurochem,1999;72(1):81-86.
127 李建雄,刘桥义,张翠清等.缺血再灌注不同时期应用1,6-二磷酸果糖对幼兔心脏的保护作用(J).临床麻醉学杂志,2002,18(9):484-486.
128 卢卫新,戴瑞鸿,1,6-二磷酸果糖对组织缺血与缺氧的保护作用.中国临床医学,2002,9(1):91-92.
129 Oz E,Arsakay G.Role of the nitric oxide pathway on ischemia reperfusion injury in an isolated perfused guinea pig heart[J].Gen Pharmacol,2000,34(1):3-7.147
130 Moens AL,Claeys MJ,Timmermans JP,et al.Myocardial ischemia/reperfusion-injury,a clinical view on a complex pathophysiological process.Int J Cardiol,2005,100(2):179-190.
131 Nonami Y,Rao V,Shiono N,et al.Quenching the effects of L-arginine on free radical injuryin cultured cardiomyocytes(J).Surg Today,1998,28(4):379-84.
132 侯文明,郭兰敏,范全心,等.体外循环中应用L-精氨酸防治心肌再灌注损伤的临床研究.临床麻醉学杂志,2001,17:66-68.
133 Riedel BJ,Gal J,Ellis G,et al,Myocardial protection using fructose-1.6-diphosphate during coronary artery bypass graft surgery:a randomized,placebo-controlled clinical trial.Anesth Analg,2004,98:20-29.
134 吕胜,张慈忱.1,6-二磷酸果糖(FDP)对心脏瓣膜置换手术患者脂质过氧化的影响.中国胸心血管外科临床杂志,1996,3:70-72.
135 Rocke DA,Gaffin SL,Wells MT,et al.Endotoxemia associatied with cardiopulmonary bypass.J Thorac Cardiovasc Surg,1987,93:832-837.
136 Gadaleta D,Fahey AL,Verma M,et al.Neutraphil leukotriene generation increases after cardiopulmonary bypass.J Thorac Cardiovasc Surg,1994,108(4):642-647.
137 夏瑞,杨光,郑利民,等.异丙酚对家兔脑缺血-再灌注损伤的保护作用.中华麻醉学杂志,2000,20:233-235.
138 蔡英民,王美纳,薛荣光,等.麻醉剂量异丙酚对大鼠脑缺血-再灌注损伤的保护作用.中华麻醉学杂志,2001,21:160-162.
139 Taniguchi T,Yamamoto K,Ohmoto N,et al.Effects ofpropofol on hemodynamic and inflammatouy response to endotoxemia in rats.Crit Care Med,2000,28:1101-1106.
140 Heine J,Leuwer M,Scheinichen D,et al.Flow cytometry evaluation of the in vitro influence of four in anaesthetics on respiratory burst ofneutrophils.Br J Anesth,1996,77(3):387-392.
141 Mikawa K,Akamatsu H,Nishina K,et al.apropofol inhibits human neutrophil functions.Anesth Analg,1998,87:695-700.
142 Hofbauer R,Frass M,Salfinger H,et al.Propofol reduces the migration of human leukocytes through endothelial cell monolayers.Crit Care Med,1999,27(9):1843-1847.
143 Chang KS,Davris RF.Propofol produces endothelium independent vasdilation and as a Ca2+channel blocker.Anesth Analg,1993,76:24-32.
144 Murphy PG,Myers PS,Davise MJ,et al.The mantioxidant potential ofpropofol(2,6-Dissopropylphenol).Br J Anesth,1992,68:613-618.
145 Green TR,Bennett SR,Nelson VM,et al.Specificity and properties of propofol as an antioxidant free radical scavenger.Toxicol Appl Pharmacol,1994,129:163-169.
146 张诗海,姚尚龙。异丙酚在成人体外循环中抗氧化效应的研究.中华麻醉学杂志,2000,20:594-596.
147 Galley HF,Dubble AM,Webster NR.The effect of midazolam and propofol on interleukin-8from human polymorphonuclear leukocytes.Anesth Analg,1998,86:1289-1293.
148 Gilliland HE,Armstrong MA,Carabine U,et al.The choice of anesthestic maintenance technique influences the anti-inflammatory cytokine response to abdominal surgery.Anesth Analg,1997,85:1394-1398.