Objective: To observe the perioperative changes of serum thrombomodulin in patients with and without cardiogenic shock undergoing off-pump coronary artery bypass grafting surgery. Methods: A total of 66 patients with coronary artery disease who underwent off-pump coronary artery bypass grafting surgery between June and December 2015 in our hospital were included in this study.The patients were divided into non-cardiogenic shock group (n=51) and shock group (n=15) according to the absence or presence of cardiogenic shock.The clinical data of the two groups were analyzed.Arterial blood samples were collected immediately after anesthesia, and at 4, 8, 16, 24, 48 and 72 hours after surgery.The levels of serum thrombomodulin were tested with enzyme-linked immunosorbent assay. Results: (1)The prevalence of diabetes was significantly higher (64.7%(33/51) vs. 20.0%(3/15), P<0.01), while prevalence of myocardial infarction was significantly lower (41.2%(21/51)vs. 100%(15/15), P<0.01) in non-cardiogenic shock group than in cardiogenic shock group.(2)The peak plasma creatinine level, troponin I level and creatine kinase MB level were significantly lower in the non-cardiogenic shock group than in the cardiogenic shock group ((88.5±36.7) μmol/L vs. (122.6±71.1) μmol/L, 1.3(0.2, 2.7) μg/L vs. 16.4(5.8, 23.4) μg/L and (18.8±4.7) μg/L vs.(49.3±15.9) μg/L, respectively, all P<0.05). (3)Mechanical ventilation time was significantly longer (11.5 (9.0, 18.0) hours vs. 20.0 (8.5, 82.5) hours, P=0.02), and frequency of intra-aortic balloon pump use (0 vs. 100%, P<0.01) was significantly higher in the cardiogenic shock group than in the non-cardiogenic shock group.(4) Prevalence of atrial fibrillation (5.9%(3/51) vs. 80.0%(12/15)) and myocardial infarction (19.6%(10/51)vs. 93.3%(14/15)) that occurred during and after surgery was significantly lower in the non-cardiogenic shock group than in the shock group(all P<0.01). (5)The serum thrombomodulin concentration was similar among various time point in the non-cardiogenic shock group: 3.30(2.68, 7.44), 4.09(2.95, 7.18), 4.35(2.68, 8.22), 3.50(2.95, 8.00), 3.41(2.60, 5.97), 3.30(2.65, 5.42)and 3.94(2.82, 5.60) μg/L, taken immediately after anesthesia, and at 4, 8, 16, 24, 48 and 72 hours after surgery respectively, and was 2.44(1.97, 2.67), 2.21(1.93, 2.83), 2.64(2.29, 2.67), 2.84(2.26, 2.94), 3.35(2.43, 4.05), 2.76(2.73, 2.97) and 3.81(2.96, 5.96)μg/L respectively, in the cardiac shock group (all P>0.05). The serum thrombomodulin levels at 4 and 8 hours after surgery were higher in the non-cardiogenic shock group than cardiogenic shock group(all P<0.05). Conclusion: Compared with the non-cardiogenic shock group, the peak serum thrombomodulin level appears later and recovers slower in cardiogenic shock patients who underwent off-pump coronary artery bypass grafting surgery.
目的： 观察心原性休克患者非体外循环冠状动脉旁路移植术围手术期血清血栓调节蛋白(TM)水平的变化。 方法： 采用前瞻性研究方法，纳入2015年6至12月在中国医科大学附属第一医院行非体外循环冠状动脉旁路移植术的冠心病患者66例。根据围手术期是否发生心原性休克，将患者分为无心原性休克组(51例)和心原性休克组(15例)。分析两组患者的临床资料，并分别于麻醉后即刻及术后4、8、16、24、48和72 h收集患者的动脉血，采用酶联免疫吸附法测量血清TM水平。 结果： (1)无心原性休克组糖尿病比率高于心原性休克组[64.7%(33/51)比20.0%(3/15)，P<0.01]，而既往心肌梗死病史比率低于心原性休克组[41.2%(21/51)比100%(15/15)，P<0.01]。(2)无心原性休克组术后血清肌酐、肌钙蛋白I和肌酸激酶同工酶(CK－MB)峰值均低于心原性休克组[分别为(88.5±36.7) μmol/L比(122.6±71.1) μmol/L、1.3(0.2，2.7) μg/L比16.4(5.8，23.4) μg/L和(18.8±4.7) μg/L比(49.3±15.9) μg/L，P均<0.05]。(3)无心原性休克组机械通气时间短于心原性休克组[11.5(9.0，18.0) h比20.0(8.5，82.5) h，P＝0.02]，使用主动脉内球囊反搏比率低于心原性休克组[0比100%(15/15)，P<0.01]。(4)无心原性休克组术中及术后发生心房颤动和心肌梗死的比率均低于心原性休克组[分别为5.9%(3/51)比80.0%(12/15)和19.6%(10/51)比93.3%(14/15)，P均<0.01]。(5)无心原性休克组麻醉后即刻及术后4、8、16、24、48和72 h的TM水平分别为3.30(2.68，7.44)、4.09(2.95，7.18)、4.35(2.68，8.22)、3.50(2.95，8.00)、3.41(2.60，5.97)、3.30(2.65，5.42)和3.94(2.82，5.60) μg/L，心原性休克组麻醉后即刻及术后4、8、16、24、48和72 h的TM水平分别为2.44(1.97，2.67)、2.21(1.93，2.83)、2.64(2.29，2.67)、2.84(2.26，2.94)、3.35(2.43，4.05)、2.76(2.73，2.97)和3.81(2.96，5.96) μg/L。无心原性休克组和心原性休克组不同时间点之间的TM水平差异均无统计学意义(P均>0.05)。无心原性休克组术后4和8 h的TM水平均高于心原性休克组(P均<0.05)，两组之间的TM水平在其余时间点差异均无统计学意义(P均>0.05)。 结论： 与无心原性休克患者比较，心原性休克患者非体外循环冠状动脉旁路移植术后血清TM高峰出现迟，恢复慢。.
Keywords: Coronary artery bypass, off-pump; Shock, cardiogenic; Thrombomodulin.