| Objective To study the myocardial protection of sevoflurane preconditioning by suppress ischemia-reperfusion injury (IRI) and systemic inflammatory response in rheumatic heart disease patients with valve replacement surgery in cardiopulmonary bypass (CPB), and explore the mechanism.Methods Twenty patients (ASAⅡ～Ⅳ) scheduled for cardiac valve replacement surgery in CPB were randomly divided into two groups:Control group (group C, n=10) and sevoflurane preconditioning group (group S, n=10). Two groups was induced with intravenous injection of midazolam (0.08～0.12mg·kg-1), etomidate(0.2～0.3mg·kg-1),fentanyl (5～10μg·kg-1) and pipecuronium (0.1mg·kg-1) and control of breath to maintain PETCO2 at 35～40mmHg after endotracheal intubation. Anesthesia maintained with intermittent i.v. boluses of midazolam, fentanyl and pipecuronium; bispectral index (BIS) maintained between 40 and 60. In group S, 1vol% sevoflurane was continuously inhaled from the beginning of operation to the beginning of CPB, and no anesthetic was inhaled in group C. Plasma levels of Inflammatory factors (including of tumor necrosis factor (TNF-a), interleukin-6, interleukin-8),creatine kinase isoenzyme (CK-MB) and cardiac troponin I (cTnI) were measured at beginning of operation (T1), immediate after aorta clamping (T2), immediate (T3) and 30min (T4) after aorta unclamping,2h (T5),6h (T6),12h (T7) and 24h (T8) after discontinuation of CPB. And record the duration of CPB, aortic cross-clamping and operation. Cardiovascular active drug, cardiac resuscitation situation, and wound drainage of 24h post-operation was recorded too.Results 1. There is no significant difference between two groups of patient's age, weight, sex ratio, preoperative cardiac function grading, cardiothoracic ratio, anesthetic dosage, CPB time, aortic cross-clamping (ACC) time, operative time and surgical method (P> 0.05).2. Serum levels of cytokines:①Compare with T1, TNF-a increased at T2, peaked at T4 (P<0.05), and recovered at T8. The increased amplitude of group C was significantly higher than group S (P<0.001 at T2-T5, and P<0.05 at T6).②Compare with T1, IL-6 increase at T2, peaked at T3 (P<0.05), and still high at T8. The increased amplitude of group C was significantly higher than group S (P＜0.001 at T2-T7, and P <0.05 at T8).③Compare with T1, IL-8 increased at T2, peaked at T4 (P<0.05), and recovered at T8. The increased amplitude of group C was significantly higher than group S (P＜0.001 at T2-T8).3. Plasma level of CK-MB and cTnI:①Compare with T1, CK-MB increased at T2, peaked at T6 (P<0.05), and didn't recover at Tg.There were no significant differences in plasma levels of CK-MB between two groups at T1-T7 (P> 0.05).②Compare with T1, cTnI increased at T2, peaked at T6 (P<0.05), and didn't recover at T8. The increased amplitude of group C was significantly higher than group S (P <0.001 at T2-T8).4. Clinical observation:In group C,4 cases auto re-jump,6 cases re-jump by defibrillation. After re-jump,2 cases with ventricular tachycardia and 1 case with premature ventricular contractions,1 case with ventricular fibrillation after re-jump; 6 cases use of dopamine or dobutamine after re-jumping. In group S,8 cases auto re-jump,2 cases re-jump by defibrillation. After re-jump, no cases appear arrhythmia and use of vasoactive drugs. The rate of auto re-jump in group S was higher than in group C (P＜0.05). Wound drainage volume postoperative 24h in group C was significantly exceed than group S (P＜0.05). Conclusion 1. In CPB period of rheumatic heart disease patients undergoing valve replacement surgery, plasma levels of inflammatory factor, Including TNF-a, IL-6, IL-8 and CK-MB, cTnI were significantly increased, indicating CPB leads myocardial damage and systemic inflammatory response.2. In CPB period of rheumatic heart disease patients undergoing valve replacement surgery, there is certain damage to myocardial cells and cardiac function. Breathe in sevoflurane before the aortic cross-clamping can reduce the systemic inflammatory response and effectively inhibit the myocardial ischemia/reperfusion injury. There is a certain effect of myocardial function protect.
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