JP2768799B2 - Cardioplegic solution - Google Patents

Description

Description: TECHNICAL FIELD The present invention relates to a myocardial protective solution. More specifically, the present invention relates to a myocardial protective solution to which succinate ions have been added.

(Problems to be Solved by the Prior Art and the Invention) Aortic occlusion is an essential means in open heart surgery, especially in left heart surgery. On the other hand, in other open heart surgery, bloodlessness and static visual field due to aortic occlusion also provide a very favorable environment in terms of safety and reliability. At that time, myocardial protection for the purpose of preventing ischemic injury at the time of interruption of coronary blood flow during surgery has been making great progress along with elucidating the pathology of myocardial ischemia. Myocardial protection based on that rationale has led to a dramatic improvement in surgical outcomes in the field of cardiac surgery, and has become an indispensable aid in cardiac surgery along with hypothermia and extracorporeal circulation.

Due to the disruption of coronary blood flow, the myocardium rapidly transitions to anaerobic metabolism, which has extremely poor energy production efficiency. The accumulation of lactate and hydrogen ions as metabolites causes a decrease in tissue pH, while mitochondria are impaired by the accumulation of fatty acid esters resulting from suppression of fatty acid oxidation, leading to suppression of energy production and depletion. I do. Eventually, the energy-dependent cell membrane damage, that is, the ion balance ability and cell volume maintenance ability of the cell membrane is impaired, and sodium ions and water enter the cells with abnormal influx of calcium ions into the cells, resulting in irreversible ischemic damage.

The concept underlying the myocardial protection method for preventing myocardial ischemic injury is “conservation of high-energy substances in the myocardium during ischemia”, and the current myocardial protection method is intermittent with myocardial local cooling. It is mainly used in combination with a multidose cardioplegia method in which a cardioplegic solution is administered to a patient. The purpose is to eliminate myocardial electromechanical activity immediately after aortic blockage and obtain a state of cardiac arrest under low temperature to achieve myocardial construction and energy conservation.

Myocardial protective fluid (cardiac arrest fluid) is a drug mainly consisting mainly of potassium ions, which is used in the myocardial protection law to protect the myocardium in anoxic condition when the aorta is blocked by obtaining electrical and mechanical arrest of the heart. One. As described above, bloodlessness and a static visual field can be obtained during cardiac surgery, and finer and more accurate surgical operations can be performed, which leads to improvement in surgical results, as described above.

The first cardioplegic solution was Melros
e) et al. dilute 2 ml of 25% potassium citrate 10-fold in extracorporeal circulation in 1955 (final potassium concentration: 245 mEq / l) and inject from the aortic root for 15 minutes at room temperature and mildly cold aorta. It begins with the announcement that shutoff is possible. Representative examples of the myocardial protective solution developed thereafter include the following.

Bretschneider solution Sodium chloride 0.70 g / l 12.0 mmol / l potassium chloride 0.75 10.0 magnesium chloride 0.41 2.0 procaine hydrochloride 2.00 7.4 mannitol 43.50 239.0 (pH 5.5 to 7.0; osmotic pressure 320 mOsm / kg) St. Thomas Hospital (St. Thomas Hospital) solution Sodium chloride 5.35 g / l 91.6 mmol / l sodium bicarbonate 2.10 25.0 potassium chloride 1.10 14.8 magnesium sulfate 0.30 1.2 magnesium chloride 3.05 15.0 potassium dihydrogen phosphate 0.16 1.2 calcium chloride 0.18 1.2 procaine hydrochloride 0.27 1.0 (pH 7.4) ; Osmotic pressure 300mOsm / kg) Modified Krebs liquid (Kawakami liquid) At the time of use, add the following agents and cool to around 4 ° C before use: Chlorpromazine 15mg / l ATP 40 β-methasone 4 heparin 25 regular insulin 50 units glycol-insulin-potassium solution (GIK solution) 5% glycol solution 1000ml regular insulin 20 units Potassium chloride 20mEq 7% sodium bicarbonate 10ml (pH 7.8; osmotic pressure 334mOsm / kg) By using such a myocardial protection method and myocardial protective solution, compare the operation performed under aortic occlusion for more than 3 hours It has been conducted in a safe manner. However, patients with higher myocardial dysfunction than before surgery or those with multiple organ disease due to prolonged heart failure may have low post-operative low output syndrome (LOS) or multiple organ failure (multiorgan failure). failure). Therefore, there is a demand for a more complete myocardial protection method, that is, development of a myocardial protective solution that prolongs the safe time of myocardial ischemia and does not decrease postoperative cardiac function.

On the other hand, after cardiac surgery, the ischemic myocardium recovers by releasing the aortic blockade, but reperfusion after myocardial ischemia sometimes causes even more severe damage (reperfusion injury). This is caused mainly by inadvertent reperfusion due to membrane changes during ischemia, causing abnormal calcium influx, sodium, and water influx into cells within 2 to 3 minutes at an early stage. It is said. Furthermore, it is said that the membrane that has suffered ischemic injury is also damaged by oxygen radicals during reperfusion. For this reason, a cautious blood flow resumption method requiring a high level of technique to prevent reperfusion injury has been developed.

From the above, there is a strong demand for the development of a myocardial protective solution that suppresses myocardial damage during ischemia as much as possible, suppresses reperfusion injury, and improves recovery of postoperative cardiac function.

(Means for Solving the Problems) Under these circumstances, the present inventors have conducted intensive studies, and as a result, have found that the above-mentioned problems can be solved by adding succinate ions to a myocardial protective solution. It was completed. That is, the present invention provides a myocardial protective solution characterized by adding succinate ion to a myocardial protective solution containing sodium ion, potassium ion, calcium ion and optionally fudosugar; 50-200 mmol /
l, a cardioplegic solution containing 10 to 50 mmol / l potassium ion, 0.02 to 1 mmol / l calcium ion, 10% (w / v) or less glucose, and 3 to 30 mmol / l succinate ion; And a cardioplegic solution kit comprising the above cardioplegic solution and an alkaline buffer.

Examples of the alkaline buffer used in the above-mentioned myocardium protective solution kit include a carbonate buffer and a tromethamine (THAM) buffer. As a preferred alkaline buffer, hydrogen carbonate ion is 100 to 1100 mmol / l, preferably 500 to
It is an aqueous solution containing 1000 mmol / l (for example, an 8.4% aqueous solution of sodium bicarbonate), and is prepared so that the hydrogencarbonate ion content is 1 to 50 mmol / l when mixed with the cardioplegic solution at the time of use.

The components other than succinate ion among the components of the above-mentioned myocardial protective solution are those commonly used in conventional myocardial protective solutions. For example, sodium chloride,
Potassium chloride and potassium dihydrogen phosphate are commonly used as potassium ion sources, and calcium chloride and the like are commonly used as calcium ion sources. In addition, metal ions of succinate which give the following succinate ions as these ion sources are also one of them.
Part can be constituted.

Specific examples of compounds that provide succinate ions include:
Succinic acid, sodium succinate, potassium succinate, calcium succinate, magnesium succinate and the like are preferable, but not limited thereto. Succinate ion, by which the above composition, myocardial ischemia, and reduced coenzyme Q ₁₀ to enhance the antioxidant action in cells, and have been suppressed reperfusion injury, of preventing the deterioration of cardiac function Show the effect.

In addition, as a preferable composition range of the myocardial protective solution of the present invention, sodium ion is 60 to 140 mmol / l, potassium ion is 15 to 40 mmol / l, and calcium ion is 0.05 to
0.5 mmol / l, glucose 2-5% (w / v), and succinate ion 5-20 mmol / l; bicarbonate ion is present in the kit of the invention at 500-1000 mmol / l. It is preferred to include it in a concentration.

The myocardial protective solution of the present invention is prepared in the form of a liquid preparation in which the above-mentioned glucose and each electrolyte ion are blended so as to be in the above-mentioned specific range, and can be prepared using the same method as a general injection. That is, for example, a predetermined amount of accurately weighed glucose, sodium chloride, potassium chloride, calcium gluconate (or calcium chloride) and sodium succinate are dissolved in distilled water for injection, and a small amount of distilled water for injection is added thereto. To a predetermined liquid volume. Then, an appropriate amount of activated carbon is added and stirred for 10 to 30 minutes. After the activated carbon is filtered off with a filter paper, it is purified and filtered with a 0.45 μm membrane filter. The obtained filtrate is filled in a container, closed, and 10
Heat sterilize with high pressure steam at 0-120 ° C for 10-60 minutes. Immediately before use, an appropriate amount of an alkali buffer, such as a sodium hydrogen carbonate solution, separately prepared by the same operation is added to the thus obtained solution to adjust the pH to 7.0 to 8.5, preferably 7.4 to 8.0.
The osmotic pressure at this time is 300 to 500 mOsm / l, preferably 330 to 400
mOsm / l.

The cardioplegic solution of the present invention can be used alone or, if necessary, as other drugs having cardioprotective action, such as lidocaine, procaine, steroids, magnesium ions, calcium antagonists (nifedipine, verapamil hydrochloride, diltiazem hydrochloride, etc.) ), anti-proteases, coenzyme Q _10, insulin to enhance glucose utilization, membranes with a stabilizing effect prostaglandin E ₁ or the like may be used in addition. Regarding the method of administering (or perfusion) the myocardial protective solution cooled to 4 ° C or less, as soon as possible after blocking the aorta, the aortic root proximal to the aortic block is 10-15 ml / kg (in children) according to the body weight. 15-20 ml / kg) is injected using a cannula, or after incision of the right atrium, a catheter with a balloon is placed in the coronary sinus and injected. The method of administering only the first time at the time of aortic blockade is hardly used at present, and the intermittent coronary perfusion method, which is administered every predetermined time, is widely used. Therefore, in the present invention, 5 to 8 ml / kg at an interval of every 20 to 30 minutes after the first administration.
(7-10 ml / kg for children). It can also be administered by continuous perfusion at a low flow rate. According to the myocardial protective solution of the present invention in which succinate ions are added to a conventional myocardial protective solution, succinic acid acts on ubiquinone in the mitochondrial electron transport system to reduce ubiquinone, thereby suppressing the production of oxygen radicals. Reduces mitochondrial dysfunction and promotes post-reperfusion recovery of ATP, creatine phosphate (CP) and other high-energy phosphate compounds (HEP) in myocardial tissue, and improves postoperative cardiac function recovery It is possible to increase.

Next, the present invention will be described in more detail based on examples, but the present invention is not limited thereto.

Example 1 Glucose (272.7 g), sodium succinate (16.4
g), sodium chloride (29.5 g), potassium chloride (15.1 g)
g) and calcium gluconate (0.45 g) were dissolved in about 9.5 l of distilled water for injection. After complete dissolution, distilled water for injection was further added to make the total volume exactly 10 l. Activated carbon (10 g) was added to this aqueous solution, and after stirring for 20 minutes, the activated carbon was filtered off with a filter paper, and the filtrate was purified and filtered with a membrane filter having a pore size of 0.45 μm. 495 ml of the purified filtrate was accurately filled into a vial, sealed, and sterilized by heating with high-pressure steam at 110 ° C. for 40 minutes. Thus, the myocardial protective solution of the present invention (495 m
l), and use a 8.4% NaHCO ₃ aqueous solution (Meiron 84;
5 ml of Otsuka Pharmaceutical Co., Ltd.) was used. Table 1 shows the composition of the obtained myocardial protective solution.

Example 2 Glucose (254.2 g), sodium succinate (21.07)
g), sodium chloride (29.51 g), potassium chloride (11.30
g) and calcium chloride (dihydrate) (0.15 g)
A myocardial protective solution of the present invention was obtained in the same manner as in Example 1 except that the amount of injection distilled water used was 10 l. 495 ml immediately before use
5 ml of an 8.4% NaHCO ₃ aqueous solution (Meiron 84; manufactured by Otsuka Pharmaceutical Co., Ltd.) was used. Table 2 shows the composition of the obtained myocardial protective solution.

Example 3 Glucose (181.8 g), sodium succinate (32.7
g), sodium chloride (59.0 g), potassium chloride (22.6 g)
g) and calcium chloride (dihydrate) (0.74 g)
In the same manner as in Example 1, a myocardial protective solution of the present invention was obtained. Immediately before use, 5 ml of 7% NaHCO ₃ aqueous solution (Meiron: manufactured by Otsuka Pharmaceutical Co., Ltd.) was added per 495 ml for use. Table 3 shows the composition of the obtained myocardial protective solution.

Example 4 Glucose (363.6 g), sodium succinate (40.9
g), sodium chloride (17.7 g), potassium chloride (15.1 g)
g) and calcium chloride (dihydrate) (0.15 g)
A myocardial protective solution of the present invention was obtained in the same manner as in Example 1. Immediately before use, an 8.4% NaHCO ₃ aqueous solution (Meiron 8 per 495 ml)
4: Otsuka Pharmaceutical Co., Ltd.) 5 ml was used. Table 4 shows the composition of the obtained myocardial protective solution.

Test Example The myocardial protective solution prepared in Example 1 was used as a test solution, and the myocardial protective solution prepared in the same manner as in Example 1 using the composition shown in Table 5 below was used as a comparative solution. The comparative solution did not contain sodium succinate. Therefore, the amount of sodium chloride was increased to make the sodium ion concentration the same as that of the test solution, and the amount of glucose was reduced to adjust the osmotic pressure.

[Test method] After preparing the above-mentioned test solution, comparative solution and Krebs-Henseleit perfusion solution, the test was performed by the following method. In addition, WKA male rats (body weight 250-
350 g) was used.

Anesthesia was performed by intraperitoneal injection of sodium pentobarbital (100 mg). After anesthesia, heparin sulfate (2 mg) was intravenously injected into the femoral vein. The chest was opened by a median sternotomy, and the heart was rapidly removed and immersed in Krebs-Henseleit buffer previously ice-cooled.

After making an incision in the main pulmonary artery to facilitate outflow of coronary perfusate, a perfusion device via the aorta [Tominaga
J. Surg. Res., 34 , 111, (1983)], immediately perform Langendorff perfusion (coronary perfusion from the aortic side, and the left ventricle is substantially free of work, ie, left The ventricle has begun an inactive heart condition that is not functioning as a pump. Thereafter, a left atrial cannula was inserted into the left atrium from the right pulmonary vein. After 10 minutes of Langendorff perfusion, the left atrial line is released and the working mode (working
mode) Perfusion (perfusate perfuses the coronary vessels from the left atrium to the left ventricle, partly, and converts partly into a working heart state in which the perfusate is pumped out against the aortic afterload). And 10 more
A minute pre-ischemic perfusion was performed. Thereafter, both the aorta and the left atrial line were closed, and a myocardial protective solution (6 ml) was immediately injected into the root of the aorta from the side branch over 1 minute. Thereafter, the heart was subjected to complete ischemia for 25 minutes. Reperfusion was begun with Langendorff perfusion, converted to working mode perfusion 5 minutes later, and performed working mode perfusion for 25 minutes. The left atrial preload was 16 cmH ₂ O and the aortic afterload was 80 cmH ₂ O.

Cardiac function recovery rate 30 minutes after reperfusion with respect to pre-ischemic value (aortic flow, cardiac output)
And myocardial tissue adenine nucleotide amounts were used.

Cardiac function was measured immediately before the onset of ischemia and 30 minutes after reperfusion (FIG. 1). The aortic flow rate was determined by measuring the flow rate flowing out of the aortic reservoir over time. Cardiac output was calculated as the sum of coronary perfusion and aortic perfusion.

Sampling of myocardial tissue adenine nucleotides and high-energy phosphate compounds was performed immediately before the start of ischemia, after the end of ischemia, and at 30 minutes after reperfusion (FIGS. 2 and 3). The tissue was pinched with Wollenberger forceps, previously cooled to -196 ° C in liquid nitrogen, immersed in liquid nitrogen, rapidly cooled and crushed. Quantification of adenine nucleotides was performed by high performance liquid chromatography [Kamiike et al., J. Biochem. 1982, 91, 1349]. T
AN indicates the sum of ATP, ADP and AMP. Creatine phosphate (CP) was measured by an enzymatic method [Methods of
Enzymatic Analysis (Methods of enzymat)
ic analysis), New York, Academic Press, 1
975]. The high energy phosphate compound (HEP) is represented by the following formula: HEP = 2ATP + ADP + CP The results are shown in FIG. 1, FIG. 2 and FIG. In the figure, the test group shows a group injected with a test solution as a myocardial protective solution during cardiac ischemia, and the comparative group shows a group injected with a comparative solution.
Regarding the recovery rate of the heart function 30 minutes after reperfusion, the test group showed a significantly better recovery rate than the comparative group in terms of aortic flow and cardiac output, as is apparent from FIG.

As is clear from FIG. 2, ATP and TAN showed significantly higher values in the test group than in the comparative group at 30 minutes after reperfusion. When comparing TAN 30 minutes after reperfusion,
In the comparative group, it was further decreased than at the end of ischemia, but not in the test group.

As for creatine phosphate (CP) and high energy phosphate compound (HEP), as is clear from FIG.
At 30 minutes after reperfusion, the test group showed a significantly higher value than the comparative group.

[Brief description of the drawings]

FIG. 1 shows the aortic flow rate and heart rate 30 minutes after reperfusion when the myocardial protective solution of the present invention (test group) and the conventional myocardial protective solution (comparative group) were injected during ischemia of an isolated rat heart. FIG. 2 is a graph showing the recovery rate of output, FIG. 2 is a graph showing ATP and TAN amounts immediately before the onset of ischemia, at the end of ischemia and 30 minutes after reperfusion in the test group and the comparative group, and FIG. FIG. 4 is a graph showing the amounts of creatine phosphate (CP) and high-energy phosphate compound (HEP) in a test group and a comparative group immediately before the start of ischemia, at the end of ischemia, and 30 minutes after reperfusion.

──────────────────────────────────────────────────続 き Continuing on the front page (72) Inventor Kazuhiko Kinoshita 2-1-601 Kuromon, Chuo-ku, Fukuoka City, Fukuoka Prefecture (72) Inventor Ryuji Tominaga 5-6-1-1-203 Nagasumi, Fukuoka City, Fukuoka Prefecture (72) Inventor Masato Sakamoto 5-11-2-406, Hakozaki, Higashi-ku, Fukuoka City, Fukuoka Prefecture (72) Inventor Yasutaka Ueno 867-330, Norimatsu, Yawata-nishi-ku, Kitakyushu City, Fukuoka Prefecture (58) Field surveyed (Int.Cl. ⁶ , DB name) A01N 1 / 02

Claims (6)

(57) [Claims] 1. A cardioplegic solution to which succinate ions are added. 2. The cardioplegic solution according to claim 1, wherein succinate ion is added to the cardioplegic solution containing sodium ion, potassium ion, calcium ion and optionally glucose. 3. The method according to claim 1, wherein the sodium ion is 50 to 200 mmol / l,
Potassium ion 10-50 mmol / l, calcium ion 0.02-1 mmol / l, glucose 10% (w / v) or less,
The myocardial protective solution according to claim 1 or 2, which contains succinate ions in an amount of 3 to 30 mmol / l. 4. A myocardial protective solution kit comprising the myocardial protective solution according to claim 1, (2) or (3) and an alkaline buffer. 5. The kit according to claim 4, wherein the alkaline buffer is a bicarbonate ion-containing aqueous solution. 6. An alkaline buffer having a bicarbonate ion concentration of 10%.
The kit according to claim 5, wherein the amount is 0 to 1100 mmol / l.