中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

小儿法四根治术后血流动力学评估:两种方式对比研究

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目的 探讨法洛四联症婴幼儿术后通过超声心动图和 Mostcare 监护仪对血流动力学的评估应用。 方法 63 例法洛四联症患儿均行一期根治手术,其中 19 例采用牛心包做跨环补片重建右室流出道,44 例采用非跨环补片处理流出道。所有病例术后即刻(T 0),8 h(T 1),12 h(T 2),24 h(T 3)和 48 h(T 4)记录超声心动图和 Mostcare 监护仪参数,同时检测血脑利钠肽协助佐证,研究两种监测方法的参数在法四根治术后的变化趋势及相关性。 结果 左室射血分数在 T 1 时(43.49%±3.82%)低于 T 0 时(48.29%±4.55%)、T 2 时(45.83%±3.69%)、T 3(53.76%±4.43%)时和 T 4 时(53.76%±4.43%,P<0.05)。心指数在 T 1 时[(1.85±0.35)L/min·m2]低于 T 0 时[(2.11±0.38)L/min·m2]、T 2 时[(2.07±0.36)L/min·m2]、T 3[(2.42±0.37)L/min·m2]时和 T 4 时[(2.82±0.42)L/min·m2P<0.05]。心脏循环效率在 T 1 时(0.19±0.05)低于 T 0 时(0.22±0.06)、T 2 时(0.22±0.05)、T 3(0.28±0.06)时和 T 4 时(0.34±0.06,P<0.05)。右心室两腔心切面面积变化分数在 T 1 时(23.17±3.11)低于 T 0 时(25.81±3.74)、T 2 时(25.38±3.43)、T 3(30.60±4.50)时和 T 4 时(36.94±5.85,(P<0.05)。脉压变异度在 T 0 时(18.76±3.58)高于 T 1 时(14.81±3.32)、T 2 时(12.44±2.94)、T 3(10.39±2.96)时和 T 4 时(9.18±1.92)(P<0.05)。血脑利钠肽在 T 1 时[(846.67±362.95)pg/ml]高于 T 0 时[(42.60±18.06)pg/ml]、T 2 时[(730.95±351.09)pg/ml]、T 3[(510.98±290.39)pg/ml]时和 T 4 时[(364.41±243.56)pg/ml] (P<0.05)。跨环补片组的左室射血分数、心脏循环效率和心指数与非跨环补片组差异无统计学意义(P>0.05);跨环补片组的右心室两腔心切面面积变化分数在各时点均明显低于非跨环补片组(P<0.05);血脑利钠肽、脉压变异度在跨环补片组明显高于非跨环补片组(P<0.05)。左室射血分数与心指数(r=0.637,P=0.001)、心脏循环效率(r=0.462,P=0.001)呈明显正相关,与血脑利钠肽(r=–0.419,P=0.001)呈明显负相关。 结论 两种方法均可准确反映心功能状态,Mostcare 与超声心动图一致性良好;采用跨环补片处理右室流出道者对右室收缩功能影响更大;Mostcare 监护仪可以实时、连续、准确的指导法四根治术后的血流动力学管理。

Objective To explore the hemodynamic assessment after radical surgery in pediatric with tetralogy of Fallot by both echocardiography and Mostcare monitor. Methods Sixty-three children with tetralogy of Fallot underwent primary repair. There were 19 patients who underwent transannular patch reconstruction of the right ventricular outflow tract while 44 patients retained the pulmonary valve annulus. The echocardiography and Mostcare monitor parameters were recorded and test brain natriuretic peptide to assist certificate at the time points of 0, 8, 12, 24 and 48 hours after operation (T 0, T 1, T 2, T 3, T 4). To analyze their correlations and the change trand at different time point after radical surgery. Results The left ventricular ejection fraction at T 1 time point(43.49±3.82)was lower than T 0 (48.29±4.55), T 2 (45.83±3.69), T 3 (53.76±4.43) and T 4 (53.76 ± 4.43) (P<0.05). The cardiac index at T 1 time point(1.85±0.35 L/min·m2) was lower than T 0 (2.11±0.38 L/min·m2), T 2 (2.07±0.36 L/min·m2], T 3 (2.42±0.37 L/min·m2) and T 4 (2.82±0.42 L/min·m2, P<0.05). The cardiac circulation efficiency at T1 time point(0.19±0.05)was lower than T 0 (0.22 ±0.06), T 2 (0.22±0.05), T 3 (0.28±0.06)and T 4 (0.34±0.06,P<0.05). The right ventricular two-chambers view fraction area change at T 1 (23.17±3.11) was lower than T 0 (25.81±3.74), T 2 (25.38±3.43), T 3 (30.60±4.50) and T 4 (36.94±5.85) (P<0.05). The pulse pressure variability was the highest at T 0 (18.76±3.58), followed by T 1 (14.81±3.32), T 2 (12.44±2.94), T 3 (10.39±2.96), and T 4 (9.18±1.92) in turns(P<0.05). The blood brain natriuretic peptide was higher at T 1 (846.67±362.95 pg/ml) than T 0 (42.60±18.06 pg/ml), T 2 (730.95±351.09 pg/ml), T 3 (510.98±290.39 pg/ml) and T 4 (364.41±243.56 pg/ml,P<0.05). There was no significant difference in left ventricular ejection fraction, cardiac circulation efficiencyand heart index between the two groups (P>0.05). The right ventricular two-chambers view fraction area change of transannular patch group was significantly lower than non-transannular patch group at each time point (P<0.05). The blood brain natriuretic peptide and pulse pressure variability were significantly higher of transannular patch group than the non-transannular patch group, the difference was statistically significant (P<0.05). Left ventricular ejection fraction was positively correlated with cardiac index (r=0.637, P=0.001) and cardiac circulation efficiency (r=0.462, P=0.001) while wassignificantly negatively correlated with blood brain natriuretic peptide (r=–0.419, P=0.001). Conclusion Both methods can accurately reflect the state of cardiac function. Mostcare have a good consistency with echocardiography. Using transannular patch to recontribute right ventricular outflow tract inoperationtook more influence on right ventricular systolic function. The Mostcare monitorcan guide the hemodynamic management after surgery in real-time, continuously and accurately.

关键词: 法洛四联症; Mostcare 监护仪; 超声心动图; 血流动力学

Key words: Tetralogy of Fallot; Mostcare monitor; echocardiography; hemodynamic

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