摘要
目的探讨法洛四联症(TOF)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。方法回顾性分析2016年2月至2018年6月在我院心脏外科接受一期根治术治疗63例TOF患儿的临床资料,其中男34例、女29例,年龄6～24(9.82±5.77)个月。19例采用牛心包做跨环补片重建右室流出道(跨环补片组),44例采用非跨环补片处理流出道(非跨环补片组)。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TOF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时(53.76%±4.43%)和T 4时(60.54%±3.23%,P<0.05)。心指数在T 1时[(1.85±0.35)L/(min·m~2)]低于T 0时[(2.11±0.38)L/(min·m~2)]、T 2时[(2.07±0.36)L/(min·m~2)]、T 3时[(2.42±0.37)L/(min·m~2)]和T 4时[(2.82±0.42)L/(min·m~2),P<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时(0.28±0.06)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时(30.60%±4.50%)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时(10.39%±2.96%)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时[(510.98±290.39)pg/ml]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、准确地指导TOF根治术后的血流动力学管理。
Objective To explore the hemodynamic assessment after radical surgery in children with tetralogy of Fallot(TOF) by both echocardiography and Mostcare monitor. Methods Clinical data of 63 children with TOF who underwent radical surgery in our hospital from February 2016 to June 2018 were retrospectively analyzed, including 34 males and 29 females, aged 6-24(9.82±5.77) months. There were 19 patients undergoing transannular patch reconstruction of the right ventricular outflow tract(a transannular patch group) while 44 patients retained the pulmonary valve annulus(a non-transannular patch group). The echocardiography and Mostcare monitor parameters were recorded and brain natriuretic peptide was tested at the time points of 0, 8, 12, 24 and 48 hours after operation(T 0, T 1, T 2, T 4) to analyze their correlations and the change trend at different time points after radical surgery. Results The left ventricular ejection fraction at T 1(43.49%±3.82%) was lower than that at T 0(48.29%±4.55%), T 2(45.83%±3.69%), T 3(53.76%±4.43%) and T 4(60.54%±3.23%, P<0.05). The cardiac index at T 1(1.85±0.35 L·min-1·m~(-2)) was lower than that at T 0(2.11±0.38 L·min-1·m~(-2)), T 2(2.07±0.36 L·min-1·m~(-2)), T 3(2.42±0.37 L·min-1·m~(-2)) and T 4(2.82±0.42 L·min-1·m~(-2),P<0.05). The cardiac circulation efficiency at T1(0.19±0.05) was lower than that at 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 that at 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%, P<0.05). The blood brain natriuretic peptide was higher at T 1(846.67±362.95 pg/ml) than that at 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 efficiency and heart index between the two groups(P>0.05). The right ventricular two-chambers view fraction area change of the transannular patch group was significantly lower than that of the nontransannular patch group at each time point(P<0.05). The blood brain natriuretic peptide and pulse pressure variability of the transannular patch group were significantly higher than those of the non-transannular patch group(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 was significantly 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 monitor has a good consistency with echocardiography. Using transannular patch to recontribute right ventricular outflow tract in operation has more influence on right ventricular systolic function. The Mostcare monitor can guide the hemodynamic management after surgery in real time, continuously and accurately.
引文
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