右心室形态和功能对婴幼儿法洛四联症矫治术后早期心动过速的预测价值

Value of right ventricular morphology and function on predicting early tachyarrhythmia after surgical rectification of tetralogy of Fallot in infants

目的探讨右心室形态和功能对婴幼儿法洛四联症（TOF）矫治术后早期心动过速的预测价值。方法选择2009年1月至2015年7月于首都医科大学附属北京安贞医院小儿心脏中心住院行TOF矫治术的患儿363例，术后24h内超声心动图测定患儿右心室射血分数（RVEF）和右心室流出径（RVOT ID），术后持续心电监护，描记常规肢体导联心电图。根据术后有无早期室上性心动过速（ESVT）和早期室性心动过速（EVT）发作分为早期心动过速组和非早期心动过速组。比较2组RVEF和RVOTID差异，对RVEF和RVOT ID进行危险分层，以RVEF≥40％和RVOT ID≤2cm／m2作为基础参考值，采用Logistic回归分析评价RVEF和RVOT ID对早期心动过速的影响。采用受试者工作特征曲线评价RVEF和RVOT ID对TOF术后早期心动过速的预测价值。结果早期心动过速组22例（ESVT19例、EVT3例）；非早期心动过速组341例。2组一般资料比较，差异无统计学意义（P〈0．05）。早期心动过速组RVEF值明显低于非早期心动过速组[（29±12）％比（40±10）％]，RVOT。明显高于非早期心动过速组[（73±19）cm／m2比（46±11）cm／m2]，差异均有统计学意义（均P〈0．05）。Pearson直线相关分析显示RVEF与RVOT ID呈负相关（r=-0．7，P〈0．05）。Logistic回归分析显示：随着RVEF的降低[〉20％～〈40％：比值比（OR）=1．23，95％置信区间（CI）：0．89～1．48，P=0．61；≤20％：OR=1．81，95％CI：1．24～2．45，P=0．01]或RVOT ID值的增加[〉2cm／m2～〈5cm／m2：OR=1．68，95％CI：1．26—2．08，P=0．03；≥5cm／m2：OR=2．74，95％CI：1．75—4．05，P〈0．01]，早期心动过速的发生风险逐渐增高。RVOT ID的曲线下面积为0．82（95％CI：0．76—0．89，P〈0．05），以3．8cm／m2为界值，RVOT ID预测早期心动过速的敏感度和特异度分别为0．83和0．67；RVEF的曲线下面积为0．58（95％CI：0．47—0．72，P=0．21）。结论婴幼儿TOF矫治术后随着RVEF的降低和RVOT ID的增高，早期心动过速发生风险明显增大；RVOT ID对早期心动过速的预测价值优于RVEF，有较高的敏感度和特异度。

Objective To explore the value of fight ventricular morphology and function on predicting early tachyarrhythmia （ET） after surgical rectification of tetralogy of Fallot （TOF） in infants. Methods Totally 363 TOF children 〈 3 years old who underwent surgical rectification of TOF from January 2009 to July 2015 were enrolled. Echocardiography was used to detect the right ventricular ejection fraction （RVEF） and right ventricular outflow tract inner diameter （RVOTID） within 24 h after surgery; electrocardiogram （ECG） and ECG monitoring were performed after surgery. The cases were divided into ET group and non-ET group. Risk stratification was performed for RVEF and RVOTID, Logistic regression analysis was used to evaluate the effects of RVEF and RVOTID on early cardiac tachycardia, taking RVEF≥40% and RVOTID ≤2 cm/m2 as reference value. The predictive value of RVEF and RVOTID on early postoperative tachycardia after rectification of TOF was evaluated by using receiver operating characteristic （ROC） curve. Results There were 22 cases in ET group （ 19 cases of early stage ven- tricular tachycardia, 3 cases of early ventrieular tachycardia） and 341 cases in non-ET group. The baseline data were not significantly different between groups （ P 〉 0.05 ）. The RVEF in ET group was significantly lower than that in non-ET group [ （29 ± 12）% vs （40 ± 10）% ], the RVOT ID in ET group was significantly higher than that in non-ET group [ （73 ±19 ） cm/m： vs （ 46 ± 11 ） cm/m2 ] （ P 〈 0. 05 ）. Pearson linear analysis showed that RVEF was negatively correlated with RVOT ID （ r = - 0. 7, P 〈 0. 05）. Logistic analysis showed that risk of ET increased as RVEF decreased [ 〉20%- 〈40% ： odds ratio （OR） = 1.23, 95% confidence interval （CI） ： 0. 89- 1.48, P=0.61; ≤20%： OR=1.81, 95% CI： 1.24-2.45, P=0.01] and RVOTID increased [ 〉2 cm/m2-〈 5 cm/m2： OR=1.68, 95%CI： 1.26-2.08, P=0. 03; ≥5 cm/m2： OR =2.74, 95%CI： 1.75-4.05, P〈0.01]. ROC showed that the area under curve （AUC） for RVOTID was 0. 82 （95% CI： 0. 76-0. 89, P 〈 0. 05 ）, the sensitivity and specificity of predicting ET was respectively 0. 83 and 0. 67, taking 3.8 cm/m2 as cut-off point ; the AUC for RVEF was 0. 58 （95% CI： 0. 47-0. 72, P = 0. 21 ）. Conclusions Decreased RVEF and increased RVOTID are associated with ET after rectification of TOF in infants ; RVOTID has higher sensitivity and specificity on predicting ET compared with RVEF.