心脏移植术后自主和起搏心肌内心电图诊断急性排斥反应的可靠性分析

Reliability of autonomous intramyocardial electrogram and ventricular evoked response to monitor acute allograft rejection after human heart transplantation

目的 探讨心肌内心电图（IMEG）在诊断心脏移植术后急性排斥反应中的作用,并评估其可靠性.方法 2004年6月至2009年3月,对32例心脏移植受者植入永久性心脏起搏器,分析自主IMEG的QRS波幅（以下简称为＂QRS＂）和心室起搏心电图（VER）的T波后支最大斜率（Tslew）变化在诊断急性排斥反应中的作用;同期进行心内膜心肌活检（EMB）,对QRS和Tslew与EMB诊断急性排斥反应进行了对照.结果 共采集IMEG 523例次,同时有自主IMEG、心室起搏VER和EMB数据的41例次,其中病理检查诊断急性排斥反应阳性17例次,阴性24例次;QRS的ROC曲线下面积（AUC）0.7537,敏感度（Se）为88.24%,特异度（Sp）为62.50%,诊断符合率为73.17%;Tslew的AUC为0.9081,Se为94.12%,Sp为87.50%,诊断符合率为90.24%;QRS与Tslew的AUC比较,Tslew优于QRS,差异有统计学意义（χ^2=4.22,P＜0.05）;联合诊断（QRS和Tslew之一阳性诊断为阳性,同时阴性诊断为阴性）AUC为0.7917,Se为100.00%,Sp为58.33%,诊断符合率为75.61%.结论 自主IMEG的QRS、心室起搏VER的Tslew用于诊断心脏移植术后急性排斥反应均是可靠指标,但Tslew优于QRS;联合应用两项指标诊断心脏移植术后急性排斥反应也是可靠指标.

Objective To investigate the reliability of intramyocardial electrogram （IMEG） in monitoring acute rejection after human heart transplantation. Methods From June 2004 to March 2009, 32 patients underwent orthotopic heart transplantations. During the operation telemetric pacemakers were placed under the skin of the body with connected bipolar electrodes implanted into epimyocardium. Postoperative IMEGs, including the autonomous IMEG and ventricular evoked response （VER） were recorded routinely. The endomyocardium biopsy （EMB） was taken routinely and performed once again when positive IMEG results or other positive signs were observed. Results Totally 523 IMEGs has been produced, 41 of VERs were recorded together with autonomous IMEGs and EMBs, in which 17 EMB specimens were confirmed positive and 24 negative. AUC of QRS was 0.7537, Se was 88.24%, Sp was 62. 50%; AUC of Tslew was 0. 9081, Se was 94. 12%, Sp was 87. 50%. QRS and Tslew had significant difference in AUC of ROC, with χ^2 = 4. 22, P〈0. 05; AUC of combined diagnostic index （positive when either QRS or Tslew is positive and negative when both values are negative） was 0. 7917, Se was 100.00%, Sp was 58. 33%. Conclusion QRS amplitude of the autonomous IMEGs, Tslew of VERs and combined diagnostic index are reliable indexes for monitoring acute allograft rejection after human heart transplantation. Furthermore, Tslew has a better prognostic value than QRS.