小儿膜周部室间隔缺损封堵术后心电图长期随访

Long-term follow-up of electrocardiogram after transcatheter closure of perimembranous ventricular septal defect in children

目的长期随访儿童经导管介入封堵膜周部室间隔缺损(ventricular septal defect,VSD)后心电图(ECG)各值,了解ECG改变规律及其转归。方法对患膜周部VSD并成功介入封堵的290例患儿进行术后ECG随访。所有患儿术前术后均检查ECG,术后分别于1、3、6个月及1、2、3、5、8年复查ECG,电脑自动测算心率(V)、P-R间期、QRS间期、QT间期及校正的QT(QTc)值,观察心律及ST-T的变化。结果随访时间:1～96个月[平均(40.16±29.2)个月]。行多因素分析发现小儿膜周部VSD引起心电改变的危险因素是年龄在6周岁以内,膜部瘤样VSD,选择封堵器大于VSD直径3mm以上者。封堵术后290例中115例(39.7%)出现各种轻重不等的ECG改变,进入5年以上长期随访的200例中持续ECG改变者43例(21.5%)。但这些患儿均无症状,生长发育良好。随访80例经过应用激素和营养心肌治疗者中仅17例仍存在ECG的改变(21.3%),未经过治疗的35例,持续存在ECG改变者有26例(74.3%)。随访5年以上仍需特别关注并定期随访的ECG改变者有25例(25/200例,12.5%)。持续ECG改变组与术前组及无ECG改变组的各值对比,均有显著差异。对于出现重度房室传导阻滞(AVB)的患儿及时放置临时起搏器以及激素和营养心肌等治疗的病例预后较好。结论本组随访提示封堵膜周部VSD慎重选择封堵器型号至关重要。对封堵术后ECG出现异常改变者,应用激素、果糖和维生素等营养心肌治疗,对心律失常的恢复或缓解有帮助。封堵术后早期发生ECG改变大部分轻微或可恢复,对一些明显的ECG改变,随访中未发现有转为三度AVB并影响患儿生长发育的病例,但对于一些ECG值的改变需要更长期随访以了解其转归和预后。

Objective To observe the long-term follow-up data of electrocardiographic（ECG）changes and prognosis after transcatheter closure of perimembranous ventricular septal defect（VSD）in children.Methods 290 pediatric patients with perimembranous VSD who successfully underwent transcatheter closure were followed up.All patients were checked ECG at 1,3,6,12,24,36,60 and 96 months post procedure.ECG analysis included heart rates,PR interval,QRS duration,QT interval,corrected QT interval,cardiac rhythm and ST-T changes.Results Follow-up time was 1-96 months and mean follow-up time was（40.16±29.2）months.Multiplicity analysis showed that risk factors causing ECG changes included the followings,age less than 6 years,VSD with aneurysm of membranous septum,and choosing too large occluder（more than 3 mm larger than VSD）.During follow-up,115 of 290 cases（39.7%）developed various ECG changes after the procedure,and 43 of 200 cases（21.5%）at five years follow-up still showed ECG changes,but all patients were asymptomatic and had satisfactory growth.Only 17 of 80 cases（21.3%）who had been treated with steroid hormones and prophylactic myocardial nutritional therapy showed ECG changes,while 26 of 35 cases（74.3%）who had not used the above treatments still showed ECG changes.25 cases（25 of 200,12.5%）with persistent ECG changes at five years follow-up required more intensive observation and further follow-up.There were significant differences of ECG changes among the pre-operation group,post-operation group and without ECG changes group.When severe AVB occurred,some cases were implanted the temporary pacemaker,and used steroid hormones and myocardial nutritional therapy,which usually made better prognosis.Conclusions It is very important to choose suitable VSD occluders.If ECG changes occurred after VSD closure,treatments including steroid hormones,fructose and vitamins,et al,should be used as early as possible,which would make benefits for recovery.Most of the ECG changes which appeared earlier after the interventional procedure usually are benign and recruitable.In our study,there are some cases with severe ECG changes,but no cases have changed into three degree AVB nor affected the patients＇growth.However,further follow-up is needed for some cases with persistent ECG changes.