原位心脏移植患者998份心电图分析

Pre- and post-orthotopic heart transplantation electrocardiogram characteristics of 998 patients

目的分析原位心脏移植术后心电图特点及其变化规律，为临床上识别和分析原位心脏移植术后心电图提供一定的依据。方法收集2008年5月至2014年5月华中科技大学附属协和医院110例原位心脏移植患者共998份标准12导联心电图，测量各时间段心电图指标并比较分析其特点。结果原位心脏移植术前平均心率（窦性心律）为（86.9±16.4）次/min，术后平均心率为（100.0±0.4）次/min。Ⅱ导联供体P波振幅术前、术后1个月、术后6年内分别为（0.124±0.069）、（0.054±0.037）和（0.073±0.049）mV，P波时限分别为（111.1±17.2）、（86.9±27.0）和（93.9±17.5）ms，P波的振幅×时限分别为（14.34±9.51）、（5.02±4.03）和（7.00±4.81）mV·ms。110例患者在心脏移植术后，83.64%（92例）患者的心电图有转位，其中，顺钟向转位占76.36%（84例）；99.09%（109例）患者出现窦性心动过速，60.91%（67例）患者出现不完全性右束支传导阻滞。有4份心电图发现假性完全性房室传导阻滞，均在术后2 d内出现。双重窦性心律可见于27.95%（263/941）的心电图中，术后1～2个月发生率最高，达40.00%（42/105）。受体心房率术后3～6个月为（104.0±10.2）次/min，术后4～5年为（95.3±4.2）次/min。Ⅱ导联受体P波振幅术后1个月、1～2年分别为（0.066±0.055）和（0.043±0.040）mV，时限分别为（52.8±34.7）和（44.4±40.5）ms，振幅×时限分别为（4.67±4.95）和（3.11±3.61）mV·ms。供体心脏胸前导联P波终末电势绝对值增加可见于48.99%（461/941）的心电图，1～2个月时V1、V2、V3导联的P波终末电势分别为－0.044（－0.066，－0.028）、－0.060（－0.087，－0.038）和－0.035（－0.056，0）mm·s。10.31%（97/941）心电图供体负向P波可出现切迹。PR段可见压低，在3～6个月时发生率可达60.24%（100/166），发生在V2、V3、V4导联分别为21.04%（198/941）、37.41%（352/941）和28.69%（270/941）。结论原位心脏移植术后心电图可发生较大变化，表现为：术后平均心率较术前加快，6个月～1年后逐渐下降，但到5～6年平均心率仍高于术前；术后1个月内供体P波常不明显或较小，术后2个月P波变大，之后P波大小较稳定；多数心电图有转位，以顺钟向转位常见；供体心脏发生的心律失常以窦性心动过速、不完全性右束支传导阻滞多见；假性完全性房室传导阻滞可于术后早期出现；随着时间的延长，双重窦性心律的发生率逐渐减低，受体心房率和P波有变小趋势；供体心脏胸前导联P波终末电势绝对值增加（以V1～V3为主）和P波可出现切迹（以V1、V2常见），PR段可见压低（以V2～V4常见）。

ObjectiveTo analyze pre- and post-operation electrocardiograms （ECGs） features of patients underwent orthotopic heart transplantation （OHT）, and provide evidences for identifying and analyzing post OHT ECGs.MethodsNine hundreds and ninty-eight pre- and post- OHT standard 12-leads ECGs from 110 consecutive patients, who underwent OHT in our hospital from May 2008 to May 2014, were analyzed.ResultsThe mean heart rate（HR）was （86.9±16.4） beats per minute before OHT, and （100.0±0.4） beats per minute after OHT. P wave′s amplitude, duration, amplitude multiplied by duration of donor heart in lead Ⅱ were （0.124±0.069）mV, （111.1±17.2）ms, （14.34±9.51）mV·ms before OHT; （0.054±0.037）mV, （86.9±27.0）ms, （5.02±4.03）mV·ms at 1 month after OHT; （0.073±0.049）mV, （93.9±17.5） ms, （7.00±4.81）mV·ms at 6 years after OHT. ECGs rotation occurred in 83.64%（92/110） patients after OHT, and prevalence of clockwise rotation was 76.36%（84/110）. Sinus tachycardia was evidenced in 99.09%（109/110） patients after OHT, and incomplete right bundle branch block was present in 60.91%（67/110） patients after OHT. Pseudo complete atrioventricular block mostly occurred at 2 days after OHT. Prevalence of double sinus rhythm was 27.95%（263/941） post OHT, 40% of them occurred between the 1st and the 2nd month post OHT; the atrial rate of recipient hearts was （104.0±10.2） beats per minucte between the 3rd and the 6th month post OHT, and was （95.3±4.2） beats per minucte between the 4th year and the 5th year. P wave′s amplitude, duration, amplitude multiplied by duration of recipient heart in lead Ⅱ were （0.066±0.055） mV, （52.8±34.7） ms, （4.67±4.95） mV·ms at 1 month after OHT, （0.043±0.040）mV, （44.4±40.5） ms , （3.11±3.61） mV·ms between the 1st year and 2nd year after OHT. The absolute value of P-wave（originating from the donor heart） terminal force in chest leads increased in 48.99%（461/941） patients post OHT, the P-wave terminal force of V1 , V2 and V3 were -0.044（-0.066, -0.028）, -0.060（-0.087, -0.038）, -0.035（-0.056, 0） mm·s. Notched P wave in chest leads was presented in 10.31%（97/941） patients post OHT. PR segment depression in chest leads occurred in 60.24%（100/166） patients between the 3rd month and the 6th month, the incidence of PR segment depression in V1 , V2 and V3 was 21.04%（198/941）, 37.41%（352/941） and 28.69%（270/941）, respectively.ConclusionsOHT is related to significantly changed ECGs. The mean HR increased significantly after OHT, then decreased gradually after half a year to one year, but it was still higher than preoperative mean HR after five or six years; the P waves of donor heart were usually inconspicuous or small in first month after OHT, and they became bigger after 2 months, and their duration and amplitude then became relatively steady afterwards. ECGs rotation, especially the clockwise rotation, was common post OHT. A variety of arrhythmias originating from the donor heart including sinus tachycardia and incomplete right bundle branch block could be found. Pseudo complete atrioventricular block could also be found in the early phase after OHT. With the extension of time, the incidence of double sinus rhythm reduced gradually. The atrial rate and P wave of recipient heart presented with a tendency to become lower. The absolute value of P-waves（originating from the donor heart） terminal force in chest leads （mainly V1, V2 and V3） increased, notched P waves in chest leads （mainly V1, V2） and PR segments depression in chest leads （mainly V2, V3 and V4） also belong to typical post OHT ECGs features.