脑钠肽在左向右分流型先天性心脏病合并心力衰竭中的诊断价值

Diagnostic value of brain natriuretic peptide in left to right shunt congenital heart disease accompanied by heart failure

目的探讨左向右分流型先天性心脏病患儿血浆脑钠肽（brain natriuretic peptide，BNP）诊断心力衰竭（心衰）的临床意义。方法回顾性分析2012年1月至2014年6月中国医科大学附属盛京医院PICU收治的符合左向右分流型先天性心脏病诊断标准的患儿52例。根据儿童心衰诊断标准分为无心衰组（18例）和心衰组（34例），比较两组血浆BNP、心脏缺损大小、左室舒张末期容积指数（left ventricular end—diastolic volume index，LVEDVI）、左室舒张早期最大充盈血流速度E峰与左室舒张晚期最大充盈血流速度A峰比值（E／A）、左室射血分数（1eft ventricular ejection fraction，LVEF）、肺动脉收缩压（pulmonary artery systolic pressure，PASP）及心胸比例是否存在差异。分析血浆BNP和心脏缺损大小、LVEDVI、E／A、心胸比例、LVEF、PASP的相关性。绘制血浆BNP诊断心衰的受试者工作特征曲线，确定诊断心衰的血浆BNP临界值。结果无心衰组与心衰组血浆BNP水平分别为87．7（22．7，165．7）pg／ml、716．5（326．8，1813．0）pg／ml，心衰组血浆BNP明显高于无心衰组（Z=5．3，P=0．01）。无心衰组与心衰组心脏缺损分别为5．0（3．0，6．8）min、7．4（5．5，9．0）mm，心衰组心脏缺损大小明显大于无心衰组（Z=3．5，P=0．01）。无心衰组与心衰组LVEDV1分别为（44．6±18．3）ml／m^3、（70．8±38．4）ml／m^3，心衰组LVEDVI明显高于无心衰组（t=2．7，P=0．01）。无心衰组与心衰组E／A比值分别为1．3±0．3、1．1±0．3，心衰组E／A明显低于无心衰组（t=2．2，P=0．04）。血浆BNP与心胸比例呈正相关（r=0．49，P=0．01），与E／A呈负相关（r=-0．28，P=0．04）。受试者工作特征曲线分析发现，血浆BNP〉181．8pg／ml时，诊断心衰的敏感度为94％，特异度为88％，曲线下面积为0．951。结论血浆BNP可作为反映儿童先天性心脏病心衰的敏感指标，推荐181．8pg／ml为诊断左向右分流型先天性心脏病合并心衰的BNP临界值。

Objective To investigate the diagnostic value of plasma B-type natriuretic peptide （BNP） in left to right shunt congenital heart disease accompanied by heart failure in PICU. Methods We retrospectively reviewed the clinical data of 52 cases diagnosed left to fight shunt congenital heart disease in the PICU of Shengjing Hospital of China Medical University from January 2012 to June 2014. The cases were divided into negative control group （n = 18 ） and heart failure group （n = 34） according to the criteria for the diagnosis of pediatric heart failure. We respectively compared plasma BNP, size of heart defects, left ventricu- lar end-diastolic volume index （LVEDVI）, ratio of left ventricular early diastolic filling blood flow velocity and left ventricular late diastolic filling blood flow velocity（ E/A）, left ventricular ejection fraction （LVEF）, pulmonary artery systolic pressure（ PASP）, and cardiothoracic ratio between the two groups. We analyzed the correlation between plasma BNP and the size of heart defects, LVEDVI, E/A, cardiothoracic ratio, LVEF, PASP. The receiver operating characteristic curve was used to determine the optimal cut-off value of plasma BNP to diagnose heart failure. Results Plasma BNP were 87. 7 （ 22. 7,165.7 ） pg/ml in negative control group and 716. 5（326. 8,1 813.0） pg/ml in heart failure group. The plasma BNP level of heart failure group was significantly higher than that of negative control group （Z = 5.3, P 〈 0. 01 ）. Size of heart defects were 5. 0（3.0,6. 8） mm in negative control group and 7. 4（5. 5,9. 0） mm in heart failure group. Size of heart defects of heart failure group was significantly higher than that of negative control group（ Z = 3.5 ,P 〈 0. 01 ）.LVEDVI were （44. 6 ± 18. 3）ml/m3 in negative control group and （70. 8 ± 38.4）ml/m3 in heart failure group. LVEDVI of heart failure group was significantly higher than that of negative control group （ t = 2. 7, P =0. 01 ）. E/A were 1.3 -±0. 3 in negative control group and 1.1 ±0. 3 in heart failure group. E/A of nega- tive control group was significantly higher than that of heart failure group （ t = 2. 2, P = 0.04 ）. Plasma BNP had a positive relation with cardiothoracic ratio （ r = 0. 49, P = 0. 01 ） and a negative correlation with E/A （ r = - 0. 28, P = 0. 04）. The optimal cut-off value of plasma BNP was 181.8 pg/ml. The sensitivity of diagnosis of heart failure was 94% and the specificity was 88%. The area under the receiver operating characteristic curve was 0. 951. Conclusion Plasma BNP may comprise a sensitive marker for heart failure of left to fight shunt congenital heart disease. It is recommended that 181.8 pg/ml is the optimal cut-off value to diagnose heart failure of left to right shunt congenital heart disease.