经导管消融儿童心室预激性扩张型心肌病临床及预后因素分析

Clinical and prognostic analysis of accessory pathway-induced dilated cardiomyopathy after catheter ablation in children

目的 探讨儿童心室预激性扩张型心肌病(简称预激性心肌病)的临床特点及影响预后的因素.方法 回顾性分析2009年1月至2018年8月于清华大学第一附属医院心脏小儿科连续住院行导管消融的心室预激右侧旁路147例患儿资料(男81例,女66例),其中预激性心肌病31例,心功能正常者116例.分析患者临床特征、心电图、超声心动图、导管消融资料,用Cox回归分析成功导管消融后影响心功能恢复的预测因素.结果 31例预激性心肌病首次就诊年龄为3.07(0.09~5.83)岁,院前误诊率87.1% (27/31).预激性心肌病的发生率为21.1%(31/147),其中右前壁旁路发生率最高[50.0%(10/20)].31例预激性心肌病的患儿旁路以右侧壁及右前壁多见,分别为41.9%(13/31)和32.3%(10/31).预激性心肌病组48.4%(15/31)无室上性心动过速发作病史,29.0%(9/31)旁路不具备逆传功能.31例预激性心肌病成功导管消融后随访8(2~36)个月,左心室舒张末期内径明显缩小[(41.6±12.8) mm比(45.6± 13.9) mm],左心室射血分数(LVEF)明显升高(56.2%±11.8%比40.8%±12.5%),差异均有统计学意义(P均<0.01).Cox回归分析显示LVEF(HR=1.08,95%CI 1.01~1.15,P=0.03)是影响心功能恢复时间的预测因素.结论 预激性心肌病临床易误诊及延误治疗,该病均发生于右侧旁路,右前壁旁路发生率最高,构成以右侧壁及右前壁多见.成功导管消融后,左心室功能可逆转并恢复正常.LVEF受损的程度越重,心功能恢复的时间越长.

Objective To investigate the clinical characteristics and prognostic factors after catheter ablation of accessory pathway (AP)-induced dilated cardiomyopathy (DCM) in children.Methods Data were collected and analyzed on 147 consecutive pediatric patients (81males and 66 females),who hospitalized in our pediatric heart center between January 2009 and August 2018 and received catheter ablation for ventricular pre-excitation (right AP).Thirty-one children were diagnosed as AP-induced DCM and 116 children with normal cardiac function served as control.Data including clinical characteristics,electrocardiogram (ECG),echocardiography,electrophysiological examination (EPS),successful ablation and follow up were analyzed.Results The median age at first examination was 3.07 (0.09,5.83) years.The pre-hospital misdiagnosis rate was 87.1% (27/31).The incidence of the AP-induced DCM was 21.1% (31/147) and the rate of right anterior free wall accessory pathway (AP) was the highest (50.0%,10/20).AP-induced DCM was more common in right free wall Aps (41.9%,13/31) and right anterior free wall (32.3%,10/31).48.4% (15/31) cases had no supraventricular tachycardia (SVT).EPS showed that 29% (9/31) of the AP did not have retrograde conduction.The median follow-up time after successful catheter ablation was 8 (2,36) months of AP-induced DCM group,LVDd was significantly decreased ((41.6±12.8)mm vs.(45.6 ± 13.9)mm,P<0.01) and LVEF ((56.2 ±11.8)% vs.(40.8 ± 12.5)%,P<0.01) was significantly increased after ablation.Cox regression analysis showed that LVEF was the predictor of the duration of cardiac function recovery (HR=1.08,95%CI 1.01-1.15,P=0.03).Conclusions Misdiagnosis rate is high for children with AP-induced DCM,leading to the delayed treatment.All of the AP-induced DCM occurred in right APs and right anterior free wall APs is the highest.Right free wall APs and right anterior free wall are most common in AP-induced DCM.Catheter ablation is a safe and effective treatment option for these patients.The lower the LVEF,the longer the cardiac function recovery.