先天性心脏病术后患儿三尖瓣环收缩期位移的研究

Study on tricuspid annular plane systolic excusion(TAPSE)after congenital heart disease surgery

目的:研究左向右分流型先天性心脏病术后早期三尖瓣环收缩期位移,了解左向右分流型先天性心脏病患儿术后早期的右心室收缩功能。方法:选择2018年6月至2018年12月收治的左向右分流型先心病手术的患儿,共20例,男、女各10例;年龄1~12个月,中位数4.5(2.0,6.8)个月;体质量3.0~9.0 kg,中位数6.0(3.7,7.7)kg。所有患儿于术后第1天晨安静状态下采集静脉血送检N末端B型脑钠肽原(NT-proBNP),并行超声心动图检查测量三尖瓣环收缩期位移(TAPSE)及左心室射血分数(LVEF )。观察并记录主动脉阻断时间、体外循环时间、术前肺炎、术前心衰对术后TAPSE的影响,分析TAPSE与术后心率、收缩压、中心静脉压、血管活性药物评分、气管插管时间、住监护室时间、NT pro-BNP及LVEF的关系。结果:全组患儿术中主动脉阻断15~87min,中位数31(28,50)min;体外循环35~117min,平均(68±22)min。术后气管插管4~117 h,平均(50±35)h;监护室停留1~14天,中位数5(2,7)天。术后LVEF 0.18~0.66,中位数0.53(0.42,0.57)。术后TAPSE 2.0~10.0mm,平均(5.2±2.0)mm。术后第1天NT-proBNP 1 548~35 000 pg/ml,平均(9 446±8 130)pg/ml。体外循环时间>60 min、术前伴有肺炎的患儿术后TAPSE更低( P<0.05)。TAPSE与术前是否伴有心衰及主动脉阻断时间( r=-0.362, P=0.119)无相关性,与心率( r=-0.303, P=0.193)、中心静脉压( r=-0.425, P=0.062)、血管活性药物评分( r=-0.418, P=0.067)及NT pro-BNP( r=-0.348, P=0.132)、术后气管插管时间( r=-0.576, P=0.007)及住监护室时间( r=-0.765, P=0.000)呈负相关趋势,与收缩压( r=0.146, P=0.54)、术后LVEF( r=0.461, P=0.041)呈正相关趋势( P<0.05)。TAPSE<5 mm患儿较TAPSE≥5 mm患儿住监护室时间更长、气管插管时间更长、中心静脉压更高、NT-pro BNP更高,差异有统计学意义, P<0.05。 结论:应用超声心动图测量TAPSE简单可行。左向右分流型先天性心脏病手术后早期TAPSE减低,提示此类患儿术后早期右心室收缩功能下降,同时合并左心室收缩功能降低,最终导致NT pro-BNP升高、患儿需要更高剂量的血管活性药物支持、气管插管时间和住监护室时间延长。应关注先天性心脏病患儿术后的右心功能。

Objective To explore the tricuspid annular plane systolic excusion(TAPSE)in children with left-to-right shunt after congenital heart disease surgery and to understand the early systolic function of right heart in thesepatient.Methods From June 2018 to December 2018,a prospective study was conducted in 20 infants after repair of left-to-right shunt congenital heart disease,including 10 males(50%)and 10 females(50%),aged from 1 to 12 months,with a median of 4.5(2.0,6.8)months,a body mass of 3.0-9.0 kg with median of 6.0(3.7,7.7)kg.On the first postoperative day,blood was taken from central venous for N-terminal pro-B-type natriuretic peptide(NT pro-BNP)test,TAPSE and left ventricular ejective fraction(LVEF)was measured by echocardiography.The effects of aortic occlusion time,cardiopulmonary bypass time,preoperative pneumonia and preoperative heart failure on TAPSE were compared.The relationship between TAPSE and heart rate,systolic pressure,central venous pressure,vasoactive drug score,endotracheal intubation time,detention time in intensive care unit,NT pro-BNP and LVEF after operation was analysed.Results The aortic cross-clamping time was 15-87 minutes,with median 31(28,50)minutes.The cardiopulmonary bypass time was 35-117 minutes,with an average of(68±22)minutes.The time of tracheal intubation was 4-117 hours,with an average of(50±35)hours.The stay time in CICU was 1-14 days,with a median of 5(2,7)days.The LVEF was 0.18-0.66,with median 0.53(0.42,0.57).The TAPSE was 2.0-10.0 mm,with an average of(5.2±2.0)mm.On the first day after operation,NT pro-BNP was 1548-35000 pg/ml,with an average of(9446±8130)pg/ml.TAPSE was negatively correlated with postoperative intubation time(r=-0.576,P=0.007)and detention time in ICU(r=-0.765,P=0.000),and positively correlated with postoperative LVEF(r=0.461,P=0.041)(P<0.05).TAPSE was negatively correlated with heart rate(r=-0.303,P=0.193),central venous pressure(r=-0.425,P=0.062),vasoactive drug score(r=-0.418,P=0.067)and NT Pro BNP(r=-0.348,P=0.132),and positively correlated with systolic pressure(r=0.146,P=0.54),but there was no statistical significance in each item.Compared with patients with TAPSE≥5mm,the detention time and tracheal intubation time were longer than those TAPSE<5 mm,the central venous pressure and NT-pro BNP was higher than those TAPSE<5 mm(P<0.05),the difference was statistically significant,other indicators had no significant difference.Conclusion It is simple and feasible to measure TAPSE by echocardiography in children after operation with left-to-right shunt congenital heart disease.TAPSE decreased postoperatively suggested that the function of right ventricle decreased at the early stage after surgery,and with left ventricle systolic function decreased,which eventually led to the increase of NT pro-BNP,the need for higher doses of vasoactive drug support,longer tracheal intubation time and the stay time in CICU.Attention should be paid to the right heart function of children after congenital heart surgery.