动脉导管未闭介入治疗后心肌损伤、炎症反应及心功能变化的临床研究

发布时间：2018-07-15 08:51

【摘要】：目的通过观测37例动脉导管未闭（Patent ductus arteriosus，PDA）患儿介入治疗前及治疗后即刻、6h、24h、72h及7d心肌损伤[肌钙蛋白（cardiac troponin I，cTnI）、肌酸激酶同工酶（MB isoenzyme of creatine kinase，CKMB）、天门冬氨酸氨基转移酶（aspatate aminotransferase,AST）]及炎症反应[C-反应蛋白（C-reactive proteinCRP）]指标的动态变化，分析PDA介入治疗后心肌损伤和炎症反应程度，探讨心肌损伤的影响因素，为PDA介入治疗的安全性提供理论支持。同时通过超声心动图(Ultrasonic cardiography, UCG)测量术前、术后3天和术后3月患儿心功能的变化，对比介入治疗前及治疗后3天、3个月患儿左心收缩功能的变化趋势，阐述介入治疗后患儿心脏结构和功能的恢复情况。材料和方法 1.研究对象选择2008年10月~2010年8月在安徽医科大学儿科临床学院(安徽省立儿童医院)心内科住院，经临床体检、心电图、X线胸片和超声心动图证实为左向右分流的PDA，且术前四肢血压和氧饱和度均在正常范围之内，拟行介入封堵治疗的患儿37例，其中男15例，女22例。中位年龄36月（4~192月）；体质量13kg（6~60kg）。所有入组患儿均符合PDA介入治疗标准（先天性心脏病经导管介入治疗指南，2004年第三期中华儿科杂志），有适应症，无禁忌症、无感染或术前感染已控制，心功能正常，无器质性肺动脉高压。按照手术要求履行知情同意，告知患儿监护人手术风险，在充分理解的前提下，签署书面手术知情同意书和临床研究知情同意书。采用国产封堵器对符合适应症的患儿进行PDA封堵。并对每位入组患儿进行术前、术后即刻、6h、24h、72h、7d，6个时间点cTnI, CKMB,AST和CRP浓度的检测，术前、术后3天及3月通过UCG测定患儿心功能。 2.研究方法检测入组患儿术前、术后即刻、6h、24h、72h、7d等6个时间点cTnI、CKMB、AST和CRP浓度，其中术前、术后6h、27h、72h、7d血清样本由研究者本人自患儿外周静脉采集，术后即刻由介入手术实施者自导管内采集，记录患儿年龄、缺损大小、曝光时间和操作时间等相关危险因素；通过UCG测量术前、3天及3月患儿心功能，分析术后心功能变化趋势。所有资料均采用EpiDate3.0软件录入，使用社会科学统计软件包(StatisticalPackage for Social Science, SPSS)13.0软件进行统计学处理。结果 PDA介入治疗术后即刻、6h、24h和72h cTnI水平(μg·L-1)分别为0.08(0-1.37)、0.09(0-0.68)、0.06(0-0.96)、0.04(0-0.96)，较术前[0.05(0-0.58)]升高，术后7d[0.04(0-0.44)]已低于术前水平，高峰出现在术后6h，升高有统计学意义(P0.05)，但术后各时段cTnI值均低于正常水平；CKMB术后即刻[14.00(4.00-75.00)]较术前[11.00(6.00-42.00)]升高，但差异无统计学意义；AST术后6h开始升高，术后24h达峰值，升高有统计学意义（P＜0.01或0.05）；CRP(mg·L-1)于术后6h[0.36(0-28)]开始升高，至72h[7.79（0.2-52.4）]达峰值，继之下降，和术前相比，，术后24h[2.5（0-30.5）]、72h[7.79(0.2-52.4)]及7d[4.1(0.2-34.57)]升高有统计学意义(P0.05)，但术后各时段CRP均低于正常水平；年龄、缺损大小、曝光时间和操作时间等与cTnI变化无明显相关。左室舒张末前后径（left ventricular end-systolic dimension，LVDD）及左室收缩末前后径（left ventricular end-systolic dimension，LVDS）术后有降低趋势，术后3月较术前降低明显，差异有统计学意义(P＜0.01或0.05)；同期左室射血分数（left ventricular ejection fraction，LVEF）及短轴缩短率（leftventricular fractional shortening，LVFS）在术后3天下降，差异有统计学意义(P＜0.01或0.05)，继之有回升趋势，至术后3月已接近术前水平。结论经导管介入治疗动脉导管未闭可造成cTnI、CKMB、AST和CRP一过性升高，年龄、缺损大小、曝光时间和操作时间与cTnI无明显相关，PDA介入治疗未引起明显心肌损伤及炎症反应，是一种安全、有效的治疗手段。术后LVDD及LVDS持续下降，为解剖畸形矫正后的正常变化，相伴随的一过性左心收缩功能下降，系恢复正常血液动力学后机体的代偿反应，无需临床干预，多于术后3月接近正常水平。
[Abstract]:objective
By observing 37 cases of Patent ductus arteriosus (PDA) before and immediately after treatment, 6h, 24h, 72h and 7d myocardial injury [cardiac troponin I, cTnI), aspartate aminotransferase, and inflammation. The dynamic changes in the index of the [C- reaction protein (C-reactive proteinCRP)] in the disease response, analyze the myocardial injury and the degree of inflammation after PDA intervention, and discuss the influencing factors of myocardial injury, and provide theoretical support for the safety of PDA intervention therapy. At the same time, 3 days after the operation and the operation by the ultrasonic cardiogram (Ultrasonic cardiography, UCG) The changes in the cardiac function of the children in March were compared. The changes in the left heart systolic function of the children before and 3 days after the treatment and the 3 months after the treatment were compared, and the recovery of the heart structure and function after the interventional therapy was described.
Materials and methods
1. research objects
In the Department of Cardiology of the Department of Pediatrics Clinical School of Medical University Of Anhui (Anhui Provincial Children's Hospital) in August ~2010 October 2008, the PDA was confirmed as left to right shunt by clinical examination, electrocardiogram, X-ray chest and echocardiography, and the blood pressure and oxygen saturation of extremities were within the normal range before operation, and 37 cases of interventional therapy were given. The median age was 15 and 22 women. The median age was 36 months (4~192 months), and the body mass was 13kg (6~60kg). All the children were in accordance with the standard of PDA intervention (the guide of interventional therapy for congenital heart disease, the third Chinese Journal of Pediatrics in 2004). There were indications, no contraindications, no infection or preoperative infection control, normal cardiac function and no organic pulmonary movement. Pulse pressure. Perform informed consent according to the operation requirements, inform the patient's guardian's risk of operation, sign the informed consent of the written operation and the informed consent of the clinical study under the premise of full understanding. Use the domestic occluder to block the PDA of the children conforming to the indications. And before the operation, immediately after the operation, 6h, 24h, 72h, 7 to each group of children. D, cTnI, CKMB, AST and CRP concentrations were detected at 6 time points, and cardiac function was measured by UCG before and 3 days after operation and in March.
2. the study method was used to detect the concentration of cTnI, CKMB, AST and CRP at 6 time points, such as cTnI, CKMB, AST and CRP, before the operation, 6h, 24h, 72h, and 7d. The samples of the 7d serum were collected from the peripheral veins of the children before the operation, and the patients were collected immediately after the operation, and the age, size of the defect, exposure time and the time of exposure were recorded. Operation time and other related risk factors; the cardiac function of the children was measured before operation, 3 days and March by UCG. The trend of cardiac function changes after the operation was analyzed. All the data were recorded by EpiDate3.0 software, and the social science statistics software package (StatisticalPackage for Social Science, SPSS) was used for statistical processing.
Result
Immediately after PDA intervention, the levels of 6h, 24h and 72h cTnI were 0.08 (0-1.37), 0.09 (0-0.68), 0.06 (0-0.96), 0.04 (0-0.96), which were higher than before the operation. The peak was lower than the preoperative level, the peak appeared after the operation, and the increase was statistically significant, but all the values were lower than the normal level after the operation. After CKMB, [14.00 (4.00-75.00)] was higher than before operation [11.00 (6.00-42.00)], but the difference was not statistically significant; 6h began to rise after AST, and the peak value of 24h reached after operation (P < 0.01 or 0.05); CRP (mg L-1) increased after operation (0-28) and reached peak value, then dropped, compared with preoperative, The postoperative 24h[2.5 (0-30.5)], 72h[7.79 (0.2-52.4)] and 7d[4.1 (0.2-34.57)] were statistically significant (P0.05), but the CRP was lower than the normal level at all times after the operation. The age, size of the defect, exposure time and operation time were not related to the changes of cTnI. The left ventricular end diastolic diameter (left ventricular end-systolic) and left ventricle Left ventricular end-systolic dimension (LVDS) had a downward trend after operation, and was significantly lower in March than before operation. The difference was statistically significant (P < 0.01 or 0.05), and the left ventricular ejection fraction (left ventricular ejection fraction, LVEF) and short axis shortening rate were 3 after the operation. The difference was statistically significant (P < 0.01 or 0.05), followed by a trend of recovery, and was close to the preoperative level in March.
conclusion
The transcatheter closure of the patent ductus arteriosus can cause an excessive increase in cTnI, CKMB, AST and CRP. Age, size of the defect, exposure time and operation time have no obvious correlation with cTnI. PDA interventional therapy does not cause obvious myocardial injury and inflammation. It is a safe and effective treatment. After operation, LVDD and LVDS continue to decline, for anatomic malformation. After normal changes, the associated left ventricular systolic function decreased, and the compensatory response of the body after normal hemodynamics was restored without clinical intervention, which was more than the normal level in March after the operation.
【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R725.4

【参考文献】