動(dòng)脈導(dǎo)管未閉介入治療后心肌損傷、炎癥反應(yīng)及心功能變化的臨床研究
發(fā)布時(shí)間：2018-07-15 08:51
【摘要】：目的 通過觀測(cè)37例動(dòng)脈導(dǎo)管未閉（Patent ductus arteriosus，PDA）患兒介入治療前及治療后即刻、6h、24h、72h及7d心肌損傷[肌鈣蛋白（cardiac troponin I，cTnI）、肌酸激酶同工酶（MB isoenzyme of creatine kinase，CKMB）、天門冬氨酸氨基轉(zhuǎn)移酶（aspatate aminotransferase,AST）]及炎癥反應(yīng)[C-反應(yīng)蛋白（C-reactive proteinCRP）]指標(biāo)的動(dòng)態(tài)變化，分析PDA介入治療后心肌損傷和炎癥反應(yīng)程度，探討心肌損傷的影響因素，為PDA介入治療的安全性提供理論支持。同時(shí)通過超聲心動(dòng)圖(Ultrasonic cardiography, UCG)測(cè)量術(shù)前、術(shù)后3天和術(shù)后3月患兒心功能的變化，對(duì)比介入治療前及治療后3天、3個(gè)月患兒左心收縮功能的變化趨勢(shì)，闡述介入治療后患兒心臟結(jié)構(gòu)和功能的恢復(fù)情況。 材料和方法 1.研究對(duì)象 選擇2008年10月~2010年8月在安徽醫(yī)科大學(xué)兒科臨床學(xué)院(安徽省立兒童醫(yī)院)心內(nèi)科住院，經(jīng)臨床體檢、心電圖、X線胸片和超聲心動(dòng)圖證實(shí)為左向右分流的PDA，且術(shù)前四肢血壓和氧飽和度均在正常范圍之內(nèi)，擬行介入封堵治療的患兒37例，其中男15例，女22例。中位年齡36月（4~192月）；體質(zhì)量13kg（6~60kg）。所有入組患兒均符合PDA介入治療標(biāo)準(zhǔn)（先天性心臟病經(jīng)導(dǎo)管介入治療指南，2004年第三期中華兒科雜志），有適應(yīng)癥，無禁忌癥、無感染或術(shù)前感染已控制，心功能正常，無器質(zhì)性肺動(dòng)脈高壓。按照手術(shù)要求履行知情同意，告知患兒監(jiān)護(hù)人手術(shù)風(fēng)險(xiǎn)，在充分理解的前提下，簽署書面手術(shù)知情同意書和臨床研究知情同意書。采用國產(chǎn)封堵器對(duì)符合適應(yīng)癥的患兒進(jìn)行PDA封堵。并對(duì)每位入組患兒進(jìn)行術(shù)前、術(shù)后即刻、6h、24h、72h、7d，6個(gè)時(shí)間點(diǎn)cTnI, CKMB,AST和CRP濃度的檢測(cè)，術(shù)前、術(shù)后3天及3月通過UCG測(cè)定患兒心功能。 2.研究方法檢測(cè)入組患兒術(shù)前、術(shù)后即刻、6h、24h、72h、7d等6個(gè)時(shí)間點(diǎn)cTnI、CKMB、AST和CRP濃度，其中術(shù)前、術(shù)后6h、27h、72h、7d血清樣本由研究者本人自患兒外周靜脈采集，術(shù)后即刻由介入手術(shù)實(shí)施者自導(dǎo)管內(nèi)采集，記錄患兒年齡、缺損大小、曝光時(shí)間和操作時(shí)間等相關(guān)危險(xiǎn)因素；通過UCG測(cè)量術(shù)前、3天及3月患兒心功能，分析術(shù)后心功能變化趨勢(shì)。所有資料均采用EpiDate3.0軟件錄入，使用社會(huì)科學(xué)統(tǒng)計(jì)軟件包(StatisticalPackage for Social Science, SPSS)13.0軟件進(jìn)行統(tǒng)計(jì)學(xué)處理。 結(jié)果 PDA介入治療術(shù)后即刻、6h、24h和72h cTnI水平(μg·L-1)分別為0.08(0-1.37)、0.09(0-0.68)、0.06(0-0.96)、0.04(0-0.96)，較術(shù)前[0.05(0-0.58)]升高，術(shù)后7d[0.04(0-0.44)]已低于術(shù)前水平，高峰出現(xiàn)在術(shù)后6h，升高有統(tǒng)計(jì)學(xué)意義(P0.05)，但術(shù)后各時(shí)段cTnI值均低于正常水平；CKMB術(shù)后即刻[14.00(4.00-75.00)]較術(shù)前[11.00(6.00-42.00)]升高，但差異無統(tǒng)計(jì)學(xué)意義；AST術(shù)后6h開始升高，術(shù)后24h達(dá)峰值，升高有統(tǒng)計(jì)學(xué)意義（P＜0.01或0.05）；CRP(mg·L-1)于術(shù)后6h[0.36(0-28)]開始升高，至72h[7.79（0.2-52.4）]達(dá)峰值，繼之下降，和術(shù)前相比，，術(shù)后24h[2.5（0-30.5）]、72h[7.79(0.2-52.4)]及7d[4.1(0.2-34.57)]升高有統(tǒng)計(jì)學(xué)意義(P0.05)，但術(shù)后各時(shí)段CRP均低于正常水平；年齡、缺損大小、曝光時(shí)間和操作時(shí)間等與cTnI變化無明顯相關(guān)。左室舒張末前后徑（left ventricular end-systolic dimension，LVDD）及左室收縮末前后徑（left ventricular end-systolic dimension，LVDS）術(shù)后有降低趨勢(shì)，術(shù)后3月較術(shù)前降低明顯，差異有統(tǒng)計(jì)學(xué)意義(P＜0.01或0.05)；同期左室射血分?jǐn)?shù)（left ventricular ejection fraction，LVEF）及短軸縮短率（leftventricular fractional shortening，LVFS）在術(shù)后3天下降，差異有統(tǒng)計(jì)學(xué)意義(P＜0.01或0.05)，繼之有回升趨勢(shì)，至術(shù)后3月已接近術(shù)前水平。 結(jié)論 經(jīng)導(dǎo)管介入治療動(dòng)脈導(dǎo)管未閉可造成cTnI、CKMB、AST和CRP一過性升高，年齡、缺損大小、曝光時(shí)間和操作時(shí)間與cTnI無明顯相關(guān)，PDA介入治療未引起明顯心肌損傷及炎癥反應(yīng)，是一種安全、有效的治療手段。術(shù)后LVDD及LVDS持續(xù)下降，為解剖畸形矯正后的正常變化，相伴隨的一過性左心收縮功能下降，系恢復(fù)正常血液動(dòng)力學(xué)后機(jī)體的代償反應(yīng)，無需臨床干預(yù)，多于術(shù)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.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2012
【分類號(hào)】：R725.4
本文編號(hào)：2123517
[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.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2012
【分類號(hào)】：R725.4
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