心脏移植术后急性排斥反应心肌内心电图监测的回顾性分析及临床意义  

A retrospective analysis of intramyocardial electrograms for monitoring acute rejection following heart transplantation

作　　者：贾一新[1] 孟旭[1] 李岩[1] 韩杰[1] 张海波[1] 罗天戈[1] 

机构地区：[1]首都医科大学附属北京安贞医院-北京市心肺血管疾病研究所心脏外科,北京100029

出　　处：《心肺血管病杂志》2012年第1期31-35,共5页Journal of Cardiovascular and Pulmonary Diseases

摘　　要：目的:研究心脏移植排斥反应发生时心肌内心电图的表现,探讨心肌内心电图(IMEG)各种数据监测急性排斥反应(AR)的临床意义。方法:回顾性分析141例次心脏移植后心肌活检结果,与同期描记的心肌内心电图数据。对移植物发生Ⅱ级(含)以上排斥反应时的心肌内心电图,分析其心率、心肌阻抗、QRS波幅、心室除极反应时间及心室除极反应T波降支最大斜率数据,并与其基础数据分析比较,判断排斥反应发生心肌内心电图的的表现,计算其变化率及在最佳诊断分割点的敏感度和特异性。回顾性分析各指标联合诊断敏感度、特异性和诊断准确率,绘制ROC曲线,检验诊断可靠性及因此可能避免的心肌活检次数和漏诊率。结果:Ⅱ级(含)以上排斥反应发生时,心肌内心电图的心率诊断的最佳分割点为+10%,其敏感度为82.8%,特异性为87.0%;心肌阻抗的诊断的最佳分割点为+15%,其敏感度为78.1%,特异性为96.1.%;QRS波幅诊断的最佳分割点为+15%,其敏感度为81.2%,特异性为92.2%;心室除极反应时间差异无统计学意义;以心室除极反应T波降支最大斜率降低10%为限,其诊断敏感度为84.3%,特异性为84.4%。如以4项指标联合诊断排斥反应,回顾性分析诊断敏感度可达95.3%,特异性为96.1%,其ROC曲线下面积为0.9237(95%CI为0.8132～0.9924)。采用心肌内心电图联合诊断可以避免52.5%心肌活检数量,将出现4.7%的漏诊率。采用IMEG监测AR的患者较未采用的患者,预计5年生存率高。结论:IMEG某些指标数据有较好的诊断排斥反应的敏感度和特异性,联合诊断将更加提高诊断的准确率,并可以减少心肌活检的次数,但也存在漏诊。连续的IMEG监测可以做为心脏移植后无创的、方便的及长期的排斥反应监测手段。Objective：To analysis the usefulness of intramyocardial electrograms for the monitoring of acute rejection following human heart transplantation.Methods：Intramyocardial electrograms（IMEG） data and concurrent endomyocardial biopsies（EMB） results of patients after heart transplantation were gathered.The total number of each is 141.The variability of heart rate,intramyocardial impedance,QRS amplitude and VER,VER T-Slew was calculated and compared retrospectively to the results of EMB,acute rejection was defined as Grade Ⅱ and higher classified according to ISHLT.sensitivity,specificity,positive predictive value,negative predictive value on cut-off point were measured,combined diagnosis standard was evaluated and receiver operating curve was presented.Results： For diagnosis of acute rejection,the Cut-off point,sensitivity and specificity of heart rate is ＋10%,82.8%,87.0% respectively.And so that in intramyocardial impedance is ＋15%,78.1%,96.1.%;in QRS amplitude is-15%,81.2%,92.2%;in VER T-slew is-10%,84.3%,84.4%.A combined diagnosis standard including these four index was evaluated,with the sensitivity 95.3%,the specificity 96.1%.The area under ROC is 0.9237,with 95%CI（0.8132,0.9924）.Following this standard,EMBs with a number of 52.5% will be avoided,yet,the rate of missed diagnosis is 4.7%.Conclusion： IMEG can be used as a non-invasive method for monitoring AR following heart transplantation.It is a continuous,safe and inexpensive method,and could reduce the need for EMB,without reducing the detection of rejection.

关 键 词：心脏移植 排斥反应 心肌内心电图 回顾性分析 

分 类 号：R540.41[医药卫生—心血管疾病]