【作者】 李丽；

【导师】 方臻飞；

【作者基本信息】 中南大学 ， 心血管内科， 2011， 硕士

【摘要】 研究目的：通过检测成人左向右分流先天性心脏病介入封堵术前、术后不同时间点血浆NT-proBNP浓度的变化,研究NT-proBNP浓度与肺动脉高压、心脏容量大小的关系及封堵前术后NT-proBNP浓度变化的规律,为临床评价CHD相关性PAH的程度及介入封堵术的治疗效果提供参考。方法：选择2010年6月～2010年10月在我科成功行封堵术的左向右分流先天性心脏病患者83例,男性41例,女性42例,年龄18-49岁,平均年龄(32±12.1岁)。另选20例健康正常人作为对照组。封堵术前依据肺动脉平均压(mPAP)分为5组：正常PAH组(mPAP<25mmHg,n=36)、轻度PAH组(25mmHg≤mPAP<35 mmHg, n=14)、中度PAH组(35 mmHg≤mPAP<50mmHg, n=12)、重度PAH组(mPAP>50mmHg,n=21),正常对照组(n=20)。术后随访分组：依据mPAP分为4组：正常PAH组(n=36)、轻度PAH组(n=14)、中度PAH组(n=12)、重度PAH组(n=21)。依据疾病类型分组：房间隔缺损组(ASD,n=37)、室间隔缺损组(VSD,n=23)、动脉导管未闭组(n=23)。所有患者术前均行右心导管检查,测右房、右室压力、肺动脉收缩压(SPAP)、肺动脉平均压(MPAP)、全肺阻力(PVR)。封堵后即刻再次复查肺动脉压力并比较其变化。所有患者术前及术后一天、四天、月、三月行经胸心脏彩超(TTE),记录不同时间点左房(LA)、左室(LV)、右房(RA)、右室(RV)大小,左室射血分数(LVEF)、肺动脉收缩压(PASP)数值,比较其变化。采用电化学发光法测定患者封堵术前后不同时间点血NT-proBNP浓度,比较术前、封堵术后即刻、术后一天、四天、一月、三月血NT-proBNP浓度含量及变化,并分析与肺动脉压力及相关心腔容量负荷及功能的相关性。结果1.术前各PAH组血浆NT-proBNP水平明显高于正常对照组(P<0.01),组间存在显著性差异(P＜0.01),重度>中度>轻度>无肺高压组>正常对照组。2.术前NT-proBNP水平与MPAP (r=0.893, p=0.000)、SPAP (r=0.921, p=0.0000)、PVR (r=0.844, p=0.000)呈正相关。3.血浆NT-proBNP浓度67.50pg/ml诊断轻度PAH灵敏度92.9%,特异度94.4%,曲线下面积92.9%；147pg/ml诊断中度PAH灵敏度91.7%,特异度75.8%,曲线下面积79.5%,236.5pg/ml诊断重度PAH灵敏度95.2%,特异度73.0%,曲线下面积97.8%。4.各PAH组术后即刻、术后一天、四天SPAP持续下降(P<0.05),不同时间点组间比较P<0.05,,有显著统计学意义,以重度PAH组下降最为明显。正常PAH组及轻度PAH组术后一月、三月SPAP变化无统计学意义(P>0.05),中度PAH组、重度PAH组在术后四天、一月、三月SPAP持续下降(P＜0.05),且不同时间点组间比较P<0.05,有显著统计学意义。5.ASD、VSD、PDA组封堵术后即刻NT-proBNP浓度较术前明显增高,(P＜0.05)有统计学意义；与术后即刻相比,术后第一天、术后四大、术后一月、术后三月中各时间点NT-proBNP浓度持续下降,组内术后各时间点两两比较,(P<0.05)有显著统计学意义；VSD组、ASD组术后一天NT-proBNP浓度与术前相比,(P>0.05)无统计学意义；PDA术后各时间点与术前相比(P<0.05)均有统计学意义。6.ASD组RA、RV内径术后各时间段与前一时间段比较明显回缩,3月恢复正常,随时间变化差异有统计学意义(P<0.05)；PDA组、VSD组LA、LV内径术后各时间段与前一时间段比较均明显回缩,3月恢复正常,随时间变化差异有统计学意义(P<0.05),7. ASD、VSD组血浆NT-ProBNP浓度在封堵术前后各时间点与LA、LVEDD、SPAP呈正相关(P<0.01),与LVEF呈负相关(P<0.01)；ASD组血浆NT-ProBNP浓度在封堵术前与RA.RVEDD相关呈正相关(P<0.01),与右房平均压(r=0.456,P<0.01)、右室舒张末期压力(r=0.458, P<0.01)、SPAP呈正相关,血浆NT-ProBNP浓度在封堵术后与RA、RVEDD相关呈正相关(P<0.01)结论左向右分流型成人先心病患者血浆NT-proBNP水平随肺动脉压力升高而逐渐增加,监测NT-proBNP水平可在一定程度上反映肺动脉压力变化,作为评价肺动脉高压的程度的一项指标。室间隔缺损、动脉导管未闭患者血浆NT-proBNP水平主要与LVEDD、LA、SPAP正相关,与LVEF负相关,房间隔缺损患者血浆NT-proBNP水平主要与RVEDD、RA呈正相关,监测NT-proBNP水平可在一定程度上反映心脏容量负荷及压力变化,可结合心脏超声等其他临床辅助检查作为评估心脏容量负荷及压力变化的一项指标。左向右分流型先心病介入封堵术后NT-proBNP水平持续下降,其改变与术后肺动脉压下降程度、心脏形态变化相符,提示介入封堵术前后监测血浆NT-proBNP浓度可作为判断患者转归及预后的指标。更多还原

【Abstract】 ObjectiveThis study was designed to detect the changes of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP)level in adult with left-to-right congenital heart defect at the stage Pre-and Post transcathetezer closure.Thus to investigate the relation between concentration of plasma NT-proBNP with degree of pulmonary artery hypertension artery hypertension(PAH) and cardiac loading condition and to evaluate operational effects of CHD.Methods8 3 cases with left-to-right shunt congenital heart disease(41 males, 42females) aged 18-49 years(mean:32±12.1 years) were enrolled in our study who received transcatheter interventional therapy successfully from June to Octerber 2010.Randomly recruited control group include 20 healthy people(10 males,10 females)aged18-49 years(mean:31±10.1 years).Before operation the subjects were divided into five groups according to their pulmonary artery mean pressure as follow:non-pulmonary hypertension group(mPAP<25 mmHg, n=36);mild pulmonary hypertension group(25 mmHg≤mPAP<35 mmHg, n=14);moderate pulmonary hypertension group(35 mmHg≤mPAP<50mmHg, n=12); severe pulmonary hypertension group (mPAP>50mmHg, n=21); control group (n=20).So as to follow-up the 83 cases were divided into four groups according to MPAP as follow:non-pulmonary hypertension group(n=36);mild pulmonary hypertension group(n=14);moderate pulmonary hypertension group(n=12); severe pulmonary hypertension group (n=21). The 83 cases were divided into three groups according to categories of CHD as follow:PDA(n=23),ASD(n=37),VSD(n=23).The right atrial pressure, right ventricular pressure,and pulmonary artery pressure were measured during right heart catheterisation before transcathetezer closure and after transcathetezer closure instantly.Cardiac size and hemodynamic index were measured by echocardiography before transcathetezer closure and 24h,96h,1 monthes and 3 monthes after transcatheter closure of CHD.The plasma NT-proBNPconcentrations in 83 patients with CHD were assayed by enzyme-linked immunoassay and radioimmunoassay respectively before transcathetezer closure, at 24h and 72h after transcatheter closure of CHD.Results1.The was significant difference about the Plasma NT-proBNP level before transcatheter closure in the five groups(P<0.01),Along with an increase in MPAP,the concentration of Plasma NT-proBNP elevated.The level of Plasma NT-proBNP in cases of serious PAH>moderate PAH>mild PAH>non-PAH group>control group(P<0.01).2.There was a positive correlation between NT-proBNP levels,MPAP,SPAP,and PVR before transcatheter closure.3.67.50pg/ml of Plasma NT-proBNP level dignose mild PAH with a sensitivity of 92.9%, and a specificity of 94.4%.147pg/ml of Plasma NT-proBNP level dignose moderate PAH with a sensitivity of 91.7%, and a specificity of 75.8%.236.5pg/mlof Plasma NT-proBNP level dignose serious PAH with a sensitivity of 95.2%, and a specificity of 73.0%.4.After transcatheter closure,the degree of SPAP gradually declined at once,24h and 96h in all PAH groups(P<0.05) and declined in 1mon,3mon in moderate PAH and serious PAH.But no difference was found about the change of SPAP in mild PAH and non-PAH in lmon, 3mon(P>0.05).5The Plasma NT-proBNP level of ASD,VSD and PDA is significantly higher after transcatheter closure immediately than those before transcatheter closure (P<0.05),but it gradually declined in the first day,the forth day,1 month and 3month(P<0.05).The Plasma NT-proBNP level of ASD and VSD was no difference between in the first day and before transcatheter closure(P>0.05).6.The diameter of RA and RV in ASD group was gradually decreased after transcatheter closure in three monthes, and the diameter of LA and LV in VSD or PDA group was gradually decreased after transcatheter closure in three monthes(P<0.05).7.In VSD and PDA patients, NT-proBNP levels positively correlated significantly with LA,LVEDD and SPAP,negatively correlated significantly with LVEF(P<0.01).In ASD patients,NT-proBNP levels positively correlated with RA and RVEDD(P<0.01).ConclusionBecause the Plasma NT-proBNP level of adult left-to-right CHD was gradually increased with the elevating of pulmonary artery pressure, it may be used as a marker to evaluate the degrees of PAH. NT-proBNP levels positively correlated significantly with LA,LVEDD and SPAP,negatively correlated significantly with LVEF in VSD and PDA patients,NT-proBNP levels positively correlated with RA and RVEDD in ASD patients,thus it may be reflect the changes of cardiac volume load and pressure load. The Plasma NT-proBNP level constantly declined after transcatheter closure with the decreasing of SPAP and enlarged chambers heart.It indicated that the Plasma NT-proBNP level could be used evaluated the effect of transcatheter closure in this kind of CHD.更多还原