作者：张军,赵雪屏,高文燕

单位：

030024 山西省太原市，山西省心血管病医院体外循环科 通信作者：张军，E-mail：13834236808@163.com

Units：

Department of Cardiopulmonary Bypass, Shanxi Cardiovascular Hospital, Taiyuan 030024, China Corresponding author: ZHANG Jun, E-mail: 13834236808@163.com

关键词：

心脏外科手术; 体外循环; 心脏复跳; 心电图; QRS波; 心肌功能;

Keywords：

Cardiac surgical procedures; Extracorporeal circulation; Cardiac rebeating; Electrocardiogram; QRSwave; Myocardial function

CLC：

DOI：

10.12114/j.issn.1008-5971.2021.00.279

Funds：

摘要：

背景体外循环(CPB)是替代心脏手术患者术中心肺功能的重要方式,准确预测CPB心脏复跳患者心功能恢复情况至关重要。心脏复跳后心电图QRS波演变或与心肌细胞功能恢复有一定关系,目前国内外尚无研究具体分析QRS波演变情况对心肌功能的预测价值。目的 探讨心脏手术患者CPB心脏复跳后心电图Ⅱ导联QRS波演变情况及其临床意义。方法 选取2019年1月至2020年8月山西省心血管病医院心脏外科收治的CPB心脏手术患者180例,其中瓣膜置换术108例,瓣膜成形术47例,冠状动脉旁路移植术(CABG)15例,瓣膜置换术联合CABG10例。观察患者CPB心脏复跳后心电图Ⅱ导联QRS波演变情况,记录术中主动脉阻断时间。比较不同手术方式患者CPB心脏复跳后15、30、> 30 min心电图Ⅱ导联QRS波演变发生率;比较CPB心脏复跳心电图Ⅱ导联QRS波发生演变与未发生演变患者的术中主动脉阻断时间;比较QRS波时限<110 ms与QRS波时限≥110 ms患者心功能指标〔纽约心脏病协会(NYHA)分级、左心室射血分数(LVEF)、血清N末端脑钠肽前体(NT-proBNP)水平〕。采用Spearman秩相关分析探讨心脏手术患者CPB心脏复跳后心电图Ⅱ导联QRS波时限与心功能指标的相关性。结果 术前,心脏手术患者心电图Ⅱ导联QRS波表现为主波向下,呈rS型。143例(79.44%)患者自CPB心脏复跳即刻自主心律和呼吸频率逐渐恢复正常,QRS波呈Rs型伴增宽;CPB心脏复跳后15 min,QRS波呈rS型伴S波增宽;CPB心脏复跳后30 min,QRS波呈Rs型,时程恢复正常;CPB心脏复跳后35 min,QRS波呈Rs型,时程缩短,而后逐渐恢复至术前形态。不同手术方式患者CPB心脏复跳后15、30、> 30 min心电图Ⅱ导联QRS波演变发生率比较,差异无统计学意义(P>0.05)。143例CPB心脏复跳后心电图Ⅱ导联QRS波发生演变者的主动脉阻断时间短于37例CPB心脏复跳后心电图Ⅱ导联QRS波未发生演变者(P <0.001)。180例患者中,QRS波时限<110 ms者88例,QRS波时限≥110 ms者92例。QRS波时限<110 ms患者NYHA分级优于QRS波时限≥110 ms患者,LVEF高于QRS波时限≥110 ms患者,血清NT-proBNP水平低于QRS波时限≥110 ms患者(P <0.05)。Spearman秩相关分析结果显示,心脏手术患者CPB心脏复跳后心电图Ⅱ导联QRS波时限与LVEF呈负相关(rs=-0.654,P <0.001),与NYHA分级、血清NT-proBNP水平呈正相关(rs值分别为0.634、0.627,P值均<0.001)。结论 心脏手术患者CPB心脏复跳后自主心律和呼吸逐渐恢复,心电图Ⅱ导联QRS波逐渐演变为主波向下,呈Rs型,时程缩短,直至恢复至术前形态,术中主动脉阻断时间可能会影响患者CPB心脏复跳后心电图Ⅱ导联QRS演变情况,而QRS波时限越长,心功能损伤越严重,故推测心电图Ⅱ导联QRS波或可作为临床评估心功能的重要指标。

Abstract：

【Abstract】 Backgroud Cardiopulmonary bypass (CPB) is an important way to replace the pulmonary function ofpatients undergoing cardiac surgery, and it is very important to accurately predict the recovery of cardiac function of patients withcardiac rebeating in CPB. The evolution of QRS wave in ECG after cardiac rebeating may be related to the recovery of myocardialcell function. At present, there is no study to specifically analyze the predictive value of QRS wave evolutionon for myocardialfunctionat at home and abroad. Objective To discuss the evolution and clinical significance of QRS wave of ECG leadⅡ aftercardiac rebeating in CPB of patients undergoing cardiac surgery.Methods A total of 180 patients who underwent cardiac surgeryunder CPB in Cardiac Surgery Department, Shanxi Cardiovascular Hospital from January 2019 to August 2020 were selected,among them, there were 108 cases of valve replacement, 47 cases of valvuloplasty, 15 cases of coronary artery bypass grafting(CABG) and 10 cases of valve replacement combined with CABG. The evolution of QRS wave in lead Ⅱ of ECG after cardiacrebeating in CPB was observed, and the intraoperative aortic occlusion time was recorded. Incidence of QRS wave evolution inlead Ⅱ of ECG at 15, 30 and > 30 min after cardiac rebeating in CPB were compared in patients with different operation methods;intraoperative aortic occlusion time was compared between the patients with QRS wave evolution or not in ECG lead Ⅱ of ECGafter cardiac rebeating in CPB; and the cardiac function indexes [New York Heart Association (NYHA) grade, left ventricularejection fraction (LVEF) , serum N-terminal pro-brain natriuretic peptide (NT-proBNP) level ] were compared between patientswith QRS wave duration < 110 ms and patients with QRS wave duration ≥ 110 ms. Spearman rank correlation analysis was used toexplore the correlation between QRS wave duration in lead Ⅱ of ECG and cardiac function indexes after cardiac rebeating in CPBof patients undergoing cardiac surgery. Results Before operation, the QRS wave in leadⅡ of ECG of patients undergoing cardiacsurgery showed the main wave downward, showing rS type; spontaneous heart rhythm and respiratory rate of 143 patients (79.44%)gradually returned to normal immediately after cardiac rebeating in CPB, and the QRS wave showed Rs type with widening; 15 minafter cardiac rebeating in CPB, QRS wave showed rS type with S wave widening; 30 min after cardiac rebeating in CPB, QRS waveshowed Rs type and the time course returned to normal; 35 min after cardiac rebeating in CPB, the QRS wave showed Rs type, thetime course was shortened, and then gradually returned to the preoperative shape. There was no significant difference in incidenceof QRS wave evolution in leadⅡ of ECG at 15, 30 and > 30 min after cardiac rebeating in CPB in patients with different operationmethods (P > 0.05) . Intraoperative aortic occlusion time of 143 patients with QRS wave evolution in leadⅡ of ECG after cardiacrebeating in CPB was shorter than that of 37 patients without QRS wave evolution (P < 0.001) . Of 180 cases of patients, 88 caseswith QRS wave duration < 110 ms, 92 cases with QRS wave duration ≥ 110 ms. NYHA grade in patients with QRS wave duration< 110 ms was better than that of patients with QRS wave duration ≥ 110 ms, LVEF was higher than that of patients with QRSwave duration ≥ 110 ms, serum NT-proBNP level was lower than that of patients with QRS wave duration ≥ 110 ms (P < 0.05) .Spearman rank correlation analysis showed that, QRS wave duration in leadⅡ of ECG was negatively correlated with LVEF(rs=-0.654, P < 0.001) , and was positively correlated with NYHA grade and serum NT-proBNP level of patients after cardiacrebeating in CPB undergoing cardiac surgery (rs value was 0.634, 0.627, respectively; P values were both < 0.001) . Conclusion Thespontaneous rhythm and breathing after cardiac rebeating in CPB of patients undergoing cardiac surgery gradually recover, and theQRS wave in lead Ⅱ of ECG gradually evolves into the main wave downward, showing Rs type, and the time course is shorteneduntil it returns to the preoperative shape.Intraoperative aortic occlusion time may affect the QRS evolution in lead Ⅱ of ECGafter cardiac rebeating in CPB of patients. The longer the QRS wave duration, the more serious the damage of cardiac function.Therefore, it is speculated that QRS wave in leadⅡ of ECG may be an important index for clinical evaluation of cardiac function.

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