- 學位論文
先天性心臟病術後早期上心室頻脈
Early postoperative supraventricular tachycardia after congenital heart disease surgery
摘要
背景 先天性心臟病患接受開心手術之後，術後早期有時會出現上心室頻脈，然而我們尚未十分瞭解其重要性、治療反應與臨床病程。我們的研究目的是釐清術後早期上心室頻脈的疾病自然史、臨床預後與危險因子。 方法 研究對象為2010年1月至2015年12月於台大醫院接受先天性心臟病手術的先天性心臟病患，我們回顧患者的病歷，特別關注病人的背景特徵、過去心臟手術史與過去上心室頻脈病史、周術期血液動力學情況、住院天數、以及上心室頻脈的發生時間、型態、治療反應與預後。上心室頻脈包含心房心律不整，和陣發性上心室心搏過速。我們定義術後早期為術後在加護病房住院期間。 結果 共有1404位先天性心臟病患在研究期間於台大醫院接受1650次先天性心臟病手術，32位病患於33次手術後發生上心室頻脈，發生率為2%。心臟結構為側畸症或大血管轉位者，術後早期上心室頻脈發生率較高，分別為9.7%與6.6%。32位術後出現上心室頻脈的患者中，24位（75%）為發紺性心臟病，10位（30%）為第二次或以上心臟手術，7位（22%）過去有上心室頻脈病史；16位（50%）術前血液動力學不穩定，其中有2位病患術後需要葉克膜支持。過去有上心室頻脈病史（勝算比16.8，95%信賴區間4.7–53.8）、與診斷為發紺性先天性心臟病（勝算比3.1，95%信賴區間1.4–7.8）、特別是側畸症（勝算比6.9，95%信賴區間2.0–25.3）和大血管轉位（勝算比3.7，95%信賴區間1.0–13.9），為術後上心室頻脈的獨立危險因子。上心室頻脈急性期治療，7位患者僅注射adenosine，22位需要amiodarone輸注，4位因血液動力學危象而需要使用同步整率電擊（DC cardioversion）。術後發生上心室頻脈的患者，住院時間顯著較長（中位數27和21天，p=0.002），但周術期死亡率和無心律不整者相當 (6.3% vs. 6.0%)。大部分病人（32位中有31位）皆需口服抗心律不整藥物維持性治療，口服藥治療時間中位數137天（範圍7–881天），其中19位（56%）可停藥，停藥後僅一位復發（5.3%）。 結論 先天性心臟病術後早期發生上心室頻脈並非罕見，過去有上心室頻脈病史，與複雜發紺性先天性心臟病，特別是側畸症與大血管轉位，是術後發生上心室頻脈的危險因子。術後上心室頻脈可能造成血液動力學不穩定，但對藥物治療反應佳，並未增加術後短期重大併發症與死亡率。
並列摘要
Background Supraventricular tachycardia (SVT) was occasionally seen in early postoperative period, but its significance, treatment, and clinical course were not clear. We aimed to clarify its natural history and clinical outcome, and to identify the risk factors. Methods Patients with congenital heart disease (CHD) and received CHD surgery in National Taiwan University Hospital between 2010/1 and 2015/12 were enrolled. We performed retrospective medical records review focusing on patients’ characteristics, previous bypass surgery and SVT history, perioperative hemodynamic condition and length of hospital stay. SVT types, treatment response and outcome were collected. The definition of SVT includes atrial arrhythmia and paroxysmal supraventricular tachycardia. Early postoperative period was defined as the time during postoperative ICU stay. Results Of 1404 CHD patients who received 1650 CHD surgeries, 32 patients developed SVT after 33 surgeries (incidence 2.0%). Patients with heterotaxy syndrome and transposition of great arteries (TGA) had highest incidence (9.7% and 6.6%). Among the 32 patients with postoperative SVT, 24 (75%) belonged to cyanotic cardiac anomalies, 10 (30%) patients had at least two times cardiac surgery history, and 7 (22%) patients had previous SVT history. The preoperative condition was hemodynamically unstable in 16 patients (50%) with 2 required extracorporeal membranous oxygenator support after surgery. SVT history before surgery (OR: 16.8, 95% CI: 4.7–53.8) and cyanotic cardiac anomaly (OR: 3.1, 95% CI: 1.4–7.8), especially heterotaxy syndrome (OR: 6.9, 95% CI: 2.0–25.3) and TGA (OR: 3.7, 95% CI: 1.0–13.9), were independent risk factors of development of SVT during the early postoperative stage. The SVT was controlled by single dose intravenous adenosine in 7, and intravenous amiodarone in 22. Four patients needed direct current cardioversion due to critical hemodynamics. Patients with postoperative SVT had significantly longer hospital stay than those without SVT (median 27 vs. 21 days, p=0.002), but the perioperative mortality did not increase (6.3% vs. 6.0%). Maintenance oral antiarrhythmic agents were needed in 31 of 32 patients. Median treatment duration was 137 days (range 7–881 days), and the medication could be discontinued in 19 (56%) patients with only one recurrence (5.3%). Conclusion Early postoperative SVT is not uncommon in CHD surgery. Patients with SVT history and complex cyanotic CHD were risk factors for SVT. Postoperative SVT may compromise hemodynamics, but after medical control, associated morbidity and mortality were low.
參考文獻
延伸閱讀
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