The "natural history" of segmental wall motion abnormalities in patients undergoing noncardiac surgery. S.P.I. Research Group.
The "natural history" of segmental wall motion abnormalities in patients undergoing noncardiac surgery. S.P.I. Research Group.
复制标题
接受非心脏手术的患者节段性室壁运动异常的“自然史”。
DOI：
10.1097/00000542-199010000-00010
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发表时间：
1990
期刊：
影响因子：
8.8
通讯作者：
Mangano,DT
中科院分区：
文献类型：
--
作者：
London,MJ;Tubau,JF;Wong,MG;Layug,E;Hollenberg,M;Krupski,WC;Rapp,JH;Browner,WS;Mangano,DT
经食管超声心动图（TEE）检测术中节段性壁运动异常（SWMA）是敏感的，但并不总是特异性的心肌缺血标志物。为了确定其发生率、特点及其与术后心脏发病率的关系，我们对156例接受非心脏手术的高危患者连续记录左心室短轴位和12导联心电图。临床盲法监测。壁运动在预先定义的临床、血流动力学和ECG事件中进行评分，并定期间隔（每位患者26+/-11个样本）。我们在32例（20%）患者中检测到44次新的或恶化的SWMA发作。大多数发作的严重程度限于严重运动不足（24/44,55%），其次是运动不足（16/44,36%）和运动障碍（4/44,9%）。其余124例患者壁运动正常或仅轻度运动不足（56/156,36%）或慢性SWMA（68/156, 44%）。已知冠状动脉疾病（CAD）患者和只有心脏危险因素的患者的新SWMA发生率没有差异（22%对19%，P=不显著），尽管CAD患者的慢性SWMA发生率明显更高（62%对41%，P= 0.02）。主动脉血管手术期间新发或加重SWMA的发生率显著高于手术期间（38% vs. 17%， P= 0.05）。大约40%的新TEE改变发生在没有明显临床事件或收缩压或心率显著变化的情况下。10例患者有新的或恶化的SWMA持续到手术结束，8例有新的运动，只有1例发生心肌梗死。在这个队列中，新发或恶化的SWMA和术中明显ST-T改变的分布（n= 19）是不一致的：只有5例患者出现了时间重叠。5例（3.2%）患者发生严重心脏并发症，均行外周血管重建术。所有心脏并发症和新的或恶化的SWMA患者也有术中或术后早期ST-T改变。我们的结论是：1)在这一高危组患者中，连续TEE记录和离线分析显示，新发或恶化的SWMA发生率相对较低（20%），其中大多数发作以严重运动不足为特征（55%）；2)在主动脉血管手术患者中发作更为常见；3)约40%的发作未伴有临床事件或明显的血流动力学改变；4)发作与术后心脏并发症相关性较差；5) TEE与心电图变化之间的不一致关系需要在临床上使用TEE时仔细监测心电图。
Intraoperative segmental wall motion abnormalities (SWMA) detected by transesophageal echocardiography (TEE) are sensitive, but not always specific, markers of myocardial ischemia. To determine their incidence, characteristics, and relation to postoperative cardiac morbidity, we continuously recorded the left ventricular short-axis view and 12-lead ECG in 156 high-risk patients undergoing non-cardiac surgery. Monitoring was clinically blinded. Wall motion was scored at predefined clinical, hemodynamic, and ECG events and at periodic intervals (26+/-11 samples per patient). We detected 44 episodes of new or worsened SWMA in 32 patients (20%). The severity of most episodes was limited to severe hypokinesis (24/44, 55%) followed by akinesis (16/44, 36%) and dyskinesis (4/44, 9%). The remaining 124 patients had normal wall motion or only mild hypokinesis (56/156, 36%) or chronic SWMA (68/156, 44%). The incidence of new SWMA did not differ for patients with known coronary artery disease (CAD) and those with cardiac risk factors only (22% vs. 19%, P= not significant), although CAD patients had a significantly greater incidence of chronic SWMA (62% vs. 41%, P= 0.02). The incidence of new or worsened SWMA was significantly greater during aortic vascular surgery (38% vs. 17%, P= 0.05). Approximately 40% of all new TEE changes occurred in the absence of either an apparent clinical event or a significant change in systolic blood pressure or heart rate. Ten patients had new or worsened SWMA persisting until the end of surgery, 8 with new akinesis, only 1 developing myocardial infarction. The distribution of new or worsened SWMA and significant intraoperative ST-T changes (n= 19) in this cohort was discordant: temporal overlap between modalities was present in only 5 patients. Major cardiac complications occurred in 5 patients (3.2%), all of whom underwent peripheral vascularization. All patients with cardiac complications and new or worsened SWMA also had intraoperative or early postoperative ST-T changes. We conclude that: 1) continuous TEE recording with offline analysis in this high-risk group of patients revealed a relatively low incidence of new or worsened SWMA (20%), most episodes of which were characterized by severe hypokinesis (55%); 2) episodes were more common in patients undergoing aortic vascular surgery; 3) approximately 40% of episodes were unaccompanied by clinical events or significant hemodynamic changes; 4) episodes were poorly correlated with postoperative cardiac complications; and 5) the discordant relation between TEE and ECG changes observed here necessitates careful monitoring of the ECG when TEE is used clinically.