Li Wei, Somerville Jane, Gibson Derek G, Henein Michael Y
Royal Brompton Hospital and Imperial College School of Medicine, London University, London, United Kingdom.
Am Heart J. 2002 Jul;144(1):173-9. doi: 10.1067/mhj.2002.123315.
To assess the effect of atrial flutter (AFL) on exercise tolerance in patients with grown-up congenital heart (GUCH), exercise tests with modified Bruce protocol were performed in 20 patients aged 21 to 62 years with GUCH (11 females, 9 males) during symptomatic AFL and again 24 to 48 hours after DC conversion to sinus rhythm (SR). At the same time, cardiac function was assessed by means of transthoracic Doppler echocardiography.
Mean exercise duration was significantly less during AFL (6.4 +/- 4.1 min) versus SR (10.9 +/- 3.7 min) (P <.001). Heart rate was faster at rest and peak exercise while in AFL (106 +/- 21 beats/min vs 77 +/- 14 beats/min, P <.001, and 157 +/- 31 beats/min vs 129 +/- 24 beats/min, P <.01, respectively). Systolic blood pressure was lower at peak exercise with AFL (112 +/- 25 mm Hg vs 137 +/- 24 mm Hg, P <.001), as was mean blood pressure increase (5.3 +/- 24.3 mm Hg vs 22.6 +/- 15.8 mm Hg) compared with SR (P <.01). Four of the 6 patients after Fontan surgery had a decrease of 16 mm Hg in systolic blood pressure at peak exercise when in AFL. The reasons for exercise termination during AFL were mainly breathlessness, chest pain, or presyncope, whereas in SR it was caused by fatigue. Echocardiography during AFL showed shorter isovolumic relaxation time (40 +/- 20 ms) compared with SR (50 +/- 20 ms) (P <.05). Ventricular long-axis excursion was reduced (left 1.0 +/- 0.3 cm vs 1.2 +/- 0.4 cm, septal 0.5 +/- 0.2 cm vs 0.7 +/- 0.3 cm, and right 0.7 +/- 0.2 cm vs 0.9 +/- 0.4 cm respectively, P <.001 for all), as were peak pulmonary and aortic flow velocities (85 +/- 30 cm/s vs 105 +/- 50 cm/s, P <.001, and 137 +/- 118 cm/s vs 143 +/- 114 cm/s, P <.02) compared with sinus rhythm. There was a close correlation between exercise duration and blood pressure increase (r = 0.6), left-sided long-axis excursion and blood pressure increase (r = 0.57), and between aortic flow velocity and right-sided long-axis excursion (r = 0.71).
Atrial flutter causes dramatic reduction in exercise tolerance in patients with GUCH, and the combination of fast heart rate and hypotension may contribute to the development of presyncope, particularly in those with Fontan surgery. Marked improvement in effort tolerance and cardiac dynamics occurs after regaining SR. Thus, improving the quality of life in patients with GUCH requires maintaining SR.
为评估心房扑动（AFL）对成人先天性心脏病（GUCH）患者运动耐量的影响，对20例年龄在21至62岁的GUCH患者（11例女性，9例男性）进行了改良Bruce方案运动试验，分别在有症状的AFL期间以及直流电转复为窦性心律（SR）后24至48小时进行。同时，通过经胸多普勒超声心动图评估心功能。
与SR（10.9±3.7分钟）相比，AFL期间平均运动持续时间显著缩短（6.4±4.1分钟）（P<.001）。在AFL期间，静息和运动高峰时心率更快（分别为106±21次/分钟对77±14次/分钟，P<.001；以及157±31次/分钟对129±24次/分钟，P<.01）。AFL时运动高峰时收缩压较低（112±25毫米汞柱对137±24毫米汞柱，P<.001），与SR相比，平均血压升高幅度也较低（5.3±24.3毫米汞柱对22.6±15.8毫米汞柱）（P<.01）。6例接受Fontan手术的患者中，4例在AFL时运动高峰时收缩压下降了16毫米汞柱。AFL期间运动终止的原因主要是呼吸困难、胸痛或先兆晕厥，而在SR时则是由疲劳引起。AFL期间的超声心动图显示，与SR（50±20毫秒）相比，等容舒张时间更短（40±20毫秒）（P<.05）。心室长轴偏移减少（左心室分别为1.0±0.3厘米对1.2±0.4厘米，室间隔为0.5±0.2厘米对0.7±0.3厘米，右心室为0.7±0.2厘米对0.9±0.4厘米，所有P<.001），与窦性心律相比，肺动脉和主动脉峰值流速也降低（85±30厘米/秒对105±50厘米/秒，P<.001；以及137±118厘米/秒对143±114厘米/秒，P<.02）。运动持续时间与血压升高之间（r = 0.6）、左侧长轴偏移与血压升高之间（r = 0.57）以及主动脉流速与右侧长轴偏移之间（r = 0.71）存在密切相关性。
心房扑动导致GUCH患者运动耐量显著降低，心率加快和低血压可能共同促成先兆晕厥的发生，尤其是在接受Fontan手术的患者中。恢复窦性心律后，运动耐力和心脏动力学有显著改善。因此，维持窦性心律对于提高GUCH患者的生活质量至关重要。
