儿童暴发性心肌炎12例临床分析

目的 探讨儿童暴发性心肌炎的临床特点及诊治策略.方法 对2007年1月至2011年12月在本院住院治疗的12例暴发性心肌炎病例进行回顾性分析.结果 男3例,女9例.年龄1个月～14岁,其中1个月～1岁5例,6岁以上5例.发病季节5月～9月8例.首发症状以精神反应差、呕吐、气促、面色苍白或发绀、发热多见.8例患儿初诊时被误诊.所有患儿CK-MB、肌钙蛋白升高,伴有心电图异常,表现为ST-T改变及低电压(9例)、传导阻滞(7例)、心律失常(8例).12例心脏彩超见左室收缩和舒张功能减低.7例X线胸片见心影增大.确诊后给予抗病毒、营养心肌、抗心力衰竭、抗休克、纠正心律失常、早期静脉滴注甲泼尼龙和大剂量丙种球蛋白,并给予镇静、吸氧等对症支持治疗.10例呼吸机辅助通气.7例安装心脏临时起搏器.经治疗,7例治愈或好转出院,目前随访一般情况良好,无活动受限的表现.病死率41.7％.结论 暴发性心肌炎起病急,进展迅速,病死率高,表现缺乏特异性,部分患儿以心外表现起病,易误诊,若能尽早诊断和及时抢救,预后相对较好.     

儿童暴发性心肌炎的临床特点及预后的影响因素

目的 调查儿童暴发性心肌炎的临床特点及预后的影响因素,为临床诊治及预后评估提供参考。方法 回顾性分析24例暴发性心肌炎患儿的临床资料。根据患儿预后分为存活组(n=12)和死亡组(n=12)。应用logistic回归分析筛选出影响暴发性心肌炎患儿预后的危险因素。结果 24例暴发性心肌炎患儿中,入院首发症状为消化系统症状者14例,神经系统症状12例,呼吸系统症状1例,循环系统症状2例。入院时血清肌酸激酶MB同工酶、肌钙蛋白I、脑钠肽水平均升高;左室射血分数减低22例(92%);心胸比值增大10例;Ⅲ度房室传导阻滞8例,ST段改变11例,室性心律2例。死亡组患儿左室射血分数低于存活组(PPOR=7.418,P结论 儿童暴发性心肌炎临床特点缺乏特异性。左室射血分数减低是暴发性心肌炎患儿预后不良的危险因素。     

临时心脏起搏在儿童暴发性心肌炎合并完全房室传导阻滞抢救中的应用(附三例报告)

目的 总结儿童暴发性心肌炎合并完全房室传导阻滞时临时心脏起搏的救治经验.方法 对3例植入临时心脏起搏器的暴发性心肌炎合并完全房室传导阻滞患儿的临床资料进行回顾分析,观察其临床疗效.结果 3例患儿中,2例在发病后及时就诊并积极安装临时心脏起搏器后好转;1例因发病时间较长,出现脏器功能衰竭而死亡.结论 对暴发性心肌炎合并完全房室传导阻滞患儿,应积极植入临时心脏起搏器,使患儿迅速改善血流动力学,安全度过危险期,改善预后.     

小儿病毒性心肌炎心电图改变及其临床意义

目的 探讨小儿病毒性心肌炎心电图改变的常见类型、在诊断中的价值及其对预后的影响.方法 依照我国现行的小儿病毒性心肌炎诊断标准对中国医科大学第一医院1990-2007年收治的病例进行筛查、核准,对符合诊断标准的147例患儿的临床资料进行回顾性总结、分析.结果 出现各种心律失常者137例(占93.2%),其中伴有s-T段、T波改变者25例,仅有S-T段、T波改变者10例(占6.8%).在心律失常中过早搏动91例(室性早搏55例,房性早搏31例,交界性早搏5例);异位性心动过速及房室颤动13例;传导阻滞44例(房室传导阻滞29例,束支传导阻滞14例,窦房传导阻滞1例);窦性心律失常22例.结论 小儿病毒性心肌炎的心电图改变以各种心律失常(尤其是过早搏动、传导阻滞)最常见,少部分病例可仅有S-T段、T波改变;心电图改变是诊断心肌炎的一个重要条件;出现异位性心动过速和(或)Ⅲ度房室传导阻滞或显著的S-T段、T波改变多提示病情严重、预后不佳.     

小儿急性心肌梗死样重症心肌炎临床分析

目的探讨小儿急性心肌梗死样重症心肌炎临床表现及预后。方法回顾性分析4例心电图有类似急性心肌梗死时ST T改变,心肌酶谱异常增高,误诊为“急性心肌梗死”患儿的病史、心电图、心肌酶谱、心律失常、心功能不全等临床表现。结果4例患儿入院时均误诊为“急性心肌梗死”。2例并发III度房室传导阻滞,其中1例出现阿斯综合征,抢救无效死亡。1例窦性心动过速误诊为室性心动过速而应用电复律死亡。1例出现心源性休克。结论当急性重症心肌炎患儿心电图、心肌酶谱出现急性心肌梗死样改变时,病情凶险,病死率极高。要结合既往史、临床表现及时作出正确诊断和处理。     

小儿急性心肌梗死样重症心肌炎临床分析

目的探讨小儿急性心肌梗死样重症心肌炎临床表现及预后。方法回顾性分析4例心电图有类似急性心肌梗死时ST-T改变。心肌酶谱异常增高，误诊为“急性心肌梗死”患儿的病史、心电图、心肌酶谱、心律失常、心功能不全等临床表现。结果4例患儿入院时均误诊为“急性心肌梗死”。2例并发Ⅲ度房室传导阻滞，其中1例出现阿斯综合征，抢救无效死亡。1例窦性心动过速误诊为室性心动过速而应用电复律死亡。1例出现心源性休克。结论当急性重症心肌炎患儿心电图、心肌酶谱出现急性心肌梗死样改变时，病情凶险，病死率极高。要结合既往史、临床表现及时作出正确诊断和处理。     

急性心肌梗死样心电图改变的儿童暴发性心肌炎临床分析

目的 报告3例酷似心肌梗死样心电图改变的暴发性心肌炎患儿诊治经过,以提高对儿童暴发性心肌炎的认识和临床诊疗水平.方法 根据患儿的症状、体征、心电图、心肌酶谱及心脏超声检查结果进行诊断,并结合文献资料进行分析.结果 3例患儿经积极救治,2例死亡,1例痊愈.结论 心电图酷似心肌梗死样改变的儿童暴发性心肌炎病情危重,可迅速进展导致死亡,临床应早期识别、积极救治,并进行深入研究.血清肌钙蛋白Ⅰ升高可能是早期识别病情及判断预后的重要指标之一.     

急性心肌梗死样心电图改变的儿童暴发性心肌炎临床分析

目的 报告3例酷似心肌梗死样心电图改变的暴发性心肌炎患儿诊治经过,以提高对儿童暴发性心肌炎的认识和临床诊疗水平.方法 根据患儿的症状、体征、心电图、心肌酶谱及心脏超声检查结果进行诊断,并结合文献资料进行分析.结果 3例患儿经积极救治,2例死亡,1例痊愈.结论 心电图酷似心肌梗死样改变的儿童暴发性心肌炎病情危重,可迅速进展导致死亡,临床应早期识别、积极救治,并进行深入研究.血清肌钙蛋白Ⅰ升高可能是早期识别病情及判断预后的重要指标之一.     

慢性心律失常儿童病因、治疗与预后的关系

目的 探讨儿童慢性心律失常的病因、治疗与预后的关系.方法 2003年9月-2006年10月收治的40例48 h～12岁患儿均有头晕、晕厥、阿-斯发作、心源性休克等临床表现,2次以上心电图(ECG)证实为完全性房室传导阻滞(CAVB)33例、窦性心动过缓5例、病窦综合征2例,并持续3 d.先天性CAVB无临床症状未行治疗,对病毒性心肌炎导致的CAVB、窦性心动过缓、病窦综合征,予抗病毒、能量合剂等治疗的同时,静脉予大剂量维生素C、异丙肾上腺素、大剂量地塞米松,部分患儿应用人血丙种球蛋白治疗,对上述治疗效果不佳的8例安置临时起搏器,其中2例安置永久性起搏器.结果 治愈28例,好转9例,死亡3例.其中治愈和好转患儿中6例均安置了永久性或临时起搏器.结论 早发现、早诊断、早期正规治疗并及时安置临时起搏器预后好;延误治疗的暴发性病毒性心肌炎、扩张型心肌病所致CAVB预后差.     

新生儿心律失常的临床分析

目的总结新生儿心律失常的类型、临床特征、治疗和预后。方法收集1999年1月~2005年11月在我院新生儿科住院的心律失常患儿14例,回顾性分析病历资料。结果阵发性室上性心动过速(室上速)4例,其中2例单纯阵发性室上速心律平治疗有效;1例伴房间隔缺损、窦房结功能不良I、I度II型窦房传导阻滞,放弃治疗;1例伴肺炎克雷伯杆菌败血症、低钾血症,对因治疗后复律。房室传导阻滞5例,其中1例低血钙致II度II型房室传导阻滞,补钙后治愈;2例III度房室传导阻滞死亡;2例放弃治疗。紊乱性房性心动过速5例,1例房间隔缺损,其余4例均无器质性心脏病;1例伴窦房结功能不良、心室扑动并发心力衰竭死亡,其余4例均未并发心力衰竭或心室率增快,随访半年,3例痊愈,1例偶有房性早搏。结论阵发性室上速常见于无器质性心脏病患儿,心律平复律效果好。房室传导阻滞的预后与病因、病情严重程度和及时诊治有关。紊乱性房性心动过速多不伴有器质性心脏病,而且对于不并发心力衰竭或心室率增快的患儿预后良好。     

CD8 + T-LYMPHOCYTES INFILTRATE THE MYOCARDIUM IN FULMINANT HERPES VIRUS MYOCARDITIS

We report two cases of fulminant viral myocarditis in previously healthy children. They were caused by herpes simplex virus (HSV)-1 (in a boy aged 3 years) and Epstein-Barr virus (EBV) (in a boy aged 12 months). We obtained the diagnosis of HSV-1 myocarditis by immunohistochemistry and the diagnosis of EBV myocarditis by in situ hybridization. Histologic examination of heart tissue from the two boys revealed mononuclear cell infiltration of the myocardium. Immunohistochemical staining identified these cells as CD8 + T-lymphocytes. CD8 + T-lymphocytes induced by herpes virus infections may play an important role in the damage to heart muscle fibers seen in fulminant myocarditis in previously healthy children. To our knowledge, this is the first report of HSV-1 or EBV myocarditis (at least in children) in which viral infection has been demonstrated in the myocardium.     

CD8+ T-lymphocytes infiltrate the myocardium in fulminant herpes virus myocarditis

We report two cases of fulminant viral myocarditis in previously healthy children. They were caused by herpes simplex virus (HSV)-1 (in a boy aged 3 years) and Epstein-Barr virus (EBV) (in a boy aged 12 months). We obtained the diagnosis of HSV-1 myocarditis by immunohistochemistry and the diagnosis of EBV myocarditis by in situ hybridization. Histologic examination of heart tissue from the two boys revealed mononuclear cell infiltration of the myocardium. Immunohistochemical staining identified these cells as CD8+ T-lymphocytes. CD8+ T-lymphocytes induced by herpes virus infections may play an important role in the damage to heart muscle fibers seen in fulminant myocarditis in previously healthy children. To our knowledge, this is the first report of HSV-1 or EBV myocarditis (at least in children) in which viral infection has been demonstrated in the myocardium.     

小儿暴发性心肌炎危险因素分析

目的：通过对小儿病毒性心肌炎临床表现、体征以及实验室检查指标等方面进行回顾性分析研究,以探讨小儿暴发性心肌炎的危险因素。方法：收集临床诊断为病毒性心肌炎患儿资料71例,分为暴发性心肌炎组(n=16)和非暴发性心肌炎组(n=55),采用χ2检验或t检验对两组患儿入院时的临床表现、心电图、心脏B超与血清生化检查等各项指标进行回顾性分析,对有统计学意义的相关因素,进行logistic多元回归分析,研究暴发性心肌炎的独立高危因素。结果：暴发性心肌炎组死亡率远高于非暴发性心肌炎组（50% vs 0%）。急性病毒性心肌炎患儿入院时血压降低、血清CK-MB水平升高、cTnI阳性、心电图QRS波时限延长、ST段改变、完全性房室传导阻滞、完全性左束支传导阻滞,以及左室射血分数和左室短轴缩短率降低与心肌炎暴发阶段密切相关。QRS波群时限延长（OR＝1.139;CI＝1.014~1.279; P<0.05）和左心室射血分数降低（OR＝0.711;CI＝0.533~0.949;P<0.05）是小儿暴发性心肌炎的独立阳性预测因素。结论：暴发性心肌炎死亡率高。入院时QRS波群时限延长和左心室射血分数降低是小儿暴发性心肌炎的独立危险因素。［中国当代儿科杂志,2009,11（8）：627-630］     

The challenges of prompt identification and resuscitation in children with acute fulminant myocarditis: case series and review of the literature

Aim: To describe the clinical presentation, triage, resuscitation and outcome of acute fulminant myocarditis in children presenting to district hospitals and referred for cardiac intensive care. Methods: Case series describing five patients (from 2 weeks to 12 years old) with a diagnosis of acute fulminant myocarditis, presented to outlying hospitals between December 2006 and December 2007 and retrieved to a cardiac intensive care unit. Results: All children were admitted with non‐specific symptoms such as vomiting, cough and poor feeding to their local hospital, where various provisional diagnoses such as viral gastroenteritis, bronchitis or renal failure were considered. Acute physiological deterioration usually prompted the referral for intensive care. Two children died at the referring hospital during stabilisation by the retrieval team. Three children survived transport to intensive care and to hospital discharge; two received mechanical support and one underwent urgent orthotopic heart transplantation. Enterovirus and parvovirus were identified as causative agents in two patients. In one case, macrophage activation syndrome was diagnosed although no clear viral trigger was identified. Median length of hospitalisation among survivors was 33 days, and mechanical cardiac support was required for a median of 12 days. Conclusions: The diagnosis and initial management of acute fulminant myocarditis is extremely challenging. Prognosis for patients admitted to a cardiac centre for early mechanical support can be very favourable, while a delay in considering the diagnosis may result in poor outcome. The diagnosis of myocarditis should be considered in any previously well child presenting with a viral prodrome and non‐specific organ dysfunction associated with dysrhythmias, shock or acute heart failure, even in the absence of cardiomegaly.     

Circulating cardiac troponins levels and cardiac dysfunction in children with acute and fulminant viral myocarditis

Objectives: To study the correlation between cardiac Troponins blood levels and degrees of cardiac dysfunction in children with acute and fulminant viral myocarditis and to study their prognostic role in predicting the outcomes and risk of having dilated cardiomyopathy. Methodology: Troponin I & T blood levels were measured in 65 children with acute or fulminant viral myocarditis. The cardiac functions of RV & LV were assessed by Doppler echocardiography. Results: The levels of cTnI & CTnT were significantly higher in patients with fulminant myocarditis than in controls and children with acute myocarditis (p < 0.05 & <0.001* respectively). The cardiac functions were significantly impaired in fulminant myocarditis than in acute myocarditis (p < 0.001*). There were negative correlations between the cardiac troponins levels and the cardiac functions measured by echocardiography in children with acute and fulminant myocarditis. There were 3 deaths (7.5%), and 10 (25%) children developed dilated cardiomyopathy in acute myocarditis while there were eight deaths (32%) and one patient (4%) who developed dilated cardiomyopathy in fulminant myocarditis group. Conclusion: Cardiac troponins levels can predict the severity of myocarditis and the prognosis on the short‐term level. Fulminant myocarditis was associated with higher levels of both cTn I & cTn T than acute myocarditis. Despite that fulminant myocarditis has a more aggressive course, the risk of developing cardiomyopathy was less than in acute myocarditis.     

体外膜肺氧合在儿童暴发性心肌炎中的应用

暴发性心肌炎是一种以急性血流动力学障碍为主要表现的急危重症,起病急、进展快,病死率高。该病目前无特效药物治疗,一般采用对症及支持疗法。近年来,体外膜肺氧合(ECMO)可为暴发性心肌炎患儿提供有效的生命支持,为心脏功能恢复赢得时间,提高该病的抢救成功率。该文就目前ECMO在儿童暴发性心肌炎中的应用和进展做一简单综述。     

儿童暴发性心肌炎的早期诊断及治疗进展

暴发性心肌炎是一种以急性血流动力学障碍为主要表现的心肌炎,临床表现多样且病死率极高。暴发性心肌炎早期诊断需依靠血清学指标、心电图、超声心动图等进行综合分析,心脏磁共振成像检查在心肌炎诊断中也具有很好的应用价值。传统的暴发性心肌炎治疗,包括对症支持、抗病毒及免疫疗法等,但对危重患儿往往难以奏效。体外膜肺氧合技术(ECMO)的开展,大大提高了儿童暴发性心肌炎的抢救成功率,成为救治儿童暴发性心肌炎的可靠手段。文章综述目前儿童暴发性心肌炎的诊断及最新治疗进展。     

Myocarditis in the setting of RSV bronchiolitis

Myocarditis in the pediatric population is commonly caused by viral pathogens, notably entero virus and adeno virus. Respiratory syncytial virus, although widespread among this population, is rarely associated with myocarditis. The incidence of myocarditis is unknown due to the variability of clinical presentation and diagnostic limitations. Data regarding prognosis is lacking in children. Patients should be monitored in a pediatric intensive care unit secondary to the risk of hemodynamic compromise. We present the case of fulminant myocarditis in a seven-month old female in the setting of respiratory syncytial virus bronchiolitis.     

Favorable Outcome of Pediatric Fulminant Myocarditis Supported by Extracorporeal Membranous Oxygenation

Myocarditis among pediatric patients varies in severity from mild disease to a fulminant course with overwhelming refractory shock and a high risk of death. Because the disease is potentially reversible, it is reasonable to deploy extracorporeal membranous oxygenation (ECMO) to bridge patients until recovery or transplantation. This study aimed to review the course and outcome of children with acute fulminant myocarditis diagnosed by clinical and echocardiographic data only who were managed by ECMO because of refractory circulatory collapse. A chart review of a single center identified 12 children hospitalized over an 8-year period who met the study criteria. Data were collected on demographics, diagnosis, disease course, and outcome. The patients ranged in age from 20 days to 8 years (25.5 ± 29.6 months). Echocardiography showed a severe global biventricular decrease in myocardial function, with a shortening fraction of 12% or less. Ten children (83.3%) were weaned off extracorporeal support after 100–408 h (mean, 209.9 ± 82.4 h) and discharged home. Two patients died: one due to multiorgan failure and one due to sustained refractory heart failure. During a long-term follow-up period, all survivors showed normal function in daily activities and normal myocardial function. The study showed that ECMO can be safely and successfully used for children with acute fulminant myocarditis diagnosed solely on clinical and radiographic grounds who need mechanical support. These patients usually have a favorable outcome, regaining normal or near normal heart function without a need for heart transplantation.