二维斑点追踪技术评估川崎病患者左室功能的研究

发布时间：2018-04-26 00:00

本文选题：二维斑点追踪 + 川崎病　；参考：《兰州大学》2017年硕士论文

【摘要】：目的运用二维斑点追踪技术(two dimensional speckle tracking imaging 2DSTI)评估川崎病(Kawasaki disease KD)患者不同时期左室心肌收缩功能变化特点,分析急性期收缩期左室峰值应变及应变率与实验室指标的相关性,通过比较冠状动脉扩张KD亚组及静脉注射免疫球蛋白(intravenous immunoglobulin IV IG)抵抗KD亚组分别与其相应对立组左室参数及实验室指标来获得各亚组左室心肌收缩功能特点,通过受试者工作曲线(receiver operating characteristics ROC))获得IVIG抵抗KD患者左室收缩期峰值应变预测值。方法于2015年1月至2016年10月连续选取兰州大学第二医院儿童医院小儿心血管科急性期诊断为KD住院患者80例,并进一步分为冠状动脉扩张亚组(左、右冠状动脉主干及左前降支中有一支内径Z值2.5)、IVIG抵抗(IVIG治疗后持续发热或体温下降后又复发且超过36小时者)亚组,同期选取50例年龄性别相匹配来我院以心脏杂音就诊但超声心动图检查结果正常儿童作为对照组。运用常规超声心动图及2DSTI技术分别于急性期(IV IG前)、亚急性期(IV IG后1周)及恢复期(IV IG后8周)获取常规参数及收缩期左室整体峰值纵向应变(systolic global longitudinal strain GLS)及应变率(systolic global longitudinal strain rate GLSR)、收缩期整体峰值环向应变(systolic global circumferential strain GCS)及应变率(systolic global circumferential strain rate GCSR)、收缩期左室各节段峰值纵向应变及应变率、各节段环向应变及应变率。1对比分析:1)各时期整体KD患者各参数与正常对照组对比。2)整体KD患者不同时期间各参数对比。3)急性期冠状动脉扩张亚组各参数与正常对照组对比,冠状动脉扩张亚组各参数与冠状动脉正常亚组对比。4)急性期IVIG抵抗亚组各参数与对照组比较,IVIG抵抗亚组各参数与IVIG应答亚组比较。5)急性期冠状动脉扩张亚组实验室指标与冠状动脉正常亚组比较;急性期IVIG抵抗亚组实验室指标与IVIG应答亚组比较。2相关性分析:急性期整体KD患者收缩期左室整体应变及应变率与其它指标相关性分析。3 ROC曲线:急性期IVIG抵抗亚组收缩期左室GLS曲线获取IVIG抵抗预测值。结果一整体KD患者各参数与正常对照组比较结果、整体患者各时期间参数比较结果及急性期患者收缩期左室GLS、GLSR与其它指标相关性分析。1)常规超声心动图示:与正常对照组相比,急性期整体KD患者左室Tei指数、左室质量(left ventricular mass LVM)、左室质量指数(left ventricular mass index LVMI)、E/Em(二尖瓣口舒张早期流速/二尖瓣环室间隔侧组织多普勒速度)、左冠状动脉(left coronary artery LCA)、右冠状动脉(right coronary artery RCA)、左前降(left anterior descending LAD)支内径均升高,差异均有统计学意义(P均0.05),亚急性期LVMI、LCA、E/Em仍较高(P均0.05),恢复期各参数间无差异;亚急性期KD患者左室Tei指数、LVM及LVMI均低于急性期(P均0.05),余参数各时期间未见明显差异。2)2DSTI示:与对照组相比,急性期整体KD患者左室GLS、基底段纵向应变、中间段纵向应变、GCS及心尖段环向应变均减低(P均0.05),亚急性期左室GLS及中间段纵向应变开始升高但仍较低(P均0.05),恢复期各参数间无明显差异;与急性期相比,亚急性期KD患者收缩期左室GLS、基底段纵向应变、GCS及心尖段环向应变均升高(P均0.05)。3)相关性分析:急性期左室收缩期GLS与E/Em、LVMI、C型反应蛋白(C-reactive protein CRP)、红细胞沉降率(erythrocyte sedimentation rate ESR)、白细胞(white blood cell WBC)、谷丙转氨酶(alanine transaminase ALT)均呈负相关(r分别=-0.66、-0.61、-0.59、-0.67、-0.64、-0.69 P均0.05),与其它参数未见明显相关性;亚急性期及恢复期左室GLS与其它变量均未见明显相关性。二亚组分析结果1)与对照组相比,急性期冠状动脉扩张组收缩期左室GLS、GLSR、基底段纵向应变、基底段纵向应变率、中间段纵向应变均低于对照组(P均0.05)。与冠状动脉正常组相比,冠状动脉扩张组ESR、CRP、ALT及AST均升高(P均0.05),余参数比较未见明显差异。2)与对照组相比,IVIG抵抗组左室Tei指数、E/Em及LVMI升高(P均0.05),收缩期左室GLS、GLSR、基底段纵向应变、心尖段纵向应变、基底段纵向应变率、心尖段纵向应变率均减低(P均0.05)。与IVIG应答组相比,IVIG抵抗组左室Tei指数、E/Em、ALB、ESR、CRP、ALT及PLT均升高(P均0.05),左室GLS及基底段纵向应变均减低(P均0.05),余参数比较未见明显差异。3)ROC曲线分析结果:收缩期左室GLS绝对值16.8%为IVIG抵抗较好的预测值(曲线下面积0.79,灵敏度0.76,特异度0.63)。结论1.整体KD患者急性期收缩期左室应变明显减低,亚急性期开始恢复,恢复期上升至正常范围,该技术对合理指导临床用药及随访有重要的作用。2.尽管KD患者急性期常规超声心动图测得LVEF及LVFS值均在正常范围,但收缩期左室GLS及GCS已出现减低,其可能是更能早期反映心肌损伤的敏感指标,2DSTI技术能对临床早期诊断KD提供重要辅助诊断信息。3.急性期KD患者减低的收缩期左室GLS与升高的实验室炎性指标呈负相关,而未见与冠状动脉扩张相关,提示急性期KD患者左室心肌收缩功能减低是心肌组织炎性损伤的结果,冠状动脉扩张可能不是急性期KD患者左室收缩功能受损加重的因素。4.IVIG抵抗患者心肌受损更严重,恢复时间较长,提示临床治疗时间、药量及种类应增加,2DSTI技术可能对IVIG抵抗患者预测有一定的帮助。总之该技术在及时为临床提供辅助诊断信息、指导用药、降低冠状动脉损伤发生率、远期随访等方面有重要的应用价值。
[Abstract]:Objective to evaluate the changes of left ventricular systolic function in patients with Kawasaki disease (Kawasaki disease KD) (two dimensional tracking imaging 2DSTI) in different periods of Kawasaki disease (Kawasaki disease KD), and to analyze the correlation between the peak strain and strain rate of the left ventricle in acute systole and the laboratory index, and compare the coronary artery dilatation KD subgroup. And intravenous immunoglobulin (intravenous immunoglobulin IV IG) resisted the left ventricular systolic function of each subgroup with the left ventricular parameters and laboratory indexes of the corresponding antagonistic group, respectively, to obtain the left ventricular systolic peak value of IVIG resistance to KD patients through the subjects' working curve (receiver operating characteristics ROC). Methods from January 2015 to October 2016, 80 hospitalized patients with KD in the pediatric cardiology department of the Second Hospital Affiliated to Lanzhou University children's hospital were selected and further divided into the coronary artery dilatation subgroup (left, right coronary artery and left anterior descending branch with an internal diameter of Z 2.5), and IVIG resistance (continuous hair after IVIG treatment). The subgroup had a relapse and more than 36 hours after the heat or temperature decline. In the same period, 50 cases of age and sex were matched in our hospital. The normal children were treated with heart murmur, but the normal children were used as the control group. The routine echocardiography and 2DSTI technique were used in the acute phase (before IV IG), the subacute phase (1 weeks after IV IG) and the recovery period (IV IG). After 8 weeks, the conventional and systolic left ventricular overall peak longitudinal strain (systolic global longitudinal strain GLS) and strain rate (systolic global longitudinal strain rate GLSR) were obtained. Ate GCSR), the peak longitudinal strain and strain rate of each segment of the left ventricle in systole, the comparison of the cyclic strain and the strain rate of.1 in each segment: 1) the parameters of the whole KD patients were compared with the normal control group.2) the whole KD patients were compared with the parameters of.3) the parameters of the acute coronary artery dilatation subgroup were compared with the normal control group, and the coronary movement was compared with the normal control group. Comparison of the parameters of the pulse dilatation subgroup and the normal subgroup of the coronary artery.4) the parameters of the IVIG resistance subgroup in the acute phase were compared with the control group. The parameters of the IVIG resistance subgroup were compared with the IVIG response subgroup,.5) the laboratory index of the acute coronary artery dilatation subgroup was compared with the normal coronary artery subgroup, and the laboratory index of the acute phase IVIG resistance subgroup and the IVIG should be in the acute phase. The.2 correlation analysis: the correlation analysis of the overall left ventricular strain and strain rate in the acute phase of the acute phase of KD patients with the other indices analysis of the.3 ROC curve: the systolic left ventricular GLS curve in the acute phase IVIG resistance subgroup obtained the predictive value of IVIG resistance. Results a whole KD patient was compared with the normal control group, and the whole patient was in every period. Compared with the normal control group, the left ventricular Tei index, the left ventricular mass (left ventricular mass LVM) and the left ventricular mass index (left ventricular mass) (left ventricular mass) were compared with the normal control group (.1) in the acute phase of the systolic left ventricular GLS, GLSR and other indexes. Left coronary artery LCA, left coronary artery (right coronary artery RCA) and left anterior descending (left anterior descending LAD) branch increased in the early flow velocity / mitral annular spacer lateral tissue, the left anterior descending (left anterior descending LAD) branch increased, the difference was statistically significant (all 0.05). The subacute period was still higher (0.05), and the recovery period was still higher. There was no difference between the parameters. The left ventricular Tei index, LVM and LVMI in the subacute KD patients were lower than the acute phase (P 0.05), and the residual parameters were not significantly different from.2) 2DSTI. Compared with the control group, the left ventricular GLS, the longitudinal strain of the basal segment, the longitudinal strain of the middle segment, the GCS and the apical circumferential strain were reduced (P 0.05), and the subacute phase of the acute phase of KD patients. The longitudinal strain of GLS and middle segment in the left ventricle began to rise but still was low (P 0.05), and there was no significant difference between the parameters of the recovery period. Compared with the acute phase, the systolic left ventricular GLS, the longitudinal strain of the basal segment, the GCS and the apical circumferential strain increased (P 0.05).3) in the subacute phase of KD patients: the acute phase of the left ventricular systolic GLS and E/Em, LVMI, C. C-reactive protein CRP, erythrocyte sedimentation rate (erythrocyte sedimentation rate ESR), leukocyte (white blood cell WBC) and alanine aminotransferase are all negative correlation, and no significant correlation with other parameters; subacute phase and recovery period There was no significant correlation between left ventricular GLS and other variables. Two subgroup analysis 1. Compared with the control group, the left ventricular GLS, GLSR, the longitudinal strain of the basal segment, the longitudinal strain rate of the basal segment and the longitudinal strain of the middle segment were lower than the control group (P 0.05) in the acute phase of coronary artery dilatation. Compared with the normal coronary artery group, the coronary artery dilatation group was ESR, C RP, ALT and AST were all increased (P 0.05). Compared with the control group, the left ventricular Tei index in the IVIG resistance group, E/Em and LVMI increased (P 0.05), the systolic left ventricular GLS, the longitudinal strain of the basement segment, the apical longitudinal strain, the longitudinal strain rate of the basal segment, and the longitudinal strain rate of the apical segment decreased (0.05). Compared with the IVIG resistance group, the left ventricular Tei index, E/Em, ALB, ESR, CRP, ALT and PLT were all increased (P 0.05), the longitudinal strain of the left ventricular GLS and the basal segment decreased (P 0.05), and the residual parameter was not significantly different from the.3) curve analysis results: the systolic left ventricular absolute value 16.8% was a better prediction value (the area under the curve is 0.79, the sensitivity is 0.76, and the specificity is 0.76. Degree 0.63). Conclusion 1. KD patients with acute systolic left ventricular strain significantly decreased, subacute phase began to recover, and the recovery period increased to normal range. This technique had an important role in rational guidance for clinical medication and follow-up. Although the values of LVEF and LVFS in KD patients were measured in normal range of LVEF and LVFS in acute stage of acute phase, but the systolic left ventricular GL S and GCS have decreased. It may be a sensitive indicator of early myocardial damage. 2DSTI technology can provide important diagnostic information for early clinical diagnosis of KD..3. in the acute phase of KD patients with reduced systolic left ventricular GLS is negatively correlated with elevated laboratory inflammatory markers, but not associated with coronary artery dilatation, suggesting acute KD suffering. The decrease of systolic function in left ventricular myocardium is the result of inflammatory injury of myocardial tissue. Coronary dilatation may not be a factor of exacerbation of left ventricular systolic function in patients with acute KD,.4.IVIG resistance patients with more severe myocardial damage and longer recovery time suggest that the time of clinical treatment, the amount of drugs and types should be increased, and 2DSTI technology may be resistant to IVIG. In a word, the technique is of great value in providing auxiliary diagnosis information in time, guiding drug use, reducing the incidence of coronary artery injury, and long term follow-up.

【学位授予单位】：兰州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R725.4;R540.45

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