斑点追踪超声心动图对左心室功能的研究

发布时间：2018-06-22 17:43

  本文选题：二维斑点追踪超声心动图 + 应变率　； 参考：《北京协和医学院》2014年博士论文

【摘要】：背景与目的：现已有充分证据证明心脏再同步化治疗(CRT)对左室收缩功能的改善是有益的,但是CRT对舒张功能的影响尚存在争论。二维斑点追踪超声心动图应变率及解旋(untwisting)对舒张功能的评估价值得深入研究。我们研究的旨在应用2D-STE技术,结合目前常用的E/E’指标,探讨CRT不同反应程度患者2D-STE应变率参数和解旋(untwisting)与左室舒张功能之间的关系。 方法：本研究包括70名实施心脏再同步化治疗的心力衰竭患者。所有患者均符合心脏再同步化治疗现有的纳入标准,并除外心房颤动和经胸超声图像质量不佳患者。于心脏再同步化治疗前及心脏再同步化治疗后12个月分别采集二维斑点追踪超声心动图图像。我们将病人分为如下3组：A组,CRT超声心动图和临床反应组,即随访中左室收缩末容积减少≥15%；且6分钟步行距离增加≥20%,或该试验没有实施,在无死亡和心脏移植情况下,NYHA心功能分级好转≥1级；B组,CRT仅临床反应组；C组,CRT无反应组,既未达到超声心动图反应标准,也未达到临床反应标准。以舒张早期二尖瓣血流峰值流速和二尖瓣环峰值速度的比值(E/E’)作为衡量左心室充盈的指标。应用2D-STE技术获取患者舒张期早期应变率(LSRE、CSRE、RSRE和RotRE)和舒张晚期应变率(LSRA、CSRA和RSRA和RotRA)、解旋(untwisting)参数(UTRIVR、UTRE)等反映舒张功能的参数,观察这些左室舒张功能参数于心脏再同步化治疗不同反应程度间变化差异。将2D-STE所得的评估舒张功能参数与E/E’比值进行相关性分析。选择有效参数计算受试者工作特征曲线(receiver operating characteristic curve,即ROC曲线)下面积。 结果：70名患者中,41名(58.6%)患者在12个月的随访中达到了超声心动图和临床反应性的标准；15名(21.4%)患者为仅临床反应者；14名(20%)为无反应者。在A组患者中观察到大多数评估左室舒张功能的参数有所改善。B组部分常规舒张功能参数显著性改善。而在C组患者观察到逐渐恶化的E/E’值。将2D-STE所测得的舒张期应变率参数与E/E’比值分别进行线性相关分析,舒张期应变率均呈负相关,其中以LSRE的相关性最佳(r=-0.778,p0.01)。将解旋参数与E/E’比值分别进行线性相关分析,均呈负相关,其中以UTRIVR的相关性最佳(r=-0.837,p0.01)。以2D-STE所测舒张早期应变率及解旋参数预测CRT超声心动图反应与否,绘制ROC曲线。UTRIVR预测CRT超声心动图反应性的ROC曲线下面积最大,为0.822(p=0.032)。UTRIVR≥11.41预测CRT超声心动图反应的敏感性为73%,特异性为75%。 结论：2D-STE的舒张期应变率指标和解旋参数可以准确评估CRT不同反应程度患者的舒张功能变化差异。其中UTRIVR与E/E’相关性优于其他参数,且与E/E’比值关系更密切,预测CRT超声心动图反应与否价值更大,可能作为评价舒张功能的更为敏感指标。 目的：为了减少起搏器电极导线相关并发症,相关研究人员开发出了无导线起搏器。无导线起搏器的主要优点是它可以经皮植入多个位置,减少感染和血管阻塞等并发症。本研究应用RT-3D STE超声心动图技术,对两组动物的左心室整体功能进行比较,探讨无导线起搏器的安全性和可行性,并验证RT-3D STE参数对评估左室收缩功能的可行性和有效性。 方法：本研究对象为体重为45-55kg的中华小型猪。实验组动物将依次植入2个无导线起搏器；对照组动物将依次植入带有2根电极导线的常规起搏器。上述装置分次植入,植入间期为4周。在静息状态下,用三维斑点追踪超声心动图评估所有动物左心室的整体三维应变。纵向应变、环形应变、面积应变和径向应变以百分数来表示。同时于植入后1个月、3个月和6个月时,评估无导线起搏器和常规起搏器起搏参数差异及工作状态下与未工作状态下左心室功能的变化。当植入完设备随访6个月后,处死实验动物后,取出心脏,暴露右心室内无导线起搏装置或电极导线。配合使用标尺对右心室中上述装置进行拍照记录。准确测量每个植入装置与心脏组织间形成的纤维粘连物的长度。同时验证RT-3D STE参数对评估左室收缩功能的可行性和有效性,并结合目前常用的左室射血分数,分析RT-3D STE参数与它的相关性。 结果：两组动物一般情况及常规超声心动图各项指标均无显著性差异。实验组和对照组的动物在植入术前及术后纵向应变、环形应变、面积应变和径向应变上没有明显的差别(P0.05)。在两组试验动物中,起搏器工作状态和未工作状态下,无导线起搏器组动物左心室整体应变值未见明显差别,常规起搏器组左心室整体应变值未见显著性变化,组间对比未见有统计学意义差别。无导线起搏器的起搏参数随着时间的延长比较稳定。在随访期间,无导线起搏器组无并发症发生,常规起搏器组有1只猪(10%)发生1根导线脱位。RT-3D STE的三维应变值参数在观察者间及观察者内有较好的一致性。RT-3D STE与左室EF值的相关性：在所有的应变值参数中,GAS与左室射血分数有较高的相关性(r=0.914,p0.01)。组织结果显示,无导线起搏器上的纤维组织明显短于导线电极上的纤维组织(p0.05)。 结论：本动物试验初步验证了单腔无导线起搏器是安全、可行的,因此可以把无导线起搏器作为一种替代技术,特别是对于患导线相关并发症风险较高的患者提供帮助。同时本研究验证了RT-3D STE技术评估左心室收缩功能的有效性,证实了GAS可作为除EF值以外评估左室收缩功能的可靠指标。
[Abstract]:Background and purpose: there is sufficient evidence to prove that cardiac resynchronization therapy (CRT) is beneficial to the improvement of left ventricular systolic function, but the effect of CRT on diastolic function is still controversial. The value of strain rate and untwisting for diastolic function is studied in depth. Our aim is to study The relationship between the 2D-STE strain rate parameters of the patients with different degree of reaction of CRT and the diastolic function of the left ventricle (untwisting) and the left ventricular diastolic function were investigated by using the 2D-STE technique combined with the current E/E 'index.
Methods: This study included 70 heart failure patients who performed cardiac resynchronization therapy. All patients were in line with the existing inclusion criteria for cardiac resynchronization therapy, with the exception of patients with atrial fibrillation and transthoracic ultrasound. Two dimensional spots were collected before and 12 months after cardiac resynchronization therapy and cardiac resynchronization therapy. Point tracking echocardiography images. We divided the patients into 3 groups: group A, CRT echocardiography and clinical response group, that is, the left ventricular end systolic volume decreased more than 15% in the follow-up, and the 6 minute walk distance increased more than 20%, or the test was not implemented. In the absence of death and heart transplantation, the NYHA cardiac function classification was better than 1; group B, CRT only The clinical response group, the C group, the CRT non response group, did not reach the standard of echocardiography, and did not reach the standard of clinical response. The index of left ventricular filling was measured by the ratio of peak flow peak velocity of mitral valve and mitral annular peak velocity (E/E ') at early diastolic velocity (E/E'). The early strain rate of the diastolic phase (LSRE, CSRE, R) was obtained by 2D-STE technique. SRE and RotRE) and late diastolic strain rates (LSRA, CSRA and RSRA and RotRA), parameter of LSRA (UTRIVR, UTRE) and other parameters reflecting diastolic function, and observe the differences between the diastolic function parameters of these left ventricular diastolic functions in the different degree of reaction in the treatment of cardiac resynchronization. The assessment of the diastolic function parameters obtained by 2D-STE is related to the E/E 'ratio. Sex analysis. Select effective parameters to calculate the area under the receiver operating characteristic curve (ROC curve).
Results: of the 70 patients, 41 (58.6%) patients reached the criteria of echocardiography and clinical responsiveness at 12 months of follow-up; 15 (21.4%) patients were only clinical responders; 14 (20%) were non responders. In the group A, most of the parameters for assessing left ventricular diastolic function improved in the group of.B partial normal diastolic functional parameters. The progressive E/E 'values were observed in the C group, and the diastolic strain rate parameters measured by 2D-STE were linearly correlated with the E/E' ratio, and the diastolic strain rates were negatively correlated, with the best correlation of LSRE (r=-0.778, P0.01). The linear correlation between the spin parameters and the ratio of E/E 'was carried out respectively. All of them were negatively correlated, with the best correlation of UTRIVR (r=-0.837, P0.01). The prediction of CRT echocardiography by the early diastolic strain rate and the spin parameter of 2D-STE was predicted by the ROC curve.UTRIVR to predict the largest area under the ROC curve of CRT echocardiography, and the 0.822 (p=0.032).UTRIVR > 11.41 predicts the CRT echocardiography. The sensitivity of the reaction was 73% and the specificity was 75%.
Conclusion: the diastolic strain rate index and spin parameter of 2D-STE can accurately assess the difference of diastolic function in patients with different degree of reaction of CRT. The correlation between UTRIVR and E/E 'is better than other parameters, and it is more closely related to the ratio of E/E'. It is more valuable to predict the response of CRT echocardiography, and may be used as a more diastolic function to evaluate the diastolic function. As a sensitive indicator.
Objective: to reduce the complications associated with the electrode wire related to the pacemaker, the researchers have developed a pacemaker without traverse. The main advantage of the pacemaker is that it can be implanted in multiple locations through the skin to reduce complications such as infection and vascular obstruction. This study applied the RT-3D STE echocardiography technique to the left ventricular overall work of two groups of animals. We can compare the safety and feasibility of non traverse pacemakers, and verify the feasibility and effectiveness of RT-3D STE parameters in evaluating left ventricular systolic function.
Methods: This study was a Chinese miniature pig with a weight of 45-55kg. In the experimental group, 2 non traverse pacemakers were implanted in the experimental group. The control group would implant a conventional pacemaker with 2 electrode conductors in turn. The above device was implanted in a sub stage and implanted in a interval of 4 weeks. The three-dimensional speckle tracking echocardiography was used in the resting state. The overall three-dimensional strain of the left ventricle of the animal. The longitudinal strain, ring strain, area strain and radial strain are expressed as a percentage. At the same time, 1 months, 3 months, and 6 months after implantation, the pacemaker and routine pacemaker pacing parameter difference and the change of left ventricular function under the working state and the non working state are evaluated. After 6 months of follow-up, the apparatus was executed, the heart was removed, the lead free pacing device or electrode in the right ventricle was exposed. With the use of a ruler, the above device was photographed. The length of the fibrous adhesion formed between each implant and the cardiac tissue was accurately measured. At the same time, the RT-3D STE parameters were verified to evaluate the left side. The feasibility and effectiveness of ventricular systolic function were analyzed, and the correlation between RT-3D STE parameters and left ventricular ejection fraction was analyzed.
Results: there was no significant difference in the general and conventional echocardiographic indexes between the two groups. There was no significant difference in the longitudinal strain, ring strain, area strain and radial strain before and after implantation (P0.05) in the experimental and control groups. In the two groups of experimental animals, the working state of pacemaker and the non working state were in the two groups of experimental animals. There was no significant difference in left ventricular overall strain value in the non traverse pacemaker group. There was no significant change in the overall left ventricular strain value in the routine pacemaker group. There was no significant difference between the groups. The pacemaker parameters of the pacemaker were more stable with the time. No complications occurred in the pacemaker group during the follow-up period. In the routine pacemaker group, there were 1 pigs (10%) with 1 traverse dislocations of.RT-3D STE. The correlation between.RT-3D STE and the left ventricular EF value was better in the observer and in the observer: in all the strain values, there was a higher correlation between GAS and left ventricular ejection fraction (r=0.914, P0.01). The fibrous tissue on the pacemaker is significantly shorter than the fibrous tissue on the wire electrode (P0.05).
Conclusion: this animal test preliminarily verified that the single cavern pacemaker is safe and feasible. Therefore, the traverse pacemaker can be used as an alternative technique, especially for patients with higher risk of lead related complications. This study validates the effectiveness of RT-3D STE technique in assessing left ventricular systolic function. GAS can be used as a reliable index for evaluating left ventricular systolic function besides EF value.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R540.45;R541
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本文编号：2053641