右心房的斑点追踪成像在肺动脉高压患者中的应用价值

发布时间：2018-08-29 16:15

【摘要】：研究背景:肺动脉高压(pulmonaryhypertension,PH)是以原发性或继发性的肺部循环阻力发生持续性上升,继而导致肺动脉收缩压(pulmonary artery systolic pressure,PASP)持续性上升,最终损害右心系统功能,甚至导致死亡为临床特征的相关性疾病,如临床不加干预,其发展迅速,预后往往不良。右心房作为右心系统不可或缺的一部分,不仅起维持右心室血流灌注充盈作用,而且在维持右心功能上起着重要的调节作用。传统超声心动图常常作为右心房结构功能的评价手段,已经广泛应用于临床。其主要借助于在二维平面上对右心房径线、容积进行测定来评估右心房的整体功能状态,然而传统超声心动图存在着一定的局限性,如:运用目测法、半定量法评估室壁运动状态时,往往导致评估结果的主观性增大,客观性下降,数据测量的可重复性较差,结果可信性下降。因此,以上局限性的存在在一定程度上限制了传统超声心动图在心功能评估上的应用。随着超声技术的发展,斑点追踪超声心动图(speckle tracking echocardiography,STE)作为一种评估心功能的新方法,能很好地克服了传统超声心动图的上述局限性,并能准确地对心肌纤维运动功能进行快速评估。STE不仅能客观反映复杂心肌运动的局部形变模式,而且无角度依赖、不受拖带效应影响,其具有的时间分辨力及空间分辨力远远优于传统超声心动图,使其测量结果更客观准确而越来越受到临床的重视。本研究运用STE对PH患者右心房心肌的应变能力进行定量分析,并结合三维超声心动图(three-dimensional echocardiography,3DE)对PH患者右心房各时相的容积功能进行定量分析,进而探讨右心房S TE应变参数与3 D E容积功能参数之间的相关性,期望为PH患者右心房功能状体的评估开辟一条新的途径。目的:运用STE对PH患者右心房心肌的应变能力进行定量分析,并结合3DE对PH患者右心房各时相的容积功能进行定量分析,进而探讨STE右心房应变参数与3DE右心房容积功能参数之间的相关性。方法:选择2015年3月至2016年8月间,本院门诊或住院诊断为PH的患者作为本研究的研究对象,共计63例,根据PH患者的PASP等级不同分为:B组(PASP=30～49mmHg)21 例;C组(PASP=50～69mmHg)21 例;D组(PASP70mmHg)21例。排除标准:器质性左心系统疾病、重度三尖瓣反流、右心室流出道狭窄、肺动脉瓣狭窄、肺动脉狭窄、严重心律失常、先天性心脏病、大量心包积液以及超声图像不清晰者。另选取来我院体检中心进行健康体检者,共计21例作为本研究的对照组即A组(PASP30mmHg)。研究开始前所有研究对象均签署知情同意书。采用GE Vivid E9超声诊断仪对所有符合入组标准的研究对象均行传统二维超声心动图、STE以及3DE检查。通过纵向应变曲线获得并记录STE应变参数:负向应变峰值(negative peak value of strain,LS-n,单位为%),正向应变峰值(positive peak value of strain,LS-p,单位为%)、总纵向应变值(total value of longitudinal strain,LS-t,单位为%)。通过绘制出右心房时间一容积曲线,由此测量、计算并记录3DE的容积功能参数:右心房最小容积(minimum volume of right atrium,V-min,单位为ml)、右心房收缩前容积(volume before contraction,V-pre,单位为ml)、右心房最大容积(maximum volume of right atrium,V-max,单位为ml)、右心房排空分数(emptying fraction of right atrium,EF,单位为%)、总排空容积(total stroke volume,SV,单位为ml)、右心房主动排空分数(active emptying fraction of right atrium,EF-act,单位为%)、右心房被动排空容积(passive stroke volume of right atrium,SV-pas,单位为ml)、右心房主动排空容积(active stroke volume of right atrium,SV-act,单位为 ml)、右心房被动排空分数(passive emptying fraction of right atrium,EF-pas,单位为%)。对所获得的3DE容积功能参数以BSA进行校正后,获得并记录相对应的容积功能指数:SVI、EFI、SVI-pas、EFI-pas、SVI-act、EFI-act、VI-max、VI-pre以及VI-min。对上述所获得得右心房STE应变参数和3DE容积功能参数进行比较分析。结合临床资料,运用ROC曲线获得右心房STE参数预测PH患者右心房心肌功能障碍的最佳界值。结果:1.B组的LS-n高于A组(P0.05),随PASP升高,PH患者的LS-n逐渐下降,即B组LS-nC组LS-nnD组LS-n(P均0.05);随PASP升高,各组的LS-p和LS-t逐渐下降,即A组LS-p和LS-tB组LS-p和LS-tC组LS-p和LS-tD组LS-p和LS-t(P均0.05)。2.随PASP升高,各组间的VI-max、VI-pre和VI-min逐渐增大,即A组VI-max、VI-pre 和 VI-minB 组VI-max、VI-pre 和VI-minC 组VI-max、VI-pre 和VI-minD 组VI-max、VI-pre和VI-min(P均0.05)。3.随PASP升高,各组间的SVI表现为先增大后减小,B组、C组和D组的SVI均明显高于A组,C组和D组均明显高于B组(P均0.05),C组与D组间差异无统计学意义(P0.05)。各组间的SVI-pas比较,差异无统计学意义(P均0.05)。随PASP升高,各组间的SVI-act表现为先增大后减小,B组、C组和D组的SVI-act均明显高于A组,C组和D组均明显高于B组(P均0.05),C组与D组间差异无统计学意义(P0.05)。4.随PASP升高,各组的EFI和EFI-pas逐渐下降,即A组EFI和EFI-pasB组EFI和EFI-pasC组EFI和EFI-pasD组EFI 和EFI-pas(P均0.05)。随PASP升高,各组间的EFI-act表现为先增大后减小,B组和C组的EFI-act均明显高于A组(P均0.05),D组的EFI-act均明显低于B组、C组(P均0.05),D组与A组差异无统计学意义(P0.05)。5.LS-n与EFI呈正相关(r=0.78,P=0.00,P0.05);LS-p与EFI呈正相关(r=0.76,P=0.00,P0.05);LS-t与EFI呈正相关(r=0.87,P=0.00,P0.05),其中LS-t与EFI的相关性最为显著。6.运用LS-t预测PH患者右心房心肌功能异常具有较高的临床应用价值:曲线下面积(Area Under The Curve,AUC)=0.87(95%CI=0.732-0.991),最佳界值为32.68(%)时,灵敏度、特异度分别为84.37%、86.65%。结论:STE为右心房功能的深入研究开辟了一种新方法,可为PH患者的病情诊断、治疗决策、疗效评估以及预后判断提供客观参考依据。
[Abstract]:BACKGROUND: Pulmonary hypertension (PH) is a related disease characterized by persistent elevation of primary or secondary pulmonary circulatory resistance, followed by persistent elevation of pulmonary arterial systolic pressure (PASP), ultimately impairing the function of the right heart system, and even leading to death. As an indispensable part of the right ventricular system, the right atrium not only plays an important role in maintaining the right ventricular perfusion, but also plays an important regulatory role in maintaining the right ventricular function. It is mainly used in clinic to evaluate the whole function of right atrium by measuring the diameter and volume of right atrium on two-dimensional plane. However, there are some limitations in traditional echocardiography, such as visual measurement and semi-quantitative evaluation of ventricular wall motion, which often leads to the subjective evaluation results and the objective evaluation results decrease. With the development of echocardiography, speckle tracking echocardiography (STE) is a new method to evaluate cardiac function. STE not only objectively reflects the local deformation pattern of complex myocardial motion, but also has no angle dependence and is not affected by towing effect. It has much better temporal and spatial resolution than transmission. In this study, STE was used to quantitatively analyze the strain capacity of right atrial myocardium in patients with PH, and three-dimensional echocardiography (3DE) was used to quantitatively analyze the volume function of right atrium in different phases of PH. Objective: To explore the correlation between right atrial TE strain parameters and 3-D-E volume function parameters in order to provide a new way for evaluating right atrial function in PH patients. Methods: From March 2015 to August 2016, 63 patients with PH diagnosed in our hospital were selected as the subjects of this study. According to the PASP grade of PH patients, 21 patients were divided into group B (PASP = 30 ~ 49mmHg) and group C (PASP = 30 ~ 49mmHg). Group D (PASP 70 mmHg) 21 cases. Exclusive criteria: organic left heart disease, severe tricuspid regurgitation, right ventricular outflow tract stenosis, pulmonary valve stenosis, pulmonary artery stenosis, severe arrhythmia, congenital heart disease, large amount of pericardial effusion and unclear ultrasound image. Another selected to our hospital physical examination center for healthy body. A total of 21 subjects were selected as the control group (PASP 30mmHg). All subjects signed informed consent before the study began. All subjects who met the inclusion criteria were examined by conventional two-dimensional echocardiography, STE and 3DE using GE Vivid E9 ultrasonic diagnostic apparatus. The STE strain was obtained and recorded by longitudinal strain curve. Parameters: Negative peak value of strain (LS-n), positive peak value of strain (LS-p), total value of longitudinal strain (LS-t), volume work of 3DE was calculated and recorded by plotting the time-volume curve of right atrium. Energy parameters: right atrial minimum volume of right atrium (V-min, ml), right atrial pre-contraction (V-pre, ml), right atrial maximum volume of right atrium (V-max, ml), right atrial emptying fraction of right atrium (EF), total Total stroke volume (SV, ml), active emptying fraction of right atrium (EF-act), passive stroke volume of right atrium (SV-pas, ml), active stroke of right atrium (SV-act, single) The volume function parameters of 3DE were corrected by BSA, and the corresponding volume function indices were obtained and recorded: SVI, EFI, SVI-pas, EFI-pas, SVI-act, EFI-act, VI-max, VI-preand VI-min. Results: 1. LS-n in group B was higher than that in group A (P 0.05), and LS-n in PH patients decreased gradually with the increase of PASP, that is, LS-n in group B LS-nC and LS-nnD (P 0.05). LS-p and LS-t in ASP increased, LS-p and LS-t decreased gradually, that is, LS-p and LS-p and LS-tB groups LS-p and LS-tC groups LS-p and LS-p and LS-t in LS-p and LS-tD groups LS-p and LS-t (all 0.05).VI-min (P The SVI of group B, group C and group D was significantly higher than that of group A, group C and group D were significantly higher than that of group B (P 0.05), and there was no significant difference between group C and group D (P 0.05). There was no significant difference in SVI-pas between groups (P 0.05). SVI-act in group B, group C and group D were significantly higher than that in group A, group C and group D were significantly higher than that in group B (P 0.05). There was no significant difference between group C and group D (P 0.05). 4. With the increase of PASP, EFI and EFI-pas in each group gradually decreased, i.e. EFI and EFI-pas in group A and EFI-pasB and EFI-pas in group EFI and EFI-pasD were significantly higher than those in group B (P 0.05). EFI-act in group B and group C was significantly higher than that in group A (P 0.05). EFI-act in group D was significantly lower than that in group B (P 0.05). There was no significant difference between group D and group A (P 0.05). LS-n was positively correlated with EFI (r = 0.78, P = 0.00, P 0.05); LS-p was positively correlated with EFI (r = 0.76, P = 0.00, P 0.05). Correlation (r = 0.87, P = 0.00, P 0.05), of which the correlation between LS-t and EFI was the most significant. TE provides a new method for in-depth study of right atrial function, which can provide objective reference for diagnosis, treatment decision-making, curative effect evaluation and prognosis judgment of PH patients.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R445.1;R544.1

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