三维应变参数对急性ST段抬高型心肌梗死后左心室重构的预测价值

发布时间：2018-03-02 00:20

  本文关键词： 三维斑点追踪超声心动图 二维斑点追踪超声心动图 左心室重构 ST段抬高型心肌梗死　出处：《广州中医药大学》2017年硕士论文　论文类型：学位论文

【摘要】：背景:二维(two-dimensional,2D)和三维(three-dimensional,3D)斑点追踪超声心动图(speckle tracking echocardiography,STE)通过追踪心肌上的"回声斑点",而定量分析长轴、圆周及短轴方向上的心肌形变和运动情况,反映心脏各个方向上的收缩功能。已有研究证实2D STE获取的整体长轴应变(global longitudinal strain,GLS)能够预测急性心肌梗死(acute myocardial infraction,AMI)后左心室重构。3D STE发展相对较晚,有关3D STE获取的各应变参数是否均有预测左心室重构价值,目前尚不明确,并且不同方向应变参数之间预测价值是否存在差异、在实际预测评估中3D模式是否优于2D模式亦均未见报道。目的:以已行经皮冠状动脉介入诊疗术(percutaneous coronary intervention,PCI)的急性 ST 段抬高型心肌梗死(ST-elevation myocardial infarction,STEMI)患者为研究对象,探讨3D STE衍生出来的多个方向的应变参数对左心室重构的预测价值,并将这些参数与2D GLS作比较,通过比较明确其中最佳的预测指标及AMI后各个方向收缩功能的改变对左心室重构的影响,探讨二维和三维模式在临床应用中的差异,为临床应用STE进行AMI后心室重构预测提供依据。方法:入选2015年06月至2015年12月在广州军区广州总医院心血管内科住院的STEMI患者共110例,平均年龄为54 ± 9岁,所有患者均行急诊PCI治疗开通罪犯血管(再灌注时间≤24小时),在PCI术后完成二维超声心动图检查、2D STE和3D STE检查以获取常规超声心动图参数和应变参数,收集患者一般临床资料,随访3月后再次复查常规超声心动图。AMI后左心室重构主要表现为左心室整体扩张,经查阅文献,AMI后左心室重构定义为3月后LVEDV增大20%,并按此标准分为左心室重构组(简称重构组)和左心室非重构组(简称非重构组)。结果:①经过3个月随访,共有26名患者出现了左心室重构,占研究总人数的24%,重构组和非重构组组间一般临床资料比较,重构组罪犯血管为前降支的比例较非重构组高(73.1%vs 48.8%,P=0.030),肌钙蛋白I水平也较非重构组显著增高(11.11±6.75 vs 8.43 ±5.31,P=0.038),差异有统计学意义;超声参数比较,重构组2D GLS(-12.5±3.2 vs-15.0±3.1,P0.001)、3D GLS(-9.9±2.2 vs-13.1±2.7,P0.001)、3D 面积应变(global area strain,GAS)(-20.3±3.9 vs-23.3±4.8,P=0.005)及 3D 径向应变(global radial strain,GRS)(29.0±7.4%vs 34.3±8.5%,P=0.007)受损程度均较非重构组严重,差异有统计学意义,而3D圆周应变(global circumferential strain,GCS)组间比较差异无统计学意义(P0.05)。②多因素逻辑回归模型显示,在分别校正单因素逻辑回归中P0.1的一般临床资料和超声参数后,2D GLS(OR=1.36,P=0.002)、3D GLS(OR=1.82,P=0.001)、3D GAS(OR=1.18,P=0.010)及3D GRS(OR=0.90,P=0.007)是左心室重构的独立预测指标。③受试者工作(receiver-operating characteristic,ROC)曲线分析显示 2D GLS、3D GLS、3D GAS和3D GRS对左心室重构具有预测价值(P0.05),各曲线下面积(area under the cure,AUC)分别为 0.72(95%CI:0.63-0.80)、0.82(95%CI:0.73-0.88)、0.68(95%CI:0.59-0.77)和 0.68(95%CI:0.58-0.77),而 3D GCS 无预测价值(P0.05),且 3D GLS 的 AUC 显著大于 2D GLS、3D GAS 和 3D GRS(P0.05)。④相关性分析显示 2D GLS(r=-0.393,P0.001)、3D GLS(r=-0.512,P0.001)、3D GCS(r =-0.674,P0.001)和 3D GAS(r =-0.667,P0.001)与 LVEF 呈负相关,3D GRS与左心室射血分数呈正相关(r =0.668,P0.001)。⑤两种模式下检查时间比较,2D STE图像获取时间(7.2± 1.6 vs 4.2± 1.4,P0.001)、分析时间(5.7±1.5vs4.7± 1.7,P=0.019)及总检查时间(12.9±2.3 vs 8.9±2.0,P0.001)均比3D STE长。结论:我们的研究证实2D GLS、3D GLS、3D GAS和3D GRS均对AMI后3个月的左心室重构具有预测价值,并且3D GLS优于其他指标,是其中预测价值最高的指标,表明长轴方向的收缩功能受损对促进左心室重构具有重要意义。这项研究还表明,3D STE是一个更实用的STE技术,有望替代2D STE应用于AMI患者预后评估。
[Abstract]:Background: two dimensional (two-dimensional, 2D) and three (three-dimensional, 3D) speckle tracking echocardiography (speckle tracking, echocardiography, STE) by tracking the myocardial echo spots, and the quantitative analysis of myocardial deformation and long axis and short axis circumferential movement direction, reflecting the cardiac contractile function on each direction. Studies have confirmed the global longitudinal strain obtained by STE (global longitudinal 2D strain, GLS) to predict the acute myocardial infarction (acute myocardial infraction, AMI.3D) left ventricular remodeling after STE development relatively late, the strain parameters for 3D STE acquisition whether left ventricular remodeling had predictive value, it is not clear, and between the forecast strain parameters in different directions and whether there are differences in the actual value, forecast evaluation in 3D model is better than 2D model are reported. Objective: to percutaneous coronary intervention The diagnosis and treatment of (percutaneous coronary intervention, PCI) of acute ST elevation myocardial infarction (ST-elevation myocardial, infarction, STEMI) patients as the research object, the predictive value of strain parameters in multiple directions to explore 3D STE derivative on the left ventricular remodeling, and these parameters and 2D GLS were compared by comparing the clear effect one of the best predictors and AMI after each direction changes of contractile function of left ventricular remodeling, to explore the difference of 2D and 3D model in clinical application, ventricular remodeling after prediction provides the basis for the clinical application of STE AMI. Methods: a total of 06 months in 2015 to December 2015 in the hospital of cardiology Genenral Hospital of PLA Guangzhou Military Area STEMI patients in 110 cases, the average age was 54 + 9 years, all patients underwent emergency PCI treatment of criminals opened blood vessels (reperfusion time less than 24 hours), completed after PCI. Two dimensional echocardiography, 2D STE and 3D STE examination to obtain the conventional echocardiographic parameters and strain parameters, collected from patients with clinical data, follow-up after March to check again the conventional echocardiographic left ventricular remodeling after.AMI showed left ventricular dilatation, by review of the literature, AMI left ventricular remodeling after defined as after March the increase of LVEDV 20%, and according to the standards for left ventricular remodeling group (the reconstruction group) and non left ventricular remodeling group (non reconstruction group). Results: after 3 months of follow-up, a total of 26 patients had left ventricular remodeling, the total number of 24%, reconstruction group and non reconstruction between group comparison of the general clinical data, criminal vascular remodeling group proportion anterior descending than non reconstruction group (73.1%vs 48.8%, P=0.030), troponin I levels are lower than the non reconstruction group was significantly higher (11.11 + 8.43 + 6.75 vs 5.31, P= 0.038), there was statistically significant difference Yi; ultrasonic parameters, 2D GLS reconstruction group (-12.5 + 3.2 vs-15.0 + 3.1, P0.001), 3D GLS (-9.9 + 2.2 vs-13.1 + 2.7, P0.001), 3D (global area strain, the area of strain GAS (-20.3) + 3.9 vs-23.3 + 4.8, P=0.005) and 3D (global radial strain, radial strain GRS (34.3) 29 + 7.4%vs + 8.5%, P=0.007) was higher than the non damaged reconstruction group is serious, the difference was statistically significant, while the circumferential strain (Global circumferential strain 3D, GCS) there was no significant difference between groups (P0.05). The display logic regression model, the general clinical data and ultrasound parameters are corrected the single factor Logistic regression after P0.1 2D GLS (OR=1.36, P=0.002), 3D GLS (OR=1.82, P=0.001), 3D GAS (OR=1.18, P=0.010) and 3D GRS (OR=0.90, P=0.007) is an independent predictor of left ventricular remodeling. The subjects work (receiver-operating characteristic ROC) curve analysis showed that 2D GLS,3D GLS,3D GAS鍜，

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