应用血流向量成像技术对HFmrEF患者左室内血流能量损耗的临床研究

发布时间：2018-09-03 18:01

【摘要】：背景心力衰竭是一种常见的临床综合征,也是各种心脏疾病的严重阶段和最后战场。2016年欧洲心脏病学会颁布的急、慢性心力衰竭诊断和治疗指南,更新了对心力衰竭的分类。在射血分数减低的心力衰竭和射血分数保留的心力衰竭之间存在一个灰区,此灰区内患者的左室射血分数在40-49%,指南将其定义为射血分数中间值的心力衰竭(heart failure with mid-range ejection fraction,HFmrEF),并明确了其诊断标准。将HFmrEF作为一个单独的组别将有助于对这组患者病理生理特点、临床特征和治疗方法的深入研究。近年来,对心腔内血流的研究主要集中在血流向量成像(vector flow mapping,VFM)、超声粒子图像测速以及心肌磁共振成像等技术上。其中VFM技术结合了彩色多普勒成像和斑点追踪两大技术,通过连续方程的计算,可以得到任意点的速度向量,同时可定量计算心腔内血流粘滞摩擦产生的能量损耗(energyloss,EL)。然而,目前未见关于HFmrEF患者左室内能量损耗的明确报道。本研究结合二维、多普勒超声心动图、二维组织追踪法(2D Tissue Tracking Analysis,2DTT),综合评估HFmrEF患者心脏结构和功能的改变,运用VFM技术定量评估其左心室内血流能量损耗的特点。研究目的1.运用VFM技术评估HFmrEF患者左心室内血流能量损耗特点。2.探讨HFmrEF患者EL与心脏结构、功能改变的相关性。材料与方法1.研究对象与分组连续选取就诊于山东大学齐鲁医院且LVEF 40-49%的住院患者43例,根据2016年ESC急、慢性心力衰竭诊断和治疗指南中HFmrEF诊断标准,选出HFmrEF患者28例;同时选取年龄、性别相匹配的健康志愿者23例。HFmrEF组内分组:按照舒张功能不全的诊断标准分为Ⅰ组(舒张功能不全,12例),Ⅱ组(非舒张功能不全,共16例)。2.临床基本资料采集对所有研究对象,记录性别、年龄,测量身高、体重,计算身体质量指数(BMI)、体表面积(BSA),记录心率、血压,对于HFmrEF组研究对象,同时记录N端脑利钠肽前体(NT-proBNP)值、空腹血糖值、甘油三酯、总胆固醇、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)的值。3.图像与数据采集使用AlokaF75心脏彩超机,采图的同时连接肢体导联,记录同步心电图。3.1二维超声技术:采集胸骨旁左心室长轴图像,定位于左室舒张末期,测量室间隔厚度(IVS)、左室内径(LVEDd)、左室后壁厚度(LVPW),计算左室质量(LVM)、左室质量指数(LVMI);定位于左室收缩末期,测量左房内径(LA)。采集标准心尖四腔心、二腔心动态图像,分别定位于左室收缩末期和舒张末期测量左室收缩末容积(ESV)及左室舒张末容积(EDV),计算左室射血分数(LVEF)、心排血量(CO);定位于左室收缩末期,测量左房容积(LAV),计算左房容积指数(LAVI);测量左室长径(L)、左室横径(S),并计算左室球形指数(SI)。3.2多普勒超声心动图:血流多普勒测量舒张早期及晚期二尖瓣跨瓣血流速度,分别记为E峰、A峰,计算E/A。组织多普勒测量二尖瓣环室间隔、侧壁心肌舒张早期运动速度峰值,将其平均值记录为e',计算E/e';测量二尖瓣环室间隔、侧壁心肌收缩波,将其平均值记录为Sm。3.3 2DTT技术:采集心尖四腔心左室动态图像进行分析。记录收缩期左室纵向长轴整体应变(GLS)。3.4 VFM技术:在VFM模式下,采集心尖三腔心动态图像。图像通过DAS-RS1工作站分析。结合心电图、瓣膜开闭及时间一流量曲线确定等容舒张期(isovolumetric relaxation period,IVR)、快速充盈期(rapid filling period,RFP)、心房收缩期(atrial contraction period,ACP)、等容收缩期(isovolumetric contraction phase,IVC)、快速射血期(rapid ejection period,REP)5 个时相,并测得各时相左心室整体的血流能量损耗。4.统计学方法采用SPSS20.0软件进行统计学分析及绘图。所有计量资料均进行Kolmogorov-Smirnov正态性检验,不符合正态分布的经过自然对数转换使之符合正态分布,正态分布的连续变量用均数±标准差表示。两组间比较用独立样本T检验。分类变量比较采用X2检验。连续变量的相关性分析采用Pearson相关分析。估计解释变量对因变量的影响程度用多元线性回归分析。估测某指标对疾病的诊断价值做ROC曲线并计算曲线下面积。P0.05认为有统计学意义。结果本研究共收集了 LVEF40-49%的住院患者43例,从中筛选出HFmrEF患者28例。HFmrEF患者的男性比例64%,平均年龄61岁;均为冠心病患者,其中单纯冠心病8例,合并高血压11例,合并糖尿病3例,同时合并高血压和糖尿病6例。1.LVEF40-49%人群与正常人比较(1)两组间年龄、性别、心率、收缩压、舒张压均无统计学差异(P0.05);LVEF40-49%人群的BMI大于正常人,差异有统计学意义(P0.05)。(2)二维超声参数比较:LVEF40-49%人群较正常人的EDV、ESV增大,SI减小,LA、LAV、LAVI增大,IVS增厚,LVEDd扩大,LVPW增厚,LVM、LVMI增加,LVEF减低,差异均有统计学意义(P0.05)。(3)血流多普勒超声参数比较:两组间E峰、A峰、E/A均无统计学差异(P0.05)。(4)组织多普勒超声参数比较:LVEF40-49%人群较正常人的e'减低,E/e'增大,Sm减低,差异均有统计学意义(P0.05)。(5)2DTT参数比较:LVEF40-49%人群的GLS较正常人减小,差异有统计学意义(P0.05),GLS达峰时间无统计学差异(P0.05)。(6)VFM参数比较:LVEF40-49%人群的各期左室整体能量损耗均较正常人减小,其中等容舒张期、快速充盈期、等容收缩期、快速射血期差异有统计学意义(P0.05);心房收缩期无统计学意义(P0.05)。2.HFmrEF患者与正常人比较(1)两组间年龄、性别、心率、收缩压、舒张压均无统计学差异(P0.05),HFmrEF组的BMI大于正常人,差异有统计学意义(P0.05)。(2)二维超声参数比较:HFmrEF组较正常人的EDV、ESV增大,SI减小,LA、LAV、LAVI 增大,IVS 增厚,LVEDd 扩大,LVPW 增厚,LVM、LVMI增加,LVEF减低,差异均有统计学意义(P0.05)。(3)血流多普勒超声参数比较:两组间E峰、A峰、E/A均无统计学差异(P0.05)。(4)组织多普勒超声参数比较:HFmrEF组较正常人的e'减低,E/e'增大,Sm减低,差异均有统计学意义(P0.05)。(5)2DTT参数比较:HFmrEF组的GLS较正常人减小,差异有统计学意义(P0.05),GLS达峰时间较正常人延长,差异有统计学意义(P0.05)。(6)VFM参数比较:HFmrEF组的各期左心室整体能量损耗均较正常人减小,其中快速充盈期、等容收缩期、快速射血期差异有统计学意义(P0.05);等容舒张期、心房收缩期差异无统计学意义(P0.05)。3.HFmrEF组内比较——按照舒张功能分级分为Ⅰ组(舒张功能不全,12例),Ⅱ组(非舒张功能不全,16例)(1)两组间性别、年龄、BMI、心率、收缩压、舒张压均无统计学差异(P0.05),血清学指标中NT-proBNP、甘油三酯、总胆固醇、HDL-C、LDL-C均无统计学差异(P0.05),Ⅱ组较Ⅰ组的血糖升高(P0.05)。(2)二维超声参数比较:Ⅰ组较Ⅱ组的EDV、ESV增大,Ⅰ组较Ⅱ组的LAV、LAVI增大,LVEDd扩大,差异均有统计学意义(P0.05)。(3)血流多普勒超声参数比较:Ⅰ组较Ⅱ组E峰增高增大,差异有统计学意义(P0.05)。(4)组织多普勒超声参数比较:Ⅰ组较Ⅱ组E/e'增大,差异有统计学意义(P0.05)。(5)2DTT参数比较:Ⅰ组较Ⅱ组的GLS减小,GLS达峰时间延长,但均无统计学差异(P＞0.05)。(6)VFM参数比较:Ⅰ组较Ⅱ组的等容舒张期、快速充盈期左室整体能量损耗增大,其中快速充盈期差异有统计学意义(P0.05);心房收缩期、等容收缩期、快速射血期能量损耗减小,但差异无统计学意义(P0.05)。4.HFmrEF组能置损耗与临床资料及超声资料的相关性分析(1)快速充盈期左室整体能量损耗与e'负相关(r=-0.453,P=0.016),与E/e'正相关(r=0.456,P=0.015),与 BMI 负相关(r=-0.444,P=0.018),与 LDL-C负相关相关(r=-0.476,P=0.016)。(2)心房收缩期左室整体能量损耗与GLS正相关(r=0.392,所有P=0.039)。(3)等容收缩期左室整体能量损耗与EDV负相关(r-0.468,P=0.012),与 ESV 负相关(r=-0.468,P=0.012),与 GLS 正相关(r=0.509,P=0.006),与 BMI 负相关(r=-0.382,P=0.045)。(4)快速射血期左室整体能量损耗与EDV负相关(r-0.419,P=0.026),与 ESV 负相关(r=-0.472,P=0.011),与 e'负相关(r=-0.392,P=0.039),与BMI 负相关(r=-0.524,P=0.004)。5.HFmrEF组能量损耗多元线性回归分析(1)快速充盈期左室整体能量损耗与E/e'(β=0.423,P=0.019)、LDL-C(β=-0.418,P=0.020)独立相关。(2)心房收缩期左室整体能量损耗与GLS(β=0.392,P=0.039)相关。(3)等容收缩期左室整体能量损耗与GLS(β=0.546,P=0.001)及BMI(β =-0.428,P=0.009)独立相关。(4)快速射血期左室整体能量损耗与BMI(β=-0.524,P=0.004)相关。6.能量损耗诊断HFmrEF效力的ROC分析为评估左室快速充盈期、等容收缩期、快速射血期三个时期能量损耗联合诊断HFmrEF的价值高低,将三个时期的能量损耗联合进行模型拟合后得到联合预测概率(模型已排除等容收缩期能量损耗),用该概率做ROC曲线并计算AUC。AUC=0.817,可知快速充盈期与快速射血期能量损耗联合诊断HFmrEF效果较好。结论1.HFmrEF患者的收缩功能和舒张功能均下降。2.HFmrEF患者的左心室内能量损耗在快速充盈期、等容收缩期、快速射血期均明显低于对照组。当伴有舒张功能不全时,快速充盈期能量损耗增大。3.快速充盈期左心室内EL与心脏舒张功能相关,而心房收缩期和等容收缩期左心室EL与心脏收缩功能相关。
[Abstract]:Background Heart failure is a common clinical syndrome and a serious stage and final battlefield of various heart diseases. In 2016, the European Society of Cardiology issued guidelines for the diagnosis and treatment of acute and chronic heart failure, which update the classification of heart failure. There is a grey area between which the left ventricular ejection fraction is 40-49%. The guideline defines it as heart failure with mid-range ejection fraction (HFmrEF) and defines its diagnostic criteria. In recent years, the study of intracardiac blood flow mainly focuses on the techniques of vector flow mapping (VFM), ultrasonic particle image velocimetry and myocardial magnetic resonance imaging (MRI). The velocity vector at any point can be obtained, and the energy loss (EL) produced by viscous friction of intracardiac blood flow can be quantitatively calculated. However, there is no definite report on the energy loss in left ventricle in patients with HFmrEF. This study combines two-dimensional, Doppler echocardiography, two-dimensional Tissue Tracking Analysis (2D Tissue Tracking Analysis, 2D Tissue Tracking Analysis). Objective 1. To evaluate the characteristics of left ventricular blood flow energy loss in patients with HFmrEF by VFM. 2. To investigate the correlation between EL and cardiac structure and function in patients with HFmrEF. Materials and Methods 1. Subjects and groupings: 43 inpatients with LVEF of 40-49% in Qilu Hospital of Shandong University were selected consecutively. According to the diagnostic criteria of HFmrEF in ESC Guidelines for Diagnosis and Treatment of Acute and Chronic Heart Failure in 2016, 28 patients with HFmrEF were selected, and 23 healthy volunteers matched in age and sex were selected. The diagnostic criteria were divided into group I (diastolic dysfunction, 12 cases) and group II (non-diastolic dysfunction, 16 cases). NT-proBNP, fasting blood glucose, triglyceride, total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) values.3. Image and data acquisition using the Aloka F75 cardiac color Doppler machine, drawing at the same time connecting limb leads, recording synchronous electrocardiogram. Left ventricular mass (LVM), left ventricular mass index (LVMI), left ventricular mass index (LVM), left atrial diameter (LA) and septal thickness (IVS), left ventricular diastolic diameter (LVEDd), left ventricular posterior wall thickness (LVPW) were measured, and left ventricular mass index (LVM) was calculated. Left ventricular end systolic volume (ESV), left ventricular end diastolic volume (EDV), left ventricular ejection fraction (LVEF), cardiac output (CO), left atrial volume (LAV), left atrial volume index (LAVI), left ventricular length (L), left ventricular transverse diameter (S), and left ventricular spherical index (SI) were measured by Doppler echocardiography. Echocardiogram: Mitral annular septum was measured by Doppler flow imaging, and early diastolic and late diastolic velocities were recorded as E and A peaks respectively. Mitral annular septum and early diastolic velocities of lateral wall myocardium were measured by E/A tissue Doppler flow imaging. Value recording was Sm.3.32 DTT: Acquisition of apical four-chamber left ventricular dynamic images for analysis. Recording systolic left ventricular longitudinal long-axis global strain (GLS). 3.4 VFM technique: Acquisition of apical three-chamber echocardiogram in VFM mode. Image analysis was performed by DAS-RS1 workstation. Isovolemic relaxation was determined by combining electrocardiogram, valvular opening and closing and time-flow curve. Isometric relaxation period (IVR), rapid filling period (RFP), atrial contraction period (ACP), isovolumetric contraction phase (IVC), rapid ejection period (REP) were measured in 5 phases, and the total energy loss of left ventricle in each phase was measured.4. Statistical methods were analyzed and plotted by SPSS20.0 software. All measurement data were tested by Kolmogorov-Smirnov normality test. The non-conforming normal distribution was transformed into normal distribution by natural logarithm, and the continuous variables of normal distribution were expressed by mean-standard deviation. Variables were compared by X2 test. Correlation analysis of continuous variables was performed by Pearson correlation analysis. Multivariate linear regression analysis was used to estimate the influence of explanatory variables on dependent variables. Among 43 hospitalized patients, 28 were selected for HFmrEF. The male proportion of HFmrEF patients was 64%, with an average age of 61 years. All patients were coronary heart disease, including 8 cases of simple coronary heart disease, 11 cases of hypertension, 3 cases of diabetes, 6 cases of hypertension and diabetes mellitus. 1. LVEF40-49% of the population were compared with normal people (1) age, sex, heart rate between the two groups. There was no significant difference in systolic and diastolic blood pressure (P 0.05); BMI of LVEF40-49% of the population was higher than that of the normal population, and the difference was statistically significant (P 0.05). (2) Two-dimensional ultrasound parameters comparison: LVEF40-49% of the population than normal people EDV, ESV increased, SI decreased, LA, LAV, LAVI increased, IVS thickened, LVEDd enlarged, LVPW thickened, LVM, LVMI increased, LVEF decreased, the difference was statistically significant. Significance (P 0.05). (3) Blood flow Doppler ultrasound parameters comparison: between the two groups E peak, A peak, E/A were no significant difference (P 0.05). (4) Tissue Doppler ultrasound parameters comparison: LVEF40-49% of the population than the normal people's e'decreased, E/e'increased, Sm decreased, the difference was statistically significant (P 0.05). (5) 2DTT parameters comparison: LVEF40-49% of the population's GLS decreased, worse than the normal people. There was no significant difference in peak time of GLS (P 0.05). (6) VFM parameters: LVEF 40-49% of the population at all stages of the overall energy loss of the left ventricle were less than normal people, including isovolumic diastolic, rapid filling, isovolumic systolic, rapid ejection period were statistically significant (P 0.05); atrial systolic period was not statistically significant (P 0.0). The BMI of HFmrEF group was higher than that of normal group (P 0.05). (2) Two-dimensional ultrasound parameters comparison: HFmrEF group EDV, ESV increased, SI decreased, LAV, LAVI increased, IVS thickened, LVEDd enlarged, LV enlarged, LV enlarged. PW thickening, LVM, LVMI increased, LVEF decreased, the difference was statistically significant (P 0.05). (3) Blood flow Doppler ultrasound parameters comparison: between the two groups E peak, A peak, E/A were not statistically significant (P 0.05). (4) Tissue Doppler ultrasound parameters comparison: HFmrEF group compared with normal people e'decreased, E/e'increased, Sm decreased, the difference was statistically significant (P 0.05). (5) 2DTT parameters. The peak time of GLS in HFmrEF group was longer than that in normal group, and the difference was statistically significant (P 0.05). (6) Compared with VFM parameters, the total energy loss of left ventricle in HFmrEF group was lower than that in normal group, including rapid filling period, isovolumic systole period and rapid ejection period. There was no significant difference in isovolumic diastolic period and atrial systolic period (P 0.05). There was no significant difference in NT-proBNP, triglyceride, total cholesterol, HDL-C, LDL-C (P 0.05). Blood glucose in group II was higher than that in group I (P 0.05). (2) Comparison of two-dimensional ultrasound parameters: EDV and ESV in group I were higher than those in group II, LAV and LAVI in group I were higher than those in group II, LVEDd were larger, the difference was statistically significant (P 0.05). (3) Comparison of Doppler ultrasound parameters in group I: EDV and ESV in group II were higher than those in group II. Compared with group II, the E peak increased significantly in group I (P > 0.05). (4) Compared with group II, the E/e'of group I increased significantly (P 0.05). (5) Compared with group II, the GLS of group I decreased and the peak time of GLS prolonged, but there was no significant difference between group I and group II (P > 0.05). In isovolumic diastolic phase, the total energy loss of left ventricle in rapid filling phase increased, and the difference was statistically significant in rapid filling phase (P 0.05); in atrial systolic phase, isovolumic systolic phase, rapid ejection phase energy loss decreased, but the difference was not statistically significant (P 0.05). 4. Correlation analysis of energy loss between HFmrEF group and clinical data and ultrasound data (1) rapid filling. Total left ventricular energy loss was negatively correlated with e's (r = - 0.453, P = 0.016), positively correlated with E/e's (r = 0.456, P = 0.015), negatively correlated with BMI (r = - 0.444, P = 0.018), and negatively correlated with LDL-C (r = - 0.476, P = 0.016). (2) Total left ventricular energy loss during atrial systole was positively correlated with GLS (r = 0.392, all P = 0.039). EDV was negatively correlated with EDV (r-0.468, P = 0.012), ESV was negatively correlated with ESV (r = - 0.468, P = 0.012), GLSwas positively correlated with GLS (r = 0.509, P = 0.006), BMI was negatively correlated with BMI (r = - 0.382, P = 0.382, P = 0.382, P = 0.045). (4) Leventventventventventricular energy loss in rapid ejectperiod was nenegatively correlwith EDV (r-0.419, P = 0.026), ESV was nenegatively correlwith ESV (r =-0.472, P = 0.472, P = 0.011, P = 0.011), P = 0.039), negative to BMI Multivariate linear regression analysis of energy loss in HFmrEF group (1) Global energy loss in left ventricle during rapid filling was independently correlated with E/e'(beta = 0.423, P = 0.019), and LDL-C (beta = - 0.418, P = 0.020). (2) Global energy loss in left ventricle during atrial systole was correlated with GLS (beta = 0.392, P = 0.039). (4) Left ventricular global energy loss during rapid ejection was correlated with BMI (beta = - 0.524, P = 0.004). 6. ROC analysis of energy loss in diagnosing HFmrEF efficacy was used to assess the value of combined diagnosis of HFmrEF in three periods: rapid filling, isovolumic systole and rapid ejection. The combined predictive probability (the model excludes isovolumic systolic energy wastage) was obtained after the model fitting. ROC curve was made and AUC.AUC=0.817 was calculated. It is concluded that the combination of rapid filling and rapid ejection energy wastage is effective in the diagnosis of HFmrEF. Conclusion 1. Systolic and diastolic functions of HFmrEF patients. The left ventricular energy loss in HFmrEF patients was significantly lower than that in the control group during rapid filling, isovolumic systolic and rapid ejection. It is related to cardiac systolic function.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.6

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