右心房的斑點追蹤成像在肺動脈高壓患者中的應(yīng)用價值
發(fā)布時間：2018-08-29 16:15
【摘要】：研究背景:肺動脈高壓(pulmonaryhypertension,PH)是以原發(fā)性或繼發(fā)性的肺部循環(huán)阻力發(fā)生持續(xù)性上升,繼而導(dǎo)致肺動脈收縮壓(pulmonary artery systolic pressure,PASP)持續(xù)性上升,最終損害右心系統(tǒng)功能,甚至導(dǎo)致死亡為臨床特征的相關(guān)性疾病,如臨床不加干預(yù),其發(fā)展迅速,預(yù)后往往不良。右心房作為右心系統(tǒng)不可或缺的一部分,不僅起維持右心室血流灌注充盈作用,而且在維持右心功能上起著重要的調(diào)節(jié)作用。傳統(tǒng)超聲心動圖常常作為右心房結(jié)構(gòu)功能的評價手段,已經(jīng)廣泛應(yīng)用于臨床。其主要借助于在二維平面上對右心房徑線、容積進行測定來評估右心房的整體功能狀態(tài),然而傳統(tǒng)超聲心動圖存在著一定的局限性,如:運用目測法、半定量法評估室壁運動狀態(tài)時,往往導(dǎo)致評估結(jié)果的主觀性增大,客觀性下降,數(shù)據(jù)測量的可重復(fù)性較差,結(jié)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傳統(tǒng)超聲心動圖在心功能評估上的應(yīng)用。隨著超聲技術(shù)的發(fā)展,斑點追蹤超聲心動圖(speckle tracking echocardiography,STE)作為一種評估心功能的新方法,能很好地克服了傳統(tǒng)超聲心動圖的上述局限性,并能準(zhǔn)確地對心肌纖維運動功能進行快速評估。STE不僅能客觀反映復(fù)雜心肌運動的局部形變模式,而且無角度依賴、不受拖帶效應(yīng)影響,其具有的時間分辨力及空間分辨力遠(yuǎn)遠(yuǎn)優(yōu)于傳統(tǒng)超聲心動圖,使其測量結(jié)果更客觀準(zhǔn)確而越來越受到臨床的重視。本研究運用STE對PH患者右心房心肌的應(yīng)變能力進行定量分析,并結(jié)合三維超聲心動圖(three-dimensional echocardiography,3DE)對PH患者右心房各時相的容積功能進行定量分析,進而探討右心房S TE應(yīng)變參數(shù)與3 D E容積功能參數(shù)之間的相關(guān)性,期望為PH患者右心房功能狀體的評估開辟一條新的途徑。目的:運用STE對PH患者右心房心肌的應(yīng)變能力進行定量分析,并結(jié)合3DE對PH患者右心房各時相的容積功能進行定量分析,進而探討STE右心房應(yīng)變參數(shù)與3DE右心房容積功能參數(shù)之間的相關(guān)性。方法:選擇2015年3月至2016年8月間,本院門診或住院診斷為PH的患者作為本研究的研究對象,共計63例,根據(jù)PH患者的PASP等級不同分為:B組(PASP=30～49mmHg)21 例;C組(PASP=50～69mmHg)21 例;D組(PASP70mmHg)21例。排除標(biāo)準(zhǔn):器質(zhì)性左心系統(tǒng)疾病、重度三尖瓣反流、右心室流出道狹窄、肺動脈瓣狹窄、肺動脈狹窄、嚴(yán)重心律失常、先天性心臟病、大量心包積液以及超聲圖像不清晰者。另選取來我院體檢中心進行健康體檢者,共計21例作為本研究的對照組即A組(PASP30mmHg)。研究開始前所有研究對象均簽署知情同意書。采用GE Vivid E9超聲診斷儀對所有符合入組標(biāo)準(zhǔn)的研究對象均行傳統(tǒng)二維超聲心動圖、STE以及3DE檢查。通過縱向應(yīng)變曲線獲得并記錄STE應(yīng)變參數(shù):負(fù)向應(yīng)變峰值(negative peak value of strain,LS-n,單位為%),正向應(yīng)變峰值(positive peak value of strain,LS-p,單位為%)、總縱向應(yīng)變值(total value of longitudinal strain,LS-t,單位為%)。通過繪制出右心房時間一容積曲線,由此測量、計算并記錄3DE的容積功能參數(shù):右心房最小容積(minimum volume of right atrium,V-min,單位為ml)、右心房收縮前容積(volume before contraction,V-pre,單位為ml)、右心房最大容積(maximum volume of right atrium,V-max,單位為ml)、右心房排空分?jǐn)?shù)(emptying fraction of right atrium,EF,單位為%)、總排空容積(total stroke volume,SV,單位為ml)、右心房主動排空分?jǐn)?shù)(active emptying fraction of right atrium,EF-act,單位為%)、右心房被動排空容積(passive stroke volume of right atrium,SV-pas,單位為ml)、右心房主動排空容積(active stroke volume of right atrium,SV-act,單位為 ml)、右心房被動排空分?jǐn)?shù)(passive emptying fraction of right atrium,EF-pas,單位為%)。對所獲得的3DE容積功能參數(shù)以BSA進行校正后,獲得并記錄相對應(yīng)的容積功能指數(shù):SVI、EFI、SVI-pas、EFI-pas、SVI-act、EFI-act、VI-max、VI-pre以及VI-min。對上述所獲得得右心房STE應(yīng)變參數(shù)和3DE容積功能參數(shù)進行比較分析。結(jié)合臨床資料,運用ROC曲線獲得右心房STE參數(shù)預(yù)測PH患者右心房心肌功能障礙的最佳界值。結(jié)果:1.B組的LS-n高于A組(P0.05),隨PASP升高,PH患者的LS-n逐漸下降,即B組LS-nC組LS-nnD組LS-n(P均0.05);隨PASP升高,各組的LS-p和LS-t逐漸下降,即A組LS-p和LS-tB組LS-p和LS-tC組LS-p和LS-tD組LS-p和LS-t(P均0.05)。2.隨PASP升高,各組間的VI-max、VI-pre和VI-min逐漸增大,即A組VI-max、VI-pre 和 VI-minB 組VI-max、VI-pre 和VI-minC 組VI-max、VI-pre 和VI-minD 組VI-max、VI-pre和VI-min(P均0.05)。3.隨PASP升高,各組間的SVI表現(xiàn)為先增大后減小,B組、C組和D組的SVI均明顯高于A組,C組和D組均明顯高于B組(P均0.05),C組與D組間差異無統(tǒng)計學(xué)意義(P0.05)。各組間的SVI-pas比較,差異無統(tǒng)計學(xué)意義(P均0.05)。隨PASP升高,各組間的SVI-act表現(xiàn)為先增大后減小,B組、C組和D組的SVI-act均明顯高于A組,C組和D組均明顯高于B組(P均0.05),C組與D組間差異無統(tǒng)計學(xué)意義(P0.05)。4.隨PASP升高,各組的EFI和EFI-pas逐漸下降,即A組EFI和EFI-pasB組EFI和EFI-pasC組EFI和EFI-pasD組EFI 和EFI-pas(P均0.05)。隨PASP升高,各組間的EFI-act表現(xiàn)為先增大后減小,B組和C組的EFI-act均明顯高于A組(P均0.05),D組的EFI-act均明顯低于B組、C組(P均0.05),D組與A組差異無統(tǒng)計學(xué)意義(P0.05)。5.LS-n與EFI呈正相關(guān)(r=0.78,P=0.00,P0.05);LS-p與EFI呈正相關(guān)(r=0.76,P=0.00,P0.05);LS-t與EFI呈正相關(guān)(r=0.87,P=0.00,P0.05),其中LS-t與EFI的相關(guān)性最為顯著。6.運用LS-t預(yù)測PH患者右心房心肌功能異常具有較高的臨床應(yīng)用價值:曲線下面積(Area Under The Curve,AUC)=0.87(95%CI=0.732-0.991),最佳界值為32.68(%)時,靈敏度、特異度分別為84.37%、86.65%。結(jié)論:STE為右心房功能的深入研究開辟了一種新方法,可為PH患者的病情診斷、治療決策、療效評估以及預(yù)后判斷提供客觀參考依據(jù)。
[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.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2016
【分類號】：R445.1;R544.1
本文編號：2211729
[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.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2016
【分類號】：R445.1;R544.1
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