-
主动脉瓣狭窄(AS)是老年人群中最常见的心脏瓣膜疾病,其死亡率和发病率较高。据美国心脏病学会(AHA)统计,老年钙化性AS已成为第三大心血管疾病,仅次于冠心病和高血压,20%~30%发生在65岁以上人群,而85岁以上人群发病率更高,达48%~57%[1]。狭窄瓣膜引起左心室后负荷增加,心肌发生向心性肥厚和肺动脉压力增高,逐渐发展,病人出现冠状动脉供血不足,出现心绞痛、呼吸困难和晕厥等症状,甚至出现心力衰竭导致死亡[2-3]。有研究[4]表明,AS病人在很长一段时间内可以无任何症状, 在无症状的病人中,心脏猝死的风险每年低于1%, 然而30%的无症状病人在2年内出现症状。外科主动脉瓣置换术是治疗AS的首选策略,尤其近年来经导管主动脉瓣置入术(TAVI)的发展,已成为AS病人的重要治疗手段[5-6]。干预的时机在无症状的重症AS病人和保留左心室射血分数(LVEF)病人中具有重要的挑战性。有研究[7]认为,左心室收缩功能受损的发展与预后不良有关,左心室收缩功能可作为一个重要的预判指标。目前常规LVEF作为一种评估左心室收缩功能的方法,并不足以评估亚临床的左心室收缩功能障碍, 需要更敏感的方法来全面评估左心室的功能。本研究旨在利用2D-STI技术检测保留LVEF的重度AS病人左心室收缩功能早期变化,并探讨应变指标与瓣膜狭窄程度及心室能量损失指数(ELI)之间的相关性。现作报道。
-
选择35例无症状重度AS病人, 主动脉瓣开口面积<1.0 cm2,使用连续多普勒测量主动脉瓣跨瓣压差(MPG)>40 mmHg[2]。所有AS病人均保留LVEF≥50%和窦性心律。排除标准:显著的冠状动脉疾病、高血压、糖尿病、严重的主动脉瓣返流或严重的二尖瓣疾病、心脏衰竭、心肌病、人工瓣膜植入、肾功能衰竭、先天性或获得主动脉疾病、主动脉瘤、心血管或主动脉手术史、结缔组织疾病、肺动脉高压、心律失常等。选择同期25名年龄和性别匹配的健康人作为对照组。2组年龄、性别血压和体表面积差异无统计学意义(P>0.05),但心率差异有统计学意义(P < 0.01)(见表 1)。
分组 n 年龄/岁 男 女 收缩压/mmHg 舒张压/mmHg 心率/(次/分) 体表面积/m2 AS组 35 73.15±6.36 18 17 123±10.3 80±5.5 76±2.7 1.82±0.25 对照组 25 72.88±5.4 13 12 122±11.5 79±5.8 74±2.6 1.80±0.21 t — 0.17 0.00Δ 0.35 0.68 2.87 0.33 P — >0.05 >0.05 >0.05 >0.05 <0.01 >0.05 Δ示χ2值 表 1 2组一般资料比较(x±s)
-
美国飞利浦公司生产的IE33型彩色多普勒超声诊断仪,X5-1相控阵探头,频率2~4 MHz,内置二维斑点追踪技术及分析软件。
-
病人平静状态下,左侧卧位,常规连接心电图,经胸左心室长轴常规测量左心室舒张末内径(LVEDD)、左心室收缩期末内径(LVESD)、室间隔(IVS)厚度、左心室后壁(LVPW)厚度。心尖四腔两腔心切面Simpson法获取LVEF。
-
受检者平静状态下,取左侧卧位,记录同步心电图。二维模式调节深度、角度、增益使心内膜清晰显示,并保持帧频60~100帧/秒,记录连续3个心动周期的左心室标准短轴切面(左心房室瓣口水平、乳头肌水平、心尖水平),以及心尖四腔、三腔、两腔切面的动态图像并存储。使用仪器内置QLAB软件,选择要分析的感兴趣区心肌范围,系统自动勾画出心肌内膜,调节感兴趣宽度使其与心肌厚度一致,对显示不佳的节段进行手动微调,随后系统会自动得出左心室各节段应变指标的牛眼图,记录左心室整体纵向应变(LVGLS)、整体环向应变(LVGCS)。
-
采用连续波多普勒从心尖五腔和心尖长轴切面测量主动脉瓣最大射流速度,获取主动脉瓣的最大和平均MPG。胸骨旁左心室长轴切面左心室收缩中期左心室流出道(LVOT)内径最大时测量LVOT内径,利用连续性方程法测定主动脉瓣瓣口面积(AVA)[8],并将其除以体表面积(BSA),计算出瓣口面积指数。
-
ELI与左心室压力恢复相关,其计算公式如下:ELI = (EOA×Aa)/(Aa-EOA)/BSA,Aa为主动脉窦管交界处面积,EOA为有效瓣口面积,BSA为体表面积[9]。
-
采用t检验、χ2检验和相关分析。
-
2组LVEDD、LVESD、LVEF差异均无统计学意义(P>0.05)。AS组病人的IVS和LVPW厚度与对照组相比更厚(P < 0.05和P < 0.01), 主动脉瓣最大MPG及平均MPG显著高于对照组(P < 0.01);AS组LVGLS和LVGCS均显著低于对照组(P < 0.01)(见表 2)。ELI与LVGLS呈显著正相关关系(r=0.55, P < 0.01);LVGLS与AVA呈正相关关系(r=0.36, P < 0.01)。
分组 n LVEDD/cm LVESD/cm LVEF/% IVS/cm LVPW/cm MPG/mmHg AVA/cm2 LVGLS/% LVGCS/% ELI/(cm2/m2) AS组 35 5.08±0.28 3.45±0.28 60.75±1.14 1.25±0.06 1.22±0.17 45.80±8.00 0.77±0.11 10.66±1.15 12.26±2.62 0.45±0.07 对照组 25 5.04±0.22 3.36±0.21 61.08±1.25 0.97±0.76 0.93±0.07 3.43±0.86 2.96±0.56 19.88±2.88 15.48±3.32 0.86±0.16 t — 0.59 1.36 1.06 2.18 8.04 26.31 22.61 17.17 5.2 13.49 P — >0.05 >0.05 >0.05 <0.05 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 表 2 2组超声心动图测量参数比较(x±s)
2D-STI评价亚临床型重度主动脉瓣狭窄病人左心室功能及相关性研究
Application value of 2D-STI in the evaluation of left ventricular function and its correlation in patients with subclinical severe aortic stenosis
-
摘要:
目的应用二维斑点追踪(2D-STI)技术定量评价保留左心室射血分数(LVEF)的重度主动脉瓣狭窄(AS)病人左心室功能及相关性。 方法选择35例重度AS并保留LVEF ≥ 50%且无其他心脏疾病的病人,同时入选25名性别年龄相匹配的健康志愿者。常规超声心动图双平面Simpsin法测量LVEF;左心室长轴切面M型超声测量室间隔(IVS)、左心室后壁(LVPW)厚度、左心室舒张末期内径(LVEDD)和收缩末期内径(LVESD);连续多普勒测量主动脉瓣口射流速度及平均跨瓣压差(MPG),连续方程法测量主动脉瓣瓣口面积(AVA);2D-STI技术获取左心室整体纵向应变(LVGLS)、整体环向应变(LVGCS);同时测量了评价心室损伤的指标能量损失指数(ELI)。 结果2组LVEDD、LVESD、LVEF差异均无统计学意义(P>0.05)。AS组病人的IVS和LVPW厚度与对照组相比更厚(P < 0.05和P < 0.01),主动脉瓣最大MPG及平均MPG显著高于对照组(P < 0.01);AS组LVGLS和LVGCS均显著低于对照组(P < 0.01)。ELI与LVGLS呈显著正相关关系(P < 0.01);LVGLS与AVA呈正相关关系(P < 0.01)。 结论严重AS的病人尽管保留有正常LVEF,但左心室收缩功能已经受损,2D-STI技术可以早期检测重度AS病人亚临床型左心室功能障碍,为AS病人得到及时干预提供依据。 Abstract:ObjectiveTo investigate the application value of two-dimensional speckle tracking imaging (2D-STI) in the quantitative evaluation of left ventricular ejection fraction (LVEF) and its correlation in patients with severe aortic stenosis (AS). MethodsThirty-five severe AS patients with reserved ventricular LVEF ≥ 50% and 25 healthy volunteers with similar gender and age were selected.The LVEF in two groups were measured using the conventional echocardiography with biplane Simpsin.The interventricular septum (IVS), left ventricular posterior wall (LVPW) thickness, left ventricular end-diastolic diameter (LVEDD) and end-systolic diameter (LVESD) were measured using M mode ultrasonography in two groups.The flow velocity and mean transprosthetic gradient (MPG), aortic valvular area (AVA), and left ventricle overall longitudinal strain (LVGLS) and global annular strain (LVGCS) in two groups were measured using the continuous doppler, continuous equation method and 2D-STI technique, respectively.At the same time, the energy loss index (ELI) for evaluating ventricular injury was measured. ResultsThe differences of the levels of LVEDD, LVESD and LVEF between two groups were not statistically significant (P>0.05).The left ventricle IVS and LVPW thickness in AS group were significantly thicker than those in control group (P < 0.05 and P < 0.01), and the biggest and average MPG in AS group were significantly higher than those in control group (P < 0.01).The LVGLS and LVGCS in AS group were significantly lower than those in control group (P < 0.01).The ELI was significantly positively correlated with LVGLS (P < 0.01), and the LVGLS was positively correlated with AVA (P < 0.01). ConclusionsThe left ventricular systolic function in severe AS patients with retained normal left ventricular is impair.2D-STI can early detect the subclinical left ventricular dysfunction in patients with severe AS, and provide the evidence for timely intervention in patients with AS. -
Key words:
- aortic stenosis /
- speckle tracking /
- left ventricular function /
- energy loss index
-
表 1 2组一般资料比较(x±s)
分组 n 年龄/岁 男 女 收缩压/mmHg 舒张压/mmHg 心率/(次/分) 体表面积/m2 AS组 35 73.15±6.36 18 17 123±10.3 80±5.5 76±2.7 1.82±0.25 对照组 25 72.88±5.4 13 12 122±11.5 79±5.8 74±2.6 1.80±0.21 t — 0.17 0.00Δ 0.35 0.68 2.87 0.33 P — >0.05 >0.05 >0.05 >0.05 <0.01 >0.05 Δ示χ2值 表 2 2组超声心动图测量参数比较(x±s)
分组 n LVEDD/cm LVESD/cm LVEF/% IVS/cm LVPW/cm MPG/mmHg AVA/cm2 LVGLS/% LVGCS/% ELI/(cm2/m2) AS组 35 5.08±0.28 3.45±0.28 60.75±1.14 1.25±0.06 1.22±0.17 45.80±8.00 0.77±0.11 10.66±1.15 12.26±2.62 0.45±0.07 对照组 25 5.04±0.22 3.36±0.21 61.08±1.25 0.97±0.76 0.93±0.07 3.43±0.86 2.96±0.56 19.88±2.88 15.48±3.32 0.86±0.16 t — 0.59 1.36 1.06 2.18 8.04 26.31 22.61 17.17 5.2 13.49 P — >0.05 >0.05 >0.05 <0.05 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 -
[1] FURUKAWA K.Recent advances in research on human aortic valve calcification[J].J Pharmacol Sci, 2014, 124(2):129. doi: 10.1254/jphs.13R05CR [2] NISHIMURA RA, OTTO CM, BONOW RO, et al.2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease:A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines[J].J Am Coll Cardiol, 2017, 70(2):252. doi: 10.1016/j.jacc.2017.03.011 [3] 郑居兵, 董然, 刘韬帅, 等.主动脉瓣重度狭窄合并左心室功能重度减低患者的手术疗效分析[J].中国医药, 2018, 13(6):830. doi: 10.3760/j.issn.1673-4777.2018.06.008 [4] DAL-BIANCO JP, KHANDHERIA BK, MOOKADAM F, et al.Management of asymptomatic severe aortic stenosis[J].J Am Coll Cardiol, 2008, 52(16):1279. doi: 10.1016/j.jacc.2008.07.020 [5] 吴永健.经导管主动脉瓣置换术的现状、研究热点和未来展望[J].中国循环杂志, 2017, 32(2):120. doi: 10.3969/j.issn.1000-3614.2017.02.002 [6] 郑居兵, 董然, 刘韬帅, 等.手术治疗重度主动脉瓣狭窄101例临床分析[J].江苏医药, 2018, 44(1):43. [7] TANIGUCHI T, MORIMOTO T, SHIOMI H, et al.Prognostic impact of left ventricular ejection fraction in patients with severe aortic stenosis[J].JACC Cardiovasc Interv, 2018, 11(2):145. doi: 10.1016/j.jcin.2017.08.036 [8] 王新房, 谢明星.超声心动图学[M].5版.北京:人民卫生出版社, 2017:400. [9] GARCIA D, DUMESNIL JG, DURAND LG, et al.Discrepancies between catheter and Doppler estimates of valve effective orifce area can be predicted from the pressure recovery phenomenon:practical implications with regard to quantifcation of aortic stenosis severity[J].J Am Coll Cardiol, 2003, 41(3):435. doi: 10.1016/S0735-1097(02)02764-X [10] MEIMOUN P, CZITROM D, CLERC J, et al.Noninvasive coronary flow reserve predicts response to exercise in asymptomatic severe aortic stenosis[J].J Am Soc Echocardiogr, 2017, 30(8):736. doi: 10.1016/j.echo.2017.04.005 [11] 王子龙, 杨性安, 王刚, 等.三维斑点追踪成像评估重度主动脉狭窄左心室纵向应变及扭转运动[J].心脑血管病防治, 2018, 18(5):371. doi: 10.3969/j.issn.1009-816x.2018.05.004 [12] 丁钱山, 张平洋, 李林, 等.三维斑点追踪技术评价射血分数正常的重度主动脉瓣狭窄患者左室心肌收缩特性[J].中国超声医学杂志, 2017, 33(2):128. doi: 10.3969/j.issn.1002-0101.2017.02.011 [13] 邓冰晴, 王开权, 李金国, 等.三维斑点追踪技术对射血分数正常的重度主动脉瓣狭窄患者左室心肌收缩功能的评价效果[J].中国心血管病研究, 2018, 16(1):27. doi: 10.3969/j.issn.1672-5301.2018.01.007 [14] WEIDEMANN F, HERRMANN S, STÖRK S, et al.Impact of myocardial fibrosis in patients with symptomatic severe aortic stenosis[J].Circulation, 2009, 120(7):577. doi: 10.1161/CIRCULATIONAHA.108.847772 [15] 林洁, 严志汉.心肌分层应变评估重度主动脉瓣狭窄患者左室心肌收缩功能变化[J].温州医科大学学报, 2018, 48(4):289. doi: 10.3969/j.issn.2095-9400.2018.04.012 [16] GEYER H, CARACCIOLO G, ABE H, et al.Assessment of myocardial mechanics using speckle tracking echocardiography:fundamentals and clinical applications[J].J Am Soc Echocardiogr, 2010, 23(4):351. doi: 10.1016/j.echo.2010.02.015 [17] BHATTACHARYYA S, HAYWARD C, PEPPER J, et al.Risk stratification in asymptomatic severe aortic stenosis:a critical appraisal[J].Eur Heart J, 2012, 33(19):2377. doi: 10.1093/eurheartj/ehs190 [18] CRAMARIUC D, GERDTS E, DAVIDSEN ES, et al.Myocardial deformation in aortic valve stenosis:relation to left ventricular geometry[J].Heart, 2010, 96(2):106. doi: 10.1136/hrt.2009.172569 [19] YOSHIDA H, SEO Y, ISHIZU T, et al.Prognostic value of energy loss coefficient for predicting asymptomatic aortic stenosis outcomes:direct comparison with aortic valve area[J].J Am Soc Echocardiogr, 2019, 32(3):351. doi: 10.1016/j.echo.2018.10.016 [20] BARKER AJ, VAN OOIJ P, BANDI K, et al.Viscous energy loss in the presence of abnormal aortic flow[J].Magn Reson Med, 2014, 72(3):620. doi: 10.1002/mrm.v72.3 [21] GARCIA D, PIBAROT P, DUMESNIL JG, et al.Assessment of aortic valve stenosis severity:a new index based on the energy loss concept[J].Circulation, 2000, 101(7):765. doi: 10.1161/01.CIR.101.7.765