陳紀(jì)昀 袁建軍 朱好輝 魏常華

二維斑點(diǎn)追蹤技術(shù)評(píng)估房間隔缺損患者封堵術(shù)后右室功能改變

陳紀(jì)昀 袁建軍 朱好輝 魏常華

目的 應(yīng)用二維斑點(diǎn)追蹤技術(shù)(2DSTI)評(píng)估房間隔缺損(ASD)患者封堵術(shù)后右室功能改變。方法 應(yīng)用2DSTI技術(shù)測(cè)量52例ASD患者(ASD組)封堵術(shù)前、術(shù)后1個(gè)月右室游離壁基底段、中段、心尖段收縮峰值應(yīng)變(￡)、收縮峰值應(yīng)變率(SRs)、舒張?jiān)缙诜逯祽?yīng)變率(SRe)、舒張晚期峰值應(yīng)變率(SRa)。41例年齡、性別匹配的正常人(正常組)作為對(duì)照, 測(cè)量方法及觀察項(xiàng)目同ASD組。結(jié)果 ASD組患者右室壁各節(jié)段的峰值應(yīng)變及應(yīng)變率均低于正常組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。隨著肺動(dòng)脈高壓(PH)程度的加重, ASD患者基底段、中段、心尖段的￡、SRs、SRe、SRa數(shù)值也逐步下降；ASD患者術(shù)后1個(gè)月與術(shù)前比較, 各節(jié)段的峰值應(yīng)變及應(yīng)變率明顯增加, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。結(jié)論 ASD患者常合并不同程度的右心室功能減退, 肺動(dòng)脈高壓越重, 右室功能減退程度越明顯, ASD患者封堵術(shù)后,其右室功能得到改善.2DSTI技術(shù)可準(zhǔn)確、客觀地評(píng)價(jià)房間隔缺損患者術(shù)后右室功能的變化。

房間隔缺損；二維斑點(diǎn)追蹤技術(shù)；右室功能；肺動(dòng)脈高壓

房間隔缺損(atrial septal defect, ASD)大約占所有先天性心臟病的18%, 患者存在左向右分流.30%的成年患者可出現(xiàn)肺動(dòng)脈高壓, 繼而導(dǎo)致右心容量負(fù)荷過重, 右心擴(kuò)大, 直至右心功能受損。如果盡早診治, 可防止心功能惡化, 因此術(shù)前對(duì)其右心室功能的評(píng)價(jià)有重要臨床意義［1］。而術(shù)后右心功能的評(píng)估對(duì)預(yù)后判斷也具有重要意義。介入封堵術(shù)已逐漸成為治療繼發(fā)孔型ASD的主要方法之一。本研究旨在探討應(yīng)用2DSTI技術(shù)評(píng)價(jià)房間隔缺損患者術(shù)后右室功能變化。現(xiàn)報(bào)告如下。

1 資料與方法

1.1 一般資料 選取2013年11月～2014年11月在河南省人民醫(yī)院成功施行房間隔缺損介入封堵術(shù)患者52例(ASD組), 女30例, 男22例, 年齡15～51歲, 平均年齡(31.10±8.26)歲。入組患者不伴或伴有不同程度肺動(dòng)脈高壓。均為竇性心律, 不合并其他心血管畸形、無心臟瓣膜疾病。隨機(jī)選擇經(jīng)輔助檢查排除肺部疾病及心血管疾病的正常人41例(正常組), 其中女28例, 男13例, 年齡17～46歲, 平均年齡(31.50±8.32)歲。兩組一般資料比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05), 具有可比性。

1.2 方法 使用Philips IE33超聲診斷儀, 探頭頻率1～5 MHz。受檢者接肢體心電圖, 均取平臥位或左側(cè)臥位, 胸骨旁及心尖各切面使用二維超聲掃查(幀頻＞100幀/s), 動(dòng)態(tài)模式下存儲(chǔ)3個(gè)完整心動(dòng)周期心尖四腔圖像, 脫機(jī)應(yīng)用Qlab7.1工作站對(duì)存儲(chǔ)的二維圖像進(jìn)行斑點(diǎn)追蹤顯像分析, 測(cè)量追蹤顯像時(shí), 進(jìn)入2DSTI成像模式, 動(dòng)態(tài)的二維四腔心圖像停幀在心內(nèi)膜顯示最清晰的收縮末期, 手動(dòng)仔細(xì)勾畫右室心內(nèi)膜邊界, 系統(tǒng)自動(dòng)追蹤心肌內(nèi)斑點(diǎn), 隨時(shí)調(diào)整感興趣區(qū)寬度,使其包納心肌全層, 運(yùn)行軟件程序可自動(dòng)逐幀追蹤感興趣區(qū)內(nèi)的心肌運(yùn)動(dòng)［2］。追蹤結(jié)束后即可得出右室壁各節(jié)段的應(yīng)變和應(yīng)變率曲線, 測(cè)量并記錄各節(jié)段峰值應(yīng)變及應(yīng)變率(￡、SRs、SRe、SRa)。

1.3 52例ASD患者亞組分組標(biāo)準(zhǔn) 肺動(dòng)脈收縮壓=三尖瓣返流壓差+右房壓, 根據(jù)肺動(dòng)脈收縮壓分為三組, 無PH：＜30 mm Hg(1 mm Hg=0.133 kPa, 無PH組8例)；輕度pH：30～40 mm Hg(輕度PH組18例)；中度pH：40～70 mm Hg(中度PH組26例)。

1.4 統(tǒng)計(jì)學(xué)方法 采用SPSS13.0統(tǒng)計(jì)學(xué)軟件對(duì)研究數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析。計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差( x-±s)表示, 兩組間比較采用t檢驗(yàn), 多組間比較采用單因素方差分析；計(jì)數(shù)資料采用χ2檢驗(yàn)。P＜0.05表示差異具有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 ASD組患者右室游離壁各節(jié)段峰值應(yīng)變、應(yīng)變率均低于正常組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。見表1。

2.2 ASD患者術(shù)后與術(shù)前比較, 右室游離壁各節(jié)段的￡、SRs、SRe、 SRa值明顯增加, 差異具有統(tǒng)計(jì)學(xué)意義(P＜0.05)。見表2。

2.3 肺動(dòng)脈收縮壓越高, 右室游離壁各節(jié)段的￡、SRs、SRe、SRa值下降越明顯。見表3。

表1 ASD組與正常組右室游離壁各節(jié)段峰值應(yīng)變、應(yīng)變率比較(±s)

表1 ASD組與正常組右室游離壁各節(jié)段峰值應(yīng)變、應(yīng)變率比較(±s)

注：與正常組比較,aP＜0.05

部位組別例數(shù)￡(%)SRs(S-1)SRe(S-1)SRa(S-1)基底段ASD組52 -20.86±6.54a-1.77±0.72a.1.47±0.66a.1.47±0.58a正常組41-33.97±7.49-2.35±0.632.57±0.831.95±0.49中段ASD組52 -20.34±6.98a-1.63±0.74a.1.57±0.51a.1.04±0.41a正常組41-32.69±5.91-2.18±0.612.32±0.591.57±0.40心尖段ASD組52 -17.36±7.66a-1.23±0.56a.1.49±0.79a.1.14±0.62a正常組41-26.19±7.11-1.63±0.452.02±6.161.46±0.64

表2 ASD患者手術(shù)前后右室壁各節(jié)段峰值應(yīng)變、應(yīng)變率比較(±s, n=52)

表2 ASD患者手術(shù)前后右室壁各節(jié)段峰值應(yīng)變、應(yīng)變率比較(±s, n=52)

注：與術(shù)前比較,aP＜0.05

部位時(shí)間￡(%)SRs(S-1)SRe(S-1)SRa(S-1)基底段術(shù)前-20.86±6.54-1.77±0.721.47±0.661.47±0.58術(shù)后1個(gè)月 -31.77±6.79a-2.30±0.64a.2.46±0.77a.1.91±0.57a中段術(shù)前-20.34±6.98-1.63±0.741.57±0.511.04±0.41術(shù)后1個(gè)月 -30.57±5.66a-2.19±0.61a.2.32±0.67a.1.55±0.44a心尖段術(shù)前-17.36±7.66-1.23±0.561.49±0.791.14±0.62術(shù)后1個(gè)月 -22.04±7.03a-1.60±0.57a.1.80±5.14a.1.47±0.56a

表3 輕、中度PH組及無PH組右室游離壁各節(jié)段二維應(yīng)變參數(shù)比較±s)

表3 輕、中度PH組及無PH組右室游離壁各節(jié)段二維應(yīng)變參數(shù)比較±s)

注：與無PH組比較,aP＜0.05,bP＞0.05

部位組別例數(shù)￡(%)SRs(S-1)SRe(S-1)SRa(S-1)基底段無PH組8-28.86±7.17-2.29±0.812.57±0.721.82±0.69輕度PH組18 -24.53±7.11a-1.96±0.77a.2.14±0.66a.1.56±0.61a中度PH組26 -19.56±6.57a-1.67±0.64a.1.77±0.71a.1.30±0.71a中段無PH組8.26.55±6.93-2.16±0.732.24±0.631.46±0.46輕度PH組18 .21.49±6.67a.1.99±0.52a.1.93±0.75a.1.27±0.52a中度PH組26 .17.53±6.71a.1.68±0.62a.1.59±0.63a.1.04±0.62a心尖段無PH組8.23.27±7.43-1.59±0.542.03±6.031.37±0.60輕度PH組18 .19.36±6.24a.1.48±0.56b.1.93±5.36b.1.19±0.56b中度PH組26 .17.33±5.36a.1.35±0.71a.1.63±6.07a.1.09±0.65a

3 討論

正常情況下, 右心室解剖結(jié)構(gòu)復(fù)雜且不規(guī)則, 以往所采用的右心室功能評(píng)估方法, 結(jié)果不夠準(zhǔn)確。國(guó)外研究顯示心肌應(yīng)變、應(yīng)變率在評(píng)估健康人及先天性心臟病患者的右心室功能有其一定的優(yōu)勢(shì)［3-5］。國(guó)外已有研究［6-9］評(píng)價(jià)ASD封堵術(shù)后左心功能變化, 但對(duì)右室功能的對(duì)比研究國(guó)內(nèi)少有報(bào)導(dǎo)。本研究結(jié)果顯示ASD組右心室游離壁各節(jié)段的峰值應(yīng)變及應(yīng)變率顯著低于正常組, 房間隔缺損是最常見的先天性心臟病之一, 通常ASD患者1歲以后自然閉合的機(jī)會(huì)不大, ASD患者長(zhǎng)期心房水平的左向右分流, 部分左心房血液經(jīng)ASD進(jìn)入右心房, 反復(fù)通過肺循環(huán), 長(zhǎng)期肺循環(huán)血流量增多, 肺動(dòng)脈收縮壓逐漸升高, 最終導(dǎo)致肺動(dòng)脈高壓, 若不接受治療,最終會(huì)導(dǎo)致右心功能受損。本研究同時(shí)顯示肺動(dòng)脈壓程度高的組別各節(jié)段應(yīng)變及應(yīng)變率的值比肺動(dòng)脈壓程度較低的組別各節(jié)段的值更低, 研究結(jié)果提示肺動(dòng)脈高壓程度越重, 右室心肌應(yīng)變能力受損越嚴(yán)重, 心功能損害也越嚴(yán)重, 因?yàn)榉块g隔缺損患者長(zhǎng)期肺循環(huán)血流量增多而導(dǎo)致肺動(dòng)脈收縮壓升高, 肺血管阻力進(jìn)行性升高, 右心后負(fù)荷加重, 隨著右心容量負(fù)荷不斷增加, 最終將導(dǎo)致右心衰竭。隨著介入治療器材和技術(shù)的不斷改進(jìn), 尤其是隨著Amplatzer封堵器的應(yīng)用, 使封堵術(shù)獲得了良好的治療效果, 封堵術(shù)后患者右室游離壁各節(jié)段的應(yīng)變及應(yīng)變率的值較術(shù)前增加, 是由于封堵術(shù)糾正了房間隔缺損的解剖畸形, 阻斷了左向右分流, 右心容量負(fù)荷輕, 肺動(dòng)脈壓力降低, 可使右心室高負(fù)荷狀態(tài)減輕, 右心形態(tài)學(xué)異常逐步發(fā)生逆轉(zhuǎn), 心功能得到改善。

綜上所述.2DSTI技術(shù)能準(zhǔn)確評(píng)價(jià)ASD患者右室功能變化, 為臨床早期無創(chuàng)準(zhǔn)確評(píng)價(jià)右室功能, 并為指導(dǎo)臨床治療提供可靠新途徑。

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Two-dimensional speckle tracking imaging in evaluation of right ventricular function change after closure in atrial septal defect patients

CHEN Ji-yun, YUAN Jian-jun, ZHU Hao-hui, et al.
Department of Ultrasound, Henan Province People’s Hospital, Zhengzhou 450003, China

Objective To apply two-dimensional speckle tracking imaging (2DSTI) in evaluation of right ventricular function change after closure in atrial septal defect (ASD) patients. Method.2DSTI was applied in detection of peak strain shrinkage (￡), systolic peak strain rate (SRs), early diastolic peak strain peak (SRe), and late diastolic peak strain peak (SRa) in right ventricular free wall basal segment, middle segment, and apical segment in 52 ASD patients (ASD group) before closure and i.1 month after operation. There were 41 normal people (normal group) with corresponding age and gender for comparison. Their detection method was the same as the ASD group. Results The ASD group had all lower peak value and strain rate of right ventricle wall in each segment than the normal group, and their difference had statistical significance (P＜0.05). The ASD group had gradually decreased ￡, SRs, SRe, and SRa values in basal segment, middle segment, and apical segment, along with the progress of pulmonary hypertension (PH). Comparing with those before operation, the ASD group had obviously increased peak value and strain rate in each segment i.1 month after operation. The difference had statistical significance (P＜0.05). Conclusion It is usual for complicated right ventricular function impairment in ASD patients. Worse pulmonary hypertension will lead to more obvious right ventricular function impairment. Closure in ASD patients can provide remarkable improvement in their right ventricular function.2DSTI can accurately and objectively evaluate changes of right ventricular function in ASD patients.

Atrial septal defect; Two-dimensional speckle tracking imaging; Right ventricular function; Pulmonary hypertension

10.14163/j.cnki.11-5547/r.2015.32.004

2015-06-24］

450003 河南省人民醫(yī)院超聲科