李 茜綜述，唐 紅審校

(四川大學(xué)華西醫(yī)院心血管內(nèi)科，四川 成都 610041)

綜述

超聲心動(dòng)圖對(duì)系統(tǒng)性紅斑狼瘡心臟并發(fā)癥的評(píng)估

李 茜綜述，唐 紅*審校

(四川大學(xué)華西醫(yī)院心血管內(nèi)科，四川 成都 610041)

系統(tǒng)性紅斑狼瘡(SLE)是一種累及全身多系統(tǒng)、多器官的復(fù)雜自身免疫性彌漫性結(jié)締組織病，心血管并發(fā)癥已成為其主要的死亡原因之一。SLE合并心血管并發(fā)癥的診斷及評(píng)估多依賴于影像學(xué)檢查。超聲心動(dòng)圖無(wú)創(chuàng)、簡(jiǎn)便、可靠，是心臟結(jié)構(gòu)和功能評(píng)估的有效手段。本文對(duì)超聲心動(dòng)圖在SLE患者心臟病變?cè)u(píng)估中的應(yīng)用做一綜述。

紅斑狼瘡，系統(tǒng)性；心血管并發(fā)癥；超聲心動(dòng)描記術(shù)

系統(tǒng)性紅斑狼瘡(systemic lupus erythematosus， SLE)是一種累及全身多個(gè)臟器的復(fù)雜自身免疫性彌漫性結(jié)締組織病，以免疫性炎癥為典型表現(xiàn)，主要累及心血管、腎臟、神經(jīng)精神系統(tǒng)、血液系統(tǒng)、肺、消化系統(tǒng)、眼及外分泌腺。SLE合并心血管并發(fā)癥的死亡率逐年升高，已成為SLE患者主要的死亡原因之一[1]。SLE患者發(fā)生心血管疾病(cardiovascular disease, CVD)的概率是正常人群的7倍[2]。SLE合并CVD的高發(fā)病率及高死亡率的原因與加速的動(dòng)脈硬化過(guò)程相關(guān)[3]，而其發(fā)生也是CVD的傳統(tǒng)危險(xiǎn)因素及狼瘡特有的危險(xiǎn)因素交互作用的結(jié)果[2-4]。一方面，SLE本身的免疫性炎癥可致血小板的不穩(wěn)定；另一方面，SLE患者有高發(fā)的傳統(tǒng)CVD危險(xiǎn)因素，如高血壓、脂代謝紊亂[5]、長(zhǎng)期激素治療所致的糖耐量降低[6]。此外，合并腎臟損害和免疫抑制療法可加重心血管損害[7-8]。

SLE患者心臟病變包括冠狀動(dòng)脈性心臟病、心肌病變、瓣膜病變、心包炎及肺動(dòng)脈高壓(pulmonary artery hypertension, PAH)，對(duì)其診斷和評(píng)估多依賴于影像學(xué)檢查。超聲心動(dòng)圖因其具有無(wú)創(chuàng)、簡(jiǎn)便、可靠的優(yōu)點(diǎn)，在其中發(fā)揮著重要的作用。

常規(guī)超聲心動(dòng)圖檢查包括M型超聲、二維超聲、頻譜多普勒、彩色多普勒、組織多普勒及經(jīng)食管超聲心動(dòng)圖(transesophageal echocardiography, TEE)等。各種超聲技術(shù)臨床常聯(lián)合應(yīng)用，互為補(bǔ)充，被廣泛應(yīng)用于心臟疾病的診斷及鑒別診斷。此外，實(shí)時(shí)三維超聲心動(dòng)圖(real-time three-dimensional echocardiography, RT-3DE)、斑點(diǎn)追蹤技術(shù)等也在心臟疾病的診治中發(fā)揮著重要作用。本文主要對(duì)超聲心動(dòng)圖在SLE患者心臟病變?cè)u(píng)估中的應(yīng)用進(jìn)行綜述。

1 冠狀動(dòng)脈性心臟病

SLE的免疫性炎癥可發(fā)生于冠狀動(dòng)脈，導(dǎo)致冠狀動(dòng)脈內(nèi)皮細(xì)胞變性壞死，局部?jī)?nèi)膜增生，管腔灶性狹窄，局部組織壞死及血栓形成，最終導(dǎo)致冠狀動(dòng)脈狹窄，輕者可致心絞痛發(fā)生，重癥者可致心肌梗死。相對(duì)于正常人群，SLE患者更易發(fā)生冠狀動(dòng)脈性心臟病[7]，至少13%的SLE患者有心絞痛、心肌梗死等冠狀動(dòng)脈受累表現(xiàn)[9]。而更多亞臨床患者缺乏特異性表現(xiàn)，尤其是年輕患者。因其他原因死亡的SLE患者中約50%均有冠狀動(dòng)脈受累[10]。

通過(guò)M型超聲心動(dòng)圖可獲取室壁的運(yùn)動(dòng)曲線。觀察室壁厚度、收縮期增厚率及運(yùn)動(dòng)幅度可判斷取樣部位心肌是否缺血。利用二維超聲心動(dòng)圖可直接觀察冠狀動(dòng)脈走行及內(nèi)徑，但由于聲窗的影響，僅能顯示部分冠狀動(dòng)脈血管。通過(guò)室壁形態(tài)改變(室壁變薄、纖維化和室壁瘤形成)和室壁運(yùn)動(dòng)異常(室壁運(yùn)動(dòng)幅度降低、消失，收縮期室壁增厚率降低或消失，甚至出現(xiàn)反向運(yùn)動(dòng))判斷受累心肌，是診斷冠心病的重要手段。對(duì)于穩(wěn)定型心絞痛的患者，運(yùn)動(dòng)負(fù)荷檢查為診斷及評(píng)估疾病嚴(yán)重程度的重要方法，可用于診斷初發(fā)穩(wěn)定型心絞痛[11]。通過(guò)超聲心動(dòng)圖的冠狀動(dòng)脈血流成像可評(píng)估冠狀動(dòng)脈血流，為診斷冠心病提供依據(jù)[12]。

2 心肌病變

尸體檢查發(fā)現(xiàn)SLE心肌病變的發(fā)生率約40%～70%，但因心功能受損而出現(xiàn)相關(guān)臨床癥狀的患者僅占10%[13]，部分左心室射血分?jǐn)?shù)(left ventricular ejection fraction， LVEF)正常的患者其心肌運(yùn)動(dòng)已出現(xiàn)異常。SLE心肌病變可導(dǎo)致心力衰竭[14]。因此，早期評(píng)估SLE患者心肌受累情況對(duì)臨床診療及預(yù)后評(píng)估具有重要意義。利用超聲心動(dòng)圖不僅可對(duì)SLE患者心功能下降進(jìn)行定量評(píng)估，通過(guò)斑點(diǎn)追蹤等超聲新技術(shù)還可發(fā)現(xiàn)亞臨床狀態(tài)下心肌運(yùn)動(dòng)異常。

2.1 左心功能評(píng)估 通過(guò)脈沖多普勒及組織多普勒對(duì)二尖瓣及肺靜脈血流、二尖瓣瓣環(huán)運(yùn)動(dòng)、肺動(dòng)脈壓力等進(jìn)行評(píng)估，可評(píng)價(jià)心室舒張功能。應(yīng)用組織多普勒可直接評(píng)價(jià)心肌運(yùn)動(dòng)，較脈沖多普勒的間接評(píng)價(jià)更為準(zhǔn)確[15]。有學(xué)者[16]評(píng)估LVEF正常的SLE患者心臟舒張功能，發(fā)現(xiàn)45.3%的患者出現(xiàn)舒張功能受損，其危險(xiǎn)因素包括病程、是否合并抗磷脂綜合征(antiphospholipid syndrome, APS)、高血壓。Shang等[17]發(fā)現(xiàn)左心室舒張功能與損傷因素相關(guān)。Roldan等[18]采用TEE獲得主動(dòng)脈壓力-應(yīng)變彈性系數(shù)對(duì)主動(dòng)脈彈性進(jìn)行評(píng)價(jià)，發(fā)現(xiàn)該指標(biāo)與SLE患者心臟舒張功能呈負(fù)相關(guān)。

除舒張功能受損外，部分SLE患者還伴收縮功能的亞臨床改變。組織多普勒、二維及三維斑點(diǎn)追蹤技術(shù)的應(yīng)用可實(shí)現(xiàn)對(duì)心肌收縮功能的評(píng)估。組織多普勒操作簡(jiǎn)單、重復(fù)性好，被廣泛應(yīng)用于心臟功能減退的評(píng)估，但受角度依賴性的限制和周圍組織的影響，準(zhǔn)確性有所下降。二維應(yīng)變分析不受角度依賴性的限制，并可評(píng)估心肌在多個(gè)方向的應(yīng)變。Bulut等[19]應(yīng)用Simpson雙平面法及二維斑點(diǎn)追蹤技術(shù)，發(fā)現(xiàn)在LVEF正常的情況下，心肌已出現(xiàn)總體應(yīng)變的下降，而僅在SLE極度活躍時(shí)才出現(xiàn)心室扭轉(zhuǎn)的下降。三維斑點(diǎn)追蹤技術(shù)可提供LVEF、三維左心室質(zhì)量、球形指數(shù)以及三維應(yīng)變等定量指標(biāo)。Huang等[20]應(yīng)用三維斑點(diǎn)追蹤技術(shù)對(duì)LVEF正常的SLE患者進(jìn)行研究，發(fā)現(xiàn)其整體縱向、環(huán)向及徑向應(yīng)變較正常對(duì)照組均有所減低，重度活動(dòng)性SLE患者中各項(xiàng)應(yīng)變的下降更明顯。

左心房在維持正常的心輸出量中有重要的作用，LVEF正常的SLE患者多已存在舒張功能的受損，此時(shí)左心房常有容量負(fù)荷的增加。Dai等[21]研究報(bào)道，LVEF正常的SLE患者存在左心房功能受損，且主要與SLE活躍程度相關(guān)。Li等[22]采用RE-3DE技術(shù)研究發(fā)現(xiàn)SLE患者左心房容積較正常對(duì)照組有所增加，隨SLE損傷指數(shù)(rheumatology damage index, SDI)的增加，左心房排空分?jǐn)?shù)減低。

亞臨床狀態(tài)下的SLE患者已存在左心功能受損，SLE病程及活動(dòng)性為其主要危險(xiǎn)因素，對(duì)于病程長(zhǎng)、疾病活動(dòng)性大的患者應(yīng)進(jìn)行密切的心功能隨訪。

2.2 右心室功能評(píng)估 SLE可引起右心室受累。此外，SLE常并發(fā)PAH，可加重右心室功能損害。研究[23-26]發(fā)現(xiàn)SLE合并PAH患者的右心室功能降低。

超聲心動(dòng)圖評(píng)估右心室功能的指標(biāo)包括三尖瓣前瓣環(huán)收縮期運(yùn)動(dòng)幅度(tricuspid annular plane systolic excursion, TAPSE)、Tei指數(shù)、組織多普勒三尖瓣前瓣環(huán)收縮期S峰(tissue Doppler systolic S wave, TDI-S)、斑點(diǎn)追蹤技術(shù)、三維右心室EF測(cè)值等。Leal等[27]研究發(fā)現(xiàn)SLE患兒右心室總體長(zhǎng)軸應(yīng)變(global peak longitudinal systolic strain, PLSS)及TAPSE均較正常對(duì)照組降低,且這兩個(gè)指標(biāo)呈現(xiàn)出較好的相關(guān)性。由于右心室形態(tài)不規(guī)則，常規(guī)LVEF測(cè)量的方法，如M型超聲及Simpson雙平面法，并不適用于對(duì)右心室的評(píng)估[28]。RT-3DE可用以評(píng)價(jià)右心室功能，其準(zhǔn)確性已被證實(shí)[29-30]。但目前關(guān)于RT-3DE技術(shù)評(píng)估SLE患者右心室功能的研究尚少。

3 瓣膜病變

SLE患者血漿中的免疫復(fù)合物及補(bǔ)體沉積于心瓣膜即可導(dǎo)致瓣膜損害，主要表現(xiàn)為瓣膜增厚(纖維化或鈣化)、瓣葉穿孔、瓣膜狹窄、瓣膜反流和疣狀心內(nèi)膜炎，可發(fā)生于所有瓣膜，但以二尖瓣及主動(dòng)脈瓣最為常見(jiàn)[31]。超聲心動(dòng)圖可用于評(píng)估瓣膜形態(tài)及功能改變，觀察瓣膜形態(tài)、贅生物的附著位置、大小、數(shù)目、形態(tài)[32]。TEE較常規(guī)經(jīng)胸超聲心動(dòng)圖診斷疣狀心內(nèi)膜炎更具優(yōu)勢(shì)[33]，但對(duì)疣狀心內(nèi)膜炎和感染性心內(nèi)膜炎的區(qū)分仍較困難[34]。另外，超聲隨訪研究[35]發(fā)現(xiàn)SLE/APS及其病程是發(fā)生瓣膜疾病的獨(dú)立危險(xiǎn)因素，且抗凝治療不能阻止疾病進(jìn)程。

4 心包炎

約40%的SLE患者存在急慢性心包損害，但多數(shù)患者無(wú)癥狀[36]。心臟壓塞，縮窄性心包炎、化膿性心包炎等嚴(yán)重并發(fā)癥較為罕見(jiàn)，而心包積液則較為常見(jiàn)。采用二維超聲心動(dòng)圖可定量測(cè)量心包積液深度，觀察有無(wú)心包增厚，為臨床診療提供參考依據(jù)。

5 PAH

PAH定義為靜息時(shí)平均肺動(dòng)脈壓(mean pulmonary arterial pressure, MPAP)≥25 mmHg，肺動(dòng)脈楔壓(pulmonary artery wedge pressure, PAWP)或左心室舒張末期壓力≤15 mmHg及持續(xù)增加的肺血管阻力(pulmonary vascular resistance, PVR)[37]。SLE相關(guān)性PAH的發(fā)病機(jī)制主要是炎細(xì)胞、自身抗體等浸潤(rùn)肺小動(dòng)脈壁，產(chǎn)生PVR，最終導(dǎo)致PAH[38]。SLE合并PAH的概率為0.5%～17.5%[39]。

目前診斷PAH的金標(biāo)準(zhǔn)為心導(dǎo)管檢查，但超聲心動(dòng)圖是篩查PAH的重要手段。常用方法是通過(guò)連續(xù)多普勒測(cè)量三尖瓣反流壓差估算肺動(dòng)脈收縮壓[40]。通過(guò)二維超聲心動(dòng)圖可觀察PAH引起的心臟結(jié)構(gòu)改變，如右心增大、肺動(dòng)脈增寬、下腔靜脈塌陷率減低等。

綜上所述，SLE患者心臟結(jié)構(gòu)及功能均存在損害。超聲心動(dòng)圖作為一種無(wú)創(chuàng)、便捷的心臟結(jié)構(gòu)及功能評(píng)估方法，對(duì)SLE患者的心臟結(jié)構(gòu)及功能評(píng)估起著重要作用。

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Assessment of cardiovascular complications in patients with systemic lupus erythematosus by echocardiography

LIXi,TANGHong*

(DepartmentofCardiology,WestChinaHospitalofSichuanUniversity，Chengdu610041，China)

Systemic lupus erythematosus (SLE) is a kind of complex autoimmune connective tissue disease involving multi-organ and multiple systems. And the cardiovascular complication is a major cause of mortality in SLE patients. The diagnosis and evaluation depend on imaging. As a non-invasive, simplicity and repeatability method， echocardiography plays a vital role in evaluating heart structure and function. The application of echocardiography in the SLE with cardiovascular complications were reviewed in this article.

Lupus erythematosus, systemic; Cardiovascular complications; Echocardiography

李茜(1990—)，女，四川巴中人，碩士，醫(yī)師。研究方向：超聲心動(dòng)圖。E-mail: plor@qq.com

唐紅，四川大學(xué)華西醫(yī)院心血管內(nèi)科，610041。

E-mail： hxyyth@qq.com

2016-07-15

2017-01-08

10.13929/j.1003-3289.201607068

R593.24； R540.45

A

1003-3289(2017)04-0624-04