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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2017, Vol. 14 ›› Issue (04) : 285 -291. doi: 10.3877/cma.j.issn.1672-6448.2017.04.010

所属专题： 文献；

心血管超声影像学

三维斑点追踪技术评价左心室射血分数正常的重度主动脉瓣狭窄患者主动脉瓣置换术后左心室心肌功能
丁钱山1, 张平洋1,†(), 董静1, 马小五1, 方玲玲1, 李林1   
  1. 1. 210006　南京医科大学附属南京医院　南京市第一医院心血管超声科
  • 收稿日期:2016-12-07 出版日期:2017-04-01
  • 通信作者: 张平洋
  • 基金资助:
    南京市2015年度科技发展计划（医疗卫生与国际合作）项目(201503022)

Evaluation of left ventricular myocardial function in patients with severe aortic stenosis underwent aortic valve replacement with preserved left ventricular ejection fraction by three-dimensional speckle tracking imaging

Qianshan Ding1, Pingyang Zhang1,†(), Jing Dong1, Xiaowu Ma1, Lingling Fang1, Lin Li1   

  1. 1. Department of Ultrasound, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing First Hospital, Nanjing 210006, China
  • Received:2016-12-07 Published:2017-04-01
  • Corresponding author: Pingyang Zhang
  • About author:
    Corresponding author: Zhang Pingyang, Email:
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引用本文：

丁钱山, 张平洋, 董静, 马小五, 方玲玲, 李林. 三维斑点追踪技术评价左心室射血分数正常的重度主动脉瓣狭窄患者主动脉瓣置换术后左心室心肌功能[J/OL]. 中华医学超声杂志（电子版）, 2017, 14(04): 285-291.

Qianshan Ding, Pingyang Zhang, Jing Dong, Xiaowu Ma, Lingling Fang, Lin Li. Evaluation of left ventricular myocardial function in patients with severe aortic stenosis underwent aortic valve replacement with preserved left ventricular ejection fraction by three-dimensional speckle tracking imaging[J/OL]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2017, 14(04): 285-291.

目的

采用三维斑点追踪（3D-STI）技术观察左心室射血分数（LVEF）正常的重度主动脉瓣狭窄（AS）患者主动脉瓣置换术（AVR）后左心室心肌功能改变特点，并评价其临床应用价值。

方法

选取2014年10月至2016年10月南京医科大学附属南京医院收治的拟行AVR的重度AS患者40例（重度AS组）和健康志愿者40名（健康对照组）。健康对照组受试者行常规超声心动图和3D-STI测量，重度AS组患者分别于术前、术后1周及术后3个月行常规超声心动图和3D-STI测量，获得左心室舒张末期内径（LVEDD）、左心室收缩末期内径（LVESD）、室间隔厚度（IVSD）、左心室后壁厚度（LVPWD）、左心室射血分数（LVEF）、左心室整体纵向应变（GLS）、左心室整体环向应变（GCS）、左心室整体径向应变（GRS）、左心室整体面积应变（GAS）及三维应变（3D-strain）。采用独立样本t检验分别比较重度AS组患者术前、术后3个月与健康对照组受试者常规超声参数、三维应变参数；采用单因素方差分析比较重度AS组患者术前、术后1周及术后3个月常规超声参数、三维应变参数，进一步组间两两比较采用LSD-t检验。

结果

与健康对照组受试者比较，重度AS组患者术前IVSD、LVPWD均增大，GLS、GRS、3D-strain均降低，GCS升高，且差异均有统计学意义（t=13.824、11.298、10.221、-6.237、-5.674、-6.584，P均<0.001），而LVEDD、LVESD、GAS差异均无统计学意义；与术前比较，重度AS组患者术后1周LVEF、GLS、GCS、GAS均降低，且差异均有统计学意义（t=-2.205、-2.093、-2.034、-3.152，P均<0.05或0.01），而LVEDD、LVESD、IVSD、LVPWD、GRS、3D-strain差异均无统计学意义；重度AS组患者术后3个月GLS、GRS、3D-strain均升高，GCS、IVSD、LVPWD均降低，且差异均有统计学意义（t=5.446、-4.923、-4.388、-3.988、4.794、4.211，P均<0.05或0.01），而LVEDD、LVESD、LVEF、GRS、GAS差异均无统计学意义。与术后1周比较，重度AS组患者术后3个月LVEF、GLS、GRS、GAS、3D-strain均升高，GCS、IVSD、LVPWD均降低，且差异均有统计学意义（t=-2.631、7.383、-4.719、2.923、-4.154、-2.109、4.747、4.323，P均<0.05或0.01），而LVEDD、LVESD差异均无统计学意义。重度AS组患者术后3个月IVSD、LVPWD、GLS及GCS仍高于健康对照组受试者，且差异均有统计学意义（t=9.809、7.066、4.752、-2.553，P<0.001或<0.01），而LVEDD、LVESD、LVEF、GRS、GAS、3D-strain差异均无统计学意义。

结论

LVEF正常的重度AS患者，其左心室心肌功能的改变及其接受AVR后的心肌功能变化均有一定特征性，3D-STI技术能较准确地对其进行评价。

关键词: 三维斑点追踪技术, 左心室射血分数, 主动脉瓣狭窄, 主动脉瓣置换术, 心肌
Objective

To evaluate left ventricular myocardial function alternation by three-dimensional speckle tracking imaging (3D-STI) after surgical aortic valve replacement (AVR) in severe aortic stenosis (AS) patients with preserved left ventricular ejection fraction (LVEF), and discuss its clinical value.

Methods

Forty patients with severe aortic stenosis who were hospitalized or outpatient in Nanjing First Hospital Affiliated to Nanjing Medical University during the period of October 2014 to October 2016 (AS group), and forty healthy volunteers (normal control group) were enrolled in this study. Normal control group underwent conventional echocardiography and 3D-STI measurement, while the AS group underwent conventional echocardiography and 3D-STI measurement at preoperative, 1 week postoperative and 3 months postoperative, then we obtained left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), interventricular septum thickness diameter (IVSd), left ventricular posterior wall thickness diameter (LVPWd), left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), global area strain (GAS) strain and 3D-strain. The independent sample t test was used to compare the difference of conventional ultrasound parameters and 3D-STI parameters between AS preoperative patients and healthy controls, AS patients at 3 months postoperative and healthy controls. The single factor analysis of variance was used to compare the difference of conventional ultrasound parameters and 3D-STI parameters in severe patients at preoperative, 1 week postoperative and 3 months postoperative. LSD-t test was used to compare in different AS groups.

Results

Compared with normal control group, IVSD, LVPWD and GCS of severe AS patients increased significantly (t=13.824, 11.298 and -6.584, all P<0.001), GLS, GRS and 3D-Strain decreased significantly (t=10.221, -6.237 and -5.674, all P<0.001), LVEDD, LVESD and GAS had no significant difference. Compared with preoperative AS patients, LVEF, GLS, GAS and GCS decreased significantly (t=-2.205, -2.093, -2.034 and -3.152, all P<0.05 or 0.01) at 1 week postoperative, LVEDD, LVESD, IVSD, LVPWD, GRS and 3D-strain had no significant difference at 1 week postoperative; GLS, GRS and 3D-strain increased significantly (t=5.446, -4.923 and -4.388, all P<0.05 or 0.01) at 3 months postoperative, GCS, IVSD and LVPWD decreased significantly (t=-3.988, 4.794 and 4.211, all P<0.05 or 0.01) at 3 months postoperative, LVEDD, LVESD, LVEF and GAS had no significant difference at 3 months postoperative. Compared with AS patients at 1 week postoperative, LVEF, GLS, GRS, GAS and 3D-strain increased significantly (t=-2.631, 7.383, -4.719, 2.923 and -4.154, all P<0.05 or 0.01) at 3 months postoperative, GCS, IVSD and LVPWD decreased significantly (t=-2.109, 4.747 and 4.323, all P<0.05 or 0.01) at 3 months postoperative. But in AS patients at 3 months postoperative, IVSD, LVPWD, GLS and GCS were still higher than those of normal control group (t=9.809, 7.066, 4.752 and -2.553, all P<0.001 or <0.05), LVEDD, LVESD, LVEF, GRS, GAS and 3D-strain had no significant difference.

Conclusion

The alternation of left ventricular myocardial function have a certain characteristic before and after aortic valve replacement in severe aortic stenosis patients with preserved LVEF, and 3D-STI can evaluate it more accurately.

Key words: Three-dimensional speckle tracking, Left ventricular ejection fraction, Aortic valve stenosis, Aortic valve replacement, Myocardium
图1~6 重度AS患者左心室各方向整体应变值及应变示意图。图1为左心室整体纵向应变；图2为左心室整体环向应变；图3为左心室整体径向应变；图4为左心室整体面积应变；图5为三维应变；图6为示意图
表1 重度AS组患者与健康对照组受试者一般临床资料比较
组别 例数 年龄（岁，±s） 性别（例，男性/女性） LVEDD（mm，±s） LVESD（mm，±s） LVEF（%，±s） 心率（次/min，±s）
重度AS组 40 58.10±12.32 25/15 47.51±3.53 29.55±3.12 63.31±4.01 69.78±10.21
健康对照组 40 59.76±11.53 25/15 48.57±3.67 28.62±3.13 63.96±3.69 72.41±8.12
检验值 ? t=-0.234 χ2=0.000 t=1.162 t=1.327 t=-0.754 t=0.794
P值 ? 0.818 1.000 0.249 0.188 0.453 0.464
表2 术前重度AS组患者与健康对照组受试者常规超声参数、三维应变参数比较（±s）
组别 例数 LVEDD（mm） LVESD（mm） IVSD（mm） LVPWD（mm） LVEF（%）
重度AS组 40 47.51±3.53 29.55±3.12 14.95±1.46 13.11±1.36 63.31±4.01
健康对照组 40 48.57±3.67 28.62±3.13 9.33±1.53 8.67±1.36 63.96±3.69
t值 ? 1.162 1.327 13.824 11.298 -0.754
P值 ? 0.249 0.188 <0.001 <0.001 0.453
组别 例数 GLS（%） GCS（%） GRS（%） GAS（%） 3D-strain（%）
重度AS组 40 -15.17±2.25 -26.93±3.19 28.66±7.64 -39.52±3.72 30.40±7.92
健康对照组 40 -20.94±2.78 -22.23±3.20 39.49±7.89 -39.57±3.01 40.56±8.10
t值 ? 10.221 -6.584 -6.237 0.056 -5.674
P值 ? <0.001 <0.001 <0.001 0.955 <0.001
表3 重度AS组患者AVR前后常规超声参数、三维应变参数比较（±s）
时间 例数 LVEDD（mm） LVESD（mm） IVSD（mm） LVPWD（mm） LVEF（%）
术前 40 47.51±3.53 29.55±3.12 14.95±1.46 13.11±1.36 63.31±4.01
术后1周 40 47.05±3.77 29.30±3.31 14.83±1.27 13.14±1.35 61.35±3.75c
术后3个月 40 47.72±3.69 29.24±3.64 13.46±1.32a 11.82±1.37b 63.48±3.49
F值 ? 0.349 0.094 15.042 12.166 3.971
P值 ? 0.706 0.910 <0.001 <0.001 0.021
时间 例数 GLS（%） GCS（%） GRS（%） GAS（%） 3D-strain（%）
术前 40 -15.17±2.25 -26.93±3.19 28.66±7.64 -39.52±3.72 30.40±7.92
术后1周 40 -14.11±2.27d -25.53±2.97f 28.15±9.46 -37.06±3.23i 30.32±9.14
术后3个月 40 -18.11±2.56e -24.07±3.24g 38.15±9.50h -39.33±3.67 38.98±9.51j
F值 ? 30.651 8.363 15.993 5.922 12.572
P值 ? <0.001 <0.001 <0.001 0.004 <0.001
表4 重度AS组患者术后3个月与健康对照组受试者常规超声参数、三维应变参数比较（±s）
组别 例数 LVEDD（mm） LVESD（mm） IVSD（mm） LVPWD（mm） LVEF（%）
重度AS组 40 47.72±3.69 29.24±3.64 13.46±1.32 11.82±1.37 63.48±3.49
健康对照组 40 48.57±3.67 28.62±3.13 9.33±1.53 8.67±1.36 63.96±3.69
t值 ? 1.391 0.820 9.809 7.066 -0.595
P值 ? 0.168 0.415 <0.001 <0.001 0.554
时间 ? GLS（%） GCS（%） GRS（%） GAS（%） 3D-strain（%）
重度AS组 40 -18.11±2.56 -24.07±3.24 38.15±9.50 -39.33±3.67 38.98±9.51
健康对照组 40 -20.94±2.78 -22.23±3.20 39.49±7.89 -39.57±3.01 40.56±8.10
t值 ? 4.752 -2.553 -0.685 0.32 -0.799
P值 ? <0.001 0.013 0.495 0.75 0.427
图9 术后3个月观察者间测量左心室整体纵向应变的Bland-Altman分析图
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