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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 (12) : 919 -926. doi: 10.3877/cma.j.issn.1672-6448.2017.12.009

所属专题： 文献；

心血管超声影像学

分层应变技术评价非ST段抬高性急性冠状动脉综合征患者左心室心肌各层收缩功能的变化
陈银花1, 陈勇1,†(), 马勇1, 袁静1, 于海迪1, 杨菲1, 吴秀秀1   
  1. 1. 225001　江苏扬州，苏北人民医院超声心动图室
  • 收稿日期:2017-03-22 出版日期:2017-12-01
  • 通信作者: 陈勇

Layer-specific strain assessment of left ventricular systolic function changes in patients with non-ST-elevation acute coronary syndrome

Yinhua Chen1, Yong Chen1,†(), Yong Ma1, Jing Yuan1, Haidi Yu1, Fei Yang1, Xiuxiu Wu1   

  1. 1. Department of Echocardiography, People′s Hosptial of Subei, Yangzhou 225001, China
  • Received:2017-03-22 Published:2017-12-01
  • Corresponding author: Yong Chen
  • About author:
    Corresponding author: Chen Yong, Email:
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引用本文：

陈银花, 陈勇, 马勇, 袁静, 于海迪, 杨菲, 吴秀秀. 分层应变技术评价非ST段抬高性急性冠状动脉综合征患者左心室心肌各层收缩功能的变化[J]. 中华医学超声杂志（电子版）, 2017, 14(12): 919-926.

Yinhua Chen, Yong Chen, Yong Ma, Jing Yuan, Haidi Yu, Fei Yang, Xiuxiu Wu. Layer-specific strain assessment of left ventricular systolic function changes in patients with non-ST-elevation acute coronary syndrome[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2017, 14(12): 919-926.

目的

应用二维斑点追踪显像（2D-STI）技术获取可疑非ST段抬高性急性冠状动脉综合征（NSTE-ACS）患者左心室区域及整体纵向分层应变，探讨分层应变参数预测冠状动脉显著狭窄的价值。

方法

选取2016年9月至2017年1月苏北人民医院收治的疑诊NSTE-ACS的患者75例，所有患者均行冠状动脉造影，其中，对照组（冠状动脉无狭窄或狭窄率<50%）24例，冠状动脉粥样硬化性心脏病（简称冠心病）组51例。冠心病组患者根据冠状动脉是否闭塞分为冠状动脉狭窄组32例，冠状动脉闭塞组19例。应用EchoPAC软件分析二维动态图像获得左心室18节段收缩期纵向分层应变，计算心内膜下心肌、中层心肌及心外膜下心肌区域纵向应变（TLSendo、TLSmid、TLSepi）及左心室心内膜下心肌、中层心肌、心外膜下心肌整体纵向应变（GLSendo、GLSmid、GLSepi）。采用单因素方差分析比较3组患者左心室区域及整体心肌纵向分层应变参数差异，进一步组间两两比较采用LSD-t检验。以冠状动脉造影结果作为诊断冠状动脉明显狭窄（狭窄率≥50%）即冠心病的金标准，绘制不同参数预测冠状动脉明显狭窄的受试者工作特征（ROC）曲线。

结果

与对照组、冠状动脉狭窄组患者比较，冠状动脉闭塞组患者TLSendo、TLSmid、TLSepi及GLSendo、GLSmid、GLSepi均减低，且差异均有统计学意义（冠状动脉闭塞组 vs对照组：t值分别为-5.819、-5.049、-4.845、-5.955、-5.036、-4.724，P均<0.01；冠状动脉闭塞组 vs冠状动脉狭窄组：t值分别为-2.983、-3.059、-2.903、-2.989、-3.192、-3.387，P均<0.01）；与对照组患者比较，冠状动脉狭窄组患者仅TLSendo及GLSendo减低，且差异均有统计学意义（t值分别为-3.981、-4.164，P均<0.01）；对照组、冠状动脉狭窄组、冠状动脉闭塞组患者TLSendo、TLSmid、TLSepi及GLSendo、GLSmid、GLSepi均呈梯度递减，但仅对照组患者3层间两两比较差异有统计学意义（TLSepi vs TLSendo、GLSepi vs GLSendo：t值均为-10.083，P均<0.01；TLSepi vs TLSmid、GLSepi vs GLSmid：t值均为-4.559，P均<0.01；TLSmid vs TLSendo、GLSmid vs GLSendo：t值均为-5.549，P均<0.01）；对照组、冠状动脉狭窄组、冠状动脉闭塞组患者左心室心内膜下心肌区域及整体纵向应变与心外膜下心肌区域及整体纵向应变绝对值差值（?TLS及?GLS）逐渐减小，且差异有统计学意义（冠状动脉闭塞组 vs对照组：t值分别为6.915、7.489，P均<0.01；冠状动脉狭窄组 vs对照组：t值分别为4.923、7.202，P均<0.01；冠状动脉闭塞组 vs冠状动脉狭窄组?TLS：t值为2.250，P<0.05），提示心内膜下心肌功能的显著受损。ROC曲线显示，GLSendo及TLSendo预测冠状动脉明显狭窄的曲线下面积最大，优于中层心肌、心外膜下心肌应变参数及总体心肌应变参数。

结论

可疑NSTE-ACS中冠心病患者左心室各层心肌收缩功能不同程度减低，尤以心内膜下心肌减低最显著，2D-STI技术获取的纵向分层应变参数可用于定量评价冠心病患者左心室各层心肌区域及整体收缩功能受损差异，可用于预测冠状动脉显著狭窄。

关键词: 超声心动描记术, 二维斑点追踪成像技术, 急性冠状动脉综合征, 心室功能，左
Objective

To analyze territorial and global longitudinal layer-specific strain of left ventricle by two-dimensional speckle tracking imaging (2D-STI) in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) and to explore the value of layer-specific strain parameters for prediction of significant coronary artery stenosis.

Methods

Seventy-five patients with suspected NSTE-ACS in People′s Hosptial of Subei from September 2016 to January 2017 were enrolled and all patients underwent coronary arteriography (CAG). Among them, there were 24 subjects in control group (coronary artery without stenosis or stenosis rate <50%) and 51 subjects in coronary atherosclerotic heart disease group (coronary heart disease, CHD). According to whether coronary artery occlusion, the CHD group was divided into coronary stenosis group (32 subjects) and coronary occlusion group (19 subjects). Using EchoPAC software, two-dimensional dynamic images were analyzed to obtain left ventricle 18-segment systolic longitudinal layer-specific strain and to calculate the territorial longitudinal strain (TLS) of endocadium, mid-myocardium and epicardium (TLSendo, TLSmid, TLSepi) and left ventricle global longitudinal strain (GLS) of endocadium, mid-myocardium and epicardium (GLSendo, GLSmid, GLSepi). The differences of left ventricle territorial and global longitudinal layer-specific strain parameters among 3 groups were compared by one-way analysis of variance and the differences between two groups were compared by LSD-t test. The receiver operating characteristic (ROC) curve of each parameter was constructed to predict significant coronary stenosis by using the results of CAG as the gold standard.

Results

Compared with control group and coronary stenosis group, TLSendo, TLSmid, TLSepi and GLSendo, GLSmid, GLSepi all decreased in patients with coronary occlusion, and the differences were statistically significant (coronary occlusion group vs. control group: t values were -5.819, -5.049, -4.845, -5.955, -5.036 and -4.724, respectively, P values were all less than 0.01; coronary occlusion group vs. coronary stenosis group: t values were -2.983, -3.059, -2.903, -2.989, -3.192 and -3.387, respectively, P values were all less than 0.01). And compared with control group, only TLSendo and GLSendo decreased in patients with coronary stenosis, and the differences were statistically significant (t values were -3.981 and -4.164, respectively, P values were all less than 0.01). TLSendo, TLSmid, TLSepi and GLSendo, GLSmid, GLSepi showed a gradient decrease in all 3 groups, but only in the control group the comparison between two of the three layers showed statistically significant differences (TLSepi vs. TLSendo, GLSepi vs. GLSendo: t values were both -10.083, P values were all less than 0.01; TLSepi vs. TLSmid, GLSepi vs. GLSmid: t values were both -4.559, P values were all less than 0.01; TLSmid vs. TLSendo, GLSmid vs. GLSendo: t values were both -5.549, P values were all less than 0.01). The absolute differences between endocardial and epicardial TLS and GLS (?TLS and ?GLS) decreased gradually from the control group, to coronary stenosis group and to coronary occlusion group, and the differences were statistically significant (coronary occlusion group vs. control group: t values were 6.915 and 7.489, respectively, P values were all less than 0.01; coronary stenosis group vs. control group: t values were 4.923 and 7.202, respectively, P values were all less than 0.01; ?TLS of patients in the coronary occlusion group vs. coronary stenosis group: t value was 2.250, P value was less than 0.05), which reflected a pronounced decrease in endocardial function. By ROC curve analysis, GLSendo and TLSendo showed the highest area under the curve in predicting significant coronary artery stenosis, which were better than strain parameters of mid-myocardium, epicardium and the entire wall thickness of the myocardium.

Conclusions

Left ventricle showed systolic dysfunction in all three layers in suspected NSTE-ACS patients with CHD, especially the endocardium. The longitudinal layer-specific strain parameters by 2D-STI can be used for quantitative evaluation of the territorial and global systolic dysfunction differences of left ventricle in all layers in suspected NSTE-ACS patients with CHD, which can also be used for prediction of significant coronary artery stenosis.

Key words: Echocardiography, Two-dimension-speckle tracking imaging, Acute coronary syndrome, Ventricular, left
表1 冠心病组与对照组患者一般临床资料比较
组别 例数 年龄（岁，±s） 性别（男性/女性，例） 心率（次/min，±s） 收缩压（mmHg，±s） 舒张压（mmHg，±s） 心电图缺血改变[%（例）] 肌钙蛋白I阳性[%（例）]
冠状动脉狭窄组 32 63.3±11.6 22/10 66.4±8.8 135.1±18.6a 77.6±11.9 62.5（20） 46.9（15）
冠状动脉闭塞组 19 58.0±10.2 15/4 75.3±15.5b 129.2±13.1 80.5±10.2 73.7（14） 63.2（12）
对照组 24 57.2±9.2 14/10 70.9±9.6 123.9±11.2 74.0±8.6 45.8（11） 12.5（3）c
检验值 ? F=2.784 χ2=2.085 F=3.933 F=3.757 F=2.101 χ2=3.573 χ2=12.438
P值 ? 0.068 0.353 0.024 0.028 0.130 0.168 0.002
表2 冠心病组与对照组患者常规二维超声参数比较（±s）
组别 例数 LVEDV（ml） LVESV（ml） LVEF（%） LVEDD（mm） LVESD（mm） WMSI
冠状动脉狭窄组 32 122.8±20.5 47.3±8.8 61.6±3.1 51.2±3.6 34.3±3.8 1.03±0.10
冠状动脉闭塞组 19 124.9±22.8 50.1±11.1 58.8±2.8a 52.3±3.2 37.5±4.3b 1.16±0.25c
对照组 24 118.4±18.0 44.3±7.8 62.8±2.9 49.9±3.4 32.4±2.6 1.01±0.03
F值 ? 0.594 2.191 9.681 2.634 10.678 6.683
P值 ? 0.555 0.119 0.000 0.079 0.000 0.002
图1，2 左心室18节段内、中、外层心肌局部和整体纵向收缩期应变值及相应牛眼图。图1为对照组患者，显示左心室18节段3层心肌纵向收缩期应变值均正常，牛眼图示各节段颜色均匀一致。左心室3层心肌整体纵向收缩期应变值亦正常；图2为冠状动脉左前降支近段90%狭窄患者，显示左心室左前降支支配区域内3层心肌纵向收缩期应变值均减低，牛眼图示左前降支支配区域各层颜色浅淡。左心室3层心肌整体纵向收缩期应变值亦减低
表3 冠心病组与对照组患者左心室区域心肌纵向分层应变参数比较（%，±s）
组别 例数 TLSendo TLSmid TLSepi F值 P值
冠状动脉狭窄组 32 -22.1±5.0b -19.6±3.8 -17.2±3.1e 11.523 <0.001
冠状动脉闭塞组 19 -17.3±6.2a -15.8±5.0c -14.0±4.3d 2.012 0.144
对照组 24 -26.2±2.6 -22.1±2.4g -19.1±2.2f 51.625 <0.001
F值 ? 18.399 14.685 14.205 ? ?
P值 ? <0.001 <0.001 <0.001 ? ?
表4 冠心病组与对照组患者左心室整体纵向分层应变参数比较（%，±s）
组别 例数 GLSendo GLSmid GLSepi F值 P值
冠状动脉狭窄组 32 -22.0±4.3b -19.9±3.4 -17.6±2.8e 12.426 <0.001
冠状动脉闭塞组 19 -17.9±5.6a -16.3±4.5c -14.5±3.8d 2.431 0.098
对照组 24 -26.2±2.6 -22.1±2.4g -19.1±2.2f 51.625 <0.001
F值 ? 20.418 15.000 13.809 ? ?
P值 ? <0.001 <0.001 <0.001 ? ?
表5 冠心病组与对照组患者左心室?TLS、?GLS比较（%，±s）
组别 例数 ?TLS ?GLS
冠状动脉狭窄组 32 4.9±2.3 4.4±1.8
冠状动脉闭塞组 19 3.4±2.2b 3.4±2.0
对照组 24 7.0±0.8a 7.0±0.8c
F值 ? 19.891 30.367
P值 ? 0.000 0.000
图3 不同参数预测冠状动脉明显狭窄的受试者工作特征曲线
表6 不同参数预测冠状动脉明显狭窄的价值
检测指标 曲线下面积 阈值 敏感度（%） 特异度（%）
GLSendo 0.846 -23.8 74.5 79.2
GLSmid 0.765 -20.8 70.6 70.8
GLSepi 0.730 -17.8 62.7 70.8
GLS 0.788 -21.2 72.5 70.8
TLSendo 0.833 -23.4 70.6 87.5
TLSmid 0.777 -20.8 74.5 70.8
TLSepi 0.757 -17.8 72.5 70.8
TLS 0.803 -21.2 76.5 70.8
WMSI 0.587 1.111 23.5 100
肌钙蛋白I 0.832 0.032 72.5 91.7
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