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中华医学超声杂志(电子版) ›› 2020, Vol. 17 ›› Issue (05) : 409 -415. doi: 10.3877/cma.j.issn.1672-6448.2020.05.004

所属专题: 文献

心血管超声影像学

经皮心肌内室间隔射频消融术治疗梗阻性肥厚型心肌病患者心脏功能的全面评估:六个月的随访研究
常康1, 王静1, 杨帆1, 康楠1, 左蕾1, 周梦垚1, 李文霞1, 王博1, 耶闯2, 刘丽文,1   
  1. 1. 710032 西安,解放军空军军医大学第一附属医院(西京医院)超声医学科 解放军空军军医大学第一附属医院(西京医院)肥厚型心肌病国际合作中心 陕西省肥厚型心肌病多学科会诊中心 西京医院肥厚型心肌病多学科诊治与遗传咨询中心
    2. 710032 西安,空军军医大学西京医院心内科
  • 收稿日期:2020-03-21 出版日期:2020-05-01
  • 通信作者: 刘丽文
  • 基金资助:
    国家国际科技合作专项(2014DFA31980); 国家自然科学基金(81601498,81901755); 陕西省重点项目(2017ZDXM-SF-058); 陕西省重点科技创新团队(2014KCT-20); 西京医院新技术、新业务资助项目(417432A); 西京医院学科助推计划(XJZT18ML74,XJZT18MJ51)

Assessment of cardiac function in patients with hypertrophic obstructive cardiomyopathy after treatment by percutaneous intramyocardial septal radiofrequency ablation: a 6-month follow-up Study

Kang Chang1, Jing Wang1, Fan Yang1, Nan Kang1, Lei Zuo1, Mengyao Zhou1, Wenxia Li1, Bo Wang1, Chuang Ye2, Liwen Liu,1   

  1. 1. Department of Ultrasound, the First Affiliated Hospital of Air Force Medical University (Xi'jing Hospital); Hypertrophic Cardiomyopathy International Cooperation Center, the First Affiliated Hospital of Air Force Medical University (Xi'jing Hospital); Multidisciplinary Consultation Center of Hypertrophic Cardiomyopathy, Shaanxi Province; Multidisciplinary Clinic and Genetic Counseling Center of Hypertrophic Cardiomyopathy, Xijing Hospital, Xi'an 710032, China
    2. Department of Cardiology, Xijing Hospital of Air Force Medical University, Xi′an 710032, China
  • Received:2020-03-21 Published:2020-05-01
  • Corresponding author: Liwen Liu
  • About author:
    Corresponding author: Liu Liwen, Email:
引用本文:

常康, 王静, 杨帆, 康楠, 左蕾, 周梦垚, 李文霞, 王博, 耶闯, 刘丽文. 经皮心肌内室间隔射频消融术治疗梗阻性肥厚型心肌病患者心脏功能的全面评估:六个月的随访研究[J/OL]. 中华医学超声杂志(电子版), 2020, 17(05): 409-415.

Kang Chang, Jing Wang, Fan Yang, Nan Kang, Lei Zuo, Mengyao Zhou, Wenxia Li, Bo Wang, Chuang Ye, Liwen Liu. Assessment of cardiac function in patients with hypertrophic obstructive cardiomyopathy after treatment by percutaneous intramyocardial septal radiofrequency ablation: a 6-month follow-up Study[J/OL]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2020, 17(05): 409-415.

目的

采用运动负荷超声结合二维斑点追踪技术评价经皮心肌内室间隔射频消融术(PIMSRA)后梗阻性肥厚型心肌病(HOCM)患者的心功能、心肌机械力学、血流动力学以及运动耐量等方面的变化,为术式的安全性和有效性提供更全面的数据支持。

方法

选取2016年6月至2018年7月在空军军医大学西京医院肥厚型心肌病诊治中心接受PIMSRA治疗的成年HOCM患者28例。收集患者的临床资料,在PIMSRA术前1周内和术后6个月进行半卧位踏车运动负荷试验,获得静息和运动达峰状态下常规超声心动图和二维斑点追踪超声参数,采用配对t检验、χ2检验以及Fisher精确概率检验对比手术前后的变化。

结果

与术前相比,术后患者前、后间隔厚度、最大左心室壁厚度以及左心室质量指数(LVMI)减低,左心室舒张末期内径(LVEDD)增大,纽约心脏病学会(NYHA)心功能分级明显改善,差异均有统计学意义(t=6.841、6.045、8.699、4.399、-3.165,χ2=15.567,P均<0.05);且无论在静息还是运动达峰状态下,术后患者左心室流出道(LVOT)内径增宽,左心室流出道压力阶差(LVOT-PG)和左心室流出道速度时间积分(LVOT-VTI)明显减低,二尖瓣收缩期前向运动(SAM)严重程度降低,二尖瓣反流面积减少,差异均有统计学意义(静息状态:t=-6.581、6.319、6.256,χ2=23.905,t=2.379;运动达峰状态:t=-5.351、6.197、5.866,χ2=15.286,t=2.747,P均<0.05)。术后患者左心室舒张功能较术前明显好转,二尖瓣环舒张早期速度(e')增大,二尖瓣舒张早期血流速度与二尖瓣环舒张早期速度的比值(E/e')比值、左心房内径(LAD)和左心房容积指数(LAVI)明显减小,差异均有统计学意义(t=-2.077、2.237、2.376、2.861,P均<0.05)。与术前相比,常规超声反映左心室收缩功能的指标,如左心室射血分数(LVEF)、二尖瓣环收缩期速度(s')和二尖瓣环收缩期位移(MAPSE)在静息状态下无明显变化,在运动达峰状态下MAPSE甚至出现略增大,差异有统计学意义(t=-2.460,P=0.021);二维斑点追踪超声反映心肌机械力学的指标中,整体径向应变(GRS)和扭转(Twist)在静息时减低,差异有统计学意义(t=3.518、4.010,P<0.05),在运动达峰状态下无明显变化,整体纵向应变(GLS)和整体环向应变(GCS)在静息和运动达峰时均无显著变化。

结论

PIMSRA手术安全有效,不仅可以显著降低患者LVOT-PG和二尖瓣反流、改善NYHA心功能分级和生活质量,术后6个月患者左心室舒张功能亦明显改善,收缩功能亦无明显损害,且左心室心肌Twist减低,恢复至接近正常水平。

Objective

To investigate the cardiac function, myocardial mechanics, hemodynamics, and exercise tolerance in patients with hypertrophic obstructive cardiomyopathy (HOCM) after treatment by percutaneous intramyocardial septal radiofrequency ablation (PIMSRA) using exercise stress echocardiography combined with two-dimensional speckle tracking imaging, and to establish the safety and efficacy of this procedure.

Methods

A consecutive series of 28 HOCM patients treated by PIMSRA at Xijing HCM Center from June 2016 to July 2018 were included and their clinical data were collected. The semi-supine bicycle stress echocardiography was performed within 1 week before and 6 months after PIMSRA. The echocardiographic data at rest and peak exercise were obtained and then compared before and after operation by use of paired t test, chi-square test, or Fisher's exact test.

Results

After PIMSRA, the thickness of the anterior and posterior septal wall, left ventricular mass index (LVMI), and left ventricular end-diastolic dimension (LVEDD) were reduced, and cardiac function class (New York Heart Association, NYHA) was significantly improved (t=6.841, 6.045, 8.699, 4.399, -3.165, χ2=15 567, P<0.05). Besides, the patients were found to have widened left ventricular outflow tract (LVOT), significantly decreased LVOT pressure gradient (LVOT-PG) and velocity time integral (LVOT-VTI), and reduced mitral regurgitation and systolic anterior motion of the mitral valve both at rest or peak exercise after the procedure (rest: t=-6.581, 6.319, 6.256, χ2=23.905, t=2.379; peak exercise: t=-5.351, 6.197, 5.866, χ2=15.286, t=2.747, P<0.05). The left ventricular diastolic function of the patients was significantly improved after PIMSRA with increased early diastolic mitral annular velocity (e') and decreased E/e' ratio, left atrial dimension (LAD), and left atrial volume index (LAVI; t=-2.077, 2.237, 2.376, 2.861, P<0.05). (The left ventricular systolic function measured by conventional echocardiography such as left ventricular ejection fraction (LVEF), systolic mitral annular velocity (s'), and mitral annular plane systolic excursion (MAPSE) did not deteriorate obviously after PIMSRA at rest, and the MAPSE at peak exercise was even slightly increased (t=-2.460, P=0.021) after PIMSRA. Moreover, the left ventricular global radial strain (GRS) and Twist, derived from two-dimensional speckle tracking imaging, were reduced at rest (t=3.518, 4.010, P<0.05) but did not change at peak exercise; while the global longitudinal and circumferential strain (GLS and GCS) did not change either at rest or peak exercise after PIMSRA.

Conclusion

As a safe and effective treatment approach for HOCM, PIMSRA could not only reduce LVOT gradient and mitral regurgitation and improve cardiac function class and living quality, but also improve left ventricular diastolic function without obvious deterioration of systolic function, and reduce Twist to nearly normal level.

表1 术前与术后6个月心功能分级、静息状态心脏超声以及血流动力学指标比较
组别 NYHA心功能分级(Ⅰ/Ⅱ/Ⅲ/Ⅳ) 室间隔厚度及左心室内径、质量(±s
AIVS(mm) PIVS(mm) MLVWT(mm) LVEDD(mm) LVMI(g/m2
术前 (6/11/11/0) 25.67±3.76 25.33±4.76 28.19±4.56 38.48±4.66 166.17±43.06
术后6个月 (19/8/1/0) 20.19±3.04 19.37±4.05 22.19±3.09 41.41±3.23 138.81±26.45
统计值 χ2=15.567 t=6.841 t=6.045 t=8.699 t=-3.165 t=4.399
P <0.001 <0.001 <0.001 <0.001 0.004 <0.001
组别 左心室流出道及SAM征
LVOT内径(mm,±s LVOT-PG(mmHg,±s LVOT-VTI(cm,±s LVOTO[例(%)] SAM(无/部分/完全)
术前 5.04±2.93 90.32±49.65 99.30±39.71 24(85.71) (4/1/23)
术后6个月 10.21±3.93 27.16±32.36 49.59±32.62 6(21.43) (12/11/5)
统计值 t=-6.581 t=6.319 t=6.256 χ2=23.262 χ2=23.905
P <0.001 <0.001 <0.001 <0.001 <0.001
组别 左心室收缩功能(±s 左心室舒张功能(±s
LVEF(%) s′(cm/s) MAPSE(cm) e′(cm/s) E/e′比值 LAD (mm) LAVI(ml/m2
术前 60.86±5.54 8.07±1.75 10.36±1.41 5.74±2.08 15.00±7.60 42.00±5.61 34.83±12.75
术后6个月 62.07±4.77 7.67±1.42 10.68±1.93 6.54±2.51 12.71±5.83 39.61±4.10 29.70±10.57
t -1.137 1.291 -1.091 -2.077 2.237 2.376 2.861
P 0.266 0.210 0.285 0.050 0.038 0.025 0.008
组别 左心室心肌机械力学(±s
GLS(%) GCS(%) GRS(%) ROTB(°) ROTA(°) Twist(°)
术前 -13.42±3.49 -18.25±5.53 31.73±8.64 -9.79±5.09 15.51±9.66 25.30±9.51
术后6个月 -14.21±3.37 -16.98±2.85 26.17±7.32 -7.56±3.98 11.45±6.09 19.00±6.45
t 1.787 -1.257 3.518 -3.230 2.733 4.010
P 0.085 0.220 0.002 0.003 0.011 <0.001
组别 二尖瓣反流(±s 左心室血流动力学(±s
长度(cm) 面积(cm2 体积(ml) HR(bpm) SBP(mmHg) DBP(mmHg)
术前 3.24±1.03 4.67±2.33 6.00±4.59 71.57±12.11 123.89±15.16 72.57±10.95
术后6个月 2.66±2.33 3.37±2.59 4.04±4.63 65.07±8.32 120.86±19.21 74.04±12.73
t 2.085 2.379 1.901 3.078 1.006 -0.645
P 0.047 0.025 0.068 0.005 0.323 0.525
表2 术前与术后6个月患者运动达峰状态心脏超声、血流动力学以及运动能力指标比较
1
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