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中华医学超声杂志(电子版) ›› 2022, Vol. 19 ›› Issue (06) : 590 -593. doi: 10.3877/cma.j.issn.1672-6448.2022.06.018

综述

心房颤动患者右心功能的超声心动图评估及临床意义
王小贤1, 许迪1, 张艳娟1, 葛贝贝1, 陈燕1, 沈艳1, 陈明龙1, 梁希晨1, 姚静1,()   
  1. 1. 210029 南京医科大学第一附属医院心内科
  • 收稿日期:2020-10-15 出版日期:2022-06-01
  • 通信作者: 姚静
  • 基金资助:
    国家自然科学基金(81771844,81571691)

Clinical significance of echocardiographic evaluation of right heart function in patients with atrial fibrillation

Xiaoxian Wang1, Di Xu1, Yanjuan Zhang1   

  • Received:2020-10-15 Published:2022-06-01
引用本文:

王小贤, 许迪, 张艳娟, 葛贝贝, 陈燕, 沈艳, 陈明龙, 梁希晨, 姚静. 心房颤动患者右心功能的超声心动图评估及临床意义[J]. 中华医学超声杂志(电子版), 2022, 19(06): 590-593.

Xiaoxian Wang, Di Xu, Yanjuan Zhang. Clinical significance of echocardiographic evaluation of right heart function in patients with atrial fibrillation[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2022, 19(06): 590-593.

表1 超声心动图评估AF患者RV结构和功能的参数及临床意义
具体参数及参考值 参数测量超声图像 优势与不足 AF患者参数变化特点
RV大小

RV基底段横径>42 mm,RV中段横径>36 mm,RV长径>86 mm,以上满足其一即提示RV扩大

RV基底段横径与CMR测量的右心室内径相关性较差 ①常伴房室腔增大;②RV扩大一般发生于左右心房增大之后
RV收缩功能相关参数

FAC<35%提示RV收缩功能不全

FAC与CMR估测的RVEF相关性好 -

RVEF<44%提示RV收缩功能不全

推荐使用3DE估测RV容积 ①RT-3DE估测AF患者的RVV准确性高,与CMR相关性好;②与窦性心律患者相比,AF患者RVEF易被低估

TAPSE<16 mm提示RV收缩功能减低

TAPSE重复性较高 TAPSE明显降低,窦性心律恢复后2 h较前显著升高

Tei>0.4(脉冲多普勒)或>0.55(组织多普勒)提示RV功能不全

①可评估RV整体收缩和舒张功能,不易受负荷影响;②但不适用心率变化大的患者 心率变化大,R-R间期绝对不等时,Tei不适用于AF患者

dp/dt<400 mmHg/s提示RV收缩功能存在异常

ASE暂不推荐dp/dt应用于临床常规测量,对于RV收缩功能不全患者可采用此法 -

S'<10 cm/s,应怀疑RV功能异常,尤其是较年轻的患者12

敏感度好,既往已有多项研究将S'作为评估AF患者RV功能的参数 AF患者S'降低,射频消融术后S'有明显改善

STI包括2D-STI和3D-STI

①无明确参考值;②无角度依赖性,可反映局部和整体收缩功能;③3D-STI克服了2D-STI跨平面失追踪的不足 ①AF患者的RVGLS及节段峰值收缩应变均显著降低,与CMR相关性好;②RVGLS判定RVEF下降的敏感度和特异度更好,可用来筛查AF患者RV功能不全;③RVGLS可以作为行心脏手术的患者术后发生AF的预测指标
RV舒张功能相关参数

三尖瓣环TDI PW:侧壁e'>8 cm/s或 E/e'>6提示RV舒张功能不全

适用于AF患者,且取侧壁测量e' ①E、e'测量重复性好,可用于AF患者右心舒张功能的评估;②RV舒张功能不全是行肺叶切除术患者术后AF发生的一个重要因素
PASP

PASP=4V2(三尖瓣反流峰值速度)+右心房压;超声心动图估测PASP上限为35或36 mmHg

PASP会随年龄和体表面积的增大而增大 ①AF可能会加重甚至会导致PAH患者右心功能不全;②PAH患者AF的发生与右心房压和右心房扩张相关
TR

①反流束面积<5.0 cm2提示轻度反流;

②5.0 cm2≤反流束面积≤10 cm2,VC<7 mm提示中度反流;③反流束面积>10 cm2、VC>7 mm、EROA>40 mm2或TR PISA半径>9 mm均可提示三尖瓣重度反流,可同时结合收缩期肝血流反转

①反流束面积仅用于诊断TR,EAE推荐VC来量化TR,VC和PISA法比血流面积法更准确;②PISA法估测反流面积受血流动力学影响小,但易受瓣膜口形状不规则影响,推荐应用3DE进行PISA测定 RVV可作为AF合并严重功能性TR的独立预测因子
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