切换至 "中华医学电子期刊资源库"
高级检索
中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2023, Vol. 20 ›› Issue (04) : 404 -410. doi: 10.3877/cma.j.issn.1672-6448.2023.04.005

心血管超声影像学

二维斑点追踪成像评价左束支起搏左心室激动顺序与同步性
王秀秀, 严霜霜, 邓晓奇, 熊峰†()   
  1. 610031　成都，西南交通大学附属医院　成都市第三人民医院心内科　成都市心血管病研究所
  • 收稿日期:2021-08-24 出版日期:2023-04-01
  • 通信作者: 熊峰
  • 基金资助:
    四川省卫生健康委科技项目(20PJ210)

Evaluation of left ventricular activation sequence and intraventricular synchronization in patients with left bundle branch pacing by two-dimensional speckle tracking imaging

Xiuxiu Wang, Shuangshuang Yan, Xiaoqi Deng, Feng Xiong†()   

  1. Department of Cardiology, Cardiovascular Institute of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, Chengdu 610031, China
  • Received:2021-08-24 Published:2023-04-01
  • Corresponding author: Feng Xiong
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

王秀秀, 严霜霜, 邓晓奇, 熊峰. 二维斑点追踪成像评价左束支起搏左心室激动顺序与同步性[J]. 中华医学超声杂志（电子版）, 2023, 20(04): 404-410.

Xiuxiu Wang, Shuangshuang Yan, Xiaoqi Deng, Feng Xiong. Evaluation of left ventricular activation sequence and intraventricular synchronization in patients with left bundle branch pacing by two-dimensional speckle tracking imaging[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2023, 20(04): 404-410.

目的

应用二维斑点追踪成像（2D-STI）对左束支起搏（LBBP）左心室激动顺序进行间接标测，并分析室内同步性。

方法

选取2020年7月至2020年12月于成都市第三人民医院成功进行LBBP的患者22例（LBBP组）和右心室流出道起搏（RVOTP）患者16例（RVOTP组），2组患者均于术后3个月随诊复查超声心动图。另选取健康成年人17例作为对照组。采用2D-STI生成应变-时间曲线，收缩早期正向曲线收缩起始时间（OTS）为心电图R波峰至正向应变达峰时间；记录负向曲线第二帧时的应变绝对值（Sn），以Sn中取值最大者（S）和第二帧时间（T）计算收缩早期应变速度（V=S/T），OTS=T-Sn/V。采用整体及各水平纵向应变达峰时间标准差（Tp-SD）作为室内同步性参数。

结果

正常组QRS时限最短（95.35±10.04）ms，LBBP组次之（113.41±11.46）ms，RVOTP组明显延长（144.94±13.03）ms，差异均有统计学意义（P均＜0.05）。各水平OTS相比较，仅RVOTP组侧壁心尖段与正常组差异有统计学意义［（29.56±13.33）ms vs（19.53±15.02）ms，P＜0.05］。各组最早激动节段的OTS值以正常组最小（10.76±9.67）ms，LBBP组次之（14.45±7.30）ms，RVOTP组最大（17.19±19.43）ms。各组最早与最晚激动节段OTS之差均在40 ms以内。RVOTP组整体、中间段Tp-SD与LBBP组、正常组相比差异均有统计学意义（P均＜0.05），而基底段、心尖段Tp-SD比较差异均无统计学意义（P均＞0.05）；LBBP组各水平Tp-SD与正常组比较差异均无统计学意义（P均＞0.05）。

结论

2D-STI可无创地标测左心室激动顺序，有助于发现激动顺序的异常改变；LBBP术后早期可维持相对正常的左心室激动顺序和室内同步性，且同步性明显优于RVOTP。

关键词: 斑点追踪超声心动图, 应变分析, 左束支起搏, 心室激动顺序, 室内同步性
Objective

To map the left ventricular activation sequence indirectly and analyze the intraventricular synchronization in patients with left bundle branch pacing (LBBP) by two-dimensional speckle tracking imaging (2D-STI).

Methods

Twenty-two patients with LBBP and 16 patients with right ventricular outflow tract pacing (RVOTP) in Chengdu Third People's Hospital from July 2020 to December 2020 were enrolled, and 17 healthy adults were selected as a control group. Strain-time curves were generated by 2D-STI. Onset time of systole (OTS) of positive curves was the time from the R wave to the positive peak strain. For negative curves, the largest value (S) of absolute strain values (Sn) at the second frame and the second frame time (T) were used to calculate the strain rate (V=S/T), and OTS was calculated as T-Sn/V. The standard deviation of peak time (Tp-SD) was used as the intraventricular synchronization parameter.

Results

QRS duration was the shortest in the control group [(95.35±10.04) ms], followed by the LBBP group [(113.41±11.46) ms], and it was significantly prolonged in the RVOTP group [(144.94±13.03) ms]; the difference between any two groups was statistically significant (P＜0.05). When comparing OTS at all levels, only OTS in the apical segment of lateral wall in the RVOTP group was significantly different from that in the control group [(29.56±13.33) ms vs (19.53±15.02) ms, P＜0.05]. OTS of the earliest excited segment was the lowest in the control group [(10.76±9.67) ms], followed by the LBBP group [(14.45±7.30) ms] and RVOTP group [(17.19±19.43) ms]. The difference of OTS between the earliest and the latest excited segments in each group was less than 40 ms. Compared with the LBBP group and the control group, Tp-SD in the global and middle segment was statistically different in the RVOTP group (P＜0.05), but there was no significant difference in Tp-SD in the basal segment and apical segment (P＞0.05). There was no significant difference in Tp-SD between the LBBP group and the control group (P＜0.05).

Conclusion

2D-STI can noninvasively map the left ventricular activation sequence and assist to find the change of activation sequence. LBBP can maintain relatively normal left ventricular activation sequence and intraventricular synchronization in the early stage after operation, and the synchronization is significantly better than that by RVOTP.

Key words: Speckle tracking echocardiography, Strain analysis, Left bundle branch pacing, Ventricular activation sequence, Intraventricular synchronization
图1 OTS测量示意图。图为纵向应变-时间曲线，0点为心电图R波峰，第一帧图像对应纵轴参考线，第二帧图像对应图中虚线，正向曲线OTS等于心电图R波峰至正向应变达峰值的时间，负向曲线OTS用第二帧时的应变代入公式计算
表1 LBBP组、RVOTP组与正常组一般资料比较
一般资料 正常组（n=17） LBBP组（n=22） RVOTP组（n=16） 统计值 P值
年龄（岁，
x¯
±s）		 59.65±9.53 66.32±12.78 68.19±12.13 F=2.514 0.091
性别［男性，例（%）］ 10（58.8） 13（59.1） 10（62.5） χ2=0.059 0.971
心率（次/分，
x¯
±s）		 73.82±8.22 70.32±9.02 69.47±8.20 H=4.720 0.094
起搏指征 χ2=1.000 0.604
Ⅱ度Ⅱ型AVB［例，（%）］ - 8（36.4） 6（37.5）
Ⅲ度AVB［例，（%）］ - 14（63.6） 10（62.5）
基础疾病
高血压［例，（%）］ - 12（54.5） 6（37.5） χ2=2.663 0.264
糖尿病［例，（%）］ - 8（36.4） 5（31.3） χ2=0.233 0.890
QRS时限（ms，
x¯
±s）		 95.35±10.04 113.41±11.46a 144.94±13.03ab F=77.080 ＜0.001
表2 LBBP组、RVOTP组与正常组常规超声心动图参数比较（
x¯
±s）
超声心动图参数 正常组（n=17） LBBP组（n=22） RVOTP组（n=16） 统计值 P值
IVSd（mm） 9.59±0.94 10.14±1.13 9.88±0.96 F=2.239 0.326
LVPWd（mm） 9.69±0.87 10.19±0.91 10.00±1.21 F=1.261 0.292
LVDd（mm） 43.06±2.38 45.45±3.22 45.06±4.28 F=2.668 0.079
LVSd（mm） 29.63±2.60 31.31±3.55 30.25±3.09 F=2.224 0.118
LAD（mm） 35.00±3.13 36.64±3.53 35.81±2.99 H=4.134 0.127
LVEF（%） 63.59±2.21 61.45±1.71 62.81±5.46 H=5.832 0.054
表3 LBBP组、RVOTP组与正常组基底段OTS比较（ms，
x¯
±s）
组别 例数 前壁 侧壁 后壁 下壁 后间壁 前间壁
正常组 17 33.60±31.48 29.65±27.50 45.94±30.81 29.24±34.05 24.94±27.47 50.35±29.65
LBBP组 22 34.09±28.75 45.73±32.32 49.48±36.33 35.68±28.54 25.27±26.10 33.50±25.29
RVOTP组 16 36.69±18.60 43.94±22.37 40.25±35.24 52.13±43.70 26.33±34.66 33.38±31.02
H值 1.043 2.970 0.835 4.005 0.669 3.644
P值 0.549 0.227 0.659 0.135 0.716 0.162
表4 LBBP组、RVOTP组与正常组中间段OTS比较（ms，
x¯
±s）
组别 例数 前壁 侧壁 后壁 下壁 后间壁 前间壁
正常组 17 19.18±23.24 29.06±34.89 20.41±21.08 19.18±21.19 13.71±15.50 19.24±14.45
LBBP组 22 21.41±22.35 25.76±21.94 24.59±15.01 26.45±25.09 16.64±13.21 19.09±14.58
RVOTP组 16 17.19±19.43 29.50±29.31 27.81±20.04 26.31±28.21 19.88±25.30 17.25±13.95
H值 0.428 0.249 3.276 0.607 1.995 0.847
P值 0.807 0.883 0.194 0.738 0.369 0.665
表5 LBBP组、RVOTP组与正常组心尖段OTS比较（ms，
x¯
±s）
组别 例数 前壁 侧壁 下壁 室间隔 心尖帽
正常组 17 18.47±11.03 19.53±15.02 16.65±15.54 10.76±9.67 17.82±11.31
LBBP组 22 18.32±5.69 22.77±9.89 22.86±11.40 14.45±7.30 25.77±10.12
RVOTP组 16 27.00±30.27 29.56±13.33a 21.63±22.02 21.00±22.73 22.06±13.04
统计值 H=0.942 H=7.943 H=4.052 H=3.157 F=2.337
P值 0.624 0.019 0.132 0.206 0.107
图2 收缩起始时间牛眼图。图a示正常组激动顺序；图b示左束支起搏组激动顺序；图c示右心室流出道起搏组激动顺序
表6 LBBP组、RVOTP组与正常组各水平Tp-SD比较（ms，
x¯
±s）
组别 例数 整体 基底段 中间段 心尖段
正常组 17 38.02±4.67 40.56±3.89 36.40±3.49 36.90±6.16
LBBP组 22 40.39±3.18 41.65±4.17 40.22±2.52 39.09±2.47
RVOTP组 16 46.80±7.08ab 44.91±2.42 51.80±9.57 ab 43.08±4.33
统计值 H=21.097 F=2.403 H=13.053 H=5.360
P值 ＜0.001 0.124 0.001 0.069
图3 达峰时间牛眼图。图a示正常组牛眼图颜色均匀一致，室内同步性好；图b示左束支起搏组牛眼图颜色较为一致，室内同步性较好；图c示右心室流出道起搏组牛眼图颜色明显不一致，室内同步性较差
4
胡敏, 江成璠, 王素霞, 等. 使用心肌机械运动顺序间接标测左室电激动顺序的临床研究 [J]. 中国心脏起搏与心电生理杂志, 2016, 30(3): 229-233.
5
Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [J]. J Am Coll Cardiol, 2019, 74(7): e51-e156.
6
Russell K, Opdahl A, Remme EW, et al. Evaluation of left ventricular dyssynchrony by onset of active myocardial force generation: a novel method that differentiates between electrical and mechanical etiologies [J]. Circ Cardiovasc Imaging, 2010, 3(4): 405-414.
7
Huang W, Su L, Wu S, et al. A novel pacing strategy with low and stable output: pacing the left bundle branch immediately beyond the conduction block [J]. Can J Cardiol, 2017, 33(12): 1736.e1-1736.e3.
8
严霜霜, 邓晓奇, 熊峰, 等. 二维斑点追踪技术评价左束支区域起搏早期左心室收缩功能及同步性 [J/CD]. 中华医学超声杂志(电子版), 2021, 18(4): 368-374.
9
张丽娟, 邓晓奇, 王淑珍, 等. 实时三维超声心动图对比评价左束支区域起搏与右室流出道起搏术后左室整体收缩功能及同步性 [J]. 临床超声医学杂志, 2021, 23(5): 347-350.
10
Hou X, Qian Z, Wang Y, et al. Feasibility and cardiac synchrony of permanent left bundle branch pacing through the interventricular septum [J]. Europace, 2019, 21(11): 1694-1702.
11
Elliott MK, Mehta V, Sidhu BS, et al. Electrocardiographic imaging of His bundle, left bundle branch, epicardial, and endocardial left ventricular pacing to achieve cardiac resynchronization therapy [J]. Heart Rhythm Case Rep, 2020, 6(7): 460-463.
12
Voigt JU, Pedrizzetti G, Lysyansky P, et al. Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging [J]. J Am Soc Echocardiogr, 2015, 28(2): 183-193.
13
Durrer D, van Dam RT, Freud GE, et al. Total excitation of the isolated human heart [J]. Circulation, 1970, 41(6): 899-912.
14
Elizari MV. The normal variants in the left bundle branch system [J]. J Electrocardiol, 2017, 50(4): 389-399.
15
徐亮. 右室不同部位起搏的左室激动顺序及收缩同步性对心功能影响的实验研究 [D]. 南京: 南京医科大学, 2011: 1-52.
16
Cerqueira MD, Weissman NJ, Dilsizian V, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association [J]. Circulation, 2002, 105(4): 539-542.
1
Karpawich PP, Justice CD, Cavitt DL, et al. Developmental sequelae of fixed-rate ventricular pacing in the immature canine heart: an electrophysiologic, hemodynamic, and histopathologic evaluation [J]. Am Heart J, 1990, 119(5): 1077-1083.
2
Tse HF, Lau CP. Long-term effect of right ventricular pacing on myocardial perfusion and function [J]. J Am Coll Cardiol, 1997, 29(4): 744-749.
3
中华医学会心电生理和起搏分会, 中国医师协会心律学专业委员会. 希氏-浦肯野系统起搏中国专家共识 [J]. 中华心律失常学杂志, 2021, 25(1): 10-36.
[1] 邢长洋, 胡伟, 陈慧芸, 张倩, 雷玉嘉, 袁丽君. 斑点追踪超声心动图在室壁运动评估自主教学中的应用[J]. 中华医学超声杂志（电子版）, 2023, 20(02): 200-206.
[2] 李沅芝, 李一丹, 丁雪晏, 郭迪晨, 叶晓光, 王江涛, 吕秀章. 二维斑点追踪超声心动图对阵发性心房颤动患者左心室功能及机械离散度的评价[J]. 中华医学超声杂志（电子版）, 2022, 19(06): 535-540.
[3] 乐元洁, 王卫栋, 贲志飞. 二维斑点追踪超声心动图联合lncRNA-肺腺癌转移相关转录因子1对脓毒症心肌病的早期诊断价值[J]. 中华危重症医学杂志(电子版), 2022, 15(03): 183-188.
[4] 杨宁, 迟超, 刘宏宇, 韩薇, 宋雨微. 超声斑点追踪技术监测心脏移植急性排斥反应一例[J]. 中华移植杂志(电子版), 2018, 12(02): 72-74.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号