血流向量成像技术评价慢性肾脏病合并舒张功能不全患者左心室能量损耗

doi:10.3877/cma.j.issn.1672-6448.2021.04.004

目的

应用血流向量成像（VFM）技术分析慢性肾脏病（CKD）合并舒张功能不全患者左心室能量损耗（EL）的变化特点，探讨其在评估CKD患者左心室舒张功能中的临床价值。

方法

选取2017年2月至2018年11月在河北医科大学第二医院治疗的58例CKD患者，依据舒张功能不全严重程度，将其分为左心房压力正常的Ⅰ级舒张功能障碍组（DD1组），左心房压力升高的Ⅱ、Ⅲ级舒张功能障碍组（DD2组），另收集同期38例健康成人作为对照组。计算左心室充盈早期、左心房收缩期、整个舒张期及收缩期的平均EL，即E-EL-ave、A-EL-ave、D-EL-ave及S-EL-ave，充盈早期及左心房收缩期平均EL比值（E/A-EL），比较3组间各参数的差异。

结果

DD1组的A-EL-ave、S-EL-ave高于对照组（均P＜0.01）。DD2组的各个时相平均EL均高于对照组（均P＜0.01）；E/A-EL对左心室舒张功能障碍伴正常左心房压CKD患者具有良好的诊断效能，其最佳截断值为＜1.27［曲线下面积（AUC）=0.900，P＜0.01］，E/A-EL和E/e'二者联合对左心室舒张功能障碍伴左心房压升高CKD患者具有良好的诊断效能，其联合因子最佳截断值为1.28（AUC=0.945，P＜0.01）。E-wave、E/e'和A-wave、心脏指数（CI）、左心房最大容积指数（LAVImax）分别与E-EL-ave和A-EL-ave有独立相关性（校正R²=0.546、0.613，均P＜0.01）。

结论

VFM技术可从血流动力学角度反映CKD患者左心室舒张功能受损程度，EL与评价左心室舒张功能的指标相关。

关键词: 心室功能, 左, 慢性肾脏病, 能量损耗, 血流向量成像

Objective

To analyze the characteristics of changes in left ventricular energy loss(EL) in patients with chronic kidney disease (CKD) with diastolic dysfunction by vector flow mapping (VFM) technique and explore the clinical value of EL in evaluating left ventricular diastolic function in patients with CKD.

Methods

Fifty-eight CKD patients were divided into two groups according to diastolic dysfunction:patients with GradeⅠ diastolic dysfunction with normal left atrial pressure (DD1 group) and those with GradeⅡor Ⅲ diastolic dysfunction with increased left atrial pressure (DD2 group). Thirty-eight healthy adults were enrolled as a control group. VFM analysis was executed to calculate the average left ventricular EL during the early filling phase (E-EL-ave), atrial filling phase (A-EL-ave), diastole phase (D-EL-ave), and systolic phase (S-EL-ave). The rate of average EL during early filling and atrial filling is expressed as E/A-EL, and the difference among the three groups were compared.

Results

A-EL-ave and S-EL-ave in the DD1 group were significantly higher than those of the control group (P＜0.01for both).Average energy loss in different phases in the DD2 group were all higher than those in the control group (P＜0.05 for all). E/A-EL had excellent diagnostic efficacy for CKD patients with normal left atrial pressure with a cut-off value of ＜1.27 (area under the curve[AUC]=0.900,P＜0.01); the combination of E/A-EL and E/ e' had excellent diagnostic efficacy for CKD patients with increased left atrial pressure with a cut-off value of 1.28 (AUC=0.945, P＜0.01). E wave,A wave,E/e',LAVImax, and cardiac index were independently correlated with E-EL-ave and A-EL-ave (adjusted R²=0.546, 0.613, P<0.01 for both), respectively.

Conclusion

VFM technology can reflect the impaired left ventricular diastolic function in CKD patients from the perspective of hemodynamics, and the energy loss is related to the indicators for evaluating left ventricular diastolic function.

Key words: Ventricular function, Left, Chronic kidney disease, Energy loss, Vector flow mapping

图1 一个心动周期的时间-流量曲线。图a为左心室充盈早期(E-filling)及左心房收缩期(A-filling)；图b为左心室收缩期(systole)

表1 3组受试者一般资料及常规超声心动图参数比较(

x ˉ

±s)

组别	例数	年龄(岁)	体表面积(m²)	间隔厚度(mm)	后壁厚度(mm)	舒张末内径(mm)	心脏指数(L/min·m²)
对照组	38	42±13	1.75±0.2	8.16±1.0	8.1±0.8	46.6±3.9	2.6±0.4
DD1组	33	54±11^a	1.79±0.2	11.27±2.2^a	9.9±1.9^a	49.7±5.0	3.2±0.8^a
DD2组	25	55±11^a	1.81±0.1	12.24±2.0^a	11.1±2.1^ab	54.8±6.0^ab	3.5±0.9^a
F值		12.082	0.480	48.598	29.902	20.830	11.273
P值		0.000	0.620	0.000	0.000	0.000	0.000
组别	例数	E/e'	TE-e'	e'(septal)(cm/s)	e'(lateral)(cm/s)	Tei指数	左心室质量指数(g/m²)
对照组	38	6.6±1.7	26.8±8.9	9.5±2.3	13.2±4.0	0.3±0.06	68.4±13.3
DD1组	33	9.1±1.9^a	24.7±9.2	6.0±1.3^a	9.1±2.2^a	0.4±0.70^a	105.6±33.4^a
DD2组	25	12.8±3.4^ab	36.5±24.0^ab	5.4±1.3^a	7.9±3.3^a	0.4±0.11^a	141.9±47.8^ab
F值		50.391	6.854	48.687	22.019	6.085	39.146
P值		0.000	0.002	0.000	0.000	0.003	0.000
组别	例数	E-wave(cm/s)	A-wave(cm/s)	E/A	左心房内径(mm)	LAVImax(ml/m²)	E/Vp
对照组	38	70.6±13.2	56.7±16.2	1.3±0.5	30.7±3.3	23.6±4.2	1.1±0.3
DD1组	33	63.0±13.3	81.4±16.3^a	0.8±0.1^a	37.4±4.4^a	36.9±8.7^a	1.2±0.4
DD2组	25	82.1±27.6^b	86.8±25.8^a	1.1±0.4^a	42.5±5.8^ab	50.4±14.7^ab	1.3±0.6^ab
F值		6.555	23.364	14.867	54.698	62.716	10.490
P值		0.002	0.000	0.000	0.000	0.000	0.000

表1 3组受试者一般资料及常规超声心动图参数比较(

x ˉ

±s)

组别	例数	年龄(岁)	体表面积(m²)	间隔厚度(mm)	后壁厚度(mm)	舒张末内径(mm)	心脏指数(L/min·m²)
对照组	38	42±13	1.75±0.2	8.16±1.0	8.1±0.8	46.6±3.9	2.6±0.4
DD1组	33	54±11^a	1.79±0.2	11.27±2.2^a	9.9±1.9^a	49.7±5.0	3.2±0.8^a
DD2组	25	55±11^a	1.81±0.1	12.24±2.0^a	11.1±2.1^ab	54.8±6.0^ab	3.5±0.9^a
F值		12.082	0.480	48.598	29.902	20.830	11.273
P值		0.000	0.620	0.000	0.000	0.000	0.000
组别	例数	E/e'	TE-e'	e'(septal)(cm/s)	e'(lateral)(cm/s)	Tei指数	左心室质量指数(g/m²)
对照组	38	6.6±1.7	26.8±8.9	9.5±2.3	13.2±4.0	0.3±0.06	68.4±13.3
DD1组	33	9.1±1.9^a	24.7±9.2	6.0±1.3^a	9.1±2.2^a	0.4±0.70^a	105.6±33.4^a
DD2组	25	12.8±3.4^ab	36.5±24.0^ab	5.4±1.3^a	7.9±3.3^a	0.4±0.11^a	141.9±47.8^ab
F值		50.391	6.854	48.687	22.019	6.085	39.146
P值		0.000	0.002	0.000	0.000	0.003	0.000
组别	例数	E-wave(cm/s)	A-wave(cm/s)	E/A	左心房内径(mm)	LAVImax(ml/m²)	E/Vp
对照组	38	70.6±13.2	56.7±16.2	1.3±0.5	30.7±3.3	23.6±4.2	1.1±0.3
DD1组	33	63.0±13.3	81.4±16.3^a	0.8±0.1^a	37.4±4.4^a	36.9±8.7^a	1.2±0.4
DD2组	25	82.1±27.6^b	86.8±25.8^a	1.1±0.4^a	42.5±5.8^ab	50.4±14.7^ab	1.3±0.6^ab
F值		6.555	23.364	14.867	54.698	62.716	10.490
P值		0.002	0.000	0.000	0.000	0.000	0.000

表2 3组受试者各个时相平均左心室能量损耗的比较(J/m·s，

x ˉ

±s)

组别	例数	E-EL-ave	A-EL-ave	D-EL-ave	S-EL-ave	E/A-EL
对照组	38	7.0±2.9	3.3±1.8	4.3±2.07	3.5±1.5	2.6±1.3
DD1组	33	5.2±2.3	7.0±2.5^a	5.0±2.7	7.13±2.5^a	0.9±0.5^a
DD2组	25	12.4±4.6^ab	8.9±3.3^a	9.4±4.5^ab	8.4±3.8^a	1.9±1.6^b
F值		9.960	14.335	14.226	23.779	6.924
P值		0.000	0.000	0.000	0.000	0.002

表2 3组受试者各个时相平均左心室能量损耗的比较(J/m·s，

x ˉ

±s)

组别	例数	E-EL-ave	A-EL-ave	D-EL-ave	S-EL-ave	E/A-EL
对照组	38	7.0±2.9	3.3±1.8	4.3±2.07	3.5±1.5	2.6±1.3
DD1组	33	5.2±2.3	7.0±2.5^a	5.0±2.7	7.13±2.5^a	0.9±0.5^a
DD2组	25	12.4±4.6^ab	8.9±3.3^a	9.4±4.5^ab	8.4±3.8^a	1.9±1.6^b
F值		9.960	14.335	14.226	23.779	6.924
P值		0.000	0.000	0.000	0.000	0.002

图2 E/A-EL、E/e'及二者联合判定慢性肾脏病（CKD）患者左心室舒张功能障碍不伴左心房压升高的受试者工作特征（ROC）曲线

图3 E/A-EL、E/e'及二者联合判定慢性肾脏病（CKD）患者左心室舒张功能障碍伴左心房压升高的受试者工作特征（ROC）曲线

图4 E-EL-ave、A-EL-ave、S-EL-ave观察者间及观察者内变异性的Bland–Altman图。图a为E-EL-ave观察者间变异性；图b为E-EL-ave观察者内变异性；图c为A-EL-ave观察者间变异性；图d为A-EL-ave观察者内变异性；图e为S-EL-ave观察者间变异性；图f为S-EL-ave观察者内变异性

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Evaluation of left ventricular energy loss by vector flow mapping in patients with chronic kidney disease with diastolic dysfunction

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Evaluation of left ventricular energy loss by vector flow mapping in patients with chronic kidney disease with diastolic dysfunction