王 薇，李 丹，黃雪蘭，楊 絮，徐景俊，鄭春梅，曹 霞

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·全科醫(yī)生技能發(fā)展·

實(shí)時(shí)三維超聲心動(dòng)圖對(duì)急性心肌梗死經(jīng)皮冠狀動(dòng)脈介入治療前后左心室功能變化的評(píng)價(jià)

王 薇，李 丹，黃雪蘭，楊 絮，徐景俊，鄭春梅，曹 霞

目的 探討應(yīng)用實(shí)時(shí)三維超聲心動(dòng)圖(RT-3DE)評(píng)價(jià)急性心肌梗死患者經(jīng)皮冠狀動(dòng)脈介入治療(PCI)前后左心室局部功能變化的應(yīng)用價(jià)值。方法 選取2012年12月—2013年12月佳木斯大學(xué)附屬第一醫(yī)院接受PCI的急性心肌梗死患者46例為病例組，其中下后壁心肌梗死組27例，下壁心肌梗死組19例；另選擇同時(shí)期體檢中心體檢健康者30例為對(duì)照組，對(duì)照組于體檢時(shí)，病例組于PCI前、PCI后1、4、12周分別做RT-3DE檢查，記錄左心室各節(jié)段舒張末期容積(rEDV)及左心室各節(jié)段收縮末期容積(rESV)，并計(jì)算出各節(jié)段射血分?jǐn)?shù)(rEF)。結(jié)果 對(duì)照組RT-3DE左心室各節(jié)段容積-時(shí)間曲線規(guī)整有序，病例組患者PCI前RT-3DE左心室各節(jié)段容積-時(shí)間曲線雜亂無序。對(duì)照組與下后壁心肌梗死組PCI前及PCI后1周下壁基底段、下壁中間段、下壁心尖段、后壁基底段、后壁中間段rEF比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；對(duì)照組與下后壁心肌梗死組PCI后4周下壁中間段、后壁中間段rEF比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。下后壁心肌梗死組患者PCI前、PCI后1周、PCI后4周及PCI后12周下壁基底段、下壁中間段、下壁心尖段、后壁基底段、后壁中間段rEF比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；其中PCI后1周后壁中間段rEF較PCI前升高(P<0.05)；PCI后4周及PCI后12周下壁基底段、下壁中間段、下壁心尖段、后壁基底段、后壁中間段rEF較PCI前及PCI后1周升高(P<0.05)；PCI后12周下壁中間段、后壁中間段rEF較PCI后4周升高(P<0.05)。對(duì)照組與下壁心肌梗死組PCI前、PCI后1周及PCI后4周下壁基底段、下壁中間段、下壁心尖段rEF比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。下壁心肌梗死組患者PCI前、PCI后1周、PCI后4周及PCI后12周下壁基底段、下壁中間段、下壁心尖段rEF比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；其中PCI后4周及PCI后12周下壁基底段、下壁心尖段rEF較PCI前及PCI后1周升高(P<0.05)；PCI后12周下壁中間段rEF較PCI前及PCI后1周升高(P<0.05)。結(jié)論 RT-3DE可較準(zhǔn)確反映急性心肌梗死患者PCI前后左心室局部收縮功能的變化，可作為評(píng)價(jià)PCI療效的有效方法。

心肌梗死；血管成形術(shù)，氣囊，冠狀動(dòng)脈；超聲心動(dòng)描記術(shù)，三維；左心室

王薇，李丹，黃雪蘭，等.實(shí)時(shí)三維超聲心動(dòng)圖對(duì)急性心肌梗死經(jīng)皮冠狀動(dòng)脈介入治療前后左心室功能變化的評(píng)價(jià)[J].中國全科醫(yī)學(xué)，2015，18(27)：3371-3375.[www.chinagp.net]

Wang W，Li D，Huang XL，et al.Change of left ventricular function in patients with acute myocardial infarction before and after PCI by RT-3DE [J].Chinese General Practice，2015，18(27)：3371-3375.

急性心肌梗死病情兇險(xiǎn)、致死率高、復(fù)發(fā)率高，給家庭和社會(huì)造成巨大的精神和經(jīng)濟(jì)負(fù)擔(dān)。經(jīng)皮冠狀動(dòng)脈介入治療(PCI)是目前治療急性心肌梗死的主要方法之一[1]，但對(duì)其術(shù)后評(píng)價(jià)的研究少見。急性心肌梗死超聲心動(dòng)圖主要改變是左心室室壁節(jié)段性運(yùn)動(dòng)異常，因此局部運(yùn)動(dòng)功能是超聲評(píng)價(jià)心肌梗死患者預(yù)后的重要指標(biāo)[2]。二維超聲心動(dòng)圖多采用雙平面simpson 法，通過假設(shè)心臟的幾何形態(tài)估測心功能,而實(shí)時(shí)三維超聲心動(dòng)圖(RT-3DE)不依賴幾何假設(shè)，可以獲得左心室的真實(shí)形狀，對(duì)各節(jié)段室壁運(yùn)動(dòng)的評(píng)估結(jié)果更加準(zhǔn)確[3-4]。本研究探討應(yīng)用RT-3DE評(píng)價(jià)急性心肌梗死患者PCI前后左心室局部功能變化的應(yīng)用價(jià)值，現(xiàn)報(bào)道如下。

1 資料與方法

1.1 臨床資料 選取2012年12月—2013年12月佳木斯大學(xué)附屬第一醫(yī)院接受PCI的急性心肌梗死患者46例為病例組，其中下后壁心肌梗死組27例，男15例、女12例，年齡20～65歲；下壁心肌梗死組19例，男12例、女7例，年齡36～68歲。病例組入選標(biāo)準(zhǔn)：患者具有心前區(qū)疼痛等癥狀，心尖區(qū)第一心音減弱等體征，心肌梗死心電圖表現(xiàn)，放射性核素檢查、超聲心動(dòng)圖顯示室壁運(yùn)動(dòng)異常，實(shí)驗(yàn)室檢查心肌酶等指標(biāo)改變?cè)\斷為急性心肌梗死[5]，超聲心動(dòng)圖可清晰顯示左心室心內(nèi)膜邊緣；排除標(biāo)準(zhǔn)：采集圖像不滿意或臨床診斷及治療資料不全者。另選擇同時(shí)期體檢中心體檢健康者30例為對(duì)照組，其中男15例，女15例；年齡20～65歲。對(duì)照組入選標(biāo)準(zhǔn)：經(jīng)檢查除外心肌梗死、先天性心臟病等器質(zhì)性病變及慢性阻塞性肺疾病、腎衰竭、高血壓等影響心臟前后負(fù)荷及功能病變者；排除標(biāo)準(zhǔn)：采集圖像不滿意者。受試者均知情同意。

1.2 儀器與方法

1.2.1 儀器 荷蘭飛利浦公司IE33型彩色多普勒超聲診斷儀，配有二維S5-1探頭，三維X5-1探頭，探頭頻率為3.0～5.0 MHz。配有QLAB分析軟件程序(3D Advanced)，可對(duì)三維數(shù)據(jù)庫進(jìn)行定量分析。

1.2.2 方法 對(duì)照組于體檢時(shí)，病例組于PCI前、PCI后1、4、12周行RT-3DE檢查，記錄左心室各節(jié)段舒張末期容積(rEDV)及左心室各節(jié)段收縮末期容積(rESV)，并計(jì)算出各節(jié)段射血分?jǐn)?shù)(rEF)。

1.2.3 圖像采集和分析 囑受試者左側(cè)臥位，連接心電導(dǎo)聯(lián)，使用容積探頭放于心尖部,顯示完整的心尖四腔切面圖像，同時(shí)清晰顯示左心室內(nèi)膜圖像，然后囑受試者屏氣，啟動(dòng)全容積功能鍵，采集4個(gè)心動(dòng)周期的動(dòng)態(tài)三維圖像。啟動(dòng)QLAB分析軟件程序(3D Advanced)，調(diào)整圖像中顯示的3個(gè)相垂直切面，使心內(nèi)膜顯示盡可能清晰，分別在收縮末期及舒張末期標(biāo)注5個(gè)取樣點(diǎn)，系統(tǒng)將自動(dòng)分析描繪左心室形態(tài)，得出容積-時(shí)間曲線并顯示rEDV、rESV。rEF=(rEDV-rESV)/rEDV×100%。

1.2.4 隨訪 病例組患者于PCI前、PCI后1、4、12周進(jìn)行門診隨訪,記錄主要不良心臟事件(包括死亡、急性心肌梗死),復(fù)查RT-3DE、心電圖、血脂等。

圖1 對(duì)照組體檢時(shí)RT-3DE左心室各節(jié)段容積-時(shí)間曲線

Figure 1 RT-3DE volume-time curves in each segment of left ventribular of the control group

圖2 病例組患者PCI前RT-3DE左心室各節(jié)段容積-時(shí)間曲線

2 結(jié)果

2.1 對(duì)照組體檢時(shí)及病例組患者PCI前RT-3DE左心室各節(jié)段容積-時(shí)間曲線 對(duì)照組體檢時(shí)左心室各節(jié)段容積-時(shí)間曲線規(guī)整有序、波峰波谷清晰明顯、峰值高度較一致，達(dá)到最大及最小容積的時(shí)間點(diǎn)較一致(見圖1)；病例組患者PCI前左心室各節(jié)段容積-時(shí)間曲線雜亂無序，曲線平直，起伏不一致，峰值減低且達(dá)到最大及最小容積的時(shí)間點(diǎn)差異較大(見圖2)。

2.2 對(duì)照組與下后壁心肌梗死組PCI前后各節(jié)段rEF比較 對(duì)照組與下后壁心肌梗死組PCI前及PCI后1周下壁基底段、下壁中間段、下壁心尖段、后壁基底段、后壁中間段rEF比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；對(duì)照組與下后壁心肌梗死組PCI后4周下壁中間段、后壁中間段rEF比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。下后壁心肌梗死組患者PCI前、PCI后1周、PCI后4周及PCI后12周下壁基底段、下壁中間段、下壁心尖段、后壁基底段、后壁中間段rEF比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；其中PCI后1周后壁中間段rEF較PCI前升高，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；PCI后4周及PCI后12周下壁基底段、下壁中間段、下壁心尖段、后壁基底段、后壁中間段rEF較PCI前及PCI后1周升高，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；PCI后12周下壁中間段、后壁中間段rEF較PCI后4周升高，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見表1)。

2.3 對(duì)照組與下壁心肌梗死組PCI前后各節(jié)段rEF比較 對(duì)照組與下壁心肌梗死組PCI前、PCI后1周及PCI后4周下壁基底段、下壁中間段、下壁心尖段rEF比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。下壁心肌梗死組患者PCI前、PCI后1周、PCI后4周及PCI后12周下壁基底段、下壁中間段、下壁心尖段rEF比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；其中PCI后4周及PCI后12周下壁基底段、下壁心尖段rEF較PCI前及PCI后1周升高，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；PCI后12周下壁中間段rEF較PCI前及PCI后1周升高，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見表2)。

3 討論

急性心肌梗死是目前心血管疾病主要的死亡原因之一，危險(xiǎn)性極大。PCI是目前較為常用的改善血管阻塞狀態(tài)的手段。能夠在短時(shí)間內(nèi)使變窄、堵塞的冠狀動(dòng)脈部分或完全再通，改善心肌的血流灌注，進(jìn)而從根本上解決冠狀動(dòng)脈血供不暢給心肌帶來的功能障礙，改善心功能[6-7]。PCI 后，早期對(duì)心功能尤其是局部收縮功能的準(zhǔn)確評(píng)價(jià)，對(duì)指導(dǎo)治療該類疾病、觀察治療效果和判斷預(yù)后具有重要的臨床指導(dǎo)意義。本研究主要通過數(shù)據(jù)對(duì)比分析探討急性心肌梗死患者PCI前后RT-3DE對(duì)心功能情況的反映能力。

近年來，隨著超聲技術(shù)的不斷發(fā)展，在心功能測定方面也出現(xiàn)了許多新技術(shù)、新方法，如M型、辛普森法、二維斑點(diǎn)追蹤技術(shù)等[8]，以上方法均基于二維方法。二維方法基于對(duì)心臟的幾何形態(tài)假設(shè)[9]，在心臟正常時(shí)測量結(jié)果較為準(zhǔn)確。而由于心臟具有復(fù)雜的三維結(jié)構(gòu)，一旦心臟發(fā)生變形，測量值與真實(shí)值之間會(huì)出現(xiàn)較大偏差。且以上方法無法在同一周期內(nèi)顯示所有心肌節(jié)段，結(jié)果會(huì)因心率等因素影響出現(xiàn)誤差[10]。因此，二維方法在檢測心功能方面的應(yīng)用受到了限制。RT-3DE是近年來開展并迅猛發(fā)展的一項(xiàng)新技術(shù)，與傳統(tǒng)的二維超聲心動(dòng)圖相比，不依賴幾何形態(tài)假設(shè)，能實(shí)時(shí)獲取左心室空間立體結(jié)構(gòu)[11-12]，從而獲得左心室整體及局部的心腔容積變化，提高超聲診斷對(duì)左心室整體及節(jié)段性收縮功能評(píng)價(jià)的準(zhǔn)確性，特別適用于左心室室壁節(jié)段性運(yùn)動(dòng)異常的心肌缺血患者。大量國內(nèi)外動(dòng)物實(shí)驗(yàn)和臨床研究肯定了RT-3DE在評(píng)估左心室整體及局部收縮功能方面的作用[13-16]。心臟磁共振成像是目前公認(rèn)的測量心臟功能的影像學(xué)金指標(biāo)，研究證實(shí)，RT-3DE與心臟磁共振成像等技術(shù)的檢測結(jié)果一致性較高[17-18]。

本研究結(jié)果顯示，病例組患者病變節(jié)段心肌缺血缺氧，心肌細(xì)胞變性壞死，導(dǎo)致該節(jié)段心肌運(yùn)動(dòng)異常，容積-時(shí)間曲線收縮期容積增加，且曲線收縮達(dá)峰值時(shí)間與正常節(jié)段不一致，因此病例組容積-時(shí)間曲線雜亂。PCI是冠狀動(dòng)脈血運(yùn)重建的主要方法之一，是改善心肌血流灌注的重要手段。PCI后4周與PCI前比較，心肌缺血的程度得到了改善，左心室各節(jié)段心肌的功能有一定程度的恢復(fù)；PCI后12周心功能進(jìn)一步增高，與對(duì)照組比較無差異。PCI前、PCI后4周、PCI后12周各節(jié)段心室局部心功能呈增加趨勢，可能由于PCI使心肌血管重建，改善了心肌缺血缺氧狀態(tài)，但有部分心肌細(xì)胞處于冬眠或頓抑狀態(tài)，因此在恢復(fù)血液供應(yīng)后，心功能需要一定時(shí)間恢復(fù)，PCI后1周時(shí)左心室各節(jié)段局部心功能無明顯改善，可能與此有關(guān)。且部分細(xì)胞的水腫、出血等也會(huì)導(dǎo)致PCI后1周時(shí)左心室各節(jié)段局部心功能無明顯升高。以上結(jié)果表明，RT-3DE能夠客觀評(píng)價(jià)急性心肌梗死患者左心室收縮功能方面的變化，與文獻(xiàn)報(bào)道一致[19]，且PCI可以改善冠狀動(dòng)脈血流狀態(tài)，改善心肌供血，對(duì)急性心肌梗死心功能的恢復(fù)療效顯著，與文獻(xiàn)報(bào)道一致[20]。

表1 對(duì)照組與下后壁心肌梗死組PCI前后各節(jié)段rEF比較(±s)

注：PCI=經(jīng)皮冠狀動(dòng)脈介入治療；與PCI前比較，aP<0.05；與PCI后1周比較，bP<0.05；與PCI后4周比較，cP<0.05；-為無此項(xiàng)

表2 對(duì)照組與下壁心肌梗死組PCI前后各節(jié)段rEF比較(±s)

注：與PCI前比較，aP<0.05；與PCI后1周比較，bP<0.05；-為無此項(xiàng)

RT-3DE可以更真實(shí)、準(zhǔn)確、無創(chuàng)地評(píng)估心室局部心功能。但目前階段該技術(shù)尚存在不足之處，RT-3DE三維容積扇角為60°，小于傳統(tǒng)二維超聲的90°，因此心腔增大患者部分心肌可能被遺漏，造成誤差，且對(duì)三維圖像質(zhì)量要求高、相關(guān)參考數(shù)據(jù)不足等也是未來需要改進(jìn)及努力的方向。

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修回日期：2015-05-27)

(本文編輯：陳素芳)

Change of Left Ventricular Function in Patients With Acute Myocardial Infarction Before and After PCI by RT-3DE

WANGWei，LIDan，HUANGXue-lan，etal.

DepartmentofPhysicalDiagnosis，theFirstAffiliatedHospitalofJiamusiUniversity，Jiamusi154002，China

Objective To investigate the application value of RT-3DE in the evaluation of the local function changes in the left ventricle of patients with acute myocardial infarction before and after percutaneous coronary intervention(PCI).Methods Enrolled 46 patients with acute myocardial infartion who received PCI in the First Affiliated Hospital of Jiamusi University from December 2012 to December 2013 as the case group.The subjects who had myocardial infarction in the inferior posterior wall were assigned into inferior posterior wall group(n=27),and the subjects who had myocardial infarction in the inferior wall were assigned into the inferior wall group(n=19).Another 30 healthy people who received physical examination in the same hospital during the same period were enrolled as the control group.The control group received RT-3DE during physical examination,and the case group received RT-3DE before PCI and at week 1,week 4 and week 12 after PCI,then rEDV and rESV of each segment of the left ventricular were recorded and the rEF of each segment was calculated.Results The RT-3DE volume-time curves were regular and ordered in each segment of left ventricular in the control group and were irregular and disordered in the case group.The control group and the inferior posterior wall group were significantly different (P<0.05) in the rEF of inferior basal segment,inferior middle segment,inferior vertex segment,posterior basal segment and posterior middle segment before PCI and at week 1 after PCI.The control group and the inferior posterior wall group were significantly different (P<0.05) in the rEF of inferior middle segment and posterior middle segment at week 4 after PCI.Before PCI and at week 1,4,12 after PCI were significantly different (P<0.05) in the rEF of inferior basal segment,inferior middle segment,inferior vertex segment,posterior basal segment and posterior middle segment in the inferior posterior wall group;the inferior posterior wall group had higher (P<0.05) rEF in posterior middle segment at week 1 after PCI than that before PCI;the inferior posterior wall group had higher (P<0.05) rEF in inferior basal segment,inferior middle segment,inferior vertex segment,posterior basal segment and posterior middle segment at week 4 and week 12 after PCI than that before PCI and at week 1 after PCI;the inferior posterior wall group had higher (P<0.05) rEF in inferior middle segment and posterior middle segment at week 12 after PCI than that at week 4 after PCI.The control group and the inferior wall group were significantly different (P<0.05) in the rEF of inferior basal segment,inferior middle segment and inferior vertex segment before PCI and at week 1 and week 4 after PCI.Before PCI and at week 1,4,12 after PCI were significantly different (P<0.05) in the rEF of inferior basal segment,inferior middle segment and inferior vertex segment in the inferior wall group;the inferior wall group had higher (P<0.05) rEF in inferior basal segment and inferior vertex segment at week 4 and week 12 after PCI than that before PCI and at week 1 after PCI;the inferior wall group had higher (P<0.05) rEF in inferior middle segment at week 12 after PCI than that before PCI and at week 1 after PCI.Conclusion RT-3DE can accurately reflect the changes of local systolic function of left ventricular after PCI and can be used as an effective method of evaluating the curative effect of PCI.

Myocardial infarction；Angioplasty,balloon，coronary artery；Echocardiography,three-dimensional:Left vetricular

黑龍江省自然科學(xué)基金面上項(xiàng)目(D201246)

154002黑龍江省佳木斯市，佳木斯大學(xué)附屬第一醫(yī)院物理診斷科(王薇，李丹，黃雪蘭，徐景俊，鄭春梅，曹霞)，CT室(楊絮)

鄭春梅，154002黑龍江省佳木斯市，佳木斯大學(xué)附屬第一醫(yī)院物理診斷科；E-mail:zhengcm6001@163.com

曹霞，154002黑龍江省佳木斯市，佳木斯大學(xué)附屬第一醫(yī)院物理診斷科；E-mail:cx59133@163.com

R 542.22

A

10.3969/j.issn.1007-9572.2015.27.024

2015-03-13；