王文娟　蔡江濤　白梅

?

超聲心動圖評估老年心肌梗死后心力衰竭患者右心功能的臨床價值

王文娟蔡江濤白梅

目的探討超聲心動圖評估老年心肌梗死后心力衰竭患者右心功能的臨床價值。方法選取2014年5月至2015年4月在我院住院治療的老年心肌梗死后心力衰竭患者108例,按照左室射血分?jǐn)?shù)(LVEF)不同分為Ⅰ組、Ⅱ組、Ⅲ組,另選取健康老年人45例作為正常對照組,采用M型超聲心動圖、組織多普勒成像(TDI)、單心動周期實時三維超聲心動圖對右心功能進(jìn)行評估。結(jié)果本研究發(fā)現(xiàn)與正常對照組相比,老年心肌梗死后心力衰竭患者的三尖瓣環(huán)收縮期位移(TAPSE)降低(F=105.018,P<0.001),室間隔Tei指數(shù)、右室游離壁三尖瓣環(huán)Tei指數(shù)均升高(F=5097.979,1075.706,P均<0.05),其中以Ⅲ組的TAPSE為最低,室間隔Tei指數(shù)、右室游離壁三尖瓣環(huán)Tei指數(shù)均為最高;正常對照組、Ⅰ組、Ⅱ組的右室舒張末期容積(RVEDV)、右室收縮末期容積(RVESV)、右室每搏量(RVSV)兩兩相比均沒有統(tǒng)計學(xué)差異(P均>0.05),Ⅲ組的RVEDV、RVESV與其余3組相比顯著增大(P均<0.05);Ⅲ組的RVSV與其余3組相比顯著降低(P<0.05);4組的右室射血分?jǐn)?shù)(RVEF)兩兩進(jìn)行比較均有統(tǒng)計學(xué)差異(P均<0.05),以Ⅲ組的RVEF為最低;老年心肌梗死后心力衰竭患者的RVEF與LVEF呈正相關(guān)關(guān)系(r=0.852,P<0.05)。結(jié)論M型超聲心動圖、TDI、單心動周期實時三維超聲心動圖3種檢測方法都可以發(fā)現(xiàn)心肌梗死后心力衰竭患者右心功能受損,但是單心動周期實時三維超聲心動圖在評估右心功能方面具有獨特的優(yōu)勢。

超聲心動圖; 心肌梗死; 心力衰竭; 右心功能

伴隨社會經(jīng)濟(jì)的快速發(fā)展,人們生活水平日益提高,人口老齡化日趨嚴(yán)重,心肌梗死的發(fā)病率越來越高,據(jù)統(tǒng)計心肌梗死的患者中有近一半會發(fā)展為心力衰竭[1],我國成年人中大約有>400多萬的心力衰竭患者[2],且絕大部分是老年人[3],以左心衰竭為多,左心衰竭可以導(dǎo)致患者的肺靜脈發(fā)生淤血,進(jìn)而使得肺動脈壓增高,引起右心室容量及右心室壓力負(fù)荷持續(xù)增加,從而導(dǎo)致右心室的擴(kuò)張和右心衰竭。以前對心肌梗死患者心功能的研究多集中在左心室[4-6],對右心室研究比較少,本研究通過采用M型超聲心動圖、組織多普勒成像(TDI)、單心動周期實時三維超聲心動圖對老年心肌梗死后心力衰竭患者的三尖瓣環(huán)收縮期位移(TAPSE)、室間隔Tei指數(shù)、右室游離壁三尖瓣環(huán)Tei指數(shù)、左室射血分?jǐn)?shù)(LVEF)及反映右心功能的參數(shù),包括右室舒張末期容積(RVEDV)、右室收縮末期容積(RVESV)、右室每搏量(RVSV)、右室射血分?jǐn)?shù)(RVEF)進(jìn)行檢測,探討超聲心動圖在評估老年心肌梗死后心力衰竭患者右心功能中的臨床價值,為臨床治療和預(yù)防老年心肌梗死后心力衰竭的發(fā)生提供理論參考。

1　資料與方法

1.1臨床資料選取2014年5月至2015年4月在我院特診科住院治療的老年心肌梗死后心力衰竭患者108例,其中男77例,女31例,年齡60～90歲,平均(73.43±8.52)歲,梗死部位均為左心室前壁,病程(18.51±7.36) h。按照單心動周期實時三維超聲心動圖測量得到的LVEF不同分為如下組別。Ⅰ組:40%≤LVEF<50%,共40例;Ⅱ組:30%≤LVEF<40%,共36例;Ⅲ組:LVEF<30%,共32例。另選取同期本院健康門診參加體檢的健康老年人45例作為正常對照組,其中男28例,女17例,年齡60～90歲,平均(74.31±9.68)歲。老年心肌梗死后心力衰竭患者及正常對照組在性別、年齡方面比較沒有統(tǒng)計學(xué)差異(P>0.05),具有可比性。

1.2納入與排除標(biāo)準(zhǔn)納入標(biāo)準(zhǔn):(1)年齡≥60歲;(2)有冠狀動脈左前降支(LAD)病變;(3)經(jīng)超聲心動圖或冠脈造影證實為急性心肌梗死;(4)心力衰竭,符合Framingham心力衰竭診斷標(biāo)準(zhǔn)[7];(5)病例資料比較詳細(xì)完整;(6)簽署書面知情同意書。排除標(biāo)準(zhǔn):(1)先天性右室疾病、瓣膜器質(zhì)性病變和肺心病引起的心力衰竭;(2)患有肝腎等重要器官疾病、感染性疾病、惡性腫瘤等的患者;(3)病例資料不完整者;(4)不配合者。

1.3方法老年心肌梗死后心力衰竭患者入院第1天進(jìn)行超聲心動圖檢測,對照組亦進(jìn)行上述檢測。所有研究對象均由一名經(jīng)驗豐富的超聲醫(yī)師進(jìn)行超聲心動圖檢查,檢測儀器為GE VIVIDi/VIVIq型彩色超聲診斷儀,配有二維探頭4V1c和三維超聲轉(zhuǎn)換探頭4Z1c,而且具有LVA、RVA容積自動分析軟件。

1.3.1M型超聲心動圖檢測:通過M型超聲心動圖檢測得到TAPSE數(shù)據(jù)。

1.3.2TDI檢測:通過TDI檢測得到室間隔Tei指數(shù)、右室游離壁三尖瓣環(huán)Tei指數(shù)數(shù)據(jù)。

1.3.3單心動周期實時三維超聲心動圖檢測:通過單心動周期實時三維超聲心動圖檢測LVEF及反映右心功能的參數(shù),包括RVEDV、RVESV、RVSV、RVEF。

2　結(jié)果

2.1TAPSE、室間隔Tei指數(shù)、右室游離壁三尖瓣環(huán)Tei指數(shù)比較本研究發(fā)現(xiàn)與正常對照組相比,老年心肌梗死后心力衰竭患者的TAPSE降低(F=105.018,P<0.01),室間隔Tei指數(shù)、右室游離壁三尖瓣環(huán)Tei指數(shù)均升高(F=5097.979,1075.706,P均<0.05),其中以Ⅲ組的TAPSE為最低,室間隔Tei指數(shù)、右室游離壁三尖瓣環(huán)Tei指數(shù)均為最高。見表1。

表1　4組TAPSE、室間隔Tei指數(shù)、右室游離壁三尖瓣環(huán)Tei指數(shù)比較

注:與正常對照組比較,*P<0.05;與Ⅰ組比較,△P<0.05;與Ⅱ組比較,▲P<0.05

2.2右心參數(shù)比較本研究發(fā)現(xiàn)4組研究對象的右心參數(shù)(RVEDV、RVESV、RVSV 、RVEF)均有統(tǒng)計學(xué)差異(F=29.484,32.667,4.665,77.243,P均<0.01),其中正常對照組、Ⅰ組、Ⅱ組的RVEDV、RVESV、RVSV兩兩相比均無統(tǒng)計學(xué)差異(P均>0.05),Ⅲ組的RVEDV、RVESV顯著高于其余3組(P均<0.05); RVSV顯著低于其余3組(P均<0.05);4組研究對象的RVEF兩兩進(jìn)行比較均有統(tǒng)計學(xué)差異(P均<0.05),以Ⅲ組的RVEF為最低。見表2。

表2　4組右心參數(shù)比較

注:與正常對照組比較,*P<0.05;與Ⅰ組比較,△P<0.05;與Ⅱ組比較,▲P<0.05

2.3老年心肌梗死后心力衰竭患者RVEF與LVEF的相關(guān)性分析本研究通過相關(guān)性分析,發(fā)現(xiàn)老年心肌梗死后心力衰竭患者的RVEF與LVEF呈正相關(guān)關(guān)系(r=0.852,P<0.05)。

3　討論

過去對心功能的研究多集中在左心室,近年來人們開始認(rèn)識到右心功能的改變對心血管疾病患者的生存率和預(yù)后起著舉足輕重的作用,評估右心功能可以幫助臨床制訂有效的治療方案并評價預(yù)后水平?，F(xiàn)在醫(yī)療影像技術(shù)在心血管疾病的診斷方面有了迅猛的發(fā)展,但是由于右心室的不規(guī)則的生理結(jié)構(gòu)特點及右心功能指數(shù)受到負(fù)荷等因素的影響[8],所以對右心功能的測量帶來了麻煩。本研究通過采用M型超聲心動圖、TDI、單心動周期實時三維超聲心動圖得到TAPSE、室間隔Tei指數(shù)、右室游離壁三尖瓣環(huán)Tei指數(shù)、LVEF及反映右心功能的參數(shù),包括RVEDV、RVESV、RVSV、RVEF來定量評估右心功能。

3.1TAPSETAPSE可以對右心室收縮功能進(jìn)行定量評估,TAPSE>15 mm為正常值范圍,TAPSE≤14 mm是心力衰竭患者預(yù)后不良的重要預(yù)測因子[9]。本研究發(fā)現(xiàn)與正常對照組相比,老年心肌梗死后心力衰竭患者的TAPSE降低，差異具有統(tǒng)計學(xué)意義,以Ⅲ組的TAPSE為最低,提示心肌梗死后心力衰竭患者收縮功能降低,TAPSE測量簡便快捷,對影像儀器及圖像質(zhì)量要求不高,但TAPSE測量只能反映三尖瓣環(huán)長軸方向的變化情況,不能反映右心室其他方位的改變,并容易受到角度的影響[10-11]。

3.2Tei指數(shù)Tei指數(shù)即心肌運(yùn)動指數(shù)(myocardial performance index, MPI),是可以對心臟的整體功能進(jìn)行綜合性評估的超聲心動圖指標(biāo),無論右心室出現(xiàn)收縮功能障礙還是舒張功能障礙,Tei指數(shù)均升高[12]。本研究發(fā)現(xiàn)老年心肌梗死后心力衰竭患者的室間隔Tei指數(shù)、右室游離壁三尖瓣環(huán)Tei指數(shù)均升高,其中以心功能分級為Ⅳ級患者的室間隔Tei指數(shù)、右室游離壁三尖瓣環(huán)Tei指數(shù)均為最高。提示心肌梗死后心力衰竭患者右心室受損,Tei指數(shù)測量比較簡單,但是目前該方法缺少大規(guī)模的人群研究,沒有標(biāo)化的右心功能測量數(shù)據(jù),而且該方法也容易受到角度的影響[13],所以在評估右心功能方面還是有誤差。

3.3RVEDV、RVESV、RVSV本研究通過單心動周期實時三維超聲心動圖檢測得到RVEDV、RVESV、RVSV等數(shù)據(jù),有研究發(fā)現(xiàn)三維超聲心動圖所測量得到的離體心室容積和實測容積具有密切相關(guān)性,是評估右心功能的可靠手段[14]。本研究發(fā)現(xiàn)正常對照組、Ⅰ組、Ⅱ組的RVEDV、RVESV、RVSV兩兩相比均無統(tǒng)計學(xué)差異,Ⅲ組的RVEDV、RVESV較其余3組為最大;RVSV較正常對照組低，提示右心室具有一定的代償機(jī)制,此代償功能可以保持右心功能正常多年,但是當(dāng)LVEF<30%以后,右心功能會顯著受損,導(dǎo)致右心室功能失代償,右心室擴(kuò)張,右心功能降低并進(jìn)展為右心衰竭。

3.4LVEF、RVEF左心衰竭時左心室收縮功能障礙可以導(dǎo)致左心室形態(tài)的改變,使得室間隔斜形肌纖維方向變成橫向,肺高壓和室間隔斜形肌纖維減少導(dǎo)致LVEF降低、右心室的擴(kuò)張及右心衰竭的形成,右心室的擴(kuò)張又會引起三尖瓣反流,從而又促進(jìn)右心室的擴(kuò)張,此惡性循環(huán)過程中,使得室間隔斜形肌纖維方向進(jìn)一步變成橫向[15-16]。本研究發(fā)現(xiàn)4組研究對象的RVEF有統(tǒng)計學(xué)差異(F=77.243,P<0.05),以Ⅲ組的RVEF為最低,通過相關(guān)性分析,發(fā)現(xiàn)老年心肌梗死后心力衰竭患者的RVEF與LVEF呈正相關(guān)關(guān)系(r=0.852,P<0.05)。表明左心功能受損,右心功能也會隨著發(fā)生改變。

綜上所述,老年心肌梗死后心力衰竭患者經(jīng)M型超聲心動圖檢測發(fā)現(xiàn)TAPSE降低,經(jīng)TDI檢測發(fā)現(xiàn)室間隔Tei指數(shù)、右室游離壁三尖瓣環(huán)Tei指數(shù)均升高,經(jīng)單心動周期實時三維超聲心動圖檢測發(fā)現(xiàn)右室容量具有一定的代償機(jī)制,此代償功能可以保持右心功能正常多年,但是當(dāng)LVEF<30%以后,右心功能會顯著受損,導(dǎo)致右心室功能失代償,右心室擴(kuò)張,右心功能降低并進(jìn)展為右心衰竭,3種檢測方法都可以發(fā)現(xiàn)心肌梗死后心力衰竭患者右心功能受損,但是單心動周期實時三維超聲心動圖在評估右心功能方面具有獨特的優(yōu)勢。

[1]Filip KS, Matthias N. Leukocyte behavior in atherosclerosis, myocardial infarction, and heart failure[J]. Science,2013,339(6116):161-166.

[2]陳發(fā)秀,胡堅,邱元芝，等.髓過氧化物酶在老年慢性心力衰竭患者中的臨床意義[J].實用老年醫(yī)學(xué),2013,27(1):50-52.

[3]許婷媛,常彬賓,彭華生，等.別嘌呤醇對伴高尿酸血癥老年慢性心力衰竭患者心功能的影響[J].實用老年醫(yī)學(xué),2013,27(1):29-31.

[4]Miller R, Davies NH, Kortsmit J, et al. Outcomes of myocardial infarction hydrogel injection therapy in the human left ventricle dependent on injectate distribution[J].Int J Numer Method Biomed Eng, 2013,29(8):870-884.

[5]Moon HH, Joo MK, Mok H, et al. MSC-based VEGF gene therapy in rat myocardial infarction model using facial amphipathic bile acid-conjugated polyethyleneimine[J].Biomaterials,2014,35 (5):1744-1754.

[6]Yang J, Ma H, Liu J, et al. Delayed-enhancement magnetic resonance imaging at 3.0 T using 0.15 mmol/kg of contrast agent for the assessment of chronic myocardial infarction[J].Eur J Radiol,2014,83(5):778-782.

[7]Kraigher KE, Lyass A, Massaro JM, et al. Association of physical activity and heart failure with preserved vs. reduced ejection fraction in the elderly: The Framingham Heart Study[J]. Eur J Heart Fail,2013,15(7):742-746.

[8]Schlangen J, Fischer G, Steendijk P, et al. Does left ventricular size impact on intrinsic right ventricular function in hypoplastic left heart syndrome[J].Int J Cardiol, 2013,167(4):1305-1310.

[9]Palazzuoli A, Silverberg DS, Calabro A, et al. Beta-erythropoietin effects on ventricular remodeling, left and right systolic function, pulmonary pressure, and hospitalizations in patients affected with heart failure and anemia[J]. Cardiovasc Pharmacol,2009,53(6): 462-467.

[10]Abel E, Jankowski A, Pison C, et al. Pulmonary artery and right ventricle assessment in pulmonary hypertension: Correlation between functional parameters of ECG-gated CT and right-side heart catheterization[J].Acta Radiol,2012,53(7):720-727.

[11]Maureen PK, Karen GO, David MN, et al. CMR assessment of right ventricular function in patients with combined pulmonary stenosis and insufficiency after correction of tetralogy of Fallot[J].Acta Radiol,2013,54(10):1132-1137.

[12]Lobmaier SM, Cruz-Lemini M, Valenzuela-Alcaraz B, et al. Influence of equipment and settings on myocardial performance index repeatability and definition of settings to achieve optimal reproduci-bility[J].Ultrasound Obstet Gynecol,2014,43(6):632-639.

[13]Lee MY, Won HS, Jeon EJ, et al. Feasibility of using Auto Mod-MPI system, a novel technique for automated measurement of fetal modified myocardial performance index[J]. Ultrasound Obstet Gynecol,2014,43(6):640-645.

[14]Yim ES, Basilico F, Corrado G. Early screening for cardiovascular abnormalities with preparticipation echocardiography: utility of focused physician-operated echocardiography in preparticipation screening of athletes[J].J Ultrasound Med,2014,33(2):307-313.

[15]Valentova M, VonHaehling S, Krause C, et al. Cardiac cachexia is associated with right ventricular failure and liver dysfunction[J].Int J Cardiol,2013,169(3):219-224.

[16]Saggar R, Khanna D, Vaidya A, et al. Changes in right heart haemodynamics and echocardiographic function in an advanced phenotype of pulmonary hypertension and right heart dysfunction associated with pulmonary fibrosis[J].Thorax,2014,69(2):123-129.

Evaluation of echocardiographic on right heart function in patients with heart failure due to myocardial infarction

WANGWen-juan,CAIJiang-tao,BAIMei.

DepartmentofSpecialClinic,ShaanxiGeneralHospitalofCAPF,Xi’an710054,China

ObjectiveTo investigate the clinical value of echocardiographic evaluation on right heart function in the patients with heart failure due to myocardial infarction.MethodsFrom May 2014 to April 2015, 108 patients with heart failure due to myocardial infarction were selected and divided into group Ⅰ, group Ⅱ, group Ⅲ according to the level of LVEF. Forty-five healthy elderly people were chosen as control group. The right cardiac function was evaluated by M-mode echocardiography, tissue Doppler imaging (TDI) and single cardiac cycle real-time three-dimensional echocardiography.ResultsCompared with normal control group, the tricuspid annular plane systolic excursion (TAPSE) of patients with heart failure due to myocardial infarction were significantly decreased(F=105.018,P<0.001), and the Tei index of the ventricular septal and the Tei index of the free wall three-point annulus in the right ventricle were significantly increased(F=5097.979,1075.706,allP<0.05). The level of TAPSE was the lowest, and The Tei index of the ventricular septal and the Tei index of the free wall three-point annulus in the right ventricle were the highest in group Ⅲ. The levels of RVEDV, RVESV, RVSV showed no significant differences between control group, group Ⅰ and group Ⅱ(P>0.05), while the levels of RVEDV and RVESV in group Ⅲ were higher and the level of RVSV were lower than those in the other three groups(P<0.05). RVEF showed significant differences between four groups (P<0.05). RVEF had a positive correlation with LVEF (r=0.852,P<0.05).ConclusionsM-mode echocardiography, TDI and single cardiac cycle real-time three-dimensional echocardiography could assess the right heart function in the patients with heart failure due to myocardial infarction, but single cardiac cycle real-time three-dimensional echocardiography has its unique advantage to evaluate right heart function.

echocardiography; myocardial infarction; heart failure; right heart function

710054陜西省西安市，武警陜西省總隊醫(yī)院特診科

R 540.45

Adoi:10.3969/j.issn.1003-9198.2016.01.020

2015-06-04)