【作者】 孙欣；

【导师】 王浩；

【作者基本信息】 北京协和医学院 ， 影像医学与核医学， 2013， 博士

【摘要】 背景与目的以往对慢性充血性心力衰竭(心衰)患者的诊断及治疗的研究多集中在分析左室功能及机械运动不同步。早期的研究表明：选择有明显心脏运动不同步的患者行CRT治疗,术后应答率高。近年来发现右室功能在心衰患者转归和预后中的作用非常重要。国外有散在小规模的单中心研究表明右室功能影响CRT疗效,术前右室功能减低的患者术后无应答率高。但是,对心衰患者左室运动不同步与右室收缩功能减低之间相关性的研究报道较少。是否有右室收缩功能减低就一定存在左室机械运动的不同步尚未明确。本研究的目的是应用二维应变及常规超声评价慢性充血性心力衰竭(心衰)患者左室运动不同步与右室收缩功能减低之间有无相关性。并分组研究右室收缩功能正常与减低的患者在左室机械运动不同步方面的差异。方法72例心衰患者行二维应变及常规超声检查。测量前间隔与后壁收缩期轴向应变达峰时间差(SPWMD),以SPWMD≥130ms为左室不同步的标准,测量收缩期三尖瓣环位移(TAPSE)等参数。并以TAPSE≤14mm为截值分为右室收缩功能正常组与减低组。另外,双平面Simpson’s法测得左心室舒张末容积(]VEDV)、收缩末容积(LVESV)及左心室射血分数(LVEF)。心尖四腔切面测得右心室面积变化率(RFAC)等。结果本研究共入选72例患者。入选患者平均年龄为(59±12)岁,男性为45例,占总体的62.5%,女性为27例,占总体的37.5%。患有缺血性心肌病者为18例,占总体的25%。全部患者中,有22例(30.56%)患者存在右室收缩功能减低,有46例(63.90%)患者存在左室内运动不同步。右室功能减低组与右室功能正常组相比,RFAC.及TAPSE明显减低,差异均有统计学意义(P<0.001),与右室功能正常组相比,右室功能减低组的LVESV更加增大,LVEF更加减低,差异有统计学意义(P<0.05),右室收缩功能正常组与减低组之间的SPWMD无明显差异(P=0.658)。在全部患者中,有8例存在TAPSE减低而SPWMD正常,32例存在TAPSE正常而SPWMD升高的情况。相关分析显示,TAPSE与SPWMD之间无明显相关(r=0.136,P=0.255)。结论心衰患者的右室功能减低与左室内机械运动不同步无明显相关。全面评价心功能需要同时定量分析左、右室功能。背景与目的心脏再同步化起搏治疗(CRT)是药物难治性心力衰竭治疗中突破性的进展。多个大规模临床试验验证了CRT可以提高心衰患者的心功能、改善其症状并降低死亡率。CRT除了能改善心室运动同步性,提高左室功能外,近年来的研究发现,CRT术后右室在多方面都发生了变化,包括收缩功能改善、逆重构、和同步性提高等,右室功能在CRT中的作用也不可轻视。有研究提示：不论术前是否有缺血性心肌病或是否存在重度肺高压,术后3个月右室功能均有改善。这种右室收缩功能的提高不依赖于右室逆重构或肺动脉压的下降,而且也不会改变右室的负荷。然而,对CRT治疗后右室收缩和舒张功能一周内即刻改变的研究报导却很少。本研究的目的是应用常规超声及组织多普勒成像技术评价充血性心力衰竭患者CRT治疗后一周内右室收缩及舒张功能有无变化。并分组研究CRT治疗有应答及无应答患者术前及术后右室功能的差异。方法因慢性充血性心力衰竭行CRT治疗的患者44例,在术前、术后1周及术后6月行超声检查。测量参数包括：右室面积变化率(RFAC), M型测得右室游离壁三尖瓣环收缩期位移(TAPSE),右室游离壁三尖瓣环收缩期运动速度(Vsr)、三尖瓣E/E’、右室心肌做功指数(RV-MPI);另外常规测量左室舒张末容积(LVEDV)、收缩末容积(LVESV)及射血分数(LVEF)等。以CRT术后6个月LVESV减小≥15%为有应答的标准进行分组。结果本研究共入选44例患者。入选患者平均年龄为61±10岁,男性为31例,占总体的70.5%,女性为13例,占总体的29.5%。缺血性心肌病患者为13例,占总例数的29.5%。依据术后6个月随访复查的超声数据,以LVESV减小大于15%为有应答的标准,有应答组患者为29例(占总例数的66%),无应答组患者为15例。与有应答组相比,术前无应答组RFAC值、TAPSE值及Vsr值低,E/E’值高,差异均有统计学意义(P<0.05),提示无应答组术前的右室收缩功能及舒张功能较有应答组减低。术后一周内,在左室功能方面,有应答组的LVEDV、LVESV及LVEF值有改善(P<0.05),无应答组则无明显改善。但两组患者的RFAC、TAPSE、Vsr、E/E’及RV-MPI在术后一周内均有改善,与术前相比差异有统计学意义,与无应答组相比,上述参数在有应答组的改善更为显著。结论无应答组术前的右室收缩功能及舒张功能较有应答组减低。CRT术后无论有应答者或无应答者,右室的收缩功能及舒张功能均可得到即刻的改善。与无应答者相比,有应答者的右室的收缩功能及舒张功能改善更为显著。背景与目的虽然心脏再同步化治疗(CRT)对慢性充血性心力衰竭的治疗有效性已经大规模临床试验验证。但是即使按照指南选择病例,仍有约三分之一的经同步化治疗的患者临床症状无明显改善,即所谓CRT无应答。迄今为止,究竟采用哪种指标、哪些数值,能最好的预测CRT疗效并进行病例的选择,国内外研究尚无定论。以往通过超声评价左室机械运动不同步预测CRT疗效得到广泛研究,选择有明显不同步的患者行CRT治疗,效果并不理想,女PROSPECT研究就对单一超声参数评价左室不同步预测CRT疗效提出了质疑。近年来发现对晚期心衰患者右室功能的分析,有助于危险分层和预测治疗有效性。目前尚未有通过联合左室不同步参数及右室功能减低参数来进行CRT疗效的预测研究。本研究的目的是探讨综合左室不同步联合右室功能减低参数在预测心脏再同步化治疗(CRT)疗效中的价值。方法因难治性心力衰竭行CRT治疗的患者60例,在术前及术后6月行二维应变及常规超声检查。测量前间隔与后壁收缩期轴向应变达峰时间差(SPWMD)≥130ms为左室不同步的标准,以收缩期三尖瓣环位移(TAPSE)≤14mm为右室功能明显减低的截值。以CRT术后6个月LVESV减小≥15%为有应答的标准,将患者分为有应答组和无应答组。分别比较各组CRT术前的各参数差异。串联SPWMD及TAPSE两参数预测疗效,其截值同前,患者的术前超声指标既符合左室不同步(SPWMD≥130ms),又符合右室功能无明显减低(APSE>14mm)者记为Both有效组,余患者均记为Both无效组。通过受试者工作曲线(ROC)评估SPWMD、TAPSE及Both这三种指标对CRT疗效的预测价值,计算并比较ROC曲线下面积。结果本研究共完成60例患者的随访。平均年龄为60.2±9.3岁,男性为34例,女性为26例。缺血性心肌病患者为15例,占总例数的25.0%。依据术后6个月随访复查的超声数据,以LVESV减小≥15%为有应答的标准,将患者分为有应答组39例,无应答组21例,有效率为65%。术前两组患者年龄、性别构成、基础心脏疾病等一般情况无明显统计学差异(P均>0.05)。与有应答组相比,术前无应答组的左心室舒张末容积和收缩末容积更大,差异有统计学意义(P<0.05),而且左室不同步程度轻,右室功能更为减低,其SPWMD值、RFAC值及TAPSE值则均有明显统计学差异(P<0.05)。术前SPWMD (AUC=0.676, P:0.026; SPWMD≥130ms时敏感度及特异度分别为92.3%和42.9%)及TAPSE(AUC=0.749, P:0.002; TAPSE≤14mm时敏感度及特异度分别为97.4%和52.4%)均对CRT疗效有预测价值。但两指标均特异度低,串联两指标后特异度明显提高(AUC=0.842,P<0.001；敏感度及特异度分别为89.7%和76.2%)。串联两指标后对CRT疗效的预测能力优于单一指标。结论综合分析左室不同步联合右室功能减低能提高超声对CRT疗效预测的价值。对CRT疗效的预测不但要在术前观察左室机械运动同步性,还要同时注意有无右室功能减低。更多还原

【Abstract】 Background and ObjectiveEchocardiography plays an important role in the care of patients with chronic congestive heart failure treated with cardiac resynchronization therapy (CRT). In the past, a large number of clinical reports have utilized echocardiography before CRT implantation to assess abnormalities of mechanical activation, known as dyssynchrony, to potentially improve patient selection. Recently, right ventricular (RV) function is recognized as a cardinal prognostic marker in patients with heart failure. There is some smaller single-center studies show that RV function significantly affects response to CRT. Poor left ventricular (LV) reverse remodeling occurs after CRT in patients with heart failure having severe RV dysfunction at baseline. Little is known the relationships between RV function and left ventricular dyssynchrony. Whether RV dysfunction is associated with LV dyssynchrony in chronic congestive heart failure patients is still unclear. We sought to understand the relationships between RV contractility and LV dyssynchrony in chronic congestive heart failure patients by using speckle tracking image and echocardiography. To study the different of LV dyssynchrony between the normal RV function group and the RV dysfunction group.MethodsA total of72patients with congestive heart failure were analyzed by standard and two-dimensional strain echocardiography. Septal to posterior wall mechanical delay (SPWMD) obtained from2D radial strain, with a≥130ms threshold indicating LV dyssynchrony. RV function was evaluated using tricuspid annular plane systolic excursion (TAPSE), with a≤14mm threshold indicating severe RV impairment. Left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV) and ejection fraction (LVEF) were calculated from apical four-chamber views, according to the modified Simpson’s rule. RV end-diastolic area and RV end-systolic area were calculated from the apical four-chamber view, and the calculation of RV fractional area change used to determine global RV systolic function. ResultsOf72patients (mean age,59±12years),45(62.5%) were males and27(37.5%) were females. The etiology of heart failure was primarily ischemic (25%). Significant RV dysfunction was observed in22(30.56%) individuals and46(63.90%) patients showed LV dyssynchrony. Patients with RV dysfunction had.lower RFAC, TAPSE (P<0.001) and higher LVESV, LVEF (P<0.05) than those with normal RV function. Patients with RV dysfunction had no more LV dyssynchrony compared to those with preserved RV function (P=0.658). In the overall population,8had low TAPSE (≤14mm) and normal SPWMD,32had normal TAPSE and high SPWMD (≥130ms). TAPSE had no correlation with SPWMD (r=0.136, P=0.255).ConclusionRV function and LV dyssynchrony are not associated. Quantitative analysis of RV function is as important as assessing LV dyssynchrony in patients with congestive heart failure. Background and ObjectiveRandomized trials tell us that CRT can transform the lives of some patients with heart failure, improving cardiac function, symptoms, quality of life, morbidity and mortality. Recently, studies that used markers of right ventricular(RV) longitudinal axis function show that there is improvement in right ventricular function as a consequence of CRT, which is independent of the effect of CRT on left ventricular function. Studies found improvement in RV function at3-month follow-up independent of the cause of heart failure (ischemic vs. non-ischemic) or the severity of pulmonary hypertension at baseline. The improvement in RV function was independent of any RV reverse remodeling or decrease in pulmonary artery pressure; hence, RV function improvement was not attributable to changes in RV workload. However, little is known about there is improvement in RV systolic and diastolic function as an immediate consequence of CRT. The purpose of this research was to evaluate the early effects of cardiac resynchronization therapy (CRT) on right ventricular systolic and diastolic function using echocardiography and tissue Doppler imaging. Evaluate the different of right ventricular function before and after CRT between responders and non-responders.MethodsForty-four consecutive heart failure patients underwent echo examination at baseline, one week, and6months after CRT. RV function was assessed by RV Fractional area change (RFAC), tricuspid annulus plane systolic Excursion (TAPSE), and velocity (Vsr), tricuspid E/E’, RV myocardial performance index (RV-MPI). Clinical parameters and left ventricular volumes were also observed. Left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV) and ejection fraction (LVEF) were calculated from apical four-chamber views, according to the modified Simpson’s rule. CRT responders were defined as those with≥15%decrease in LV end-systolic volume at6months.ResultsOf44patients (mean age,61±10years),31(70.5%) were males and13(29.5%) were females. The etiology of heart failure was primarily ischemic (29.5%).29(66%) were CRT responders which were defined as those with>15%decrease in LV end-systolic volume at6months,15(34%) were non-responders. Compare to the responders, non-responders had lower baseline RV systolic and diastolic function, such as lower RFAC, TAPSE, Vsr and higher E/E’(P<0.05). Within one week of CRT, there was an early improvement in LV function as demonstrated by an increase in LVEDV, LVESV and LVEF (P<0.05) in responders, but not in non-responders. Within one week of CRT, there was an early improvement in RV function as demonstrated by an increase in RFAC and TAPSE and Vsr, and a decrease in RV-E/E’ and RV-MPI(P<0.05) in all subjects. Responders, compared with non-responders, were more likely to have slightly higher improvement in RV systolic and diastolic function.ConclusionCompare to the responders, non-responders had lower baseline RV systolic and diastolic function. RV systolic and diastolic function improved not only in responders, but also in non-responders after CRT. It showed more improvement in RV systolic and diastolic function in responders compared with non-responders. Background and ObjectivesCardiac resynchronization therapy (CRT) has been proven unequivocally beneficial for patients with advanced chronic heart failure with prolonged QRS complexes. Despite enthusiasm of giving this therapy to patients who fulfilled the current recommendation, nonresponse was observed in about one-third of patients who may not show clinical or left ventricular(LV) reverse remodeling response.Numerous recent published reports have utilized echocardiographic techniques to potentially aide in patient selection for CRT prior to implantation. However, no ideal approach has yet been found. Different echocardiography-based imaging modalities have been used to assess this intraventricular dyssynchrony. However, all approaches for assessing intra-LV dyssynchrony have individually given disappointing results, especially in the PROSPECT study. Recently, right ventricular (RV) function is recognized as a cardinal prognostic marker in patients with heart failure. The purpose of this study was to test the hypothesis that a combined echocardiographic assessment of RV dysfunction and LV radial dyssynchrony by speckle-tracking strain may predict response to CRT.MethodsWe studied60heart failure patients before and6months after CRT. Septal to posterior wall mechanical delay (SPWMD) obtained from speckle-tracking radial strain, with a>130ms threshold indicating LV dyssynchrony. RV dysfunction was assessed by M-mode for tricuspid annulus plane systolic Excursion (TAPSE), and severe RV dysfunction was defined as TAPSE<14mm. CRT responders were defined as those with>15%decrease in LV end-systolic volume at6months. The combined approach for the whole group, using a SPWMD>130ms radial strain cut-off and TAPSE>14mm RV function cut-off, named Both-responder. Others named Both-nonresponder. Receiver operating characteristic (ROC) curves were constructed first for LV dyssynchrony and RV dysfunction individually to determine optimal sensitivities and specificities and then for the combined approach with areas under the ROC curves initially compared by logistic regression analysis.ResultsOf60patients (mean age,60.2±9.3years),34were males and26were females. The etiology of HF was primarily ischemic (25%).39(65%) were CRT responders which were defined as those with≥15%decrease in LV end-systolic volume at6months,21(35%) were non-responders。 The responder and nonresponder groups were similar with respect to age, gender distribution and the etiology of heart failure(P>0.05). Compare to the responders, non-responders had lager LVEDV, LVESV, slightly LV dyssynchrony and lower baseline RV systolic function (P<0.05). SPWMD is relatively valuable in predicting CRT responders(AUC=0.676, P=0.026; SPWMD>130ms has the relatively high sensitivity of92.3%and low specificity of42.9%), TAPSE is also relatively valuable in predicting CRT responders(AUC=0.749, P=0.002; TAPSE≤14mm has the relatively high sensitivity of97.4%and low specificity of52.4%), Combined RV dysfunction and LV radial dyssynchrony predicted CRT response with89.7%sensitivity and76.2%specificity, which was significantly better than either technique alone (AUC=0.842, P<0.001).ConclusionsCombined RV dysfunction and LV radial dyssynchrony permits accurate echo prediction of response to CRT. To predict reverse remodeling after CRT, it should analysis RV dysfunction as well as LV radial dyssynchrony.更多还原