【作者】 王海燕；

【导师】 王志斌；

【作者基本信息】 青岛大学 ， 内科学， 2004， 硕士

【摘要】 目的 检测肥厚性心肌病(HCM)病人左室舒张早期血流传播速度的变化，探讨左室舒张早期血流传播速度与心肌肥厚和左室局部舒张功能之间的关系，以及在HCM左室舒张功能评价中的临床应用价值。方法 选取HCM病人52例和年龄匹配的健康志愿者30例。在胸骨旁二尖瓣腱索水平、乳头肌水平和心尖水平左室短轴切面，应用二维超声心动图测量室间隔、左室前壁、侧壁和下壁等12个心肌节段的室壁厚度，以计算左室心肌厚度指数(WTI)和心肌肥厚不对称性指数(WAI)。在心尖四腔心切面，应用脉冲多普勒超声获取舒张期二尖瓣血流频谱，测量舒张早期峰值流速(E)、心房收缩期峰值流速(A)、E／A和E波减速时间(DT)。在心尖四腔心和心尖两腔心切面，应用组织多普勒成像获取室间隔、左室侧壁、前壁和下壁的基底段和中间段等8个心肌节段沿左室长轴运动的速度频谱，测量每个心肌节段的舒张早期心肌峰值运动速度(Em)和位移(De)、心房收缩期心肌峰值运动速度(Am)和位移(Da)以及Em／Am，计算各指标的平均值和左室心肌舒张不协调性指数(RAI)。在心尖四腔心切面，应用彩色M型多普勒超声心动图测量左室舒张早期血流传播速度(Vp)。结果WTI在HCM组和正常对照组之间存在显著性差异，分别为184.56+23.81和111.21+8.88(t=-11.69，P＜0.0001)，WAI也存在着显著性差异，分别为0.36+0.11和0.07+0.01(t=-14.04，P＜0.0001)。HCM组E、A、E／A和DT与正常对照组之间无显著性差异(t=-0.99～2.23，P＞0.05)。HCM组左室各心肌节段的Em、De、Em／Am、平均Em、平均De和平均Fm／Am明显小于正常对照组(t=0.09～14.13，P＜0.0001)，Am和平均Am也显著小于正常对照组(t=-2.31～5.38，P＜0.05)。RAI在HCM组和正常对照组分别为0.11±0.02和0.04+0.01，二者之间存在着显著性差异(t=-3.67，P＜0.0001)。Vp在HCM组和正常对照组分别为33.54±10.08cm／s和66.20±17.50 cm／s，二者之间存在着显著性差异(t=8.42，P＜0.0001)，多元线性回归分析表明在HCM病人RAI、LVEF和WAI是Vp的重要影响因素。根据左室舒张功能减退的不同程度，将52例HCM病人分为主动松弛性减低、假性正常化和限制型充盈三个亚组。在正常对照组、主动松弛性减低组、假性正常化组和限制型充盈组，Vp分别为(66.20+17.50)cm／s、(42.44±9.17)cm／s、(34.85+9.99)中文摘要em/S和(21.86士5.48)ernjs，呈逐渐减小的显著性变化(F= 29.80，P<0.001)，spearma。等级相关分析显示Vp的变化与左室舒张功能分级之间存在良好的相关性(r=0.41，p<0.001)。平均Eln、平均De和平均Em/Am在正常对照组、主动松弛性减低组、假性正常化组和限制型充盈组也呈逐渐减小的显著性变化(F=5.05一66.93，p<0.001)，Spearman等级相关分析显示平均Em，平均De和平均Em/Am的变化与左室舒张功能分级之间的相关性良好(r= 0.55一0.61，尸<0.001)，尽管平均Am和平均Da的变化也存在显著性差异(介2.18一22.20，p<0.00一)，但是speannan等级相关分析显示平均Am和平均Da的变化与左室舒张功能分级之间的无显著相关性(r二一0.051一0.18，P>0.05)。在正常对照组、主动松弛性减低组、假性正常化组和限制型充盈组，E呈现先减小后增大的显著性变化(F= 17.55，P<0 .001)，但是spe~an等级相关分析显示E的变化与左室舒张功能分级之间无相关性(r=o.26，尸>0.05)，A、E/A和DT在各组之间无显著性差异。结论HCM病人Vp显著低于正常对照组，并且随着左室舒张功能减退程度的加重，VP逐渐减小，左室局部心肌的松弛性能也随之逐渐减低。HCM病人的VP与左室肥厚心肌的不对称性分布及左室局部舒张功能之间相互关联，但受左室肥厚影响较小。更多还原

【Abstract】 Objective To assess the change of the left ventricular early diastolic flow propagation velocity (Vp) in patients with hypertrophic cardiomyopathy, and to discuss the relation between Vp and left ventricular regional diastolic function as well as myocardial hypertrophy and the clinical application value of Vp in evaluating left ventricular diastolic function in patients with hypertrophic cardiomyopathy. Methods We studied 52 patients with hypertrophic cardiomyopathy and 30 healthy volunteers matched with age. The thickness of twelve myocardial segments of interseptal, lateral, inferior and anterior left ventricular wall was measured ar mitral, papillary muscle and apical level from a cross sectional image in the parasternal short axis view by transthoracic two-dimensional echocardiography to calculate left ventricular wall thickness index (WTI) and left ventricular wall asymmetry index (WAI). From the apical four chamber view, the image of mitral inflow was obtained and early diastolic peak flow velocity (E), late diastolic peak flow velocity (A), the ratio of E/A and deceleration time of E wave were measured. From the apical four chamber and two chamber view, the basical segment and middle segment of interventricular septal, left ventricular lateral wall, anterior wall and inferior wall were obtained by tissue Doppler imaging. Early diastolic myocardial motion velocity (Em) and displacement (De), late diastolic peak myocardial motion velocity(Am) and displacement (Da), and the ratio of Em/Am were measured. The mean value of parameters and left ventricular wall relaxation asynchrony index (RAI) were calculated. From the apical four chamber view, left ventricular early diastolic flow propagation velocity (Vp) was measured by color M-mode echocardiography. Results WTI was significantly higher in the HCM group than in the control group, 154.56+23.81 and 92.94+8.88, respectively (t= -11.69, P<0.0001) . WAI was also significantly higher, 0.36+0.11 and 0.07+0.01, respectively (t= -14.04, p<0.0001) . There were no significant differences in E, A, E/A and DT between the control and HCM groups (t= -0.99-2.23, P>0.05). Em, Am, Em/Am, De, Da, mean Em, mean Am, mean Em/Am, mean De and mean Da were significantly lower in the HCM group than in the control group ( t= 0.09-14.13, P<0.0001) . The value of RAI were 0.11+0.02 and 0.04+0.01 in the control group and HCM group respectively and there was a significant difference ( t= -3.67. P<0.0001 ) . The value of Vp were 38.54+ 10.08 cm/s and66.20+ 17.50 cm/s in the control group and HCM group, respectively, and there was a significant difference ( t= 8.42, p<0.0001) . Multinomial linear regression analysis showed WTI, RAI, WAI and LVEF were determinant to Vp in HCM group. According to various degrees of left ventricular diastolic dysfunction, hypertrophic cardiomyopathy group (52 cases) was divided into three subgroups: damaged left ventricular effective relaxation subgroup, pseudonormal filling pattern subgroup and restrictive filling pattern subgroups. The values of Vp in different left ventricular diastolic function groups were(66.20+ 17.50) cm/s, (42.44+9.17) cm/s, (34.85+9.99) cm/sand (21.86+5.48) cm/s, respectively. There was a decreasing gradually trend and a significantly difference(F= 29.80, P<0.001) . Spearman rank correlation analysis showed the correlation between the change of Vp and the degrees of left ventricular diastolic dysfunction was excellent (r= 0.41, p<0.001) . The mean Em and mean Em/Am decreased gradually significantly in the control group, damaged left ventricular effective relaxation subgroup, pseudonormal filling pattern subgroup and restrictive filling pattern subgroup (F= 5.05-66.93, P<0.001) . Spearman rank correlation analysis showed the values of the mean Em, mean De and mean Em/Am decreased gradually, and there were significant differences (F= 5.05-66.93, p<0.001) . Spearman rank correlation analysis showed there were excellent correlation between the changes of the mean Em, mean De, mean Em/Am and the degrees of left ventricular dias更多还原