【作者】 董丽莉；

【导师】 陈灏珠；

【作者基本信息】 复旦大学 ， 内科学， 2011， 博士

【摘要】 第一部分斑点追踪显像技术定量评价右心室容量负荷改变对左心室扭转功能的影响第一节斑点显像技术定量评价房间隔缺损患者左心室扭转功能目的：应用斑点追踪显像技术评价右心室容量负荷增加[不合并肺动脉高压的房间隔缺损(ASD)患者)]对左心室扭转功能的影响。方法：45例单纯Ⅱ孔型房间隔缺损患者知情同意后入组为ASD组,另有45例年龄性别匹配的健康志愿者作为对照组,选用GE Vivid7彩色超声显像仪(配M3S探头,1.7-3.4Hz)采集常规超声心动图像。用EchoPAC 7.0 (GE-Vingmed, Horton, Norway)软件后期脱机分析得到斑点追踪参数。结果：ASD组患者的左室舒张末容积较小(62.0±11.1 ml比69.9±10.1 ml,P=0.001),左室EF较低(65.4±0.5%比69.4±0.6%,P=0.001)。两组间的心尖旋转参数相似。ASD组的心底部的旋转峰值明显降低并延迟出现(-5.4±2.8°比-6.9±2.6°,P<0.001；118.3±18.8%比96.1±12.6%的收缩期,P<0.001);ASD组的心底部收缩早期逆时针波峰值较高、持续时间更长(5.1±3.3°比1.8±1.4°,P<0.001；75.4±26.7%比42.5±24.4%的收缩期,P<0.001)。ASD组的左室整体扭转也明显降低(11.9±5.9°比14.6±3.5°,P<0.05)。两组间的解旋参数无显著性差异。结论：ASD患者的左室扭转功能下降,容量负荷增加主要影响左室心底部,致心底部出现收缩早期高而宽的逆时针扭转波,其顺时针主波较小、波峰延迟出现。第二节斑点追踪显像技术定量评价房间隔缺损封堵术对左心室扭转功能的影响目的：应用斑点追踪显像技术研究右心室容量负荷改变[不合并肺动脉高压的房间隔缺损(ASD)患者封堵术后)]对左心室扭转功能的影响。方法：30例单纯Ⅱ孔型房间隔缺损患者知情同意后入组,在接受经皮介入房间隔缺损封堵前及术后一天采集超声心动图像做自身对比,选用GE Vivid7彩色超声显像仪(配M3S探头,1.7-3.4Hz)采取常规超声心动图像。用EchoPAC 7.0 (GE-Vingmed, Horton,Norway)软件后期脱机分析得到斑点追踪参数。结果：封堵术后一天患者的左室舒张末容积增加(69.6±6.3 m1 vs.62.1±5.0 ml,P=0.007),左室EF升高(69.3±5.7% vs.65.9±5.2%,P=0.007),左室收缩末容积变化不明显。封堵前后患者的心尖扭转参数无明显变化,心底部收缩早期的逆向波变小、时限变窄(2.O±1.8°.VS.5.1±3.2,P<O.001;105.516.5% VS.118.0±18.5% of systolic period,P=O.001),顺时针主波幅度增加(-7.1±3.2°vs.-5.4±2.9°,P=0.014)。左室整体扭转明显改善(16.1±6.7°vs.12.2±6.3°,P=0.001)。结论：ASD封堵术后早期左室整体扭转明显改善,这主要与心底部扭转改善相关,提示斑点追踪显像技术能够准确敏感的评价容量负荷改变时的左心室扭转功能。第二部分斑点追踪显像技术定量评价右心室压力负荷增加对左心室扭转功能的影响目的：应用斑点追踪显像技术评价肺动脉高压实验动物模型和肺动脉高压患者的左心室扭转功能变化。方法：(1)动物实验部分：12条健康毕格犬经右心导管测压后经导管注入脱氢野百合碱2mg/kg制作慢性肺动脉高压模型,8周后随访右心导管测压。选用GEVivid7彩色超声显像仪(配M3S探头,1.7-3.4Hz)分别在术前和术后8周采集常规超声心动图像。用EchOPAC 7.0(GE-Vingmed,Horton,Norway)软件后期脱机分析得到斑点追踪参数。(2)临床研究部分：24例确诊为肺动脉高压患者(男5例,年龄33±15岁)和25例正常对照组(男5例,年龄32±14岁),分别接受超声心动图检查和右心导管检查。选用GE Vivid7彩色超声显像仪(配M3S探头,1.7-3.4Hz)在右心导管术前一天采集常规超声心动图像。用EchoPAC 7.0 (GE-Vingmed,Horon,Norway)软件后期脱机分析得到斑点追踪参数。结果：(1)动物实验部分：12条犬存活8条造模成功(8周时PASP=21.63±3.58mmHg, PVR=391.00±240.57 dyn-s/cm5)。8周时犬的ACT缩短(16.3±2.9 vs 12.8±2.5%RR, P=0.006)、TAPSE变差(1.11±0.16 vs 0.79±0.22cm,P=0.010),左右心室形态无显著变化。STI分析显示犬的心底部旋转角度下降(-4.8±2.9 vs-2.6±2.7°,P=0.021),心尖部和左心室整体的解旋率均下降(-99.0±35.8 vs-60.9±28.7°/s,P=0.024；-145.2±55.1 vs -87.5±34.3°/s,P=0.018)。(2)临床研究部分：PH组均为重度肺动脉高压(PASP=98.4±27.7mmHg, PVR=1337.4±765.8 dyn-s/cm5)。右心室增大,左心室舒张末和收缩末容积均较小(44.5±15.1 vs 70.6±15.6ml,P<0.001; 13.4±7.1 vs 22.0±5.1ml,P<0.001),但左心室EF无明显差异；TAPSE较小(1.44±0.32 vs 2.28±0.31cm,P<0.001)、Tei指数均较差。STI分析显示心底部、心尖部和左心室整体扭转角度均较小(心底-5.5±3.1 vs -7.0±2.7°,P=0.042；心尖9.3±4.8 vs 14.4±5.8°,P=0.005；左室13.0±5.0 vs 20.14±6.8°,P<0.001),心底部达峰时间延迟(124.0±31.5 vs 102.7±17.5%收缩期,P=0.022),心尖部达峰时间提前(82.3±23.2 vs 98.6±10.3%收缩期,P=0.015)；心底部的扭转速率较低(-52.4±19.6 vs -70.8±28.0°/s,P=0.019)、解旋率达峰时间延迟(135.2±17.6 vs 122.9±9.3%收缩期,P=0.017),左心室的扭转速率较低(97.2±38.3vs 127.0±39.2°/s,P=0.022)。PH组的心尖-心底达峰时间差绝对值和用收缩期标化后的百分数均差于对照组(-56.8±62.0 vs -6.8±25.4ms,P=0.001;-79.2±46.5 vs-44.5±24.6%收缩期,P=0.004)。其中,心底部的扭转速率值和达峰时间与肺动脉收缩压负相关(r=-0.610,P=0.02;r=-0.618,P=0.018)结论：早期轻度肺动脉高压时,左心室心底部的扭转幅度降低,重度肺动脉高压会影响心底部、心尖部和左心室整体的扭转功能,提示STI可用于早期评估PH患者的左心室扭转功能。更多还原

【Abstract】 Part I. Evaluation of Left Ventricle Torsional Function in Right Ventricle Volume Overload Individuals Using Two-Dimensional Speckle Tracking ImagingSection I. Evaluation of Left Ventricle Torsional Function in Patients with Secundum Atrial Septal Defect Using Two-dimensional Speckle Tracking ImagingBackgrounds:A novel ultrasound speckle tracking imaging (STI) allows the noninvasive assessment of left ventricular (LV) torsional deformation. There is no data available on the impact of right ventricular (RV) volume overload on LV twist and untwisting in atrial setpal defect (ASD). This study sought to evaluate LV torsional deformation using STI method in patients with ASD and normal pulmonary pressure.Methods:Forty-five asymptomatic adults with isolated secundum ASDs were enrolled in this study. Using commercially available 2-dimensional strain software, we analyzed basal and apical LV short-axis images in these patients with ASD and 45 age-and sex-matched normal subjects. LV twist was defined as the difference between LV apical and basal rotation.Results:As expected, patients with ASD had significantly smaller LV end-diastolic volume (62.0±1.1 ml vs.69.9±10.1 ml, P=0.001) and lower LV ejection fraction (EF) values (65.4±0.5% vs.69.4±0.6%, P=0.001) in comparison with the matched controls. The apical rotation parameters were similar between two groups. However, the peak basal rotation was significantly depressed (-5.4±2.8°vs.-6.9±2.6°,P＜0.001) and the time to peak rotation was significantly delayed (118.3±18.8% vs.96.1±12.6% of systolic period, P＜0.001) in patients with ASD. The peak basal initial counterclockwise rotation in ASD group was significantly higher (5.1±3.3°vs. 1.8±1.4°, P＜0.001) and its duration was longer (75.4±26.7% vs. 42.5±24.4% of systolic period, P＜0.001) than that in control group. LV peak twist was also reduced significantly in patients with ASD (11.9±5.9°vs.14.6±3.5°, P<0.005) in comparison with the matched controls while the LV untwisting parameters including peak untwisting rate and time to peak untwisting rate were similar between two groups.Conclusions:LV systolic twist was reduced but distolic untwisting remained unchanged in patients with ASD. The depressed LV twist was mainly due to the altered basal rotation which was characterized by a reduced and delayed clockwise rotation following an abnormally enhanced and extended initial counterclockwise rotation during early systole.Section II. Evaluation of Left Ventricle Torsional Function in Patients Undergoing Transcatheter Closure of Secundum Atrial Septal Defect Using Two-dimensional Speckle Tracking ImagingBackgrounds:Left ventricular (LV) torsional deformation plays an important role with respect to LV ejection and filling. However, no data are available on the impact of overload relief on LV torsional deformation after transcatheter ASD closure. This study sought to evaluate LV twist and untwisting before and early after device closure of ASD using the speckle tracking imaging (STI).Methods:We acquired basal and apical LV short-axis ultrasound images in 30 patients before and 1-day after transcatheter ASD closure. All data were offline analyzed with Echopac 7.0 software.Results:LV end-diastolic volume (69.6±6.3 ml vs.62.1±5.0 ml, P=0.007) and LV ejection fraction (69.3±5.7% vs.65.9±5.2%, P=0.007) were increased significantly after successful closure of ASD while end-systolic volume was unchanged (P> 0.005). After transcatheter ASD closure, there was no significant difference in peak apical rotation and time to the peak (P> 0.005 for both). However, a significantly improved basal rotation was recorded, including significantly increased peak clockwise rotation (-7.1±3.2°vs.-5.4±2.9°, P= 0.0014), decreased initial counterclockwise rotation (2.0±1.8°vs.5.1±3.2°, P< 0.001) and shortened time to peak clockwise rotation (105.5±16.5% vs.118.0±18.5% of systolic period, P= 0.001). LV twist was significantly improved in patients with ASD after the device closure (16.1±6.7°vs.12.2±6.3°, P=0.001), whereas there was no significant difference in peak untwisting rate, time to the peak and untwisting during IVRT (P> 0.05 for all).Conclusions:LV systolic twist could be significantly improved but diastolic untwisting remained unchanged after transcatheter ASD closure. This improvement was mainly attributed to the improved LV basal rotation rather than the unchanged apical rotation.Part II. Experimental and Clinical Evaluation of Left VentricleTorsional Function in Right Ventricle Pressure Overload Individuals Using Two-Dimensional Speckle Tracking ImagingObjective:A novel ultrasound speckle tracking imaging (STI) allows the noninvasive assessment of left ventricular (LV) torsional deformation. There is little data available on the impact of right ventricular (RV) pressure overload on LV twist and untwisting in pulmonary arterial hypertension (PH). This study sought to evaluate LV torsional deformation using STI method in dogs and patients with PH.Methods:Animal experiments:Following right heart catheterization, chronic pulmonary hypertension model was established in 12 healthy Beagle dogs by the injection of monocrotaline dehydrogenation 2mg/kg into the right ventricular through right heart catheter. Repeated right heart catheterization was performed after 8 weeks. Conventional echocardiography images were collected using a GE Vivid 7 ultrasound system with a M3S probe (1.7-3.4 MHz) before the initial catheterization and at 8 weeks follow-up. Offline analysis were performed with EchoPAC 7.0 sofeware (GE-Vingmed, Horton, Norway) to obtain the associated speckle tracking parameters.Clinical research:Echocardiography and right heart catheterization were performed in 24 patients with pulmonary hypertension (5 males, aged 33±15 years) and 25 normal controls (5 males, aged 32±14 years). Conventional echocardiography images were collected using a GE Vivid 7 ultrasound system with a M3S probe (1.7-3.4 MHz)before the initial catheterization and at 8 weeks folloW—up.Offline analysis were performed with EchoPAC 7.0 sofeware(GE-Vingmed,Horton,Norway) to obtain the associated speckle tracking parameters.Results:Animal experiments:Of the 12 dogs,chronic pulmonary hypertension model was successfully established in 8 survivors(At 8 weeks,PASP=21.63±3.58 mmHg, PVR=391.00±240.57 dyn.s/cm5).Compared with the initial parameters,ACT was shortened(16.3±2.9 vs 12.8±2.5% RR,p=0.006)and TAPSE was decreased signifcantly(1.11±0.16 vs 0.79±0.22 cm,p=0.010)at 8 weeks,while the left and right ventricular morphology had no significant change.STI analysis showed that the basal rotation angle decreased significantly afer the pulmonary hyperension occured (-4.8±2.9 vs±2.6±2.7°,p=0.021),and both the apical and global untwisting rates of left ventricle were also reduced significantly(-99.0±35.8 vs-60.9±28.7°/s,p= 0.024；-145.2±55.1 vs-87.5±34.3°/s,p=0.018).CIinical research:All patients in the PH group were diagnosed as severe pulmonary hypertension(PASP=98.4±27.7mmHg,PVR=1337.4±765.8 dyn-s/cm5),with enlarged right ventricle, reduced left ventricular end-diastolic and end-systolic volumes(44.5±15.1 vs 70.6±15.6 ml,p<0.001；13.4±7.1 vs 22.0±5.1 ml,p <0.001,respectively)and similar left ventricular EF compared with the control.The TAPSE(1.44±0.32 vs 2.28±0.31 cm,p<0.001)was lower and the Tei indexes were higher in the PH group.STI analysis showed that,as compared with the control,the patients with PH were associated with reduced basal,apex and global torsional angles of lefc ventricle(basal-5.5±3.1 vs-7.0±2.7.,p=0.042；apical 9.3±4.8 vs 14.4±5.8°,P=0.005；global 13.0±5.O vs 20.1±6.8.,p<0.001；respectively),delayed time to the peak torsion at the base,(124.0±31.5 vs 102.7±17.5% systolic period,P =0.022),shortened time to the peak torsion at the apex(82.3±23.2 vs 98.6±10.3% systolic,p=0.015),lower untwisting rate(-52.4±l9.6 vs-70.8±28.0./s,P=0.019) and delayed time to the peak at the base(135.2±17.6 vs 122.9±9.3％systolic,p= 0.017),lower torsional rate at the apex of left ventricular(97.2±38.3 vs 127.0±39.2./s,p=0.022). Both the absolute value and systolic period-standardized percentage of the time difference to the peak torsion between the apex and the base PH group were longer than those in the control(-56.8±62.0 vs-6.8±25.4ms,p= 0.001；-79.2±46.5 vs-44.5±24.6% systolic,p=0.004).The peak torsional rate and the time to the peak at the base were negatively correlated with the pulmonary systolic pressure (r=-0.610, P= 0.02; r=-0.618, P= 0.018, respectively)Conclusion:In early and mild pulmonary hypertension, the basal torsion of left ventricular was decreased. In severe pulmonary hypertension, all the basal, apical and globle torsions were injured. STI can be used for early assessment of left ventricular torsional function in patients with PH.更多还原