【作者】 马国平；

【导师】 籍振国；

【作者基本信息】 河北医科大学 ， 内科学， 2009， 硕士

【摘要】 背景:流行病学资料显示左室舒张功能不全和舒张性心力衰竭患者占慢性充血性心力衰竭病人总数的40%～50%,而这些患者的射血分数正常或相对正常。多普勒超声心动图已成为目前无创评价心室舒张功能最常用、最重要的方法,二尖瓣环的超声组织多谱勒的舒张早期峰值(Ea)、二尖瓣口血流脉冲多谱勒舒张早期血流峰值(E)、舒张晚期峰值(A)、舒张早期二尖瓣血流速度E波与多普勒组织成像舒张早期二尖瓣环速度比值(E/Ea)都可预测左室舒张功能,但其特异性及敏感性有待于研究及证实。因此,我们收集了40例患者在冠状动脉造影时,用左心导管法确定LVEDP,与超声心动图指标相比较,来评价超声心动图指标预测左室舒张功能的特异性及敏感性。目的:观察二尖瓣环的超声组织多谱勒的舒张早期峰值(Ea)、二尖瓣口血流脉冲多谱勒舒张早期血流峰值(E)、舒张晚期峰值(A)与导管法测得的左室舒张末期压力(LVEDP)的相关性分析,以通过无创伤的超声心动图检查评价左心室舒张功能。方法:选择因反复胸痛行冠脉造影患者40例。经冠状动脉造影术确认冠状动脉狭窄程度<50%的患者作为无显著冠状动脉狭窄组;经冠状动脉造影术确认一支及一支以上内径1.5mm及以上的冠状动脉狭窄=75%的患者作为冠心?CHD)组。所有入选患者行冠状动脉造影术后,然后置入6F猪尾导管于左心室,连接充液换能器,测量并记录左室舒张末压。于冠脉造影术前24小时内行经胸二维超声心动图检查,获取左心房内径(LAD)、左心室舒张末内径(LVEDD)、左心室收缩末内径(LVESD)左心室后壁厚度(LVPWT),室间隔厚度(IVST);然后用双平面-辛普森方法测量左室舒张末期容积(LVEDV)、左室收缩末期容积(LVESV)和左室射血分数(LVEF);测量二尖瓣口舒张早期峰值血流速度(E)、舒张晚期峰值血流速度(A),计算两者比值E/A;用多普勒组织成像技术测量舒张早期运动速度峰值(Ea)、舒张晚期运动速度峰值(Aa),计算两者比值Ea/Aa;再计算出E/Ea比值。用SPSS 13.0统计软件包比较无显著冠状动脉狭窄组和CHD组参数之间的差异,分析超声心动图指标与LVEDP的相关性。结果:1两组一般情况比较:年龄、性别、血脂、血糖、肝功能、肾功能、收缩压、舒张压无显著差异。2超声心动图指标2.1 CHD组LAD(37.66±5.94mm)、E/Ea比值(11.68±2.84)较无显著冠状动脉狭窄组LAD(30.45±3.49mm)、E/Ea比值(8.60±1.90)增高(P<0.05);CHD组较无显著冠状动脉狭窄组A峰、Aa均增高(P<0.05)。2.2 CHD组LVEF(60.39±10.03)、E峰(72.90±11.19cm/s)较无显著冠状动脉狭窄组LVEF(62.67±8.79)、E峰(77.33±7.20cm/s)虽略有降低,但无显著性差异(P>0.05);CHD组IVST、LVPWT、LVEDD、LVESD、LVEDV、LVESV虽有所增高,但与无显著冠状动脉狭窄组比较,无显著性差异(P>0.05)。2.3 CHD组Ea(6.49±1.40 cm/s)、Ea/Aa(0.79±0.28)、E/A(1.04±0.17)较无显著冠状动脉狭窄组Ea(9.36±2.12cm/s)、Ea/Aa(1.57±0.63)、E/A(1.20±0.27)均降低(P<0.05)。2.4 CHD组E/Ea升高主要与Ea的明显降低有关,因两组E峰比较无显著性差异;CHD组的E/A降低,虽然同时伴有E峰的降低和A峰的升高,但主要与A峰的升高有关;CHD组Ea/Aa的降低,虽然同时伴有Ea的降低和Aa的升高,但主要是Ea的降低。3心导管指标CHD组LVEDP平均为(16.60±6.21mmHg),无显著冠状动脉狭窄组为(8.51±1.68mmHg),CHD组较无显著冠状动脉狭窄组明显增高,两者相比有显著的统计学差异(P<0.05)。4线性相关分析E/Ea与LVEDP呈正相关(r值为0.8175,P<0.05),LAD、LVEDV与LVEDP呈正相关(r值分别为0.3777,0.3798,P<0.05),E/A与LVEDP无显著相关(r值为-0.1260,P>0.05)。5 E/A及E/Ea异常发生率与LVEDP异常发生率的比较E/Ea=10估计LVEDP=15mmHg的敏感性为94%,高于E/A估计LVEDP=15mmHg的敏感性(26%),两者相比P<0.05,有显著的统计学差异;E/Ea=10估计LVEDP>15mmHg的特异性为73%,高于E/A估计LVEDP=15mmHg的特异性(44%),两者相比P<0.05,差异有显著性。结论:1严重的冠状动脉狭窄对左心室舒张功能有明显影响。2多普勒超声心动图是评价左室舒张功能的重要手段,其中,左室舒张功能明显下降时,Ea也明显下降,E/Ea则与LVEDP相关,二者结合可用于评价舒张功能受损的严重程度及左室充盈压。3左房大小与LVEDP相关,与Ea、E/Ea等多普勒超声心动图指标结合,可以作为评价左室舒张功能的重要指标,以提高诊断或排除左室舒张功能不全的准确性和可靠性。4在CHD中,E/Ea比值比E/A比值更能准确评价左室舒张功能,尤其是预测LVEDP。更多还原

【Abstract】 Background:Epidemiologic data indicate that left ventricular diastolic dysfunction(DD) and diastolic heart failure(DHF),that is symptomatic DD and a distinct form of heart failure,are very common in 40-50%of patients with chronic heart failure have normal or relatively normal left ventricular ejections fractions.Doppler echocardiography has become the most common and important method to evaluate left ventricular diastolic function because of its non-invasion.Early diastolic velocities of mitral annulus(Ea),transmitral diastolic early peak inflow velocity(E),transmitral diastolic late peak inflow velocity(A) and the ratio of mitral velocity to early diastolic velocity of the mitral annulus(E/Ea) can predict left ventricular diastolic function,but the specificity and the sensitivity need to be studied and verified.Therefor,we collection forty patients performed cardiac catheterization for selected coronary artery angiography to measure LVEDP and compared with echocardiographic finding to evaluate the specificity and the sensitivity in predicting LVEDP by echocardiographic finding.Objective:To observe the early diastolic peak velocity of mitral annulus(Ea),the early diastolic peak velocity of the mitral inflow(E)and the late diastolic peak velocity of mitral inflow(A) and the relationship between the velocities and left ventricular end diastolic pressure(LVEDP) which obtained bycardiac catheterization.Methods:Forty patients with repeated chest pain performed cardiac catheterization for selected coronary artery angiography.Patients with the degree of coronary artery stenosis (50%which were diagnosed by cardiac catheterization were as a non-obvious coronary stenosis group.The patients with one or more coronary arteries(the diameter=1.5mm) stenosis =75% were as coronary heart disease group.After the coronary artery angiography,LVEDP were measured and recorded. Echocardiography was performed before 24 hours of the angiography.Left atrial dimensions(LAD),left ventricular end diastolic(LVEDD) and systolic dimension(LVESD), interventricular septal thickness(IVST),left ventricular posterior wall thickness(LVPWT) were measured by echocardiography. Measurements of left ventricular end-diastolic volume (LVEDV),end-systolic volume(LVESV) and ejection fraction(LVEF) was obtained by biplane Simpson’s method.The early diastolic peak velocity of mitral annulus(Ea),the early diastolic peak filling velocity of mitral inflow(E),late diastolic peak filling velocity(A) were analyzed.E/Ea ratio and E/A ratio were calculated.SPSS 13.0 software package was used to compare the differences of the parameters between two groups and to analyze the correlation between the LVEDP and the parameters from the echocardiogram.Results:1 There were no statistically significant difference between non-obvious coronary stenosis group and CHD group in age, sex,serum levels of lipid,serum levels of glucose,liver function, renal function,systolic blood pressure and diastolic blood pressure(P>0.05).2 Echocardiographic finding:2.1 Significant more increases were noted in LAD in CHD group than non-obvious coronary stenosis group(30.45±3.49mm, P<0.05).E/Ea ratios in CHD group were significantly higher than those in non-obvious coronary stenosis group(11.68±2.84 vs 8.60±1.90,P<0.05).Compared with the measurements of non-obvious coronary stenosis group increased A and Aa were found in CHD group(P<0.05).2.2 LVEF and E peaks in CHD group were lower than those in non-obvious coronary stenosis group(60.39±10.03 vs 62.67±8.79 and 72.90±11.19 cm/s vs 77.33±7.20 cm/s),but there was no statistical difference between CHD group and non-obvious coronary stenosis group(P>0.05).Compared with non-obvious coronary stenosis group,increased IVST,LVPWT, LVEDD,LVESD,LVEDV and LVESV were found in CHD group,but there was no statistical difference(P>0.05). 2.3 Significant more decreases were noted in Ea,Ea/Aa and E/A in CHD group than non-obvious coronary stenosis group(6.49±1.40cm/s vs 9.36±2.12cm/s,0.79±0.28 vs 1.57±0.63, 1.04±0.17 vsl.20±0.27,P<0.05).2.4 The increase in E/Ea ratio in CHD group was mainly because of the decreased Ea.The decreased Ea was the major reason for decreased Ea/Aa in CHD group,though Aa increase in CHD group at the same time.For decreased E/A in CHD group,the increased A is the major reason.3 Linear correlation analyses:Significant correlations were found between E/Ea ratio and LVEDP(r=0.8175,P<0.05). There was no significant correlations between E/A and LVEDP (r=-0.1260,P>0.05).Correlations were found between LAD and LVEDP(r=0.3777,P<0.05),E/A and LVEDP(r=0.3798,P<0.05).4 The comparison of abnormality incidence rate between E/A,E/Ea and LVEDP.The Sensitivity of E/Ea=10 estimating LVEDP>15mmHg was 94%and was better than 16%of E/A(P<0.05).The specificity of E/Ea=10 predicting LVEDP>15mmHg was 73%and the specificity of E/A was 44%.There was a significant statistical difference in the specificity between E/Ea and E/A.Conclusions:1 Severe coronary stenosis had a great influence on left ventricular diastolic function.2 Doppler echocardiography is an important tool in the evaluation of left ventricular diastolic function.Ea correlates with the degree of left ventricular dysfunction.E/Ea ratio correlates with LVEDP,and the combination of Ea and E/Ea ratio is useful in the evaluation of diastolic function.3 Left atrial size,which correlates with LVEDP,may be an important morphologic index in the estimation of left ventricular diastolic function by combining with other Dopplerechocardiography indexes such as Ea and E/Ea.4 In CHD,E/Ea is more accurate reflection of left ventricular diastolic function than E/A,especially for estimation of LVEDP.更多还原