四维超声心动图结合二维斑点追踪技术评价肺动脉高压患者右心功能和预后

Value of four-dimensional echocardiography combined with speckle tracking technique on the assessment of right heart function and prognosis in patients with pulmonary arterial hypertension

目的应用四维超声心动图结合二维斑点追踪技术评价肺动脉高压患者的右心功能及预后。方法2017年7至11月,采用前瞻性研究方法纳入2015年9月至2017年7月在上海交通大学医学院附属仁济医院东院及南院经右心导管确诊的肺动脉高压患者51例作为肺动脉高压组,同期招募年龄和性别与肺动脉高压组相匹配的健康志愿者26名作为对照组。肺动脉高压组患者年龄(45.8±15.5)岁,男性6例,女性45例;对照组年龄(45.4±14.6)岁,男性4名,女性22名。分别获取二维和四维超声心动图图像,测量右心结构和功能的相关指标,然后利用斑点追踪技术测量各心室与心房的心肌应变。肺动脉高压组患者自2017年7月随访至2018年8月,观察终点事件(包括全因死亡、再入院和临床恶化)的发生情况。结果对照组与肺动脉高压组的二维超声心动图参数[包括三尖瓣环收缩期位移(TAPSE)、右心室面积变化分数(FAC)和右心室收缩压(RVSP)]、斑点追踪技术参数[包括左心室整体纵向收缩期峰值应变(LVGLS)、右心室整体纵向收缩期峰值应变(RVGLS)、左心房储备功能(LASr)、左心房管道功能(LASc)、左心房泵功能(LASp)、右心房储备功能(RASr)、右心房管道功能(RASc)、右心房泵功能(RASp)]和四维超声心动图参数[包括右心室舒张末期容积(RVEDV)、右心室收缩末期容积(RVESV)、右心室收缩容积(RVSV)、右心室游离壁长轴应变(RVLSf)、室间隔长轴应变(IVSLS)和右心室射血分数(RVEF)]差异均有统计学意义(P<0.01或0.05)。Spearman相关分析显示,RVEF与6min步行距离(r=0.540,P<0.001)、B型利钠肽(r=-0.545,P<0.001)、纽约心脏协会(NYHA)心功能分级(r=-0.583,P<0.001)、TAPSE(r=0.595,P<0.001)、LVGLS(r=-0.461,P=0.001)、LASc(r=0.453,P=0.002)、RASc(r=0.532,P<0.001)、RVESV(r=-0.418,P=0.004)、RVSV(r=0.351,P=0.017)和IVSLS(r=-0.450,P=0.002)均相关。Pearson相关分析显示,RVEF与FAC(r=0.579,P<0.001)、RVSP(r=-0.442,P=0.002)、RVGLS(r=-0.521,P<0.001)、LASr(r=0.483,P=0.001)、RASr(r=0.617,P<0.001)、RASp(r=0.513,P<0.001)和RVLSf(r=-0.592,P<0.001)均相关。随访(10.4±2.7)个月后,肺动脉高压组共有14例患者出现终点事件,包括死亡4例,再入院5例,临床恶化5例。多因素Cox回归分析显示,RVEF升高是肺动脉高压患者发生终点事件的独立保护因素(HR=0.702,P=0.043),RVSP升高是肺动脉高压患者发生终点事件的独立危险因素(HR=1.083,P=0.017)。受试者工作特征(ROC)曲线显示,RVEF和RVSP对肺动脉高压患者发生终点事件有较高的预测价值,曲线下面积(AUC)分别为0.835(P=0.001)和0.820(P=0.001)。结论四维超声心动图测量的RVEF与二维超声心动图测量的右心功能参数相关,并可判断肺动脉高压患者预后。二维斑点追踪技术测量的右心房和左心房功能在一定程度上反映右心功能。

ObjectiveTo investigate the value of four-dimensional echocardiography combined with speckle tracking technique on the assessment of right heart function and prognosis in patients with pulmonary arterial hypertension (PAH).MethodsIn this prospective study, 51 patients with PAH diagnosed by right heart catheterization in east hospital and south hospital of Renji hospital affiliated to school of medicine of Shanghai Jiaotong University from September 2015 to July 2017 were enrolled as PAH group from July to November 2017. Meanwhile, 26 healthy volunteers with age and sex matched with pulmonary hypertension patients were recruited as control group. The patients were aged (45.8±15.5) years old in PAH group, and there were 6 males and 45 females. The healthy volunteers were aged (45.4±14.6) years old in control group, and there were 4 males and 22 females. Two-dimensional and four-dimensional echocardiographic images were obtained to measure the structure and function of the right heart. The myocardial strain of each ventricle and atrium was measured by sparkle tracking. The patients in PAH group were followed up from July 2017 to August 2018 to observe the endpoint events including all-cause death, re-hospitalization, and clinical deterioration.ResultsThere were significant differences in two-dimensional echocardiographic parameters(including tricuspid annular plane systolic excursion (TAPSE), right ventricular area change fraction (FAC), and right ventricular systolic pressure (RVSP)), speckle tracking parameters (including global longitudinal systolic peak strain of left ventricle (LVGLS), global longitudinal systolic peak strain of right ventricle (RVGLS),left atrial reservoir function(LASr), left atrial conduit function (LASc), left atrial pump function (LASp), right atrial reservoir function (RASr), right atrial conduit function (RASc), and right atrial pump function (RASp)), and four-dimensional echocardiographic parameters(including right ventricular end diastolic volume (RVEDV) , right ventricular end systolic volume(RVESV), right ventricular stroke volume(RVSV), right ventricular freewall longitudinal strain(RVLSf), interventricular septum longitudinal strain(IVSLS), right ventricular ejection fraction(RVEF)) between control group and PAH group (all P<0.01 or 0.05).Spearman correlation analysis showed that RVEF was correlated with 6-minute walking distance (r=0.540, P<0.001), B-type natriuretic peptide (r=-0.545,P<0.001), New York Heart Association (NYHA) cardiac function classification(r=-0.583, P<0.001), TAPSE(r=0.595, P<0.001), LVGLS (r=-0.461, P=0.001) ,LASc (r=0.453, P=0.002) ,RASc (r=0.532, P<0.001) ,RVESV (r=-0.418, P=0.004) , RVSV (r=0.351, P=0.017) , and IVSLS (r=-0.450, P=0.002) . Pearson correlation analysis also showed that RVEF was correlated with FAC(r=0.579, P<0.001),RVSP (r=-0.442, P=0.002) ,RVGLS (r=-0.521, P<0.001) , LASr (r=0.483, P=0.001) , RASr (r=0.617, P<0.001) , RASp (r=0.513, P<0.001) , and RVLSf (r=-0.592, P<0.001) .After a follow-up of (10.4±2.7) months, there were 4 all-cause deaths, 5 re-hospitalizations and 5 clinical deterioration. Multivariate Cox regression analysis showed that increased RVEF was independent protective factor for end-point events in PAH patients (HR=0.702, P=0.043), and increased RVSP was independent risk factor for end-point events in PAH patients (HR=1.083, P=0.017). The receiver operating characteristic (ROC) curve showed that RVEF and RVSP could be used to predict the end-point events in PAH patients. The area under the curve (AUC) was 0.835(P=0.001) and 0.820(P=0.001), respectively.ConclusionsRVEF measured by four-dimensional echocardiography is correlated with right ventricular function parameters measured by two-dimensional echocardiography and can be used to estimate the prognosis of PAH patients. The right atrial and left atrial function assessed by speckle tracking can also reflect the right ventricular function to a certain extent.