三维斑点追踪技术在肥厚型心肌病危险分层和预后评估中的应用

The role of three-dimensional speckle tracking imaging in risk stratification and prognosis in hypertrophic cardiomyopathy

目的采用常规超声和三维斑点追踪（3D-STI）技术评估肥厚型心肌病（HCM）患者心功能特征，以期找到能够预测不良临床事件和具有随访价值的超声指标。方法选取成人HCM患者180例行常规超声和3D-STI检查。对入选患者进行随访，记录发生的终点事件。终点事件分为一级和二级终点，一级终点指心源性猝死（SCD）或SCD等位事件，二级终点指发生急性心肌梗死、因心力衰竭住院、血栓栓塞、终末期HCM任意一项。复合终点指发生一级或二级终点。结果①共完成随访HCM患者175例，平均随访（435±204）d；共25例（14．3％）达到复合终点，其中一级终点8例，二级终点17例。②与无一级终点组（167例）相比，一级终点组纽约心功能分级（NYHA）Ⅲ／Ⅳ级所占比例较高，二尖瓣环收缩期和舒张早期峰值速度（MVs’和MVe＇）、三尖瓣环收缩期峰值速度（TVs’）及左室三维整体纵向应变（GLS）均明显减低（P〈0．05）。GLS（风险比0．72，95％可信区间0．53—0．98，P=0．035）和TVS’（风险比0．70，95％可信区间0．54—0．91，P=0．007）是HCM患者一级终点事件的独立预测指标；GLS绝对值≤11．7％或TVs’≤12．7cm／s的患者更易发生一级终点事件。③与一级终点结果类似，复合终点组（25例）较无复合终点组（150例）NYHA11I／Ⅳ级所占比例明显升高，左房前后径（LAD）增大，MVS’、MVe’、TVs’和GLS均明显减低（P〈0．05）。其中，GLS（风险比0．68，95％可信区间0．56—0．81，P=0．000）可独立预测复合终点事件；且GLS绝对值≤12．9％的患者更易发生复合终点事件。结论3D-STI参数GLS联合常规超声参数TV s’对HCM不良心血管事件具有预测价值。

Objective To investigate whether three-dimensional speckle tracking imaging （3D-STI） combined with conventional echocardiography can identify cardiac functional characteristics and predict adverse cardiovascular events in patients with hypertrophic cardiomyopathy （HCM）. Methods One hundred and eighty HCM patients were involved in the study. All patients were followed up to March 2017 after comprehensive evaluation of 3D-STI and conventional echocardiography for endpoint events. The endpoint events were divided into the primary and secondary endpoints. The primary endpoints included sudden cardiac death （SCD）, survival after cardioversion and appropriate implantable cardioverterdefibrillator（ICD） discharge; the secondary endpoints included acute myocardial infarction, heart failure hospitalization, thromboembolism and endstage HCM. The composite endpoints contained primary or secondary endpoints. Results （1）Totally 175 HCM patients completed the follow-up [（435 ± 204） days]. During follow-up, 25 patients （14.3%） reached composite endpoints：8 cases of the primary endpoints （3 cases of sudden cardiac death, 3 cases of survival after defibrillation, and 2 cases of appropriate implantable cardioverter-defibrillator discharge）; i7 cases of the second endpoints （14 cases of heart failure hospitalization, 2 cases of thromboembolism, and 1 case of end-stage HCM）. （2） Patients with primary endpoints had higher NYHA class, reduced systolic and early diastolic mitral annular velocities （MV s＇ and MV e＇）, decreased systolic tricuspid annular velocity （TV s＇）, and impaired 3D left ventricular global longitudinal strain （GLS）, as compared to those without primary endpoints （n = 167） （P 〈0.05）. Impaired3D GLS （hazard ratio was 0.72,95% CI was 0.53 - 0.98, P = 0.035） and decreased TV s＇ （hazard ratio was 0. 70,95 % CI was 0.54 - 0.91, P = 0.007） were independent predictor factor for primary endpoints. 3D GLS ≤ 11.7% or TV s＇≤12.7 cm/s raised the risk of primary endpoints. （3）Similarly, HCM patients with composite endpoints （ n = 25） had higher NYHA class, enlarged left atrial diameter （LAD）, reduced MV s＇, MV e＇ and TV s＇, as well as impaired 3D GLS （ P 〈0.05）, when compared to those without composite endpoints （n = 150）. Moreover, impaired 3D GLS （hazard ratio was 0.68,95% CI was 0.56- 0.81, P = 0. 000） was independent predictor for composite endpoints; and patients with 3D GLS≤ 12.9% was more susceptible to composite endpoints. Conclusions 3D GLS combined with TV s＇ are of value in predicting adverse cardiovascular events.