多普勒超声心动图评估肺动脉压力的临床价值

The detective value of doppler echocardiography in pulmonary arterial hypertension

目的:比较多普勒超声心动图(DE)和右心导管检查(RHC)估测肺动脉压力(PAP)值有无差异。方法:连续入选2006年1月1日至2017年11月1日,就诊于大连医科大学附属第一医院同时行RHC和DE的患者,根据是否存在心脏解剖畸形分为先天性心脏病(CHD)组和无分流组,排除<14 岁及存在右心室流出道梗阻和肺动脉瓣狭窄或其他复杂等畸形的患者。肺动脉高压(PAH)诊断标准参照2015年ESC/ERS肺动脉高压诊断与治疗指南。结果:研究共纳入347例患者,其中CHD组312例,无分流组 35 例。RHC 确诊 PAH 患者 269 例(77.5%),SPAP [50. 81(35,55)]mmHg( I mmHg = 0. 133 kPa);无PAH患者78例(22. 5%),SPAP [25. 58(24,29)]mmHg。两组在年龄、体质量、心功能不全、红细胞分布宽度、BNP、右心室流出道宽度、右心室内径、左心房前后径、右心房前后径、右心房上下径及肺动脉内径等,差异均有统计学意义。年龄、体质量是患者发生PAH的影响因素,年龄大、体质量大的患者PAH发生风险增加(OR=1. 022,1. 028,P=0. 038,0. 046);缺损直径大小是CHD发生PAH的影响因素,缺损直径越大,发生PAH风险越高(r=1. 063, P=0. 004)。在RHC确诊的的269例PAH患者中,发现 RHC 估测 SPAP 高于 DE 估测 SPAP[50. 81 (35,55)m. 41. 19(22,53. 5)mmHg,P<0. 001],而无分流组中估测 SPAP 值,差异无统计学意义[69. 42(44. 5,87)vs.70. 48 (44. 5,93) mmHg,P = 0. 846];但二者估测的SPAP呈正相关(r= 0. 598, P<0. 001)。SPAP>36 mmHg时,DE确诊PAH灵敏性和特异性最高,分别为71. 7%和64. 3%。结论:应用DE估测的SPAP与RHC估测的SPAP值相关性较好,但二者仍存在一定差异,DE估测的SPAP低于RHC估测的SPAP;DE在评估无分流PAH患者SPAP准确性较高。

Objective: To compare whether there was any difference in the pulmonary arterial pressure (PAP) between doppler echocardiography ( DE) and right heart catheterization ( RHC ). Methods : Patients were enrolled in the study between January 1, 2006 and November 1, 2017 from The First Affiliated Hospital of Dalian Medical University who were tested PAP both by RHC and DE. The patients were divided into two groups according to the presence or absence of cardiac anatomy, congenital heart disease ( CHD) Group and no shunt group. In the study, we excluded the patients younger than 14 years old and the patients with right ventricular outflow tract obstruction, pulmonary valve stenosis or other complex deformities. The diagnostic criteria of pul-monary arterial hypertension (PAH) referred to the 2015 ESC/ERS Guidelines. Results: A total of 347 patients were enrolled in the study, including 312 CHD patients and 35 non-shunt patients. 269 patients (77. 5%) were diagnosed with PAH by RHC, which SPAP was 50. 81 (35,55)mmHg. In the contrary, 78 ca-ses (22. 5%) were diagnosed without PAH, which SPAP was 25. 58(24,29) mmHg. Age, weight, heart fail-ure ,RDW, BNP, right ventricular outflow tract width, right ventricular diameter, the anteroposterior diameter of left and right atrium, the suprainferior diameter of right atrium, pulmonary artery diameter were distributed different between PAH group and non-PAH group. Age and weight were independent factors of patients with PAH (OR=1.022, 1.028, respectively, P = 0. 038, 0.036, respectively). The defect diameter of CHD pa-tients was the independent risk factor of PAH in CHD patients ( OR = 1. 063 ,P = 0. 004). In the 269 PAH pa-tients, there was significantly different in the SPAP between the DE and RHC[ 50. 81(35,55)vs. 41. 19(22, 53. 5)mmHg, P<0. 001], and the SPAP tested by DE was lower than the SPSP tested by RHC. However, we found that there was no differences in the SPAP between DE and RHC in the non-shunt group [ 69. 42 ( 44. 5, SI)vs. 70. 48(44. 5,93)mmHg, P=0. 846]. A positive correlation was found in SPAP between DE and RHC in PAH patients ( r = 0. 598 ,P<0. 001). The diagnostic performance of optimal values of SPAP was 36 mmHg in DE with sensitivity 76. 8% and specificity 63.4%. Conclusions: The SPAP estimated by DE was consistent with the SPSP tested by RHC, and that predicted by RHC, but there was still different between the two exami-nations. The SPAP estimated by DE is lower than that estimated by RHC. DE was a better alternative measure for PAH patients without shunting.