海拔高度对克山病患者右心结构及功能的影响

Effects of altitude on the structure and function of right heart in patients with chronic Keshan disease

目的分析不同海拔高度慢型克山病(CKD)患者超声心动图的差异性表现,探讨不同海拔高度对CKD患者右心结构及功能的影响,为CKD的影像学诊断提供参考依据。方法根据我国地势的三级阶梯分布,在第一级阶梯(4000m以上)的西藏自治区选择30例CKD患者作为青藏高原组,在第二级阶梯(1000~2000m)的甘肃省选择31例CKD患者作为黄土高原组,在第三级阶梯(500m以下)的山东省选择42例CKD患者作为平原组。对所有研究对象进行超声心动图检查,就心脏形态、血流动力学和心功能3个方面进行对比分析。结果青藏高原组、黄土高原组和平原组的右房橫径[RATD,(49.75±8.40)、(45.64±7.63)、(43.56±7.34)mm]、右室橫径[RVTD,(50.89±7.13)、(46.56±5.62)、(43.27±6.01)mm]、右室壁厚度[RVWT,(4.75±1.02)、(3.53±0.61)、(3.37±0.51)mm]、肺主动脉内径[MPAD,(32.87±3.62)、(28.93±2.12)、(28.44±2.71)mm]组间比较差异均有统计学意义(F=5.36、12.91、37.08、23.33,P均<0.01),且青藏高原组均高于黄土高原组和平原组(P均<0.05),黄土高原组的RVTD高于平原组(P<0.05)。青藏高原组、黄土高原组和平原组的右室面积变化分数[FAC,(24.85±2.75)%、(26.26±3.42)%、(26.73±3.14)%]、三尖瓣收缩期位移[TAPSE,(12.87±1.12)、(14.59±1.63)、(14.13±1.31)mm]组间比较差异均有统计学意义(F=3.36、13.47,P<0.05或<0.01),且青藏高原组均低于黄土高原组和平原组(P均<0.05)。青藏高原组、黄土高原组和平原组的右室Tei指数(0.87±0.18、0.78±0.16、0.71±0.14)、三尖瓣舒张早期最大充盈速度/三尖瓣环舒张早期峰值速度[E/E′,9.48±1.22、8.64±0.91、8.12±1.13]、肺动脉收缩压[SPAP,(49.58±11.76)、(44.35±11.41)、(42.67±12.13)mmHg,1mmHg=0.133kPa]组间比较差异均有统计学意义(F=12.89、13.99、3.12,P<0.01或<0.05),且青藏高原组右室Tei指数、E/E′均高于黄土高原组和平原组(P均<0.05),黄土高原组的Tei指数、E/E′高于平原组(P均<0.05)。结论居住地海拔高度对CKD患者的右心结构和功能有影响,随海拔高度增加,CKD患者右心扩大、右室收缩和舒张功能降低,同时合并较高的肺动脉压。

Objective To analyze the difference of echocardiography in patients with chronic Keshan disease (CKD) at different altitudes areas, explore the effects of altitude on the structure and functional of right heart in CKD patients, and provide a reference for imaging diagnosis of CKD. Methods According to the three step distribution of the terrain in China, 30 cases of CKD patients in the first step (altitude > 4 000 m) of Tibet autonomous region were randomly selected as the Tibetan plateau group. In the second step (altitude: 1 000-2 000 m), 31 cases were randomly selected in Gansu Province as the Loess plateau group. In the third step(altitude < 500 m), 42 cases were randomly selected in Shandong Province as the plain group. Echocardiography was used to analyze the morphology, hemodynamics and function of right heart. Results Right atrial transverse diameter (RATD), right ventricular transverse diameter (RVTD), right ventricular lateral wall thickness (RVWT) and main pulmonary artery diameter (MPAD) of the Tibetan plateau group, the Loess plateau group and the plain group (mm: 49.75 ± 8.40, 45.64 ± 7.63, 43.56 ± 7.34;50.89 ± 7.13, 46.56 ± 5.62, 43.27 ± 6.01;4.75 ± 1.02, 3.53 ± 0.61, 3.37 ± 0.51;32.87 ± 3.62, 28.93 ± 2.12, 28.44 ± 2.71) were significant differences among the three groups (F = 5.36, 12.91, 37.08, 23.33, P < 0.01). The above indexes of the Tibetan plateau group were higher than those of the Loess plateau group and the plain group (P < 0.05). RVTD of Loess plateau group was higher than that of plain group (P < 0.05). The fractional area change [FAC,(24.85 ± 2.75)%,(26.26 ± 3.42)%,(26.73 ± 3.14)%], tricuspid annular plane systolic excursion [TAPSE,(12.87 ± 1.12),(14.59 ± 1.63),(14.13 ± 1.31) mm] of the Tibetan plateau group, the Loess plateau group and the plain group were significant differences among the three groups (F = 3.36, 13.47, P < 0.05 or < 0.01);the above indexes of the Tibetan plateau group were lower than those of the Loess plateau group and the plain group (P < 0.05). Tei index (0.87 ± 0.18, 0.78 ± 0.16, 0.71 ± 0.14), tricuspid flap diastolic maximum filling speed/tricuspid annulus early diastolic peak velocity (E/E′, 9.48 ± 1.22, 8.64 ± 0.91, 8.12 ± 1.13), systolic pulmonary artery pressure [SPAP,(49.58 ± 11.76),(44.35 ± 11.41),(42.67 ± 12.13) mmHg, 1 mmHg = 0.133 kPa] of the Tibetan plateau group, the Loess plateau group and the plain group were significant differences among the three groups (F = 12.89, 13.99, 3.12, P < 0.01 or < 0.05);the Tei index and E/E′ of the Tibetan plateau group were higher than those of the Loess plateau group and the plain group (P < 0.05). Tei index, E/E′ of the Loess plateau group were higher than those of the plain group (P < 0.05). Conclusions The right heart structure and function of CKD patients are affected by the altitude of their residence. With the increase of altitude, the right heart is enlarged, the right ventricular systolic and diastolic functions are decreased, and SPAP is increased in CKD patients.