自动瓣环运动定量技术评价蒽环类药物对乳腺癌患者右室收缩功能的影响

Effect of anthracycline on right ventricular systolic function in patients with breast cancer by automatic tracking of motion annular displacement

目的应用自动瓣环运动定量(aTMAD)技术评价蒽环类药物对乳腺癌患者右室收缩功能的影响。方法选取50例行表柔比星为主化疗方案治疗的乳腺癌患者,分别于化疗前和化疗第2、4周期后行二维超声心动图检查,获取左室射血分数(LVEF)、右室面积变化率(RVFAC)及三尖瓣环收缩期位移(TAPSE);二维斑点追踪技术获取右室整体纵向峰值应变(RVGLS);aTMAD测量三尖瓣环位移(TAD),获取三尖瓣环右室游离壁收缩期峰值位移(T1)、三尖瓣环间隔收缩期峰值位移(T2)、三尖瓣环连线中点峰值位移(Tm)及Tm与右室舒张末期最大纵径比值(Tm%)。比较各组上述参数的差异,分析TAD与RVFAC、TAPSE、RVGLS的相关性,以及各超声参数与蒽环类药物累积剂量的相关性,绘制受试者工作特征(ROC)曲线分析各超声参数预测蒽环类药物心脏毒性的诊断效能;并对各超声参数进行重复性检验。结果①与化疗前比较,化疗第4周期后LVEF、RVFAC及TAPSE均降低,化疗第2、4周期后RVGLS、T1、T2、Tm及Tm%均降低,差异均有统计学意义(均P<0.05)。②化疗前后各周期Tm%与RVGLS均呈强相关(r=0.848、0.748、0.795,均P<0.05),与RVFAC均呈弱相关(r=0.544、0.447、0.347,均P<0.05),与TAPSE均呈弱相关(r=0.436、0.291、0.305,均P<0.05);RVGLS、T1、T2、Tm及Tm%与药物累积剂量均呈负相关(r=-0.785、-0.852、-0.730、-0.765、-0.862,均P<0.05)。③ROC曲线分析显示:RVGLS预测蒽环类药物心脏毒性的截断值为18.35%,敏感性90.7%,特异性85.7%,曲线下面积0.942;Tm%的截断值为15.15%,敏感性95.3%,特异性85.7%,曲线下面积0.930。④重复性检验显示:RVGLS和Tm%观察者内的组内相关系数分别为0.891、0.937,观察者间的组内相关系数分别为0.850、0.890。结论应用aTMAD技术测量TAD可以评价乳腺癌化疗患者右室收缩功能障碍,且Tm%较RVGLS测量更简便易行、重复性好,具有重要的临床应用价值。

Objective To evaluate the effect of anthracycline on right ventricular function in patients with breast cancer by automatic tracking of motion annular displacement(aTMAD).Methods Fifty breast cancer patients receivd anthracycline-based chemotherapy were selected,two-dimensional echocardiograpy were performed before chemotherapy and after 2nd and 4th cycle of chemotherapy.The left ventricular ejection fraction(LVEF),right ventricular fractional area change(RVFAC),and tricuspid annular plane systolic excursion(TAPSE)were obtained.The global longitudinal peak strain of right ventricle(RVGLS)was obtained by two-dimensional speckle tracking technology.Tricuspid annulus displacement(TAD)was measured by aTMAD,and the peak systolic displacement of the free wall of the right ventricle of the tricuspid annulus(T1),peak systolic displacement of the tricuspid annulus interval(T2),peak displacement of the midpoint of the line of the tricuspid annulus(Tm)and the maximum longitudinal diameter ratio of Tm to the end diastolic of the right ventricle(Tm%)were obtained.The differences of the above parameters in each chemotherapy cycle were compared,and the correlations between the TAD and RVFAC,TAPSE,RVGLS were analyzed,and the correlation between the ultrasonic parameters and the accumulated dose of anthracycline were compared.Receiver operating characteristic(ROC)curves were drawn to analyze the diagnostic efficacy of ultrasonic parameters in predicting cardiac toxicity of anthracyclines,and RVGLS and Tm%were tested for repeatability.Results①Compared with before chemotherapy,LVEF,RVFAC and TAPSE were decreased after the 4th cycle of chemotherapy,while RVGLS,T1,T2,Tm and Tm%were decreased after the 2nd and 4th cycles of chemotherapy,the differences were statistically significant(all P<0.05).②There were strong correlation between Tm%and RVGLS(r=0.848,0.748,0.795,all P<0.05),and a weak correlation with RVFAC(r=0.544,0.447,0.347,all P<0.05)and weak correlation with TAPSE(r=0.436,0.291,0.305,all P<0.05)in each cycle before and after chemotherapy.RVGLS,T1,T2,Tm and Tm%were negatively correlated with drug accumulated doses(r=-0.785,-0.852,-0.730,-0.765,-0.862,all P<0.05).③ROC curve analysis showed that the cutoff value of RVGLS for predicting cardiac toxicity of anthracyclines was 18.35%,the diagnostic sensitivity was 90.7%,specificity was 85.7%,and area under the curve was 0.942.The cut-off value of Tm%was 15.15%,the diagnostic sensitivity was 95.3%,specificity was 85.7%,and area under the curve of 0.930.④Reproducibility tests showed that the intra-observer ICC for RVGLS and Tm%were 0.891 and 0.937,and the inter-observer ICC were 0.850 and 0.890,respectively.Conclusion aTMAD can be used to evaluate right ventricular global systolic dysfunction in patients with breast cancer received chemotherapy,and Tm%is more convenient than RVGLS,which is repeatable and worthy of clinical promotion.