左心室压力-应变环评价妊娠期高血糖患者左心室收缩功能的定量研究

Quantitative evaluation of left ventricular systolic function in hyperglycemia during pregnancy by left ventricular pressure-strain loop

目的应用左室压力-应变环(PSL)检测妊娠期高血糖患者左室心肌做功参数的变化进而评估左心室收缩功能。方法前瞻性随机选取2021年6月至2022年3月就诊于哈尔滨医科大学附属第二医院并经临床诊断为妊娠期高血糖的孕妇97例,根据血糖值将患者分为妊娠期显性糖尿病(ODM)组39例,妊娠期糖尿病(GDM)组58例;另选同期62例健康孕妇作为对照组。收集孕妇的基本临床资料,采集心脏常规二维参数,通过二维斑点追踪技术进行整体纵向应变(GLS)分析,再将袖带血压作为左室压力构建PSL,计算并比较各组整体心肌做功指数(GWI)、整体有用功(GCW)、整体无用功(GWW)和整体做功效率(GWE)的差异。分析心肌做功参数与GLS、糖化血红蛋白(HbA1c)的相关性,并通过Logistic回归分析得出影响左心室收缩功能的独立影响因素。从研究对象中随机选取病例组20例,计算观察者内及观察者间组内相关系数(ICC)进行重复性检验。结果①常规超声参数:三组间比较差异无统计学意义(均P>0.05)。②GLS及左室心肌做功参数:GDM、ODM组较对照组GWI、GWE、GCW、GLS明显减低(均P<0.001),GWW明显增高(P<0.001);ODM组较GDM组GWI、GWE、GCW、GLS减低(均P<0.001),GWW增高(P<0.001)。③GWE、GWI、GCW与GLS呈负相关(r=-0.525、-0.408、-0.435,均P<0.05),GWW与GLS呈正相关(r=0.348,P<0.05);GWE、GWI、GCW与HbA1c呈负相关(r=-0.325、-0.262、-0.250,均P<0.05),GWW与HbA1c呈正相关(r=0.175,P<0.05);其中GWE与两者相关性较好(r=-0.525、-0.323)。④GWE、1小时葡萄糖耐量试验(1 h OGTT)及HbA1c是妊娠期高血糖患者左心室收缩功能的影响因素。⑤GWI、GWE、GCW、GWW及GLS对妊娠期高血糖患者的心脏功能具有较高的预测价值,其中GWE预测价值最高(AUC为0.879,最佳截断值为94.5%,特异性为0.76,敏感性为0.82),优于GLS。⑥心肌做功参数观察者内、观察者间重复性较好。结论应用PSL获得的心肌做功参数是评估妊娠期高血糖患者左心室收缩功能损害早期、敏感的参数,可为临床实施早期干预、改善预后提供可靠的客观量化指标。

Objective To detect the changes of left ventricular myocardial work parameters,and evaluate the left ventricular systolic function in patients with hyperglycemia during pregnancy by left ventricular pressure-strain loop(PSL).Methods From June 2021 to March 2022,97 pregnant women who were admitted to the Second Affiliated Hospital of Harbin Medical University and clinically diagnosed as gestational hyperglycemia were prospectively and randomly selected.According to the blood glucose level,the patients were divided into gestational dominant diabetes mellitus(ODM)group(39 cases)and gestational diabetes mellitus(GDM)group(58 cases).Meanwhile,another 62 healthy pregnant women were selected as control group.The basic clinical data of the pregnant women were collected,and the conventional two-dimensional parameters of the heart were collected.The global longitudinal strain(GLS)was analyzed by two-dimensional speckle tracking technique.Then the cuff blood pressure was used as the left ventricular pressure to construct a non-invasive left ventricular pressure-strain loop.The global myocardial work index(GWI),global constructive work(GCW),global wasted work(GWW)and global work efficiency(GWE)of each group were calculated and compared.The correlation between myocardial performance parameters and GLS,glycated hemoglobin(HbA1c)were analyzed,and the independent factors affecting left ventricular systolic function were obtained by Logistic regression analysis.Twenty cases were randomly selected from the study subjects,and the intraclass correlation coefficients(ICC)of within the observers and between observers were calculated for repeatability test.Results①Conventional ultrasound parameters:There were no significant differences among the three groups(all P>0.05).②GLS and left ventricular myocardial performance parameters:GWI,GWE,GCW and GLS in GDM and ODM groups were significantly lower than those in control group(all P<0.001),GWW was significantly higher than control group(P<0.001);GWI,GWE,GCW and GLS in ODM group were lower than those in GDM group(all P<0.001),while GWW was higher than control group(P<0.001).③GWE,GWI and GCW were negatively correlated with GLS(r=-0.525,-0.408,-0.435;all P<0.05),GWW was positively correlated with GLS(r=0.348,P<0.05).GWE,GWI and GCW were negatively correlated with HbA1c(r=-0.325,-0.262,-0.250;all P<0.05),while GWW was positively correlated with HbA1c(r=0.175,P<0.05).④GWE,1 h oral glucose tolerance test and HbA1c were the influencing factors of left ventricular systolic function in patients with hyperglycemia during pregnancy.⑤The predictive values of GWI,GWE,GCW,GWW and GLS for cardiac function in patients with gestational hyperglycemia were high,and the predictive value of GWE was the highest(AUC:0.87,the best truncation value:94.5%,specificity:0.76,sensitivity:0.82)and better than GLS.⑥The repeatability of myocardial work parameters was better in both groups.Conclusions Myocardial work parameters obtained by PSL are early and sensitive parameters for evaluating left ventricular systolic function impairment in patients with hyperglycemia during pregnancy which can provide reliable and objective quantitative indicators for early clinical intervention and improvement of prognosis.