發(fā)布時(shí)間：2018-04-26 00:00

  本文選題：二維斑點(diǎn)追蹤 + 川崎病　； 參考：《蘭州大學(xué)》2017年碩士論文

【摘要】：目的運(yùn)用二維斑點(diǎn)追蹤技術(shù)(two dimensional speckle tracking imaging 2DSTI)評估川崎病(Kawasaki disease KD)患者不同時(shí)期左室心肌收縮功能變化特點(diǎn),分析急性期收縮期左室峰值應(yīng)變及應(yīng)變率與實(shí)驗(yàn)室指標(biāo)的相關(guān)性,通過比較冠狀動脈擴(kuò)張KD亞組及靜脈注射免疫球蛋白(intravenous immunoglobulin IV IG)抵抗KD亞組分別與其相應(yīng)對立組左室參數(shù)及實(shí)驗(yàn)室指標(biāo)來獲得各亞組左室心肌收縮功能特點(diǎn),通過受試者工作曲線(receiver operating characteristics ROC))獲得IVIG抵抗KD患者左室收縮期峰值應(yīng)變預(yù)測值。方法于2015年1月至2016年10月連續(xù)選取蘭州大學(xué)第二醫(yī)院兒童醫(yī)院小兒心血管科急性期診斷為KD住院患者80例,并進(jìn)一步分為冠狀動脈擴(kuò)張亞組(左、右冠狀動脈主干及左前降支中有一支內(nèi)徑Z值2.5)、IVIG抵抗(IVIG治療后持續(xù)發(fā)熱或體溫下降后又復(fù)發(fā)且超過36小時(shí)者)亞組,同期選取50例年齡性別相匹配來我院以心臟雜音就診但超聲心動圖檢查結(jié)果正常兒童作為對照組。運(yùn)用常規(guī)超聲心動圖及2DSTI技術(shù)分別于急性期(IV IG前)、亞急性期(IV IG后1周)及恢復(fù)期(IV IG后8周)獲取常規(guī)參數(shù)及收縮期左室整體峰值縱向應(yīng)變(systolic global longitudinal strain GLS)及應(yīng)變率(systolic global longitudinal strain rate GLSR)、收縮期整體峰值環(huán)向應(yīng)變(systolic global circumferential strain GCS)及應(yīng)變率(systolic global circumferential strain rate GCSR)、收縮期左室各節(jié)段峰值縱向應(yīng)變及應(yīng)變率、各節(jié)段環(huán)向應(yīng)變及應(yīng)變率。1對比分析:1)各時(shí)期整體KD患者各參數(shù)與正常對照組對比。2)整體KD患者不同時(shí)期間各參數(shù)對比。3)急性期冠狀動脈擴(kuò)張亞組各參數(shù)與正常對照組對比,冠狀動脈擴(kuò)張亞組各參數(shù)與冠狀動脈正常亞組對比。4)急性期IVIG抵抗亞組各參數(shù)與對照組比較,IVIG抵抗亞組各參數(shù)與IVIG應(yīng)答亞組比較。5)急性期冠狀動脈擴(kuò)張亞組實(shí)驗(yàn)室指標(biāo)與冠狀動脈正常亞組比較;急性期IVIG抵抗亞組實(shí)驗(yàn)室指標(biāo)與IVIG應(yīng)答亞組比較。2相關(guān)性分析:急性期整體KD患者收縮期左室整體應(yīng)變及應(yīng)變率與其它指標(biāo)相關(guān)性分析。3 ROC曲線:急性期IVIG抵抗亞組收縮期左室GLS曲線獲取IVIG抵抗預(yù)測值。結(jié)果一整體KD患者各參數(shù)與正常對照組比較結(jié)果、整體患者各時(shí)期間參數(shù)比較結(jié)果及急性期患者收縮期左室GLS、GLSR與其它指標(biāo)相關(guān)性分析。1)常規(guī)超聲心動圖示:與正常對照組相比,急性期整體KD患者左室Tei指數(shù)、左室質(zhì)量(left ventricular mass LVM)、左室質(zhì)量指數(shù)(left ventricular mass index LVMI)、E/Em(二尖瓣口舒張?jiān)缙诹魉?二尖瓣環(huán)室間隔側(cè)組織多普勒速度)、左冠狀動脈(left coronary artery LCA)、右冠狀動脈(right coronary artery RCA)、左前降(left anterior descending LAD)支內(nèi)徑均升高,差異均有統(tǒng)計(jì)學(xué)意義(P均0.05),亞急性期LVMI、LCA、E/Em仍較高(P均0.05),恢復(fù)期各參數(shù)間無差異;亞急性期KD患者左室Tei指數(shù)、LVM及LVMI均低于急性期(P均0.05),余參數(shù)各時(shí)期間未見明顯差異。2)2DSTI示:與對照組相比,急性期整體KD患者左室GLS、基底段縱向應(yīng)變、中間段縱向應(yīng)變、GCS及心尖段環(huán)向應(yīng)變均減低(P均0.05),亞急性期左室GLS及中間段縱向應(yīng)變開始升高但仍較低(P均0.05),恢復(fù)期各參數(shù)間無明顯差異;與急性期相比,亞急性期KD患者收縮期左室GLS、基底段縱向應(yīng)變、GCS及心尖段環(huán)向應(yīng)變均升高(P均0.05)。3)相關(guān)性分析:急性期左室收縮期GLS與E/Em、LVMI、C型反應(yīng)蛋白(C-reactive protein CRP)、紅細(xì)胞沉降率(erythrocyte sedimentation rate ESR)、白細(xì)胞(white blood cell WBC)、谷丙轉(zhuǎn)氨酶(alanine transaminase ALT)均呈負(fù)相關(guān)(r分別=-0.66、-0.61、-0.59、-0.67、-0.64、-0.69 P均0.05),與其它參數(shù)未見明顯相關(guān)性;亞急性期及恢復(fù)期左室GLS與其它變量均未見明顯相關(guān)性。二亞組分析結(jié)果1)與對照組相比,急性期冠狀動脈擴(kuò)張組收縮期左室GLS、GLSR、基底段縱向應(yīng)變、基底段縱向應(yīng)變率、中間段縱向應(yīng)變均低于對照組(P均0.05)。與冠狀動脈正常組相比,冠狀動脈擴(kuò)張組ESR、CRP、ALT及AST均升高(P均0.05),余參數(shù)比較未見明顯差異。2)與對照組相比,IVIG抵抗組左室Tei指數(shù)、E/Em及LVMI升高(P均0.05),收縮期左室GLS、GLSR、基底段縱向應(yīng)變、心尖段縱向應(yīng)變、基底段縱向應(yīng)變率、心尖段縱向應(yīng)變率均減低(P均0.05)。與IVIG應(yīng)答組相比,IVIG抵抗組左室Tei指數(shù)、E/Em、ALB、ESR、CRP、ALT及PLT均升高(P均0.05),左室GLS及基底段縱向應(yīng)變均減低(P均0.05),余參數(shù)比較未見明顯差異。3)ROC曲線分析結(jié)果:收縮期左室GLS絕對值16.8%為IVIG抵抗較好的預(yù)測值(曲線下面積0.79,靈敏度0.76,特異度0.63)。結(jié)論1.整體KD患者急性期收縮期左室應(yīng)變明顯減低,亞急性期開始恢復(fù),恢復(fù)期上升至正常范圍,該技術(shù)對合理指導(dǎo)臨床用藥及隨訪有重要的作用。2.盡管KD患者急性期常規(guī)超聲心動圖測得LVEF及LVFS值均在正常范圍,但收縮期左室GLS及GCS已出現(xiàn)減低,其可能是更能早期反映心肌損傷的敏感指標(biāo),2DSTI技術(shù)能對臨床早期診斷KD提供重要輔助診斷信息。3.急性期KD患者減低的收縮期左室GLS與升高的實(shí)驗(yàn)室炎性指標(biāo)呈負(fù)相關(guān),而未見與冠狀動脈擴(kuò)張相關(guān),提示急性期KD患者左室心肌收縮功能減低是心肌組織炎性損傷的結(jié)果,冠狀動脈擴(kuò)張可能不是急性期KD患者左室收縮功能受損加重的因素。4.IVIG抵抗患者心肌受損更嚴(yán)重,恢復(fù)時(shí)間較長,提示臨床治療時(shí)間、藥量及種類應(yīng)增加,2DSTI技術(shù)可能對IVIG抵抗患者預(yù)測有一定的幫助�？傊摷夹g(shù)在及時(shí)為臨床提供輔助診斷信息、指導(dǎo)用藥、降低冠狀動脈損傷發(fā)生率、遠(yuǎn)期隨訪等方面有重要的應(yīng)用價(jià)值。
[Abstract]:Objective to evaluate the changes of left ventricular systolic function in patients with Kawasaki disease (Kawasaki disease KD) (two dimensional tracking imaging 2DSTI) in different periods of Kawasaki disease (Kawasaki disease KD), and to analyze the correlation between the peak strain and strain rate of the left ventricle in acute systole and the laboratory index, and compare the coronary artery dilatation KD subgroup. And intravenous immunoglobulin (intravenous immunoglobulin IV IG) resisted the left ventricular systolic function of each subgroup with the left ventricular parameters and laboratory indexes of the corresponding antagonistic group, respectively, to obtain the left ventricular systolic peak value of IVIG resistance to KD patients through the subjects' working curve (receiver operating characteristics ROC). Methods from January 2015 to October 2016, 80 hospitalized patients with KD in the pediatric cardiology department of the Second Hospital Affiliated to Lanzhou University children's hospital were selected and further divided into the coronary artery dilatation subgroup (left, right coronary artery and left anterior descending branch with an internal diameter of Z 2.5), and IVIG resistance (continuous hair after IVIG treatment). The subgroup had a relapse and more than 36 hours after the heat or temperature decline. In the same period, 50 cases of age and sex were matched in our hospital. The normal children were treated with heart murmur, but the normal children were used as the control group. The routine echocardiography and 2DSTI technique were used in the acute phase (before IV IG), the subacute phase (1 weeks after IV IG) and the recovery period (IV IG). After 8 weeks, the conventional and systolic left ventricular overall peak longitudinal strain (systolic global longitudinal strain GLS) and strain rate (systolic global longitudinal strain rate GLSR) were obtained. Ate GCSR), the peak longitudinal strain and strain rate of each segment of the left ventricle in systole, the comparison of the cyclic strain and the strain rate of.1 in each segment: 1) the parameters of the whole KD patients were compared with the normal control group.2) the whole KD patients were compared with the parameters of.3) the parameters of the acute coronary artery dilatation subgroup were compared with the normal control group, and the coronary movement was compared with the normal control group. Comparison of the parameters of the pulse dilatation subgroup and the normal subgroup of the coronary artery.4) the parameters of the IVIG resistance subgroup in the acute phase were compared with the control group. The parameters of the IVIG resistance subgroup were compared with the IVIG response subgroup,.5) the laboratory index of the acute coronary artery dilatation subgroup was compared with the normal coronary artery subgroup, and the laboratory index of the acute phase IVIG resistance subgroup and the IVIG should be in the acute phase. The.2 correlation analysis: the correlation analysis of the overall left ventricular strain and strain rate in the acute phase of the acute phase of KD patients with the other indices analysis of the.3 ROC curve: the systolic left ventricular GLS curve in the acute phase IVIG resistance subgroup obtained the predictive value of IVIG resistance. Results a whole KD patient was compared with the normal control group, and the whole patient was in every period. Compared with the normal control group, the left ventricular Tei index, the left ventricular mass (left ventricular mass LVM) and the left ventricular mass index (left ventricular mass) (left ventricular mass) were compared with the normal control group (.1) in the acute phase of the systolic left ventricular GLS, GLSR and other indexes. Left coronary artery LCA, left coronary artery (right coronary artery RCA) and left anterior descending (left anterior descending LAD) branch increased in the early flow velocity / mitral annular spacer lateral tissue, the left anterior descending (left anterior descending LAD) branch increased, the difference was statistically significant (all 0.05). The subacute period was still higher (0.05), and the recovery period was still higher. There was no difference between the parameters. The left ventricular Tei index, LVM and LVMI in the subacute KD patients were lower than the acute phase (P 0.05), and the residual parameters were not significantly different from.2) 2DSTI. Compared with the control group, the left ventricular GLS, the longitudinal strain of the basal segment, the longitudinal strain of the middle segment, the GCS and the apical circumferential strain were reduced (P 0.05), and the subacute phase of the acute phase of KD patients. The longitudinal strain of GLS and middle segment in the left ventricle began to rise but still was low (P 0.05), and there was no significant difference between the parameters of the recovery period. Compared with the acute phase, the systolic left ventricular GLS, the longitudinal strain of the basal segment, the GCS and the apical circumferential strain increased (P 0.05).3) in the subacute phase of KD patients: the acute phase of the left ventricular systolic GLS and E/Em, LVMI, C. C-reactive protein CRP, erythrocyte sedimentation rate (erythrocyte sedimentation rate ESR), leukocyte (white blood cell WBC) and alanine aminotransferase are all negative correlation, and no significant correlation with other parameters; subacute phase and recovery period There was no significant correlation between left ventricular GLS and other variables. Two subgroup analysis 1. Compared with the control group, the left ventricular GLS, GLSR, the longitudinal strain of the basal segment, the longitudinal strain rate of the basal segment and the longitudinal strain of the middle segment were lower than the control group (P 0.05) in the acute phase of coronary artery dilatation. Compared with the normal coronary artery group, the coronary artery dilatation group was ESR, C RP, ALT and AST were all increased (P 0.05). Compared with the control group, the left ventricular Tei index in the IVIG resistance group, E/Em and LVMI increased (P 0.05), the systolic left ventricular GLS, the longitudinal strain of the basement segment, the apical longitudinal strain, the longitudinal strain rate of the basal segment, and the longitudinal strain rate of the apical segment decreased (0.05). Compared with the IVIG resistance group, the left ventricular Tei index, E/Em, ALB, ESR, CRP, ALT and PLT were all increased (P 0.05), the longitudinal strain of the left ventricular GLS and the basal segment decreased (P 0.05), and the residual parameter was not significantly different from the.3) curve analysis results: the systolic left ventricular absolute value 16.8% was a better prediction value (the area under the curve is 0.79, the sensitivity is 0.76, and the specificity is 0.76. Degree 0.63). Conclusion 1. KD patients with acute systolic left ventricular strain significantly decreased, subacute phase began to recover, and the recovery period increased to normal range. This technique had an important role in rational guidance for clinical medication and follow-up. Although the values of LVEF and LVFS in KD patients were measured in normal range of LVEF and LVFS in acute stage of acute phase, but the systolic left ventricular GL S and GCS have decreased. It may be a sensitive indicator of early myocardial damage. 2DSTI technology can provide important diagnostic information for early clinical diagnosis of KD..3. in the acute phase of KD patients with reduced systolic left ventricular GLS is negatively correlated with elevated laboratory inflammatory markers, but not associated with coronary artery dilatation, suggesting acute KD suffering. The decrease of systolic function in left ventricular myocardium is the result of inflammatory injury of myocardial tissue. Coronary dilatation may not be a factor of exacerbation of left ventricular systolic function in patients with acute KD,.4.IVIG resistance patients with more severe myocardial damage and longer recovery time suggest that the time of clinical treatment, the amount of drugs and types should be increased, and 2DSTI technology may be resistant to IVIG. In a word, the technique is of great value in providing auxiliary diagnosis information in time, guiding drug use, reducing the incidence of coronary artery injury, and long term follow-up.

【學(xué)位授予單位】：蘭州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R725.4;R540.45

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