本文選題：二維斑點(diǎn)追蹤超聲心動(dòng)圖 + 應(yīng)變率　； 參考：《北京協(xié)和醫(yī)學(xué)院》2014年博士論文

【摘要】：背景與目的：現(xiàn)已有充分證據(jù)證明心臟再同步化治療(CRT)對(duì)左室收縮功能的改善是有益的,但是CRT對(duì)舒張功能的影響尚存在爭(zhēng)論。二維斑點(diǎn)追蹤超聲心動(dòng)圖應(yīng)變率及解旋(untwisting)對(duì)舒張功能的評(píng)估價(jià)值得深入研究。我們研究的旨在應(yīng)用2D-STE技術(shù),結(jié)合目前常用的E/E’指標(biāo),探討CRT不同反應(yīng)程度患者2D-STE應(yīng)變率參數(shù)和解旋(untwisting)與左室舒張功能之間的關(guān)系。 方法：本研究包括70名實(shí)施心臟再同步化治療的心力衰竭患者。所有患者均符合心臟再同步化治療現(xiàn)有的納入標(biāo)準(zhǔn),并除外心房顫動(dòng)和經(jīng)胸超聲圖像質(zhì)量不佳患者。于心臟再同步化治療前及心臟再同步化治療后12個(gè)月分別采集二維斑點(diǎn)追蹤超聲心動(dòng)圖圖像。我們將病人分為如下3組：A組,CRT超聲心動(dòng)圖和臨床反應(yīng)組,即隨訪中左室收縮末容積減少≥15%；且6分鐘步行距離增加≥20%,或該試驗(yàn)沒(méi)有實(shí)施,在無(wú)死亡和心臟移植情況下,NYHA心功能分級(jí)好轉(zhuǎn)≥1級(jí)；B組,CRT僅臨床反應(yīng)組；C組,CRT無(wú)反應(yīng)組,既未達(dá)到超聲心動(dòng)圖反應(yīng)標(biāo)準(zhǔn),也未達(dá)到臨床反應(yīng)標(biāo)準(zhǔn)。以舒張?jiān)缙诙獍暄鞣逯盗魉俸投獍戥h(huán)峰值速度的比值(E/E’)作為衡量左心室充盈的指標(biāo)。應(yīng)用2D-STE技術(shù)獲取患者舒張期早期應(yīng)變率(LSRE、CSRE、RSRE和RotRE)和舒張晚期應(yīng)變率(LSRA、CSRA和RSRA和RotRA)、解旋(untwisting)參數(shù)(UTRIVR、UTRE)等反映舒張功能的參數(shù),觀察這些左室舒張功能參數(shù)于心臟再同步化治療不同反應(yīng)程度間變化差異。將2D-STE所得的評(píng)估舒張功能參數(shù)與E/E’比值進(jìn)行相關(guān)性分析。選擇有效參數(shù)計(jì)算受試者工作特征曲線(receiver operating characteristic curve,即ROC曲線)下面積。 結(jié)果：70名患者中,41名(58.6%)患者在12個(gè)月的隨訪中達(dá)到了超聲心動(dòng)圖和臨床反應(yīng)性的標(biāo)準(zhǔn)；15名(21.4%)患者為僅臨床反應(yīng)者；14名(20%)為無(wú)反應(yīng)者。在A組患者中觀察到大多數(shù)評(píng)估左室舒張功能的參數(shù)有所改善。B組部分常規(guī)舒張功能參數(shù)顯著性改善。而在C組患者觀察到逐漸惡化的E/E’值。將2D-STE所測(cè)得的舒張期應(yīng)變率參數(shù)與E/E’比值分別進(jìn)行線性相關(guān)分析,舒張期應(yīng)變率均呈負(fù)相關(guān),其中以LSRE的相關(guān)性最佳(r=-0.778,p0.01)。將解旋參數(shù)與E/E’比值分別進(jìn)行線性相關(guān)分析,均呈負(fù)相關(guān),其中以UTRIVR的相關(guān)性最佳(r=-0.837,p0.01)。以2D-STE所測(cè)舒張?jiān)缙趹?yīng)變率及解旋參數(shù)預(yù)測(cè)CRT超聲心動(dòng)圖反應(yīng)與否,繪制ROC曲線。UTRIVR預(yù)測(cè)CRT超聲心動(dòng)圖反應(yīng)性的ROC曲線下面積最大,為0.822(p=0.032)。UTRIVR≥11.41預(yù)測(cè)CRT超聲心動(dòng)圖反應(yīng)的敏感性為73%,特異性為75%。 結(jié)論：2D-STE的舒張期應(yīng)變率指標(biāo)和解旋參數(shù)可以準(zhǔn)確評(píng)估CRT不同反應(yīng)程度患者的舒張功能變化差異。其中UTRIVR與E/E’相關(guān)性優(yōu)于其他參數(shù),且與E/E’比值關(guān)系更密切,預(yù)測(cè)CRT超聲心動(dòng)圖反應(yīng)與否價(jià)值更大,可能作為評(píng)價(jià)舒張功能的更為敏感指標(biāo)。 目的：為了減少起搏器電極導(dǎo)線相關(guān)并發(fā)癥,相關(guān)研究人員開(kāi)發(fā)出了無(wú)導(dǎo)線起搏器。無(wú)導(dǎo)線起搏器的主要優(yōu)點(diǎn)是它可以經(jīng)皮植入多個(gè)位置,減少感染和血管阻塞等并發(fā)癥。本研究應(yīng)用RT-3D STE超聲心動(dòng)圖技術(shù),對(duì)兩組動(dòng)物的左心室整體功能進(jìn)行比較,探討無(wú)導(dǎo)線起搏器的安全性和可行性,并驗(yàn)證RT-3D STE參數(shù)對(duì)評(píng)估左室收縮功能的可行性和有效性。 方法：本研究對(duì)象為體重為45-55kg的中華小型豬。實(shí)驗(yàn)組動(dòng)物將依次植入2個(gè)無(wú)導(dǎo)線起搏器；對(duì)照組動(dòng)物將依次植入帶有2根電極導(dǎo)線的常規(guī)起搏器。上述裝置分次植入,植入間期為4周。在靜息狀態(tài)下,用三維斑點(diǎn)追蹤超聲心動(dòng)圖評(píng)估所有動(dòng)物左心室的整體三維應(yīng)變。縱向應(yīng)變、環(huán)形應(yīng)變、面積應(yīng)變和徑向應(yīng)變以百分?jǐn)?shù)來(lái)表示。同時(shí)于植入后1個(gè)月、3個(gè)月和6個(gè)月時(shí),評(píng)估無(wú)導(dǎo)線起搏器和常規(guī)起搏器起搏參數(shù)差異及工作狀態(tài)下與未工作狀態(tài)下左心室功能的變化。當(dāng)植入完設(shè)備隨訪6個(gè)月后,處死實(shí)驗(yàn)動(dòng)物后,取出心臟,暴露右心室內(nèi)無(wú)導(dǎo)線起搏裝置或電極導(dǎo)線。配合使用標(biāo)尺對(duì)右心室中上述裝置進(jìn)行拍照記錄。準(zhǔn)確測(cè)量每個(gè)植入裝置與心臟組織間形成的纖維粘連物的長(zhǎng)度。同時(shí)驗(yàn)證RT-3D STE參數(shù)對(duì)評(píng)估左室收縮功能的可行性和有效性,并結(jié)合目前常用的左室射血分?jǐn)?shù),分析RT-3D STE參數(shù)與它的相關(guān)性。 結(jié)果：兩組動(dòng)物一般情況及常規(guī)超聲心動(dòng)圖各項(xiàng)指標(biāo)均無(wú)顯著性差異。實(shí)驗(yàn)組和對(duì)照組的動(dòng)物在植入術(shù)前及術(shù)后縱向應(yīng)變、環(huán)形應(yīng)變、面積應(yīng)變和徑向應(yīng)變上沒(méi)有明顯的差別(P0.05)。在兩組試驗(yàn)動(dòng)物中,起搏器工作狀態(tài)和未工作狀態(tài)下,無(wú)導(dǎo)線起搏器組動(dòng)物左心室整體應(yīng)變值未見(jiàn)明顯差別,常規(guī)起搏器組左心室整體應(yīng)變值未見(jiàn)顯著性變化,組間對(duì)比未見(jiàn)有統(tǒng)計(jì)學(xué)意義差別。無(wú)導(dǎo)線起搏器的起搏參數(shù)隨著時(shí)間的延長(zhǎng)比較穩(wěn)定。在隨訪期間,無(wú)導(dǎo)線起搏器組無(wú)并發(fā)癥發(fā)生,常規(guī)起搏器組有1只豬(10%)發(fā)生1根導(dǎo)線脫位。RT-3D STE的三維應(yīng)變值參數(shù)在觀察者間及觀察者內(nèi)有較好的一致性。RT-3D STE與左室EF值的相關(guān)性：在所有的應(yīng)變值參數(shù)中,GAS與左室射血分?jǐn)?shù)有較高的相關(guān)性(r=0.914,p0.01)。組織結(jié)果顯示,無(wú)導(dǎo)線起搏器上的纖維組織明顯短于導(dǎo)線電極上的纖維組織(p0.05)。 結(jié)論：本動(dòng)物試驗(yàn)初步驗(yàn)證了單腔無(wú)導(dǎo)線起搏器是安全、可行的,因此可以把無(wú)導(dǎo)線起搏器作為一種替代技術(shù),特別是對(duì)于患導(dǎo)線相關(guān)并發(fā)癥風(fēng)險(xiǎn)較高的患者提供幫助。同時(shí)本研究驗(yàn)證了RT-3D STE技術(shù)評(píng)估左心室收縮功能的有效性,證實(shí)了GAS可作為除EF值以外評(píng)估左室收縮功能的可靠指標(biāo)。
[Abstract]:Background and purpose: there is sufficient evidence to prove that cardiac resynchronization therapy (CRT) is beneficial to the improvement of left ventricular systolic function, but the effect of CRT on diastolic function is still controversial. The value of strain rate and untwisting for diastolic function is studied in depth. Our aim is to study The relationship between the 2D-STE strain rate parameters of the patients with different degree of reaction of CRT and the diastolic function of the left ventricle (untwisting) and the left ventricular diastolic function were investigated by using the 2D-STE technique combined with the current E/E 'index.
Methods: This study included 70 heart failure patients who performed cardiac resynchronization therapy. All patients were in line with the existing inclusion criteria for cardiac resynchronization therapy, with the exception of patients with atrial fibrillation and transthoracic ultrasound. Two dimensional spots were collected before and 12 months after cardiac resynchronization therapy and cardiac resynchronization therapy. Point tracking echocardiography images. We divided the patients into 3 groups: group A, CRT echocardiography and clinical response group, that is, the left ventricular end systolic volume decreased more than 15% in the follow-up, and the 6 minute walk distance increased more than 20%, or the test was not implemented. In the absence of death and heart transplantation, the NYHA cardiac function classification was better than 1; group B, CRT only The clinical response group, the C group, the CRT non response group, did not reach the standard of echocardiography, and did not reach the standard of clinical response. The index of left ventricular filling was measured by the ratio of peak flow peak velocity of mitral valve and mitral annular peak velocity (E/E ') at early diastolic velocity (E/E'). The early strain rate of the diastolic phase (LSRE, CSRE, R) was obtained by 2D-STE technique. SRE and RotRE) and late diastolic strain rates (LSRA, CSRA and RSRA and RotRA), parameter of LSRA (UTRIVR, UTRE) and other parameters reflecting diastolic function, and observe the differences between the diastolic function parameters of these left ventricular diastolic functions in the different degree of reaction in the treatment of cardiac resynchronization. The assessment of the diastolic function parameters obtained by 2D-STE is related to the E/E 'ratio. Sex analysis. Select effective parameters to calculate the area under the receiver operating characteristic curve (ROC curve).
Results: of the 70 patients, 41 (58.6%) patients reached the criteria of echocardiography and clinical responsiveness at 12 months of follow-up; 15 (21.4%) patients were only clinical responders; 14 (20%) were non responders. In the group A, most of the parameters for assessing left ventricular diastolic function improved in the group of.B partial normal diastolic functional parameters. The progressive E/E 'values were observed in the C group, and the diastolic strain rate parameters measured by 2D-STE were linearly correlated with the E/E' ratio, and the diastolic strain rates were negatively correlated, with the best correlation of LSRE (r=-0.778, P0.01). The linear correlation between the spin parameters and the ratio of E/E 'was carried out respectively. All of them were negatively correlated, with the best correlation of UTRIVR (r=-0.837, P0.01). The prediction of CRT echocardiography by the early diastolic strain rate and the spin parameter of 2D-STE was predicted by the ROC curve.UTRIVR to predict the largest area under the ROC curve of CRT echocardiography, and the 0.822 (p=0.032).UTRIVR > 11.41 predicts the CRT echocardiography. The sensitivity of the reaction was 73% and the specificity was 75%.
Conclusion: the diastolic strain rate index and spin parameter of 2D-STE can accurately assess the difference of diastolic function in patients with different degree of reaction of CRT. The correlation between UTRIVR and E/E 'is better than other parameters, and it is more closely related to the ratio of E/E'. It is more valuable to predict the response of CRT echocardiography, and may be used as a more diastolic function to evaluate the diastolic function. As a sensitive indicator.
Objective: to reduce the complications associated with the electrode wire related to the pacemaker, the researchers have developed a pacemaker without traverse. The main advantage of the pacemaker is that it can be implanted in multiple locations through the skin to reduce complications such as infection and vascular obstruction. This study applied the RT-3D STE echocardiography technique to the left ventricular overall work of two groups of animals. We can compare the safety and feasibility of non traverse pacemakers, and verify the feasibility and effectiveness of RT-3D STE parameters in evaluating left ventricular systolic function.
Methods: This study was a Chinese miniature pig with a weight of 45-55kg. In the experimental group, 2 non traverse pacemakers were implanted in the experimental group. The control group would implant a conventional pacemaker with 2 electrode conductors in turn. The above device was implanted in a sub stage and implanted in a interval of 4 weeks. The three-dimensional speckle tracking echocardiography was used in the resting state. The overall three-dimensional strain of the left ventricle of the animal. The longitudinal strain, ring strain, area strain and radial strain are expressed as a percentage. At the same time, 1 months, 3 months, and 6 months after implantation, the pacemaker and routine pacemaker pacing parameter difference and the change of left ventricular function under the working state and the non working state are evaluated. After 6 months of follow-up, the apparatus was executed, the heart was removed, the lead free pacing device or electrode in the right ventricle was exposed. With the use of a ruler, the above device was photographed. The length of the fibrous adhesion formed between each implant and the cardiac tissue was accurately measured. At the same time, the RT-3D STE parameters were verified to evaluate the left side. The feasibility and effectiveness of ventricular systolic function were analyzed, and the correlation between RT-3D STE parameters and left ventricular ejection fraction was analyzed.
Results: there was no significant difference in the general and conventional echocardiographic indexes between the two groups. There was no significant difference in the longitudinal strain, ring strain, area strain and radial strain before and after implantation (P0.05) in the experimental and control groups. In the two groups of experimental animals, the working state of pacemaker and the non working state were in the two groups of experimental animals. There was no significant difference in left ventricular overall strain value in the non traverse pacemaker group. There was no significant change in the overall left ventricular strain value in the routine pacemaker group. There was no significant difference between the groups. The pacemaker parameters of the pacemaker were more stable with the time. No complications occurred in the pacemaker group during the follow-up period. In the routine pacemaker group, there were 1 pigs (10%) with 1 traverse dislocations of.RT-3D STE. The correlation between.RT-3D STE and the left ventricular EF value was better in the observer and in the observer: in all the strain values, there was a higher correlation between GAS and left ventricular ejection fraction (r=0.914, P0.01). The fibrous tissue on the pacemaker is significantly shorter than the fibrous tissue on the wire electrode (P0.05).
Conclusion: this animal test preliminarily verified that the single cavern pacemaker is safe and feasible. Therefore, the traverse pacemaker can be used as an alternative technique, especially for patients with higher risk of lead related complications. This study validates the effectiveness of RT-3D STE technique in assessing left ventricular systolic function. GAS can be used as a reliable index for evaluating left ventricular systolic function besides EF value.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2014
【分類號(hào)】：R540.45;R541
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本文編號(hào)：2053641