本文關(guān)鍵詞： 三維斑點(diǎn)追蹤超聲心動圖 二維斑點(diǎn)追蹤超聲心動圖 左心室重構(gòu) ST段抬高型心肌梗死　出處：《廣州中醫(yī)藥大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：背景:二維(two-dimensional,2D)和三維(three-dimensional,3D)斑點(diǎn)追蹤超聲心動圖(speckle tracking echocardiography,STE)通過追蹤心肌上的"回聲斑點(diǎn)",而定量分析長軸、圓周及短軸方向上的心肌形變和運(yùn)動情況,反映心臟各個(gè)方向上的收縮功能。已有研究證實(shí)2D STE獲取的整體長軸應(yīng)變(global longitudinal strain,GLS)能夠預(yù)測急性心肌梗死(acute myocardial infraction,AMI)后左心室重構(gòu)。3D STE發(fā)展相對較晚,有關(guān)3D STE獲取的各應(yīng)變參數(shù)是否均有預(yù)測左心室重構(gòu)價(jià)值,目前尚不明確,并且不同方向應(yīng)變參數(shù)之間預(yù)測價(jià)值是否存在差異、在實(shí)際預(yù)測評估中3D模式是否優(yōu)于2D模式亦均未見報(bào)道。目的:以已行經(jīng)皮冠狀動脈介入診療術(shù)(percutaneous coronary intervention,PCI)的急性 ST 段抬高型心肌梗死(ST-elevation myocardial infarction,STEMI)患者為研究對象,探討3D STE衍生出來的多個(gè)方向的應(yīng)變參數(shù)對左心室重構(gòu)的預(yù)測價(jià)值,并將這些參數(shù)與2D GLS作比較,通過比較明確其中最佳的預(yù)測指標(biāo)及AMI后各個(gè)方向收縮功能的改變對左心室重構(gòu)的影響,探討二維和三維模式在臨床應(yīng)用中的差異,為臨床應(yīng)用STE進(jìn)行AMI后心室重構(gòu)預(yù)測提供依據(jù)。方法:入選2015年06月至2015年12月在廣州軍區(qū)廣州總醫(yī)院心血管內(nèi)科住院的STEMI患者共110例,平均年齡為54 ± 9歲,所有患者均行急診PCI治療開通罪犯血管(再灌注時(shí)間≤24小時(shí)),在PCI術(shù)后完成二維超聲心動圖檢查、2D STE和3D STE檢查以獲取常規(guī)超聲心動圖參數(shù)和應(yīng)變參數(shù),收集患者一般臨床資料,隨訪3月后再次復(fù)查常規(guī)超聲心動圖。AMI后左心室重構(gòu)主要表現(xiàn)為左心室整體擴(kuò)張,經(jīng)查閱文獻(xiàn),AMI后左心室重構(gòu)定義為3月后LVEDV增大20%,并按此標(biāo)準(zhǔn)分為左心室重構(gòu)組(簡稱重構(gòu)組)和左心室非重構(gòu)組(簡稱非重構(gòu)組)。結(jié)果:①經(jīng)過3個(gè)月隨訪,共有26名患者出現(xiàn)了左心室重構(gòu),占研究總?cè)藬?shù)的24%,重構(gòu)組和非重構(gòu)組組間一般臨床資料比較,重構(gòu)組罪犯血管為前降支的比例較非重構(gòu)組高(73.1%vs 48.8%,P=0.030),肌鈣蛋白I水平也較非重構(gòu)組顯著增高(11.11±6.75 vs 8.43 ±5.31,P=0.038),差異有統(tǒng)計(jì)學(xué)意義;超聲參數(shù)比較,重構(gòu)組2D GLS(-12.5±3.2 vs-15.0±3.1,P0.001)、3D GLS(-9.9±2.2 vs-13.1±2.7,P0.001)、3D 面積應(yīng)變(global area strain,GAS)(-20.3±3.9 vs-23.3±4.8,P=0.005)及 3D 徑向應(yīng)變(global radial strain,GRS)(29.0±7.4%vs 34.3±8.5%,P=0.007)受損程度均較非重構(gòu)組嚴(yán)重,差異有統(tǒng)計(jì)學(xué)意義,而3D圓周應(yīng)變(global circumferential strain,GCS)組間比較差異無統(tǒng)計(jì)學(xué)意義(P0.05)。②多因素邏輯回歸模型顯示,在分別校正單因素邏輯回歸中P0.1的一般臨床資料和超聲參數(shù)后,2D GLS(OR=1.36,P=0.002)、3D GLS(OR=1.82,P=0.001)、3D GAS(OR=1.18,P=0.010)及3D GRS(OR=0.90,P=0.007)是左心室重構(gòu)的獨(dú)立預(yù)測指標(biāo)。③受試者工作(receiver-operating characteristic,ROC)曲線分析顯示 2D GLS、3D GLS、3D GAS和3D GRS對左心室重構(gòu)具有預(yù)測價(jià)值(P0.05),各曲線下面積(area under the cure,AUC)分別為 0.72(95%CI:0.63-0.80)、0.82(95%CI:0.73-0.88)、0.68(95%CI:0.59-0.77)和 0.68(95%CI:0.58-0.77),而 3D GCS 無預(yù)測價(jià)值(P0.05),且 3D GLS 的 AUC 顯著大于 2D GLS、3D GAS 和 3D GRS(P0.05)。④相關(guān)性分析顯示 2D GLS(r=-0.393,P0.001)、3D GLS(r=-0.512,P0.001)、3D GCS(r =-0.674,P0.001)和 3D GAS(r =-0.667,P0.001)與 LVEF 呈負(fù)相關(guān),3D GRS與左心室射血分?jǐn)?shù)呈正相關(guān)(r =0.668,P0.001)。⑤兩種模式下檢查時(shí)間比較,2D STE圖像獲取時(shí)間(7.2± 1.6 vs 4.2± 1.4,P0.001)、分析時(shí)間(5.7±1.5vs4.7± 1.7,P=0.019)及總檢查時(shí)間(12.9±2.3 vs 8.9±2.0,P0.001)均比3D STE長。結(jié)論:我們的研究證實(shí)2D GLS、3D GLS、3D GAS和3D GRS均對AMI后3個(gè)月的左心室重構(gòu)具有預(yù)測價(jià)值,并且3D GLS優(yōu)于其他指標(biāo),是其中預(yù)測價(jià)值最高的指標(biāo),表明長軸方向的收縮功能受損對促進(jìn)左心室重構(gòu)具有重要意義。這項(xiàng)研究還表明,3D STE是一個(gè)更實(shí)用的STE技術(shù),有望替代2D STE應(yīng)用于AMI患者預(yù)后評估。
[Abstract]:Background: two dimensional (two-dimensional, 2D) and three (three-dimensional, 3D) speckle tracking echocardiography (speckle tracking, echocardiography, STE) by tracking the myocardial echo spots, and the quantitative analysis of myocardial deformation and long axis and short axis circumferential movement direction, reflecting the cardiac contractile function on each direction. Studies have confirmed the global longitudinal strain obtained by STE (global longitudinal 2D strain, GLS) to predict the acute myocardial infarction (acute myocardial infraction, AMI.3D) left ventricular remodeling after STE development relatively late, the strain parameters for 3D STE acquisition whether left ventricular remodeling had predictive value, it is not clear, and between the forecast strain parameters in different directions and whether there are differences in the actual value, forecast evaluation in 3D model is better than 2D model are reported. Objective: to percutaneous coronary intervention The diagnosis and treatment of (percutaneous coronary intervention, PCI) of acute ST elevation myocardial infarction (ST-elevation myocardial, infarction, STEMI) patients as the research object, the predictive value of strain parameters in multiple directions to explore 3D STE derivative on the left ventricular remodeling, and these parameters and 2D GLS were compared by comparing the clear effect one of the best predictors and AMI after each direction changes of contractile function of left ventricular remodeling, to explore the difference of 2D and 3D model in clinical application, ventricular remodeling after prediction provides the basis for the clinical application of STE AMI. Methods: a total of 06 months in 2015 to December 2015 in the hospital of cardiology Genenral Hospital of PLA Guangzhou Military Area STEMI patients in 110 cases, the average age was 54 + 9 years, all patients underwent emergency PCI treatment of criminals opened blood vessels (reperfusion time less than 24 hours), completed after PCI. Two dimensional echocardiography, 2D STE and 3D STE examination to obtain the conventional echocardiographic parameters and strain parameters, collected from patients with clinical data, follow-up after March to check again the conventional echocardiographic left ventricular remodeling after.AMI showed left ventricular dilatation, by review of the literature, AMI left ventricular remodeling after defined as after March the increase of LVEDV 20%, and according to the standards for left ventricular remodeling group (the reconstruction group) and non left ventricular remodeling group (non reconstruction group). Results: after 3 months of follow-up, a total of 26 patients had left ventricular remodeling, the total number of 24%, reconstruction group and non reconstruction between group comparison of the general clinical data, criminal vascular remodeling group proportion anterior descending than non reconstruction group (73.1%vs 48.8%, P=0.030), troponin I levels are lower than the non reconstruction group was significantly higher (11.11 + 8.43 + 6.75 vs 5.31, P= 0.038), there was statistically significant difference Yi; ultrasonic parameters, 2D GLS reconstruction group (-12.5 + 3.2 vs-15.0 + 3.1, P0.001), 3D GLS (-9.9 + 2.2 vs-13.1 + 2.7, P0.001), 3D (global area strain, the area of strain GAS (-20.3) + 3.9 vs-23.3 + 4.8, P=0.005) and 3D (global radial strain, radial strain GRS (34.3) 29 + 7.4%vs + 8.5%, P=0.007) was higher than the non damaged reconstruction group is serious, the difference was statistically significant, while the circumferential strain (Global circumferential strain 3D, GCS) there was no significant difference between groups (P0.05). The display logic regression model, the general clinical data and ultrasound parameters are corrected the single factor Logistic regression after P0.1 2D GLS (OR=1.36, P=0.002), 3D GLS (OR=1.82, P=0.001), 3D GAS (OR=1.18, P=0.010) and 3D GRS (OR=0.90, P=0.007) is an independent predictor of left ventricular remodeling. The subjects work (receiver-operating characteristic ROC) curve analysis showed that 2D GLS,3D GLS,3D GAS鍜，

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