本文選題：超聲心動描記術(shù) + 冠狀動脈��； 參考：《承德醫(yī)學(xué)院》2016年碩士論文

【摘要】：冠狀動脈粥樣硬化性心臟病,簡稱冠心病,多由冠狀動脈狹窄、痙攣或供血不足引發(fā)的心肌功能發(fā)生障礙而出現(xiàn)的心肌壞死、重構(gòu)等器質(zhì)性病變。1979年世界衛(wèi)生組織將冠心病分為5種臨床類型,即:無癥狀性心肌缺血、心絞痛、心肌梗死、缺血性心力衰竭及猝死。近年來冠心病發(fā)病年齡向年輕化發(fā)展,發(fā)病率呈現(xiàn)出了明顯的上升趨勢,嚴(yán)重威脅著患者的生命,嚴(yán)重增加了社會和家庭的負(fù)擔(dān)。因此,冠心病的早期發(fā)現(xiàn)、早期治療及定期隨訪尤為重要。目前,冠心病的診斷方法較多,應(yīng)用較普遍的有:(1)冠狀動脈造影及冠狀動脈加強CT:可以清晰顯示冠狀動脈病變情況,但是造影劑有明顯的腎毒性,不適用于長期的隨訪;(2)心電圖:部分心絞痛患者只有在心絞痛發(fā)作時才會有ST段的改變,且無特異性,當(dāng)病情緩解后,心電圖恢復(fù)正常,因此心電圖正常的患者并不能排除冠心病;(3)放射性核素檢查:可以觀察室壁的運動及左室射血分?jǐn)?shù),但是其費用較高且放射性核素對身體有較大傷害;(4)磁共振成像:準(zhǔn)確性好,可重復(fù)性高,但是無法進(jìn)行實時觀察,不能進(jìn)行床旁檢查;(5)超聲心動圖:無創(chuàng)、無輻射、費用低、安全、操作簡單、可反復(fù)使用、準(zhǔn)確率高,并可動態(tài)觀察等特點,優(yōu)于冠狀動脈加強CT、心肌核素顯像、心肌核磁共振等,另外超聲心動圖可以對危重、不適于移動的病人進(jìn)行床旁檢查,更適用于臨床。因此超聲心動圖是冠心病患者不可或缺的輔助檢查,對冠心病患者具有重要作用。第一部分RT3D-STI技術(shù)評價無RWMA冠狀動脈狹窄患者左心室整體舒張功能目的:應(yīng)用實時三維斑點追蹤成像(real-time three-dimensional specke tracking imaging,RT3D-STI)技術(shù)獲得左心室整體應(yīng)變顯像舒張功能指數(shù)(strain imaging diastolic index,SI-DI),評價無節(jié)段性室壁運動異常(regionalwallmotionabnormality,rwma)的冠狀動脈病變患者左室的整體舒張功能,探討rt3d-sti在早期診斷冠心病的價值。方法:根據(jù)冠狀動脈造影(coronaryangiography,cag)結(jié)果將擬診斷為冠心病(coronaryheartdisease,chd)但無rwma的92例患者分為2組:對照組即冠狀動脈無狹窄組,42例;病例組即冠狀動脈狹窄組,50例。經(jīng)胸超聲心動圖采集常規(guī)二維及三維全容積圖像,獲得常規(guī)參數(shù)二尖瓣舒張期血流頻譜的e峰(e)、二尖瓣環(huán)組織多普勒的e峰(e’)等及左心室收縮末期的整體縱向應(yīng)變(globlelongitudinalstrain,gls)、徑向應(yīng)變(globleradialstrain,grs)、面積應(yīng)變(globleareastrain,gas)、圓周應(yīng)變(globlecircumferentialstrain,gcs)及相應(yīng)方向舒張期前1/3時的應(yīng)變,進(jìn)而根據(jù)公式計算四個方向應(yīng)變顯像舒張指數(shù)(si-di),分析各個參數(shù)對冠狀動脈病變的診斷價值。結(jié)果:對照組和病例組兩組之間相比,常規(guī)參數(shù)e、e’等及三維應(yīng)變參數(shù)gls、grs、gcs、gas之間差異無統(tǒng)計學(xué)意義(p0.05);兩組之間縱向應(yīng)變顯像舒張指數(shù)(longitudinalstrainimagingdiastolicindex,l-si-di)、徑向應(yīng)變顯像舒張指數(shù)(radialstrainimagingdiastolicindex,r-si-di)、圓周應(yīng)變顯像舒張指數(shù)(circumferentialstrainimagingdiastolicindex,c-si-di)、面積應(yīng)變顯像舒張指數(shù)(areastrainimagingdiastolicindex,a-si-di)差異有統(tǒng)計學(xué)意義(p0.05);roc曲線表明l-si-di、r-si-di、a-si-di及c-si-di的靈敏性分別為90.5%、85.7%、81.0%、81.0%,特異性分別為82.0%、68.0%、78.0%、56.0%,l-si-di的特異度和靈敏度均最高;冠狀動脈gensini積分與l-si-di、r-si-di、a-si-di有相關(guān)性(p0.05),r分別為-0.706、-0.410、-0.547。結(jié)論:冠狀動脈狹窄患者左室整體舒張功能的減低較整體收縮功能早。rt-3d-sti技術(shù)明顯優(yōu)于常規(guī)二維超聲心動圖,并且可以定量評價冠狀動脈狹窄患者左室整體舒張功能,對冠心病的早期診斷有重要的預(yù)期作用。第二部分rt3d-sti技術(shù)評價無rwma冠狀動脈狹窄患者左心室局部舒張功能目的:應(yīng)用RT3D-STI技術(shù)獲得無RWMA的冠心病患者不同冠狀動脈供血區(qū)局部心肌各方向的SI-DI,評價左心室局部舒張功能,探討RT3D-STI技術(shù)對早期診斷冠狀動脈病變的部位和程度的價值。方法:擬診斷為CHD但無RWMA的患者140例,共420支冠狀動脈主要分支,根據(jù)CAG結(jié)果分為無冠狀動脈狹窄組,共101支、輕度冠狀動脈狹窄組(冠狀動脈狹窄50%),共112支、中度冠狀動脈狹窄組(冠狀動脈狹窄50%~75%),共95支、重度冠狀動脈狹窄組(冠狀動脈狹窄75%),共112支。經(jīng)胸采集動態(tài)三維全容積圖像,計算各方向SI-DI,分析其對冠狀動脈病變情況的診斷價值。結(jié)果:輕度冠狀動脈狹窄組A-SI-DI、L-SI-DI、R-SI-DI均低于無冠狀動脈狹窄組(P0.05);中度冠狀動脈狹窄組L-SI-DI、A-SI-DI、R-SI-DI及C-SI-DI均低于無冠狀動脈狹窄組(P0.05),A-SI-DI、L-SI-DI及C-SI-DI均低于輕度冠狀動脈狹窄組(P0.05);重度冠狀動脈狹窄組L-SI-DI、A-SI-DI、R-SI-DI及C-SI-DI均低于無冠狀動脈狹窄組和輕度冠狀動脈狹窄組(P0.05),A-SI-DI、L-SI-DI、R-SI-DI均低于中度冠狀動脈狹窄組(P0.05)。ROC曲線結(jié)果顯示L-SI-DI的靈敏度最高,是84.0%;A-SI-DI的特異度最高,是78.9%。結(jié)論:RT3D-STI技術(shù)對早期冠心病的發(fā)現(xiàn)和診斷有重要作用,缺血冠狀動脈供血區(qū)局部心肌的舒張功能減低的出現(xiàn)較收縮功能早,心肌舒張功能對心肌缺血更敏感,SI-DI能夠在一定程度上反映冠狀動脈的狹窄程度和部位。
[Abstract]:Coronary atherosclerotic heart disease, referred to as coronary heart disease (CHD), is divided into 5 types of clinical types of coronary heart disease (.1979), namely, asymptomatic myocardial ischemia, angina, myocardial infarction, and lack of coronary heart disease, due to myocardial dysfunction caused by coronary artery stenosis, spasticity or insufficiency of blood supply. Congestive heart failure and sudden death. In recent years, the age of coronary heart disease has developed to a young age. The incidence of coronary heart disease has shown an obvious upward trend, which seriously threatens the life of the patients and seriously increases the burden of society and family. Therefore, early detection of coronary heart disease, early treatment and regular follow-up are particularly important. More widely used: (1) coronary arteriography and coronary artery strengthening CT: can clearly show the coronary artery disease, but the contrast agent has obvious renal toxicity and is not suitable for long-term follow-up. (2) electrocardiogram (ECG): partial angina patients only have ST segment changes when angina pectoris are made, and no specificity, when the condition is relieved, The electrocardiogram was restored to normal, so the patients with normal electrocardiogram could not exclude coronary heart disease; (3) radionuclide examination: can observe the movement of the wall and the left ventricular ejection fraction, but the cost is higher and the radionuclide has greater harm to the body; (4) magnetic resonance imaging: the accuracy is good, the repeatability is high, but can not be observed in real time, but can not be observed in real time, no It can carry out bedside examination; (5) echocardiography: noninvasive, no radiation, low cost, safety, simple operation, repeated use, high accuracy, and dynamic observation, it is superior to coronary artery CT, myocardial radionuclide imaging, myocardial MRI and so on. Besides, ultrasound cardiogram can be used for bedside examination of critical, unsuitable patients, more suitable for bedside examination. Therefore, echocardiography is an indispensable auxiliary examination for patients with coronary heart disease and plays an important role in patients with coronary heart disease. Part 1 RT3D-STI technique is used to evaluate the overall left ventricular diastolic function of patients without RWMA coronary artery stenosis: the application of real-time 3D three-dimensional specke tracking imag (real-time three-dimensional specke tracking imag) Ing, RT3D-STI) technique obtained the left ventricular overall strain imaging diastolic function index (strain imaging diastolic index, SI-DI), evaluate the overall diastolic function of the left ventricle of patients with coronary artery disease without segmental ventricular wall movement (regionalwallmotionabnormality, RWMA), and explore the value of rt3d-sti in early diagnosis of coronary heart disease. The results of coronaryangiography (CAG) were made to be diagnosed as coronaryheartdisease (CHD), but 92 patients without RWMA were divided into 2 groups: the control group, that is, the coronary artery stenosis group, 42 cases, the case group, the coronary artery stenosis group, and the 50 cases. The conventional two and three dimensional full volume images were collected by transthoracic echocardiography, and the conventional parameters were obtained. E peak (E) of the mitral diastolic blood flow spectrum, e peak of Doppler (E ') in mitral annulus and the overall longitudinal strain (globlelongitudinalstrain, GLS) at the end of left ventricular systole, radial strain (globleradialstrain, GRS), area strain (globleareastrain, gas), circumferential strain (globlecircumferentialstrain, GCS) and corresponding diastole The strain of the pre phase 1/3, and then the four directional strain imaging diastolic index (si-di) was calculated according to the formula, and the diagnostic value of each parameter to the coronary artery disease was analyzed. Results: compared with the two groups in the control group and the case group, the difference between the conventional parameters e, e 'and the three dimensional strain parameters GLS, GRS, GCS, gas was not statistically significant (P0.05); between the two groups, the difference was not statistically significant. Longitudinal strain imaging diastolic index (longitudinalstrainimagingdiastolicindex, l-si-di), radial strain imaging diastolic index (radialstrainimagingdiastolicindex, r-si-di), circumferential strain imaging diastolic index (circumferentialstrainimagingdiastolicindex, c-si-di), area strain imaging diastolic index (areastrainimagingdiastolicindex) The difference was statistically significant (P0.05), and the ROC curve showed that the sensitivity of l-si-di, r-si-di, a-si-di and c-si-di were 90.5%, 85.7%, 81%, 81% respectively, and the specificity and specificity were the highest, respectively, and the specificity and sensitivity of l-si-di were the highest, and the Gensini integral of the coronary artery was correlated with l-si-di, r-si-di, and a-si-di. 0.706, -0.410, -0.547. conclusion: the reduction of left ventricular diastolic function in patients with coronary artery stenosis is better than that of the whole systolic function earlier than that of the conventional two-dimensional echocardiography, and it can quantitatively evaluate the left ventricular diastolic function in patients with coronary artery stenosis, which has an important expected effect on the early diagnosis of cor pulmonale. Second parts have an important expected effect on the early diagnosis of coronary heart disease. Rt3d-sti technique was used to evaluate the left ventricular diastolic function of left ventricular in patients with RWMA coronary artery stenosis. RT3D-STI technique was used to obtain SI-DI in different directions of local myocardium in different coronary artery blood supply areas without RWMA, to evaluate the local diastolic function of left ventricle, and to explore the location and course of early diagnosis of coronary artery disease by RT3D-STI technique. Methods: 140 patients who were diagnosed as CHD but without RWMA were divided into 420 branches of coronary artery, which were divided into no coronary artery stenosis group, 101 branches, 50% mild coronary stenosis group (50% coronary stenosis), 112 branches of moderate coronary artery stenosis (coronary artery stenosis 50%~75%), a total of 95 branches and severe coronary stenosis. The narrow group (coronary artery stenosis 75%), with a total of 112 branches. The dynamic three-dimensional full volume images were collected through the chest and the SI-DI was calculated in all directions. Results: the A-SI-DI, L-SI-DI, and R-SI-DI in the mild coronary artery stenosis group were lower than those without the coronary stenosis group (P0.05), and the moderate coronary stenosis group L-SI-DI, A-SI-DI, R-SI-. Both DI and C-SI-DI were lower than those without coronary artery stenosis (P0.05), A-SI-DI, L-SI-DI and C-SI-DI were lower than those in mild coronary stenosis group (P0.05), and L-SI-DI, A-SI-DI, R-SI-DI and C-SI-DI in severe coronary stenosis group were lower than those in no coronary stenosis group and mild coronary stenosis group (P0.05). The results of the arterial stenosis group (P0.05).ROC curve showed that the sensitivity of L-SI-DI was the highest, it was 84%, and the specificity of A-SI-DI was the highest. It was the 78.9%. conclusion: RT3D-STI technology had an important role in the detection and diagnosis of early coronary heart disease. The diastolic function of the local myocardium in the ischemic coronary artery supply area was earlier than that of the contractile function, and the cardiac diastolic function was in the heart. Myocardial ischemia is more sensitive. SI-DI can reflect the degree and location of coronary artery to a certain extent.

【學(xué)位授予單位】：承德醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2016
【分類號】：R541.4;R816.2

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本文編號：1859180