用应变和组织多普勒成像评价心功能
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摘要
第一部分用应变和组织多普勒成像评价猪心功能及与压力容量环结果比较
研究目的
用超声心动图无创性评价局部心肌的收缩舒张功能,为临床心脏功能快速、准确诊断提供依据仍是当前超声领域要解决的课题。本研究以“压力—容积环”作为金标准,比较几种负荷状态下左室功能的不同参数,探讨组织多普勒成像技术和应变成像技术评价心脏功能的价值。证实组织多普勒成像技术和超声应变成像技术可以作为评估心功能的手段,为进一步评价更为复杂的心脏手术的心功能变化提供参考资料。
方法
试验用10头麻醉猪,气管插管,机械通气。经颈动脉插入心导管至左心室,建立压力-容量环。经股静脉插管进入下腔静脉,充盈球囊阻断下腔静脉降低前负荷。经股动脉插管进入降主动脉,充盈球囊部分阻断降主动脉增加后负荷。分别采用增加麻醉剂量减弱心肌收缩力,注射肾上腺素加强心肌收缩力。分别在基础状态、改变心脏前后负荷、改变心肌收缩性状态下,经心导管插管测量血流动力学参数变化;用常规超声心动图测量左室容积流量改变;超声组织多普勒成像测量左室心肌的收缩、舒张速度;超声应变和应变率成像测量左室心肌的应变值和应变率。将超声测值与压力-容量环测值比较,同时比较不同血流动力学下超声测量指标的变化。
结果
1.不同血流动力学状态下超声测量左室不同心肌节段应变值与压力-容量环测量前负荷再充盈搏功(PRSW)测值相关良好(r=0.59～0.81)。
2.不同血流动力学状态下组织多普勒成像测量左室侧壁、室间隔、左室后壁不同心肌节段收缩运动速度与压力-容量环测量前负荷再充盈搏功(PRSW)测值相关良好(r=0.52～0.64)。
3.基础状态下室间隔和左室侧壁从心底至心尖长径应变值、室间隔与左室后壁短径应变值呈非同一性。
4.组织多普勒成像测量室间隔和左室侧壁从心底至心尖收缩期、舒张期峰值速度也不一致。
5.超声测量应变值和运动速度,随血流动力学状态变化而改变。
6.超声显像成功率,组织多普勒成像最高(94%),应变成像次之(86%～91%),应变率成像(23%)和斑点追踪较差(29%～41%)。
结论
1.超声应变成像和组织多普勒成像能够定量和准确评价静息状态和不同负荷状态下局部心肌的收缩功能。
2.静息状态下,左室壁侧壁与室间隔、左室后壁与室间隔不同节段应变值和收缩、舒张峰值速度非同一性。在改变心脏负荷以及改变心肌收缩力等不同血流动力学条件下,仍然保持这种差别的规律性,提示应变和组织多普勒成像指标属于负荷依赖性,在分析室壁节段运动异常时应考虑其规律性。
第二部分应变和应变率成像评价冠脉支架术后左心室收缩功能变化
研究目的
探讨应变和应变率成像技术在定量评估冠心病(CHD)患者冠状动脉支架置入术后左心室收缩功能变化的临床应用价值。
方法
选取心内科住院诊断为CHD并行冠脉支架术患者30例,男23例,女7例,年龄45-75岁,平均年龄55.75±9.03岁,分别在术前1天及术后7天进行常规超声心动图检查,用二维灰阶和M型超声观察左室室壁运动,用Simpson双平面法测量左室射血分数(EF);在超声组织速度成像(TVI)状态下获取心尖四腔、两腔、左室长轴切面动态图像,将室间隔、侧壁、前壁、下壁、前间隔和后壁分别按照基底段、中间段和心尖段划分为18个节段。观察经支架治疗室壁的基底段和中间段,测量其收缩期最大应变(ε)和最大应变率(SR)数值并与20例健康人相应节段心肌比较,同时分析冠心病患者冠脉血运重建前后经支架治疗心肌节段的应变(ε)和应变率(SR)变化及左室整体收缩功能(EF)变化。
结果
1.正常对照组240个被研究心肌节段,235个节段的应变和应变率—时间曲线的形态整体有一定的规律性,收缩期最大应变和收缩期最大应变率数值个体变化不大。其中95个节段(约40%)可检测到心电图T波后出现的代表室壁收缩后收缩(PSS)的应变率波形。
2.CHD患者术前被研究心肌节段共360个,二维和M型超声结合检出122个室壁运动异常节段,185个节段的应变和应变率—时间曲线失去正常形态,轮廓杂乱,波峰低小、消失甚至倒置,峰值较正常心肌节段明显降低(P＜0.05),被研究心肌节段中有160(85%)个节段出现收缩后收缩(PSS)波;左室射血分数(0.536±0.084)低于正常对照组(0.719±0.061),P＜0.05。
3.冠脉造影显示狭窄严重并经支架置入术治疗的缺血心肌节段共188个,术后观察和前后对比分析只研究这些节段。二维和M型超声显示的122个室壁运动异常节段中有102个节段与冠脉造影显示狭窄严重并支架术治疗的分支对应的供血区域一致,二维和M型结合检测缺血心肌灵敏度为54%,特异度为88%;185个应变和应变率异常节段中有172个节段与冠脉造影显示狭窄严重并支架术治疗的分支对应的供血区域一致,检出缺血心肌灵敏度为91%,特异度为92%。冠心病患者支架置入术后7天,102个室壁运动异常节段中有97个节段运动较前改善或恢复正常,172个术前应变和应变率—时间曲线波形异常的节段中有169个节段波形趋于正常,轮廓趋于整齐,原降低的峰值较治疗前明显上升(P＜0.05),但较正常心肌节段仍减低,160个出现PSS波的节段中有92个节段的PSS波消失或峰值降低。术后7天射血分数(0.582±0.079)比术前1天的射血分数(0.536±0.084)升高,p＜0.05。
结论
超声应变和应变率成像可识别冠心病患者缺血心肌节段,灵敏度和特异度均高于二维和M型超声观察室壁运动,能定量评价冠状动脉支架置入术前后左室壁局部心肌收缩功能的变化,客观评价冠脉支架置入术的疗效,判断冠心病患者临床预后。收缩后收缩可能是识别心肌缺血的一个较好指标。
Objective
There is currently no optimal method for quantifying regional myocardial systolic dysfunction by echocardiography.Tissue Doppler imaging(TDI)- derived strain rate and strain measurements are new quantitative indices of intrinsic cardiac deformation.The aim of this study was to validate and compare these new indices of regional cardiac function to measurements of pressure-volume loops as an independent gold standard.
Material and Methods
Animal Preparation
Ten male pigs weighing 23.4 to 30.2 kg were anesthetized,intubated,and mechanically ventilated.An ear vein was cannulated for infusion purposes.A balloon catheter was advanced into the inferior vena cava through the right femoral vein.The balloon was inflated to reduce venous return and decrease preload.The thoracic aorta was cannulated with a catheter in the right femoral artery.The aortic balloon was inflated to cause an occlusion and increase the afterload of LV.Insert jugular vein catheter to record right atrial pressure.A high-fidelity pressure catheter was advanced into the LV (retrograde from the right carotid artery through the aortic valve) to record pressure volume loop and recordings were taken at end expiration.From a surface ECG the heart rate was monitored.Double Desflurane decreases contractility and Infuse Adrenaline increase contractility.
echocardiography
In 10 anesthetized pigs,transthoracic ehocardiography was performed.All studies were acquired with the use of a Vivid 7 digital ultrasound scanner(GE Medical Systems). After views were optimized in fundamental mode,images were acquired in TDI mode. Both myocardial velocities and strain values could be assessed from the same heartbeat. Myocardial longitudinal strain was measured on apical four chamber view of left ventricle (LV) and myocardial radial strain was measured on parastemal short axis view of LV.3 cardiac cycles were stored in cineloop format.The studies were stored digitally for subsequent offline analysis.Analysis of strain imagines(SI) and TDI images was performed offline on a personal computer with the aid of a customized software package (Echopac,GE Medical Systems).Peak longitudinal strain was assessed from the basal, mid,and apical segments,using the same regions as for peak systolic myocardial velocity measurements.Peak radial strain and peak systolic myocardial velocity were measured from interventricular septum and posterior wall of LV.
Statistical Analysis
Values are expressed as the mean±SD.Comparisons between values by echocardiography and PV loop were performed by linear regression analysis.Differences between myocardial peak systolic strains and peak velocities in each myocardial segment were analyzed with paired Student's t tests.Comparisons of myocardial peak systolic strains and velocities at baseline and different hemodynamic were analyzed with one-way ANOVA methods.A value of P less than 0.05 was considered statistically significant.
Results
There is a good correlation between the echocardiographic values and PV loops.In normal condition,longitudinal strain and myocardial Doppler velocities decreased progressively from base to apex.Myocardial strain and Doppler velocities were changed under different hemodynamic conditions in all segments.Like myocardial Doppler velocities,strain is load-dependent.
Conclusions
Myocardial strain and velocity by Doppler echocardiography may represent a new, powerful method for quantifying regional myocardial function noninvasively in pigs under different conditions.
Objective
This study was done to estimate the left ventricular regional systolic function using strain and strain rate imaging in patients with coronary heart disease(CHD) before and after intracoronary stent implantation.
Material and methods
Thirty patients with coronary heart disease were scanned by conventional echocardiography and dynamic tissue velocity imaging(TVI) at the day before and the seventh day after intracoronary stent implantation,twenty healthy people as control.Left ventricular ejection fraction(LVEF) was measured by Simpson's method.The dynamic tissue velocity imagings(TVI) were obtained at apical four-chamber view,apical two-chamber view and apical longitudinal view.Septal,lateral,anterior,inferior, anteroseptal and posterior walls were divided into basal,mid and apical segments respectively.The systolic peak strain(ε) and strain rate(SR) were measured respectively for basal and middle segments of ischemic myocardium and compared with that of the controls.The relationship between strain and strain rate in different regional wall and contractile function were analyzed in patients with coronary heart disease before and after intracoronary stent implantation.
Results
(1) The shapes of strain and strain rate-time curve of 235/240 normal myocardial segments were regularity and the systolic peak value of strain and strain rate did not vary with individual.The postsystolic shortening(PSS) wave appeared in 95/240 segments.
(2) 360 LV segments were investigated in patients with coronary heart disease,and we found 122 segments with regional wall motion abnormalities by gray-scale two-dimensional and M-mode echocardiography.Compared with normal myocardium,the shapes of strain and strain rate-time curve of 185 segments before operation were deformed and the systolic peak value of strain and strain rate was lower than that of controls(P＜0.05).The postsystolic shortening(PSS) wave appeared in 160 segments before operation.LVEF(0.536±0.084)was lower than controls(0.719±0.061 ),P＜0.05.
(3) 188 LV ischemic myocardial segments were improved by intracoronary stent implantation and were investigated after operation.Among 122 segments with regional wall motion abnormalities demonstrated by two-dimensional and M-mode echocardiography,102 segments were accordance with angiographiy ischemic segments. Disceming ischemic myocardium by gray-scale two-dimensional and M-mode echocardiography was 54%sensitivity and 84%specificity.172/185 segments of strain and strain rate abnormalities were accordance with above-mentioned segments.The best cut-off was a value of over 20%normal reference value that predicted ischemic myocardial segments with a 91%sensitivity and 93%specificity.97/102 segments with wall motion abnormalities were improved at the seventh day after operation.The shapes of strain and strain rate-time curve of 169/172 ischemic myocardial segments at the seventh day after operation were nearly normal and the systolic peak value of strain and strain rate were higher than that before operation(P＜0.05).The PSS wave disappeared in 92/160 segments.LVEF at the seventh day after operation(0.582±0.079) were higher than that before operation(0.536±0.084),p＜0.05.
Conclusions
SI and SRI can differentiate abnormal perfusion segments from normal ones and can quantitive analyze the left ventricular regional myocardial functional changes.The postsystolic shortening(PSS) may be a fine index to discem ischemic myocardium.
研究目的
用超声心动图无创性评价局部心肌的收缩舒张功能,为临床心脏功能快速、准确诊断提供依据仍是当前超声领域要解决的课题。本研究以“压力—容积环”作为金标准,比较几种负荷状态下左室功能的不同参数,探讨组织多普勒成像技术和应变成像技术评价心脏功能的价值。证实组织多普勒成像技术和超声应变成像技术可以作为评估心功能的手段,为进一步评价更为复杂的心脏手术的心功能变化提供参考资料。
方法
试验用10头麻醉猪,气管插管,机械通气。经颈动脉插入心导管至左心室,建立压力-容量环。经股静脉插管进入下腔静脉,充盈球囊阻断下腔静脉降低前负荷。经股动脉插管进入降主动脉,充盈球囊部分阻断降主动脉增加后负荷。分别采用增加麻醉剂量减弱心肌收缩力,注射肾上腺素加强心肌收缩力。分别在基础状态、改变心脏前后负荷、改变心肌收缩性状态下,经心导管插管测量血流动力学参数变化;用常规超声心动图测量左室容积流量改变;超声组织多普勒成像测量左室心肌的收缩、舒张速度;超声应变和应变率成像测量左室心肌的应变值和应变率。将超声测值与压力-容量环测值比较,同时比较不同血流动力学下超声测量指标的变化。
结果
1.不同血流动力学状态下超声测量左室不同心肌节段应变值与压力-容量环测量前负荷再充盈搏功(PRSW)测值相关良好(r=0.59～0.81)。
2.不同血流动力学状态下组织多普勒成像测量左室侧壁、室间隔、左室后壁不同心肌节段收缩运动速度与压力-容量环测量前负荷再充盈搏功(PRSW)测值相关良好(r=0.52～0.64)。
3.基础状态下室间隔和左室侧壁从心底至心尖长径应变值、室间隔与左室后壁短径应变值呈非同一性。
4.组织多普勒成像测量室间隔和左室侧壁从心底至心尖收缩期、舒张期峰值速度也不一致。
5.超声测量应变值和运动速度,随血流动力学状态变化而改变。
6.超声显像成功率,组织多普勒成像最高(94%),应变成像次之(86%～91%),应变率成像(23%)和斑点追踪较差(29%～41%)。
结论
1.超声应变成像和组织多普勒成像能够定量和准确评价静息状态和不同负荷状态下局部心肌的收缩功能。
2.静息状态下,左室壁侧壁与室间隔、左室后壁与室间隔不同节段应变值和收缩、舒张峰值速度非同一性。在改变心脏负荷以及改变心肌收缩力等不同血流动力学条件下,仍然保持这种差别的规律性,提示应变和组织多普勒成像指标属于负荷依赖性,在分析室壁节段运动异常时应考虑其规律性。
第二部分应变和应变率成像评价冠脉支架术后左心室收缩功能变化
研究目的
探讨应变和应变率成像技术在定量评估冠心病(CHD)患者冠状动脉支架置入术后左心室收缩功能变化的临床应用价值。
方法
选取心内科住院诊断为CHD并行冠脉支架术患者30例,男23例,女7例,年龄45-75岁,平均年龄55.75±9.03岁,分别在术前1天及术后7天进行常规超声心动图检查,用二维灰阶和M型超声观察左室室壁运动,用Simpson双平面法测量左室射血分数(EF);在超声组织速度成像(TVI)状态下获取心尖四腔、两腔、左室长轴切面动态图像,将室间隔、侧壁、前壁、下壁、前间隔和后壁分别按照基底段、中间段和心尖段划分为18个节段。观察经支架治疗室壁的基底段和中间段,测量其收缩期最大应变(ε)和最大应变率(SR)数值并与20例健康人相应节段心肌比较,同时分析冠心病患者冠脉血运重建前后经支架治疗心肌节段的应变(ε)和应变率(SR)变化及左室整体收缩功能(EF)变化。
结果
1.正常对照组240个被研究心肌节段,235个节段的应变和应变率—时间曲线的形态整体有一定的规律性,收缩期最大应变和收缩期最大应变率数值个体变化不大。其中95个节段(约40%)可检测到心电图T波后出现的代表室壁收缩后收缩(PSS)的应变率波形。
2.CHD患者术前被研究心肌节段共360个,二维和M型超声结合检出122个室壁运动异常节段,185个节段的应变和应变率—时间曲线失去正常形态,轮廓杂乱,波峰低小、消失甚至倒置,峰值较正常心肌节段明显降低(P＜0.05),被研究心肌节段中有160(85%)个节段出现收缩后收缩(PSS)波;左室射血分数(0.536±0.084)低于正常对照组(0.719±0.061),P＜0.05。
3.冠脉造影显示狭窄严重并经支架置入术治疗的缺血心肌节段共188个,术后观察和前后对比分析只研究这些节段。二维和M型超声显示的122个室壁运动异常节段中有102个节段与冠脉造影显示狭窄严重并支架术治疗的分支对应的供血区域一致,二维和M型结合检测缺血心肌灵敏度为54%,特异度为88%;185个应变和应变率异常节段中有172个节段与冠脉造影显示狭窄严重并支架术治疗的分支对应的供血区域一致,检出缺血心肌灵敏度为91%,特异度为92%。冠心病患者支架置入术后7天,102个室壁运动异常节段中有97个节段运动较前改善或恢复正常,172个术前应变和应变率—时间曲线波形异常的节段中有169个节段波形趋于正常,轮廓趋于整齐,原降低的峰值较治疗前明显上升(P＜0.05),但较正常心肌节段仍减低,160个出现PSS波的节段中有92个节段的PSS波消失或峰值降低。术后7天射血分数(0.582±0.079)比术前1天的射血分数(0.536±0.084)升高,p＜0.05。
结论
超声应变和应变率成像可识别冠心病患者缺血心肌节段,灵敏度和特异度均高于二维和M型超声观察室壁运动,能定量评价冠状动脉支架置入术前后左室壁局部心肌收缩功能的变化,客观评价冠脉支架置入术的疗效,判断冠心病患者临床预后。收缩后收缩可能是识别心肌缺血的一个较好指标。
Objective
There is currently no optimal method for quantifying regional myocardial systolic dysfunction by echocardiography.Tissue Doppler imaging(TDI)- derived strain rate and strain measurements are new quantitative indices of intrinsic cardiac deformation.The aim of this study was to validate and compare these new indices of regional cardiac function to measurements of pressure-volume loops as an independent gold standard.
Material and Methods
Animal Preparation
Ten male pigs weighing 23.4 to 30.2 kg were anesthetized,intubated,and mechanically ventilated.An ear vein was cannulated for infusion purposes.A balloon catheter was advanced into the inferior vena cava through the right femoral vein.The balloon was inflated to reduce venous return and decrease preload.The thoracic aorta was cannulated with a catheter in the right femoral artery.The aortic balloon was inflated to cause an occlusion and increase the afterload of LV.Insert jugular vein catheter to record right atrial pressure.A high-fidelity pressure catheter was advanced into the LV (retrograde from the right carotid artery through the aortic valve) to record pressure volume loop and recordings were taken at end expiration.From a surface ECG the heart rate was monitored.Double Desflurane decreases contractility and Infuse Adrenaline increase contractility.
echocardiography
In 10 anesthetized pigs,transthoracic ehocardiography was performed.All studies were acquired with the use of a Vivid 7 digital ultrasound scanner(GE Medical Systems). After views were optimized in fundamental mode,images were acquired in TDI mode. Both myocardial velocities and strain values could be assessed from the same heartbeat. Myocardial longitudinal strain was measured on apical four chamber view of left ventricle (LV) and myocardial radial strain was measured on parastemal short axis view of LV.3 cardiac cycles were stored in cineloop format.The studies were stored digitally for subsequent offline analysis.Analysis of strain imagines(SI) and TDI images was performed offline on a personal computer with the aid of a customized software package (Echopac,GE Medical Systems).Peak longitudinal strain was assessed from the basal, mid,and apical segments,using the same regions as for peak systolic myocardial velocity measurements.Peak radial strain and peak systolic myocardial velocity were measured from interventricular septum and posterior wall of LV.
Statistical Analysis
Values are expressed as the mean±SD.Comparisons between values by echocardiography and PV loop were performed by linear regression analysis.Differences between myocardial peak systolic strains and peak velocities in each myocardial segment were analyzed with paired Student's t tests.Comparisons of myocardial peak systolic strains and velocities at baseline and different hemodynamic were analyzed with one-way ANOVA methods.A value of P less than 0.05 was considered statistically significant.
Results
There is a good correlation between the echocardiographic values and PV loops.In normal condition,longitudinal strain and myocardial Doppler velocities decreased progressively from base to apex.Myocardial strain and Doppler velocities were changed under different hemodynamic conditions in all segments.Like myocardial Doppler velocities,strain is load-dependent.
Conclusions
Myocardial strain and velocity by Doppler echocardiography may represent a new, powerful method for quantifying regional myocardial function noninvasively in pigs under different conditions.
Objective
This study was done to estimate the left ventricular regional systolic function using strain and strain rate imaging in patients with coronary heart disease(CHD) before and after intracoronary stent implantation.
Material and methods
Thirty patients with coronary heart disease were scanned by conventional echocardiography and dynamic tissue velocity imaging(TVI) at the day before and the seventh day after intracoronary stent implantation,twenty healthy people as control.Left ventricular ejection fraction(LVEF) was measured by Simpson's method.The dynamic tissue velocity imagings(TVI) were obtained at apical four-chamber view,apical two-chamber view and apical longitudinal view.Septal,lateral,anterior,inferior, anteroseptal and posterior walls were divided into basal,mid and apical segments respectively.The systolic peak strain(ε) and strain rate(SR) were measured respectively for basal and middle segments of ischemic myocardium and compared with that of the controls.The relationship between strain and strain rate in different regional wall and contractile function were analyzed in patients with coronary heart disease before and after intracoronary stent implantation.
Results
(1) The shapes of strain and strain rate-time curve of 235/240 normal myocardial segments were regularity and the systolic peak value of strain and strain rate did not vary with individual.The postsystolic shortening(PSS) wave appeared in 95/240 segments.
(2) 360 LV segments were investigated in patients with coronary heart disease,and we found 122 segments with regional wall motion abnormalities by gray-scale two-dimensional and M-mode echocardiography.Compared with normal myocardium,the shapes of strain and strain rate-time curve of 185 segments before operation were deformed and the systolic peak value of strain and strain rate was lower than that of controls(P＜0.05).The postsystolic shortening(PSS) wave appeared in 160 segments before operation.LVEF(0.536±0.084)was lower than controls(0.719±0.061 ),P＜0.05.
(3) 188 LV ischemic myocardial segments were improved by intracoronary stent implantation and were investigated after operation.Among 122 segments with regional wall motion abnormalities demonstrated by two-dimensional and M-mode echocardiography,102 segments were accordance with angiographiy ischemic segments. Disceming ischemic myocardium by gray-scale two-dimensional and M-mode echocardiography was 54%sensitivity and 84%specificity.172/185 segments of strain and strain rate abnormalities were accordance with above-mentioned segments.The best cut-off was a value of over 20%normal reference value that predicted ischemic myocardial segments with a 91%sensitivity and 93%specificity.97/102 segments with wall motion abnormalities were improved at the seventh day after operation.The shapes of strain and strain rate-time curve of 169/172 ischemic myocardial segments at the seventh day after operation were nearly normal and the systolic peak value of strain and strain rate were higher than that before operation(P＜0.05).The PSS wave disappeared in 92/160 segments.LVEF at the seventh day after operation(0.582±0.079) were higher than that before operation(0.536±0.084),p＜0.05.
Conclusions
SI and SRI can differentiate abnormal perfusion segments from normal ones and can quantitive analyze the left ventricular regional myocardial functional changes.The postsystolic shortening(PSS) may be a fine index to discem ischemic myocardium.
引文
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