分层应变技术评价非ST段抬高性急性冠状动脉综合征患者左心室心肌各层收缩功能的变化
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摘要
目的应用二维斑点追踪显像(2D-STI)技术获取可疑非ST段抬高性急性冠状动脉综合征(NSTE-ACS)患者左心室区域及整体纵向分层应变,探讨分层应变参数预测冠状动脉显著狭窄的价值。方法选取2016年9月至2017年1月苏北人民医院收治的疑诊NSTE-ACS的患者75例,所有患者均行冠状动脉造影,其中,对照组(冠状动脉无狭窄或狭窄率<50%)24例,冠状动脉粥样硬化性心脏病(简称冠心病)组51例。冠心病组患者根据冠状动脉是否闭塞分为冠状动脉狭窄组32例,冠状动脉闭塞组19例。应用Echo PAC软件分析二维动态图像获得左心室18节段收缩期纵向分层应变,计算心内膜下心肌、中层心肌及心外膜下心肌区域纵向应变(TLSendo、TLSmid、TLSepi)及左心室心内膜下心肌、中层心肌、心外膜下心肌整体纵向应变(GLSendo、GLSmid、GLSepi)。采用单因素方差分析比较3组患者左心室区域及整体心肌纵向分层应变参数差异,进一步组间两两比较采用LSD-t检验。以冠状动脉造影结果作为诊断冠状动脉明显狭窄(狭窄率≥50%)即冠心病的金标准,绘制不同参数预测冠状动脉明显狭窄的受试者工作特征(ROC)曲线。结果与对照组、冠状动脉狭窄组患者比较,冠状动脉闭塞组患者TLSendo、TLSmid、TLSepi及GLSendo、GLSmid、GLSepi均减低,且差异均有统计学意义(冠状动脉闭塞组vs对照组:t值分别为-5.819、-5.049、-4.845、-5.955、-5.036、-4.724,P均<0.01;冠状动脉闭塞组vs冠状动脉狭窄组:t值分别为-2.983、-3.059、-2.903、-2.989、-3.192、-3.387,P均<0.01);与对照组患者比较,冠状动脉狭窄组患者仅TLSendo及GLSendo减低,且差异均有统计学意义(t值分别为-3.981、-4.164,P均<0.01);对照组、冠状动脉狭窄组、冠状动脉闭塞组患者TLSendo、TLSmid、TLSepi及GLSendo、GLSmid、GLSepi均呈梯度递减,但仅对照组患者3层间两两比较差异有统计学意义(TLSepi vs TLSendo、GLSepi vs GLSendo:t值均为-10.083,P均<0.01;TLSepi vs TLSmid、GLSepi vs GLSmid:t值均为-4.559,P均<0.01;TLSmid vs TLSendo、GLSmid vs GLSendo:t值均为-5.549,P均<0.01);对照组、冠状动脉狭窄组、冠状动脉闭塞组患者左心室心内膜下心肌区域及整体纵向应变与心外膜下心肌区域及整体纵向应变绝对值差值(?TLS及?GLS)逐渐减小,且差异有统计学意义(冠状动脉闭塞组vs对照组:t值分别为6.915、7.489,P均<0.01;冠状动脉狭窄组vs对照组:t值分别为4.923、7.202,P均<0.01;冠状动脉闭塞组vs冠状动脉狭窄组?TLS:t值为2.250,P<0.05),提示心内膜下心肌功能的显著受损。ROC曲线显示,GLSendo及TLSendo预测冠状动脉明显狭窄的曲线下面积最大,优于中层心肌、心外膜下心肌应变参数及总体心肌应变参数。结论可疑NSTE-ACS中冠心病患者左心室各层心肌收缩功能不同程度减低,尤以心内膜下心肌减低最显著,2D-STI技术获取的纵向分层应变参数可用于定量评价冠心病患者左心室各层心肌区域及整体收缩功能受损差异,可用于预测冠状动脉显著狭窄。
Objective To analyze territorial and global longitudinal layer-specific strain of left ventricle by two-dimensional speckle tracking imaging(2 D-STI) in patients with suspected non-ST-elevation acute coronary syndrome(NSTE-ACS) and to explore the value of layer-specific strain parameters for prediction of significant coronary artery stenosis. Methods Seventy-five patients with suspected NSTE-ACS in People′s Hosptial of Subei from September 2016 to January 2017 were enrolled and all patients underwent coronary arteriography(CAG). Among them, there were 24 subjects in control group(coronary artery without stenosis or stenosis rate < 50%) and 51 subjects in coronary atherosclerotic heart disease group(coronary heart disease, CHD). According to whether coronary artery occlusion, the CHD group was divided into coronary stenosis group(32 subjects) and coronary occlusion group(19 subjects). Using Echo PAC software, two-dimensional dynamic images were analyzed to obtain left ventricle 18-segment systolic longitudinal layer-specific strain and to calculate the territorial longitudinal strain(TLS) of endocadium, mid-myocardium and epicardium(TLSendo, TLSmid, TLSepi) and left ventricle global longitudinal strain(GLS) of endocadium, mid-myocardium and epicardium(GLSendo, GLSmid, GLSepi). The differences of left ventricle territorial and global longitudinal layer-specific strain parameters among 3 groups were compared by one-way analysis of variance and the differences between two groups were compared by LSD-t test. The receiver operating characteristic(ROC) curve of each parameter was constructed to predict significant coronary stenosis by using the results of CAG as the gold standard. Results Compared with control group and coronary stenosis group, TLSendo, TLSmid, TLSepi and GLSendo, GLSmid, GLSepi all decreased in patients with coronary occlusion, and the differences were statistically significant(coronary occlusion group vs. control group: t values were-5.819,-5.049,-4.845,-5.955,-5.036 and-4.724, respectively, P values were all less than 0.01; coronary occlusion group vs. coronary stenosis group: t values were-2.983,-3.059,-2.903,-2.989,-3.192 and-3.387, respectively, P values were all less than 0.01). And compared with control group, only TLSendo and GLSendo decreased in patients with coronary stenosis, and the differences were statistically significant(t values were-3.981 and-4.164, respectively, P values were all less than 0.01). TLSendo, TLSmid, TLSepi and GLSendo, GLSmid, GLSepi showed a gradient decrease in all 3 groups, but only in the control group the comparison between two of the three layers showed statistically significant differences(TLSepi vs. TLSendo, GLSepi vs. GLSendo: t values were both-10.083, P values were all less than 0.01; TLSepi vs. TLSmid, GLSepi vs. GLSmid: t values were both-4.559, P values were all less than 0.01; TLSmid vs. TLSendo, GLSmid vs. GLSendo: t values were both-5.549, P values were all less than 0.01). The absolute differences between endocardial and epicardial TLS and GLS(?TLS and ?GLS) decreased gradually from the control group, to coronary stenosis group and to coronary occlusion group, and the differences were statistically significant(coronary occlusion group vs. control group: t values were 6.915 and 7.489, respectively, P values were all less than 0.01; coronary stenosis group vs. control group: t values were 4.923 and 7.202, respectively, P values were all less than 0.01; ?TLS of patients in the coronary occlusion group vs. coronary stenosis group: t value was 2.250, P value was less than 0.05), which reflected a pronounced decrease in endocardial function. By ROC curve analysis, GLSendo and TLSendo showed the highest area under the curve in predicting significant coronary artery stenosis, which were better than strain parameters of mid-myocardium, epicardium and the entire wall thickness of the myocardium. Conclusions Left ventricle showed systolic dysfunction in all three layers in suspected NSTE-ACS patients with CHD, especially the endocardium. The longitudinal layer-specific strain parameters by 2 D-STI can be used for quantitative evaluation of the territorial and global systolic dysfunction differences of left ventricle in all layers in suspected NSTE-ACS patients with CHD, which can also be used for prediction of significant coronary artery stenosis.
Objective To analyze territorial and global longitudinal layer-specific strain of left ventricle by two-dimensional speckle tracking imaging(2 D-STI) in patients with suspected non-ST-elevation acute coronary syndrome(NSTE-ACS) and to explore the value of layer-specific strain parameters for prediction of significant coronary artery stenosis. Methods Seventy-five patients with suspected NSTE-ACS in People′s Hosptial of Subei from September 2016 to January 2017 were enrolled and all patients underwent coronary arteriography(CAG). Among them, there were 24 subjects in control group(coronary artery without stenosis or stenosis rate < 50%) and 51 subjects in coronary atherosclerotic heart disease group(coronary heart disease, CHD). According to whether coronary artery occlusion, the CHD group was divided into coronary stenosis group(32 subjects) and coronary occlusion group(19 subjects). Using Echo PAC software, two-dimensional dynamic images were analyzed to obtain left ventricle 18-segment systolic longitudinal layer-specific strain and to calculate the territorial longitudinal strain(TLS) of endocadium, mid-myocardium and epicardium(TLSendo, TLSmid, TLSepi) and left ventricle global longitudinal strain(GLS) of endocadium, mid-myocardium and epicardium(GLSendo, GLSmid, GLSepi). The differences of left ventricle territorial and global longitudinal layer-specific strain parameters among 3 groups were compared by one-way analysis of variance and the differences between two groups were compared by LSD-t test. The receiver operating characteristic(ROC) curve of each parameter was constructed to predict significant coronary stenosis by using the results of CAG as the gold standard. Results Compared with control group and coronary stenosis group, TLSendo, TLSmid, TLSepi and GLSendo, GLSmid, GLSepi all decreased in patients with coronary occlusion, and the differences were statistically significant(coronary occlusion group vs. control group: t values were-5.819,-5.049,-4.845,-5.955,-5.036 and-4.724, respectively, P values were all less than 0.01; coronary occlusion group vs. coronary stenosis group: t values were-2.983,-3.059,-2.903,-2.989,-3.192 and-3.387, respectively, P values were all less than 0.01). And compared with control group, only TLSendo and GLSendo decreased in patients with coronary stenosis, and the differences were statistically significant(t values were-3.981 and-4.164, respectively, P values were all less than 0.01). TLSendo, TLSmid, TLSepi and GLSendo, GLSmid, GLSepi showed a gradient decrease in all 3 groups, but only in the control group the comparison between two of the three layers showed statistically significant differences(TLSepi vs. TLSendo, GLSepi vs. GLSendo: t values were both-10.083, P values were all less than 0.01; TLSepi vs. TLSmid, GLSepi vs. GLSmid: t values were both-4.559, P values were all less than 0.01; TLSmid vs. TLSendo, GLSmid vs. GLSendo: t values were both-5.549, P values were all less than 0.01). The absolute differences between endocardial and epicardial TLS and GLS(?TLS and ?GLS) decreased gradually from the control group, to coronary stenosis group and to coronary occlusion group, and the differences were statistically significant(coronary occlusion group vs. control group: t values were 6.915 and 7.489, respectively, P values were all less than 0.01; coronary stenosis group vs. control group: t values were 4.923 and 7.202, respectively, P values were all less than 0.01; ?TLS of patients in the coronary occlusion group vs. coronary stenosis group: t value was 2.250, P value was less than 0.05), which reflected a pronounced decrease in endocardial function. By ROC curve analysis, GLSendo and TLSendo showed the highest area under the curve in predicting significant coronary artery stenosis, which were better than strain parameters of mid-myocardium, epicardium and the entire wall thickness of the myocardium. Conclusions Left ventricle showed systolic dysfunction in all three layers in suspected NSTE-ACS patients with CHD, especially the endocardium. The longitudinal layer-specific strain parameters by 2 D-STI can be used for quantitative evaluation of the territorial and global systolic dysfunction differences of left ventricle in all layers in suspected NSTE-ACS patients with CHD, which can also be used for prediction of significant coronary artery stenosis.
引文
1 Damman P,van GN,Wallentin L,et al.Timing of angiography with a routine invasive strategy and long-term outcomes in non-ST-segment elevation acute coronary syndrome:a collaborative analysis of individual patient data from the FRISC II(Fragmin and Fast Revascularization During Instability in Coronary Artery Disease),ICTUS(Invasive Versus Conservative Treatment in Unstable Coronary Syndromes),and RITA-3(Intervention Versus Conservative Treatment Strategy in Patients With Unstable Angina or Non-ST Elevation Myocardial Infarction)Trials[J].JACC Cardiovasc Interv,2012,5(2):191-199.
2 Duncker DJ,Traverse JH,Ishibashi Y,et al.Effect of NO on transmural distribution of blood flow in hypertrophied left ventricle during exercise[J].Am J Physiol,1999,276(4):H1305-H1312.
3 Lang RM,Badano LP,Mor-Avi V,et al.Recommendations for cardiac chamber quantification by echocardiography in adults:an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging[J].J Am Soc Echocardiogr,2015,28(1):1-39.
4 Bassand JP,Hamm CW,Ardissino D,et al.Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes[J].Eur Heart J,2007,28(13):1598-1660.
5 Abbate A,Vetrovec G,Crea F.Low diagnostic yield of elective coronary angiography[J].N Engl J Med,2010,363(1):92-93.
6 Adamu U,Schmitz F,Becker M,et al.Advanced speckle tracking echocardiography allowing a three-myocardial layer-specifc analysis of deformation parameters[J].Eur J Echocardiogr,2009,10(2):303-308.
7 Leitman M,Lysiansky M,Lysyansky P,et al.Circumferential and longitudinal strain in 3 myocardial layers in normal subjects and in patients with regional left ventricular dysfunction[J].J Am Soc Echocardiogr,2010,23(1):64-70.
8史静,潘翠珍,舒先红,等.二维斑点追踪显像技术定量评价正常成年人左心室心肌分层应变[J].中华超声影像学杂志,2015,24(5):378-381.
9 Xie MY,Yin JB,Lv Q,et al.Assessment of the left ventricular systolic function in multi-vessel coronary artery disease with normal wall motion by two dimensional speckle tracking echocardiography[J].Eur Rev Med Pharmacol Sci,2015,19(20):3928-3934.
10 Biering-S鴕ensen T,Hoffmann S,Mogelvang R,et al.Myocardial strain analysis by 2-dimensional speckle tracking echocardiography improves diagnostics of coronary artery stenosis in stable angina pectoris[J].Circ Cardiovasc Imaging,2014,7(1):58-65.
11 Zuo H,Yan J,Zeng H,et al.Diagnostic power of longitudinal strain at rest for the detection of obstructive coronary artery disease in patients with type 2 diabetes mellitus[J].Ultrasound Med Biol,2015,41(1):89-98.
12 Sarvari SI,Haugaa KH,Zahid W,et al.Layer-specific quantification of myocardial deformation by strain echocardiography may reveal significant CAD in patients with non-ST-segment elevation acute coronary syndrome[J].JACC Cardiovasc Imaging,2013,6(5):535-544.
13 Zhang L,Wu WC,Ma H,et al.Usefulness of layer-specific strain for identifying complex CAD and predicting the severity of coronary lesions in patients with non-ST-segment elevation acute coronary syndrome:Compared with Syntax score[J].Int J Cardiol,2016,223(11):1045-1052.
14 Liu C,Li J,Ren M,et al.Multilayer longitudinal strain at rest may help to predict signifcant stenosis of the left anterior descending coronary artery in patients with suspected non-ST-elevation acute coronary syndrome[J].Int J Cardiovasc Imaging,2016,32(12):1675-1685.
15 Reimer KA,Jennings RB.The″wavefront phenomenon″of myocardial ischemic cell death.Ⅱ.Transmural progression of necrosis within the framework of ischemic bed size(myocardium at risk)and collateral flow[J].Lab Invest,1979,40(6):633-644.
2 Duncker DJ,Traverse JH,Ishibashi Y,et al.Effect of NO on transmural distribution of blood flow in hypertrophied left ventricle during exercise[J].Am J Physiol,1999,276(4):H1305-H1312.
3 Lang RM,Badano LP,Mor-Avi V,et al.Recommendations for cardiac chamber quantification by echocardiography in adults:an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging[J].J Am Soc Echocardiogr,2015,28(1):1-39.
4 Bassand JP,Hamm CW,Ardissino D,et al.Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes[J].Eur Heart J,2007,28(13):1598-1660.
5 Abbate A,Vetrovec G,Crea F.Low diagnostic yield of elective coronary angiography[J].N Engl J Med,2010,363(1):92-93.
6 Adamu U,Schmitz F,Becker M,et al.Advanced speckle tracking echocardiography allowing a three-myocardial layer-specifc analysis of deformation parameters[J].Eur J Echocardiogr,2009,10(2):303-308.
7 Leitman M,Lysiansky M,Lysyansky P,et al.Circumferential and longitudinal strain in 3 myocardial layers in normal subjects and in patients with regional left ventricular dysfunction[J].J Am Soc Echocardiogr,2010,23(1):64-70.
8史静,潘翠珍,舒先红,等.二维斑点追踪显像技术定量评价正常成年人左心室心肌分层应变[J].中华超声影像学杂志,2015,24(5):378-381.
9 Xie MY,Yin JB,Lv Q,et al.Assessment of the left ventricular systolic function in multi-vessel coronary artery disease with normal wall motion by two dimensional speckle tracking echocardiography[J].Eur Rev Med Pharmacol Sci,2015,19(20):3928-3934.
10 Biering-S鴕ensen T,Hoffmann S,Mogelvang R,et al.Myocardial strain analysis by 2-dimensional speckle tracking echocardiography improves diagnostics of coronary artery stenosis in stable angina pectoris[J].Circ Cardiovasc Imaging,2014,7(1):58-65.
11 Zuo H,Yan J,Zeng H,et al.Diagnostic power of longitudinal strain at rest for the detection of obstructive coronary artery disease in patients with type 2 diabetes mellitus[J].Ultrasound Med Biol,2015,41(1):89-98.
12 Sarvari SI,Haugaa KH,Zahid W,et al.Layer-specific quantification of myocardial deformation by strain echocardiography may reveal significant CAD in patients with non-ST-segment elevation acute coronary syndrome[J].JACC Cardiovasc Imaging,2013,6(5):535-544.
13 Zhang L,Wu WC,Ma H,et al.Usefulness of layer-specific strain for identifying complex CAD and predicting the severity of coronary lesions in patients with non-ST-segment elevation acute coronary syndrome:Compared with Syntax score[J].Int J Cardiol,2016,223(11):1045-1052.
14 Liu C,Li J,Ren M,et al.Multilayer longitudinal strain at rest may help to predict signifcant stenosis of the left anterior descending coronary artery in patients with suspected non-ST-elevation acute coronary syndrome[J].Int J Cardiovasc Imaging,2016,32(12):1675-1685.
15 Reimer KA,Jennings RB.The″wavefront phenomenon″of myocardial ischemic cell death.Ⅱ.Transmural progression of necrosis within the framework of ischemic bed size(myocardium at risk)and collateral flow[J].Lab Invest,1979,40(6):633-644.