心脏磁共振心功能指标评估肺动脉高压患者预后的价值
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摘要
目的探讨心脏磁共振(CMR)成像指标与肺动脉高压(PH)患者预后的关系。方法纳入我院经右心导管插入确诊并行CMR检查的PH患者90例,分析其CMR图像并计算心功能指标:右心室和左心室舒张末期容积指数(EDVI)、收缩末期容积指数(ESVI)、每搏输出量指数(SVI)、射血分数(EF),以及右房室瓣环收缩期位移(TAPSE)。随访终点为发生主要心血管不良事件(MACE)。采用两独立样本t检验对发生MACE患者(MACE组)与未发生MACE患者(non-MACE组)的CMR指标进行比较。采用Cox比例风险回归模型分析终点事件的独立预测因素,根据受试者工作特征(ROC)曲线获得的最佳截断值绘制Kaplan-Meier生存曲线。结果与non-MACE组相比,MACE组患者右心室EF、左心室SVI、TAPSE均降低[(27.00±9.92)%vs(32.68±11.34)%、(29.14±8.73)m L/m2 vs(35.41±11.59)m L/m2、(12.51±4.17)mm vs(16.04±7.37)mm],右心室EDVI和ESVI均升高[(139.72±48.70)mL/m2vs(116.07±44.79)mL/m2、(104.26±42.88)mL/m2vs(79.37±35.67)mL/m2],差异均有统计学意义(t=-2.065、-2.286、-2.089、2.076、2.668,P均<0.05)。多因素分析结果显示,左心室SVI、TAPSE是PH患者发生MACE的独立预测因素[风险比(HR)=0.942、0.904,P=0.039、0.022]。ROC曲线确定的左心室SVI、TAPSE的最佳截断值分别为30.27 mL/m2、15.65 mm,Kaplan-Meier生存分析结果示当LVSVI≤30.27 mL/m2、TAPSE≤15.65 mm时MACE发生率增加(P=0.001、0.019)。结论发生MACE的PH患者左心、右心功能均较差,TAPSE、左心室SVI可作为PH患者发生MACE的独立预测因素。
Objective To explore the effect of cardiac magnetic resonance(CMR) imaging parameters on prognosis of the patients with pulmonary hypertension(PH). Methods Ninety PH patients, who were diagnosed by right heart catheterization and received CMR examination in our hospital, were enrolled for this study. The cardiac functional parameters, including end-diastolic volume index(EDVI), end-systolic volume index(ESVI), stroke volume index(SVI)and ejection fraction(EF) of the right ventricle and left ventricle, and tricuspid annular plane systolic excursion(TAPSE),were analyzed. The study end-point was major adverse cardiovascular event(MACE). Two independent sample t test was used to analyze the differences of CMR parameters between MACE group and non-MACE group. Cox proportional hazards regression model was used to determine the independent predictors of end-point events. Kaplan-Meier survival curve was drawn based on the optimal cut-off value of receiver operating characteristic(ROC) curve. Results Compared with the non-MACE group, the right ventricular EF, left ventricular SVI and TAPSE were decreased in the MACE group([27.00±9.92]% vs [32.68±11.34]%, [29.14±8.73] mL/m2 vs [35.41±11.59] mL/m2 and [12.51±4.17] mm vs[16.04±7.37] mm), while the right ventricular EDVI and ESVI were increased([139.72±48.70] mL/m2 vs [116.07±44.79] mL/m2 and [104.26±42.88] mL/m2 vs [79.37±35.67] mL/m2), and the differences were significant(t=-2.065,-2.286,-2.089, 2.076 and 2.668, all P<0.05). Multivariate analysis showed that left ventricular SVI and TAPSE were independent predictors of MACE in the PH patients(hazard ratio [HR]=0.942 and 0.904, P=0.039 and 0.022). The optimal cut-off values of left ventricular SVI and TAPSE determined by ROC curve were 30.27 mL/m2 and 15.65 mm, respectively.Kaplan-Meier survival analysis showed that the incidence of MACE was significantly increased when left ventricular SVI≤30.27 mL/m2 or TAPSE≤15.65 mm(P=0.001 and 0.019). Conclusion The left and right heart functions of PH patients with MACE are poor. TAPSE and left ventricular SVI are the independent predictors of MACE in the PH patients.
Objective To explore the effect of cardiac magnetic resonance(CMR) imaging parameters on prognosis of the patients with pulmonary hypertension(PH). Methods Ninety PH patients, who were diagnosed by right heart catheterization and received CMR examination in our hospital, were enrolled for this study. The cardiac functional parameters, including end-diastolic volume index(EDVI), end-systolic volume index(ESVI), stroke volume index(SVI)and ejection fraction(EF) of the right ventricle and left ventricle, and tricuspid annular plane systolic excursion(TAPSE),were analyzed. The study end-point was major adverse cardiovascular event(MACE). Two independent sample t test was used to analyze the differences of CMR parameters between MACE group and non-MACE group. Cox proportional hazards regression model was used to determine the independent predictors of end-point events. Kaplan-Meier survival curve was drawn based on the optimal cut-off value of receiver operating characteristic(ROC) curve. Results Compared with the non-MACE group, the right ventricular EF, left ventricular SVI and TAPSE were decreased in the MACE group([27.00±9.92]% vs [32.68±11.34]%, [29.14±8.73] mL/m2 vs [35.41±11.59] mL/m2 and [12.51±4.17] mm vs[16.04±7.37] mm), while the right ventricular EDVI and ESVI were increased([139.72±48.70] mL/m2 vs [116.07±44.79] mL/m2 and [104.26±42.88] mL/m2 vs [79.37±35.67] mL/m2), and the differences were significant(t=-2.065,-2.286,-2.089, 2.076 and 2.668, all P<0.05). Multivariate analysis showed that left ventricular SVI and TAPSE were independent predictors of MACE in the PH patients(hazard ratio [HR]=0.942 and 0.904, P=0.039 and 0.022). The optimal cut-off values of left ventricular SVI and TAPSE determined by ROC curve were 30.27 mL/m2 and 15.65 mm, respectively.Kaplan-Meier survival analysis showed that the incidence of MACE was significantly increased when left ventricular SVI≤30.27 mL/m2 or TAPSE≤15.65 mm(P=0.001 and 0.019). Conclusion The left and right heart functions of PH patients with MACE are poor. TAPSE and left ventricular SVI are the independent predictors of MACE in the PH patients.
引文
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[18]HOETTE S,CREUZéN,GüNTHER S,MONTANID,SAVALE L,JA?S X,et al.RV fractional area change and TAPSE as predictors of severe right ventricular dysfunction in pulmonary hypertension:a CMR study[J].Lung,2018,196:157-164.
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[21]王丹,张璋,杨帆,张乐,杨振文,任雯,等.不同室间隔形态肺高血压患者的心室功能特点:CMR初步研究[J].中国肺癌杂志,2018,21:397-402.
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[23]ZHAO J,WANG Q,LIU Y,TIAN Z,GUO X,WANG H,et al.Clinical characteristics and survival of pulmonary arterial hypertension associated with three major connective tissue diseases:a cohort study in China[J].Int J Cardiol,2017,236:432-437.
[24]CHUNG L,FARBER H W,BENZA R,MILLER D P,PARSONS L,HASSOUN P M,et al.Unique predictors of mortality in patients with pulmonary arterial hypertension associated with systemic sclerosis in the REVEAL registry[J].Chest,2014,146:1494-1504.
[25]LAMBOVA S.Cardiac manifestations in systemic sclerosis[J].World J Cardiol,2014,6:993-1005.
[2]ZHANG Z,WANG M,YANG Z,YANG F,LI D,YUT,et al.Noninvasive prediction of pulmonary artery pressure and vascular resistance by using cardiac magnetic resonance indices[J].Int J Cardiol,2017,227:915-922.
[3]VAN DE VEERDONK M C,KIND T,MARCUS J T,MAURITZ G J,HEYMANS M W,BOGAARD H J,et al.Progressive right ventricular dysfunction in patients with pulmonary arterial hypertension responding to therapy[J].J Am Coll Cardiol,2011,58:2511-2519.
[4]GALIèN,HUMBERT M,VACHIERY J L,GIBBS S,LANG I,TORBICKI A,et al;ESC Scientific Document Group.2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension:the Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology(ESC)and the European Respiratory Society(ERS):endorsed by:Association for European Paediatric and Congenital Cardiology(AEPC),International Society for Heart and Lung Transplantation(ISHLT)[J].Eur Heart J,2016,37:67-119.
[5]杨帆,李东,杨振文,张璋,王丹,于铁链.基于CMR的肺动脉径线测量评价肺高血压的临床实用价值[J].中国肺癌杂志,2017,20:93-99.
[6]CORONA-VILLALOBOS C P,KAMEL I R,RASTEGARN,DAMICO R,KOLB T M,BOYCE D M,et al.Bidimensional measurements of right ventricular function for prediction of survival in patients with pulmonary hypertension:comparison of reproducibility and time of analysis with volumetric cardiac magnetic resonance imaging analysis[J].Pulm Circ,2015,5:527-537.
[7]NOGUCHI A,KATO M,KONO M,OHMURA K,OHIRA H,TSUJINO I,et al.Bi-ventricular interplay in patients with systemic sclerosis-associated pulmonary arterial hypertension:detection by cardiac magnetic resonance[J].Mod Rheumatol,2017,27:481-488.
[8]L U R Z P,P U R A N I K R,N O R D M E Y E R J,MUTHURANGU V,HANSEN M S,SCHIEVANO S,et al.Improvement in left ventricular filling properties after relief of right ventricle to pulmonary artery conduit obstruction:contribution of septal motion and interventricular mechanical delay[J].Eur Heart J,2009,30:2266-2274.
[9]PALAU-CABALLERO G,WALMSLEY J,VAN EMPELV,LUMENS J,DELHAAS T.Why septal motion is a marker of right ventricular failure in pulmonary arterial hypertension:mechanistic analysis using a computer model[J].Am J Physiol Heart Circ Physiol,2017,312:H691-H700.
[10]HARDZIYENKA M,CAMPIAN M E,REESINK H J,SURIE S,BOUMA B J,GROENINK M,et al.Right ventricular failure following chronic pressure overload is associated with reduction in left ventricular mass:evidence for atrophic remodeling[J].J Am Coll Cardiol,2011,57:921-928.
[11]MURATA M,TSUGU T,KAWAKAMI T,KATAOKAM,MINAKATA Y,ENDO J,et al.Prognostic value of three-dimensional echocardiographic right ventricular ejection fraction in patients with pulmonary arterial hypertension[J].Oncotarget,2016,7:86781-86790.
[12]MATHAI S C,SIBLEY C T,FORFIA P R,MUDD J O,FISHER M R,TEDFORD R J,et al.Tricuspid annular plane systolic excursion is a robust outcome measure in systemic sclerosis-associated pulmonary arterial hypertension[J].J Rheumatol,2011,38:2410-2418.
[13]RUSHMER R F,CRYSTAL D K,WAGNER C.The functional anatomy of ventricular contraction[J].Circ Res,1953,1:162-170.
[14]GHIO S,KLERSY C,MAGRINI G,D’ARMINI A M,SCELSI L,RAINERI C,et al.Prognostic relevance of the echocardiographic assessment of right ventricular function in patients with idiopathic pulmonary arterial hypertension[J].Int J Cardiol,2010,140:272-278.
[15]C A R L S S O N M,U G A N D E R M,H E I B E R G E,ARHEDEN H.The quantitative relationship between longitudinal and radial function in left,right,and total heart pumping in humans[J].Am J Physiol Heart Circ Physiol,2007,293:H636-H644.
[16]LI Y,WANG Y,YANG Y,LIU M,MENG X,SHI Y,et al.Tricuspid annular displacement measured by2-dimensional speckle tracking echocardiography for predicting right ventricular function in pulmonary hypertension:a new approach to evaluating right ventricle dysfunction[J/OL].Medicine(Baltimore),2018,97:e11710.doi:10.1097/MD.0000000000011710.
[17]FORFIA P R,FISHER M R,MATHAI S C,HOUSTEN-HARRIS T,HEMNES A R,BORLAUG B A,et al.Tricuspid annular displacement predicts survival in pulmonary hypertension[J].Am J Respir Crit Care Med,2006,174:1034-1041.
[18]HOETTE S,CREUZéN,GüNTHER S,MONTANID,SAVALE L,JA?S X,et al.RV fractional area change and TAPSE as predictors of severe right ventricular dysfunction in pulmonary hypertension:a CMR study[J].Lung,2018,196:157-164.
[19]H O S Y,N I H O YA N N O P O U L O S P.A n a t o m y,echocardiography,and normal right ventricular dimensions[J].Heart,2006,92(Suppl 1):i2-i13.
[20]PEACOCK A J,CRAWLEY S,MCLURE L,BLYTHK G,VIZZA C D,POSCIA R,et al.Changes in right ventricular function measured by cardiac magnetic resonance imaging in patients receiving pulmonary arterial hypertension-targeted therapy:the EURO-MRstudy[J].Circ Cardiovasc Imaging,2014,7:107-114.
[21]王丹,张璋,杨帆,张乐,杨振文,任雯,等.不同室间隔形态肺高血压患者的心室功能特点:CMR初步研究[J].中国肺癌杂志,2018,21:397-402.
[22]KNIGHT D S,STEEDEN J A,MOLEDINA S,JONESA,COGHLAN J G,MUTHURANGU V.Left ventricular diastolic dysfunction in pulmonary hypertension predicts functional capacity and clinical worsening:a tissue phase mapping study[J/OL].J Cardiovasc Magn Reson,2015,17:116.doi:10.1186/s12968-015-0220-3.
[23]ZHAO J,WANG Q,LIU Y,TIAN Z,GUO X,WANG H,et al.Clinical characteristics and survival of pulmonary arterial hypertension associated with three major connective tissue diseases:a cohort study in China[J].Int J Cardiol,2017,236:432-437.
[24]CHUNG L,FARBER H W,BENZA R,MILLER D P,PARSONS L,HASSOUN P M,et al.Unique predictors of mortality in patients with pulmonary arterial hypertension associated with systemic sclerosis in the REVEAL registry[J].Chest,2014,146:1494-1504.
[25]LAMBOVA S.Cardiac manifestations in systemic sclerosis[J].World J Cardiol,2014,6:993-1005.