超声心动图分层应变技术评价肥厚型梗阻性心肌病改良扩大Morrow术后左心室游离壁逆重构及预测影响因素
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摘要
目的:采用超声心动图分层应变技术,评价肥厚型梗阻性心肌病(HOCM)改良扩大Morrow术后左心室游离壁逆重构及其预测影响因素。方法:本研究入选我院2014-06到2014-12期间成功接受改良扩大Morrow术式的HOCM患者60例(HOCM组),男性41例(68.3%),平均年龄(39.1±15.2)岁,采集术前和术后6~24个月临床和超声心动图资料;同期选取健康人40例作为正常对照组。用超声分层应变技术分析术前和术后左心室游离壁三层心肌的(心内膜下、中层和心外膜下心肌)纵向应变和环形应变的变化,用线性回归法识别左心室游离壁逆重构的影响因素。左心室游离壁厚度≥15 mm的节段定义为增厚左心室游离壁节段。结果 :HOCM组患者术后左心室游离壁的前壁、侧壁、后壁和下壁厚度与术前比较均变薄;术后游离壁纵向应变[(-13.8±4.8)%vs(-17.0±5.2)%]和环形应变[(-23.7±3.8)%vs(-25.4±3.7)%]均增厚;差异有统计学意义(P<0.05)。△(术前值-术后值)超声左心室质量指数大于外科切除质量指数[(13.5±30.9)g/m2 vs(3.4±2.0)g/m2,P<0.05]。线性回归分析显示,影响术后左心室游离壁纵向应变的独立因素是术前增厚左心室游离壁节段数(r=-0.680,P<0.001)和年龄(r=0.638,P<0.001),影响术后左心室游离壁环形应变的因素是△左心室流出道(LVOT)压差(r=0.386,P=0.005)。结论 :对于HOCM患者,(1)改良扩大Morrow术后,LVOT梗阻解除引起左心室游离壁的逆重构(室壁厚度变薄,质量减低,功能改善);(2)左心室游离壁的三层心肌均发生逆重构;(3)LVOT压差缓解越好、增厚左心室游离壁节段数越小、年龄较大的患者术后逆重构较好。
Objectives: To evaluate the predictor and risk factor of left ventricular(LV) free wall reverse remodeling in patients with obstructive hypertrophic cardiomyopathy(HCM) after modified Morrow procedure by three-layer speckle tracking of echocardiography.Methods: Our investigation included 2 groups: HCM group, n =60 patients who had successful modified Morrow procedure in our hospital from 2014-06 to 2014-12, there were 41(68.3%) male with the average age of(39.1 ± 15.2) years. Control group, n=40 healthy subjects. Three-layer speckle tracking echocardiography was conducted to analyze pre- and post-operative LV free wall three-layer myocardium(endocardial, mid, and epicardial layers) changes at longitudinal strain(LS) and circumferential strain(CS). Clinical and echocardiography information were collected at pre- and(6-24) months post-operation. The impact factors for LV free wall reverse remodeling was identified by liner regression analysis and the segment's thickness ≥ 15 mm was defined as the hypertrophic LV free segment.Results: In HCM group, compared with pre-operative condition, the post-operative thickness of LV free wall including anterior, anterolateral and inferolateral were reduced; while both post-operative LS and CS elevated(-13.8 ± 4.8) % vs(-17.0 ± 5.2) % and(-23.7 ± 3.8) % vs(-25.4 ± 3.7) %, P<0.05. LV mass index by echocardiography was larger than LV mass index by surgical resection(13.5 ± 30.9) g/m2 vs(3.4 ± 2.0) g/m2, P<0.05. Liner regression analysis indicated that the number of preoperative hypertrophic segments(r=-0.680, P<0.001) and age(r=0.638, P<0.001) were the independent impact factors for post-operative LS; △ left ventricular outflow tract(LVOT) gradient(r=0.386, P=0.005) was the independent impact factor for post-operative CS.Conclusion: 1After modified Morrow procedure, LVOT obstruction disappeared which leaded LV free wall reverse remodeling in HCM patients, 2 three-layer myocardium of LV free wall all had reverse remodeling, 3 better improved LVOT gradient were with less number of hypertrophic segments; the elder patients usually had the better post-operative reverse remodeling.
Objectives: To evaluate the predictor and risk factor of left ventricular(LV) free wall reverse remodeling in patients with obstructive hypertrophic cardiomyopathy(HCM) after modified Morrow procedure by three-layer speckle tracking of echocardiography.Methods: Our investigation included 2 groups: HCM group, n =60 patients who had successful modified Morrow procedure in our hospital from 2014-06 to 2014-12, there were 41(68.3%) male with the average age of(39.1 ± 15.2) years. Control group, n=40 healthy subjects. Three-layer speckle tracking echocardiography was conducted to analyze pre- and post-operative LV free wall three-layer myocardium(endocardial, mid, and epicardial layers) changes at longitudinal strain(LS) and circumferential strain(CS). Clinical and echocardiography information were collected at pre- and(6-24) months post-operation. The impact factors for LV free wall reverse remodeling was identified by liner regression analysis and the segment's thickness ≥ 15 mm was defined as the hypertrophic LV free segment.Results: In HCM group, compared with pre-operative condition, the post-operative thickness of LV free wall including anterior, anterolateral and inferolateral were reduced; while both post-operative LS and CS elevated(-13.8 ± 4.8) % vs(-17.0 ± 5.2) % and(-23.7 ± 3.8) % vs(-25.4 ± 3.7) %, P<0.05. LV mass index by echocardiography was larger than LV mass index by surgical resection(13.5 ± 30.9) g/m2 vs(3.4 ± 2.0) g/m2, P<0.05. Liner regression analysis indicated that the number of preoperative hypertrophic segments(r=-0.680, P<0.001) and age(r=0.638, P<0.001) were the independent impact factors for post-operative LS; △ left ventricular outflow tract(LVOT) gradient(r=0.386, P=0.005) was the independent impact factor for post-operative CS.Conclusion: 1After modified Morrow procedure, LVOT obstruction disappeared which leaded LV free wall reverse remodeling in HCM patients, 2 three-layer myocardium of LV free wall all had reverse remodeling, 3 better improved LVOT gradient were with less number of hypertrophic segments; the elder patients usually had the better post-operative reverse remodeling.
引文
[1]Maron MS,Olivotto I,Betocchi S,et al.Effect of left ventricular outflow tract obstruction on clinical outcome in hypertrophic cardiomyopathy.N Engl J Med,2003,348:295-303.
[2]Gersh BJ,Maron BJ,Bonow RO,et al.2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy:executive summary:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Circulation,2011,124:2761-2796.
[3]Cannon RR,Mc Intosh CL,Schenke WH,et al.Effect of surgical reduction of left ventricular outflow obstruction on hemodynamics,coronary flow,and myocardial metabolism in hypertrophic cardiomyopathy.Circulation,1989,79:766-775.
[4]Maron BJ.Controversies in cardiovascular medicine.Surgical myectomy remains the primary treatment option for severely symptomatic patients with obstructive hypertrophic cardiomyopathy.Circulation,2007,116:196-206.
[5]Wang S,Luo M,Sun H,et al.A retrospective clinical study of transaortic extended septal myectomy for obstructive hypertrophic cardiomyopathy in China.Eur J Cardiothorac Surg,2013,43:534-540.
[6]Lang RM,Bierig M,Devereux RB,et al.Recommendations for chamber quantification:a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group,developed in conjunction with the European Association of Echocardiography,a branch of the European Society of Cardiology.J Am Soc Echocardiogr,2005,18:1440-1463.
[7]Nagueh SF,Appleton CP,Gillebert TC,et al.Recommendations for the evaluation of left ventricular diastolic function by echocardiography.J Am Soc Echocardiogr,2009,22:107-133.
[8]Zoghbi WA,Enriquez-Sarano M,Foster E,et al.Recommendations for evaluation of the severity of native valvular regurgitation with twodimensional and Doppler echocardiography.J Am Soc Echocardiogr,2003,16:777-802.
[9]Cerqueira MD,Weissman NJ,Dilsizian V,et al.Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart.A statement for healthcare professionals from the CardiacImaging Committee of the Council on Clinical Cardiology of the American Heart Association.Circulation,2002,105:539-542.
[10]Almaas VM,Haugaa KH,Strom EH,et al.Noninvasive assessment of myocardial fibrosis in patients with obstructive hypertrophic cardiomyopathy.Heart,2014,100:631-638.
[11]王巍,马维国,孙寒松,等.肥厚型梗阻性心肌病合并冠心病的外科治疗效果.中国循环杂志,2007,22:296-298.
[12]然鋆,宋云虎,胡盛寿,等.163例肥厚型梗阻性心肌病的外科治疗及疗效评价.中国循环杂志,2013,28:136-139.
[13]Mc Leod CJ,Ommen SR,Ackerman MJ,et al.Surgical septal myectomy decreases the risk for appropriate implantable cardioverter defibrillator discharge in obstructive hypertrophic cardiomyopathy.Eur Heart J,2007,28:2583-2588.
[14]Maron BJ,Rowin EJ,Casey SA,et al.Risk stratification and outcome of patients with hypertrophic cardiomyopathy≥60 years of age.Circulation,2013,127:585-593.
[15]Maron BJ,Rowin EJ,Casey SA,et al.Hypertrophic cardiomyopathy in adulthood associated with low cardiovascular mortality with contemporary management strategies.J Am Coll Cardiol,2015,65:1915-1928.
[16]Maron BJ,Dearani JA,Ommen SR,et al.Low mperative mortality achieved with surgical septal myectomy:role of dedicated hypertrophic cardiomyopathy centers in the management of dynamic subaortic obstruction.J Am Coll Cardiol,2015,66:1307-1308.
[17]Maron MS,Maron BJ.Clinical impact of caontemporary cardiovascular magnetic resonance imaging in hypertrophic cardiomyopathy.Circulation,2015,132:292-298.
[18]Maron BJ,Casey SA,Chan RH,et al.Independent Assessment of the European Society of Cardiology Sudden Death Risk Model for Hypertrophic Cardiomyopathy.Am J Cardiol,2015,116:757-764.
[2]Gersh BJ,Maron BJ,Bonow RO,et al.2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy:executive summary:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Circulation,2011,124:2761-2796.
[3]Cannon RR,Mc Intosh CL,Schenke WH,et al.Effect of surgical reduction of left ventricular outflow obstruction on hemodynamics,coronary flow,and myocardial metabolism in hypertrophic cardiomyopathy.Circulation,1989,79:766-775.
[4]Maron BJ.Controversies in cardiovascular medicine.Surgical myectomy remains the primary treatment option for severely symptomatic patients with obstructive hypertrophic cardiomyopathy.Circulation,2007,116:196-206.
[5]Wang S,Luo M,Sun H,et al.A retrospective clinical study of transaortic extended septal myectomy for obstructive hypertrophic cardiomyopathy in China.Eur J Cardiothorac Surg,2013,43:534-540.
[6]Lang RM,Bierig M,Devereux RB,et al.Recommendations for chamber quantification:a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group,developed in conjunction with the European Association of Echocardiography,a branch of the European Society of Cardiology.J Am Soc Echocardiogr,2005,18:1440-1463.
[7]Nagueh SF,Appleton CP,Gillebert TC,et al.Recommendations for the evaluation of left ventricular diastolic function by echocardiography.J Am Soc Echocardiogr,2009,22:107-133.
[8]Zoghbi WA,Enriquez-Sarano M,Foster E,et al.Recommendations for evaluation of the severity of native valvular regurgitation with twodimensional and Doppler echocardiography.J Am Soc Echocardiogr,2003,16:777-802.
[9]Cerqueira MD,Weissman NJ,Dilsizian V,et al.Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart.A statement for healthcare professionals from the CardiacImaging Committee of the Council on Clinical Cardiology of the American Heart Association.Circulation,2002,105:539-542.
[10]Almaas VM,Haugaa KH,Strom EH,et al.Noninvasive assessment of myocardial fibrosis in patients with obstructive hypertrophic cardiomyopathy.Heart,2014,100:631-638.
[11]王巍,马维国,孙寒松,等.肥厚型梗阻性心肌病合并冠心病的外科治疗效果.中国循环杂志,2007,22:296-298.
[12]然鋆,宋云虎,胡盛寿,等.163例肥厚型梗阻性心肌病的外科治疗及疗效评价.中国循环杂志,2013,28:136-139.
[13]Mc Leod CJ,Ommen SR,Ackerman MJ,et al.Surgical septal myectomy decreases the risk for appropriate implantable cardioverter defibrillator discharge in obstructive hypertrophic cardiomyopathy.Eur Heart J,2007,28:2583-2588.
[14]Maron BJ,Rowin EJ,Casey SA,et al.Risk stratification and outcome of patients with hypertrophic cardiomyopathy≥60 years of age.Circulation,2013,127:585-593.
[15]Maron BJ,Rowin EJ,Casey SA,et al.Hypertrophic cardiomyopathy in adulthood associated with low cardiovascular mortality with contemporary management strategies.J Am Coll Cardiol,2015,65:1915-1928.
[16]Maron BJ,Dearani JA,Ommen SR,et al.Low mperative mortality achieved with surgical septal myectomy:role of dedicated hypertrophic cardiomyopathy centers in the management of dynamic subaortic obstruction.J Am Coll Cardiol,2015,66:1307-1308.
[17]Maron MS,Maron BJ.Clinical impact of caontemporary cardiovascular magnetic resonance imaging in hypertrophic cardiomyopathy.Circulation,2015,132:292-298.
[18]Maron BJ,Casey SA,Chan RH,et al.Independent Assessment of the European Society of Cardiology Sudden Death Risk Model for Hypertrophic Cardiomyopathy.Am J Cardiol,2015,116:757-764.