超声二维斑点跟踪技术评价左室收缩功能的临床研究
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摘要
左室整体收缩功能的评价是临床常规检测项目,直接关系到患者治疗方案的选择及其预后的评估。左室射血分数(Left ventricular ejective fraction,LVEF)一直是日常临床工作中最常用和被普遍接受的左室收缩功能指标。但某些病理状态,如左室扩大、室壁增厚,会影响其对左室收缩功能评价的准确性。有研究表明,在慢性心衰患者,超声测定的射血分数与心功能分级及脑钠肽之间的相关性差,而且传统的超声测定左室射血分数很大程度上依赖图象质量。寻找非图像依赖、准确、便捷地评价左室功能的方法具有重要的临床意义。
实时三维超声心动图(Real time three dimensional echocardiography, RT3DE)是近年应用于临床的新技术,能够更直观、更全面地显示心脏的解剖结构,更准确地定量分析心脏功能和血流动力学改变。已有的研究表明:与传统的二维超声心动图比较,RT3DE对心脏的解剖结构能够提供更准确、更丰富的信息,对心脏大小和功能的评价与金标准MRI接近。但是此方法仍然依赖与图像的质量,并且操作费时,不能适用于临床日常应用。
左室心肌的运动包括长轴和短轴方向的运动以及旋转运动,其与心肌纤维的复杂走行有关。其中,长轴方向上的运动在心室的收缩中起主要作用,所以临床上通过测量二尖瓣瓣环收缩期位移评价左室整体收缩功能。以往的研究主要应用M型超声和组织多普勒(Tissume doppler imaging,TDI)技术,存在费时、角度依赖、可重复性较差等缺点。应用二维斑点追踪技术(Speckle-tracking imaging,STI)评价瓣环位移时,只要标记瓣环及心尖部的三个位点,STI技术能自动给出瓣环中点收缩期位移,不仅简单、易行,更重要的是该方法基本不依赖于患者的图像质量,因此,更适宜临床常规应用。
新近发展的STI技术,通过识别二维图像的心肌回声斑点来追踪心肌的运动轨迹。在二维超声图像的基础上,在室壁中选定一定范围的感兴趣区,随着心动周期,分析软件根据组织灰阶自动追踪上述感兴趣区内不同像素的心肌组织在每一帧图像中的位置,并与上一帧图像中的位置相比较,计算整个感兴趣区内各节段心肌的变形。由于斑点追踪技术与组织多普勒频移无关,因此不受声束方向与室壁运动方向间夹角的影响,没有角度依赖性,故二维斑点追踪技术能更准确反映心肌的运动。有研究表明,此技术测量结果与超声微测仪及心肌加标记磁共振(Magnetic resonance imaging,MRI)所得结果高度相关,观察者内和观察者间的差异也较小,提示重复性较好,可靠性较高。STI技术是评价局部心肌运动的新方法,不仅能够判断局部心肌纵向,轴向,径向的变形能力而且能评价左心室整体扭转运动,为全面评价心肌运动提供了新的手段。本研究应用此项技术评价左室心肌三个方向上的整体应变,左室整体扭转及二尖瓣环收缩期最大位移与传统指数LVEF的关系,探讨LVEF与心肌自身运动特性之间的关系以寻找更快捷、准确地评价左室整体功能的新方法。
本研究分为三个部分,第一部分主要应用STI技术研究正常成人左室心肌三个方向上的整体应变,左室整体扭转及收缩期二尖瓣环最大位移(Mitral annulus displacement,MAD)与传统指数LVEF的关系,进一步验证STI技术测量二尖瓣环位移评价左室整体收缩功能的可行性。第二、三部分分别对扩张型心肌病患者以及不同左心室构型的原发性高血压患者的左心室整体心肌应变特点与LVEF及二尖瓣环位移的关系及进行分析,观察不同病理状态下,左室心肌在不同方向上的运动规律的改变及与二尖瓣环收缩期位移的关系,以期为临床提供一种简单实用的评价左室整体收缩功能的超声手段。
第一部分超声二维斑点跟踪成像技术评价正常人左心室收缩功能的研究
目的:应用STI技术获取二尖瓣环收缩期位移(MAD),探讨MAD作为评价左室整体收缩功能指标的可行性和准确性。
方法:选择健康志愿者36例,男21例,女15例,平均38.4±15.4岁。PHILIPS公司生产的iE33彩色超声诊断仪,患者取左侧卧位,连续采集三个心动周期。采用X3-1矩阵型实时三维探头,于心尖区采集心尖四腔切面,将采集好的全容积动态三维数据传输到Qlab6.0工作站,脱机进行定量分析。分别于心尖四腔、两腔切面二尖瓣环处及心尖处描记五点进行心内膜自动勾画,系统自动算出LVEF。采用S5-1超声探头,记录并存储标准心尖四腔、两腔和心尖长轴切面以及瓣环、乳头肌和心尖部左室短轴切面的二维灰阶图像,使用Qlab6.0工作站对所有图像进行脱机分析。心尖位的切面共分18个节段,短轴切面共分18个节段。在短轴上可同时测量最大收缩期峰值径向应变,( Radial st rain,Rs)、圆周应变(Circumferential strain,Cs)和旋转角度( Rotation angle,Rot)。心尖位图像上可测最大收缩期峰值纵向应变(Longitudinal strain,Ls)。心尖位上18个节段纵向应变峰值平均值为左室整体纵向应变(GLs),短轴切面18个节段的应变平均收缩期峰值为左室整体径向应变(GRs)、圆周应变(GCs)。测量心底整体最大收缩期旋转角度(Rotation base,Rot-B)、心尖整体最大收缩期旋转角度(Rotation apex,Rot-A)。LVtw定义为:LVtw=Rot-A-Rot-B。采用心尖四腔图像,分别于二尖瓣瓣环左室侧壁、后室间隔与心尖处描记三点,系统自动算出二尖瓣环中点处收缩期最大位移。
结果:(1)可重复性检验:LVEF观察者内的变异系数为9.0%,观察着间的变异系数为12.1%;MAD观察者内的变异系数为8.1%,观察着间的变异系数为10.4%;(2)左室整体心肌应变及扭转与LVEF的关系:GLs、GRs、GCs及LVtw与LVEF均显著相关,r值分别为-0.75、0.52、-0.51和0.61(P<0.01)。其中,GLs、GCs为LVEF的独立预测因子,beta值分别为-0.66、-0.35,回归方程为LVEF=23.74-1.12GLS-0.85GCs (P<0.01)。(3)左室整体心肌应变及扭转与MAD的关系:MAD与GLs、GRs、LVtw均显著相关,r值分别为-0.73、0.47和0.46(P<0.01);GCs与MAD的相关性较差,r值为-0.35(P<0.05)。GLs是MAD的独立预测因子,回归方程为MAD=3.35-0.55GLs(P<0.01)。(4)MAD与LVEF的关系:36例志愿者MAD的均值为14.77±1.97(mm),范围(11.2mm～18.1mm);MAD与LVEF显著相关,r值为0.84,二者的直线相关方程为LVEF=39.05+1.88MAD(P<0.01)
结论:超声二维斑点追踪技术为我们提供了一个评价左室整体收缩功能定量新工具,二尖瓣环收缩期位移可以作为一种简单、快速和无创性评价左室整体收缩功能的新方法。
第二部分超声二维斑点跟踪成像技术评价扩张性心肌病患者左心室收缩功能的研究
目的:应用STI评价扩张性心肌病患者(Dilatedncardiomyopathy,DCM)的左室心肌力学特性,探讨测定二尖瓣环收缩期位移(MAD)评价左室收缩功能的可行性。
方法:DCM组20例,男15例,女5例,年龄33～65岁,平均(40±15)岁。全部病例符合WHO关于扩张型心肌病诊断标准。正常组:36例,男21例,女15例,年龄18～68岁,平均(38.4±15.4)岁。PHILIPS公司生产的iE33彩色超声诊断仪,采用X3-1矩阵型实时三维探头,患者取左侧卧位,于心尖区采集心尖四腔切面,将采集好的全容积动态三维数据传输到Qlab6.0工作站,脱机进行定量分析。分别于心尖四腔、两腔切面二尖瓣环处及心尖处描记五点进行心内膜自动勾画,系统自动算出LVEF。采用S5-1超声探头,记录并存储标准左室短轴切面,心尖切面的二维灰阶图像,使用Qlab6.0工作站对所有图像进行脱机分析。计算左室整体纵向应变(GLs),左室整体径向应变(GRs)、圆周应变(GCs)。测量心底整体最大收缩期旋转角度(Rot-B)、心尖整体最大收缩期旋转角度(Rot-A)。LVtw定义为:LVtw=Rot-A-Rot-B。采用心尖四腔图像,分别于二尖瓣瓣环左室侧壁、后室间隔与心尖处描记三点,系统自动算出MAD。
结果:(1)DCM组纵向、轴向及径向应变曲线形态紊乱,其应变峰值失去对照组的变化规律,心底及心尖部旋转角度明显减低,二尖瓣环运动幅度明显减低。(2)对照组GLs、GRs、GCs及LVtw与LVEF均显著相关(P<0.01)。其中GLs、GCs为LVEF的独立预测因子,beta值分别为-0.66、-0.35(P<0.01),回归方程为LVEF=23.7-1.1GLS-0.85GCs。DCM组GLs、GRs、GCs及LVtw与LVEF亦显著相关(P<0.01)。其中GLs、GCs为LVEF的独立预测因子,beta值分别为-0.53、-0.43(P<0.01),回归方程为LVEF=2.0-1.7GLS-1.3GCs。(3)对照组MAD与GLs、GRs、GCs、LVtw显著相关(P<0.01)。GLs是MAD的独立预测因子,回归方程为MAD=3.4-0.6GLs。DCM组MAD与GLs、GRs、GCs、及LVtw显著相关(P<0.01)。GLs及LVtw是MAD的独立预测因子,beta值分别为-0.52、-0.42(P<0.01)。回归方程为MAD=0.6-0.3GLs+0.6LVtw。(4)对照组MAD与LVEF显著相关(r=0.84,P<0.01),直线相关方程分别为LVEF=39.1+1.9MAD;DCM组MAD与LVEF显著相关(r=0.91,P<0.01),直线相关方程分别为LVEF=0.05+4.5MAD。以MAD为8.9mm作为诊断LVEF≤50%的截断点,其敏感性为100%,特异性为95%。
结论:应用STI技术评价DCM患者左室整体功能,表明二尖瓣环收缩期位移不仅仅反映了心肌纵向的运动,而且是反映左室整体运动的参数。为临床应用二尖瓣环收缩期位移作为评价左室整体收缩功能的指标提供了更有力的证据,MAD和LVEF之间存在良好的相关性,有望成为临床常规评价评DCM患者的一种快捷、准确的新方法。
第三部分超声二维斑点跟踪成像技术评价高血压患者左心室收缩功能的研究
目的:应用STI评价高血压患者的左室收缩功能,探讨当左室构型改变时,二尖瓣环收缩期位移作为评价左室整体收缩功能指标的可行性和准确性。
方法:原发性高血压病患者40例,其中男性21例,女性19例,平均年龄50.9±15.3岁。年龄和性别与高血压组相匹配的健康志愿者30例,其中男性16例,女性14例,平均年龄48.4±17.3岁。按Ganau分型法,即根据左室质量指数(Left ventricular mass index ,LVMI)和相对室壁厚度(RWT)将其分为两组:①左室正常构型(left ventricle normal geometric, LVN)组,即LVMI和RWT均在正常范围[LVMI≤116g/m2(男)或LVMI≤109g/m2(女),RWT≤0.42,20例];②左室重构(Left ventricle remodeling ,LVR)组,包括向心性重构(LVMI在正常范围,RWT>0.42,10例)、向心性肥厚(LVMI与RWT均超出正常范围,8例)和离心性肥厚(LVMI超过正常高限,RWT≤0.42,2例)。先行常规超声心动图检查获取以下参数:舒张末期室间隔厚度(Diastolic interventricular septal thickness,IVSTd)、左室后壁厚度(Diastolic posterior wall thickness,LVPWTd)和左室内径(Left ventricular end-diastolic diameter,LVEDd)。应用公式计算左室重量(LVM)、左室质量指数(LVMI),左室相对室壁厚度( RWT)。应用实时三维超声心动图计算LVEF。记录并存储标准左室短轴切面,心尖切面的二维灰阶图像,使用Qlab6.0工作站对所有图像进行脱机分析。计算左室整体纵向应变(GLs),左室整体径向应变(GRs)、圆周应变(GCs)。测量心底整体最大收缩期旋转角度、心尖整体最大收缩期旋转角度。LVtw定义为:LVtw=Rot-A-Rot-B。采用心尖四腔图像,分别于二尖瓣瓣环左室侧壁、后室间隔与心尖处描记三点,系统自动算出MAD。
结果:(1)与对照组比较,各参数除LVtw外,LVN组无明显变化,LVR组均明显减低(P<0.01);LVN及LVR组LVtw均显著高于对照组(P<0.01)。(2)对照组MAD与LVEF显著相关,r值为0.84,直线相关方程为LVEF=39.15+1.90 MAD;LVN组MAD与LVEF显著相关,r值为0.83,直线相关方程为LVEF=12.96+3.85MAD;LVR组MAD与LVEF显著相关,r值为0.76,直线相关方程为LVEF=35.36+2.41MAD。(3)三组GLs、GRs、GCs及LVtw与LVEF显著相关,其中对照组GLs、GCs为LVEF的独立预测因子,beta值分别为-0.66、-0.35,回归方程为LVEF=23.7-1.1GLS-0.85GCs(P<0.01);LVN组GLs为LVEF的独立预测因子,beta值为-0.73,回归方程为LVEF=25.63-2.13GLS(P<0.01);LVR组GCs、LVtw为LVEF的独立预测因子,beta值分别为-0.40、0.47,回归方程为LVEF=30.29+1.60 LVtw-0.59GC(sP<0.01)。(4)三组GLs、GRs、GCs及LVtw与MAD显著相关,GLs是MAD的独立预测因子。对照组的回归方程为MAD=3.4-0.6GLs(P<0.01);LVN组回归方程为MAD=5.59-0.44GLs(P<0.01);LVR组回归方程为MAD=3.41-0.56GLs(P<0.01)。
结论:STI技术可以评价高血压患者发生构型改变时的整体功能变化,MAD有望成为临床评价高血压患者左心室收缩功能的快捷方法。
The left ventricular global contraction function's appraisal is the clinical conventional examination project, it plays an important clinical role in assessing the patient’s therapeutic schedule and prognosis. The left ventricular ejective fraction (LVEF)has been in the daily clinical work is most commonly used and acceptted generally. But certain pathological state, same as the left ventricular expands, the ventricular wall thickening, will affect accuracy on assessing the left ventricular contraction function. Some research indicated that in the chronic congestive heart failure patient, the correlation between the left ventricular ejective fraction by echocardiography measuring and cardiac functional grading and the brain sodium peptide was bad, moreover the left ventricular ejective fraction by echocardiography measuring rely on the ultrasound image quality to a great extent. It has the important clinical significance to search the method for evaluating the left ventricular function with the non-image dependence, accurately, conveniently.
Recent years, the Real-time three dimensional echocardiography(RT3DE)is the clinical new technology, could show heart’s anatomic structure more direct-viewing and comprehensively, and it could be quantitative analysis heart function and blood stream dynamics change accurately. The existing research indicated: Compares with the traditional two-dimensional echocardiography, RT3DE can provide the more accurate and affluent message of heart's anatomic structure, it is close to the heart size and the function appraisal with golden standard MRI. But this method still rely on the image quality, and operate time-consuming, cannot be suitable for the clinical daily application.
The left ventricular cardiac muscle's movement including the long axis and the minor axis direction's movement as well as the rotary motion concerned with the complex myofibrillar.the long axis direction movement play an important role in left ventricle's contraction, we can evaluate the global systolic function of left ventricle by the mitral annular plane systolic excursion. The former research mainly made use of M-mode echocardiography(MME)and tissume doppler imaging(TDI) to evaluate the global systolic function of left ventricle by the mitral annular plane systolic excursion,it was time-consuming, the angle dependence and the repeatability is bad. By speckle tracking imaging (STI) to evaluate the global function of the left ventricle is suitable the clinical conventional application, we only can mark the three site of valve ring and apex of heart, the technique of STI can calculate the mitral annular plane systolic excursion automatically, it is not only simple, feasibility, and not rely on patient's image quality, therefore,
Recently developed the STI technology, traces myocardial motion path through the recognition the myocardial echo spot of two-dimensional image. In the two-dimensional sonogram foundation, we can designate the certain scope region of interest(ROI) in the ventricular wall following the cardiac cycle(CC). According to the organization gray scale, the analyse software automatically trace every frame image’s myocard structure site of different image element in the region of interest, and compare with previous image's site, it can calculate each segment myocardial distortion in the region of interest. Because speckle tracking imaging is independence on doppler frequency shift and angle, it has not the angle influence between sound beam direction and the wall motion, therefore two-dimensional speckle tracking imaging can reflect myocardial movement more exactly. Some research indicated that the measurements using speckle tracking imaging have good correlation with sonomicrometry and myocard tagging magnetic resonance imaging(MRI), the difference between intra-observer and inter-observer is also small, the reproducibility and reliability is good. The STI may be a new modality to evaluate the region myocard movement, it can not only judge the region myocard movement’s distortion ability of longitudinal, axial, radial direction, moreover can evaluate the left ventricle globle twisting motion. This research evaluate three directions’strain of left ventricle myocard and the left ventricle global twist and the systolic displacemen of mitral annulus by STI. The correlation between these parameter with LVEF is analyzed respectively. We approach the correlation in order to determine the global function of the left ventricle with simplicity and accuracy.
The studies were divided into three parts. In the first part, to study three directions’strain of left ventricle myocard, the left ventricle global twist and systolic displacemen of characteristic by STI in healthy subjects, we analyzed the correlation between these parameter with LVEF respectively in order to determine the feasibility and the accuracy of mitral annulus displacement by speckle tracking imaging to evaluate the global function of the left ventricle.In the next two parts, we analyzed the correlation of left ventricle myocard strain’s characteristic and LVEF and mitral annulus displacement in patients with dilated cardiomyopathy and hypertension with different patterns of left hypertrophic geometric models respectively. To observe the correlation bewteen different directions’motion method of left ventricle myocard and mitral annulus displacement under different pathologic state, hoping to find a new promising modality to evaluate the global systolic function of left ventricle for clinical routine practice with its simplicity and accuracy.
Part I Evaluation of left ventricular systolic function in healthy subjects using two-dimensional speckle tracking imaging
Objective: To determine the feasibility and the accuracy of mitral annulus displacement(MAD) by speckle tracking imaging to evaluate the global function of the left ventricle.
Methods: The study population consisted of 36 healthy subjects, male 21, female 15,average age 38.4±15.4 years.The patients took the decubitus, high frame rate two-dimensional(2D) images of three consecutive cardiac cycles were recorded. We used PHILIPS iE33 color ultrasonograph with X3-1 matrix transducer of real time three dimension,the volume 3D were gathered from the LV apical four-chamber view and these data were transferred to Qlab6.0 work station for offline analysis. Endocardium were drew automatically five spots at mitral annulus and apex of hear from the LV apical four-chamber view, two-chamber view, system calculated LVEF.With M3S transducer,the 2D gray-scale image of LV apical four-chamber view, two-chamber view, long-axis view and the short-axis views at the levels of mitral annulus,papillary muscle and apex of the LV were recorded and stored respectively, all images were transferred to Qlab6.0 work station for offline analysis. The cross-section of apex of heart is divided 18 segments,the cross-section of short axis is divided 18 segments, the software algorithm segmented the LV long axis into 18 segments meanwhile short axis into 16 equidistant segments. Peak systolic circumferential strain(Cs), peak systolic radial strain(Rs), the LV twist (LVtw) were measured from short axis, peak systolic (Ls) were measured from long axis. 18 segments’average value of LV long axis’s strain was global longitudinal strain(GLs), 16 segments’average value of LV short axis’s strain was global circumferential strain(GCs),global radial strain(GRs). LV twist was defined as apical rotation relative to the base. MAD was obtained from LV apical four-chamber view by making the three site of mitral valve ring and apex of heart.
Result: (1) Repeatability test:The intra-observer coefficient of differentiation of LVEF was 9.0%,the inter-observer was 12.1%; The intra-observer coefficient of differentiation of MAD was 8.1%,the inter-observer was 10.1%. (2) The relation of LV global strain and twist with LVEF: LVEF was correlated with GLs, GRs, GCs, LVtw significantly (r=-0.75,0.52,-0.51and0.61respectively,P < 0.01). Multi-variant regression analysis indicated that GLs and GCs were the independent predictors of LVEF (beta=-0.66and -0.35,respectively),LVEF=23.74-1.12GLS-0.85GCs (P<0.01). (3) The relation of LV global strain and twist with MAD: A good correlation was showed between MAD and GLs, GRs,and LVtw (r=-0.73, 0.47and0.46respectively,P<0.01)but a weak correlations with GCs (r=-0.35,P<0.05). GLs was the independent predictor of MAD,MAD=3.35-0.55GLs(P<0.01). (4) An excellent correlation was found between MAD and LVEF (r=0.84,P<0.01),LVEF=39.05+1.88MAD(P<0.01).
Conclusion: MAD showed a novel correlation with LVEF, and with its simplicity and accuracy, MAD may be a new promising modality to evaluate the global systolic function of left ventricle for clinical routine practice.
Part II Evaluation of left ventricular systolic function in patients with dilated cardiomyopathy by two-dimensional speckle tracking imaging
Objective: To determine the feasibility and the accuracy of mitral annulus displacement by speckle tracking imaging (MAD) to evaluate the global function of the left ventricle in patients with dilated cardiomyopathy(DCM).
Methods: The study population consisted of 20 DCM, male 5, female 15, average age 40±15 years, the whole subjects conforms to WHO to diagnose the standard about DCM. 36 healthy subjects, male 21, female 15, average age 38.4±15.4 years. We used PHILIPS iE33 color ultrasonograph with X3-1 matrix transducer of real time three dimension, the volume 3D were gathered from the LV apical four-chamber view and these data were transferred to Qlab6.0 work station for offline analysis.Endocardium were drew automatically five spots at mitral annulus and apex of hear from the LV apical four-chamber view, two-chamber view, system calculated LVEF. With M3S transducer, the 2D gray-scale image of standard LV long-axis view and the short-axis views were recorded and stored respectively, all images were transferred to Qlab6.0 work station for offline analysis, the following parameters were obtained, the global peak systolic longitudinal strain (GLs), circumferential strain (GCs), radial strain (GRs) and the left ventricular twist (LVtw).LV twist was defined as apical rotation relative to the base. MAD was obtained from LV apical four-chamber view by making the three site of mitral valve ring and apex of heart.
Result: (1) The curve shape longitudinal strain,circumferential strain and radial were disorder in DCM group, its strain peak value loses change regularity compared with the control group. The parameters in DCM group were significantly lower than those in the healthy subjects(P<0.01=. (2) In the control group, LVEF was correlated with GLs, GRs, GCs, LVtw significantly(r = -0.75,0.52,-0.51 and 0.61 respectively,P < 0.01 = . Multi-variant regression analysis indicated that GLs and GCs were the independent predictors of LVEF (beta = -0.66 and -0.35,respectively), LVEF=23.74-1.12GLS-0.85GCs(P<0.01).In DCM group, LVEF was correlated with GLs, GRs, GCs, LVtw too(P<0.01), GLs and GCs were the independent predictors of LVEF (beta=-0.53 and -0.43, P<0.01,respectively). LVEF=2.0-1.7GLS-1.3GCs. (3) In the control group, a good correlation was showed between MAD and GLs,GCs,GRs, and LVtw(P<0.01), GLs was the independent predictors of MAD, MAD=3.4-0.6GLs; In DCM group, MAD was correlated with GLs, GCs, GRs, and LVtw(P<0.01), GLs and LVtw were the independent predictors of MAD(beta=-0.52and-0.42, P<0.01, respectively), MAD=0.6-0.3GLs+0.6LVtw. (4) In the control group an excellent correlation was found between MAD and LVEF (r=0.84,P<0.01), LVEF=39.05+1.88MAD(P<0.01); In DCM group, an excellent correlation was found between MAD and LVEF (r=0.91,P<0.01), LVEF=0.05+4.5MAD. The cut-off value of TMAD for LVEF≤50% was 8.9mm with a sensitivity of 100% and a specificity of 95% .
Conclusion: Using STI the technical appraisal DCM patient LV global function, indicated that the MAD has not only reflected the myocard longitudinal movement, moreover reflected the LV whole motion. MAD showed a novel correlation with LVEF and with its simplicity and accuracy,MAD may be a new promising modality to evaluate the global systolic function of left ventricle for clinical routine practice.
Part III Evaluation of left ventricular systolic function in patients with hypertension by two-dimensional speckle tracking imaging
Objective: To determine the feasibility and the accuracy of mitral annulus displacement by speckle tracking imaging (MAD) to evaluate the global function of the left ventricle Reconstitution in patients with hypertension.
Methods: 40 patients with essential hypertension (male 21,female 19, average age50.9±15.3years), 30 age- and gender- matched healthy volunteers (male 16,female 14, average age 48.4±17.3 years) as the control group. All hypertension patients were divided into two groups according to left ventricular mass index (LVMI)and relative wall thickness(RWT);①left ventricle normal geometric, LVN,20 patients, male LVMI≤116g/m2, female LVMI≤109g/m2, RWT≤0.42;②left ventricle remodeling, LVR, including concentric restructure (LVMI in normal range, the RWT>0.42,10), the concentric hypertrophy (LVMI and RWT surpasses normal range,8) and eccentric hypertrophy (LVMI surpasses normal range, RWT≤0.42,2). The advance echocardiographic examination were performed and some paremeters were acquired, including diastolic interventricular septal thickness (IVSTd), diastolic posterior wall thickness(LVPWTd), left ventricular end-diastolic diameter(LVEDd). The application formula calculates LVM, LVMI, RWT. With the tissue speckle tracking imaging, the following parameters were obtained using a Qlab 6.0 workstation: MAD, the global peak systolic longitudinal strain (GLs), circumferential strain (GCs), radial strain (GRs) and the left ventricular twist (LVtw). The left ventricular ejectionfraction (LVEF) was calculated based on real time three-dimension echocardiography. The difference of these parameters between control group andLVN,LVAgroup was compared and the correlation between MAD, LVEF, GLs, GCs, GRs and LVtw were analyzed respectively.
Result: (1) The parameters except LVtw were significantly lower in LVR group than those of the control group(P<0.01) while there was no significant difference in LVN group; LVtw were significantly lower in LVR and LVN group than those of the control group (P<0.01). (2) A good correlation was showed between MAD and LVEF in LVNandLVA group and the control group(control group:r=0.84, LVEF=39.15+1.90MAD; LVN group:r=0.83, LVEF=12.96+3.85MAD; LVR group:r=0.76, LVEF=35.36+2.41MAD, respectively). (3) In the three group, LVEF was correlated with GLs, GRs, GCs, LVtw significantly. Multi-variant regression analysis indicated that GLs and GCs were the independent predictors of LVEF in control group(beta=-0.66and-0.35,P<0.01,respectively, LVEF=23.7-1.1GLS-0.85GCs), GLs was the independent predictors of LVEF in LVN group(beta=-0.73, P<0.01, LVEF=25.63-2.13GLs), GCs and LVtw were the independent predictors of LVEF in LVR group(beta=-0.40 and 0.47, P<0.01, respectively, LVEF=30.29+1.60LVtw-0.59GCs). (4) A good correlation was showed between MAD and GLs, GRs, GCs and LVtw in three group, GLs was the independent predictor of MAD(control group: MAD=3.4-0.6GLs; LVN group:MAD=5.59-0.44GLs;LVR group: MAD=3.41-0.56GLs,P<0.01, respectively).
Conclusion: The global function of the left ventricular remodeling in patients with hypertension could be assessed by using STI, and MAD may be an easy and simple method for evaluation of the global systolic function of remodeling the left ventricle.
实时三维超声心动图(Real time three dimensional echocardiography, RT3DE)是近年应用于临床的新技术,能够更直观、更全面地显示心脏的解剖结构,更准确地定量分析心脏功能和血流动力学改变。已有的研究表明:与传统的二维超声心动图比较,RT3DE对心脏的解剖结构能够提供更准确、更丰富的信息,对心脏大小和功能的评价与金标准MRI接近。但是此方法仍然依赖与图像的质量,并且操作费时,不能适用于临床日常应用。
左室心肌的运动包括长轴和短轴方向的运动以及旋转运动,其与心肌纤维的复杂走行有关。其中,长轴方向上的运动在心室的收缩中起主要作用,所以临床上通过测量二尖瓣瓣环收缩期位移评价左室整体收缩功能。以往的研究主要应用M型超声和组织多普勒(Tissume doppler imaging,TDI)技术,存在费时、角度依赖、可重复性较差等缺点。应用二维斑点追踪技术(Speckle-tracking imaging,STI)评价瓣环位移时,只要标记瓣环及心尖部的三个位点,STI技术能自动给出瓣环中点收缩期位移,不仅简单、易行,更重要的是该方法基本不依赖于患者的图像质量,因此,更适宜临床常规应用。
新近发展的STI技术,通过识别二维图像的心肌回声斑点来追踪心肌的运动轨迹。在二维超声图像的基础上,在室壁中选定一定范围的感兴趣区,随着心动周期,分析软件根据组织灰阶自动追踪上述感兴趣区内不同像素的心肌组织在每一帧图像中的位置,并与上一帧图像中的位置相比较,计算整个感兴趣区内各节段心肌的变形。由于斑点追踪技术与组织多普勒频移无关,因此不受声束方向与室壁运动方向间夹角的影响,没有角度依赖性,故二维斑点追踪技术能更准确反映心肌的运动。有研究表明,此技术测量结果与超声微测仪及心肌加标记磁共振(Magnetic resonance imaging,MRI)所得结果高度相关,观察者内和观察者间的差异也较小,提示重复性较好,可靠性较高。STI技术是评价局部心肌运动的新方法,不仅能够判断局部心肌纵向,轴向,径向的变形能力而且能评价左心室整体扭转运动,为全面评价心肌运动提供了新的手段。本研究应用此项技术评价左室心肌三个方向上的整体应变,左室整体扭转及二尖瓣环收缩期最大位移与传统指数LVEF的关系,探讨LVEF与心肌自身运动特性之间的关系以寻找更快捷、准确地评价左室整体功能的新方法。
本研究分为三个部分,第一部分主要应用STI技术研究正常成人左室心肌三个方向上的整体应变,左室整体扭转及收缩期二尖瓣环最大位移(Mitral annulus displacement,MAD)与传统指数LVEF的关系,进一步验证STI技术测量二尖瓣环位移评价左室整体收缩功能的可行性。第二、三部分分别对扩张型心肌病患者以及不同左心室构型的原发性高血压患者的左心室整体心肌应变特点与LVEF及二尖瓣环位移的关系及进行分析,观察不同病理状态下,左室心肌在不同方向上的运动规律的改变及与二尖瓣环收缩期位移的关系,以期为临床提供一种简单实用的评价左室整体收缩功能的超声手段。
第一部分超声二维斑点跟踪成像技术评价正常人左心室收缩功能的研究
目的:应用STI技术获取二尖瓣环收缩期位移(MAD),探讨MAD作为评价左室整体收缩功能指标的可行性和准确性。
方法:选择健康志愿者36例,男21例,女15例,平均38.4±15.4岁。PHILIPS公司生产的iE33彩色超声诊断仪,患者取左侧卧位,连续采集三个心动周期。采用X3-1矩阵型实时三维探头,于心尖区采集心尖四腔切面,将采集好的全容积动态三维数据传输到Qlab6.0工作站,脱机进行定量分析。分别于心尖四腔、两腔切面二尖瓣环处及心尖处描记五点进行心内膜自动勾画,系统自动算出LVEF。采用S5-1超声探头,记录并存储标准心尖四腔、两腔和心尖长轴切面以及瓣环、乳头肌和心尖部左室短轴切面的二维灰阶图像,使用Qlab6.0工作站对所有图像进行脱机分析。心尖位的切面共分18个节段,短轴切面共分18个节段。在短轴上可同时测量最大收缩期峰值径向应变,( Radial st rain,Rs)、圆周应变(Circumferential strain,Cs)和旋转角度( Rotation angle,Rot)。心尖位图像上可测最大收缩期峰值纵向应变(Longitudinal strain,Ls)。心尖位上18个节段纵向应变峰值平均值为左室整体纵向应变(GLs),短轴切面18个节段的应变平均收缩期峰值为左室整体径向应变(GRs)、圆周应变(GCs)。测量心底整体最大收缩期旋转角度(Rotation base,Rot-B)、心尖整体最大收缩期旋转角度(Rotation apex,Rot-A)。LVtw定义为:LVtw=Rot-A-Rot-B。采用心尖四腔图像,分别于二尖瓣瓣环左室侧壁、后室间隔与心尖处描记三点,系统自动算出二尖瓣环中点处收缩期最大位移。
结果:(1)可重复性检验:LVEF观察者内的变异系数为9.0%,观察着间的变异系数为12.1%;MAD观察者内的变异系数为8.1%,观察着间的变异系数为10.4%;(2)左室整体心肌应变及扭转与LVEF的关系:GLs、GRs、GCs及LVtw与LVEF均显著相关,r值分别为-0.75、0.52、-0.51和0.61(P<0.01)。其中,GLs、GCs为LVEF的独立预测因子,beta值分别为-0.66、-0.35,回归方程为LVEF=23.74-1.12GLS-0.85GCs (P<0.01)。(3)左室整体心肌应变及扭转与MAD的关系:MAD与GLs、GRs、LVtw均显著相关,r值分别为-0.73、0.47和0.46(P<0.01);GCs与MAD的相关性较差,r值为-0.35(P<0.05)。GLs是MAD的独立预测因子,回归方程为MAD=3.35-0.55GLs(P<0.01)。(4)MAD与LVEF的关系:36例志愿者MAD的均值为14.77±1.97(mm),范围(11.2mm～18.1mm);MAD与LVEF显著相关,r值为0.84,二者的直线相关方程为LVEF=39.05+1.88MAD(P<0.01)
结论:超声二维斑点追踪技术为我们提供了一个评价左室整体收缩功能定量新工具,二尖瓣环收缩期位移可以作为一种简单、快速和无创性评价左室整体收缩功能的新方法。
第二部分超声二维斑点跟踪成像技术评价扩张性心肌病患者左心室收缩功能的研究
目的:应用STI评价扩张性心肌病患者(Dilatedncardiomyopathy,DCM)的左室心肌力学特性,探讨测定二尖瓣环收缩期位移(MAD)评价左室收缩功能的可行性。
方法:DCM组20例,男15例,女5例,年龄33～65岁,平均(40±15)岁。全部病例符合WHO关于扩张型心肌病诊断标准。正常组:36例,男21例,女15例,年龄18～68岁,平均(38.4±15.4)岁。PHILIPS公司生产的iE33彩色超声诊断仪,采用X3-1矩阵型实时三维探头,患者取左侧卧位,于心尖区采集心尖四腔切面,将采集好的全容积动态三维数据传输到Qlab6.0工作站,脱机进行定量分析。分别于心尖四腔、两腔切面二尖瓣环处及心尖处描记五点进行心内膜自动勾画,系统自动算出LVEF。采用S5-1超声探头,记录并存储标准左室短轴切面,心尖切面的二维灰阶图像,使用Qlab6.0工作站对所有图像进行脱机分析。计算左室整体纵向应变(GLs),左室整体径向应变(GRs)、圆周应变(GCs)。测量心底整体最大收缩期旋转角度(Rot-B)、心尖整体最大收缩期旋转角度(Rot-A)。LVtw定义为:LVtw=Rot-A-Rot-B。采用心尖四腔图像,分别于二尖瓣瓣环左室侧壁、后室间隔与心尖处描记三点,系统自动算出MAD。
结果:(1)DCM组纵向、轴向及径向应变曲线形态紊乱,其应变峰值失去对照组的变化规律,心底及心尖部旋转角度明显减低,二尖瓣环运动幅度明显减低。(2)对照组GLs、GRs、GCs及LVtw与LVEF均显著相关(P<0.01)。其中GLs、GCs为LVEF的独立预测因子,beta值分别为-0.66、-0.35(P<0.01),回归方程为LVEF=23.7-1.1GLS-0.85GCs。DCM组GLs、GRs、GCs及LVtw与LVEF亦显著相关(P<0.01)。其中GLs、GCs为LVEF的独立预测因子,beta值分别为-0.53、-0.43(P<0.01),回归方程为LVEF=2.0-1.7GLS-1.3GCs。(3)对照组MAD与GLs、GRs、GCs、LVtw显著相关(P<0.01)。GLs是MAD的独立预测因子,回归方程为MAD=3.4-0.6GLs。DCM组MAD与GLs、GRs、GCs、及LVtw显著相关(P<0.01)。GLs及LVtw是MAD的独立预测因子,beta值分别为-0.52、-0.42(P<0.01)。回归方程为MAD=0.6-0.3GLs+0.6LVtw。(4)对照组MAD与LVEF显著相关(r=0.84,P<0.01),直线相关方程分别为LVEF=39.1+1.9MAD;DCM组MAD与LVEF显著相关(r=0.91,P<0.01),直线相关方程分别为LVEF=0.05+4.5MAD。以MAD为8.9mm作为诊断LVEF≤50%的截断点,其敏感性为100%,特异性为95%。
结论:应用STI技术评价DCM患者左室整体功能,表明二尖瓣环收缩期位移不仅仅反映了心肌纵向的运动,而且是反映左室整体运动的参数。为临床应用二尖瓣环收缩期位移作为评价左室整体收缩功能的指标提供了更有力的证据,MAD和LVEF之间存在良好的相关性,有望成为临床常规评价评DCM患者的一种快捷、准确的新方法。
第三部分超声二维斑点跟踪成像技术评价高血压患者左心室收缩功能的研究
目的:应用STI评价高血压患者的左室收缩功能,探讨当左室构型改变时,二尖瓣环收缩期位移作为评价左室整体收缩功能指标的可行性和准确性。
方法:原发性高血压病患者40例,其中男性21例,女性19例,平均年龄50.9±15.3岁。年龄和性别与高血压组相匹配的健康志愿者30例,其中男性16例,女性14例,平均年龄48.4±17.3岁。按Ganau分型法,即根据左室质量指数(Left ventricular mass index ,LVMI)和相对室壁厚度(RWT)将其分为两组:①左室正常构型(left ventricle normal geometric, LVN)组,即LVMI和RWT均在正常范围[LVMI≤116g/m2(男)或LVMI≤109g/m2(女),RWT≤0.42,20例];②左室重构(Left ventricle remodeling ,LVR)组,包括向心性重构(LVMI在正常范围,RWT>0.42,10例)、向心性肥厚(LVMI与RWT均超出正常范围,8例)和离心性肥厚(LVMI超过正常高限,RWT≤0.42,2例)。先行常规超声心动图检查获取以下参数:舒张末期室间隔厚度(Diastolic interventricular septal thickness,IVSTd)、左室后壁厚度(Diastolic posterior wall thickness,LVPWTd)和左室内径(Left ventricular end-diastolic diameter,LVEDd)。应用公式计算左室重量(LVM)、左室质量指数(LVMI),左室相对室壁厚度( RWT)。应用实时三维超声心动图计算LVEF。记录并存储标准左室短轴切面,心尖切面的二维灰阶图像,使用Qlab6.0工作站对所有图像进行脱机分析。计算左室整体纵向应变(GLs),左室整体径向应变(GRs)、圆周应变(GCs)。测量心底整体最大收缩期旋转角度、心尖整体最大收缩期旋转角度。LVtw定义为:LVtw=Rot-A-Rot-B。采用心尖四腔图像,分别于二尖瓣瓣环左室侧壁、后室间隔与心尖处描记三点,系统自动算出MAD。
结果:(1)与对照组比较,各参数除LVtw外,LVN组无明显变化,LVR组均明显减低(P<0.01);LVN及LVR组LVtw均显著高于对照组(P<0.01)。(2)对照组MAD与LVEF显著相关,r值为0.84,直线相关方程为LVEF=39.15+1.90 MAD;LVN组MAD与LVEF显著相关,r值为0.83,直线相关方程为LVEF=12.96+3.85MAD;LVR组MAD与LVEF显著相关,r值为0.76,直线相关方程为LVEF=35.36+2.41MAD。(3)三组GLs、GRs、GCs及LVtw与LVEF显著相关,其中对照组GLs、GCs为LVEF的独立预测因子,beta值分别为-0.66、-0.35,回归方程为LVEF=23.7-1.1GLS-0.85GCs(P<0.01);LVN组GLs为LVEF的独立预测因子,beta值为-0.73,回归方程为LVEF=25.63-2.13GLS(P<0.01);LVR组GCs、LVtw为LVEF的独立预测因子,beta值分别为-0.40、0.47,回归方程为LVEF=30.29+1.60 LVtw-0.59GC(sP<0.01)。(4)三组GLs、GRs、GCs及LVtw与MAD显著相关,GLs是MAD的独立预测因子。对照组的回归方程为MAD=3.4-0.6GLs(P<0.01);LVN组回归方程为MAD=5.59-0.44GLs(P<0.01);LVR组回归方程为MAD=3.41-0.56GLs(P<0.01)。
结论:STI技术可以评价高血压患者发生构型改变时的整体功能变化,MAD有望成为临床评价高血压患者左心室收缩功能的快捷方法。
The left ventricular global contraction function's appraisal is the clinical conventional examination project, it plays an important clinical role in assessing the patient’s therapeutic schedule and prognosis. The left ventricular ejective fraction (LVEF)has been in the daily clinical work is most commonly used and acceptted generally. But certain pathological state, same as the left ventricular expands, the ventricular wall thickening, will affect accuracy on assessing the left ventricular contraction function. Some research indicated that in the chronic congestive heart failure patient, the correlation between the left ventricular ejective fraction by echocardiography measuring and cardiac functional grading and the brain sodium peptide was bad, moreover the left ventricular ejective fraction by echocardiography measuring rely on the ultrasound image quality to a great extent. It has the important clinical significance to search the method for evaluating the left ventricular function with the non-image dependence, accurately, conveniently.
Recent years, the Real-time three dimensional echocardiography(RT3DE)is the clinical new technology, could show heart’s anatomic structure more direct-viewing and comprehensively, and it could be quantitative analysis heart function and blood stream dynamics change accurately. The existing research indicated: Compares with the traditional two-dimensional echocardiography, RT3DE can provide the more accurate and affluent message of heart's anatomic structure, it is close to the heart size and the function appraisal with golden standard MRI. But this method still rely on the image quality, and operate time-consuming, cannot be suitable for the clinical daily application.
The left ventricular cardiac muscle's movement including the long axis and the minor axis direction's movement as well as the rotary motion concerned with the complex myofibrillar.the long axis direction movement play an important role in left ventricle's contraction, we can evaluate the global systolic function of left ventricle by the mitral annular plane systolic excursion. The former research mainly made use of M-mode echocardiography(MME)and tissume doppler imaging(TDI) to evaluate the global systolic function of left ventricle by the mitral annular plane systolic excursion,it was time-consuming, the angle dependence and the repeatability is bad. By speckle tracking imaging (STI) to evaluate the global function of the left ventricle is suitable the clinical conventional application, we only can mark the three site of valve ring and apex of heart, the technique of STI can calculate the mitral annular plane systolic excursion automatically, it is not only simple, feasibility, and not rely on patient's image quality, therefore,
Recently developed the STI technology, traces myocardial motion path through the recognition the myocardial echo spot of two-dimensional image. In the two-dimensional sonogram foundation, we can designate the certain scope region of interest(ROI) in the ventricular wall following the cardiac cycle(CC). According to the organization gray scale, the analyse software automatically trace every frame image’s myocard structure site of different image element in the region of interest, and compare with previous image's site, it can calculate each segment myocardial distortion in the region of interest. Because speckle tracking imaging is independence on doppler frequency shift and angle, it has not the angle influence between sound beam direction and the wall motion, therefore two-dimensional speckle tracking imaging can reflect myocardial movement more exactly. Some research indicated that the measurements using speckle tracking imaging have good correlation with sonomicrometry and myocard tagging magnetic resonance imaging(MRI), the difference between intra-observer and inter-observer is also small, the reproducibility and reliability is good. The STI may be a new modality to evaluate the region myocard movement, it can not only judge the region myocard movement’s distortion ability of longitudinal, axial, radial direction, moreover can evaluate the left ventricle globle twisting motion. This research evaluate three directions’strain of left ventricle myocard and the left ventricle global twist and the systolic displacemen of mitral annulus by STI. The correlation between these parameter with LVEF is analyzed respectively. We approach the correlation in order to determine the global function of the left ventricle with simplicity and accuracy.
The studies were divided into three parts. In the first part, to study three directions’strain of left ventricle myocard, the left ventricle global twist and systolic displacemen of characteristic by STI in healthy subjects, we analyzed the correlation between these parameter with LVEF respectively in order to determine the feasibility and the accuracy of mitral annulus displacement by speckle tracking imaging to evaluate the global function of the left ventricle.In the next two parts, we analyzed the correlation of left ventricle myocard strain’s characteristic and LVEF and mitral annulus displacement in patients with dilated cardiomyopathy and hypertension with different patterns of left hypertrophic geometric models respectively. To observe the correlation bewteen different directions’motion method of left ventricle myocard and mitral annulus displacement under different pathologic state, hoping to find a new promising modality to evaluate the global systolic function of left ventricle for clinical routine practice with its simplicity and accuracy.
Part I Evaluation of left ventricular systolic function in healthy subjects using two-dimensional speckle tracking imaging
Objective: To determine the feasibility and the accuracy of mitral annulus displacement(MAD) by speckle tracking imaging to evaluate the global function of the left ventricle.
Methods: The study population consisted of 36 healthy subjects, male 21, female 15,average age 38.4±15.4 years.The patients took the decubitus, high frame rate two-dimensional(2D) images of three consecutive cardiac cycles were recorded. We used PHILIPS iE33 color ultrasonograph with X3-1 matrix transducer of real time three dimension,the volume 3D were gathered from the LV apical four-chamber view and these data were transferred to Qlab6.0 work station for offline analysis. Endocardium were drew automatically five spots at mitral annulus and apex of hear from the LV apical four-chamber view, two-chamber view, system calculated LVEF.With M3S transducer,the 2D gray-scale image of LV apical four-chamber view, two-chamber view, long-axis view and the short-axis views at the levels of mitral annulus,papillary muscle and apex of the LV were recorded and stored respectively, all images were transferred to Qlab6.0 work station for offline analysis. The cross-section of apex of heart is divided 18 segments,the cross-section of short axis is divided 18 segments, the software algorithm segmented the LV long axis into 18 segments meanwhile short axis into 16 equidistant segments. Peak systolic circumferential strain(Cs), peak systolic radial strain(Rs), the LV twist (LVtw) were measured from short axis, peak systolic (Ls) were measured from long axis. 18 segments’average value of LV long axis’s strain was global longitudinal strain(GLs), 16 segments’average value of LV short axis’s strain was global circumferential strain(GCs),global radial strain(GRs). LV twist was defined as apical rotation relative to the base. MAD was obtained from LV apical four-chamber view by making the three site of mitral valve ring and apex of heart.
Result: (1) Repeatability test:The intra-observer coefficient of differentiation of LVEF was 9.0%,the inter-observer was 12.1%; The intra-observer coefficient of differentiation of MAD was 8.1%,the inter-observer was 10.1%. (2) The relation of LV global strain and twist with LVEF: LVEF was correlated with GLs, GRs, GCs, LVtw significantly (r=-0.75,0.52,-0.51and0.61respectively,P < 0.01). Multi-variant regression analysis indicated that GLs and GCs were the independent predictors of LVEF (beta=-0.66and -0.35,respectively),LVEF=23.74-1.12GLS-0.85GCs (P<0.01). (3) The relation of LV global strain and twist with MAD: A good correlation was showed between MAD and GLs, GRs,and LVtw (r=-0.73, 0.47and0.46respectively,P<0.01)but a weak correlations with GCs (r=-0.35,P<0.05). GLs was the independent predictor of MAD,MAD=3.35-0.55GLs(P<0.01). (4) An excellent correlation was found between MAD and LVEF (r=0.84,P<0.01),LVEF=39.05+1.88MAD(P<0.01).
Conclusion: MAD showed a novel correlation with LVEF, and with its simplicity and accuracy, MAD may be a new promising modality to evaluate the global systolic function of left ventricle for clinical routine practice.
Part II Evaluation of left ventricular systolic function in patients with dilated cardiomyopathy by two-dimensional speckle tracking imaging
Objective: To determine the feasibility and the accuracy of mitral annulus displacement by speckle tracking imaging (MAD) to evaluate the global function of the left ventricle in patients with dilated cardiomyopathy(DCM).
Methods: The study population consisted of 20 DCM, male 5, female 15, average age 40±15 years, the whole subjects conforms to WHO to diagnose the standard about DCM. 36 healthy subjects, male 21, female 15, average age 38.4±15.4 years. We used PHILIPS iE33 color ultrasonograph with X3-1 matrix transducer of real time three dimension, the volume 3D were gathered from the LV apical four-chamber view and these data were transferred to Qlab6.0 work station for offline analysis.Endocardium were drew automatically five spots at mitral annulus and apex of hear from the LV apical four-chamber view, two-chamber view, system calculated LVEF. With M3S transducer, the 2D gray-scale image of standard LV long-axis view and the short-axis views were recorded and stored respectively, all images were transferred to Qlab6.0 work station for offline analysis, the following parameters were obtained, the global peak systolic longitudinal strain (GLs), circumferential strain (GCs), radial strain (GRs) and the left ventricular twist (LVtw).LV twist was defined as apical rotation relative to the base. MAD was obtained from LV apical four-chamber view by making the three site of mitral valve ring and apex of heart.
Result: (1) The curve shape longitudinal strain,circumferential strain and radial were disorder in DCM group, its strain peak value loses change regularity compared with the control group. The parameters in DCM group were significantly lower than those in the healthy subjects(P<0.01=. (2) In the control group, LVEF was correlated with GLs, GRs, GCs, LVtw significantly(r = -0.75,0.52,-0.51 and 0.61 respectively,P < 0.01 = . Multi-variant regression analysis indicated that GLs and GCs were the independent predictors of LVEF (beta = -0.66 and -0.35,respectively), LVEF=23.74-1.12GLS-0.85GCs(P<0.01).In DCM group, LVEF was correlated with GLs, GRs, GCs, LVtw too(P<0.01), GLs and GCs were the independent predictors of LVEF (beta=-0.53 and -0.43, P<0.01,respectively). LVEF=2.0-1.7GLS-1.3GCs. (3) In the control group, a good correlation was showed between MAD and GLs,GCs,GRs, and LVtw(P<0.01), GLs was the independent predictors of MAD, MAD=3.4-0.6GLs; In DCM group, MAD was correlated with GLs, GCs, GRs, and LVtw(P<0.01), GLs and LVtw were the independent predictors of MAD(beta=-0.52and-0.42, P<0.01, respectively), MAD=0.6-0.3GLs+0.6LVtw. (4) In the control group an excellent correlation was found between MAD and LVEF (r=0.84,P<0.01), LVEF=39.05+1.88MAD(P<0.01); In DCM group, an excellent correlation was found between MAD and LVEF (r=0.91,P<0.01), LVEF=0.05+4.5MAD. The cut-off value of TMAD for LVEF≤50% was 8.9mm with a sensitivity of 100% and a specificity of 95% .
Conclusion: Using STI the technical appraisal DCM patient LV global function, indicated that the MAD has not only reflected the myocard longitudinal movement, moreover reflected the LV whole motion. MAD showed a novel correlation with LVEF and with its simplicity and accuracy,MAD may be a new promising modality to evaluate the global systolic function of left ventricle for clinical routine practice.
Part III Evaluation of left ventricular systolic function in patients with hypertension by two-dimensional speckle tracking imaging
Objective: To determine the feasibility and the accuracy of mitral annulus displacement by speckle tracking imaging (MAD) to evaluate the global function of the left ventricle Reconstitution in patients with hypertension.
Methods: 40 patients with essential hypertension (male 21,female 19, average age50.9±15.3years), 30 age- and gender- matched healthy volunteers (male 16,female 14, average age 48.4±17.3 years) as the control group. All hypertension patients were divided into two groups according to left ventricular mass index (LVMI)and relative wall thickness(RWT);①left ventricle normal geometric, LVN,20 patients, male LVMI≤116g/m2, female LVMI≤109g/m2, RWT≤0.42;②left ventricle remodeling, LVR, including concentric restructure (LVMI in normal range, the RWT>0.42,10), the concentric hypertrophy (LVMI and RWT surpasses normal range,8) and eccentric hypertrophy (LVMI surpasses normal range, RWT≤0.42,2). The advance echocardiographic examination were performed and some paremeters were acquired, including diastolic interventricular septal thickness (IVSTd), diastolic posterior wall thickness(LVPWTd), left ventricular end-diastolic diameter(LVEDd). The application formula calculates LVM, LVMI, RWT. With the tissue speckle tracking imaging, the following parameters were obtained using a Qlab 6.0 workstation: MAD, the global peak systolic longitudinal strain (GLs), circumferential strain (GCs), radial strain (GRs) and the left ventricular twist (LVtw). The left ventricular ejectionfraction (LVEF) was calculated based on real time three-dimension echocardiography. The difference of these parameters between control group andLVN,LVAgroup was compared and the correlation between MAD, LVEF, GLs, GCs, GRs and LVtw were analyzed respectively.
Result: (1) The parameters except LVtw were significantly lower in LVR group than those of the control group(P<0.01) while there was no significant difference in LVN group; LVtw were significantly lower in LVR and LVN group than those of the control group (P<0.01). (2) A good correlation was showed between MAD and LVEF in LVNandLVA group and the control group(control group:r=0.84, LVEF=39.15+1.90MAD; LVN group:r=0.83, LVEF=12.96+3.85MAD; LVR group:r=0.76, LVEF=35.36+2.41MAD, respectively). (3) In the three group, LVEF was correlated with GLs, GRs, GCs, LVtw significantly. Multi-variant regression analysis indicated that GLs and GCs were the independent predictors of LVEF in control group(beta=-0.66and-0.35,P<0.01,respectively, LVEF=23.7-1.1GLS-0.85GCs), GLs was the independent predictors of LVEF in LVN group(beta=-0.73, P<0.01, LVEF=25.63-2.13GLs), GCs and LVtw were the independent predictors of LVEF in LVR group(beta=-0.40 and 0.47, P<0.01, respectively, LVEF=30.29+1.60LVtw-0.59GCs). (4) A good correlation was showed between MAD and GLs, GRs, GCs and LVtw in three group, GLs was the independent predictor of MAD(control group: MAD=3.4-0.6GLs; LVN group:MAD=5.59-0.44GLs;LVR group: MAD=3.41-0.56GLs,P<0.01, respectively).
Conclusion: The global function of the left ventricular remodeling in patients with hypertension could be assessed by using STI, and MAD may be an easy and simple method for evaluation of the global systolic function of remodeling the left ventricle.
引文
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