嗜铬细胞瘤患者心血管表现的临床研究
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摘要
研究背景：嗜铬细胞瘤/副节瘤(Pheochromocytomas and paragangliomas, PH/PCL)是少见疾病,可造成血压异常与心肌损害。目前,国内外对PH/PCL患者心脏结构、功能及血流动力学异常的临床研究资料较少,尚缺乏针对PH/PCL患者的基于二维斑点追踪技术心肌应变与应变率分析的大系列病例研究。
研究方法：入选2010年10月至2013年4月期间就诊于北京协和医院的78例PH/PCL患者,分析血压异常、心脏损害等心血管表现发生率与表现形式。46例健康体检者作为对照。对比PH/PCL患者与健康对照超声心动图表现,并比较左室肥厚、左室纵向应变异常等不同亚组PH/PCL患者临床表现,以及常规超声参数,纵向应变应变率参数,手术过程中血液动力学变化、液体需要量、血管活性药物应用等情况。
研究结果：
1.78例患者中,66例(84.6%)有高血压,3例(3.8%)病程中有低血压病史。45例(57.7%)存在可疑心脏损害,其中急性左心功能不全3例(3.8%),心肌酶与心电图ST-T段动态变化6例(7.7%),病程中出现左室射血分数下降6例(7.7%)(其中5例于随访后恢复正常),出现心律失常30例(38.5%),超声心动图诊断左室肥厚25例(32.1%)。
2.以有无左室肥厚将高血压PH/PCL患者分为两组,两组高血压病程、表现为持续与阵发血压升高比例与血压水平相当,肥厚组24小时尿去甲肾(435[61-766]vs.110[35-242]g/24h, p=0.006)、肾上腺素(3.51[3.01-4.53]vs.2.88[2.32-3.89]μg/24h,p=0.016)显著高于高血压非左室肥厚组,24小时尿多巴胺无显著差异。
3.78例PH/PCL患者左室射血分数(75[70-79]vs.72[65-75]%,p=0.002)、心搏指数(3.30±0.75vs.2.80±0.24L/min.m2, p<0.001)、左室质量指数(56.9[41.1-109.5]vs.46.9[41.1-57.0]g/m2,p=0.002)、左房容积指数(25.62±7.02vs.19.03±5.07mL/m2,p<0.001)、二尖瓣E/E’(平均)(8.42±3.93vs.6.46±2.44,p=0.003)高于健康对照组,二尖瓣环侧壁侧E’(11.72±3.34vs.13.50±4.32cm/s,p=0.012)低于对照组。
4.左室肥厚PH/PCL患者心率(93.4±20.6vs.77.3±15.8bpm,p=0.001)显著高于无左室肥厚患者,心律失常(16例/25例vs.14例/53例,p=0.001)、病程中发生急性左心功能不全(3例/25例vs.0例/53例,p=0.030),LVEF持续下降(3例/25例vs.0例/53例,p=0.030)、心电图ST-T段改变比例(15例/25例vs.11例/53例,p=0.001)高于无肥厚者。
5.所有78例患者(-18.5±3.8vs.-21.6±1.2%,p<0.001),与75例左室射血分数正常患者(-18.9±3.3vs.-21.6±1.2%,p<0.001)左室收缩期纵向应变峰值均显著低于16例健康对照。
6.左室肥厚PH/PCL患者左室收缩期纵向应变峰值(-15.3±3.9vs.-20.0±2.7%,p<0.001)显著低于无肥厚患者者,而无左室肥厚患者显著低于健康对照(-20.0±2.7vs.-21.6±1.2%,p=0.001)。
7.行手术切除肿瘤的56例患者中,9例纵向应变异常者术中液体净入量显著高于手术时间与出血量无显著差异的47例应变正常者(3200[2700-4700]vs.2550[1863-3300]ml,p=0.037)。
结论：
1. PH/PCL可引起明显血压异常、心律失常和心肌损害,少数出现左室射血分数下降,大多可逆。
2.儿茶酚胺升高是PH/PCL患者心肌肥厚的原因,并独立于高血压。
3. PH/PCL患者中左室肥厚与心律失常、急性左心功能不全、左室舒张功能障碍与左室充盈压升高有关。
4.部分左室射血分数正常PH/PCL患者存在亚临床左室收缩功能异常。
5. PH/PCL患者左室纵向应变异常与左室肥厚、心律失常、左室充盈压升高和术中液体需要量增加相关。
Background Pheochromocytomas and paragangliomas (PH/PCL) are rare tumors, which can cause blood pressure alterations and cardiac injuries. Reports regarding changes of cardiac structure and function, of hemodynamics in PH/PCL patients are few. This is the first study to apply two dimensional speckle tracking echocardiography in the evaluation of a case series of PH/PGL patients.
Methods Seventy-eight PH/PGL patients receiving medical attention in Peking Union Medical College Hospital from October2010to April2013and46healthy controls were included in this study. Conventional echocardiographic parameters, speckle tracking left ventricular(LV) longitudinal strain and strain rate parameters were compared between patients and controls. Prevalence and presentations of cardiovascular manifestations including blood pressure abnormalities and cardiac injuries among patients were recorded. Clinical presentations, echocardiographic parameters, intraoperative hemodynamic changes, fluid and inotropic support regimes were compared among subgroups of patients with or without LV hypertrophy or left ventricular longitudinal strain abnormalities.
Results
1. Of the78patients,66(84.6%) were hypertensive,3(3.8%) experienced hypotensive episodes,45(57.7%) had histories indictive of cardiac injuries, including3(3.8%) with acute left-sided heart failure episodes,6(7.7%) with concurrent evolving cardiac enzyme elevation and alteration of ECG ST-T segment,6(7.7%) with decreased left ventricular ejection fraction(LVEF),5of which restored during follow-up,30(38.5%) with arrhythmias,25(32.1%) with LV hypertrophy as evidened by echocardiographic parameters.
2. Among hypertensive PH/PGL patients, levels of24-hour urinary norepinephrine (435[61-766] vs.110[35-242]μg/24h, p=0.006) and epinephrine(3.51[3.01-4.53] vs.2.88[2.32-3.89] μg/24h, p=0.016) were significantly higher in LV hypertrophic group than in normal geometry group, while the duration, manifestation (sustained vs. paroxysmal) and degree of blood pressure elevation did not differ between the two groups.
3. LVEF(75[70-79] vs.72[65-75]%, p=0.002), cardiac output index(3.30±0.75vs. 2.80±0.24L/min.m2, p<0.001), left ventricular mass index(LVMI)(56.9[41.1-109.5] vs.46.9[41.1-57.0] g/m2, p=0.002), left atrial volume index(LAVI)(25.62±7.02vs.19.03±5.07mL/m2, p<0.001) and mitral valve(MV) E/E'(average) ratio (8.42±3.93vs.6.46±2.44, p=0.003) in78PH/PGL patients was significantly higher than in46healthy controls. MV lateral E' velocity (11.72±3.34vs.13.50±4.32cm/s, p=0.012) was significantly lower in patients than in controls.
4. LV hypertrophy was associated with higher heart rate(93.4±20.6vs.77.3±15.8bpm, p=0.001), more prevalent arrhythmias(16in25vs.14in53, p=0.001), acute left-sided heart failure episodes(3in25vs.0in53, p=0.030), sustained LVEF depression(3in25vs.0in53, p=0.030) and ECG ST-T segment alterations in PH/PGL patients.
5. Comparing with16healthy control, LV peak systolic longitudinal strain was significantly lower in78PH/PGL patients(-18.5±3.8vs.-21.6±1.2%, p<0.001) as well as75PH/PGL patients with preserved LVEF (-18.9±3.3vs.-21.6±1.2%, p<0.001).
6. PH/PGL patients with normal LV geometry had significantly higher peak systolic longitudinal strain than patients with LV hypertrophy(-20.0±2.7vs.-15.3±3.9%, p<0.001), and significantly lower value than healthy controls(-20.0±2.7vs.21.6±1.2%, p=0.001).
7. In56patients undergoing surgical resection of the tumors,9patients with abnormal longitidinal strain required significantly higher net fluid intake(3200[2700-4700] vs.2550[1863-3300]ml, p=0.037) than47patients with normal longitudinal strain, while the blood loss and duration of surgeries of the two groups did not differ significantly.
Conclusions
1. PH/PGL can cause blood pressure alterations, arrhythmias, and cardiomyopathies. Decreased LVEF, often reversible, occurs occasionally.
2. Catecholamine is a causal factor of LV hypertrophy in PH/PGL patients independent of hypertension.
3. LV hypertrophy in PH/PGL patients is associated with arrhythmias, acute left-sided heart failure, LV diastolic dysfunction and elevated LV filling pressure.
4. Subclinical LV systolic dysfunction is present in certain PH/PGL patients with preserved LV ejeciton fraction.
5. LV longitudinal strain abnormalities in PH/PGL patients is associated with LV hypertrophy and the need for more rigourous fluid regiems during surgery.
研究方法：入选2010年10月至2013年4月期间就诊于北京协和医院的78例PH/PCL患者,分析血压异常、心脏损害等心血管表现发生率与表现形式。46例健康体检者作为对照。对比PH/PCL患者与健康对照超声心动图表现,并比较左室肥厚、左室纵向应变异常等不同亚组PH/PCL患者临床表现,以及常规超声参数,纵向应变应变率参数,手术过程中血液动力学变化、液体需要量、血管活性药物应用等情况。
研究结果：
1.78例患者中,66例(84.6%)有高血压,3例(3.8%)病程中有低血压病史。45例(57.7%)存在可疑心脏损害,其中急性左心功能不全3例(3.8%),心肌酶与心电图ST-T段动态变化6例(7.7%),病程中出现左室射血分数下降6例(7.7%)(其中5例于随访后恢复正常),出现心律失常30例(38.5%),超声心动图诊断左室肥厚25例(32.1%)。
2.以有无左室肥厚将高血压PH/PCL患者分为两组,两组高血压病程、表现为持续与阵发血压升高比例与血压水平相当,肥厚组24小时尿去甲肾(435[61-766]vs.110[35-242]g/24h, p=0.006)、肾上腺素(3.51[3.01-4.53]vs.2.88[2.32-3.89]μg/24h,p=0.016)显著高于高血压非左室肥厚组,24小时尿多巴胺无显著差异。
3.78例PH/PCL患者左室射血分数(75[70-79]vs.72[65-75]%,p=0.002)、心搏指数(3.30±0.75vs.2.80±0.24L/min.m2, p<0.001)、左室质量指数(56.9[41.1-109.5]vs.46.9[41.1-57.0]g/m2,p=0.002)、左房容积指数(25.62±7.02vs.19.03±5.07mL/m2,p<0.001)、二尖瓣E/E’(平均)(8.42±3.93vs.6.46±2.44,p=0.003)高于健康对照组,二尖瓣环侧壁侧E’(11.72±3.34vs.13.50±4.32cm/s,p=0.012)低于对照组。
4.左室肥厚PH/PCL患者心率(93.4±20.6vs.77.3±15.8bpm,p=0.001)显著高于无左室肥厚患者,心律失常(16例/25例vs.14例/53例,p=0.001)、病程中发生急性左心功能不全(3例/25例vs.0例/53例,p=0.030),LVEF持续下降(3例/25例vs.0例/53例,p=0.030)、心电图ST-T段改变比例(15例/25例vs.11例/53例,p=0.001)高于无肥厚者。
5.所有78例患者(-18.5±3.8vs.-21.6±1.2%,p<0.001),与75例左室射血分数正常患者(-18.9±3.3vs.-21.6±1.2%,p<0.001)左室收缩期纵向应变峰值均显著低于16例健康对照。
6.左室肥厚PH/PCL患者左室收缩期纵向应变峰值(-15.3±3.9vs.-20.0±2.7%,p<0.001)显著低于无肥厚患者者,而无左室肥厚患者显著低于健康对照(-20.0±2.7vs.-21.6±1.2%,p=0.001)。
7.行手术切除肿瘤的56例患者中,9例纵向应变异常者术中液体净入量显著高于手术时间与出血量无显著差异的47例应变正常者(3200[2700-4700]vs.2550[1863-3300]ml,p=0.037)。
结论：
1. PH/PCL可引起明显血压异常、心律失常和心肌损害,少数出现左室射血分数下降,大多可逆。
2.儿茶酚胺升高是PH/PCL患者心肌肥厚的原因,并独立于高血压。
3. PH/PCL患者中左室肥厚与心律失常、急性左心功能不全、左室舒张功能障碍与左室充盈压升高有关。
4.部分左室射血分数正常PH/PCL患者存在亚临床左室收缩功能异常。
5. PH/PCL患者左室纵向应变异常与左室肥厚、心律失常、左室充盈压升高和术中液体需要量增加相关。
Background Pheochromocytomas and paragangliomas (PH/PCL) are rare tumors, which can cause blood pressure alterations and cardiac injuries. Reports regarding changes of cardiac structure and function, of hemodynamics in PH/PCL patients are few. This is the first study to apply two dimensional speckle tracking echocardiography in the evaluation of a case series of PH/PGL patients.
Methods Seventy-eight PH/PGL patients receiving medical attention in Peking Union Medical College Hospital from October2010to April2013and46healthy controls were included in this study. Conventional echocardiographic parameters, speckle tracking left ventricular(LV) longitudinal strain and strain rate parameters were compared between patients and controls. Prevalence and presentations of cardiovascular manifestations including blood pressure abnormalities and cardiac injuries among patients were recorded. Clinical presentations, echocardiographic parameters, intraoperative hemodynamic changes, fluid and inotropic support regimes were compared among subgroups of patients with or without LV hypertrophy or left ventricular longitudinal strain abnormalities.
Results
1. Of the78patients,66(84.6%) were hypertensive,3(3.8%) experienced hypotensive episodes,45(57.7%) had histories indictive of cardiac injuries, including3(3.8%) with acute left-sided heart failure episodes,6(7.7%) with concurrent evolving cardiac enzyme elevation and alteration of ECG ST-T segment,6(7.7%) with decreased left ventricular ejection fraction(LVEF),5of which restored during follow-up,30(38.5%) with arrhythmias,25(32.1%) with LV hypertrophy as evidened by echocardiographic parameters.
2. Among hypertensive PH/PGL patients, levels of24-hour urinary norepinephrine (435[61-766] vs.110[35-242]μg/24h, p=0.006) and epinephrine(3.51[3.01-4.53] vs.2.88[2.32-3.89] μg/24h, p=0.016) were significantly higher in LV hypertrophic group than in normal geometry group, while the duration, manifestation (sustained vs. paroxysmal) and degree of blood pressure elevation did not differ between the two groups.
3. LVEF(75[70-79] vs.72[65-75]%, p=0.002), cardiac output index(3.30±0.75vs. 2.80±0.24L/min.m2, p<0.001), left ventricular mass index(LVMI)(56.9[41.1-109.5] vs.46.9[41.1-57.0] g/m2, p=0.002), left atrial volume index(LAVI)(25.62±7.02vs.19.03±5.07mL/m2, p<0.001) and mitral valve(MV) E/E'(average) ratio (8.42±3.93vs.6.46±2.44, p=0.003) in78PH/PGL patients was significantly higher than in46healthy controls. MV lateral E' velocity (11.72±3.34vs.13.50±4.32cm/s, p=0.012) was significantly lower in patients than in controls.
4. LV hypertrophy was associated with higher heart rate(93.4±20.6vs.77.3±15.8bpm, p=0.001), more prevalent arrhythmias(16in25vs.14in53, p=0.001), acute left-sided heart failure episodes(3in25vs.0in53, p=0.030), sustained LVEF depression(3in25vs.0in53, p=0.030) and ECG ST-T segment alterations in PH/PGL patients.
5. Comparing with16healthy control, LV peak systolic longitudinal strain was significantly lower in78PH/PGL patients(-18.5±3.8vs.-21.6±1.2%, p<0.001) as well as75PH/PGL patients with preserved LVEF (-18.9±3.3vs.-21.6±1.2%, p<0.001).
6. PH/PGL patients with normal LV geometry had significantly higher peak systolic longitudinal strain than patients with LV hypertrophy(-20.0±2.7vs.-15.3±3.9%, p<0.001), and significantly lower value than healthy controls(-20.0±2.7vs.21.6±1.2%, p=0.001).
7. In56patients undergoing surgical resection of the tumors,9patients with abnormal longitidinal strain required significantly higher net fluid intake(3200[2700-4700] vs.2550[1863-3300]ml, p=0.037) than47patients with normal longitudinal strain, while the blood loss and duration of surgeries of the two groups did not differ significantly.
Conclusions
1. PH/PGL can cause blood pressure alterations, arrhythmias, and cardiomyopathies. Decreased LVEF, often reversible, occurs occasionally.
2. Catecholamine is a causal factor of LV hypertrophy in PH/PGL patients independent of hypertension.
3. LV hypertrophy in PH/PGL patients is associated with arrhythmias, acute left-sided heart failure, LV diastolic dysfunction and elevated LV filling pressure.
4. Subclinical LV systolic dysfunction is present in certain PH/PGL patients with preserved LV ejeciton fraction.
5. LV longitudinal strain abnormalities in PH/PGL patients is associated with LV hypertrophy and the need for more rigourous fluid regiems during surgery.
引文
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