应用超声背向散射积分技术评价糖尿病心肌病变的研究
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摘要
目的 本研究应用超声背向散射积分技术研究糖尿病患者的心肌超声组织特征，旨在探讨超声背向散射积分(Integrated Backscatter，IBS)参数测定在评价糖尿病患者心肌病变方面的临床应用价值。
方法 采用HP SONOS 5500型超声诊断仪，该机配置声学密度定量-背向散射积分(AD-IBS)联机采样分析软件，检测了17例无微血管并发症的2型糖尿病患者(Ⅰ组)和17例有微血管并发症的糖尿病患者(Ⅱ组)以及16例正常人(对照组)心肌的心动周期时间平均背向散射积分(IBS)、背向散射积分标化值(IBS％)、背向散射积分周期变异幅度(CVIB)、背向散射积分跨壁梯度(TGIB)等超声背向散射积分参数，采样部位为胸骨旁左室长轴切面室间隔及左室后壁心肌的中间段。同时测定糖尿病患者的糖化血红蛋白(HbAlc)水平。运用t检验进行三组受检者心肌超声背向散射积分参数的显著性检验，对糖尿病患者的TGIB与HbAlc进行相关性分析，P＜0.05定义为有统计学意义。
结果 1．糖尿病Ⅰ组室间隔及左室后壁心肌的IBS％均明显高于对照组(P＜0.05)；糖尿病Ⅱ组室间隔及左室后壁心肌的IBS％均显著高于对照组(P＜0.01)。2．糖尿病Ⅰ组室间隔及左室后壁心肌的CVIB均明显低于对照组(P＜0.05)；糖尿病Ⅱ组室间隔及左室后壁心肌的CVIB均显著低于对照组(P＜0.01)。3．糖尿病Ⅰ组室间隔及左室后壁心肌的TGIB均显著高于对照组(P＜0.01)；糖尿病Ⅱ组室间隔及左室后壁心肌的TGIB均显著高于对照组(P＜0.001)。4．糖尿病Ⅱ组室间隔及左室后壁心肌的IBS％均明显高于糖尿病Ⅰ组(P＜0.05，P＜0.01)。5．糖尿病Ⅱ组室间隔及左室后壁心肌的CVIB均明显低于糖尿病Ⅰ组(P＜0.05)。6．糖尿病Ⅱ组室间隔及左室后壁心肌的TGIB均显著高于糖尿病Ⅰ组(P＜0.01)。7．糖尿病组(Ⅰ组、Ⅱ组)室间隔及左室后壁心肌的TGIB与糖化血红蛋白(HbAlc)水平之间呈较高的相关性，相关系数有统计学意义(相关系数分别为0.481，0.642，P＜0.01，P＜0.001)。
结论 心肌超声背向散射积分参数测定可敏感地早期检测糖尿病患者的心肌病变，协助判断心肌病变的程度，揭示其内在进展，作为一种无创、安全、费用低的检查值得临床推广和应用。
Objective To evaluate the diagnostic value of ultrasonic integrated
backscatter (IBS) technique in detecting myocardial damage in patients with type 2 Diabetes Mellitus .
Methods Seventeen type 2 Diabetes Mellitus patients without noncardiac
diabetic complications, seventeen type 2 Diabetes Mellitus patients with noncardiac diabetic complications and sixteen normal subjects were studied by Hewlett Packard SONOS echocardiographic system with AD-IBS. The time averaged value of IB(IBS),the calibrated time-averaged value of IB(IBS% ) , the magnitude of the cyclic variation of IB(CVIB),and the transmural gradient of IBS%(TGIB) were detected. The area of interest for backscatter measurements was placed in the septum wall and in the left ventricular posterior wall(parasternal long-axis view ).Glycosylated hemoglobin (HbAlc) was measured in the patients with type 2 Diabetes Mellitus .Intergroup differences were tested for significance by means of Student's t tests.The correlation between TGffi and HbAlc was analyzed.
Resu Its 1 .The IBS% of the septum and left ventricular posterior wall was
significantly higher in diabetic patients than in the control group(P<0.05).2.The CVIB of the septum and left ventricular posterior wall was significantly lower in diabetic patients than in the control group(P<0.05).3.The TGIB values increased significantly in the patients group (P<0.01).4. Integrated backscatter parameters of patients with noncardiac diabetic complications had significant difference from those of patients without noncardiac diabetic complications (P<0.05) .5.In
diabetic patients ,there was a significant correlation between glycosylated hemoglobin (HbAlc) and TGIB(r=0.481,0.642,P<0.01,P<0.001).
Conlusions Ultrasonic integrated backscatter parameters are helpful in
assessing myocardial damage sensitively and determining of the degrees of myocardium injury of type 2 Diabetes Mellitus patients.
方法 采用HP SONOS 5500型超声诊断仪，该机配置声学密度定量-背向散射积分(AD-IBS)联机采样分析软件，检测了17例无微血管并发症的2型糖尿病患者(Ⅰ组)和17例有微血管并发症的糖尿病患者(Ⅱ组)以及16例正常人(对照组)心肌的心动周期时间平均背向散射积分(IBS)、背向散射积分标化值(IBS％)、背向散射积分周期变异幅度(CVIB)、背向散射积分跨壁梯度(TGIB)等超声背向散射积分参数，采样部位为胸骨旁左室长轴切面室间隔及左室后壁心肌的中间段。同时测定糖尿病患者的糖化血红蛋白(HbAlc)水平。运用t检验进行三组受检者心肌超声背向散射积分参数的显著性检验，对糖尿病患者的TGIB与HbAlc进行相关性分析，P＜0.05定义为有统计学意义。
结果 1．糖尿病Ⅰ组室间隔及左室后壁心肌的IBS％均明显高于对照组(P＜0.05)；糖尿病Ⅱ组室间隔及左室后壁心肌的IBS％均显著高于对照组(P＜0.01)。2．糖尿病Ⅰ组室间隔及左室后壁心肌的CVIB均明显低于对照组(P＜0.05)；糖尿病Ⅱ组室间隔及左室后壁心肌的CVIB均显著低于对照组(P＜0.01)。3．糖尿病Ⅰ组室间隔及左室后壁心肌的TGIB均显著高于对照组(P＜0.01)；糖尿病Ⅱ组室间隔及左室后壁心肌的TGIB均显著高于对照组(P＜0.001)。4．糖尿病Ⅱ组室间隔及左室后壁心肌的IBS％均明显高于糖尿病Ⅰ组(P＜0.05，P＜0.01)。5．糖尿病Ⅱ组室间隔及左室后壁心肌的CVIB均明显低于糖尿病Ⅰ组(P＜0.05)。6．糖尿病Ⅱ组室间隔及左室后壁心肌的TGIB均显著高于糖尿病Ⅰ组(P＜0.01)。7．糖尿病组(Ⅰ组、Ⅱ组)室间隔及左室后壁心肌的TGIB与糖化血红蛋白(HbAlc)水平之间呈较高的相关性，相关系数有统计学意义(相关系数分别为0.481，0.642，P＜0.01，P＜0.001)。
结论 心肌超声背向散射积分参数测定可敏感地早期检测糖尿病患者的心肌病变，协助判断心肌病变的程度，揭示其内在进展，作为一种无创、安全、费用低的检查值得临床推广和应用。
Objective To evaluate the diagnostic value of ultrasonic integrated
backscatter (IBS) technique in detecting myocardial damage in patients with type 2 Diabetes Mellitus .
Methods Seventeen type 2 Diabetes Mellitus patients without noncardiac
diabetic complications, seventeen type 2 Diabetes Mellitus patients with noncardiac diabetic complications and sixteen normal subjects were studied by Hewlett Packard SONOS echocardiographic system with AD-IBS. The time averaged value of IB(IBS),the calibrated time-averaged value of IB(IBS% ) , the magnitude of the cyclic variation of IB(CVIB),and the transmural gradient of IBS%(TGIB) were detected. The area of interest for backscatter measurements was placed in the septum wall and in the left ventricular posterior wall(parasternal long-axis view ).Glycosylated hemoglobin (HbAlc) was measured in the patients with type 2 Diabetes Mellitus .Intergroup differences were tested for significance by means of Student's t tests.The correlation between TGffi and HbAlc was analyzed.
Resu Its 1 .The IBS% of the septum and left ventricular posterior wall was
significantly higher in diabetic patients than in the control group(P<0.05).2.The CVIB of the septum and left ventricular posterior wall was significantly lower in diabetic patients than in the control group(P<0.05).3.The TGIB values increased significantly in the patients group (P<0.01).4. Integrated backscatter parameters of patients with noncardiac diabetic complications had significant difference from those of patients without noncardiac diabetic complications (P<0.05) .5.In
diabetic patients ,there was a significant correlation between glycosylated hemoglobin (HbAlc) and TGIB(r=0.481,0.642,P<0.01,P<0.001).
Conlusions Ultrasonic integrated backscatter parameters are helpful in
assessing myocardial damage sensitively and determining of the degrees of myocardium injury of type 2 Diabetes Mellitus patients.
引文
1 Unsitupa MJ.Mustonen JN,Juhani KE.Diabetic heart muscle disease.Ann Med, 1990,22:377-379
2 Smogorzewski M,Galfayan V.Massry SG.High glucose concentration causes a rise in [Ca2+]i of cardiac myocytes.Kidney International, 1998, 53:1237-1243
3 Rodrigues B,Cam Mc,McNeill JH.Metabolic disturbances in diabetic cardiomyopathy.Mol Cell Biochem, 1998,180:53-57
4 Masuyama T,Valantine HA,Gibbons R,et al.Serial measurement of integrated ultrasonic backscatter in human cardiac allografts for the recognition of acute rejection .Circulation,1990,81:829-839
5 Lattanzi F,Di Bello V,Picano E,et al ,Normal ultrasonic myocardial reflectivity integrated in athletes with increased left ventricular mass: A tissue characterization study . Circulation ,1992,85 (5) : 1828-1834
6 Naito J ,Masuyama T,Tanoachi J,et al .Analysis of transmural trend of myocardial integrated ultrasound backscatter for differentiation of hypertrophic cardiomyopathy and ventricular hypertrophy due to hypertension.J Am Coll Cardiol,1994, 24(2) :517-524
7 Vitale DF,Bonow RO,Gerundo G.Alterations in ultrasonic backscatter during exercise-induced myocardial ischemia in humans.Circulation, 1995,92:1452-1457
8 Naito J,Masuyama T,Mano,T,et al.Ultrasonic myocardial tissue characterization in patients with dilated cardiomyopathy:value in noninvasive assessment of myocardial fibrosis.Am Heart J,1996, 131:115-121．
9 Naito J,Masuyama T,Yamamoto K,et al. Myocardial integrated ultrasonic backscatter in patients with old myocardial infarction: comparison with radionuclide evaluation. Am Heart J, 1996,132:54-60
10 Schecter SO,Teichhloz LE,Klig V,et al.Ultrasonic tissue characteri-zation.Echocardiography, 1996,13:415-430
11 Mimbs LW, O'Donnell M, Miller JG,et al.Detection of cardiomyopathic changes induced by doxorubicin based on quantitative analysis of ultrasonic backscatter. Am J Cardiol ,1981,47:1056-1062
12 Hoyt RH,Skorton DJ,Cottirs SM,et al.Ultrasonic backscatter and collagen in normal ventricular myocardium. Circulation, 1984, 69:775-782
13 Mimbs JW, O'Donnell M,Bauwens D,et al.The dependence of ultrasonic attenuation and backscatter on collagen content in dog and rabbit hearts .Circ Res,1980,47:49-56
14 Hoyt RH,Collins SM,Skorton DJ,et al.Assessment of fibrosis in infarcted human hearts by analysis of ultrasonic backscatter. Circulation 1985,71:740-744
15 Miller JG,Perez JE,Sobel BE.Ultrasonic characterization of myocardium. Prog Cardiovasc Dis.l985,28:85-110
16 Perez JE,Miller JG,Barazilai B,et al.Progress in quantitative ultrasonic characterization of myocardium: from the laboratory to the bedside.J Am Soc Echocardiogr 1988,1:294-305
17 Picno E,Pelosi G,Marzilli M,et al.In vivo quantitative ultrasonic evaluation of myocardial fibrosis in man.Circulaion, 1990,81:58-64
18 Lythall D,Bishop J,Greenbaum RA,et al.Relaionship between myocardial collagen on echo amplitude in non fibrotic hearts Eur Heart J 1993,14:344-350
19 Madaras EI,Barzilai B,Perez JE,et al.Changes in myocardial backscatter throughout cardiac cycle. Ultrasonic Imaging, 1983,5:229-239
20 Wickline SA ,Thomas III LJ,Miller JG,et al.A relationship between ultrasonic integrated backscatter and myocardial contractile function. J Clin Invest, 1985,76:2151-2160
21 O'Brein PD, O'Brein WD,Rhyne TL,et al.Relation of ultrasonic backscatter and acoustic propagation properties to myofibrillar length and myocardial thickness.Circulation,1995,1(91) :171-175
22 Pasquet A ,D'Hondt AM,Melin JA,et al.Relation of ultrasonic tissue characterization with integrated backscatter to contractile reserve in chronic left ventricular ischemic dysfunction.Am J Cardiol,1998,81(1) :68-74
23 Kiran B Sugar,Lori E Pelc,Theodore L Rhyne,et al.Influence of heart rate,preload,afterload, and inotropic state on myocardial ultrasonic backscatter. Circulation, 1988,77(2) :478-483
24 Naito J,Masuyama T,Mano T,et al.Influence of preload,afterload,and contractility on myocardial ultrasonic tissue characterization with integrated backscatter.Ultrasound Med Biol,1996,22(3) :305-312
25 Holland MR,Wilkenshoff UM,Finch JAE,et al.Effcts of myocardial fiber orientation in echocardiography:quantitative measurements and computer simulation of the regional dependence of backscatter ultrasound in the parasternal
short-axis view.J Am Soc Echocardiogr,1998,11(10) :929-937
26 Ledet T.Diabetic cardiomyopathy:quantitative histological studies of the heart from young juvenile diabetics.Acta Path Microiol.Scand. Sect. A, 1976,84:421-428
27 Regan TJ,Weisse AB .Diabetic cardiomyopthy J Am Coll Cardiol, 1992,19:1165-1166
28 Regan TJ,Lyons MM,Ahmed SS,et al.Evidence for cardiomyopathy in familial diabetes mellitus J Clin Invest, 1977,60:885-899
29 Kannel WB ,Hjortland M,Castelli WP.Role of diabetes in congestive heart failure:the Framingham study.Am J cardiol, 1974,34:29-34
30 Factor SM,Borezuk A.Charron MJ,et al.Myocardial alterations in diabetes and hypertension.Diab Res Clin Pract, 1996,31(Suppl):S133-S 142
31 Ruber S,Diugash J,Yaceglu YZ,et,al.New type of cardiomegaly associated with diabetic glomeruloselerosis.Am J Cardiol, 1972, 30:595-602
32 Thompson EDW.Structural manifestations of diabetic cardiomyopathy in the rat and its reversal by insulin treatment.Am J Anat, 1988,182:270-282
33 Di Bello V,Talarico L,Picano E,et al.Increased echodensity of myocardial wall in the diabetic heart:an ultrasound tissue characterization study.J Am Coll Caridol,1995,25(6) :1408-1415
34 Naito J,Masuyama T,Mano,et al.Analysis of transmural trend of myocardial integrated ultrasonic backscatter in patients with old myocardial infarction.UltrasoundMed.Biol,1996,22:807-814
35 Wickline SA,Verdonk E,Wong AK,et al.Structural remodeling of human myocardial tissue after infarction:quantification with ultrasonic backscatter. Circulation, 1992,85:259-268．
36 Naito J,Koretsune Y,Sakamoto N,et al.Transmural heterogeneity of myocardial integrated bacdscatter in diabetic patients without overt cardiac diseased.Diabetes Res Clin Pract,2001,52(1) : 11-20
37 Kawaguchi M , Techigawara M , Ishihata T , et al. A comparison of ultrastructural changes on endomyocardial biopsy specimens obtained from patients with diabetes mellitus with and without hypertension. Heart Vessel, 1997,12:267-274
38 Thompson E.D.W.Structural manifestations of diabetic cardiomyopathy in the rat and its reversal by insulin treatment. Am J Anat, 1988,182:270-282
39 Grossman E, Messerli F.H. Diabetic and hypertensive heart disease.Ann Intern Med,1996,125:304-310
2 Smogorzewski M,Galfayan V.Massry SG.High glucose concentration causes a rise in [Ca2+]i of cardiac myocytes.Kidney International, 1998, 53:1237-1243
3 Rodrigues B,Cam Mc,McNeill JH.Metabolic disturbances in diabetic cardiomyopathy.Mol Cell Biochem, 1998,180:53-57
4 Masuyama T,Valantine HA,Gibbons R,et al.Serial measurement of integrated ultrasonic backscatter in human cardiac allografts for the recognition of acute rejection .Circulation,1990,81:829-839
5 Lattanzi F,Di Bello V,Picano E,et al ,Normal ultrasonic myocardial reflectivity integrated in athletes with increased left ventricular mass: A tissue characterization study . Circulation ,1992,85 (5) : 1828-1834
6 Naito J ,Masuyama T,Tanoachi J,et al .Analysis of transmural trend of myocardial integrated ultrasound backscatter for differentiation of hypertrophic cardiomyopathy and ventricular hypertrophy due to hypertension.J Am Coll Cardiol,1994, 24(2) :517-524
7 Vitale DF,Bonow RO,Gerundo G.Alterations in ultrasonic backscatter during exercise-induced myocardial ischemia in humans.Circulation, 1995,92:1452-1457
8 Naito J,Masuyama T,Mano,T,et al.Ultrasonic myocardial tissue characterization in patients with dilated cardiomyopathy:value in noninvasive assessment of myocardial fibrosis.Am Heart J,1996, 131:115-121．
9 Naito J,Masuyama T,Yamamoto K,et al. Myocardial integrated ultrasonic backscatter in patients with old myocardial infarction: comparison with radionuclide evaluation. Am Heart J, 1996,132:54-60
10 Schecter SO,Teichhloz LE,Klig V,et al.Ultrasonic tissue characteri-zation.Echocardiography, 1996,13:415-430
11 Mimbs LW, O'Donnell M, Miller JG,et al.Detection of cardiomyopathic changes induced by doxorubicin based on quantitative analysis of ultrasonic backscatter. Am J Cardiol ,1981,47:1056-1062
12 Hoyt RH,Skorton DJ,Cottirs SM,et al.Ultrasonic backscatter and collagen in normal ventricular myocardium. Circulation, 1984, 69:775-782
13 Mimbs JW, O'Donnell M,Bauwens D,et al.The dependence of ultrasonic attenuation and backscatter on collagen content in dog and rabbit hearts .Circ Res,1980,47:49-56
14 Hoyt RH,Collins SM,Skorton DJ,et al.Assessment of fibrosis in infarcted human hearts by analysis of ultrasonic backscatter. Circulation 1985,71:740-744
15 Miller JG,Perez JE,Sobel BE.Ultrasonic characterization of myocardium. Prog Cardiovasc Dis.l985,28:85-110
16 Perez JE,Miller JG,Barazilai B,et al.Progress in quantitative ultrasonic characterization of myocardium: from the laboratory to the bedside.J Am Soc Echocardiogr 1988,1:294-305
17 Picno E,Pelosi G,Marzilli M,et al.In vivo quantitative ultrasonic evaluation of myocardial fibrosis in man.Circulaion, 1990,81:58-64
18 Lythall D,Bishop J,Greenbaum RA,et al.Relaionship between myocardial collagen on echo amplitude in non fibrotic hearts Eur Heart J 1993,14:344-350
19 Madaras EI,Barzilai B,Perez JE,et al.Changes in myocardial backscatter throughout cardiac cycle. Ultrasonic Imaging, 1983,5:229-239
20 Wickline SA ,Thomas III LJ,Miller JG,et al.A relationship between ultrasonic integrated backscatter and myocardial contractile function. J Clin Invest, 1985,76:2151-2160
21 O'Brein PD, O'Brein WD,Rhyne TL,et al.Relation of ultrasonic backscatter and acoustic propagation properties to myofibrillar length and myocardial thickness.Circulation,1995,1(91) :171-175
22 Pasquet A ,D'Hondt AM,Melin JA,et al.Relation of ultrasonic tissue characterization with integrated backscatter to contractile reserve in chronic left ventricular ischemic dysfunction.Am J Cardiol,1998,81(1) :68-74
23 Kiran B Sugar,Lori E Pelc,Theodore L Rhyne,et al.Influence of heart rate,preload,afterload, and inotropic state on myocardial ultrasonic backscatter. Circulation, 1988,77(2) :478-483
24 Naito J,Masuyama T,Mano T,et al.Influence of preload,afterload,and contractility on myocardial ultrasonic tissue characterization with integrated backscatter.Ultrasound Med Biol,1996,22(3) :305-312
25 Holland MR,Wilkenshoff UM,Finch JAE,et al.Effcts of myocardial fiber orientation in echocardiography:quantitative measurements and computer simulation of the regional dependence of backscatter ultrasound in the parasternal
short-axis view.J Am Soc Echocardiogr,1998,11(10) :929-937
26 Ledet T.Diabetic cardiomyopathy:quantitative histological studies of the heart from young juvenile diabetics.Acta Path Microiol.Scand. Sect. A, 1976,84:421-428
27 Regan TJ,Weisse AB .Diabetic cardiomyopthy J Am Coll Cardiol, 1992,19:1165-1166
28 Regan TJ,Lyons MM,Ahmed SS,et al.Evidence for cardiomyopathy in familial diabetes mellitus J Clin Invest, 1977,60:885-899
29 Kannel WB ,Hjortland M,Castelli WP.Role of diabetes in congestive heart failure:the Framingham study.Am J cardiol, 1974,34:29-34
30 Factor SM,Borezuk A.Charron MJ,et al.Myocardial alterations in diabetes and hypertension.Diab Res Clin Pract, 1996,31(Suppl):S133-S 142
31 Ruber S,Diugash J,Yaceglu YZ,et,al.New type of cardiomegaly associated with diabetic glomeruloselerosis.Am J Cardiol, 1972, 30:595-602
32 Thompson EDW.Structural manifestations of diabetic cardiomyopathy in the rat and its reversal by insulin treatment.Am J Anat, 1988,182:270-282
33 Di Bello V,Talarico L,Picano E,et al.Increased echodensity of myocardial wall in the diabetic heart:an ultrasound tissue characterization study.J Am Coll Caridol,1995,25(6) :1408-1415
34 Naito J,Masuyama T,Mano,et al.Analysis of transmural trend of myocardial integrated ultrasonic backscatter in patients with old myocardial infarction.UltrasoundMed.Biol,1996,22:807-814
35 Wickline SA,Verdonk E,Wong AK,et al.Structural remodeling of human myocardial tissue after infarction:quantification with ultrasonic backscatter. Circulation, 1992,85:259-268．
36 Naito J,Koretsune Y,Sakamoto N,et al.Transmural heterogeneity of myocardial integrated bacdscatter in diabetic patients without overt cardiac diseased.Diabetes Res Clin Pract,2001,52(1) : 11-20
37 Kawaguchi M , Techigawara M , Ishihata T , et al. A comparison of ultrastructural changes on endomyocardial biopsy specimens obtained from patients with diabetes mellitus with and without hypertension. Heart Vessel, 1997,12:267-274
38 Thompson E.D.W.Structural manifestations of diabetic cardiomyopathy in the rat and its reversal by insulin treatment. Am J Anat, 1988,182:270-282
39 Grossman E, Messerli F.H. Diabetic and hypertensive heart disease.Ann Intern Med,1996,125:304-310