摘要
尿毒症性心肌病是尿毒症患者常见的合并症之一，其严重影响了患者的生活质量和生存率，是尿毒症病人死亡的重要原因。因此临床上及时、正确诊断该病对指导治疗、提示预后有着重要意义。本研究旨在应用常规超声检查及引入TEI指数和DTI技术全面的就超声心动图对尿毒症性心肌病的诊断价值进行评价。
研究中对30例尿毒症患者（平均51.2岁）和30例正常体检者（平均53.0岁）进行常规二维超声心动图检查，测量其心腔内径，观察心包及瓣膜情况；通过Simpson方法测量左心功能；并通过多普勒超声心动图测量其综合射血等容期指数（TEI），应用多普勒组织成像技术（DTI）进一步分析左室舒张功能。对病例组及正常组进行对比研究以获得研究数据。并对12例接受肾移植的患者术后2周进行随访，观察、比较手术前后心脏结构及功能在超声心动图上的改变。
结果提示：与对照组相比，①在心脏结构方面，各心室腔腔径均有显著差异，心腔内径明显扩大，且以左心房、左心室更为明显。舒张期与收缩期室间隔及左室后壁厚度明显增加，
LVmass（心肌质量）亦较正常组明显增大，均证实尿毒症患者存在左室心肌肥厚。且腔径的扩大与心肌肥厚同时存在，有别于三种原发性心肌病的结构改变。多有程度不同的心包积液存在，考虑与毒素引起的非炎症性心包炎有关，也有别于其他类型心肌病。②在研究中还可发现病例组心肌回声有所改变，且改变的心肌回声呈现3种不同类型，不同类型又提示了其疾病的严重程度有所不同。③在心脏功能方面，研究发现患者组心脏收缩及舒张功能均有下降，其中又以舒张功能下降尤为明显，并证明了左室舒张功能障碍作为尿毒症患者心肌损害的早期指标是常见的。试验中也发现了舒张功能的假性正常化问题，并对其进行了进一步的研究。④应用TEI指数及DTI检测，结果均提示病例组舒张功能明显异常，并避免了常规超声心动图可能出现的假性正常化。从而评价了该指数和技术在尿毒症心肌病中的诊断意义。⑤在肾移植术后2周病人的超声心动图检查中，可发现与术前相比较，心腔大小（尤以左室明显）及室壁厚度有明显改善，收缩功能及舒张功能也有所改善，但尚无统计学意义。⑥研究还从指导临床治疗和提示预后两方面进行了探讨。在超声心动图检测的基础上，临床医生可对患者的心功能损害程度有明确的认识，并提出相应的治疗对策。同时也将
明确患者的临床预后，对临床工作有着重大意义。
综上研究表明尿毒症心肌病的超声心动图表现与正常对照组有显著差异，二维及多普勒超声心动图是检测尿毒症心肌损害的实用、敏感、无创检查，能为临床诊断、治疗提供指导并提示预后。其中TEI指数和DTI技术的应用为更及时、准确的分析心脏舒张功能提供了有力依据，为早期诊断及治疗提供了保障，且易行、实用，可广泛应用于临床。
Uremic Cardiomyopathy is a common complication of uremic cases that severely affect the life quality and survival rate of patients, and it is also one of common death causes of uremia patients. So it would have important meaning to guide the treatment and point out the prognosis，if you could timely and correctly diagnose this disease in clinic. This study means to assess the value of the echocardiography in diagnosing the uremic cardiomyopathy by using common echocardiography and introducing the TEI and DTI technology.
In this study, the common echocardiography was performed in 30 patients with uremia and in 30 healthy controls. We can measure the cardiac structure and observe the condition of pericardium and valves. We can measure the heart function by Simpon method and measure the TEI by Dopple echocardiography, also can further assess the left ventricular diastolic function by Dopple tissue imaging technology. The results will be gained by comparing the data of patients to that of healthy. 12 patients， who
received the kidney transplant surgery, received the echocardiography examination again after two weeks of surgery. The results would compared with original data. All of above, the study indicate that the heart enlarged, especially the left atrial and left ventricle，by compared the uremic patients with healthy cases; Interventricular septum and left ventricle obviously hypertrophied，left ventricular mass were apparently increased, left ventricular diastolic and systolic function was reduced. The diastole function was obviously reduced and this change would be found earlier. Both the results of TEI and DTI point out that the diastole function was obviously anormal and they also can get rid of the false normal results. In the study, we also found the morbility of pericardial effusion was higher in patients and myocardium echoes could be divided into three patterns. After examination of echocardiography for those who received kidney transplant surgery, we found that the heart enlargement and ventricle hypertrophy were all improved, but improvement of the diastolic and systolic function was not significant. From this study, we can get a conclusion that the expressions of echocardiography in patients with uremic
cardiomyopathy were obviously different from those in healthy cases. So echocardiography is a practical sensitive and non-trauma examination for diagnosing the uremic cardiomyopathy. It can offer guide for diagnosis and treatment, and also can point out the prognosis. By using TEI and DTI telegraphy, we can more timely and correctly access the cardiac diastole function and offer the guarantee for diagnosis earlier, so we can extensively used them in clinic.
引文
1.张树林主编，心脏舒张功能. 超声心动图学（第一版），北京医科大学中国协和医科大学联合出版社，1996：90.
2.周永昌、郭万学主编，超声心动图.超声医学（第三版），北京，科学技术文献出版社，1998：584~594.
3.李越主编，超声心动图新技术. 北京，科学文献技术出版社，2001：38~122
4.夏红梅、高云华、杨成业，左房M超评价冠心病左室舒张功能的临床研究. 中国医学影像技术，2000，11：13~15.
5.Cohen GI，Pietrolungo JF，Thomas JD，et al. A Practical guide to assessment of venticular diastolic fundction using Doppler echocardiography. CJJ，JACC，1996，27：1753~1758.
6.高峻，李治安，王新房等，多普勒组织成像探测二尖瓣环E/A比率评价左室舒张功能价值的探讨. 中国超声医学杂志，2000，11：849~853.
7.Abe M, Oki T, et al. Difference in the left ventricular wall motion velocities between aortic and mitral regurgitation by pulsed tissue Doppler imaging. J Am soc Echocardior, 1999,12:5~21.
8.刘爱玲, 王霞等. 应用声学定量评价冠心病左室舒张功能. 人民军医，2002，10：73~74.
9.张梅，张运等. 声学定量技术与心导管技术评价左心舒张功能对比研究. 中国心血管杂志，2002，1：46~47.
10.叶任高主编，冠状动脉粥样硬化性心脏病. 内科学（第五版），北京，人民卫生出版社，2001：280~309.
11.张志寿，扩张性心肌病. 心肌疾病的诊断与治疗，北京，人民军医出版社，2001：242~246.
12.史春志，李示野等，尿毒症性心肌病和超声心动图异常表现及心功能评价. 中国超声诊断杂志，2003，4：580~582.
13.冯均才，杨惠标. 尿毒症患者的心功能损害及防治进展. 国外医学内科学分册，1999，26（9）：380~383.
14.Caires G，Drumond A，Silva G，et al. Diastolic dysfunction in patients with chromic kidney failure on a hemodialysis program. Rev Port Cardiol，1998，17（7-8）：597~607.
15.胡大一主编，舒张性心力衰竭. 心脏病学实践2002-规范化治疗，人民卫生出版社，2002：375.