摘要
目的：
应用二维斑点追踪显像技术测量急性心肌梗死(AMI)患者圆周应变及左室扭转指标,分析患者左心室缺血心肌的运动特点,初步探讨急性心肌梗死对心肌应变和左心室扭转的影响及其意义；并探讨该技术在评价急性心肌梗死患者临床治疗及判断预后方面的应用价值。
方法：
入选急性心肌梗死患者143例,根据不同研究目的选择合适患者进行分组：1、根据心肌梗死部位不同：分为前壁心肌梗死组(59例)和下壁心肌梗死组(67例)；2、根据前壁心肌梗死患者左室射血分数(LVEF)不同：分为左室射血分数正常组(LVEF≥50%,37例)和左室射血分数下降组(LVEF＜50%,27例)：3、根据治疗方法不同：分为急诊PCI组(95例)、择期PCI组(27例)和保守治疗组(14例),并对患者进行平均10个月随访；4、根据左心室整体扭转角度峰值(Ptw)及左心室整体圆周应变(GCS)不同：以Ptw12°为界,分为Ptw≥12°组(63例)和Ptw<12°组(41例)；以GCS-12%为界,分为GCS≤-12%组(68例)和GCS>-12%组(36例)。
应用GE Vivid 7超声诊断仪,行常规二维超声检查,测量左室舒张末期内径(LVDd)、左室收缩末期内径(LVDs)、二尖瓣血流频谱E/A值、E峰减速时间(EDT)、左室射血分数(LVEF);留取胸骨旁左室短轴切面(二尖瓣、乳头肌、心尖水平)二维图像,应用二维应变软件测量各个节段圆周应变及旋转角度,记录各节段圆周应变峰值并计算GCS,同时记录心尖旋转角度峰值(PAR)及达峰时间、心底部旋转角度峰值(PBR)及达峰时间、左室整体扭转角度峰值(Ptw)及达峰时间。
结果：
1、急性心肌梗死患者圆周应变及旋转曲线特征：左心室短轴切面(二尖瓣、乳头肌、心尖水平)各节段圆周应变曲线紊乱,整体圆周应呈负向波即峰值为负值。心尖部各节段逆时针旋转，基底部各节段顺时针旋转,左心室整体为逆时针方向旋转。
2、不同心肌梗死部位分组比较：(1)前壁心肌梗死组前壁、室间隔、心尖各节段圆周应变峰值较下壁心肌梗死组明显减小,而下壁心肌梗死组后壁、下壁各节段圆周应变峰值较前壁心肌梗死组明显减小，且前壁心梗组GCS较下壁心梗组减小,p<0.05；(2)前壁心肌梗死组与下壁心肌梗死组比较,PAR显著减小,但PBR、Ptw差异无统计学意义；(3)对LVEF≥50%患者进行亚组分析,其结果与上述结果一致。
3、根据前壁心肌梗死不同左室射血分数分组：(1) LVEF<50%组基底部、乳头肌及心尖水平多个节段圆周应变峰值较LVEF≥50%组减小,前壁及室间隔各节段下降尤为显著,p<0.05；GCS亦明显下降；(2)两组患者PAR、PBR、Ptw相比较,LVEF<50%组均明显减小,p<0.05；(3)前壁心肌梗死、下壁心肌梗死患者GCS均与LVEF呈显著负相关。
4、Ptw与LVEF相关,r=0.345,p<0.01
5、不同治疗方法分组：急诊PCI与择期PCI两组患者住院期间各指标间无统计学差异；急诊PCI组及择期PCI组随访时GCS、PAR、Ptw均较住院时明显改善,p<0.05,而两组的改善程度无明显差异；保守治疗组随访前后上述指标无明显变化；
6、分别以GCS-12%及Ptw12°为界分组：GCS下降组死亡率明显增高，而Ptw分组死亡率无显著差异。
结论：
1、圆周应变值能准确定位梗死节段,可作为评价梗死心肌节段运动的定量指标。
2、左室整体圆周应变值能准确反映左室整体收缩功能,且可能较LVEF更敏感。
3、旋转、扭转参数是左室收缩功能的良好指标,心尖部旋转在左室扭转中起重要作用。
4、AMI患者及早开通梗死相关动脉预后较好，但尚需大样本进一步研究。
5、梗死早期的左室整体圆周应变峰值能在一定程度上反映AMI患者的预后,GCS-12%可作为AMI患者预后的预测指标,但尚需加大样本以进一步研究。
Objective:
To measure the index of left ventricular circumferential strain and twist in patients with acute myocardial infarction (AMI) by two-dimensional speckle tracking imaging (STI), analyze the charateristics of movement that LV ischemic muscle, and preliminarily assess AMI effect on the myocardial strain and left ventricular twist; To evaluate the clinical value of STI in clinical treatment and prognosis of AMI patients.
Methods:
143 patients with AMI are selected. They are divided according to different objectives:1. Be divided into two groups according to different parts of myocardial infarction:anterior myocardial infarction group (n=59) and inferior myocardial infarction group (n=67); 2. Be divided according to different left ventricular ejection fraction (LVEF) of anterior myocardial infarction patients:normal LVEF group (LVEF>50%, n=37) and abnormal LVEF group (LVEF<50%. n=27); 3. Be divided according to different therapeutic methods:emergeney percutancous intervention group (n=95), selecting time percutancous intervention group (n=27) and conservative treatment group (n=14), and do a follow-up of them, on average 10 months after discharge; 4. Be divided separately according to different LV global peak twist (Ptw) and LV global circumferential strain (GCS):To Ptw12°for critical value, Ptw≥12°group (n=63) and Ptw<12°group (n=41); To GCS-12% for critical value, GCS≤-12% group (n=68) and GCS>-12% group (n=36).
To do the conventional two-dimensional echocardiography with GE Vivid 7 ultrasound diagnostic applications, and conventional data including the LV diastolic diameter (LVDd), LV systolic diameter (LVDs), LVEF, E/A and E peak deceleration time (EDT); circumferential strain (Cs) and rotation were measured in the left ventricular short-axis views using 2D-strain software. To measure Cs of every section and calculate GCS, and then separately measure apical peak rotation (PAR), basal peak rotation (PBR), LV global peak twist (Ptw) and the time to peak.
Results:
1. The characteristic of Cs and rotation curve in AMI patients:the Cs curve of every section are disordered in left ventricular short-axis view (mitral, papillary muscle, apex level), GCS is negative wave, which means the peak is negative. The rotation of apical is anticlockwise, the rotation of basal is clockwise, and the rotation of left ventricular is anticlockwise in systole.
2. Be divided according to different parts of myocardial infarction:(1) The Cs of anterior, ventricular septal and apex in anterior myocardial infarction group is lower than them in inferior myocardial infarction group, while the Cs of posterior and inferior in inferior myocardial infarction group is lower than them in anterior myocardial infarction group, and the GCS of anterior myocardial infarction group is much lower than inferior myocardial infarction group.P<0.05; (2) Compared with inferior myocardial infarction, the value of PAR have significantly decreased in anterior myocardial infarction, but the values of PBR and Ptw have no significant difference; (3) For analysis of LVEF>50% patients, the results are the same as above.
3. Be divided according to different LVEF of anterior myocardial infarction patients: (1) Compared with the normal LVEF group, many sections Cs peak of basal, papillary muscle, apex level decreased in LVEF<50% group, the anterior and ventricular septal decreased primarily, p<0.05; GCS also significant decreased; (2) The value of PAR, PBR and Ptw in two groups, LVEF<50% group all significant decreased; (3) The negative correlation was found between GCS of anterior and inferior myocardial infarction patients and LVEF.
4. Ptw is correlated with LVEF, r=0.345,P<0.01.
5. Be divided according to different therapeutic method:Every index of patients in emergeney percutaneous coronary intervention (PCI) group and selecting time PCI group have no significant difference during in hospital; the value of GCS, PAR, Ptw in the follow-up improved in emergeney PCI group and selecting time PCI group, p<0.05. but improved degree of the two groups have no significant difference; these indexes in conservative treatment group have no significant difference.
6. To Ptw12°and GCS-12% for critical value:The mortality significantly increased in lower GCS group, while be divided according to Ptw, the mortality have no significant difference.
Conclusions:
1. Cs can accurately position infarcted section, and can serve as quantitative index of evaluating regional motion of infarcted myocardium.
2. GCS can reflect LV global systolic function, and maybe more accurate than LVEF.
3. The value of rotation and twist are good indexes that can reflect LV systolic function, and the rotation of apical is very important in LV twist.
4. The prognosis of patients with AMI that timely relieving of infarct-related artery is better, but needing increase the sample for research.
5. The value of GCS maybe can assess prognosis of patients with AMI, GCS-12% can serve as a index that assess prognosis of patients with AMI. but the number of the samples must be increased for futher research. Keywords:Speckle tracking imaging Acute myocardial infarction Circumferential strain Left ventricular twist Left ventricular ejection fraction
引文
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