超声心动图右室面积变化分数筛查左心室射血分数降低的心力衰竭患者心脏同步性研究

doi:10.16150/j.1671-2870.2022.03.007

摘要/Abstract

摘要：

目的：观察左室射血分数降低的心力衰竭（heart failure with reduced ejection fraction,HFrEF）患者的心脏机械收缩同步性情况,进而探讨采用超声心动图右室面积变化分数（right ventricular fractional area change,RVFAC）在该人群中筛查心脏机械收缩不同步者的临床价值。方法：54例HFrEF住院患者接受心电图、常规超声心动图、组织多普勒及二维斑点追踪显像检查,并根据超声心动图RVFAC结果（<18%、18%~34%和≥34%）分组,观察并比较各组间的心脏电学不同步及机械不同步（包括心室间不同步、房室不同步、左心室内不同步）情况。结果：根据RVFAC结果将患者分为3组,第1组RVFAC<18%（右心室功能显著下降）19例（35.2%）;第2组RVFAC为18%~34%（轻度下降）19例（35.2%）;第3组RVFAC≥34%（正常）16例（29.6%）。3组患者间的完全性左束支传导阻滞发生率无差异,但第1组QRS时限较第3组明显延长[（146.7±37.5） ms比（105.7±31.0） ms,P=0.003];与第2组及第3组比较,第1组的电学不同步发生率较高（以下顺序均为第1组比第2组比第3组,72%比58%比28%,P=0.012）,房室不同步[LV-FT/RR,（37.1±10.2） ms比（45.6±8.4） ms比（48.5±5.6） ms,P<0.01]以及心室间不同步[心室间机械延迟时间（interventricular mechanical delay, IVMD）,（49.9±29.9） ms比（26.4±27.0） ms比（6.9±35.4） ms,P<0.01]程度更重。左心室内不同步方面,3组间发生率和不同步指数差异无统计学意义。与右室功能正常的第3组患者比较,第1组的室间隔闪烁（septal flash, SF）现象检出率增高（47%比37%,P=0.02）,而第1组与第2组间无差异。结论：在HFrEF患者中,存在严重右室收缩功能异常者,其心脏机械收缩不同步的发生率更高,程度更重。超声心动图RVFAC可用于筛查HFrEF患者中需要接受心脏再同步化治疗者。

关键词: 心力衰竭, 心脏机械收缩不同步, 右室收缩功能, 超声心动图

Abstract:

Objective: To investigate the status of synchronization of cardiac mechanical contraction by means of echocardiogram in heart failure patients with reduced ejection fraction (HFrEF), and analyze use of right ventricular fractional area change (RVFAC) for screening cardiac mechanical dyssynchrony in the population. Methods: A total of 54 hospitalized patients with HFrEF were enrolled, with a mean left ventricular ejection fraction(LVEF) of 33.2%±10.1%. The patients received echocardiogram, echocardiographic and tissue Doppler imaging and 2D speckle tracking imaging. and were divided into three groups according to RVFAC level: Group 1, 19 patients with RVFAC<18%; Group 2, 19 patients with RVFAC 18%-34%; Group 3,16 patients with RVFAC≥34%. The occurrence and degree of of cardiac electrical and mechanical dyssynchrony (atrioventricular dyssynchrony, interventricular dyssynchrony and intraventricular dyssynchorny) were compared between the 3 groups. Results: There was no significant difference in the proportion of complete left bundle branch block among the 3 groups. However, compared with that in Group 3, mean QRS duration was significantly prolonged in group 1[(146.7±37.5) ms vs. (105.7±31.0) ms, P=0.003]. Compared with group 2 and 3, group 1 had higher the prevalence rate of electrical dyssynchrony (QRS>120 ms)（72%, 58%, 28%, P=0.012）, and higher the abnormal rate and more severe degree of both atrioventricular dyssynchrony index[LV-FT/RR, (37.1±10.2) ms vs. (45.6±8.4) ms vs. (48.5±5.6) ms, P<0.01] and interventricular dyssynchrony index [interventricular mechanical delay, IVMD, (49.9±29.9) ms vs. (26.4±27.0) ms vs. (6.9±35.4) ms, P<0.01]. For intraventricular dyssynchorny, asynchrony index showed no significant difference between 3 groups. Furthermore, compared with group 3 which had normal right ventricular function, Group 1 had a higher detection rate of septal flash (SF) sign (47% vs 37% in group 3, P=0.02). Conclusions: In those with HFrEF, patients with severe abnormal right ventricular systolic function have higher risk of cardiac mechanical dyssynchrony, and dyssynchrony is often more severe. RVFAC by echocardiogram may help to select those who will be benefit from cardiac resynchronization therapy in heart failure patients with HFrEF.

Key words: Heart failure, Cardiac mechanical dyssynchrony, Right ventricular systolic function, Echocardiography

中图分类号:

R541.6

桂燕萍, 陈晔芬, 施仲伟, 许燕. 超声心动图右室面积变化分数筛查左心室射血分数降低的心力衰竭患者心脏同步性研究[J]. 诊断学理论与实践, 2022, 21(03): 331-335.

GUI Yanping, CHEN Yefen, SHI Zhongwei, XU Yan. Study on use of right ventricular fractional area change assessed by echocardiogram for evaluating cardiac synchrony in heart failure patients with reduced left ventricular ejection fraction[J]. Journal of Diagnostics Concepts & Practice, 2022, 21(03): 331-335.

图/表 3

图1

表1

表2

参考文献 22

[1]	Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure[J]. N Engl J Med, 2002, 346(24):1845-1853. doi: 10.1056/NEJMoa013168 URL
[2]	Glikson M, Nielsen JC, Kronborg MB, et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy[J]. Eur Heart J, 2021, 42(35):3427-3520. doi: 10.1093/eurheartj/ehab364 URL
[3]	Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology(ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC[J]. Eur Heart J, 2016, 37(27):2129-2200. doi: 10.1093/eurheartj/ehw128 pmid: 27206819
[4]	van Everdingen WM, Walmsley J, Cramer MJ, et al. Echocardiographic prediction of cardiac resynchronization therapy response requires analysis of both mechanical dyssynchrony and right ventricular function: a combined analysis of patient data and computer simulations[J]. J Am Soc Echocardiogr, 2017, 30(10):1012-1020. doi: 10.1016/j.echo.2017.06.004 URL
[5]	Damy T, Ghio S, Rigby AS, et al. Interplay between right ventricular function and cardiac resynchronization therapy: an analysis of the CARE-HF trial (Cardiac Resynchronization-Heart Failure)[J]. J Am Coll Cardiol, 2013, 61(21):2153-2160. doi: 10.1016/j.jacc.2013.02.049 URL
[6]	Sharma A, Bax JJ, Vallakati A, et al. Meta-analysis of the relation of baseline right ventricular function to response to cardiac resynchronization therapy[J]. Am J Cardiol, 2016, 117(8):1315-1321. doi: 10.1016/j.amjcard.2016.01.029 URL
[7]	Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging[J]. Eur Heart J Cardiovasc Imaging, 2015, 16(3):233-270. doi: 10.1093/ehjci/jev014 URL
[8]	Cleland JG, Daubert JC, Erdmann E, et al. The CARE-HF study (Cardiac Resynchronisation in Heart Failure study): rationale, design and end-points[J]. Eur J Heart Fail, 2001, 3(4):481-489. pmid: 11511435
[9]	Lane RE, Chow AWC, Chin D, et al. Selection and optimisation of biventricular pacing: the role of echocardiography[J]. Heart, 2004,90(Suppl VI):vi10-vi16.
[10]	Yu CM, Lin H, Zhang Q, et al. High prevalence of left ventricular systolic and diastolic asynchrony in patients with congestive heart failure and normal QRS duration[J]. Heart, 2003, 89(1):54-60. pmid: 12482792
[11]	Bennett S, Tafuro J, Duckett S, et al. Septal flash as a predictor of cardiac resynchronization therapy response: a systematic review and meta-analysis[J]. J Cardiovasc Echogr, 2021, 31(4):198-206. doi: 10.4103/jcecho.jcecho_45_21 URL
[12]	Vecera J, Penicka M, Eriksen M, et al. Wasted septal work in left ventricular dyssynchrony: a novel principle to predict response to cardiac resynchronization therapy[J]. Eur Heart J Cardiovasc Imaging, 2016, 17(6):624-632. doi: 10.1093/ehjci/jew019 pmid: 26921169
[13]	Calle S, Delens C, Kamoen V, et al. Septal flash: At the heart of cardiac dyssynchrony[J]. Trends Cardiovasc Med, 2020, 30(2):115-122. doi: 10.1016/j.tcm.2019.03.008 URL
[14]	Lu KJ, Chen JX, Profitis K, et al. Right ventricular global longitudinal strain is an independent predictor of right ventricular function: a multimodality study of cardiac magnetic resonance imaging, real time three-dimensional echocardiography and speckle tracking echocardiography[J]. Echocardiography, 2015, 32(6):966-974. doi: 10.1111/echo.12783 URL
[15]	Haddad F, Peterson T, Fuh E, et al. Characteristics and outcome after hospitalization for acute right heart failure in patients with pulmonary arterial hypertension[J]. Circ Heart Fail, 2011, 4(6):692-699. doi: 10.1161/CIRCHEARTFAILURE.110.949933 URL
[16]	Haddad F, Doyle R, Murphy DJ, et al. Right ventricular function in cardiovascular disease, part Ⅱ: pathophysiolo-gy, clinical importance, and management of right ventri-cular failure[J]. Circulation, 2008, 117(13):1717-1731. doi: 10.1161/CIRCULATIONAHA.107.653584 URL
[17]	Anavekar NS, Gerson D, Skali H, et al. Two-dimensional assessment of right ventricular function: an echocardiographic-MRI correlative study[J]. Echocardiography, 2007, 24(5):452-456. doi: 10.1111/j.1540-8175.2007.00424.x URL
[18]	Dillon JC, Chang S, Feigenbaum H. Echocardiographic manifestations of left bundle branch block[J]. Circulation, 1974, 49(5):876-880. pmid: 4828608
[19]	Corteville B, de Pooter J, de Backer T, et al. The electrocardiographic characteristics of septal flash in patients with left bundle branch block[J]. Europace, 2017, 19(1):103-109. doi: 10.1093/europace/euv461 pmid: 26843575
[20]	Beela AS, ünlü S, Duchenne J, et al. Assessment of mechanical dyssynchrony can improve the prognostic value of guideline-based patient selection for cardiac resynchronization therapy[J]. Eur Heart J Cardiovasc Imaging, 2019, 20(1):66-74. doi: 10.1093/ehjci/jey029 URL
[21]	Doltra A, Bijnens B, Tolosana JM, et al. Mechanical abnormalities detected with conventional echocardiography are associated with response and midterm survival in CRT[J]. JACC Cardiovasc Imaging, 2014, 7(10):969-979. doi: 10.1016/j.jcmg.2014.03.022 URL
[22]	Maass AH, Vernooy K, Wijers SC, et al. Refining success of cardiac resynchronization therapy using a simple score predicting the amount of reverse ventricular remodelling: results from the Markers and Response to CRT (MARC) study[J]. Europace, 2018, 20(2):e1-e10.

指标	第1组（n=19）	第2组（n=19）	第3组（n=16）
年龄（岁）	57.2±12.8	60.8±18.2	56.8±16.5
男性（%）	11（57）	10（52）	8（50）
心率（次/min）	88.1±14.1	79.0±12.2^c）	71.7±12.3^c）
美国纽约心脏病协会分级（1~4）	3.5±0.5	3.0±0.7^a）	2.7±0.5^a）
左房内径（mm）	49.9±6.5	48.6±6.9	44.4±5.3^a）
左室舒张末内径（mm）	70.9±6.2	66.7±7.5	60.6±6.8^c）,d）
左室收缩末容积（mL）	176.9±41.7	131.8±35.2^a）,b）	92.6±25.7^c）,d）
LVEF（%）	28.9±11.1	31.2±8.5^a）,b）	37.1±8.9^c）,d）
二尖瓣反流（1°~4°）	2.5±1.1	2.2±1.2	1.6±1.1
E（m/s）	1.3±0.3	0.9±0.2	0.8±0.2^c）
S/D	0.4±0.2	0.8±0.5^c）	1.0±0.3^c）
E/Ea	29.9±10.3	16.1±8.1^a）	11.9±5.6^a）
三尖瓣环收缩期位移（mm）	8.9±2.7	11.2±5.2^c）,d）	13.1±3.2^c）,d）
左心室整体长轴应变（%）	-11.1±4.5	-14.1±4.8^c）	-16.1±3.8^c）

指标	第1组（n=19）	第2组（n=19）	第3组（n=16）
QRS时限（ms）	146.7±37.5	123.5±25.4	105.7±31.0^b）
CLBBB（%）	10（52）	11（57）	10（52）
LV-FT/RR（%）	37.1±10.2	45.6±8.4^b）	48.5±5.6^b）
IVMD（ms）	49.9±29.9	26.4±27.0^b）	6.9±35.4^b）
Ts-SD（ms）	42.0±11.8	41.5±11.4	42.9±12.3
SF（%）	9（47）	8（42）	6（37）^a）