经食管实时三维超声心动图对比研究不同部位缺血致中度及以上二尖瓣反流瓣环形态及功能变化

目的 采用经食管实时三维超声心动图(RT-3D-TEE)对比分析不同部位缺血致中度及以上二尖瓣反流时二尖瓣瓣环形态及功能的变化规律,为外科成形术提供依据.方法选择前壁或下后壁心肌梗死缺血性心肌病伴中度及以上二尖瓣反流患者各11例(前壁病变组/下后壁病变组)和阵发性房颤患者20例(对照组).对所有患者进行RT-3D-TEE检查,获取完整心动周期内的实时三维超声图像,并使用Qlab软件后处理分析计算二尖瓣瓣环最大投影面积A-max、二尖瓣瓣环投影面积变化率A-change、二尖瓣瓣环最大面积出现于R-R间期的时间点AR-R%、二尖瓣瓣环最大周长C-max、二尖瓣瓣环周长变化率C-change、二尖瓣瓣环最大高度H-max、二尖瓣瓣环高度变化率H-change、二尖瓣瓣环在长轴方向最大位移D、二尖瓣瓣环最大前后径DAP、二尖瓣瓣环最大左右径DAIPm及上述两种径线比值DAIPm/DAP.结果 对照组A-change、AR-R%、C-change、D分别为(22.5±5.7)%、(54.6±5.0)%、(13.9±4.2)%、(15.1±1.8)mm,前壁病变组分别为(18.4±4.1)%、(58.8±5.8)%、(12.5±2.9)%、(11.2±1.6)mm;下后壁病变组分别为(16.0±4.1)%、(62.8±7.1)%、(8.0±2.6)%、(11.1±2.3)mm,3组间的差异均有统计学意义(F=6.780、7.245、9.827、22.346,P＜0.05).前壁病变组、下后壁病变组A-change明显低于对照组,差异均有统计学意义(t=-2.23,P=0.032;t=-3.53,P=0.001),但前壁病变组与下后壁病变组之间的差异无统计学意义(t=1.15,P=0.258).对照组、前壁病变组、下后壁病变组的AR-R%均出现在舒张期,下后壁病变组AR-R%出现的时相较其他各组明显延迟.前壁病变组、下后壁病变组AR-R%均高于对照组,且下后壁病变组与对照组之间的差异有统计学意义(t=3.76,P=0.001),但前壁病变组与对照组之间的差异无统计学意义(t=1.91,P=0.063);同时下后壁病变组AR-R%也高于前壁病变组,但差异无统计学意义(t=1.62,P=0.113).前壁病变组、下后壁病变组C-change均低于对照组,且下后壁病变组与对照组之间的差异有统计学意义(t=4.39,P=0.000),但前壁病变组与对照组之间的差异无统计学意义(t=-1.01,P=0.318);同时下后壁病变组C-change也明显低于前壁病变组,差异有统计学意义(t=-2.98,P=0.005).前壁病变组、下后壁病变组的D明显小于对照组,差异均有统计学意义(t=-5.43,P=0.000;t=-5.57,P=0.000),但前壁病变组与下后壁病变组之间的差异无统计学意义(t=0.12,P=0.903).对照组、前壁病变组、下后壁病变组A-max、C-max、H-max、H-change、DAIPm、DAP、DAIPm/DAP的差异均无统计学意义(F=1.340、1.440、0.391、1.421、0.046、0.926、1.107,P均＞0.05).结论 采用RT-3D-TEE定量评价不同部位缺血致二尖瓣反流时二尖瓣瓣环形态及运动变化规律是可行的.下后壁缺血性心肌病致中度及以上二尖瓣反流患者二尖瓣瓣环运动受损相对更明显,外科可进行针对性二尖瓣成形治疗.

Quantification of mitral annulus dynamics in different locations of ischeminc mitral regurgitation using transesophageal real-time 3-dimensional echocardiography

Objective To quantitatively assess the changes in shape and function of mitral annulus（MA） in moderate or more degree mitral regurgitatin（IMR） resulted from ischemic cardiomyopathy in different locations,and provide a pre-peration evaluation for mitral valvuloplasty.Methods Real-time 3-dimensional transesophageal echocardiography（RT-3D-TEE） was performed in 20 paroxysmal atrial fibrillation patients,11 anterior myocardial infarction（MI） patients with moderate IMR,and 11 inferior or posterior MI patients with moderate IMR.The real-ime three-dimensional dynamic images were obtained in a complete cardiac cycle.The parameters of RT-3D-TEE,including maximum area of MA in projection plane（A-max）,change rate of MA area in projection plane（A-change）,maximum area of MA in projection plane timing（AR-R%）,maximum perimeter of MA（C-max）,change rate of MA perimeter（C-change）,maximum height of MA（H-max）,change rate of MA height（H-change）,MA maximum displacement from end diastole（D）,anterolateral to posteromedial diameter of annulus（DAIPm）,anterior to posterior diameter of annulus（DAP）,and DAIPm/DAP,were analyzed by 3D-QLab software.Results For the values of A-change,AR-R%,C-change,and D,they were（22.5±5.7）%,（54.6±5.0）%,（13.9±4.2）%,and（15.1±1.8）mm in the group of control;were（18.4±4.1）%,（58.8±5.8）%,（12.5±2.9）%,and（11.2±1.6）mm in the group of anterior;were（16.0±4.1）%,（62.8±7.1）%,（8.0±2.6）%,and（11.1±2.3） mm in the group of inferior-posterior respectively.There were significant differences among the three groups in the above parameters（F=6.780,7.245,9.827,22.346,P〉0.05）.The values of A-change in groups of anterior and inferior-posterior were significantly lower than that in group of control（t=-2.23,P=0.032;t=-3.53,P=0.001）.However,there were no significant differences between anterior and inferior-posterior（t=1.15,P=0.258）.The AR-R% appeared in the diastolis for all of the three groups.But the AR-R% in inferior-posterior occurred significantly later than other two groups.The values of AR-R% in groups of anterior and inferior-posterior were higher than that in group of control,but the significant difference was present only in the comparison of inferior-posterior and control（t=3.76,P=0.001）.There was also no significant difference between inferior-posterior and anterior（t=1.62,P=0.113）.The values of C-change in groups of anterior and inferior-posterior were lower than that in group of control（t=4.39,P=0.000;t=-2.98,P=0.005）.But no significant difference between anterior and control was found（t=-1.01,P=0.318）.Similarly,the values of D in groups of anterior and inferior-posterior were lower than that in group of control（t=-5.43,P=0.000;t=-5.57,P=0.000）.But no significant difference between anterior and inferior-posterior was found（t=0.12,P=0.903）.In addition,there were no significant differences among the three groups in the following parameters： A-max,C-max,H-max,H-change,DAIPm,DAP,DAIPm/DAP（F=1.340,1.440,0.391,1.421,0.046,0.926,1.107,all P〉0.05）.Conclusions MA tracking by RT-3D-TEE was feasible for all subjects in this study.The function impairment of MA is relatively more severe in inferior or posterior MI patients with moderate or more degree IMR.We can quantitatively assess the change of MA in patients with mitral regurgitation due to ischemina of different locations,and provide evidence for targeted surgical mitral valvuloplasty.