应用超声多普勒评价不同QRS时限心力衰竭患者的收缩同步性

目的应用常规超声和组织多普勒技术评价收缩不同步在QRS时限正常及增宽的心力衰竭患者中的发生率。方法选择60例纽约心脏病学会(NYHA)分级心功能Ⅲ级的扩张型心肌病患者,其中QRS时限≤120ms者30例,QRS时限>120ms者30例,均接受常规超声和组织多普勒检查。以左、右心室射血前间期之差>40ms作为室间收缩不同步的指标。应用组织多普勒技术分别测量室间隔和左心室侧壁基底部心肌达到收缩峰值的时间,二者时差>60ms定义为室内收缩不同步。满足室间、室内收缩不同步标准任一项即视为存在收缩不同步。结果QRS时限≤120ms的心力衰竭患者中有23.3%存在收缩不同步,而QRS时限>120ms者中不同步比例高达86.7%,二者差异有统计学意义(P<0.01)。未发现QRS时限与超声证实的收缩不同步间存在相关性(P=0.112)。结论尽管QRS时限增宽心力衰竭患者的不同步比例很高,但仍有一定比例的患者同步性尚好。同时,亦有一定比例的QRS时限正常者存在收缩不同步。     

慢性心力衰竭校正QT间期与QT离散度及心功能相关性

目的 :探讨慢性心力衰竭患者校正QT间期 (QTc)与QT离散度 (QTd)及心功能超声参数相关性。方法 :研究了 12 6例左室射血分数 (LVEF) <4 5 %的慢性心力衰竭患者QTc与QTd、QRS间期、临床指标、心脏超声心动图参数的相关性。结果 :QTc与年龄 (r =0 .2 1,P <0 .0 1)、左室舒张末期直径 (r =0 .2 6 ,P <0 .0 1)、左房直径 (r =0 .2 4 ,P <0 .0 1)、QRS间期 (r =0 .37,P <0 .0 1)、QTd(r =0 .4 1,P <0 .0 1)呈正相关 ;与短轴缩短率 (r=- 0 .2 8,P <0 .0 1)、LVEF(r =- 0 .33,P <0 .0 1)呈负相关 ;与二尖瓣E波和A波峰值速度比值、等容舒张时间无相关性 (P >0 .0 5 )。多元回归分析显示 ,QTc和QTd、QRS间期、LVEF存在独立相关性。结论 :QTc与心力衰竭患者预后影响因素有关 ;QTc与QTd存在独立相关性 ,其生物相关性值得进一步研究     

心力衰竭患者的QT间期动态性的特点

目的：研究心衰患者QT间期动态性的特点,为预测心衰患者猝死风险提供参考。方法：从我院心内科住院病人选择80例慢性心衰患者（心衰组）,并另选择50例健康志愿者（健康对照组）,行24h动态心电图、体表心电图及心脏彩超检查,测量其左室射血分数（LVEF）、左心室舒张末期容量（LVEDV）、收缩末期容量（LVESV）、QT间期离散度（QTd）、心率变异性指标：24h正常RR间期标准差（SDNN）、QT／RR相关直线的斜率。结果：与健康对照组比较,心衰组的LVESV[（34．0±8．3）ml比（90．4±15．4）ml]、LVEDV[（86．0±32．2）ml比（150．3±30．4）ml]、OTd[（35．6±8．5）ms比（46．6±10．4）ms]、QTe／RR[（0．136±0．021）比（0．175±0．023）]和QTp／RR[（0．130±0．026）比（0．158±0．033）]斜率显著增大;SDNN[（140．3±53．3）ms比（100．4±40．3）ms]和LVEF[（60．6±8．4）％比（38．5±8．8）％]显著降低（P均〈0．01）。结论：心力衰竭患者心室复极的不稳定性使其QT／RR斜率明显高于正常者。     

左心室射血分数与心电图QRS波时程比值对老年心力衰竭患者心功能的评估

目的探讨LVEF与心电图QRS波时程(QRSd)比值(TEF)对老年射血分数保留的心力衰竭(心衰)患者心功能的评估价值。方法选取老年窦性心律左心功能不全患者879例,根据纽约心功能分级,Ⅰ级56例,Ⅱ级302例,Ⅲ级462例和Ⅳ级59例。治疗前完成心电图和心脏超声检查及心功能评估。LVEF减低定义为50%,TEF低值切入点定义为0.625,按年龄、LVEF、心电图QRSd分类统计,获取TEF,比较相关指标对心功能的评估。结果心功能Ⅰ～Ⅳ级患者LVEF分别为(59.72±3.01)%、(57.43±5.54)%、(48.12±5.63)%、(33.41±6.53)%,差异有统计学意义(P0.05);心电图QRSd分别为(84.71±5.12)ms、(87.92±9.42)ms、(97.81±10.73)ms、(112.61±22.13)ms,差异有统计学意义(P0.05)。TEF分别为0.71±0.07、0.66±0.11、0.50±0.09、0.31±0.10,差异有统计学意义(P0.05)。左心功能不全患者LVEF与TEF阳性检出率比较,差异有统计学意义(44.82%vs 69.40%,P0.01)。直线回归分析显示,QRSd、LVEF与TEF与心功能分级有较好相关性(r=0.510,r=0.730,r=0.729,P=0.000)。结论 TEF是评估老年射血分数保留的心衰患者心功能的较好指标。     

应用组织多普勒成像评价不同QRS时限心力衰竭患者的心室同步性

目的 应用组织多普勒技术评价不同QRS时限心力衰竭(心衰)患者心室收缩的同步性.方法 选择48例心衰患者(心衰组),其中QRS时限≤120 ms者25例(QRS时限≤120 ms心衰组),QRS时限＞120 ms者23例(QRS时限＞120 ms心衰组),以及25名正常人(对照组),测量左、右心室射血前间期并计算其差值(IVD);用组织多普勒技术测量12节段心肌收缩达峰时间(Ts),并计算(1)12节段Ts最大差值(Ts-diff),(2)12节段Ts的标准差(Ts-SD),(3)基底段室间隔及左室侧壁的Ts之差(S-LW-diff).结果 QRS时限≤120 ms心衰组、QRS时限＞120 ms心衰组和对照组IVD分别为31.00±15.21 ms、61.33±27.67 ms和15.89±7.56 ms,Ts-diff分别为70.29±35.25 ms、98.07±46.04 ms和47.86±16.78 ms,Ts-SD分别为24.64±12.84 ms、33.61±15.58 ms和15.24±5.65 ms,S-LW-diff分别为54.28±20.81 ms、76.32±42.38 ms和32.62±20.34ms,两心衰组与对照组间差异均有统计学意义(均为P＜0.05).QRS时限≤120 ms心衰组和QRS时限＞120 ms心衰组患者中均存在收缩不同步(44.00%比95.65%,P＜0.05).结论 QRS时限正常的心衰患者中存在一定比例的收缩不同步,QRS时限增宽的心衰患者的不同步比例更高.     

心脏再同步化治疗慢性心力衰竭的疗效评价及无效原因分析

目的 评价心脏再同步化治疗(CRT)对慢性心力衰竭患者的临床和超声心动图疗效,总结CRT无效的原因.方法 研究施行CRT的患者53例,男37例,女16例,年龄41～82岁.患者术前均采用血流多普勒和组织多普勒的方法进行收缩不同步的评价,术前和术后6个月进行美国纽约心脏病学会(NYHA)心功能分级评价、心电图和超声心动图检查.临床有效者定义为术后6个月NYHA心功能分级改善1级以上的患者.超声心动图有效者定义为术后6个月左室收缩末容积缩小＞15%或左室射血分数绝对值增加＞5%的患者.结果 CRT术后6个月时,7例患者死亡,46例患者存活.其中NYHA心功能分级至少改善1级者40例,临床有效率为75.5%;超声心动图有效者37例(69.8%).术后6个月:左心室缩小;左室射血分数由(27.4±6.7)%增加到(40.4±10.0)%,P＜0.01;左心房内径缩小;二尖瓣反流减少;肺动脉收缩压由(49.6±13.6)mm Hg(1 mm Hg=0.133 kPa)降低为(38.7±14.5)mm Hg.窦性心律组(42例)的超声有效率显著高于心房颤动组(11例).在窦性心律患者中,与CRT无效组(10例)相比,有效组(32例)起搏前的QRS较宽(P＜0.05),肺动脉收缩压较低(P＜0.05),左室射血前时间较长(P＜0.05);起搏前两组间腔室大小、LVEF、二尖瓣反流面积和组织多普勒的各个收缩不同步参数的差异无统计学意义.结论 CRT能改善心力衰竭患者的左室收缩功能和左室重构,减少二尖瓣反流,降低肺动脉收缩压.窦性心律组的CRT疗效优于心房颤动组.在非缺血性心肌病和左束支传导阻滞患者占多数的研究中,QRS宽度、左室射血前时间和肺动脉收缩压可能预测CRT的疗效.     

左心室肥厚与心电QRS、ST-T变化的关系

左心室肥厚与心电ＱＲＳ、ＳＴ－Ｔ变化的关系汪庚辛田利平杨回珍（洛阳市第二人民医院４７１００９）关健词心肌病，肥大性超声心动描记术心电描记术心电图及心电向量图对左室肥厚诊断的敏感性较低，心脏超声检查为心室肥厚患者的心肌肥厚程度提供了客观定量指标。作者对...     

三维超声左心室造影结合核素评价心力衰竭患者左心室收缩功能与同步性

目的应用三维超声左心室造影(C3DE)结合门控核素心肌灌注显像(GSMPI)相位分析评价慢性心力衰竭患者左心室收缩功能与同步性。方法选择老年慢性心力衰竭患者31例,根据LVEF分为轻-中度组18例(LVEF 35%～50%)和重度组13例(LVEF35%),另选同期健康体检者15例为对照组。入选者1周内行C3DE和GSMPI。C3DE参数包括左心室16、12节段达最低收缩末容积时间标准差(Tmsv-16SD、Tmsv-12SD),左心室16、12节段收缩非同步指数(16R-SDI、12R-SDI)、左心室舒张末期容积(LVEDV)、左心室收缩末期容积(LVESV)及LVEF;GSMPI参数包括相位直方图带宽(phase histogram bandwidth,PHB)、相位标准差(phase stress scores,PSD)及LVEF。分析各组左心室收缩功能与同步性的差异。结果与对照组比较,轻-中度组和重度组Tmsv-16SD[(66.0±35.7)ms和(137.1±48.5)ms vs (49.0±37.9)ms]、Tmsv-12SD[(45.6±32.7)ms和(126.5±48.6)ms vs (40.1±41.4)ms],16R-SDI[(8.5±4.0)%和(15.1±4.3)%vs (5.8±4.4)%]、12R-SDI[(5.8±3.6)%和(15.1±5.3)%vs (5.1±5.8)%],PHB(36.8±11.5和69.6±25.5 vs 27.6±9.8)和PSD(8.9±5.5和16.1±6.0 vs 6.4±4.2)明显延长,且重度组较轻-中度组延长更明显(P0.05);LVEDV、LVESV明显增大,LVEF明显减低;重度组左心室收缩失同步发生率明显高于轻-中度组,差异有统计学意义(76.9%vs 27.7%,P0.05);Tmsv-16SD、16R-SDI、PHB和PSD均与LVEF呈负相关(r=-0.74、r=-0.74,r=-0.69、r=-0.62,P0.01)。结论 C3DE能较准确评价左心室收缩功能与同步性,心力衰竭患者存在不同程度的左心室收缩不同步,且与LVEF相关。     

心力衰竭患者QRS波间期与心脏机械收缩功能失同步化的相关性研究

目的评价充血性心力衰竭(CHF)患者QRS间期与左右心室间、左心室内不同步运动参数的相关关系。方法 81例CHF患者及26名健康体检者作为对照组纳入本研究。行常规及彩色组织多普勒显像(TDI)检查。以左、右心室问收缩延迟(IVMD)>33ms定义室间不同步运动,以二尖瓣环6位点中任意2点QRS波起始至心室收缩顶峰的间期(TsP)最长延迟>121ms,或6位点TsP的标准差(TsP-SD)>47ms定义左心室内收缩不同步。比较QRS≥120 ms与QRS<120ms的CHF患者室间、室内不同步发生率,分析QRS间期与室间、室内不同步参数的相关关系。结果 CHF患者IVMD较对照组明显延长[(25.7±16.3)ms比(12.8±8.8)ms,P<0.0001],IVMD与QRS间期呈明显正相关(r=0.44,P<0.0001)。CHF伴QRS≥120ms(n=31)者室间不同步发生率明显高于CHF伴QRS<120ms者(n=50)(66.7%比20.9%,P<0.05)。CHF患者TsP最长延迟及TsP-SD较对照组明显延长,TsP最长延迟及TsP-SD与QRS间期呈弱相关。结论 CHF患者室间不同步运动发生率明显高于对照组,ORS间期增宽与室间不同步的关系可能更密切。     

实时三维超声心动图定量评价心力衰竭患者左心室收缩同步性

目的应用实时三维超声心动图定量评价心力衰竭患者左心室收缩同步性。方法选择诊断为心力衰竭的患者21例作为心力衰竭组,同期另选健康志愿者20例作为正常组。实时三维经胸超声心动图检查,应用Qlab软件计算左心室整体和17节段容积时间曲线变化,参数包括左心室舒张末容积、左心室收缩末容积和LVEF。分别计算左心室16、12和6节段达最低左心室收缩末容积时间(Tmsv)的标准差(Tmsv 16-SD、Tmsv-12 SD、Tmsv 6-SD)、左心室16、12和6节段Tmsv的最大时间差异(Tmsv16-Dif、Tmsv 12-Dif、Tmsv6-Dif)。同时系统将所测的绝对值自动进行标准化,得到左心室1 6、12和6节段最大差异的标准化值(Tmsv16-SD/R-R、Tmsv12 SD/R R、Tmsv6-SD/R-R、Tmsv16-Dif/R-R、Tmsv12-Dif/R-R、Tmsv6-Dif/R-R)。结果与正常组比较,心力衰竭组LVEF明显降低,左心室舒张末容积和左心室收缩末容积明显升高,差异有统计学意义(P<0.05);Tmsv16-SD、Tmsv12-SD、Tmsv6-SD,Tmsv16-Dif、Tmsv12-Dif、Tmsv6-Dif,Tmsv16-SD/R-R、Tmsv12-SD/R-R、Tmsv 6-SD/R-R,Tmsv16-Dif/R R、Tmsv12-Dif/R-R、Tmsv6-Dif/R-R参数值均明显升高,差异有统计学意义(P<0.01)。结论实时三维超声心动图的左心室容积时间曲线能全面显示心室容积、室壁运动及功能的动态变化,为心力衰竭患者的诊断、心脏再同步化治疗及预后评估提供更完整的定量信息。     

多普勒超声心动图检测慢性心力衰竭患者心肌生物能量消耗水平的变化及临床意义

目的 分析慢性心力衰竭(心衰)患者的多普勒超声指标心肌生物能量消耗(MEE)与左心室结构指标及其收缩、舒张、整体功能指标及心衰严重程度(NYHA心功能分级)、C反应蛋白(CRP)、N末端B型利钠肽原(NT-proBNP)之间的关系,探讨MEE用于评估慢性心衰心功能状况的临床价值.方法 选择慢性心衰住院患者99例,据左室射血分数(LVEF)值分为LVEF正常的心衰(HFNEF)组37例,LVEF降低的心衰(HFREF)组62例(其中LVEF>35%、<50%及≤35%分别为30例及32例);据NYHA心功能分级分为Ⅱ级(26例)、Ⅲ级(42例)、Ⅳ级(31例);对照组30例.采用多普勒超声心动图检测并计算MEE及常规结构指标,左心室收缩(LVEF、LVFS)、舒张(E/A、EDT、IVRT)及整体功能指标(Tei指数),并测定各组血清CRP、血浆NT-proBNP水平,分析各组间各参数的差异,探讨MEE与上述指标间的相关性.结果 HFNEF组患者MEE水平与对照组差异无统计学意义(P>0.05),HFREF组患者MEE水平较对照组明显增加(P<0.01);慢性心衰组MEE随LVEF的降低及NYHA心功能分级级别的升高而显著增加(P<0.05);双变量相关分析显示,MEE与心室结构及收缩、舒张、整体功能指标、NYHA心功能分级及血清CRP、血浆NT-proBNP水平之间均具有相关性,其中关系最密切的是左心室收缩功能指标,即MEE与LVEF、LVFS均呈明显负相关[分别为r=-0.540、P<0.01,r=-0.454、P<0.01].结论 随左心室收缩功能障碍及心衰程度的加重,慢性心衰患者的MEE水平逐步升高,MEE与现有的心功能评价指标(如LVEF值、NYHA分级、NT-proBNP 等)均呈明显相关,特别与左心室收缩功能指标关系密切.MEE可从心肌生物能量学角度有效评定慢性心衰患者的心功能状况.     

Left ventricular electromechanical delay in patients with heart failure and normal QRS duration and in patients with right and left bundle branch block.

AIMS: We sought to define the reference values of intra-left ventricular (LV) electromechanical delay (EMD), and to assess the prevalence (and pattern) of intra-LV dyssynchrony in patients with heart failure (HF) and normal QRS and in patients with right and left bundle branch block. METHODS AND RESULTS: We used tissue Doppler imaging echocardiography and a six-LV wall model to study LV EMD in 103 patients [41 with HF and normal QRS, 22 with right bundle branch block (RBBB), and 40 with left bundle branch block (LBBB)], and in 59 controls. In controls, the median intra-LV EMD was 17 ms, (inter-quartile range 13-30); 95% of controls had a value < or =41 ms. Patients showed a longer intra-LV EMD than controls: 33 ms (20-57) in patients with normal QRS, 32 ms (23-50) in RBBB patients, and 50 ms (30-94) in LBBB patients. Intra-LV dyssynchrony (defined as intra-LV EMD >41 ms) was present in 39, 36, and 60% of the patients, respectively. On average, HF patients showed the same pattern of activation as controls, from the septum to the posterior wall, but activation times were significantly prolonged. In RBBB patients the activation sequence was directed from inferior to anterior and in LBBB from anterior to inferior wall. CONCLUSIONS: Left ventricular dyssynchrony was present in several patients with HF and normal QRS, and in patients with RBBB; conversely, 40% of LBBB patients showed values of LV EMD within the normal range. Left ventricular activation sequence was different between groups. Assessment of LV synchronicity by means of imaging techniques may be more important than QRS duration or morphology in selecting patients for cardiac resynchronization treatment.     

Interventricular and intraventricular dyssynchrony are common in heart failure patients, regardless of QRS duration.

AIMS: The study aimed at evaluating the prevalence of interventricular and intraventricular contractile dyssynchrony in heart failure patients with either normal or prolonged QRS duration. METHODS AND RESULTS: Echocardiography and tissue Doppler imaging (TDI) were performed in 158 consecutive patients with advanced left ventricular dysfunction (LVEF<35%); 61 patients had a normal QRS duration (Group 1), 21 patients had left bundle branch block with a QRS duration between 120 and 150 ms (Group 2) and 76 patients had a QRS duration #10878;150 ms (Group 3). Interventricular dyssynchrony (defined by the presence of an interventricular mechanical delay greater than 40 ms) was found in 12.5%, 52.4% and 72% of patients in Group 1, 2 and 3, respectively (p < 0.001). Intraventricular dyssynchrony (defined by the presence of one or more differences greater than 50 ms among regional pre-ejection periods) was observed in 29.5%, 57.1% and 71% of patients in Group 1, 2 and 3, respectively (p < 0.001). No relationship was found between interventricular and intraventricular dyssynchrony. CONCLUSIONS: A substantial proportion of heart failure patients with a slightly prolonged QRS or even with normal conduction may exhibit ventricular dyssynchrony. Both standard echocardiography and TDI are necessary to describe the entire spectrum of mechanical abnormalities due to dyssynchrony.     

Relationship between QRS duration and left ventricular dyssynchrony in patients with end-stage heart failure

INTRODUCTION: Patients with end-stage heart failure and a wide QRS complex are considered candidates for cardiac resynchronization therapy (CRT). However, 20% to 30% of patients do not respond to CRT. Lack of left ventricular dyssynchrony may explain the nonresponse. Accordingly, we evaluated the presence of left ventricular dyssynchrony using tissue Doppler imaging (TDI) in 90 consecutive patients with heart failure. METHODS AND RESULTS: Ninety patients with severe heart failure (left ventricular ejection fraction <35%, New York Heart Association class III-IV) were prospectively evaluated. Based on QRS duration, 30 consecutive patients with a narrow QRS complex were included (QRS duration 150 ms). All patients underwent TDI to assess left ventricular dyssynchrony. Extensive left ventricular dyssynchrony was defined as an electromechanical delay on TDI between the septum and lateral wall, the so-called septal-to-lateral delay, of >60 ms. Severe dyssynchrony was observed in 27% of patients with narrow QRS complex, 60% with intermediate QRS duration, and 70% with wide QRS complex. No relation existed between QRS duration and septal-to-lateral delay. CONCLUSION: From 30% to 40% of heart failure patients with QRS duration >120 ms do not exhibit left ventricular dyssynchrony, which may explain the nonresponse to CRT. Alternatively, 27% of patients with heart failure and a narrow QRS complex show significant left ventricular dyssynchrony and may be candidates for CRT.     

Prevalence of dyssynchrony derived from echocardiographic criteria in heart failure patients with normal or prolonged QRS duration

Cardiac resynchronization therapy (CRT) for heart failure is targeted at specific patients with mechanical dyssynchrony. We aimed to evaluate the prevalence of dyssynchrony in heart failure patients with either normal or prolonged QRS duration using Doppler imaging. Sixty heart failure patients with idiopathic dilated cardiomyopathy (30 with prolonged QRS duration 30 with normal QRS duration) underwent standard echocardiography and tissue Doppler imaging examinations. Difference between left and right ventricular pre-ejection intervals of more than 40 msec was considered a marker of interventricular dyssynchrony. Intraventricular dyssynchrony was defined as a delay of 60 msec between the time to peak velocities of the septum and left ventricular lateral wall. Patients who have either intra- or interventricular dyssynchrony were defined as with cardiac dyssynchrony. Dyssynchrony was observed in 7 (23.3%) heart failure patients with normal QRS duration versus 26 (86.7%) patients with prolonged QRS duration. There was significant difference between the prevalence of dyssynchrony derived from echo criteria in two groups (P<0.05). Although patients with prolonged QRS duration have a high prevalence of dyssynchrony, yet some still have good cardiac synchronicity. Moreover, dyssynchrony also exists in a small percentage of heart failure patients with normal QRS duration. To identify the potential responders for CRT, both QRS duration and cardiac synchronicity should be assessed.     

老年慢性心力衰竭患者细胞因子和心率变异性的相关性研究

目的 观察老年慢性心力衰竭(CHF)患者炎性细胞因子和心率变异性(HRV)的相关性.方法 128例60岁及以上老年CHF患者(CHF组),对照组50例为健康体检者.比较两组炎性细胞因子包括肿瘤坏死因子可溶性受体Ⅰ、Ⅱ(sTNF-RⅠ、sTNF-RⅡ)和白细胞介素6(IL-6)表达水平,24 h内的全部HRV参数[正常心动周期的标准差(SDNN)、24 h内5 min节段平均心动周期的标准差(SDANN)、24 h内全部5 min节段所有心动周期标准差的平均值(SDNNI)、相邻正常心动周期差值均方的平均根(rMSSD)和相邻两正常心动周期差值大于50 ms的个数所占的百分比(pNN50)],分析二者相关性.结果 CHF组患者HRV参数低于对照组:SDNN分别为(99.8±22.4)和(146.6±43.2)ms、SDANN分别为(85.5±23.6)和(138.7±40.9)ms、SDNNI分别为(41.7±15.8)和(56.9±18.8)ms、rMSSD分别为(23.4±13.0)和(30.0±12.9)ms、pNN50分别为(5.5±3.8)和(12.0±4.7)%;CHF患者炎性细胞因子明显高于对照组(均为P＜0.05);CHF患者HRV参数与炎性细胞因子浓度间呈负相关(r≥-0.44,P＜0.05).结论 炎性细胞因子sTNF-R Ⅰ、sTNF-RⅡ和IL-6可能是老年CHF患者HRV下降的原因之一.