超声心动图评价左心室射血分数正常终末期肾病患者左心室重构和功能的价值研究

doi:10.12114/j.issn.1007-9572.2019.00.795

摘要/Abstract

摘要： 背景　心血管疾病是终末期肾病（ESRD）死亡率升高的最主要原因，其病理基础是心脏结构及功能的改变。在临床工作中，比较关注心功能衰竭尤其是左心室射血分数（LVEF）的异常，而忽略其他重要指标的异常。目的　应用常规超声心动图评价LVEF正常ESRD患者的左心室重构及功能。方法　选取2016年1月—2018年6月首次于复旦大学附属金山医院透析治疗且随访LVEF正常的ESRD患者121例作为病例组；另选取同期年龄、性别相匹配，体格检查、心电图检查及常规超声心动图检查均正常的50例健康体检者作为对照组。比较两组一般资料，主动脉根部内径（AOd）、腔室大小〔左心房内径（LAd）、左心室舒张末期内径（LVEDd）、左心室收缩末期内径（LVESd）、左心房容积（LAV）、左心室舒张末期容积（LVEDV）、左心室收缩末期容积（LVESV）、左心室整体舒张末期容积（gLVEDV）、左心室整体收缩末期容积（gLVESV）〕及其经体表面积（BSA）校正值、左心室构型〔室间隔厚度（IVST）、左心室后壁厚度（LVPWT）、左心室质量（LVM）、左心室质量指数（LVMI）及相对室壁厚度（RWT）〕、左心室收缩功能参数〔左心室短轴缩短率（LVFS）、LVEF、左心室整体射血分数（gLVEF）及左房室瓣环左心室收缩期峰值运动速度（S'）〕、左心室整体功能（左心室Tei指数）、舒张功能参数〔左房室瓣左心室舒张早期峰值流速（E峰）、左房室瓣左心室舒张晚期峰值流速（A峰）、E/A、左房室瓣E峰减速时间（DT）、等容舒张时间（IVRT）、左房室瓣环左心室舒张早期峰值运动速度（E'）、左房室瓣环左心室舒张晚期峰值运动速度（A'）、E'/A'及E/E'）〕；分析ESRD舒张功能障碍患者左心室构型、gLVEF情况，ESRD患者左心室构型与gLVEF情况。结果　病例组患者体质量、BMI、BSA小于对照组，收缩压（SBP）、舒张压（DBP）、脉压（DP）大于对照组（P<0.05）。病例组AOd、AOd/BSA、LAd、LAd/BSA、LVEDd、LVEDd/BSA、LVESd、LVESd/BSA、LAV、左心房容积指数（LAVI）、LVEDV、LVEDV/BSA、LVESV、LVESV/BSA、gLVEDV、gLVEDV/BSA、gLVESV、gLVESV/BSA大于对照组，IVST、LVPWT、RWT厚于对照组，LVM、LVMI重于对照组，LVFS、LVEF、gLVEF小于对照组（P<0.05）。121例ESRD患者左心室构型分型：构型正常17例（14.0%），构型异常104例（86.0%）（以离心性肥厚55例和向心性肥厚48例为主）；gLVEF异常39例（32.2%），gLVEF正常82例（67.8%）。病例组E峰、A峰快于对照组，E/A低于对照组，DT、IVRT、左心室Tei指数大于对照组，S'〔室间隔（s）〕、E'（s）、E'〔侧壁（l）〕、E'/A'（s）、E'/A'（l）慢于对照组，A'（l）、E/室间隔与侧壁左房室瓣环左心室舒张早期峰值运动速度的平均值〔E'（av）〕快于对照组（P<0.05）。121例ESRD患者左心室舒张功能分型：舒张功能正常5例（4.1%），舒张功能障碍116例（95.9%）。116例舒张功能障碍ESRD患者包括104例（86.0%）左心室构型异常者及39例（32.2%）gLVEF异常者。121例ESRD患者中左心室构型及gLVEF正常者14例，左心室构型正常、gLVEF异常者3例，左心室构型异常、gLVEF正常者68例，左心室构型及gLVEF均异常者36例。结论　LVEF正常ESRD患者左心室存在不同程度的左心室重构及功能改变，表现为腔室扩大、室壁增厚、收缩及舒张功能亦存在不同程度减退；左心室构型或收缩功能正常ESRD患者舒张功能不完全正常，舒张功能障碍早于左心室收缩功能及构型异常，因此全面评估LVEF正常ESRD患者的左心室重构及功能不容忽视。

关键词: 肾病；每搏输出量；心室重构；心室功能, 左；超声心动描记术；病例对照研究

Abstract: Background　Cardiovascular diseases continue to be a leading cause of death in ESRD.The basic pathology may be the changes of cardiac structure and function.In daily clinical practice，more attention is often paid to heart failure，particularly when left ventricular ejection fraction（LVEF） is abnormal，while many other important cardiac parameters are ignored.Objective　To assess the left ventricular remodeling and function in ESRD patients with preserved LVEF by using echocardiography.Methods　Participants were selected from Jinshan Hospital of Fudan University from January 2016 to June 2018，including 121 ESRD patients receiving the initial dialysis in this hospital and with preserved LVEF during the follow-up period（case group），and 50 age- and sex-matched physical examinees with normal results of physical examination，electrocardiogram and routine echocardiography（control group）.Intergroup comparisons were made in terms of general data，aortic diameter （AOd），parameters of chamber size（LAd，LVEDd，LVESd，LAV，LVEDV，LVESV，gLVEDV，gLVESV）and their values after body surface area（BSA） correction，left ventricular configuration （IVST，LVPWT，LVM，LVMI and RWT），systolic function parameters 〔LVFS, LVEF, gLVEF and peak systolic mitral annular velocity（S'）〕，global left ventricular function （LV Tei index），diastolic function parameters 〔peak early diastolic E-wave velocity（E peak）， peak late diastolic A-wave velocity（A peak），E/A，deceleration time （DT），iso-volumic relaxation time （IVRT），peak early diastolic mitral annular velocity（E'），peak late diastolic mitral annular velocity （A'），E'/A' and E/E'〕.The left ventricular configuration and the status of the gLVEF were analyzed in ESRD patients，and were further analyzed in those with diastolic dysfunction.Results　The case group showed lower mean weight，BMI，BSA, higher mean systolic blood pressure （SBP），diastolic blood pressure （DBP） and pulse pressure difference （DP） compared with the control group（P<0.05）.The case group demonstrated greater mean AOd，AOd/BSA，LAd，LAd/BSA，LVEDd，LVEDd/BSA，LVESd，LVESd/BSA，LAV，LAVI，LVEDV，LVEDV/BSA，LVESV，LVESV/BSA，gLVEDV，gLVEDV/BSA，gLVESV，and gLVESV/BSA，and thicker mean IVST，LVPWT，and RWT，LVM，LVMI as well as less mean LVFS，LVEF and gLVEF compared with the control group （P<0.05）.In case group，left ventricular configuration was normal in 17 cases （14.0%），abnormal in 104 cases （86.0%），mainly centrifugal hypertrophy in 55 cases and centrifugal hypertrophy in 48 cases；gLVEF was abnormal in 39 cases （32.2%） and normal in 82 cases （67.8%）.Compared with the control group，case group had faster mean E peak and A peak，lower mean E/A，greater mean DT，IVRT，and LV Tei index，slower mean S'（s），E'（s），E'（l），E'/A'（s），and E'/A' （l），and higher mean A'（l），and E/E'（av）（P<0.05）.In case group，the left ventricular diastolic function was normal in 5 （4.1%），and diastolic dysfunction in 116 （95.9%）.And those with diastolic dysfunction included 104 （86.0%） with abnormal left ventricular configuration and 39 （32.2%） with abnormal gLVEF.Of the ESRD patients，14 were found with normal left ventricular configuration and gLVEF，3 with normal left ventricular configuration and abnormal gLVEF，68 with abnormal left ventricular configuration and normal gLVEF，and 36 with abnormal left ventricular configuration and gLVEF.Conclusion　There were left ventricular remodeling characterized by dilation of cardiac chambers，thickened ventricular wall and cardiac systolic and diastolic dysfunction in ESRD patients with preserved LVEF.And the LV diastolic dysfunction was prior to the systolic dysfunction and left ventricular remodeling.So comprehensively evaluating left ventricular remodeling and left ventricular diastolic function in ESRD patients with preserved LVEF counts for much，and is not allowed to neglect in clinical work.

Key words: Nephrosis；Stroke volume；Ventricular remodeling；Ventricular function, left；Echocardiography；Case-control studies

张志华,莫为春,郑风雅,等. 超声心动图评价左心室射血分数正常终末期肾病患者左心室重构和功能的价值研究[J]. 中国全科医学, 2020, 23(12): 1497-1503. DOI: 10.12114/j.issn.1007-9572.2019.00.795.
ZHANG Zhihua,MO Weichun,ZHENG Fengya, et al. Echocardiographic Evaluation of the Left Ventricular Remodeling and Function in End Stage Renal Disease Patients with Preserved Left Ventricular Ejection Fraction　[J]. Chinese General Practice, 2020, 23(12): 1497-1503. DOI: 10.12114/j.issn.1007-9572.2019.00.795.

参考文献

［1］CAI Q J，MUKKU V K，AHMAD M.Coronary artery disease in patients with chronic kidney disease：a clinical update［J］．Curr Cardiol Rev，2013，9（4）：331-339.
［2］HERZOG C A，ASINGER R W，BERGER A K，et al．Cardiovascular disease in chronic kidney disease.A clinical update from Kidney Disease：Improving Global Outcomes （KDIGO）［J］．Kidney Int，2011，80（6）：572-586．DOI：10.1038/ki.2011.223.
［3］RAMESH S，ZALUCKY A，HEMMELGARN B R，et al．Incidence of sudden cardiac death in adults with end-stage renal disease：a systematic review and meta-analysis［J］．BMC Nephrol，2016，17（1）：78．DOI：10.1186/s12882-016-0293-8.
［4］BANSAL N.Evolution of cardiovascular disease during the transition to end-stage renal disease［J］．Semin Nephrol，2017，37（2）：120-131．DOI：10.1016/j.semnephrol.2016.12.002.
［5］MATSUSHITA K，BALLEW S H，CORESH J.Influence of chronic kidney disease on cardiac structure and function［J］．Curr Hypertens Rep，2015，17（9）：581．DOI：10.1007/s11906-015-0581-x.
［6］ROSS B A，WALD R，GOLDSTEIN M B，et al．Relationships between left ventricular structure and function according to cardiac MRI and cardiac biomarkers in end-stage renal disease［J］．Can J Cardiol，2017，33（4）：501-507．DOI：10.1016/j.cjca.2016.11.021.
［7］DUPONT L，WINTHER S，J?RGENSEN H S，et al．Atrial function，atrial volume and cardiovascular clinical outcomes in patients with end-stage renal disease ——a study of cardiac computed tomography［J］．J Cardiovasc Comput Tomogr，2017，11（5）：389-396．DOI：10.1016/j.jcct.2017.07.001.
［8］MATSUO H，DOHI K，MACHIDA H，et al．Echocardiographic assessment of cardiac structural and functional abnormalities in patients with end-stage renal disease receiving chronic hemodialysis［J］．Circ J，2018，82（2）：586-595．DOI：10.1253/circj.CJ-17-0393.
［9］LEVEY A S.A Decade After the KDOQI CKD Guidelines［J］．Am J Kidney Dis，2012，60（5）：683-685．DOI：10.1053/j.ajkd.2012.08.019.
［10］LANG R M，BADANO L P，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］．J Am Soc Echocardiogr，2015，28（1）：1-39.e14．DOI：10.1016/j.echo.2014.10.003.
［11］DEVEREUX R B.Detection of left ventricular hypertrophy by M-mode echocardiography.Anatomic validation，standardization，and comparison to other methods［J］．Hypertension，1987，9（2 Pt 2）：II19-26．DOI：10.1161/01.hyp.9.2_pt_2.ii19.
［12］LANG R M，BIERIG M，DEVEREUX R B，et al．Recommendations for chamber quantification：a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group，developed in conjunction with the European Association of Echocardiography，a branch of the European Society of Cardiology［J］．J Am Soc Echocardiogr，2005，18（12）：1440-1463．DOI：10.1016/j.echo.2005.10.005.
［13］FOPPA M，DUNCAN B B，ROHDE L E.Echocardiography-based left ventricular mass estimation.How should we define hypertrophy?［J］．Cardiovasc Ultrasound，2005，3：17．DOI：10.1186/1476-7120-3-17.
［14］NAGUEH S F，SMISETH O A，APPLETON C P，et al．Recommendations for the evaluation of left ventricular diastolic function by echocardiography：an update from the American society of echocardiography and the European association of cardiovascular imaging［J］．J Am Soc Echocardiogr，2016，29（4）：277-314．DOI：10.1016/j.echo.2016.01.011.
［15］BLACK C，SHARMA P，SCOTLAND G，et al．Early referral strategies for management of people with markers of renal disease：a systematic review of the evidence of clinical effectiveness，cost-effectiveness and economic analysis［J］．Health Technol Assess，2010，14（21）：1-184．DOI：10.3310/hta14210.
［16］CHAHAL N S，LIM T K，JAIN P，et al．Population-based reference values for 3D echocardiographic LV volumes and ejection fraction［J］．JACC Cardiovasc Imaging，2012，5（12）：1191-1197．DOI：10.1016/j.jcmg.2012.07.014.
［17］MACRON L，LIM P，BENSAID A，et al．Single-beat versus multibeat real-time 3D echocardiography for assessing left ventricular volumes and ejection fraction：a comparison study with cardiac magnetic resonance［J］．Circ Cardiovasc Imaging，2010，3（4）：450-455．DOI：10.1161/CIRCIMAGING.109.925966.
［18］DE SIMONE G.Left ventricular geometry and hypotension in end-stage renal disease：a mechanical perspective［J］．J Am Soc Nephrol，2003，14（10）：2421-2427．DOI：10.1097/01.asn.0000088724.66957.fc.
［19］COHN J N.Critical review of heart failure：the role of left ventricular remodeling in the therapeutic response［J］．Clin Cardiol，1995，18（9 Suppl 4）：Ⅳ4-12．DOI：10.1002/clc.4960181603.
［20］KONSTAM M A，KRAMER D G，PATEL A R，et al．Left ventricular remodeling in heart failure：current concepts in clinical significance and assessment［J］．JACC Cardiovasc Imaging，2011，4（1）：98-108．DOI：10.1016/j.jcmg.2010.10.008.
［21］井静，葛淼，杨子祁，等．不同心率和地理环境因子与健康成年男性左室射血分数参考值的相关性［J］．中国医学科学院学报，2018，40（4）：487-492．DOI：10.3881/j.issn.1000-503X.10021.
［22］JIA E Z，XU Z X，YANG Z J，et al．Severity of coronary atherosclerosis is an independent predictor of the left ventricular ejection fraction［J］．Clin Exp Pharmacol Physiol，2011，38（2）：109-112．DOI：10.1111/j.1440-1681.2010.05474.x.
［23］SAWATARI H，OHKUSA T，RAHAMAWATI A，et al．Left ventricular ejection fraction predicts severity of posttraumatic stress disorder in patients with implantable cardioverter-defibrillators［J］．Clin Cardiol，2016，39（5）：263-268．DOI：10.1002/clc.22521.
［24］FARSHID A，PATHAK R，SHADBOLT B，et al．Diastolic function is a strong predictor of mortality in patients with chronic kidney disease［J］．BMC Nephrol，2013，14：280．DOI：10.1186/1471-2369-14-280.
［25］CHEN S C，CHANG J M，TSAI Y C，et al．Ratio of transmitral E-wave velocity to early diastole mitral annulus velocity with cardiovascular and renal outcomes in chronic kidney disease［J］．Nephron Clin Pract，2013，123（1/2）：52-60．DOI：10.1159/000351513.