| Part One The value of three-dimensional echocardiography multi-regionals dyssynchronous systolic parameters to evaluated coronary stenosis and its relation of left ventricular systolic functionBackgroud:Insufficient blood supply in myocardial tissue due to coronary artery stenosis in patients with coronary heart disease.The cardiac function was abnormal and the systolic and diastolic mechanical capacity were decreased with ischemic segments. But in non-ischemic myocardial segments contraction amplitude and systolic and diastolic synchronized abnormalities occur,it is prone to different levels of mechanical systolic dyssynchrony phenomenon which occurs mainly in the left ventricular of each segment. Left ventricular mechanical systolic dyssnchrony may have a direct impact on cardiac function in patients after coronary stenosis.What will happen about the changes of the mechanical systolic synchronized as the varying degrees of coronary stenosis which they supplied?What about the relations with the degree of stenosis and the systolic dyssynchronization? How to detect the mechanical systolicn dyssynchronized by the noninvasive method and it’s relation about cardiac systolic function?These issues are rarely reported at present. Although coronary angiography can explicitly check out the presence of coronary artery disease, but still unable to accurately assess changes in functional changes and mechanical systolic of coronary stenosis as myocardial segments synchronized motion. Clinical extent for the "mechanical systolic dyssynchronous movement" mainly dependent on prolonged QRS duration in present.But there are number of clinical studies shown that relying solely on the electrocardiogram QRS complex width couldn’t accurately reflect the mechanical systolic dyssynchronous.So how to determine whether mechanical systolic dyssynchronous in accurate and reasonable and looking for a mechanical systolic of the heart can be used to evaluate the synchronized movement of indicators to assess more valuable, and thus better for the comprehensive assessment of coronary artery stenosis in patients with the disease is of great significance. Further Studies have shown that the amino-terminal brain natriuretic peptide (NT-proBNP) can reflect the extent of myocardial damage and coronary stenosis.This study aims to apply real-time three-dimensional echocardiography technology, combined with use of coronary angiography for coronary artery stenosis in varying degrees, combined with multi-segment myocardial dyssynchronous parameters and NT-proBNP to explore for noninvasive assessment of coronary stenosis of a variety of parameters, reverse infer the presence or absence of coronary artery stenosis and the degree of coronary stenosis as suspicious so whether need to further coronary angiography provides a preliminary selected method.Object:(1) Observed ventricular segmental coronary stenosis after mechanical contraction asynchrony change and its noninvasive assessment.(2) Explore the real-time three-dimensional echocardiography dyssynchronous multi-segment parameters to assess the value of different degrees of coronary stenosis.(3) To investigate the relationship between left ventricular systolic mechanical dyssynchrony with varying degrees of coronary artery stenosis and it’s relation of heart systolic function.(4) Explore the three-dimensional echocardiography dyssynchronous multi-segment systolic parameters’s cut-off point value to evaluated coronary stenosis>75% and the predicted degree of stenosis of sensitivity and specificity, thereby providing a preliminary selected method for the evaluation of clinically suspected coronary stenosis.Methods:(1) Patients with coronary artery disease inpatient since January 2010 to June 2014.All of them underwent coronary angiography and based on different degrees of left main coronary artery/left anterior descending artery stenosis group.There were all 152 cases as the degree of stenosis >75% for group A,the degree of stenosis <75% for group B total 211 cases, while coronary angiography showed coronary branch choose no significant stenosis 124 cases as group C (compared group).(2) Clinical data records of all selected age, height, weight, heart rate, blood pressure and the presence of diabetes history.(3) Coronary angiography:clinical patients with suspected coronary artery stenosis, select the femoral artery or brachial artery puncture site, draped after lidocaine local anesthesia, using Siemens company produced DIGITRONⅡ type DSA instrument establishing arterial channel using Seldinger’s method, through the femoral artery with a Judkins method or radial artery, the left and right coronary arteries were injected contrast agent Omnipaque, line the left coronary artery from 4 to 6 standard position, the right coronary artery 2 to 3 standard posture conventional angiography.(4) NT-proBNP measured:patients undergoing coronary angiography before extracting blood 3-4ml specimens from around the sample is placed containing EDTA-Na2 anticoagulant tube and centrifuged plasma instrument for the United States Roche’s Elecsys2010 automatic immunoassay analyzer, Roche’s kit selection of brain natriuretic peptide precursor diagnostic kits, reagents in strict accordance with the provisions of mode operation, the use of double-antibody sandwich electrochemiluminescence immunoassay completed by the appropriate professional and technical personnel of plasma NT-proBNP concentration detection. Using ROC curves to assess the NT-proBNP to predict coronary artery stenosis> 75% sensitivity and specificity of its three-dimensional multi-segmental systolic dyssynchronous parameters correlation.(5) Real-time three-dimensional echocardiography:All echocardiography dates were obtained by Philips iE-33.The dates quantitative analysis were by Qlab quantitative analysis software. The parameters include left ventricular segments 16,12,6 end of time standard minimum volume contraction difference (TmsvSD-16, TmsvSD-12, TmsvSD-6) later, and after each of the above parameters of heart rate correction value TmsvSD-16%, TmsvSD -12%, TmsvSD-6%, ie dyssynchronous index (16R-SDI,12R-SDI,6R-SDI).While the overall draw three-dimensional ultrasound and multi-segment left ventricular volume-time curves, time-displacement parameters map by dyssynchronous multi-segment indicator parameters, curve graph to be observed in patients with coronary artery stenosis.In order to comparied and analysis of different degree of stenosis in the case of cardiac systolic function has not yet occurred significantly reduced, early its multi-segmental assessment of the state of dyssynchronous parameter changes, and ejection fraction and NT-proBNP.Using ROC curve for multi-segment dyssynchronous systolic parameters to assess the degree of coronary stenosis different cut-off value, sensitivity, specificity, and identify valuable indicators to evaluate the predictive value for the degree of stenosis and judged dyssynchronous ventricular mechanical systolic in patients with coronary heart condition and to get a relatively objective and accurate method.(6) Statistical analysis:The data processing and analysis by SPSS16.0 software. Measurement data were expressed as mean ± standard deviation.Count data were expressed as percentage (%) and the rates were compared using chi-square test. General clinical data between groups were compared using two independent samples t-test. Among groups were compared using one-way analysis of variance. For the detection of targets was non-normal distribution between the two groups were compared using two independent samples rank sum test (Mann-Whitney U test). Correlation analysis between the two sets of data, in line with normal distribution were analyzed using Pearson method, does not meet the normal distribution were analyzed using Spearman method. Correlation test between the two indexes using linear correlation analysis. Asynchronous multi-segment parameters for predicting coronary artery stenosis using subjects diagnostic characteristic curve (receiver operator curve, ROC) to assess of dyssynchronous multi-regionals parameters by subjects diagnostic characteristic curve (receiver operator curve, ROC) and calculated the area under the curve (area under curve, AUC). P<0.05 was considered statistically differences and P<0.01 was considered statistically differences significant.Results:(1) Comparison of clinical data between the three groups: There were no statistically significant differences with age, height, weight in three groups.But the heart rate, LVEF, NT-proBNP in three groups had statistically significant differences (P<0.05). Among the three groups no gender difference was significant (χ2= 2.503, P= 0.286) and history of hypertension, diabetes mellitus by chi-square test showed that among the groups there were significant difference (χ2=10.482,P=0.005;χ2= 10.866,P=0.004).(2) Compare with multiple segments dyssynchronization parameters and it’s relationship with systolic left ventricular ejection fraction in three groups: There had statistically significant with multi-segmental systolic dyssynchronous in three groups(p=0.000).The Tmsvl6-SD,Tmsvl2-SD,Tmsv6-SD and LVEF exists a significant negative correlation (r=-0.761,-0.740,-0.726, both P= 0.000); The 16R-SDI,12R-SDI,6R-SDI were also exists a significant negative correlation with LVEF (r=-0.713,-0.699,-0.677, both P=0.000).(3) The value of multi-segmental systolic dyssynchronous parameters to prediction of coronary artery stenosis>75%: 16R-SDI,12R-SDI,6R-SDI were taken cut-off value 6.1ms,4.5ms,3.2ms predicting left main coronary artery/left anterior descending artery stenosis>75% sensitivity and specificity were 89%,87%;88%,85%;82%,80%.Tmsvl6-SD, Tmsv12-SD, Tmsv6-SD cut-off value were taken 15.1ms,10.7ms,8.5ms predicting left main coronary artery/left anterior descending artery stenosis>75% sensitivity and specificity were 80%,74%; 81%,73%;82%,71%.(4) The Relationship of NT-proBNP and multi-segmental systolic dyssynchronous parameters and it’s value to predict of coronary stenosis>75%: Tmsv16-SD, Tmsvl2-SD, Tmsv6-SD and NT-proBNP showed a moderate correlation (r=0.652,0.625,0.606, both P=0.000); 16R-SDI,12R-SDI,6R-SDI and NT-proBNP was moderate correlation (r=0.632,0.616,0.600, both P=0.000). NT-proBNP concentrations were negatively correlated with LVEF (r=-0.784, P=0.000), NT-proBNP concentration cut-off value was 702.5pmol/L prediction of coronary artery stenosis>75% sensitivity was 84%, specificity of 74%.(5) The morphological changes of left ventricular multi-segmental time-displacement maps and volume-time curves: The time-displacement parameters showed myocardial ischemic area and adjacent segment systolic delay (partial red) and no ischemic area regional systolic synchrony were well (mostly green or blue).The multi-segmental parameters systolic degree of coronary stenosis delayed substantially consistent relationship. The volume-time graphs in group C showed orderly arrangement, the subject were inverted parabolic rise and fall more consistent support segment branch downs, the Tmsv were relatively concentrated. The VTCs interwoven irregular fluctuation amplitude irregular movement, the rise and fall segment branch range of motion flat in myocardial ischemic area.The distribution trend with messy aggravation of coronary artery stenosis were more obviously.Conclusions:(1) The segmental wall mechanical systolic would be dyssynchrony as coronary artery stenosis.The real-time three-dimensional echocardiography dyssynchronous multi-segmental parameters can be used to quantitatively evaluated coronary stenosis after different segments of mechanical ventricular systolic dyssynchrony and it had a consistent relationship with the degree of coronary stenosis.It could be as the assessment of coronary segmental stenosis ventricular systolic asynchrony, condition assessment of a non-invasive method.This study suggests that 16R-SDI>6.1%,12R-SDI>4.5%,6R-SDI>3.2% could be used to predict coronary artery stenosis>75%.(2) This study shows that the three-dimensional echocardiography dyssynchronous multi-segmental parameters combined with CAG and NT-proBNP results of the assessment of coronary artery stenosis>75% cut-off value, the sensitivity, specificity,.It can be used to infer the reverse coronary patients with suspected coronary heart disease and to determine whether to have CAG check.(3) There had a significant negative correlation between multi-segmental parameters and left ventricular systolic function.It can be used to quantitative assessment of coronary stenosis after myocardial segments dyssynchrony due to left ventricular systolic dysfunction.(4) From time-displacement parameters maps and volume-time curves can display ventricular volume, wall motion and function of the dynamic changes.It also can be intuitive, timely evaluation of coronary stenosis after left ventricular mechanical systolic dyssynchronization status change and can be a complementary method of varying degrees of coronary stenosis evaluation of left ventricular function as assessed.Part Two The value of RT-3DE to assessment of coronary artery stenosis compared with CAGBackgroud:Ischemic heart disease has become common cardiovascular disease in our country. At present, coronary angiography (CAG) as a "gold standard" to examination and diagnosis of ischemic heart disease. The advantage is some other means of inspection unmatched, but CAG also have some shortcomings, such as medical hardware, operator skill level and proficiency higher, larger inspection fees.And it also couldn’t quantitative analysis segmental function of myocardial ischemia. Conventional ultrasound technology can semi-quantitative assessment of coronary artery stenosis. However, this method have some deficiencies such as subjective, low sensitivity and couldn’t assess the ventricular cavity morphological changes. As soon as it difficult to complete all myocardial segments of the image is displayed in the same cardiac cycle and access. Real-time three-dimensional echocardiography can quantitative evaluation of ventricular function and overall volume segment size, motion and functional status, especially for the evaluation of deformation has occurred atrioventricular cavity advantage. Exercise and functional status of different theoretical ventricular myocardial segments should be closely associated with the segment myocardial coronary blood supply, so real-time three-dimensional echocardiography can use to detect coronary stenosis by it’s velocity dominated region, time and volume changes, etc.As compared with coronary angiography and three-dimensional echocardiography multi-segments parameters used to reverse infer the myocardial segments corresponding to myocardial ischemia and coronary stenosis seriously. So as to explored the value of three-dimensional echocardiography to evaluation of coronary stenosis, as well as a preliminary screening tool to decide whether the need for further invasive CAG and other checks as patient who suspected coronary artery stenosis.lt maybe have some practical and added value for clinical diagnosis.Objective:(1) Comparative study of different branches of coronary artery stenosis> 75% of the corresponding wall segment myocardial blood flow velocity, time and volume with no significant coronary.(2) Quantitative study of the relationship with coronary artery which stenosis>75% between three-dimensional echocardiography parameters and to test it’s correlation with CAG.(3) As a preliminary study evaluating the above parameters of coronary stenosis> 75% cut-off value, sensitivity, specificity by ROC curve analysis,.And to analyze real-time three-dimensional echocardiographic reverse inference techniques for prediction of coronary stenosis play a greater role, and the method as a preliminary screening tool if necessary clinical coronary angiography. Method:In this study,combined with coronary angiography and real time three-dimensional echocardiography to check the different branches of the coronary artery stenosis (stenosis>75%) and no significant coronary stenosis which dominated wall’s motion speed, time and volume changes quantitative analysisy.As with VTC curves and the bull’s-eye diagram analysis to explored three-dimensional echocardiography’s value of the different branches of coronary artery stenosis compared with CAG results.The patients from January 2010 to June 2014 to our hospital with unstable angina 474 cases, all subjects generally normal ECG tips or hints T wave changes, ST segment depression. Two dimensional echocardiography showed the wall motion almost abnormal or slightly weakened. All subjects underwent CAG inspection and the CAG results showed single artery stenosis>75%. Depend on the CAG results,all patients divided into three groups, group A(left anterior descending artery,134 cases), group B(left circumflex artery 105 cases), group C(the right coronary artery 119 cases).group N (the coronary artery angiography no significant stenosis 116 cases as compared group).All subjects were checked by real-time three-dimensional echocardiography. The left ventricular 17 segments volume-time curves and related parameters sunch as range of motion segments (EA), motion peak time (TS), segment ejection fraction (sEF) by Qlab 3DQ Advanced Analysis program.The resulting the degree of coronary stenosis>75% cut-off value of the area under the curve and related indicators to determined these parameters to predict the degree of stenosis>75% sensitivity and specificity by the multiple parameters ROC curve analysis.Statistical analysis using SPSS 16.0 software.The measurement data were expressed as mean ± standard deviation and the count data as a percentage (%).General clinical data between groups were compared using two independent samples t-test. Among groups were compared using one-way analysis of variance.Between sets of data correlation analysis using Pearson or Spearman method. Three-dimensional ultrasound parameters for each group variable ROC curve analysis, the area under the curve of each parameter on the parameters used to determine the degree of coronary stenosis>75% cut-off value, sensitivity, specificity. P<0.05 was considered statistically difference and P<0.01 was considered statistically significant.Results:(1) Compared with different groups:the indicators of age, gender, heart rate, height, weight differences between the groups were not statistically significant (P>0.05).It showed that among the groups balanced gender distribution by chi-square analysis (%2= 1.995, P>0.05). The blood pressure, blood lipids were higher in coronary artery stenosis groups (group A, B, C) than the group N (P<0.05).(2) EA,TS and sEF in group A of anterior and pre-septal’s basal, middle and apical segments were less than that in group B, C and group N(P<0.05).(3) In group B,the basal,the middle and the apical segments of lateral and postwall’s EA, TS, sEF less than group A, C and group N (P<0.05).(4) In group C, the EA,TS,and Sef of the basal segment, middle segment and apical segment in interial and post-septal wall’s were less than group A, B and group N as same as include post wall’s the basal segment, middle segment (P<0.05).(5) The LV volumes-time curves (VTCs) showing an overall inverted parabola and the shape curve is large, trough approaching in group N. But the curves were irregular curve shape, ischemic segments curve is relatively less volatile than the messy traveling curve and even appear reverse motion curve in the lesion groups. The left ventricular time-displacement parameters for each segment performance figure for the overall light green and uniform in group N.The LV time-displacement parameters showing the performance of the color distribution were uneven, ischemic segments were significantly darker colors and red in the lesion groups.(6) ROC curves analysis showed:TS and sEF in the anterior and pre-septal wall in group A;EA and sEF in the lateral and post wall in group B; EA and sEF in group C were used to determined the coronary stenosis branch>75% sensitivity and specificity were above 80%.So it shows that above parameters had a good diagnostic value for assess the coronary stenosis degree.The cut-off values of these parameters can be use as one of the methods to evaluation the coronary artery branch stenosis>75% by ROC curves analysis.Conclusions:(1) Coronary artery stenosis corresponding segment myocardial’s EA, TS, sEF were less than no significant stenosis the supply branch myocardial segments.Three-dimensional echocardiography showed segmental wall motion, time and volume parameters may reflect coronary different branches of coronary stenosis.(2) The myocardial velocity, volume and systolic motion time were showed abnormal corresponding with coronary stenosis.The VTC curves and time-displacement parameters map color change could be visualized with severely coronary artery stenosis. Whereby the site of coronary artery disease can be inferred, myocardial ischemic segments and extent.(3) There had a well correlation between the parameters of ischemic myocardial segments and the degree of coronary artery stenosis in patients with coronary heart disease. Real-time three-dimensional echocardiography can reverse assess corresponds to speculate whether coronary have stenosis.So can providing theoretical basis for clinical diagnosis and played the role of initial screening while the line on the need for further coronary angiography.Meanwhile it can reduce unnecessary bodily injury and economic burden in some patients and maybe increase the positive value of coronary angiography.(4) This study suggests that:anterior,pre-septal walls take TS cutoff value 30-32ms, sEF take cutoff value 45.5%-47.5% can used to predict left descending artery stenosis>75%; lateral, posterior walls EA take cutoff value 5.25-5.65mm,lateral wall sEF take cutoff value 48.5% can used to predict the circumflex artery stenosis>75%; posterior wall of the EA to take cutoff value 6.25mm, sEF take cutoff value 48.5%-49.5% can used to predict the right coronary artery stenosis>75%. |
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