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目的:评价简化的超声心动图评分系统无创评估左心疾病相关性肺动脉高压患者血流动力学特征。方法:回顾性分析上海市肺科医院肺循环科2015年8月至2018年7月经右心导管(right heart catheter,RHC)确诊的85例左心疾病相关性肺动脉高压(pulmonary hypertension due to left heart disease,PH-LHD)即血流动力学为毛细血管后肺动脉高压(post-capillary pulmonary hypertension,post-PH)患者,根据舒张压梯度(diastolic pressure gradient,DPG)分为孤立性毛细血管后肺动脉高压(isolated post-capillary pulmonary hypertension,Ipc-PH)(DPG<7 mmHg,1 mmHg=0.133 kPa)组和混合性毛细血管后与毛细血管前肺动脉高压(combined post-capillary and pre-capillary pulmonary hypertension,Cpc-PH)(DPG≥7 mmHg)组;同时随机抽取同期 RHC 确诊的65例动脉性肺动脉高压(pulmonary arterial hypertension,PAH)即血流动力学为毛细血管前肺动脉高压(precapillary pulmonary hypertension,pre-PH)患者。收集所有患者的临床资料数据、超声心动图(Echocardiographic,Echo)以及血流动力学数据。分析Echo各参数在组间的差异,利用Logistic回归分析建立预测PH-LDH血流动力学特征的评分系统。结果:1.共有150例患者纳入研究,平均年龄55.7±16.9岁,男性62例,女性88例。其中PAH患者65例,PH-LDH患者85例,后者中包括Ipc-PH 72例,Cpc-PH 13例。2.在血流动力学参数上,pre-PH组与post-PH组在上腔静脉压(superior vena cava pressure,SVCP)(3.4±2.9 vs 10.6±7 mmHg,P<0.001)、右房平均压(mean right atrial pressure,mRAP)(3.6±2.9 vs 10.6±6.7 mmHg,P<0.001)、右室平均压(mean right ventricular pressure,mRVP)(7.3±4.3 vs14.8±9.5 mmHg,P<0.001)、肺动脉舒张压(pulmonary artery diastolic pressure,dPAP)(28±12 vs 21.4±7.5 mmHg,P<0.001)、肺动脉平均压(mean pulmonary artery pressure,mPAP)(48.1 ± 14.5 vs 37.9±13 mmHg,P<0.001)、肺小动脉平均压(mean pulmonary artery wedge pressure,mPAWP)(5.5±2.8 vs 21.1 ±6.3 mmHg,P<0.001)、DPG(22.6± 11.9 vs 0.3±6.4 mmHg,P<0.001)、肺血管阻力(pulmonary vascular resistance,PVR)(9.8±4.5 vs 3.8±3.2 WU,P<0.001)、全肺阻力(total pulmonary resistance,TPR)(11±4.7 vs 8.5±4.6 WU,P=0.001)上存在统计学差别。3.在Echo检查中,pre-PH组与post-PH相比,在主动脉根部内径(aortic root diameter,AO)(23.8±4.8 vs 28.3±4.8 mm,P<0.001)、左房内径(left atrial diameter,LA)(30.9±4.1vs 45.6±9 mm,P<0.001)、左室舒张末期内径(left ventricular end diastolic diameter,LVEDd)(39.2±5.7 vs 49.4±9.1 mm,P<0.001)、左室收缩末期内径(left ventricular end systolic diameter,LVEDs)(21.5±4.8 vs 31.9±9.2 mm,P<0.001)、室间隔厚度(interventricular septum diastolic thickness,IVSd)(7.5± 1.6 vs 9.4±2.4 mm,P<0.001)、左室后壁厚度(diastolic left ventricular posterior wall thickness,LVPWd)(8.1±1.7 vs 9.5± 1.9 mm,P<0.001)、肺动脉收缩压(pulmonary artery systolic pressure,PASP)(78.6±20.3 vs 57.4± 17 mmHg,P<0.001)、右房纵径(right atrial systolic longitudinal diamete,RAIDs)(50.1±7.2 vs 56.3±10.4 mm,P<0.001)、舒张期右室横径(right ventricular diastolic diameter,RVDd)(40.3±6.6 vs 35.2±6.2 mm,P<0.001)、二尖瓣 E 峰(mitral valve E wave,MV-E wave)(59.4±20.4 vs 106.9±42.5 cm/s,P<0.001)、三尖瓣 E 峰(tricuspid valve E wave,TV-E wave)(50.5± 15.8 vs 64.6±21.8 cm/s,P<0.001)、主动脉瓣上 Vmax(93± 18.7 vs 110.6±40.8 cm/s,P=0.002)、左心室射血分数(left ventricular ejection fraction,LV EF)(75.9±7.7 vs 62.1 ± 12.1%,P<0.001)、左心室短轴缩短率(left ventricular fractional shortening,LV FS)(44.6±7.3 vs 35.1 ±8.4%,P<0.001)、右心房压力(right atrial pressure,RAP)(6.4±2.3 vs 8.7±3.7 mmHg,P<0.001)、二尖瓣 Sm(9.9±2.4 vs 7.6±2 cm/s,P<0.001)、二尖瓣 Em(9.8±3 vs 8.6±3 cm/s,P=0.017)和E/Em(6.7±3.4 vs 14.4±10,P<0.001)上存在统计学差别。4.经单因素logisitc回归分析显示,上述参数均可预测post-PH;多因素logistic回归分析显示,LA(OR 1.53,95%CI 1.26-1.85,P<0.001)、LVEDs(OR 1.23,95%CI 1.06-1.43,P=0.006)、RAP(OR 1.38,95%CI 1.02-1.85,P=0.034)、E/Em(OR 1.28,95%CI 1.08-1.51,P=0.005)为诊断post-PH的独立预测因素。根据ROC曲线测得界值,建立评分系统(LA≥38.5 mm 为 2 分,LVEDs≥28.5 mm 为 1 分,RAP≥8 mmHg为1分,E/Em≥8.6为1分)。利用该评分系统≥2分诊断post-PH的曲线下面积为0.969,的敏感性为95.3%,特异性为89.2%。5.在RHC检查中,与Ipc-PH组患者相比,Cpc-PH组患者有着更高的dPAP(19.9±5.7 vs 30± 10.2 mmHg,P<0.001)、mPAP(35.5±9.8 vs 51.5±19.6 mmHg,P=0.012)、PVR(3.0±1.6 vs 8.5±5.3 WU,P=0.003)和 TVR(7.6±3.0 vs 13.5±7.9WU,P=0.019)。6.在Echo检查中,Ipc-PH组与Cpc-PH组患者相比,两个组别在主肺动脉宽度(main pulmonary artery diameter,MPA)(28.1±5.3 vs 32±4.2 mm,P=0.015)、PASP(54±13.9 vs 75.9±21 mmHg,P<0.001)、右室游离壁厚度(right ventricular free wall systolic diameter,RVWDd)(6.6±1.4 vs 7.8±1.4 mm,P=0.005)、右房横径(right atrial systolic diamete,RADs)(44.7±7.7 vs 50.1±8.3 mm,P=0.025)、RAIDs(55.2±9.8 vs 62.1±12.4 mm,P=0.028)与 RVDd(34.4±5.9 vs 39.5±6.7 mm,P=0.006)存在显著差别。7.经单因素logistic回归分析显示,上述参数均可预测Cpc-PH;多因素logistic回归分析显示,PASP(OR 1.09,95%CI 1.04-1.14,P=0.001)和 RVDd(OR 1.18,95%CI 1.03-1.35,P=0.015)为 Cpc-PH 独立预测因素,两者联合(PASP≥62.5 mmHg,RVDd≥35.6 mm)诊断Cpc-PH的曲线下面积为0.874,敏感性为84.6%,特异性为77.8%。结论:基于Echo参数LA、LVEDs、RAP以及E/Em指标建立简化的评分系统,有助于预测post-PH。此外,结合Echo参数PASP和RVDd可进一步鉴别Icp-PH与Cpc-PH。