肺动脉高压超声技术评估沈节艳课件

肺动脉高压 超声技术评估,上海仁济医院心内科 沈节艳,3.1. 慢性阻塞性肺疾患（COPD） 3.2. 肺间质病变 3.3. 睡眠呼吸障碍 3.4. 肺泡通气不足 3.5. 高海拔 3.6. 发育障碍,4.1. 近端血栓栓塞性肺动脉高压 4.2. 远端血栓栓塞性肺动脉高压 4.3. 非血栓性栓塞性肺动脉高压,肉瘤、组织细胞增殖症X、肿瘤、淋巴管瘤病等,Simonneau G et al. J Am Coll Cardiol 2004; 43: 5S-12S,修订的 WHO 关于 PH 的分类 2009 ACCF/AHA,2.1. 左心疾病引起 2.2. 左心瓣膜病引起,1.1. (IPAH)特发性 1.2. (FPAH) 家族性 1.3. (APAH)相关因素: CTD,CHD, Portal H, HIV, Drug, other 1.4. 相关肺静脉或肺毛细血管引起的 1.5 新生儿持续性肺动脉高压,PAMP 25 mmHg ,LVEDP 15 mmHg,1.肺动脉高压,2.左心病变性 肺高压,3. 肺或低氧性肺高压,4. 慢性血栓栓塞性,5.其他,肺动脉高压（1）,1.1. 特发性肺动脉高压(IPAH) 没有明确的基础疾病， 性别比例：男：女：1：2.4 原发性肺动脉高压发病年龄高峰 男性：30-40岁 女性：20-30 岁, 女性生育后3个月以内发病风险增高1.7倍 1.2. 家族性肺动脉高压 (FPAH) 疾病具有家族性 占原发性肺动脉高压中的6%-10% 约有50%的家族性特发性肺动脉高压患者存在染色体2q33上编码骨形成蛋白II型受体(BMPR2)基因突变,Simonneau G et al. J Am Coll Cardiol 2004; 43: 5S-12S Lane KB et al. Nat Genet 2000; 26(1): 814,1. 肺动脉高压 (2),1.3. 相关因素引起的肺动脉高压 (APAH): 1.3.1. 结缔组织疾病 SSc ，SLE ，MCTD 1.3.2. 先天性体-肺分流 ASD, VSD, PDA 1.3.3. 门脉高压 1.3.4. HIV感染 1.3.5. 食欲抑制药物和毒物所致：食欲抑制剂芬氟拉明 1.3.6. 其他,Simonneau G et al. J Am Coll Cardiol 2004; 43: 5S-12S,1. 肺动脉高压（3）,1.4. 相当严重的肺静脉和肺毛细血管疾病 1.4.1. 肺静脉闭塞症 (PVOD) 1.4.2. 肺毛细血管瘤 (PCH) 肺静脉闭塞症 (PVOD)和肺毛细血管瘤 (PCH)具有肺动脉高压共同特征： 相似的组织学异常表现：肺小动脉内膜纤维化及中膜肥厚 相似的危险因素：硬皮病、 HIV 感染 抑制食欲药物, 家族性 BMPR2 突变 相似的临床表现 使用血管扩张剂和前列环素时必须十分小心以免引起肺水肿 1.5. 新生儿持续性肺动脉高压,Simonneau G et al. J Am Coll Cardiol 2004; 43: 5S-12S,PAH预后,Median life expectancy from the time of diagnosis in IPAH was 2.8 years. Five years survival rate was around 24%,DAlonzo GE, Barst RJ, Ayres SM, et al. Ann Intern Med 1991;115(5):343-9 Oakley CW. Chest 1994;105(2 Suppl):29S-32S,超声心动图在肺动脉高压诊断中的价值,无创伤测量肺动脉压力及阻力PASP, PAMP, PADP, PVR 筛查早期诊断 评估右心室功能-预后评估 鉴别肺动脉高压的病因- 先心病、结缔组织性、特发性肺动脉高压、肺血栓栓塞性 排除左心病变所致的肺静脉高压- 风湿性二尖瓣狭窄，限制性心肌病，高心，冠心, 扩心等,ACCP Evidence-Based Clinical Practice Guidelines CHEST2004;126:14S,连续多普勒如何估测评价肺动脉压?,肺动脉收缩压 肺动脉舒张压 肺动脉平均压 肺血管阻力,多普勒血流速度测压力,肺动脉收缩压的测定 三尖瓣反流（TR）速度法,RVSP =4vmax2+PRA, V=4m/s, PRA =10mmHg, RVSP=74mmHg PASP,右心房压力评估,RAP近似值：5mmHg（无/少三尖瓣返流时) 10mmHg (轻中度三尖瓣返流时) 15mmHg(右心明显增大，重度三尖瓣返流时） RAP可由下腔静脉（IVC）宽度估测。如随呼吸运动IVC塌陷50%，则RAP10mmHg。,超声测量SPAP的正常值范围,TR 频谱获得率74 RVSP（SPAP）随年龄 / 体重指数而增高 在肥胖 / 高龄人群中假阳性率 超声测SPAP正常值范围：1557mmHg(平均285mmHg） 超声测SPAP40mmHg-筛查PH,McQuillan BM,et al. Circulation.2001;104:2797802.,超声测量PASP与右心导管对比,多普勒超声心动图可能低估了严重PH患者的SPAP，而高估了肺动脉压力正常人群的SPAP。,敏感性：0.791 特异性：0.60.98,ACCP Evidence-Based Clinical Practice Guidelines CHEST2004;126:14S,肺动脉反流（PR）速度法,肺动脉反流舒张早期峰值速度可用于评估肺动脉平均压（PAMP）， Masuyama公式： PAMP = 4 peak VPR2 肺动脉反流舒张末期速度反映了肺动脉和右心室舒张末期压力阶差，因而： PADP = 4 PREDV2 + RAP,右室流出道血流加速时间（Act）,肺动脉压力增高，肺动脉血流加速时间Act显著缩短。Mahans回归方程测定肺动脉平均压 PAMP = 79 0.45 Act Mahans公式适用范围：心率60-100次/分 适用于难以获取肺动脉反流多普勒频谱者,先天分流性心脏病肺动脉压测量,室水平分流估测法: PASPRVSP = LVSP- p =SBP-p= SBP-4vmax2 (vmax: 室缺左向右分流的峰值速度) 大动脉水平分流估测法: PASP = AOSP- p =SBP-p= SBP-4vmax2 (vmax: 动脉导管未闭左向右分流的峰值速度),肺总阻力估测,肺动脉平均压（由肺动脉瓣反流估测肺动脉平均压) 肺动脉流量 肺动脉瓣环直径面积 根据肺动脉瓣血流图估测流速-时间积分 根据RR间期估测心率 肺总阻力肺动脉平均压/肺动脉流量80（单位：达因.秒.厘米5）,肺血流量测定,肺血管阻力估测,超声肺动脉收缩压与右室流出道时间流速积分比(SPAP /（HR x TVIRVOT) ) 相当于肺动脉压与肺血流量之比与导管PVRI相关(r = 0.860; 95% CI 0.759-0.920) SPAP / (HR x TVIRVOT)值 0.076 预测PVRI 15 WU/m2. 敏感性86%，特异性82%。,Haddad F et al. J Am Soc Echocardiogr. 2009 May;22(5):523-9,肺血管阻力估测,三尖瓣反流压差与右室流出道时间流速积分比(TRPG/TVIRVOT) 相关于肺血管阻力PVR(r= 0.82) PVR = 187 + TRPG/TVIRVOT x 118, (r= 0.82, p 7.6 提示预后不佳 （85% sensitivity，92% specificity）,Kouzu H, et al. Am J Cardiol. 2009 Mar 15;103(6):872-6,二种肺血管阻力估测方法比较,SPAP / (HR x TVIRVOT)法与导管实测PVRI的r=0.86, TRV(TRPG) / TVIRVOT法与导管实测PVRI的r=0.724,Haddad F et al. J Am Soc Echocardiogr. 2009 May;22(5):523-9,肺血管阻力测定,当PVR 8 Wood，超声TRV/VTIRVOT与导管PVR的相关性差(r = 0.17)。,Rajagopalan N, et al. Echocardiography. 2009 May;26(5):489-94.,多普勒超声评价右室功能,心包积液 右心室/右心房大小 右心室球性功能Tei 指数 左室偏心指数 三尖瓣环收缩期前移 组织Doppler和斑点追综法评价右室功能,右房大小测定,面积长度法衡量右房容积 右房27 cm2,提示预后差,右室大小测定,心尖四腔观测量右室内径,正常值分别为: RVD1: 2.0-2.8 cm, RVD2: 2.7-3.3 cm, RVD3: 7.1-7.9 cm.,右心室球性功能Tei 指数,右室Tei 指数与生存率,左心室偏心指数,左心偏心指数 (LV-EI) = D2/D1, D2/D1 1.2 为异常.,三尖瓣环收缩期前移,三尖瓣环收缩期前移(TAPSE) 正常值2.0cm, TAPSE1.5cm /1.8cm, 提示右室功能严重受损,预后不佳.,Miller D et al. J Am Soc Echocardiogr. 2004 May;17(5):443-7 Forfia PR et al. Am J Respir Crit Care Med. 2006 Nov 1;174(9):1034-41.,组织多普勒显象TDI,TDI检测三尖瓣环侧面和间膈面的平均收缩期速度TASV（TDI）与MRI测得右室射血分数RVEF高度相关(r = 0.74; P 45% ( 95% CI 0.84-0.98; sensitivity 83%; specificity 86%; P .0001).,Sade LE, et al. J Am Soc Echocardiogr. 2009 Apr;22(4):361-8.,斑点追踪法检测右室功能,正常人及肺动脉高压患者舒张期（A ，C ）收缩期（B，D）右室心内膜追踪测运动方向和速度,Pirat B,et al. Am J Cardiol 2006;98:699 704,斑点追踪法检测早期右室功能减退,早于：肺动脉压力升高，TDI，TAPSE 不受取样角度影响 右室侧壁基底段的纵向strain rate最敏感。 右室侧壁基底段收缩期速度/Strain/Strain Rate与PASP、PVR、RV负相关 右室侧壁收缩期峰值strain rate =-1.67s-1预测PASP50mmHg 敏感性80，特异性78,Pirat B,et al. Am J Cardiol 2006;98:699 704 Matias C, et al. Journal of Cardiovascular Medicine 2009, 10:129134,斑点追踪法检测肺动脉高压,Pirat B,et al. Am J Cardiol 2006;98:699 704,*p 0.01 compared with normal controls; p 0.05 compared with patients with mild PAH.,肺高压的病因诊断,特发性肺动脉高压 先天性体-肺分流性肺动脉高压 结缔组织病相关性肺高压 肺栓塞性肺高压 风湿性二尖瓣狭窄肺静脉高压,肺动脉高压(PAH) 肺动脉瓣收缩中期半关闭,肺动脉高压(PAH) M型示室间膈与左室后壁呈同向运动,二维超声,右心房、右心室增大、右心室肥厚； 室间隔变扁平，左心室呈“D”型；,脉冲多普勒示肺动脉瓣血流图峰值前移，提示肺动脉高压 连续多普勒估测肺动脉收缩压为108mmhg,继发孔型房缺（双向分流）伴重度肺动脉高压PAH associated with ASD,静脉窦型房缺伴肺动脉高压 PAH associated with ASD (TEE),肌部室缺伴重度肺动脉高压 PAH associated with VSD,狼疮相关性肺动脉高压 PAH associated with SLE,风心，二尖瓣重度狭窄-肺静脉高压 PH due to severe mitral stenosis,肺动脉内血栓（术前） Thrombosis in PA (before surgery),短轴观示右肺动脉内团块状物延伸至肺动脉总干及左肺动脉，且右肺动脉内血流完全阻塞，中重度肺动脉高压,术后 (after surgery),手术后，相同切面示肺动脉总干及左肺动脉内血流通畅,谢谢 !,Echocardiographic Evaluation of Pulmonary Arterial Hypertension,SHEN JieYan, PHCR Department of Cardiology SJTUMC Shanghai RenJi Hospital,3.1. COPD 3.2. Interstitial lung disease 3.3. sleep disordered breathing 3.4. alveolar hypoventilation dis. 3.5. high altitude 3.6. Developmental abnormalities,4.1. TE of proximal a. 4.2. TE of distal a. 4.3. Non-thrombotic embolism,Sarcoidosis, histiocytosis X, lymphangiomatosis,etc,Simonneau G et al. J Am Coll Cardiol 2004; 43: 5S-12S,Revised WHO Classification of PH 2009 ACCF/AHA,2.1. Left-sided atr. or ventri. disease 2.2. Left-sided valvular heart disease,1.1. Idiopathic (IPAH) 1.2. Familial (FPAH) 1.3. Associated with (APAH): CTD,CHD, Portal H, HIV, Drug 1.4. PVOD、PCH 1.5 PPHN,1. PAH (Pulmonary arterial hypertension),2. PH associated with left heart disease,3. PH with lung respiratory and / or hypoxia,4. PH due to chronic thrombotic / embolic d. (CTEPH),5.Miscellaneous,Prognosis of PAH,Median life expectancy from the time of diagnosis in IPAH was 2.8 years. Five years survival rate was around 24%,DAlonzo GE, Barst RJ, Ayres SM, et al. Ann Intern Med 1991;115(5):343-9 Oakley CW. Chest 1994;105(2 Suppl):29S-32S,Value of Echocardiography in the diagnosis of PAH,Non-invasive measurement of PASP, PAMP, PADP, PVR -screening early detection Evaluation right heart function -evaluation of prognosis Evaluation etiology of PAH -Differential diagnosis: CHD,CTD,IPAH, Exclusion other causes of PH -Rumatic mitral stenosis，restrictive cardiomyopathy，hypertrophy，coronary heart disease, dilated cardiomyopathy,etc.,ACCP Guidelines CHEST2004;126:14S,Doppler Echocardiography detection of pulmonary arterial pressure & resistance,Pulmonary Arterial Systolic Pressure (PASP) Pulmonary Arterial Diastolic Pressure (PADP) Pulmonary Arterial Mean Pressure (PAMP) Pulmonary Vascular Resistance (PVR),Bernurli Equation,Detection of PASP by tricuspid regurgitation (TR) peak velocity,RVSP =4vmax2+PRA, V=4m/s, PRA =10mmHg, RVSP=74mmHg PASP,Evaluation of right atrial pressure (RAP),Approximation of RAP：5mmHg 10mmHg 15mmHg Evaluation of RAP according to wideness of inferior vena cava,Echo Detection of PASP,TR jets can be assessed in 74% of PH RVSP（PASP) increased with age and/or body mass index of the population potential false positive echo diagnoses of PH in aged and/or obese patients normal PASP range :1557 mm Hg (mean 285 mm Hg) Echo PASP40mmHg-PH,McQuillan BM,et al. Circulation.2001;104:2797802.,Comparison between Echo estimation and RHC measurement of PASP,Doppler echocardiography may underestimate PASP in patients with severe PH, and overestimate PASP in populations comprised mostly of subjects with normal pressures.,Sensitivity：0.791 Specificity：0.60.98,ACCP Evidence-Based Clinical Practice Guidelines CHEST2004;126:14S,Pulmonary Regurgitation（PR）method,Pulmonary regurgitation early diastolic peak velocity estimate PAMP by Masuyama equation： PAMP = 4 peak VPR2 Pulmonary regurgitation end diastolic velocity estimate PADP by Bernoulli equation： PADP = 4 PREDV2 + RAP,Right ventricular outflow tract Acceleration time（Act）,When PAP increase, Act will shortened. Mahans equation: PAMP = 79 0.45 Act HR:60-100/min PR jet difficult to get,Pulmonary pressure measurement in congenital heart disease,Estimation from ventricular left to right shunt: PASPRVSP = LVSP- p =SBP-p= SBP-4vmax2 (Vmax: peak velocity of left to right shunt in VSD) Estimation from arterial left to right shunt: PASP = AOSP- p =SBP-p= SBP-4vmax2 (Vmax: peak velocity of left to right shunt in PDA),Total Pulmonary Resistance (TPR),PAMP（Estimated by PR jet) Pulmonary Flux (Qp) Diameter-area of pulmonary annular Velocity time intergal (VTI) of pulmonary flow Heart rate by RR interval TPRPAMP/Qp80（dyn.s.cm5）,Measurement of pulmonary flux,Estimation of pulmonary vascular resistance,The ratio of SPAP/(HRxTVIRVOT) correlated very well with invasive PVRI measurements (r = 0.860; 95% CI 0.759-0.920). A cutoff value of 0.076 provided well-balanced sensitivity (86%) and specificity (82%) to determine PVRI 15 WU/m2.,Haddad F et al. J Am Soc Echocardiogr. 2009 May;22(5):523-9,Estimation of pulmonary vascular resistance,The TRPG/TVIRVOT ratio, showed an significant correlation with invasive PVR, with coefficient of correlation 0.82. PVR = 187 + TRPG/TVIRVOT x 118, (r= 0.82, p 7.6 showed 85% sensitivity and 92% specificity for identifying patients in the poor-prognosis group.,Kouzu H, et al. Am J Cardiol. 2009 Mar 15;103(6):872-6,Comparison between two estimation of PVR,The ratio SPAP / (HR x TVIRVOT) correlated with invasive PVRI, r=0.86, The ratio TRV(TRPG) / TVIRVOT correlated with invasive PVRI, r=0.724,Haddad F et al. J Am Soc Echocardiogr. 2009 May;22(5):523-9,Estimation of pulmonary vascular resistance,In a subset of patients with invasive PVR 8 Wood units (r = 0.17).,Rajagopalan N, et al. Echocardiography. 2009 May;26(5):489-94.,Evaluation of Right Heart Function,Pericardial Effusion Enlargement of Right ventricle / atrium RV global systolic functionTei index Left ventricular eccentricity index tricuspid annular plane systolic excursion (TAPSE) Tissue Doppler Imaging (TDI) and Speckle-tracking (ST),Assessment of right atrial size,Area-length method to determine right atrial volume A right atrial size 27 cm2 is pathologic and with poor prognosis,Right ventricular diameters,the normal values of the basal (RVD1), midcavity (RVD2), and longitudinal (RVD3) diameters in the apical 4-chamber view at end diastole of right ventricle are: 2.0-2.8 cm, 2.7-3.3 cm and 7.1-7.9cm.,RV global systolic function Tei index,Tei index and survival rate,Left ventricular eccentricity index (LV-EI),LV-EI = D2/D1, abnormal values are 1.2,Tricuspid Annular Plane Systolic Excursion (TAPSE),the tricuspid annulus will normally move toward the apex approximately 2.0 cm. TAPSE1.5cm / 1.8cm: RV dysfunction and poor prognosis.,Miller D et al. J Am Soc Echocardiogr. 2004 May;17(5):443-7 Forfia PR et al. Am J Respir Crit Care Med. 2006 Nov 1;174(9):1034-41.,Tissue Doppler Imaging (TDI),TDI detected average systolic velocity from the tricuspid lateral and septal annulus (TASV) had the highest correlation to the RVEF (r = 0.74; P 45% ( 95% CI 0.84-0.98; sensitivity 83%; specificity 86%; P .0001).,Sade LE, et al. J Am Soc Echocardiogr. 2009 Apr;22(4):361-8.,Evaluation of RV Function by Speckle Tracking Method,Automated tracking of the RV endocardial borders in diastole and systole in a control subject (A, B) and in a patient with severe PAH (C, D) indicating the direction of the motion and the amplitude of the velocity.,Pirat B,et al. Am J Cardiol 2006;98:699 704,Speckle-tracking evaluate early alterations in RV function,Early than pressure increase、TDI、TAPSE angle independent strain rate of basal RV free wall is best sensitive Systolic velocity, strain, and strain rate of the basal RV free wall