超聲心動圖對系統(tǒng)性紅斑狼瘡心臟并發(fā)癥的評估

李 茜綜述，唐 紅審校

(四川大學華西醫(yī)院心血管內(nèi)科，四川 成都 610041)

綜述

超聲心動圖對系統(tǒng)性紅斑狼瘡心臟并發(fā)癥的評估

李 茜綜述，唐 紅*審校

(四川大學華西醫(yī)院心血管內(nèi)科，四川 成都 610041)

系統(tǒng)性紅斑狼瘡(SLE)是一種累及全身多系統(tǒng)、多器官的復雜自身免疫性彌漫性結締組織病，心血管并發(fā)癥已成為其主要的死亡原因之一。SLE合并心血管并發(fā)癥的診斷及評估多依賴于影像學檢查。超聲心動圖無創(chuàng)、簡便、可靠，是心臟結構和功能評估的有效手段。本文對超聲心動圖在SLE患者心臟病變評估中的應用做一綜述。

紅斑狼瘡，系統(tǒng)性；心血管并發(fā)癥；超聲心動描記術

系統(tǒng)性紅斑狼瘡(systemic lupus erythematosus， SLE)是一種累及全身多個臟器的復雜自身免疫性彌漫性結締組織病，以免疫性炎癥為典型表現(xiàn)，主要累及心血管、腎臟、神經(jīng)精神系統(tǒng)、血液系統(tǒng)、肺、消化系統(tǒng)、眼及外分泌腺。SLE合并心血管并發(fā)癥的死亡率逐年升高，已成為SLE患者主要的死亡原因之一[1]。SLE患者發(fā)生心血管疾病(cardiovascular disease, CVD)的概率是正常人群的7倍[2]。SLE合并CVD的高發(fā)病率及高死亡率的原因與加速的動脈硬化過程相關[3]，而其發(fā)生也是CVD的傳統(tǒng)危險因素及狼瘡特有的危險因素交互作用的結果[2-4]。一方面，SLE本身的免疫性炎癥可致血小板的不穩(wěn)定；另一方面，SLE患者有高發(fā)的傳統(tǒng)CVD危險因素，如高血壓、脂代謝紊亂[5]、長期激素治療所致的糖耐量降低[6]。此外，合并腎臟損害和免疫抑制療法可加重心血管損害[7-8]。

SLE患者心臟病變包括冠狀動脈性心臟病、心肌病變、瓣膜病變、心包炎及肺動脈高壓(pulmonary artery hypertension, PAH)，對其診斷和評估多依賴于影像學檢查。超聲心動圖因其具有無創(chuàng)、簡便、可靠的優(yōu)點，在其中發(fā)揮著重要的作用。

常規(guī)超聲心動圖檢查包括M型超聲、二維超聲、頻譜多普勒、彩色多普勒、組織多普勒及經(jīng)食管超聲心動圖(transesophageal echocardiography, TEE)等。各種超聲技術臨床常聯(lián)合應用，互為補充，被廣泛應用于心臟疾病的診斷及鑒別診斷。此外，實時三維超聲心動圖(real-time three-dimensional echocardiography, RT-3DE)、斑點追蹤技術等也在心臟疾病的診治中發(fā)揮著重要作用。本文主要對超聲心動圖在SLE患者心臟病變評估中的應用進行綜述。

1 冠狀動脈性心臟病

SLE的免疫性炎癥可發(fā)生于冠狀動脈，導致冠狀動脈內(nèi)皮細胞變性壞死，局部內(nèi)膜增生，管腔灶性狹窄，局部組織壞死及血栓形成，最終導致冠狀動脈狹窄，輕者可致心絞痛發(fā)生，重癥者可致心肌梗死。相對于正常人群，SLE患者更易發(fā)生冠狀動脈性心臟病[7]，至少13%的SLE患者有心絞痛、心肌梗死等冠狀動脈受累表現(xiàn)[9]。而更多亞臨床患者缺乏特異性表現(xiàn)，尤其是年輕患者。因其他原因死亡的SLE患者中約50%均有冠狀動脈受累[10]。

通過M型超聲心動圖可獲取室壁的運動曲線。觀察室壁厚度、收縮期增厚率及運動幅度可判斷取樣部位心肌是否缺血。利用二維超聲心動圖可直接觀察冠狀動脈走行及內(nèi)徑，但由于聲窗的影響，僅能顯示部分冠狀動脈血管。通過室壁形態(tài)改變(室壁變薄、纖維化和室壁瘤形成)和室壁運動異常(室壁運動幅度降低、消失，收縮期室壁增厚率降低或消失，甚至出現(xiàn)反向運動)判斷受累心肌，是診斷冠心病的重要手段。對于穩(wěn)定型心絞痛的患者，運動負荷檢查為診斷及評估疾病嚴重程度的重要方法，可用于診斷初發(fā)穩(wěn)定型心絞痛[11]。通過超聲心動圖的冠狀動脈血流成像可評估冠狀動脈血流，為診斷冠心病提供依據(jù)[12]。

2 心肌病變

尸體檢查發(fā)現(xiàn)SLE心肌病變的發(fā)生率約40%～70%，但因心功能受損而出現(xiàn)相關臨床癥狀的患者僅占10%[13]，部分左心室射血分數(shù)(left ventricular ejection fraction， LVEF)正常的患者其心肌運動已出現(xiàn)異常。SLE心肌病變可導致心力衰竭[14]。因此，早期評估SLE患者心肌受累情況對臨床診療及預后評估具有重要意義。利用超聲心動圖不僅可對SLE患者心功能下降進行定量評估，通過斑點追蹤等超聲新技術還可發(fā)現(xiàn)亞臨床狀態(tài)下心肌運動異常。

2.1 左心功能評估 通過脈沖多普勒及組織多普勒對二尖瓣及肺靜脈血流、二尖瓣瓣環(huán)運動、肺動脈壓力等進行評估，可評價心室舒張功能。應用組織多普勒可直接評價心肌運動，較脈沖多普勒的間接評價更為準確[15]。有學者[16]評估LVEF正常的SLE患者心臟舒張功能，發(fā)現(xiàn)45.3%的患者出現(xiàn)舒張功能受損，其危險因素包括病程、是否合并抗磷脂綜合征(antiphospholipid syndrome, APS)、高血壓。Shang等[17]發(fā)現(xiàn)左心室舒張功能與損傷因素相關。Roldan等[18]采用TEE獲得主動脈壓力-應變彈性系數(shù)對主動脈彈性進行評價，發(fā)現(xiàn)該指標與SLE患者心臟舒張功能呈負相關。

除舒張功能受損外，部分SLE患者還伴收縮功能的亞臨床改變。組織多普勒、二維及三維斑點追蹤技術的應用可實現(xiàn)對心肌收縮功能的評估。組織多普勒操作簡單、重復性好，被廣泛應用于心臟功能減退的評估，但受角度依賴性的限制和周圍組織的影響，準確性有所下降。二維應變分析不受角度依賴性的限制，并可評估心肌在多個方向的應變。Bulut等[19]應用Simpson雙平面法及二維斑點追蹤技術，發(fā)現(xiàn)在LVEF正常的情況下，心肌已出現(xiàn)總體應變的下降，而僅在SLE極度活躍時才出現(xiàn)心室扭轉(zhuǎn)的下降。三維斑點追蹤技術可提供LVEF、三維左心室質(zhì)量、球形指數(shù)以及三維應變等定量指標。Huang等[20]應用三維斑點追蹤技術對LVEF正常的SLE患者進行研究，發(fā)現(xiàn)其整體縱向、環(huán)向及徑向應變較正常對照組均有所減低，重度活動性SLE患者中各項應變的下降更明顯。

左心房在維持正常的心輸出量中有重要的作用，LVEF正常的SLE患者多已存在舒張功能的受損，此時左心房常有容量負荷的增加。Dai等[21]研究報道，LVEF正常的SLE患者存在左心房功能受損，且主要與SLE活躍程度相關。Li等[22]采用RE-3DE技術研究發(fā)現(xiàn)SLE患者左心房容積較正常對照組有所增加，隨SLE損傷指數(shù)(rheumatology damage index, SDI)的增加，左心房排空分數(shù)減低。

亞臨床狀態(tài)下的SLE患者已存在左心功能受損，SLE病程及活動性為其主要危險因素，對于病程長、疾病活動性大的患者應進行密切的心功能隨訪。

2.2 右心室功能評估 SLE可引起右心室受累。此外，SLE常并發(fā)PAH，可加重右心室功能損害。研究[23-26]發(fā)現(xiàn)SLE合并PAH患者的右心室功能降低。

超聲心動圖評估右心室功能的指標包括三尖瓣前瓣環(huán)收縮期運動幅度(tricuspid annular plane systolic excursion, TAPSE)、Tei指數(shù)、組織多普勒三尖瓣前瓣環(huán)收縮期S峰(tissue Doppler systolic S wave, TDI-S)、斑點追蹤技術、三維右心室EF測值等。Leal等[27]研究發(fā)現(xiàn)SLE患兒右心室總體長軸應變(global peak longitudinal systolic strain, PLSS)及TAPSE均較正常對照組降低,且這兩個指標呈現(xiàn)出較好的相關性。由于右心室形態(tài)不規(guī)則，常規(guī)LVEF測量的方法，如M型超聲及Simpson雙平面法，并不適用于對右心室的評估[28]。RT-3DE可用以評價右心室功能，其準確性已被證實[29-30]。但目前關于RT-3DE技術評估SLE患者右心室功能的研究尚少。

3 瓣膜病變

SLE患者血漿中的免疫復合物及補體沉積于心瓣膜即可導致瓣膜損害，主要表現(xiàn)為瓣膜增厚(纖維化或鈣化)、瓣葉穿孔、瓣膜狹窄、瓣膜反流和疣狀心內(nèi)膜炎，可發(fā)生于所有瓣膜，但以二尖瓣及主動脈瓣最為常見[31]。超聲心動圖可用于評估瓣膜形態(tài)及功能改變，觀察瓣膜形態(tài)、贅生物的附著位置、大小、數(shù)目、形態(tài)[32]。TEE較常規(guī)經(jīng)胸超聲心動圖診斷疣狀心內(nèi)膜炎更具優(yōu)勢[33]，但對疣狀心內(nèi)膜炎和感染性心內(nèi)膜炎的區(qū)分仍較困難[34]。另外，超聲隨訪研究[35]發(fā)現(xiàn)SLE/APS及其病程是發(fā)生瓣膜疾病的獨立危險因素，且抗凝治療不能阻止疾病進程。

4 心包炎

約40%的SLE患者存在急慢性心包損害，但多數(shù)患者無癥狀[36]。心臟壓塞，縮窄性心包炎、化膿性心包炎等嚴重并發(fā)癥較為罕見，而心包積液則較為常見。采用二維超聲心動圖可定量測量心包積液深度，觀察有無心包增厚，為臨床診療提供參考依據(jù)。

5 PAH

PAH定義為靜息時平均肺動脈壓(mean pulmonary arterial pressure, MPAP)≥25 mmHg，肺動脈楔壓(pulmonary artery wedge pressure, PAWP)或左心室舒張末期壓力≤15 mmHg及持續(xù)增加的肺血管阻力(pulmonary vascular resistance, PVR)[37]。SLE相關性PAH的發(fā)病機制主要是炎細胞、自身抗體等浸潤肺小動脈壁，產(chǎn)生PVR，最終導致PAH[38]。SLE合并PAH的概率為0.5%～17.5%[39]。

目前診斷PAH的金標準為心導管檢查，但超聲心動圖是篩查PAH的重要手段。常用方法是通過連續(xù)多普勒測量三尖瓣反流壓差估算肺動脈收縮壓[40]。通過二維超聲心動圖可觀察PAH引起的心臟結構改變，如右心增大、肺動脈增寬、下腔靜脈塌陷率減低等。

綜上所述，SLE患者心臟結構及功能均存在損害。超聲心動圖作為一種無創(chuàng)、便捷的心臟結構及功能評估方法，對SLE患者的心臟結構及功能評估起著重要作用。

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Assessment of cardiovascular complications in patients with systemic lupus erythematosus by echocardiography

LIXi,TANGHong*

(DepartmentofCardiology,WestChinaHospitalofSichuanUniversity，Chengdu610041，China)

Systemic lupus erythematosus (SLE) is a kind of complex autoimmune connective tissue disease involving multi-organ and multiple systems. And the cardiovascular complication is a major cause of mortality in SLE patients. The diagnosis and evaluation depend on imaging. As a non-invasive, simplicity and repeatability method， echocardiography plays a vital role in evaluating heart structure and function. The application of echocardiography in the SLE with cardiovascular complications were reviewed in this article.

Lupus erythematosus, systemic; Cardiovascular complications; Echocardiography

李茜(1990—)，女，四川巴中人，碩士，醫(yī)師。研究方向：超聲心動圖。E-mail: plor@qq.com

唐紅，四川大學華西醫(yī)院心血管內(nèi)科，610041。

E-mail： hxyyth@qq.com

2016-07-15

2017-01-08

10.13929/j.1003-3289.201607068

R593.24； R540.45

A

1003-3289(2017)04-0624-04