超声心动图对系统性红斑狼疮心脏并发症的评估

李 茜综述，唐 红审校

(四川大学华西医院心血管内科，四川 成都 610041)

综述

超声心动图对系统性红斑狼疮心脏并发症的评估

李 茜综述，唐 红*审校

(四川大学华西医院心血管内科，四川 成都 610041)

系统性红斑狼疮(SLE)是一种累及全身多系统、多器官的复杂自身免疫性弥漫性结缔组织病，心血管并发症已成为其主要的死亡原因之一。SLE合并心血管并发症的诊断及评估多依赖于影像学检查。超声心动图无创、简便、可靠，是心脏结构和功能评估的有效手段。本文对超声心动图在SLE患者心脏病变评估中的应用做一综述。

红斑狼疮，系统性；心血管并发症；超声心动描记术

系统性红斑狼疮(systemic lupus erythematosus， SLE)是一种累及全身多个脏器的复杂自身免疫性弥漫性结缔组织病，以免疫性炎症为典型表现，主要累及心血管、肾脏、神经精神系统、血液系统、肺、消化系统、眼及外分泌腺。SLE合并心血管并发症的死亡率逐年升高，已成为SLE患者主要的死亡原因之一[1]。SLE患者发生心血管疾病(cardiovascular disease, CVD)的概率是正常人群的7倍[2]。SLE合并CVD的高发病率及高死亡率的原因与加速的动脉硬化过程相关[3]，而其发生也是CVD的传统危险因素及狼疮特有的危险因素交互作用的结果[2-4]。一方面，SLE本身的免疫性炎症可致血小板的不稳定；另一方面，SLE患者有高发的传统CVD危险因素，如高血压、脂代谢紊乱[5]、长期激素治疗所致的糖耐量降低[6]。此外，合并肾脏损害和免疫抑制疗法可加重心血管损害[7-8]。

SLE患者心脏病变包括冠状动脉性心脏病、心肌病变、瓣膜病变、心包炎及肺动脉高压(pulmonary artery hypertension, PAH)，对其诊断和评估多依赖于影像学检查。超声心动图因其具有无创、简便、可靠的优点，在其中发挥着重要的作用。

常规超声心动图检查包括M型超声、二维超声、频谱多普勒、彩色多普勒、组织多普勒及经食管超声心动图(transesophageal echocardiography, TEE)等。各种超声技术临床常联合应用，互为补充，被广泛应用于心脏疾病的诊断及鉴别诊断。此外，实时三维超声心动图(real-time three-dimensional echocardiography, RT-3DE)、斑点追踪技术等也在心脏疾病的诊治中发挥着重要作用。本文主要对超声心动图在SLE患者心脏病变评估中的应用进行综述。

1 冠状动脉性心脏病

SLE的免疫性炎症可发生于冠状动脉，导致冠状动脉内皮细胞变性坏死，局部内膜增生，管腔灶性狭窄，局部组织坏死及血栓形成，最终导致冠状动脉狭窄，轻者可致心绞痛发生，重症者可致心肌梗死。相对于正常人群，SLE患者更易发生冠状动脉性心脏病[7]，至少13%的SLE患者有心绞痛、心肌梗死等冠状动脉受累表现[9]。而更多亚临床患者缺乏特异性表现，尤其是年轻患者。因其他原因死亡的SLE患者中约50%均有冠状动脉受累[10]。

通过M型超声心动图可获取室壁的运动曲线。观察室壁厚度、收缩期增厚率及运动幅度可判断取样部位心肌是否缺血。利用二维超声心动图可直接观察冠状动脉走行及内径，但由于声窗的影响，仅能显示部分冠状动脉血管。通过室壁形态改变(室壁变薄、纤维化和室壁瘤形成)和室壁运动异常(室壁运动幅度降低、消失，收缩期室壁增厚率降低或消失，甚至出现反向运动)判断受累心肌，是诊断冠心病的重要手段。对于稳定型心绞痛的患者，运动负荷检查为诊断及评估疾病严重程度的重要方法，可用于诊断初发稳定型心绞痛[11]。通过超声心动图的冠状动脉血流成像可评估冠状动脉血流，为诊断冠心病提供依据[12]。

2 心肌病变

尸体检查发现SLE心肌病变的发生率约40%～70%，但因心功能受损而出现相关临床症状的患者仅占10%[13]，部分左心室射血分数(left ventricular ejection fraction， LVEF)正常的患者其心肌运动已出现异常。SLE心肌病变可导致心力衰竭[14]。因此，早期评估SLE患者心肌受累情况对临床诊疗及预后评估具有重要意义。利用超声心动图不仅可对SLE患者心功能下降进行定量评估，通过斑点追踪等超声新技术还可发现亚临床状态下心肌运动异常。

2.1 左心功能评估 通过脉冲多普勒及组织多普勒对二尖瓣及肺静脉血流、二尖瓣瓣环运动、肺动脉压力等进行评估，可评价心室舒张功能。应用组织多普勒可直接评价心肌运动，较脉冲多普勒的间接评价更为准确[15]。有学者[16]评估LVEF正常的SLE患者心脏舒张功能，发现45.3%的患者出现舒张功能受损，其危险因素包括病程、是否合并抗磷脂综合征(antiphospholipid syndrome, APS)、高血压。Shang等[17]发现左心室舒张功能与损伤因素相关。Roldan等[18]采用TEE获得主动脉压力-应变弹性系数对主动脉弹性进行评价，发现该指标与SLE患者心脏舒张功能呈负相关。

除舒张功能受损外，部分SLE患者还伴收缩功能的亚临床改变。组织多普勒、二维及三维斑点追踪技术的应用可实现对心肌收缩功能的评估。组织多普勒操作简单、重复性好，被广泛应用于心脏功能减退的评估，但受角度依赖性的限制和周围组织的影响，准确性有所下降。二维应变分析不受角度依赖性的限制，并可评估心肌在多个方向的应变。Bulut等[19]应用Simpson双平面法及二维斑点追踪技术，发现在LVEF正常的情况下，心肌已出现总体应变的下降，而仅在SLE极度活跃时才出现心室扭转的下降。三维斑点追踪技术可提供LVEF、三维左心室质量、球形指数以及三维应变等定量指标。Huang等[20]应用三维斑点追踪技术对LVEF正常的SLE患者进行研究，发现其整体纵向、环向及径向应变较正常对照组均有所减低，重度活动性SLE患者中各项应变的下降更明显。

左心房在维持正常的心输出量中有重要的作用，LVEF正常的SLE患者多已存在舒张功能的受损，此时左心房常有容量负荷的增加。Dai等[21]研究报道，LVEF正常的SLE患者存在左心房功能受损，且主要与SLE活跃程度相关。Li等[22]采用RE-3DE技术研究发现SLE患者左心房容积较正常对照组有所增加，随SLE损伤指数(rheumatology damage index, SDI)的增加，左心房排空分数减低。

亚临床状态下的SLE患者已存在左心功能受损，SLE病程及活动性为其主要危险因素，对于病程长、疾病活动性大的患者应进行密切的心功能随访。

2.2 右心室功能评估 SLE可引起右心室受累。此外，SLE常并发PAH，可加重右心室功能损害。研究[23-26]发现SLE合并PAH患者的右心室功能降低。

超声心动图评估右心室功能的指标包括三尖瓣前瓣环收缩期运动幅度(tricuspid annular plane systolic excursion, TAPSE)、Tei指数、组织多普勒三尖瓣前瓣环收缩期S峰(tissue Doppler systolic S wave, TDI-S)、斑点追踪技术、三维右心室EF测值等。Leal等[27]研究发现SLE患儿右心室总体长轴应变(global peak longitudinal systolic strain, PLSS)及TAPSE均较正常对照组降低,且这两个指标呈现出较好的相关性。由于右心室形态不规则，常规LVEF测量的方法，如M型超声及Simpson双平面法，并不适用于对右心室的评估[28]。RT-3DE可用以评价右心室功能，其准确性已被证实[29-30]。但目前关于RT-3DE技术评估SLE患者右心室功能的研究尚少。

3 瓣膜病变

SLE患者血浆中的免疫复合物及补体沉积于心瓣膜即可导致瓣膜损害，主要表现为瓣膜增厚(纤维化或钙化)、瓣叶穿孔、瓣膜狭窄、瓣膜反流和疣状心内膜炎，可发生于所有瓣膜，但以二尖瓣及主动脉瓣最为常见[31]。超声心动图可用于评估瓣膜形态及功能改变，观察瓣膜形态、赘生物的附着位置、大小、数目、形态[32]。TEE较常规经胸超声心动图诊断疣状心内膜炎更具优势[33]，但对疣状心内膜炎和感染性心内膜炎的区分仍较困难[34]。另外，超声随访研究[35]发现SLE/APS及其病程是发生瓣膜疾病的独立危险因素，且抗凝治疗不能阻止疾病进程。

4 心包炎

约40%的SLE患者存在急慢性心包损害，但多数患者无症状[36]。心脏压塞，缩窄性心包炎、化脓性心包炎等严重并发症较为罕见，而心包积液则较为常见。采用二维超声心动图可定量测量心包积液深度，观察有无心包增厚，为临床诊疗提供参考依据。

5 PAH

PAH定义为静息时平均肺动脉压(mean pulmonary arterial pressure, MPAP)≥25 mmHg，肺动脉楔压(pulmonary artery wedge pressure, PAWP)或左心室舒张末期压力≤15 mmHg及持续增加的肺血管阻力(pulmonary vascular resistance, PVR)[37]。SLE相关性PAH的发病机制主要是炎细胞、自身抗体等浸润肺小动脉壁，产生PVR，最终导致PAH[38]。SLE合并PAH的概率为0.5%～17.5%[39]。

目前诊断PAH的金标准为心导管检查，但超声心动图是筛查PAH的重要手段。常用方法是通过连续多普勒测量三尖瓣反流压差估算肺动脉收缩压[40]。通过二维超声心动图可观察PAH引起的心脏结构改变，如右心增大、肺动脉增宽、下腔静脉塌陷率减低等。

综上所述，SLE患者心脏结构及功能均存在损害。超声心动图作为一种无创、便捷的心脏结构及功能评估方法，对SLE患者的心脏结构及功能评估起着重要作用。

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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，硕士，医师。研究方向：超声心动图。E-mail: plor@qq.com

唐红，四川大学华西医院心血管内科，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