超音波検査技術

ISSN: 1881-4506
一般社団法人日本超音波検査学会
〒162-0801 東京都新宿区山吹町358-5
Japanese Journal of Medical Ultrasound Technology 48(4): 384-397 (2023)
doi:10.11272/jss.407

研究Research Paper

心エコー法による右房圧推定精度の検証：ガイドラインに基づく副次的指標の再考Validation of Echocardiographic Estimation of the Right Atrial Pressure: Reconsideration of Guideline-Based Secondary Indices

村山 迪史1,2，加賀 早苗1,2，小野田 愛梨3，岡田 一範4，中鉢 雅大2，横山 しのぶ2，西野 久雄2，青柳 裕之5，玉置 陽生5，本居 昂5，石坂 傑5，岩野 弘幸2,6，永井 利幸5，辻野 一三7，安斉 俊久5Michito Murayama1,2, Sanae Kaga1,2, Airi Onoda3, Kazunori Okada4, Masahiro Nakabachi2, Shinobu Yokoyama2, Hisao Nishino2, Hiroyuki Aoyagi5, Yoji Tamaki5, Ko Motoi5, Suguru Ishizaka5, Hiroyuki Iwano2,6, Toshiyuki Nagai5, Ichizo Tsujino7, Toshihisa Anzai5

1 北海道大学大学院保健科学研究院Faculty of Health Sciences, Hokkaido University

2 北海道大学病院超音波センターDiagnostic Center for Sonography, Hokkaido University Hospital

3 北海道大学大学院保健科学院Faculty of Health Sciences, Hokkaido University

4 日本医療大学保健医療学部Faculty of Health Sciences, Japan Healthcare University

5 北海道大学大学院医学研究院循環病態内科学教室Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University

6 手稲渓仁会病院循環器内科Division of Cardiovascular Medicine, Teine Keijinkai Hospital

7 北海道大学医学研究院呼吸器内科学教室Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University

受付日：2023年1月4日Received: January 4, 2023
受理日：2023年5月12日Accepted: May 12, 2023
発行日：2023年8月1日Published: August 1, 2023
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目的：アメリカ心エコー図学会のガイドラインには，下大静脈計測に基づく右房圧推定の精度を補完するものとして，拘束型の右室流入血流速波形，拡張早期の右室流入血流速度と三尖弁輪運動速度との比，肝静脈血流速波形のsystolic filling fractionが示されている．本研究では，これらの副次的指標が右房圧上昇の予測能を改善させるかを明らかにするとともに，右房面積計測の付加的価値を検討する．

対象と方法：心疾患患者128例において右心カテーテル検査で平均右房圧を計測し，≧8 mmHgを上昇とした．下大静脈の径とsniffによる虚脱率から，推定右房圧を3, 8，15 mmHgに分類した（モデル1）．右室流入血流速波形の拘束型パターン，拡張早期の右室流入血流速度と三尖弁輪運動速度との比，systolic filling fractionを評価に加えて，推定右房圧の再分類を行った（モデル2）．右房の最小と最大面積および容積を計測し，それぞれのexpansion indexを算出した．

結果：右房圧の上昇を29例に認めた．ロジスティック回帰分析で，モデル1における推定右房圧とsystolic filling fractionは，平均右房圧上昇と有意に関連した（ともにp＜0.05）．拘束型パターンを呈した例はなく，拡張早期の右室流入血流速度と三尖弁輪運動速度との比は右房圧上昇と関連しなかった．右房の形態・機能指標は，いずれも右房圧上昇と関連し（すべてp＜0.05），最小右房面積が最も強く関連した（右室面積変化率で補正後のオッズ比：10.64, p＜0.01）．尤度比検定では，モデル2の右房圧上昇の予測能はモデル1と同等であったが，systolic filling fractionと最小右房面積を用いた新しいモデルは，モデル1より良好に右房圧上昇を予測できた．

結論：従来の副次的指標を用いた再分類により右房圧上昇の予測能は改善しなかった．肝静脈血流速波形のsystolic filling fractionと最小右房面積を右房圧の評価に加えると，右房圧上昇の予測能は改善した．

Purpose: Sonographic measurements of the inferior vena cava parameters are common noninvasive methods for estimating the right atrial pressure. In intermediate cases in which the inferior vena cava parameters showed an indeterminate value, the current guidelines of the American Society of Echocardiography recommended using the secondary indices, which include the restrictive right-sided diastolic filling pattern, ratio of early-diastolic transtricuspid flow velocity to tricuspid annular velocity, and hepatic venous systolic filling fraction. We aimed to clarify whether the aforementioned secondary indices improve the diagnostic ability of an elevated right atrial pressure using the inferior vena cava parameters and test the incremental predictive value of the right atrial area measurement.

Patients and Methods: In 128 consecutive patients with various cardiac diseases referred for cardiac catheterization, the elevated right atrial pressure was defined as ≥ 8 mmHg. Based on the inferior vena cava morphology, the estimated right atrial pressures were determined as 3, 8, and 15 mmHg (model 1). Additionally, the restrictive filling pattern, ratio of early-diastolic transtricuspid flow velocity to tricuspid annular velocity, and systolic filling fraction were evaluated to reclassify the intermediate value of 8 mmHg (model 2). The right atrial minimum and maximum areas and volumes were measured at the ventricular end diastole and systole, respectively, and the expansion indices were calculated.

Results: An elevated right atrial pressure was observed in 29 patients. Logistic regression analysis showed that the estimated right atrial pressure based on the inferior vena cava indices and systolic filling fraction were significantly associated with an elevated right atrial pressure (p < 0.05). The restrictive filling pattern was not observed in any of the patients, and the ratio of early-diastolic transtricuspid flow velocity to tricuspid annular velocity was not associated with an elevated right atrial pressure. The right atrial morphological and functional parameters were significantly associated with an elevated right atrial pressure (p < 0.05). Notably, the minimum right atrial area demonstrated the strongest association with the right atrial pressure elevation (odds ratio adjusted for right ventricular systolic function, 10.64; p < 0.01). The predictive ability of model 2 was comparable with that of model 1 (global χ2 values, 9 and 11 for models 1 and 2, respectively; p =  0.28). In contrast, incorporated with the systolic filling fraction and minimal right atrial area as the secondary indices, the predictive ability of the new model was improved compared with that of model 1 (global χ2 values, 9 and 25 for model 1 and the new model, respectively; p < 0.01).

Conclusion: Reclassification using the guideline-recommended secondary indices failed to improve the predictive ability of an elevated right atrial pressure. In contrast, a combination of the systolic filling fraction and minimal right atrial area with the inferior vena cava indices improved the predictive ability of an elevated right atrial pressure.

Key words: right atrial pressure; right atrial pressure estimation; guidelines; minimal right atrial area

© 2023 一般社団法人日本超音波検査学会© 2023 Japanese Society of Sonographers

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