第一部分：实时三维超声新指标SV/ESV在慢性血栓栓塞性肺动脉高压患者右心功能评价中的应用价值。研究目的：探究实时三维超声心动图评估的SV/ESV能否有效评估右室-肺动脉偶联及其在慢性血栓栓塞性肺动脉高压（CTEPH）患者右心功能评价中的作用。研究方法：回顾性地纳入2016年1月至2021年10月于中日友好医院明确诊断为CTEPH并接受PEA治疗的患者及年龄性别匹配的健康受试者。通过Spearmen相关性分析SV/ESV与Ees/Ea、TAPSE/PASP之间的相关性，并探究了不同WHO心功能分级、心脏指数（CI）及右室-肺动脉偶联指标差异。随后，根据SV/ESV三分位数将所有患者分为三组，比较三组之间临床资料差异，并进一步分析SV/ESV与上述指标之间相关性。研究结果：研究共纳入67例CTEPH患者及30例健康受试者。正常对照组中的SV/ESV为1.17±0.37，SV/ESV与Ees/Ea相关性（r=0.853，P＜0.001）远高于TAPSE/PASP与Ees/Ea的相关性（r=0.347，P=0.045）。根据SV/ESV三分位数分为三组（低分位组：＜0.357，中分位组：0.357-0.526，高分位组：>0.526），WHO功能分级IV级的患者主要出现在SV/ESV低分位数组，SV/ESV与6WMD呈正相关（r=0.435，P=0.004）；中高分位数组患者超声心动图上出现心包积液较低分位数组的患者明显减少。SV/ESV与多个右心功能相关超声指标具有相关性：右房横径（r=-0.282，P=0.027）、RV/LV比值（r=-0.386，P=0.003）、左室舒张径（r=0.369，P=0.006）。研究结论：实时三维超声心动图评估的SV/ESV与核磁导管法获取的Ees/Ea具有良好的相关性，能较为可靠地评估右室-肺动脉偶联，且较传统指标更有优势。SV/ESV可用于CTEPH患者的右心功能评估，在CTEPH病情评估中具有重要作用。关键词：慢性血栓栓塞性肺动脉高压，右室-肺动脉偶联，实时三维超声心动图，每搏输出量/收缩末期容积。第二部分：慢性血栓栓塞性肺动脉高压患者肺动脉血栓内膜剥脱术后右室-肺动脉偶联变化。研究目的：随访PEA术后右室-肺动脉偶联改善情况，发现右室-肺动脉偶联对于PEA术后结局的预测价值。研究方法：连续纳入基线评估及1周间隔内临床资料完整且完善了右心导管、超声心动图评估的患者。随访PEA术后患者1月及3-6月的血流动力学及右心功能数据。采用配对样本t检验或Wilcoxon秩和检验分析PEA术后血流动力学及右心功能改善情况，通过Spearman相关分析右室-肺动脉偶联变化与血流动力学、功能指标变化的相关性，并使用Mann-Whitney U检验分析PEA术后是否功能受限、有无残余肺动脉高压分组患者之间右室-肺动脉偶联差异。研究结果：本研究共纳入90名临床资料、超声心动图数据及右心导管数据完整的患者。PEA术后3-6月复查血流动力学、超声心动图评估的右心功能指标均有一定程度改善，术后1月、3-6月SV/ESV较基线均显著改善（P＜0.001），但术后1月及3-6月间变化并不显著（P=0.31）。PEA术后3-6月无残余肺动脉高压组和残余肺动脉高压两组间SV/ESV存在差异（0.68±0.39 vs 0.34±0.11，P=0.0142），单因素回归分析发现SV/ESV可能与PEA术后3-6个月发生残余肺动脉高压的风险有关（OR 0.029，95%CI 0.000-0.414，P=0.029）。研究结论：随着PEA术后血流动力学改善，右室-肺动脉偶联指标有一定程度的改善；三维超声评估的右室-肺动脉偶联比二维超声功能指标更好地反映PEA后血流动力学改善。基线时右室-肺动脉偶联状况更好的患者出现残余肺动脉高压的比例更低。关键词：慢性血栓栓塞性肺动脉高压，右室-肺动脉偶联，每搏输出量/收缩末期容积，肺动脉血栓内膜剥脱术。

PART 1：The application value of the new real-time 3-dimensional ultrasound new index SV/ESV in the right heart function evaluation of patients with chronic thromboembolic pulmonary hypertension.Objective:To investigate whether SV/ESV assessed by the real-time 3-dimensional (3D) echocardiography could represent right ventricular-pulmonary arterial coupling effectively and to verify the role of right ventricular-pulmonary arterial coupling in the evaluation of right heart function in patients with chronic thromboembolic pulmonary hypertension (CTEPH).Methods:We retrospectively analyzed patients with the definite diagnosis of CTEPH who were admitted to China-Japan Friendship Hospital and treated with pulmonary endarterectomy (PEA) and healthy subjects from January 2016 to October 2021. The correlation between SV/ESV, Ees/Ea and TAPSE/PASP were analyzed by Spearmen's correlation coefficient, and the differences in right ventricle-pulmonary arterial coupling between WHO functional class and cardiac index (CI) were investigated. We divided all patients according to SV/ESV tertile and compared the clinical data and differences among groups. The correlation between SV/ESV and the mentioned indexes was analyzed by Pearson and Spearman correlation.Results:A total of 67 patients with CTEPH and 30 healthy subjects were included in the study. The mean SV/ESV in normal controls was 1.17±0.37, and SV/ESV correlated with Ees/Ea (r=0.853, P<0.001) much more than TAPSE/PASP correlated with Ees/Ea (r=0.347, P=0.045). Patients were divided into 3 groups according to SV/ESV tertile (low tertile group: <0.357, middle tertile group: 0.357-0.526, and high tertile group: >0.526); patients with WHO functional class IV were mainly found in the low SV/ESV tertile group, and SV/ESV was positively correlated with 6WMD (r=0.435, P=0.004); patients in the middle and high tertile groups. The presence of pericardial effusion on echocardiography was significantly less in patients in the mid- to high-quartile group compared with those in the low-quartile group, and SV/ESV correlated with several right heart function related ultrasound indicators, including right atrial transverse diameter (r=-0.282, P=0.027), RV/LV ratio (r=-0.386, P=0.003), and left ventricular diastolic diameter (r=0.369, P=0.006).Conclusion:The SV/ESV assessed by real-time three-dimensional echocardiography has a good correlation with the Ees/Ea obtained by the MRI catheter method, which can more reliably assess the right ventricle-pulmonary coupling, and has more advantages than traditional indicators. SV/ESV can be used for the evaluation of right ventricular function in patients with CTEPH and plays an important role in the evaluation of CTEPH.Keywords: chronic thromboembolic pulmonary hypertension, right ventricle-pulmonary arterial coupling, real-time 3D echocardiography, stroke volume/end-systolic volume.PART 2:Changes in right ventricular-pulmonary arterial coupling after pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension.Objective:To verify the role of right ventricular-pulmonary arterial coupling in the evaluation of right heart function in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and to find the predictive value of right ventricular-pulmonary arterial coupling for post-pulmonary endarterectomy (PEA) outcomes.Methods:Patients with complete clinical data and complete right heart catheterization and echocardiographic evaluation within 1-week intervals were consecutively included. The data of hemodynamics and right ventricular function were followed up for 1 month and 3-6 months after PEA. Paired-samples t test or Wilcoxon rank sum test was used to analyze the improvement of hemodynamics and right ventricular function after PEA. The Mann-Whitney U test was used to analyze the differences in right ventricle-pulmonary arterial coupling between groups of patients with or without residual pulmonary hypertension after PEA.Results:A total of 90 patients with complete clinical data, echocardiographic data, and catheterization data were included in the study. right heart function indicators assessed by hemodynamics, functional status, and echocardiography improved to some extent on review 3-6 months after PEA surgery, and SV/ESV improved significantly from baseline at 1 month and 3-6 months after surgery (P < 0.001), but changes between 1 month and 3-6 months after surgery were not significant. There was a difference in SV/ESV between the group with and without residual pulmonary hypertension at 3-6 months after PEA (0.68±0.39 vs 0.34±0.11, P=0.0142). Univariate regression analysis revealed that SV/ESV may be associated with an increased risk of residual pulmonary hypertension at 3-6 months after PEA (OR 0.029. 95% CI 0.000-0.414, P=0.029).Conclusion:With the improvement of hemodynamics after PEA, the right ventricle-pulmonary artery coupling index improved to a certain extent; the right ventricle-pulmonary artery coupling assessed by 3D ultrasound better reflects the hemodynamics after PEA than the functional index of 2D ultrasound improve. Patients with better RV-pulmonary coupling at baseline had lower rates of residual pulmonary hypertension.Keywords: chronic thromboembolic pulmonary hypertension, right ventricle-pulmonary arterial coupling, stroke volume/end-systolic volume, pulmonary endarterectomy.