TOF解剖形态和心功能变化的MRI研究

【作者】 朱娟；

【导师】 黄仲奎；

【作者基本信息】 广西医科大学 ， 人体解剖和组织胚胎学， 2007， 博士

【摘要】 第一部分法洛四联症及肺动脉发育不良的MRI研究目的:讨论MRI在TOF诊断中的价值,重点探讨MRI测量的Mcgoon比、PAI和肺动脉流速、流量诊断TOF及肺动脉发育不良的临床意义。材料与方法:1、实验材料选择2003年5月～2006年12月在广西医科大学第一附属医院手术证实为TOF的88例中41例作为病例组,其中男25例,女16例。年龄3～29岁,平均年龄11.6岁,体表面积0.60m~2～1.80m~2,平均1.03±0.24m~2。另外选择9例死亡者作为死亡组进行手术疗效的评估。全部病例术前均行MRI和UCG检查。12例在术后1周至1个月内完成MRI、UCG复查。正常对照组30例,男15例,女15例,年龄12～31岁,平均年龄22.7岁,体表面积1.34m~2～1.84m~2,平均1.57±0.27m~2。全部行MRI检查。2、方法MRI检查设备用美国GE公司生产的Signa 1.5T MR超导扫描仪,8通道体部分相阵列线圈。UCG检查所用仪器为HP Sonos 5500和HP Sonos 7500,探头S4频率2.0～4.0 MHz,S3频率1.0～3.0 MHz。MRI采用的扫描序列有DIRFSE、FIESTA和PC MRI。检查步骤:(1)DIRFSE扫描心脏横断位、肺动脉长轴位、心室长、短轴位及双斜位影像。(2)FIESTA选择性扫描心脏横断位、肺动脉长轴位、心室长、短轴位及双斜位其中两个或两个以上轴位。(3)PC MRI扫描主肺动脉及左右肺动脉短轴位。(4)在GE ADW4.2工作站用流速分析软件(Cv—FLOW)测量和计算各项肺动脉流速、流量指标。3、肺动脉和心脏的测量指标:形态指标:MPA、LPA、RPA、AAO、DAO、OTRV、DRVW;肺动脉流速流量指标:Vmmpa、Vmlpa、Vmrpa、Vpmap、FVmpa、FVlpa、FVrpa,计算Mcgoon比、PAI、Vp/Vm。4、研究项目:(1)观察TOF组心脏及血管的解剖与形态学异常,与术中结果对照。(2)统计正常对照组与TOF组的Mcgoon比、PAI及血流动力学指标,将两组结果进行比较。(3)分析比较MR/和UCG测量结果的相关性。(4)统计手术前后心脏及血管的形态指标和肺动脉流速流量指标的变化。结果:1、TOF组的MRI术前表现:(1)肺动脉狭窄表现为右室流出道肌束增粗、管腔变窄;肺动脉瓣增厚、粘连,开放受限;主肺动脉及其分支变窄。其中包括41例右室流出道狭窄(OTRV:5mm～22mm,平均11.26mm;),35例肺动脉瓣狭窄(单纯瓣膜狭窄9例,瓣环+瓣膜狭窄26例)和20例主肺动脉狭窄(轻度狭窄8例,中度狭窄10例,重度狭窄2例)。MR/测量结果:TOF组PAl低于正常对照组(P＜0.05),与UCG有良好的相关性(r=0.51,P＜0.05)。TOF组MPA、LPA、Mcgoon比和PAI均小于正常对照组(P＜0.05);PAI、LPA和RPA与UCG有良好的相关性(P＜0.05):TOF组Vpmpa和Vp/Vm明显高于正常对照组(P＜0.05),FVmpa低于正常对照组(P＜0.05)。Vp/Vm与UCG测量的PG有良好的相关性(r=0.63,P＜0.05)。右室流出道狭窄组的FVmpa大于流出道合并肺动脉瓣、肺动脉狭窄组(P＜0.05);流出道合并肺动脉瓣狭窄组的Vpmpa和Vp/Vm大于单纯流出道狭窄和流出道合并肺动脉瓣+肺动脉狭窄组(P＜0.1);Vpmpa与流出道狭窄程度、VSD大小和右室前壁厚度(DRVW)有正相关趋势。(2)室间隔缺损表现为室间隔上部、主动脉瓣下或肺动脉瓣下室间隔信号不连。其中嵴下型31例,干下型10例,VSD大小:0.9cm～2.0cm,平均1.24cm。(3)主动脉骑跨表现为升主动脉前移、增粗,骑跨于室间隔上方;OR范围:30%～70%,平均55.33%。(4)右室肥厚右心室壁明显增厚,与左室壁相当甚至超过左室壁,心室腔正常或扩大;DRVW范围:6mm～20mm,平均9.26mm。(5)心外畸形包括11例纵膈侧支,6例永存左上腔,5例右位动脉弓,1例左肺动脉缺如,1例动脉导管未闭;MRI检出率高于USG(x2=62.57,P＜0.01)。2、TOF术后的MRI分析结果:9例死亡者的PAI明显低于存活组(P＜0.05)。术后TOF组MPA、OTRV明显增宽(P＜0.05),PAI值增大;PAVmax、PG、Vpmpa、Vp/Vm明显降低(P＜0.05)。结论:1、MRI诊断TOF,特别是TOF合并大血管畸形方面有其独特的优越性。2、MRI测量的PAI、Mcgoon比能准确地反映肺动脉的发育情况,可作为术前及术后评估肺动脉发育的指标。3、Vpmpa,Vp/Vm和FVmpa能够准确反映肺动脉的血流动力学改变,可作为术前及术后了解肺动脉血流改变的参考指标。第二部分TOF心功能的MRI研究目的:通过用MRI测量一组TOF患者手术前后左右心室功能的变化,并与UCG测定的左室功能对比,探讨MRI心功能测定在诊断和评估TOF患者心功能临床应用价值。材料与方法:1、实验材料选择2005年5月至2006年12月在广西医科大学第一附属医院手术证实的88例TOF中的30例作为病例组,其中男22例,女8例,龄5～26岁,平均年龄12.5岁。临床心功能分级为Ⅰ级者9例,Ⅱ级者16例,Ⅲ级者5例。另外选择9例死亡者作为死亡组进行手术疗效的评估。全部病例术前均行MRI和UCG检查,术后12例在一周至一个月内完成MRI和UCG复查。设正常对照组30例,男15例,女15例,年龄12～31岁,平均年龄22.7岁,体表面积1.34m~2～1.84m~2,平均1.57±0.27m~2。全部行MRI检查。2、方法MRI检查设备用美国GE公司生产的Signa 1.5TMR超导扫描仪,8通道体部分相阵列线圈。UCG检查所用仪器为HP Sonos 5500和HP Sonos 7500,探头S4频率2.0～4.0 MHz,S3频率1.0～3.0 MHz。MRI检查步骤:(1)用实时定位技术(real time loc)获得标准左室长轴位图像。(2)用FIESTA序列垂直左心室长轴扫描获得标准左室短轴位图像。(3)使用GE ADW4.2工作站心功能软件(Massanalysis)对扫描结果进行分析。3、心功能测量指标:LVEDV、RVEDV、LVEF、RVEF、LVCO、RVCO。4、研究项目:(1)统计手术前后MRI测量LVEDV、RVEDV、LVEF、RVEF和LVCO、RVCO,并将结果进行分组比较。(2)分析MRI测定的LVEDV、LVEF和LVCO与UCG测定结果的相关性。结果:1、术前MRI心功能分析结果:TOF组的LVEDV、RVEDV低于正常对照组(p＜0.05);LVEF、RVEF高于正常对照组(P＜0.05)MRI测量的LVEDV、LVEF与UCG具有良好的相关性。心功能Ⅰ级组LVEDV、RVEDV明显大于Ⅱ级组(P＜0.1)。Ⅰ级组LVEDV、LVEF和RVEDV大于Ⅲ级组(P＜0.1)。Ⅱ级组LVCO大于Ⅲ级组(P＜0.1);2、术后MRI心功能分析结果:死亡组RVCO明显低于存活组(P＜0.1);术后LVEDV、LVCO、RVEDV和RVCO明显增加(P＜0.1)。肺动脉瓣轻度返流组和无返流组之间的各项心功能指标无统计学差异。结论:1、MRI心功能测定能够较准确、敏感的反映心功能的情况,是临床评价心功能的可靠方法。2、EDV、EF和CO可作为手术前后评价心室功能的有效指标。3、TOF术后MRI随访右室功能有助于临床医师评估TOF患者的手术预后,指导术后管理。更多还原

【Abstract】 Objectives:To study the value of MRI in diagnosis of TOF with pulmonary dysplasia using two index:Mcgoon ratio and Pulmonary artery index(PAI).Materials and Methods:41 cases of patients with TOF were selected from 88 cases of congenital heart disease admitted in the first affiliated hospital of Guangxi medical university from May 2003 to December 2006.In the 41 cases,25 males and 16 females,age from 3 years to 26 years,meaning age 11.6 years.Body surface areas(BSA)were 0.60m~2～1.80m~2,average 1.03±0.24m~2. In addition,9 cases of death were selected as an group for evaluation of operational curative effect.All patients was underwent MRI and ultrasound cardiography(UCG)examination before operation.Nine patients with TOF were dead after operation,twelve cases of TOF patients reviewed with MRI and UCG postoperation within one week to one month.Besides,30 healthy volunteers were set as control group,15 males and 15 females,age from 3 years to 31 years, mean age 22.7 years,BSA were 1.34m~2～1.84m~2,average 1.57±0.27m~2.All of them were underwent MRI exam for contrast.MRI equipments was Signa 1.5T superconduct scanner produced by Am GE company,body phase array coil was used.UCG facilities was Sonos 5500 and Sonos 7500 ultrasound scanners producted by Am HP company.The detector S4 frequence was 2.0～4.0 MHz,detector S3 was 1.0～3.0 MHz.Scan sequence included:Double inverse fast spin echo sequence(DIRFSE),fast imaging employing steadystate acquisiton(FIASTA)and phase contrast flow MR imaging(PC MRI).MRI scan steps:(1)First scaned with DIRFSE sequence,scaned section included transverse plane,ventricular short axial plane and ventricular long axial plane, pulmonary long axial plane and double oblique plane.(2)then selectively scaned two or more section in(1)with FIESTA sequence.(3)then scaned pulmonary transections with PC MRI.(4)Image data were disposed in GE ADW4.2 workstation with flow analysis software(Cv-FLOW).3.Study indexs: mophological index:MPA,LPA,RPA,AAO,DAO,OTRV,DRVW;pulmonary dynamic indexs:Vmmpa,Vmlpa,Vmrpa,Vpmap,FVmpa,FVlpa,Fvrpa; calculated Mcgoon ratio,PAI and Vp/Vm with equation.4.Study items:(1) Observed the mophological appearance of TOF group and compared with operational finding.(2)Calculated pulmonary and cardiac indexs of TOF group and contrasted with normal control group.(3)Analysis the correlativity of results tested by MRI and UCG respectively.(4)Investigated the change of morphology and flow dynamics of pulmonary arteries and heart pre and postoperation.Results:1.MRI findings preoperation:(1)Pulmonary stenosis(41 cases) presented as the thickening of outflow wall with confined cavity;pulmonary valves were thickening and limitively open;the main and bilateral pulmonary branches stenosis were seen in most of patients.Statistical results:the MPA, LPA,McGoon ratio and PAI of TOF group were all smaller than that in control group(P＜0.05);Vmmpa was smaller in TOF group than that in control group(P＜0.05);but the Vpmap and Vp/Vm were higher in TOF group than that in control group(P＜0.05).In contrast with UCG,we found that Vpmpa and Vp/Vm tested by MRI had positive correlativity with PG tested by UCG(r=0.63,P＜0.05).Grouped by the obstructed locas of pulmonary,we found that the FVmpa in the group with right ventricular outflow obstruction was evidently higher than that in the group with outflow tract and pulmonary stenosis;The Vpmpa in the group just with outflow tract and another group with pulmonary valve stenosis was evidently faster than that in the group with outflow obstruction,and outfolw tract and main pulmonary stenosis.We also found that the Vpmpa had a positive relation with the degree of outflow stenosis, size of VSD and thickeness of right ventricular anterior wall(DRVW).(2) Ventricular septal defect(41 cases)presented as the signal losed in the upper part of ventricular septum.The size of VSD was ranged from 0.9cm to 2.0cm, average 1.24cm.(3)Aortic override presented as the ascending aorta moved forword and overrided ventricular septum.The percentage of aortic override were ranged from 30%to 70%,average 55.33%.(4)Right ventricular hypertrophy presented as the thickening of right ventricular wall.The thickeness of right ventricular anterior wall(DRVW)were ranged from 6mm～20mm,average 26mm.(5)Extracardiac malformations including 11 cases of systemic-pulmonary collateral branch,6 cases of left superior vena cava,5 cases of right descending aorta,1 case of left pulmonary absence.The diagnosic rate of MRI was higher than UCG in extracardiac malformation(x 2 = 62.57, P＜0.01).2.Results after operation:The PAI of death was obviously lower than the survival.It revealed a greatly enlarged in MPA and OTRV(p＜0.05),PAI was increasing but not significant.Aortic override were cured.PAVmax,PG, Vpmpa,Vp/Vm were discended significantly(p＜0.05).Conclusions:(1)The study result indicated that MRI was an optimal metod in diagnosis of complex congenital heart disease.(2)PAI and Mcgoon ratio measured by MRI could reflect the growth of pulmonary atrery,that would be very helpful to evaluate pulmonary development condition preoperation and postoperation.(3)Vpmpa,Vp/Vm and FVmpa could demostrate the pulmoanry dynamic change and reflect the tension gap between right ventricle and pulmonary artery indirectly,that would help to evaluate the pulmonary dynamic situation before and after operation. Objective:To approach the clinical application of MRI in evalution of ventricular function of TOF.Materials and Methods:30 patients with TOF were selected from 88 cases of TOF patients confirmed by operation admitted in the first affiliated hospital of Guangxi medical university from May 2004 to December 2006.22 male and 8 female,age from 5 years to 26 years,mean age 12.5 years.Cardiachierarchy wereⅠgrade 9 cases,Ⅱgrade 16 cases,Ⅲgrade 5 cases.In additon,9 cases of death were selected as a group for evaluation of the curative effect of operation. Every patient was underwent MRI and UCG exam before operation and twelve patients rechecked with MRI and UCG postoperation within one week to one month.Besides,30 healthy volunteers were set as control group,15 males and 15 females age from 3 years to 31 years,mean age 22.7 years,BSA were 1.34m~2～1.84m~2,average 1.57±0.27m~2.All of them were underwent MRI exam for contrast.2.Methods:MRI equipment was Signa 1.5T superconduct scanner produced by American GE company with phase array coil.UCG facility was HP Sonos 5500 and HP Sonos 7500 ultrasound scanner producted by American HP company.The frequence of detector S4 was 2.0～4.0 MHz, frequence of detector S3 was 1.0～3.0 MHz.MRI scan steps:(1)First used real time loc techqiue to get the standard left ventricular long axial plane.(2)then scaned the standard short axial plane of left ventricle with FIESTA sequence.(3) then image data were disposed in GE ADW4.2 workstation with cardiac function analysis softwares(Mass analysis).Result come out in the format of text.3.Study items:(1)Calculated the cardiacfunctional indexs preoperation and made a contrast with postoperation.(2)Analysised the correlativity of results tested by MRI and UCG respectively.Results:(1)Results tested preoperation indicated:LVEDV,RVEDV in TOF group were significantly smaller than that in control group(P＜0.05)but the EF in TOF group was much higher(P＜0.05).In contrast with UCG,we found that LVEDV and LVEF have positive correlativity with UCG(rlvedv=0.78, rlvef=0.80,P＜0.05).but we had not found any correlativity in LVCO.Grouped with the cardiac chierarchy,we found positive correlativity between clinic cardiac chierarchy and heart function parameters tested by MRI.In nine cases of death,we found that the RVCO in mortal group were greatly lower than that in survival group(P＜0.05).(2)Results after operation:LVEDV,LVCO,RVEDV, and RVCO increased obviously(P＜0.1).There was not significant difference in the ventricular function between the pulmonary backstreaming group and the group without pulmonary backstreaming.Conclusions:(1)MRI was an sensitive,reliable procedure for evalution of ventricular function.(2)EDV,EF,CO were available indexs for evaluation of cardiac function.(3)following up right ventricular function with MRI could help medical management postoperation.更多还原