【作者】 李士建；

【导师】 田建明； 王莉； 陆建平； 王飞； 刘崎；

【作者基本信息】 第二军医大学 ， 影像医学与核医学， 2008， 博士

【摘要】 属性不符背景和目的:先天性心脏病是在胎儿出生前所形成的器质性心脏病变,据估算,我国先天性心脏病约占活产新生儿的7‰～8‰,每年先天性心脏病手术4万余例,其中复杂性先天性心脏病约占20%。复杂性先天性心脏病指法乐氏四联症、右室双出口、大动脉转位、单心室等心血管畸形复杂的疾病,仍为外科治疗难题。近10年来,复杂先天性心脏病外科治疗有了新的进展,主要表现在:手术时期小龄化;遗留成人复杂先天性心脏病的外科治疗;手术方法创新和改进以及晚期手术后并发症的处理等。复杂性先天性心脏由于心脏大血管的畸形病变多发并且严重,解剖结构关系复杂多变,术前检查了解病变的解剖信息、严重程度及功能情况,了解心脏及大血管的发育情况,对于对病例选择、手术方案制订、术后评估等有重要的价值,也是影像诊断不断研究的主题。先天性复杂型心脏病利用其他非创伤性影像学技术检查往往不易达成完整性诊断,以往需要进行创伤性心血管造影检查确诊。影像学检查主要有心脏磁共振成像(CMR),超声心脏图(UCG),和X线心血管造影(ACG)检查等。磁共振检查在先心病诊断中的应用已越来越普遍,各种畸形显示的敏感性也越来越高,但综合运用磁共振多技术,系统评估复杂先心病的报道较少。本研究综合运用磁共振多种技术,主要从临床最需要的形态及功能入手,与手术结果相对照,研究对复杂性先天性心脏病的应用价值,并选取最典型、多见的法乐氏四联症,与超声心动图、X线心血管检查进行对比研究,探求复杂先心病最优化的检查方法及临床应用价值。研究方法:收集我院41例复杂先心病患者术前心脏磁共振成像、超声心动图及X线心血管造影检查结果,并与手术结果对照,从心脏部分,周围大血管情况及肺动脉显示情况,对照分析各种检查方法的优势及不足。磁共振检查采用多种磁共振技术,首先行身体方位标准平面定位像。平扫包括主动脉弓到膈面水平的横断面及冠状面扫描,研究及评估心脏、主动脉弓、肺静脉、上下腔静脉及纵隔的状况。电影磁共振扫描心脏主要轴面包括左室短轴,长轴水平及垂直平面,进行心脏的测量或功能分析。最后行动态增强磁共振血管造影,了解血流途径,显示各期血管,用来评估心脏缺陷及与有关的大血管异常,范围包括心脏及胸部大血管。超声检查先行多部位、多切面观察心脏形态、内部结构及其连接关系,然后进行多谱勒检查观察血流情况。X线心血管造影检查进行选择性右室血管造影,多角度显示心腔及大血管的形态及空间排列关系。结果:本组法乐氏四联症病例中手术证实心内畸形及病变共192处,心脏磁共振检查确诊171处,诊断符合率为89.1%;超声心脏图检查确诊181处,诊断符合率为94.8%;X线心心血管造影检查确诊129处,诊断符合率为84.9%。本组法乐氏四联症病例中手术证实心周大血管畸形及病变共18处,心脏磁共振除一例较小的动脉导管未闭未能显示外,其余改变均能清楚显示,检出率达94.4%。超声心脏图显示出5处,检出率27.8%;X线心血管造影只是重点显示,仅显示12处,检出率为66.7%。心脏磁共振检查对于本组法乐氏四联症所有病例肺动脉树均能完全或大部分清楚显示,检出率达100%;超声心脏图检查显示11例,检出率为47.8%;X线心血管造影检查检出17例,检出率为73.9%。磁共振成像、超声心脏图及X线心血管造影均能有效显示法乐氏四联症心脏的改变,均有较高的检出率,按高到低是超声心脏图,磁共振成像,X线心血管造影。但对于心外大血管的显示,磁共振检查、超声心脏图及X线心血管造影有明显的差异。本组病例中,磁共振成像对心外大血管的显示显示出巨大的优势,特别是对于肺动脉,对于手术证实的病变全部检出。超声心脏图对于心外大血管的显示大大受限,仅能显示纵隔内的大血管,检出率低,对于肺动脉分支及远端的显示不理想。X线心血管造影对于心脏及大血管的显示均有较好的检出率,传统上作为影像学检查的金标准,但在本组病例中,检出率均低于磁共振成像。结论:心脏磁共振检查、超声心脏图以及X线心血管造影作为心脏大血管病变的诊断、评估的重要手段,各有所长。复杂先心病主要畸形的显示磁共振检查、超声心脏图以及X线心血管造影均有较高的检出率。对于心脏本身的畸形,尤其是瓣膜及血流异常,超声心脏图是最佳影像检查方法,可清楚显示瓣膜形态及运动,房室间隔的缺损,脉冲多普勒技术进行血流动力学测定;对于心脏房室壁的显示,磁共振成像有更高的精确性和重复性,亦能进行血流动力学的精确测更多还原

【Abstract】 ##原图像无英文摘要内容 Background and objectiveThe congenital heart disease(CHD) exists in the form of all kinds of organic heart pathological change which formed prior to birth.It is reported that approximately 7%0,-8%0 of neonates in our country have CHD,and there are more than 40,000 operations for CHD every year, approximately 20%of the cases is complex congenital heart disease (CCHD).CCHD exists in the form of tetralogy of Fallot(TOF),doubleoutlet of rightventricle(DORV),transposition of the great arteries (TGA),single ventricle(SV) and other diseases with complex cardiovascular abnormalities.In the recent 10 years,surgical therapy of CCHD had the new progress.Cardiovascular abnormalities of CCHD are often multiple and serious,it has the important value for choosing the cases,making operative plan and evaluation of operation to comprehend the information about anatomy of abnormal,degree of severity,function of the heart and vascular growth.And it is also a subject of the imaging diagnosis.It was very hard to make a complete diagnosis of CCHD by other non-wound imaging examinations,and it often need X-ray Cardiac angiography.The imaging methods comprise cardiac magnetic resonance(CMR), ultrasonic cardiogram(UCG) and x-ray cardiac angiography(CAG). Cardiac magnetic resonance is more and more generally used in diagnosis of CHD.The reports on clinical study of combined MR imaging in determination of CCHD is less.In the study,we use combined MR imaging to determinate CCHD, mainly the morphous and function of heart which can supply most of the clinical requirement.We compare the diagnostic evaluation of CMR, UCG and ACG in patients with tetralogy of Fallot(TOF,which is most common and typical) before operation,and to evaluate the diagnostic value for complex congenital heart disease by using multimodality MR imaging.Materials and methodsForty-one patients with a diagnosis of complex congenital heart disease who underwent CMR,UCG and ACG were retrospectively reviewed.The imaging examinations were studied to assess their usefulness in providing information regarding the anatomic abnormalities.Cardiac MRI can combine multimodality MR imaging technique to provide anatomic and functional information,including Dark-blood, white-blood sequences,cine MR,Contrast enhanced MR angiography (CE-MRA).In general,the images obtained with a rigorous orientation along the body axes(axial plane for example) are indispensable for the topographic images of the cardiac,for the evaluation of the pericardium, of the aorta,of the anterior wall of the right ventricle,of the pulmonary veins,of the superior and inferior cava veins and for the study of the mediastinal space.A correct evaluation of heart morphology requires that the images be obtained according to oblique planes along the main axes of the heart.This involves the use of planes passing through the short axis of the left ventricle,and the long vertical and horizontal axes.Contrast enhanced dynamic MR imaging can provide information of blood flow and vessel and is helpful in demonstrating the cardiovascular abnormalities. Ultrasonic cardiogram(UCG) is used to observe the morphous,the internal structure and the connection relations of the heart and vascellum with multi-spots and multi-section.Doppler is used to observe the blood flow.X-ray cardiac angiography(CAG) is used to display morphous and the spatial arrangement relations of cardiac vessel with Selective right ventriculography.CMR findings of intracardiac abnormalities,nonpulmonary features, pulmonary abnormalities were compared with information obtained at UCG,ACG and at surgery.ResultsThere are 192 intracardiac abnormalities confirmed by surgery in 41 patients,CMR accurately diagnoses 171 of them(89.1%),while UCG 181 cases(94.8%),ACG 129 cases(84.9%) totally.Of 18 nonpulmonary extracardiac features,CMR accurately diagnoses 17 of them(94.4%),while UCG 5 cases(27.8%),ACG 12 cases(66.7%). In the pulmonary abnormalities,CMR got the accuracy of 100%(23/23), while UCG got 47.8%(11/23),ACG 73.9%(17/23).CMR,UCG and ACG all got a high accuracy in intracardiac abnormalities,UCG is the best.But in extracardiac abnormalities,especially pulmonary abnormalities,CMR is more excellent than UCG and ACG.ConclusionCMR、UCG and ACG both have advantages and limitations,in diagnosing cardiovascular diseases.The main abnormalities of complex congenital heart disease can be demonstrated well by CMR、UCG and ACG.But for the intracardiac abnormalities,UCG is the best method, which can provide information regarding blood and anatomic of valvular.更多还原