【作者】 刘娟；

【导师】 倪锐志； 顾云； 骆志玲； 王钰；

【作者基本信息】 昆明医学院 ， 内科学， 2008， 硕士

【摘要】 目的探讨常规经胸超声心动图(TTE)和应变(ε)及应变率成像技术(SRI)在定量评估房间隔缺损(ASD)患者封堵术前、术后右心系统的腔室大小、功能及局部心肌收缩性的变化,探讨应变及应变率成像技术的临床应用价值。方法随机选取在昆明医学院第一附属医院心内科住院诊断为先天性心脏病继发孔中央型房间隔缺损并行导管封堵术患者33例,男8例,女25例,年龄12～43岁,平均26.47±12.34岁,均用Amplatzer封堵器治疗,分别在ASD术前1天、术后3天及术后3个月行超声心动图检查。另外,选择健康志愿者20人为对照组,男性4人,女性16人,年龄11～45岁,平均26.25±12.57岁。①右室局部心肌应变和应变率的测量:在超声组织速度成像(TVI)模式下获取心尖四腔切面动态图像,将室间隔、右室游离壁分别按照基底段、中间段和心尖段划分为6个节段,测量20例健康人及先心病ASD组封堵术前及术后室壁的基底段和中间段收缩期峰值应变(ε)、应变率(SR)数值。②右心系统腔室大小的测量:胸骨旁左心室长轴切面测量右室舒张末期前后径,心尖四腔切面测量右室舒张末期上下径、左右径,右房收缩末期上下径、左右径。③肺动脉内径及肺动脉收缩压的测量:胸骨旁大动脉短轴切面测量主肺动脉内径(MPA);应用多普勒技术记录三尖瓣最大返流速度,并根据三尖瓣最大返流速度估算肺动脉收缩压(PASP)。④右室容量及功能测量:心尖四腔切面Simpson法计算右室收缩末期容积(RVESV)、右室舒张末期容积(RVEDV)、右室每搏量(RVSV)、右室射血分数(RVEF)。结果33例ASD患者封堵术前检查及术后3天、3个月随访,①右室局部心肌应变和应变率的变化:ASD组右室游离壁基底段和中间段收缩期峰值ε、SR值均高于正常对照组相应节段,差异有统计学意义(P＜0.05);ASD患者术后3天、3个月右室游离壁、室间隔基底段和中间段收缩期峰值ε、SR与术前比较,差异无统计学意义(P＞0.05)。②右心系统腔室大小的变化:术后3天右房收缩末期上下径、左右径,右室舒张末期前后径、左右径,均比术前缩小,差异有统计学意义(P＜0.05)。右室舒张末期上下径在术后3天缩小不明显,但术后3个月较术前明显缩小,差异有统计学意义(P＜0.05)。术后3个月右心房收缩末期上下径、左右径,右心室舒张末期前后径、左右径较术后3天缩小,差异有统计学意义(P＜0.05)。③肺动脉内径及肺动脉收缩压的变化:术后3天肺动脉中段内径与术前比较缩小不明显,差异无统计学意义(P＞0.05),术后3个月与术前、术后3天比较均有缩小,差异有统计学意义(P＜0.05);术后3天及术后3个月肺动脉收缩压均比术前降低,差异有统计学意义(P＜0.05),但术后3个月肺动脉收缩压与术后3天比较降低不明显,差异无统计学意义(P＞0.05)。④右室容量及功能的变化:术后3天右心室舒张末期容积(RVEDV)、右心室每搏输出量(RVSV)、右心室射血分数(RVEF)均较术前明显减少,差异有统计学意义(P＜0.05),而右心室收缩末期容积(RVESV)减少不明显(P＞0.05)。术后3个月随访,RVEDV、RVESV、RVSV、RVEF较术前进一步减少,差异有统计学意义(P＜0.05)。术后3个月的RVEDV、RVESV、RVSV较术后3天减少,差异有统计学意义(P＜0.05),但RVEF与术后3天比较无明显差异(P＞0.05)。结论ASD封堵治疗减轻了右心系统的容量负荷,术后右房、右室、肺动脉内径进行性缩小,肺动脉压降低,但封堵术前、术后短期比较右室游离壁基底段、中间段及室间隔基底段、中间段收缩期峰值应变(ε)和应变率(SR)无明显变化,表明ASD封堵术后右室心肌收缩性保持不变。更多还原

【Abstract】 Objective This study was done to evaluate the changes of the right heart dimension, systolic function and regional myocardial contractility using conventional echocardiography and strain as well as strain rate imaging before and after transcatheter closure of atrial septal defect(ASD),and to discuss its clinical value.Methods 33 patients with ASD(mean age 26.47±12.34 years,8 male,25 female) were diagnosed as secundum ASD in the First Affiliated Hospital of Kunming Medical College,and all had been successfully received Amplatzer septal occluder(ASO).They were scanned by conventional echocardiography and dynamic tissue velocity imaging(TVI)before and after the three days and three months undergoing transcatheter closure of ASD.Besides,twenty healthy volunteers(mean age 26.25±12.57 years,4 male,16 female)were selected as control group.①Regional myocardial contractility of right ventricle(RV)were measured by strain and strain rate.The dynamic tissue velocity imaging(TVI)were obtained at apical four-chamber view.Septal and right free walls were divided into basal,mid and apical segments respectively.The systolic peak strain(ε)and strain rate(SR)were measured at basal and mid segments before and after transcatheter closure of ASD and compared with that of the controls.②The diameters of RA and RV was measured.The end-diastolic anterior-posterior diameter of RV was measured at the parasternal long axis view of left ventricle.The end-diastolic fluctuate diameter and left-right diameter of RV,and end-systolic fluctuate and left-right diameter of RA were measured at the apical four-chamber view.③The main pulmonary artery diameter and pulmonary artery systolic pressure were measured.The main pulmonary artery diameter(MPA)was measured at the parasternal aortic short axis view.The pulmonary artery systolic pressure(PASP)was evaluated by peak velocity of tricuspid regurgitation,using continuous wave Doppler at the apical four-chamber view.④Right ventricle volume and function were calculated.Right ventricular end-systolic volume(RVESV), end-diastolic volume(RVEDV),stroke volume(RVSV)and ejection fraction(RVEF) were calculated with Simpson method at the apical four-chamber view.Results Thirty-three patients received transcatheter closure of ASD were examined before and after the three days and three months.①Peak systolic strain and strain rate of the mid segment in right free wall are higher than that of the basal segment in controls(P＜0.05).Compared with the control group,the peak systolic strain and strain rate of mid and basal segments in right free wall in ASD group increased significantly(P＜0.05).Peak systolic strain and strain rate of the mid and basal segments in right free wall and interventricular septal before and after transcatheter closure of ASD were not significantly different(P＞0.05).②Compared with the diameters before ASD closure,the end-diastolic fluctuate diameter and left-right diameter of RA,the end-diastolic anterior-posterior diameter and left-right diameter of RV decreased significantly(P＜0.05)after three days.The end-diastolic fluctuate diameter of RV did not decrease significantly(P＞0.05)after three days,but the diameter decreased significantly(P＜0.05)after three months.Compared with the diameters after three days,the end-systolic fluctuate diameter and left-right diameter of RA,the end-diastolic anterior-posterior diameter and left-right diameter of RV decreased significantly(P＜0.05)after three month.③Compared with the diameter before ASD closure,the main pulmonary artery diameter did not decreased(P＞0.05) after three days,but the diameter decreased significantly(P＜0.05)after three month. Compared with that before ASD closure,the pulmonary artery systolic pressure decreased significantly(P＜0.05)after the three days and three months.But the pulmonary artery systolic pressure three months later is not lower signifcantly than that three clays later(P＞0.05).④Compared with the values before ASD closure, RVESV,RVEDV and RVEF reduced significantly(P＜0.05)after three days,however, RVESV did not reduce(P＞0.05).After three months RVEDV、RVESV、RVSV、and RVEF reduced more significantly than that before ASD closure(P＜0.05).After three months RVEDV、RVESV、RVSV reduced more significantly than that of after three days(P＜0.05),but RVEF did not decrease significantly(P＞0.05).Conclusion The preload of right heart was reduced after transcatheter closure of ASD. The diameter of right ventricle,right atrium and pulmonary artery gradually decreased, and the pulmonary artery systolic pressure decreased.However,the systole peak strain(ε)and strain rate(SR)on the middle and basal segments in right free wall and interventricular septal before and after transcatheter closure of ASD did not change.It indicates that the increased regional myocardial contractility of right ventricular did not change after ASD closure.更多还原