【作者】 王鹏；

【导师】 郭涛； 韩明华； 赵玲； 李淑敏； 骆志玲；

【作者基本信息】 昆明医学院 ， 内科学， 2009， 硕士

【摘要】 背景:实时三维超声心动图(RT-3DE)是心脏超声诊断技术的最新进展,可显著提高心血管疾病超声诊断的精度和效率。将该项超声影像学新技术应用于心内起搏导线的检查,国内外尚少报道。目的:借助RT-3DE成像技术观察21例永久起搏器治疗患者的心内起搏导线位置、走行、形态等,比较该方法与传统二维超声成像(2DE)技术的优缺点,分析RT-3DE观察心内起博导线的精度和效率,为随访起搏患者探索一种新的手段。方法:随机选取2007年7月～2009年1月在昆明医学院第一附属医院成功植入永久心脏起搏器的患者21例,其中男13例、女8例,平均年龄72.76±5.86岁(58～85岁)。术后第3月均接受RT-3DE检查,观察心内起搏导线的电极位置、导线走行、毗邻关系,以及三尖瓣返流情况,同时测量左房径(LA)、左室舒张末径(LVDd)、三尖瓣返流(TR)、左室短轴缩短率(FS)、左室射血分数(LVEF)等超声指标,与常规2DE检查及术前参数对比。采用SPSS13.0统计软件包观测数据,均以P＜0.05判为差异有显著性。结果:①2DE和RT-3DE均能检测到19例患者的心内起搏导线(检出率均90.48%)。检出的19例患者中RT-3DE对起搏电极尖端的显示率高于2DE(100%与53%,P＜0.05)。②RT-3DE不仅更易清晰显示心内起搏导线在心腔各部位的走行及毗邻关系,还可更精确显示电极尖端在心内膜面的具体位置,准确率甚至高于常规X线透视(借助X线判断电极尖端位于心尖游离壁的患者中漏检2例,漏判率16.67%;判断电极尖端位于心尖间隔面的患者中误判2例,误判率29.57%)。③2DE和RT-3DE均可探测出起搏患者三尖瓣返流及其程度,其中RT-3DE还可进一步判别返流是否与跨越瓣口的起搏导线有关。④在多个观察窗位中,检测效率最高的依次为剑突下四腔、右心两腔、心尖四腔、胸骨旁四腔(P均＜0.05)。⑤依据RT-3DE所见,将患者的起搏电极尖端所在位置分为心尖偏间隔组和心尖偏游离壁组。偏间隔组的右房内径(RA)和三尖瓣返流(TR)较术前增加(△+1.71±0.76mm、P=0.047与△+25.71±11.34cm/S,P=0.001);左室短轴缩短率(FS)、左室射血分数(LVEF)较术前下降(△-3.14±1.57%、P=0.002与△-4.86±1.85%、P=0.00)。偏游离壁组的左房径(LA)、右房径(RA)、左室舒张末径(LVDd)、右室径(RV)、三尖瓣返流(TR)均较术前增加(△+3.58±1.16mm、P=0.002;△+1.25±1.06mm、P=0.002;△+3.92±1.68mm、P=0.00;△+1.17±0.94mm、P=0.003:△+50.83±25.39cm/S、P=0.00):左室短轴缩短率(FS)与左室射血分数(LVEF)较术前下降(△-3.67±1.44%、P=0.00与△-6.42±2.54%、P=0.00)。两组的三尖瓣返流程度未见明显统计学差异(P均＞0.05)。偏室间隔组术后左室舒张末径(LVDd)低于偏游离壁组(51.75±3.67mm和45.71±6.10mm,P=0.015);左室短轴缩短率(FS)高于偏游离壁组(25.75±3.05%和31.29±3.73%,P=0.003);三尖瓣返流(TR)低于偏游离壁组(282.50±16.30和260.00±26.46,P=0.033)。⑥21例患者中2例患者的心内导线即不能被2DE,也不能被RT-3DE清晰显示(失败率9.52%)。结论:①、RT-3DE观察心内起搏导线的走行、电极位置、毗邻关系等高效可行,与2DE和X线透视相比具有简便、安全、经济、易重复等优点。②、RT-3DE与2DE相比,不仅能检出三尖瓣返流,而且能判断该返流系否与起搏导线跨过三尖瓣口所致。③、RT-3DE用于观察心内起搏导线的最优超声探查窗依次为:剑突下四腔、右心两腔、心尖四腔、胸骨旁四腔。④、精确判断起搏电极在右室尖的位置,RT-3DE优于2DE,且起搏电极位于心尖偏间隔的血流动力学指标改善程度优于偏游离壁,提示起搏器植入术中右室尖电极似应尽可能定位于偏间隔侧。⑤、尽管采用RT-3DE观察心内起搏导线,仍有9.52%的失败率,提示RE-3DE观察心内起搏导线存在局限性。更多还原

【Abstract】 OBJECTIVE To Explore the feasibility and the application of the lead by the real-time three-dimensional echocardiography(RT-3DE) and contrast with the two-dimensional echocardiography,which can make a guidance for device implantation.METHOD The study subjects consists of 22 patients who do permanent cardiac pacemaker implantation from July 2007 to January 2009 in the First affiliated Hospital of Kunming Medical College.The pacemaker’ leads was observated by RT-3DE after operation and was assessed their position、pathway、adjacent and the backstreaming of tricuspid valve.The we measure the preoperative and postoperative index with echocardiographic which include:left atrial diameter(LA),left ventricular end-diastolic diameter(LVDd),tricuspid regurgitation(TR),cardiac function index (left ventricular fraction shortening(FS),left ventricular ejection fraction(EF),and evaluate the effect of the treatment and prognosis of pacemakers.To discuss the imaging principle,the research advancement,the imaging characteristic of observation to the lead with RT-3DE,and contrast to the announcements and the local with wo-dimensional echocardiography,so make a better guidance to the method of operation.RESULTS The top lead can be observed by 2DE and RT-3DE,but the display of RT-3DE was higher than 2DE.RT-3DE can not only show the pathway of lead:the superior vena cava→right atrium→tricuspid valve→right ventricle,but also locate the specific location of the lead.We can found the tricuspid valve regurgitation by CDFI after operation,but it can not be displayed the cause of it.Through adjusting the images of RT-3DE and rotating the multi-angle obervations,it can shows the relation between the lead and tricuspid valve and we can determine the cause of tricuspid valve regurgitation.To compare a number of images,we can found the number of exact location cases pacemaker leads which were show by xiphoid four-chamber, right ventricular two-chamber,apical four-chamber,parasternal four-chamber were 19、15、14、3 respectively.According to the observation of the exact top lead position, the patients were divided into two groups:cardiac apex to free wall group and cardiac apex to ventricular septum group.To compare the indexs of cardiac structure and function,we can found the RA and TR of ventricular septum group were increased than preoperation,P＜0.05;FS、EF were decreased than preoperation,P＜0.01.The degree of regurgitation(mild,moderate,severe) than preoperation have no significant difference,P＞0.05.The LA、RA、LVDd、RV、TR of free wall group were increased than preoperation.FS、EF of free wall group were decreased than preoperation.The degree of regurgitation(mild,moderate,severe) than preoperation have no significant difference,P＞0.05.To compare to the two groups,we found that LVDd of ventricular septum group was decreased than free wall group,P＜0.05;FS of ventricular septum group was increased than free wall group,P＜0.01;TR of ventricular septum group was decreased than free wall group,P＜0.05.CONCLUSION the observation to the lead of pacemaker is feasible.The pathway、exact location、extent、adjacent、the relationship between the tricuspid valve and lead can been displayed clearly by RT-3DE.The best imaging of showing the lead is xiphoid four-chamber;the second is fight ventricular two-chamber;the third is apical four-chamber;the last is parasternal four-chamber.The lead location of cardiac apex to ventricular septum is better than the location of cardiac apex to free wall.更多还原