【作者】 肖明虎；

【导师】 王浩； 吕秀章； 李建蓉；

【作者基本信息】 中国协和医科大学 ， 影像医学与核医学， 2010， 硕士

【摘要】 目的:通过经胸超声心动图观察舒张末期右心室前壁厚度与左心室后壁厚度比值(right ventricle end-diastolic anterior wall and left ventricle end-diastolic posterior wall thickness ratio, RVAW/LVPW ratio)、主肺动脉内径与升主动脉内径比值(main pulmonary artery diameter and ascended aorta diameter ratio, PA/AO ratio)和室水平左向右分流峰值压差(left to right shunt pressure gradient, LRPG),评价其在先天性心脏病室间隔缺损患者(VSD)肺动脉压力(pulmonary arterial pressure, PAP)的临床价值。方法：入选202例单纯先天性心脏病室间隔缺损患者,所有病人均接受经胸超声心动图检查和右心导管测压。根据右心导管所测肺动脉平均压(mean pulmonary artery pressure, PAMP)将所有病人分为四组：无肺动脉高压组,PAMP< 25mmHg;轻度肺动脉高压组,PAMP≥25 mmHg且< 40 mmHg;中度肺动脉高压组,PAMP≥40 mmHg且<60 mmHg;重度肺动脉高压组,PAMP≥60 mmHg。采用协方差分析排除年龄因素对RVAW/LVPW ratio; PA/AO ratio的影响,比较各组间以上各变量的差异。各组间LRPG的差异采用One-Way ANOVA分析.RVAW/LVPW ratio、PA/AO ratio和LRPG与PAMP间的相关关系通过Pearson相关性分析。采用受试者工作特征曲线(ROC)评价RVAW/LVPW比值法、PA/AO比值法和LRPG法对入选的肺动脉高压的诊断价值。结果：各组间RVAW、PA、AO、LRPG以及RVAW/LVPW ratio、PA/AO ratio差异均有显著统计学意义；各组间LVPW差异无统计学意义。RVAW/LVPW ratio、PA/AO ratio以及LRPG与右心导管所测PAMP有良好相关性(r值分别为0.732；0.556;-0.647,P均<0.001)。选RVAW/LVPW ratio为0.6作为诊断肺动脉高压阳性(PAMP≥25 mm Hg)界点时,敏感性和特异性分别是80%和69%。选RVAW/LVPWratio为0.9作为诊断重度肺动脉高压(PAMP≥60 mm Hg)界点时,敏感性和特异性分别是93%和94%。选取室水平左向右分流压差为49 mm Hg作为肺动脉高压阳性诊断界点时,敏感性和特异性分别是76%和92%；选取室水平左向右分流压差为25mmHg作为诊断重度PAH界点时,敏感性和特异性分别是89%和80%。选PA/AO ratio为1.2作为诊断肺动脉高压阳性界点时,敏感性和特异性分别是72%和70%。选PA/AO ratio为1.45作为诊断重度肺动脉高压界点时,敏感性和特异性分别是61%和80%。对于室间隔缺损患者：①LRPG、PA/AO ratio和RVAW/LVPW ratio均可以用于PAH的诊断和分级；②各方法在轻度PAH的诊断中准确性均较差；各方法在重度PAH的诊断中准确性均较高,而以RVAW/LVPW比值法准确性最高；③三种方法相比较,在轻度PAH诊断中,LRPG法准确性最高；PA/AO ratio准确性最差。结论：超声心动图RVAW/LVPW ratio法、PA/AO ratio法和LRPG法可以用来评估室间隔缺损患者肺动脉压力的严重程度,其中RVAW/LVPW ratio法和LRPG法较PA/AO ratio法更准确。更多还原

【Abstract】 Background:Transthoracic Doppler echocardiography is recommended to evaluate the presence of pulmonary arterial hypertension (PAH). However, some recent studies have revealed that Doppler echocardiographic for pulmonary artery pressure estimatias may frequently be inaccurate. Objectives:The aim of this study was to determine the prognostic value of some quantitative echocardiographic criterion for PAH in patients with congenital ventricular septal defect, including left to right shunt pressure gradient (LRPG), the thickness ratio of the right ventricle end-diastolic anterior wall to the left ventricle end-diastolic posterior wall (RVAW/LVPW ratio) and the ratio of main pulmonary artery diameter to ascended aorta diameter (PA/AO ratio).Methods:A total of 202 patients with isolated congenital ventricular septal defect (VSD) were enrolled in this study and classified into 4 groups according to their mean pulmonary artery pressure (PAMP) by right-heart catheterization:A group without-PAH,with PAMP< 25 mmHg A group of mild-PAH, with PAMP≥25 mmHg and< 40 mmHg; A group of moderate-PAH, with PAMP≥40 mmHg and<60 mmHg; A group of severe-PAH, with PAMP≥60 mmHg. Bivariate correlations were evaluated using Pearson’s correlation coefficient. Univariate correlations were evaluated using Pearson’s correlation coefficient. The discriminatory ability of LRPG, PA/AO ratio and RVAW/LVPW ratio for PAH was assessed using the receiver operating characteristic curve (ROC). Results:The RVAW/LVPW ratio, PA/AO ratio and LRPG were correlated well with mean pulmonary artery pressure (PAMP) measured by right-heart catheterization (r= 0.732, r= 0.556; r=-0.647; P＜0.0001; resprctively). The sensitivity and specificity of RVAW/LVPW ratio≥0.6 for predicting PAH defined as PMAP≥25 mm Hg were 80% and 69%, with a high area under the ROC (AUC,0.80; 95% CI,0.76-0.86). The sensitivity and specificity of RVAW/LVPW ratio≥0.9 for diagnosing severe PAH (PAMP≥60 mmHg) were 93% and 94%, with a high AUC, (0.97;95%CI,0.94-0.99). The sensitivity and specificity of PA/AO ratio≥1.2, and LRPG≤49 mmHg for predicting PAH defined as PMAP> 25 mm Hg were 72% and 70%,76% and 92%, respectively The sensitivity and specificity of PA/AO ratio≥1.45, and LRPG≤25 mmHg for diagnosing severe PAH (PAMP>60 mmHg) were 61% and 80%,89% and 80%, respectivelyConclusion:These variables, including RVAW/LVPW ratio, PA/AO ratio and LRPG derived from echocardiography, have a good prognostic value regarding the severity of PAH in patients with VSD, especially RVAW/LVPW ratio and LRPG更多还原