【作者】 马晓静；

【导师】 黄国英； 贾兵； 刘芳；

【作者基本信息】 复旦大学 ， 儿科学， 2008， 博士

【摘要】 全容积三维超声心动图(full-volume three-dimensional echocardiography,FV3DE)是近年来超声心动图领域的新进展。FV3DE采集后的观察方法主要包括三维容积观和二维切面观,其优点在于“任意”方位和“任意”角度观察心脏,得到传统的二维超声心动图(two-dimensional echocardiography,2DE)所无法显示的图像。FV3DE的定量诊断主要包括在选取的二维切面观中进行长度、面积等测量和运用后处理软件实现三维自动边界描汜,由此得到心腔的容量、由容量衍生而来的心功能以及由容量衍生而来的同步性参数。为了更好地利用FV3DE强大的定性和定量诊断能力,必须对FV3DE的剖切剖视方法、测量方法及其在具体心脏疾病中的应用进行研究。经食管超声心动图(transesophageal echocardiography,TEE)是将超声探头置于食管或胃的内部,从心脏的后方或下方对心脏和大血管进行扫查的影像学诊断方法。TEE可避开胸骨和含气肺组织的遮挡,为经胸超声显像不佳的病例提供新的探查途径,在心血管疾病的术前诊断、术中监测和术后评价中发挥重要作用。TEE已成为当前儿科心血管领域中具有重要价值的诊断工具。但是儿科病例的大样本研究报道尚不多见,其应用价值和局限性仍有待深入探索。为此,本课题对FV3DE和TEE的方法学及其在小儿法洛四联症(tetralogy ofFallot,TOF)诊治中的应用价值进行研究。第一部分全容积三维超声在法洛四联症诊治中的应用研究研究目的建立FV3DE诊断先天性心脏病(congenital heart disease,CHD)的方法学;在TOF患儿中验证该FV3DE诊断方案的可行性;采用FV3DE定量评价TOF儿童心房和心室的容量和功能。材料与方法采集FV3DE图像数据库,采用在线或离线QLAB工作站进行后处理。使用“Autocrop”功能键和“Plane Adjust”功能键进行正交剖切和任意方位上的剖切,获得感兴趣区各个角度的剖视容积观。在多平面重建(MPR)界面中,正交移动或任意移动轴线获得感兴趣的切面观。根据Van Praagh节段分析法,采用上述方法定性和定量诊断TOF。结果(1)建立心脏FV3DE剖切剖视方法学,显示心尖四腔心FV3DE数据库正交平面(冠状面、矢状面、水平面)依次剖切所观察到的容积观和系列切面观,提出非正交平面上感兴趣区容积观和切面观的显示方法,并对特定心血管结构的常用容积观进行命名。(2)采用FV3DE正交平面连续剖切剖视容积观和主要畸形的常用容积观诊断TOF,验证了上述方法诊断TOF的可行性。与手术结果比较,FV3DE诊断TOF的符合率为100%;对主要畸形室间隔缺损(ventricular septal defect,VSD)位置和右室流出道梗阻(right ventricular outflow tract obstruction,RVOTO)位置的符合率分别为100%和97.2%,均高于2DE;但对合并的心外畸形和细微结构的检出率不如2DE叠加彩色多普勒。(3)从FV3DE中截取的切面观提供了定量诊断TOF畸形的新方法。FV3DE测量VSD最大径与手术测值无显著差异,而传统2DE的VSD测值低于手术测值;FV3DE显示漏斗部的前后径小于左右径,提示TOF漏斗部的横截面不是圆形的。FV3DE、2DE和手术探查测量肺动脉瓣环直径无显著差异,且FV3DE与手术测值的相关性更高(r=0.899 vs.r=0.839)。FV3DE、2DE和心血管造影测量左、右肺动脉直径无显著差异,且FV3DE与心血管造影测值的相关性比2DE更高(r=0.947 vs.0.797)和(r=0.987 vs.r=0.831)。从FV3DE中截取的切面观可测量RVOT各部位的横截面积。从FV3DE得到的肺动脉直径指数(PDI)和肺动脉截面积指数(PAI)分别与心血管造影的McGoon指数和Nakata指数良好相关(r=0.877和r=0.983)。与正常对照组比较,TOF组的左、右心室的射血分数均减小;左房被动收缩容量、被动收缩分数和全部排空容量减小(p＜0.05),左房主动收缩分数和右房主动收缩容量、主动收缩分数、全部排空容量和全部排空分数增大(p＜0.05)。小结FV3DE正交平面和任意平面的剖切剖视方法以及特定心血管结构的典型容积观为CHD的定性诊断提供了新方法;从FV3DE中截取的正交切面观和任意切面观为心血管腔径的定量诊断提供了新的测量平面,FV3DE尚可直接测量心腔容量。在小儿TOF中验证了上述FV3DE的定性和定量诊断方法的重要价值。第二部分经食管超声心动图在法洛四联症诊治中的应用研究研究目的建立小儿CHD围术期TEE的方法学;并验证该围术期TEE诊断方案对TOF术前诊断与术后评价的应用价值。材料与方法采用儿科专用双平面或多平面TEE探头,体外循环开始前,首先进行术前TEE诊断;手术完成、心脏复跳、体外循环停止后再次进行术后TEE探查,以评价即刻手术效果。在体外循环期间,将TEE探头留置于胃中,且机器运行处于冻结状态。对105例TOF外科手术儿童进行围术期TEE研究。结果(1)建立围术期TEE方法学,提出适用于儿科CHD的TEE切面观和观察特定的心血管结构常用的TEE切面观。在977例CHD患儿中验证TEE诊断方法的价值,发现有68例(7.0%)TEE对TTE的诊断作出更正或补充,包括间隔类缺损(尤其是房间隔缺损)、各类瓣膜畸形和右室异常肌束;有10例(1.0%)TEE漏诊或显示欠清,但TTE可以较清楚地显示,包括动脉导管未闭、主动脉缩窄和肺静脉异位引流。(2)采用上述围术期TEE方法诊断TOF,验证了其诊断TOF的可行性。与手术结果比较,TEE诊断TOF的符合率为100%;对主要畸形VSD位置和RVOTO位置的符合率分别为99.0%和98.1%,均高于TTE;且对合并畸形的检出率较高。(3)术后TEE发现即刻VSD残余分流发生率为30.8%,RVOT残余梗阻发生率17.3%,肺动脉反流发生率67.3%。TEE发现残余梗阻的程度与是否采用跨瓣补片无关;但跨瓣补片组肺动脉反流程度比扩大补片组严重;保留肺动脉瓣不能减轻肺动脉反流程度,采用Contegra重建RVOT可减少肺动脉反流的发生率。小结适用于儿科CHD的TEE切面观和观察特定的心血管结构常用的TEE切面观对小儿CHD的围术期监测具有重要价值;在小儿TOF中验证了术前TEE可为外科手术方案的制定提供充分信息,术后TEE可对手术效果进行即刻评价,并发现不同的手术方式对RVOT残余问题的影响。更多还原

【Abstract】 Full-volume three-dimensional echocardiography(FV3DE) is one of the recent new developments in the arena of echohcardiography.There are basically two methods of displaying FV3DE datasets,namely volume-rendered view and two-dimensional cross-sectional view from any desired cut-planes.It makes the cardiovascular observation from any orientation and any angle possible.Any images can be generated from FV3DE as desired,some of which are physically unobtainable by conventional two-dimensional echocardiography(2DE) with either transthoracic or tranesophageal acoustic windows.Quantitative analysis of FV3DE is also accessible. Measurements of length or area can be done in the cross-sectional view,while achievements of volume,volume-derived function or volume-derived synchronicity curves are realized in the volume-rendered view with matched analytical software.To make the best use of FV3DE,the study of morphologic or quantitative analysis and its clinical application in heart disease should be carried out.Transesophageal echocardiography(TEE) is the imaging diagnostic technique scanning cardiovascular structure from the rear or bottom of the heart by the probe within esophagus or stomach.TEE provides a novel scanning way,especially in the cases with imperfect acoustic window of transthoracic echocardiography(TTE), remote from costal bone and air-borne pulmonary tissue.TEE plays an important role, such as preoperative diagnosing,perioperative monitoring or postoperative evaluating, in cardiovascular disease.It has already become one of the significant imaging tools in the field of pediatric cardiology.While,regretfully,there is few reports about pediatric cases with large sample.The potential clinical value and its dormant limitations are still to be discovered.Given these together,our study aimed to discuss the image-analytical methodology of FV3DE and TEE,focusing our attention on the applicable value of these new technologies in pediatric patients with tetralogy of Fallot(TOF). PartⅠThe Application of Full-volume Three-dimensional Echocardiography in Patients with Tetralogy of FallotObjectiveTo establish the methodology for diagnosis of congenital heart disease(CHD) with FV3DE,to test the feasibility of the examination protocol of FV3DE in cases with tetralogy of Fallot(TOF),one of representatives of complex CHD,and to test the reliability of quantifying TOF with FV3DE.MethodsThe images were post-processed with online or offline QLAB workstation after the FV3DE datasets acquired."Autocrop" and "Plane Adj" functional keys were used to display the volumetric view for the region of interest(ROI) from any angle when the FV3DE datasets were cropped orthogonally or arbitrarily.In the multiplanar reconstruction(MPR) window,ROI in cross-sectional view was obtained by moving the orthogonal axis or oblique axis.Based on Van Praagh sequential segmental approach,following the above rule,TOF was diagnosed morphologically and quantitatively by post-processing software.Results1.Establishing the examination protocol for FV3DE.The volumetric views and sectional views from FV3DE dataset were displayed by consecutive orthogonal cropping,including coronal,saggital and horizontal directions.The views of ROI at non-orthogonal planes were also displayed by appropriate cropping.In addition,the typical volumetric views of cardiovascular structure were nominated.2.TOF was diagnosed with volumetric views by consecutive orthogonal cropping and typical volumetric views of main malformations from FV3DE datasets.Compared with surgical findings,the accordance rate of FV3DE in diagnosing TOF was 100%. The accordance rate was 100%and 97.2%in determining the positions of ventricular septal defect(VSD) and right ventricular outflow tract obstruction(RVOTO), respectively,both of which were higher than 2DE.However,the detectable rate for co-existed extracardiac anomalies and minute structures was lower than 2DE plus color Doppler imaging.3.It provided a novel approach to quantify TOF with cross-sectional view extracted from FV3DE datasets.No significant difference was observed between FV3DE and surgical observation in measuring VSD.While,conventional 2DE underestimated the size of VSD.Smaller anterior-posterior diameter was revealed as compared with lateral diameter by FV3DE,suggesting the morphology of infundibulum of TOF was not circular shape.No significant difference was observed between FV3DE,2DE and surgical observation in measuring the diameter of pulmonary valvular annulus,but FV3DE was better correlated with surgical observation than 2DE(r=0.899 vs. r=0.839).No significant difference was observed between FV3DE,2DE and angiography in measuring LPA or RPA.The correlation coeffients between FV3DE and angiography were higher than those between 2DE and angiography(LPA: r=0.947 vs.r=0.797 and RPA:r=0.987 vs.r=0.831).The sectional area of RVOT could be measured by FV3DE.The pulmonary diameter index(PDI) and the pulmonary area index(PAI) derived from FV3DE were well correlated with McGoon index and Nakata index derived from angiography(r=0.877 and r=0.983, respectively).Compared with healthy control group,the TOF group had decresed LVEF and RVEF;Smaller LA.Vmax,larger RA.Vmax and RA.Vp,decreased LA.Vpe,LA.Vpef and LA.Vte,increased LA.Vaef,RA.Vae,RA.Vaef,RA.Vte and RA.Vtef.ConclusionsThe study provided the new method to dignose CHD with the volumetric views from FV3DE dataset by cropping orthogonally or arbitrarily.It provided the new planes to measure the diameter or area of cardiovascular structure with the appropriate sectional views from FV3DE dataset.Cardiac volume could also be measured by FV3DE without geometrical hypothesis.It suggested that the volumetric view and cross-sectional view from FV3DE datasets made great innovations at the morphologic or quantitative diagnosis in children with TOF.PartⅡThe Application of Transesophageal Echocardiography in Patients with Tetralogy of FallotObjectiveTo establish the methodology of perioperative TEE in children with CHD,and to test the feasibility of the examination protocol for perioperative TEE in patients with TOF. MethodsPediatric biplane or multiplane TEE was used.Before bypass was initiated,the preoperative TEE diagnoses were made.TEE was performed again to evaluate the instant result of the operation after the spontaneous beat of the heart was resumed. During bypass,the probe was frozen staying in stomach.The study of perioperative TEE was carried out in 105 cases of TOF to elucidate its application value during perioperative period.Results1.Establishing the examination protocol for perioperative TEE.The sectional views of TEE for diagnosing pediatric CHD were selected.The appropriate sectional views of TEE to display given cardiovascular structure were also provided.The value of above protocol was validated by 977 cases with CHD,among which,TEE made corrections or supplements for TTE in 68 cases(7.0%),including septal defects(atrial septal defects,especially),valvular malformations and abnormal muscular bundles in ventricle.Compared with TTE,TEE had limitations in 10 cases(1.0%),including patent ductus arteriosus,coarctation of aorta,and anomalous pulmonary venous connection.2.Compared with surgical findings,the accordance rate of TEE in diagnosing TOF was 100%.The accordance rate was 99.0%and 98.1%in determining the positions of VSD and RVOTO,respectively,both of which were higher than TTE.In addition,the detectable rate for co-existed anomalies by TEE was also higher than that by TTE.3.Postoperative TEE showed that residual shunt rate was 30.8%,residual obstruction rate was 17.3%and pulmonary regurgitation rate was 67.3%,respectively,.Residual RVOTO was not correlated with transannular patch(TAP),but the patients underwent TAP were more apt to pulmonary regurgitation(PR) than those only with enlargement patch.Preservation of pulmonary valve could not decrease the degree of PR. Reconstruction of RVOT with Contegra could reduce the occurrence of PR.ConclusionsThe examination protocol for perioperative TEE had great impact on diagnosing TOF before operation and detecting residual problems after operation,which might influence the treatment strategy and improve the quality of surgical procedures.The value of perioperative TEE was validated in children with TOF.Preoperative TEE provided suffiecnt information for surgical plan,while postoperative TEE could evaluate the surgical results instantly.The impacts of different surgical method on residual problems of RVOT were also detected by TEE.更多还原