【作者】 袁莉；

【导师】 王新房；

【作者基本信息】 华中科技大学 ， 影像医学与核医学， 2007， 博士

【摘要】 第一部分实时三维超声评价正常人的左室整体和局部收缩功能目的应用实时三维超声心动图结合半自动内膜边界探测技术,测量正常成人的左室整体及局部容积参数和收缩功能,探讨该方法的可行性、准确性、重复性,及正常成人左室各节段的局部收缩功能差异。方法健康志愿者36例,应用Philips iE33成像系统采集三维数据,使用Research-Arena 4D LV-Analysis CAP2.5分析软件脱机测量左室整体和节段容积及收缩功能参数,包括左室整体舒张末期容积(global end-diastolic volume, gEDV)、节段舒张末期容积(regional end-diastolic volume, rEDV)、整体收缩末期容积(global end-systolic volume, gESV)、节段收缩末期容积(regional end-systolic volume, rESV)、整体每搏量(global stroke volume, gSV)、节段每搏量(regional stroke volume, rSV)、整体射血分数(global ejection fraction, gEF)和节段射血分数(regional ejection fraction, rEF)。选取20例志愿者的左室整体容积及收缩功能参数的RT-3DE测值与二维超声心动图(two dimensional echocardiography, 2DE)的双平面Simpson’s法测值比较,并将全部志愿者的左室节段容积及收缩功能参数测值行各节段内比较。结果左室整体收缩功能检测:①RT-3DE与Simpson’s法所测gEDV、gESV、gSV和gEF差异均无统计学意义;②RT-3DE与Simpson’s法所测gEDV、gESV、gSV和gEF均高度相关;③检查者与复查者之间gEDV、gESV、gSV及gEF的RT-3DE测值高度相关,且变异小。左室局部收缩功能检测:①正常人左室各节段容积-时间曲线均显示为“U”型波状,形态较为一致。各节段波峰均在舒张末期时间点,波谷纵横坐标相近,均位于收缩末期时间点附近。各节段射血分数-时间曲线显示为倒“U”型曲线,其最低点为0,位于舒张末期时间点;其最高点纵横坐标相近,位于收缩末期时间点附近。②各室壁对应节段的rEDV、rESV和rSV测值从基底段向心尖段均呈递减趋势,基底段测值明显大于中间段和心尖段测值,而大部分中间段和心尖段的对应节段测值之间差异无统计学意义;③各室壁对应节段的rEF测值从基底段向心尖段呈逐渐递增趋势,但存在显著差异的节段数明显较前述容积参数减少;④沿左室长轴纵向比较,rEDV、rESV和rSV测值的演变规律为基底节段组大于中间和心尖节段组),而中间和心尖节段组测值之间差异无统计学意义。rEF测值的演变规律为基底节段组明显低于中间和心尖节段组,而中间和心尖节段组之间rEF测值差异无统计学意义;⑤沿左室短轴横向比较,rEDV、rESV和rSV测值的演变规律为:前壁、前间隔和侧壁节段组最大,后壁和后间隔节段组次之,下壁节段组最小。rEF测值的演变规律为前间隔、前壁节段组小于侧壁、后壁和下壁节段组。结论应用实时三维超声心动图结合半自动内膜边界探测技术可简便、准确、重复性高地评价正常人的左室整体和局部收缩功能。正常成人的左室各节段局部收缩功能存在差异,rEDV、rESV、rSV和rEF在左室基底段和中间、心尖段之间,以及左室短轴方向各节段之间有明显差异。第二部分实时三维超声评价冠心病患者的左室整体和局部收缩功能目的应用实时三维超声心动图(three-dimensional echocardiography, RT-3DE)结合半自动内膜边界探测技术,测量冠心病患者的左室整体及局部容积参数和收缩功能,探讨该方法评价冠心病患者左室收缩功能的的可行性、准确性、重复性,并揭示冠心病患者左室整体及节段收缩功能的变化特点及治疗后改善情况。方法冠心病患者42例,正常对照者36例,应用Philips iE33成像系统采集三维数据,使用Research-Arena 4D LV-Analysis CAP2.5分析软件脱机测量左室整体舒张末期容积(global end-diastolic volume, gEDV)、节段舒张末期容积(regional end-diastolic volume, rEDV)、整体收缩末期容积(global end-systolic volume, gESV)、节段收缩末期容积(regional end-systolic volume, rESV)、整体每搏量(global stroke volume, gSV)、节段每搏量(regional stroke volume, rSV)、整体射血分数(global ejection fraction, gEF)和节段射血分数(regional ejection fraction, rEF)。①选取其中25例患者的左室整体容积参数和射血分数RT-3DE测值与二维超声心动图(two dimensional echocardiography, 2DE)的双平面Simpson’s法测值比较。②根据冠脉造影的结果,将42例患者分成三组:A组为14例单纯左前降支病变患者,B组为12例左回旋支病变和/或右冠状动脉病变患者,C组为16例包含左前降支病变的双支或多支病变患者(冠脉狭窄程度≥75%定义为冠脉病变)。将A组、B组、C组和正常对照组所测的左室整体及节段容积和收缩功能参数比较。③采集其中20例行血运重建术患者术前1～3天、术后一周和术后三个月的RT-3DE左室图像,并分析患者术前和术后随访中左室整体和局部收缩功能变化情况。结果RT-3DE与2DE测值比较:①RT-3DE法与双平面Simpson’s法所测冠心病组gEDV、gESV、gSV和gEF均高度相关,但相关系数较正常组相应测值有所降低;②RT-3DE与双平面Simpson’s法所测冠心病组gEDV、gESV、gSV和gEF差异均无统计学意义;③检查者与复查者之间冠心病组gEDV、gESV、gSV及gEF的RT-3DE测值高度相关,且测值一致性好;④RT-3DE法与Simpson’s法的观察者间变异在冠心病组均较正常组有所增加,且冠心病组中Simpson’s法的观察者间变异增加更明显,大于RT-3DE法的观察者间变异。冠心病分组的收缩功能检测:①A组、C组的gEDV和gESV均较正常对照组增大,且C组的gEDV和gESV较A组和B组增大;②C组的gSV较正常对照组减小;gEF测值为正常对照组>B组>A组>C组;③冠心病组的左室节段容积-时间曲线杂乱,形态多样。病变节段曲线曲度变小,各节段曲线波谷纵横坐标远离。各节段射血分数-时间曲线也呈现类似变化,曲线杂乱,形态多样,病变节段曲线曲度变小,各节段曲线最高点纵横坐标远离;④在冠心病A组,前间隔、前壁、心尖部各节段rEF测值较正常组对应节段测值明显降低,后间隔基底段、后间隔中间段和侧壁中间段rEF测值稍有降低,且上述病变节段大部分出现rEDV、rESV增大和rSV减小;⑤在冠心病B组,后壁、下壁、后间隔各节段及侧壁中间段的rEF测值较正常组减低,且上述病变节段中,rEDV未见明显变化,大部分节段出现rESV增大和/或rSV减小;⑥在冠心病C组,左室各节段rEF测值均出现不同程度的降低,rEDV,rESV不同程度的增大。⑦在冠心病A组和B组内,病变节段的rEF测值较正常节段明显减低,差异有统计学意义。冠心病组血运重建术前后RT-3DE测值比较:①术后一周复查,gEDV、gESV、gSV及gEF测值较术前均未见明显改变,前壁基底段和前间隔基底段的rEF测值较术前升高;②术后三月随访,gEDV、gESV、gSV测值较术前无明显改变,而gEF测值较术前升高,前壁基底段和前间隔基底段rEF测值较术后一周时改善更明显,并出现更多节段的rEF测值较术前有不同程度的升高。结论应用实时三维超声心动图结合半自动内膜边界探测技术可简便、准确、重复性高地评价冠心病患者的左室整体和局部收缩功能,并可用于血运重建术的疗效随访。冠心病患者可出现左室整体和局部收缩功能的降低,且左室收缩功能改变受冠状动脉受累支数及血运重建术的影响。第三部分实时三维超声评价急性心肌梗塞犬整体和局部收缩功能目的应用实时三维超声心动图(RT-3DE)结合半自动内膜边界探测技术,测量冠脉结扎后急性心梗犬的左室整体及局部收缩功能变化,探讨该方法评价急性心梗犬左室收缩功能的的可行性和准确性,以及冠脉结扎部位不同对于左室收缩功能的影响。方法能成功建立犬的急性心肌梗塞模型并进入统计分析的实验犬20只。根据冠脉结扎部位将全部实验犬分为两组:①左前降支(LAD)结扎组11只;②左回旋支(LCX)结扎组9只。分别于结扎前、结扎后10分钟内、1小时和3小时行RT-3DE检查,并使用Research-Arena 4D LV-Analysis CAP2.5分析软件脱机测量左室整体和节段容积参数和收缩功能,包括左室整体舒张末期容积(global end-diastolic volume, gEDV)、节段舒张末期容积(regional end-diastolic volume, rEDV)、整体收缩末期容积(global end-systolic volume, gESV)、节段收缩末期容积(regional end-systolic volume, rESV)、整体每搏量(global stroke volume, gSV)、节段每搏量(regional stroke volume, rSV)、整体射血分数(global ejection fraction, gEF)和节段射血分数(regional ejection fraction, rEF)。结果急性心梗犬左室整体收缩功能变化:①LAD结扎组中,冠脉结扎后10分钟内和结扎后1小时分别出现了gESV和gEDV增大,并持续到结扎后3小时;②LAD结扎组中,结扎10分钟内出现gEF降低,并在结扎后1小时继续降低,3小时后有所改善,但无统计学意义;③LCX结扎组中,冠脉结扎后10分钟内出现gESV增大,并持续到结扎后3小时,结扎后1小时出现gEDV增大,结扎后3小时有所回缩;④LCX结扎组中,冠脉结扎后10分钟内出现gEF降低,并在结扎后1小时继续降低,3小时后有所改善;⑤冠脉结扎后10分钟内、1小时和3小时,LAD结扎组所测gEF均较LCX结扎组gEF测值低。急性心梗犬左室局部收缩功能变化:①基础态犬的节段左室容积-时间曲线呈“U”型曲线,各曲线形态一致。各节段波峰均位于舒张末期时间点,波谷纵横坐标靠近,位于收缩末期时间点附近。各节段射血分数-时间曲线显示为倒“U”型曲线,最低点为0,位于舒张末期时间点,最高点纵横坐标靠近,位于收缩末期时间点附近;②冠脉结扎后,左室各节段容积-时间曲线变得杂乱,形态多样。病变节段曲线曲度变小,各节段曲线波谷纵横坐标离散,病变节段波谷较浅。各节段射血分数-时间曲线也出现类似变化,曲线杂乱,形态多样,病变节段曲线曲度变小,最高点纵坐标减少,各节段曲线最高点纵横坐标离散;③LAD结扎主要累及左室前壁、前间隔和心尖节段心肌,结扎10分钟内即出现前间隔、前壁及心尖节段rEF测值减低,结扎后1小时上述节段中部分出现rEF测值继续减低,同时侧壁基底段、侧壁中间段及后间隔中间段也出现rEF测值减低,结扎后3小时少数受累节段rEF测值较结扎后1小时有所上升;④LCX结扎主要累及左室基底部、下壁和后壁节段的心肌,结扎后10分钟内即出现基底部各节段、后壁中间段和下壁中间段的rEF测值减低,结扎后1小时上述节段中部分出现rEF测值继续减低,同时后间隔中间段和下壁心尖段也出现rEF测值减低,结扎后3小时少数受累节段rEF测值较结扎后1小时有所上升。结论应用实时三维超声心动图结合半自动内膜边界探测技术可简便、准确地评价急性心肌梗塞犬左室整体和局部收缩功能变化,左前降支和左回旋支结扎对于犬的左室整体和局部收缩功能影响有所不同。更多还原

【Abstract】 Part 1. Assessment of global and regional normal left ventricular systolic function by real time three dimensional echocardiographyObjective: To explore the feasibility, accuracy and reproducibility of real-time three dimensional echocardiography(RT-3DE) combined with semi-automatic boundary detection method in evaluating global & regional volume parameters and systolic function of normal left ventricle(LV), and to explore the heterogeneity of regional normal left ventricle systolic function.Methods: Thirty-six normal volunteers were studied, and all the three-dimensional echocardiographic datasets were acquired by Philips iE33 medical system. Then a series of LV parameters, namely, global end diastolic volume (gEDV), regional end diastolic volume (rEDV), global end systolic volume (gESV), regional end systolic volume (rESV), global stroke volume (gSV) , regional stroke volume (rSV), global ejection fraction (gEF) and regional ejection fraction (rEF), were off-line measured by Research-Arena 4D LV-Analysis CAP2.5 software. In 20 volunteers, global LV volume parameters acquired from RT-3DE were compared with corresponding values measured by biplane Simpson’s method using two-dimensional echocardiography(2DE). Then all the regional LV volume parameters in different LV segments were compared respectively.Results: Evaluation of global LV systolic function:①No statistical differences are found between RT-3DE and Simpson’s method in gEDV, gESV, gSV and gEF calculations.②gEDV, gESV, gSV and gEF measured by RT-3DE strongly correlate with those measured by Simpson’s method.③Using RT-3DE, gEDV, gESV, gSV and gEF measured by the first examinator strongly correlate with those values measured by the second examinator, and inter-observer variabilities of RT-3DE are small.Evaluation of regional LV systolic function:①Regional volume-time curves of normal LV are“U-shaped”and uniform. Corresponding phases of all curve peaks are end diastole, and phases of valleys are in the neighborhood of end systole. Regional EF-time curves of normal LV are inversely“U-shaped”. The valleys are zero, with corresponding phases being end diastole. The phases of peaks are in the neighborhood of end systole.②rEDV, rESV and rSV decrease from basal segment to apical segment in every LV wall. All the basal segments and apical segments are statistical differences, while in most of walls, there are no statistical differences between middle segments and apical segments.③rEF arise from basal segment to apical segment in every LV wall, but less segments are statistically different.④Comparing along LV longitude, rEDV, rESV, rSV of basal-segment group are larger than those of mid-segment group and apical-segment group, howerer, there are no statistical differences between mid-segment group and apical-segment group. rEF of basal-segment group are smaller than those of other two groups, howerer, there are no statistical differences between mid-segment group and apical-segment group.⑤Comparing along LV circumference, rEDV, rESV, rSV of anterior, anteroseptal and lateral segment group are largest, those of posterior and septal segment group take 2nd place, and those of inferior segment group are smallest. rEF in anterior and anteoseptal segment group is smaller than that in lateral, posterior and inferior segment group.Conclusions The new method of RT-3DE combined with semi-automatic boundary detection method can conveniently, feasibly, accurately and high-repeatedly measure globe and regional normal LV systolic function. Regional systolic function of normal LV is heterogeneity, rEDV, rESV, rSV and rEF show statistical differences between LV middle, apical segment and basal segment, and between LV walls in circumferential sectors. Part 2. Assessment of global and regional left ventricular systolic function in patients with coronary artery disease by real time three dimensional echocardiographyObjective: To explore the feasibility, accuracy and reproducibility of real-time three dimensional echocardiography(RT-3DE) combined with semi-automatic boundary detection method in evaluating global & regional left ventricular(LV) volume parameters and systolic function in patients with coronary artery disease(CAD), and to explore the characteristic of systolic function in CAD together with functional improvement after revascularization. Methods: Forty-two patients with CAD and 36 normal volunteers were studied, and all the three-dimensional echocardiographic datasets were acquired by Philips iE33 medical system. Then a series of LV parameters, namely, global end diastolic volume (gEDV), regional end diastolic volume (rEDV), global end systolic volume (gESV), regional end systolic volume (rESV), global stroke volume (gSV) , regional stroke volume (rSV), global ejection fraction (gEF) and regional ejection fraction (rEF), were off-line measured by Research-Arena 4D LV-Analysis CAP2.5 software.①In 25 patients, global LV volume parameters acquired from RT-3DE were compared with corresponding values measured by biplane Simpson’s method using two-dimensional echocardiography(2DE).②According to angiography findings, 42 patients were divided into 3 groups. Group A consists of 14 patients with isolated left anterior descending artery(LAD) stenosis, group B consists of 12 patients with left circumflex artery(LCX) stenosis, and group C consists of 16 patients with LAD stenosis and other main coronary artery stenosis (a percent area stenosis of≥75%). Global and regional LV volume parameters of group A, group B, group C and normal contrast group were compared.③In 20 patients undergone revascularization therapy, RT-3DE images were acquired 1~3 days preoperatively, 1 week postoperatively and 3 months postoperatively respectively, and analyzed to reveal changes of global and regional LV systolic function after revascularization.Results: Comparison of global LV systolic function values from RT-3DE and 2DE:①In CAD group, gEDV, gESV, gSV and gEF measured by RT-3DE strongly correlate with those measured by Simpson’s method, but the correlation coefficients are lower than those in normal group.②In CAD group, no statistical differences are found between RT-3DE and Simpson’s method in gEDV, gESV, gSV and gEF calculations.③In CAD group, using RT-3DE, gEDV, gESV, gSV and gEF measured by the first examinator are consistent with and strongly correlate with those values measured by the second examinator.④Comparing with normal group, inter-observer variability of RT-3DE and Simpson’s method increase in CAD group, and inter-observer variability of Simpson’s method increased markedly, which is much larger than that of RT-3DE.Evaluation of regional LV systolic function of CAD group:①gEDV and gESV in group A and C incearse than normal group, besides, gEDV and gESV in group C are larger than group A and B.②gSV in group C is smaller than normal group, and relationship of gEF in different groups is normal group>group B>group A>group C.③In CAD group, regional LV volume-time curves are disuniform. Curvatures of ischemic segments decrease, and coordinates of curve valleys are disperse. Regional LV EF-time curves show similar changes, becoming disuniform. Curvatures of ischemic segments decrease, and coordinates of curve peaks are disperse.④In group A, rEF in anteroseptal, anterior and apical segments are much lower than corresponding segments values in normal group. rEF in basal septal, mid septal and mid lateral segments are slightly lower than corresponding segments values in normal group. However, in most of above-mentioned segments, rEDV, rESV increase and rSV decrease.⑤In group B, rEF in posterior, inferior, septal segments and mid lateral segments are lower than corresponding segments values in normal group. In above-mentioned segments, rEDV show no evident change, while in most of the segments, rESV increase and/or rSV decrease.⑥In all segments of group C, rEF are lower than corresponding segments values in normal group, moreover rESV and rEDV increase.⑦ In group A and B, rEF of ischemic segments is much lower than that of normal segments, and there is statistical difference between them.Comparison of LV systolic function before and afte revascularization:①Comparing with pre-operation, 1 week after revascularization, gEDV, gESV, gSV and gEF show unobvious change, but rEF of basal anterior and basal anteroseptal segments increase.②Comparing with pre-operation, 3 months after revascularization, gEDV, gESV, gSV show unobvious change, but gEF increases. rEF of basal anterior and basal anteroseptal segments much more increase, and rEF of other segments become increased.Conclusions The new assessment method of RT-3DE combined with semi-automatic boundary detection method can conveniently, feasibly, accurately and high-repeatedly measure globe and regional LV systolic function of patients with CAD, and it can be used in follow-up study of revascularization therapy. Global and regional LV systolic function of patients with CAD decrease, and the decrease is affected by number of stenostic coronary artery and revascularization therapy. Part 3. Assessment of global and regional left ventricular systolic function in acute myocardial infarction canine by real time three dimensional echocardiographyObjective: To explore the feasibility and accuracy of real-time three dimensional echocardiography(RT-3DE) combined with semi-automatic boundary detection method measure global and regional left ventricular(LV) volume parameters and systolic function in acute myocardial infarction(AMI) canine, and to explore the effect of coronary artery ligation site on global and regional LV systolic function.Methods: Twenty canines were successfully undergone coronary artery ligation and suffered from AMI. According to coronary artery ligation site, all the canines were divided into 2 groups: left anterior descending artery(LAD) ligation group(11 canines)and left circumflex artery(LCX) ligation group(9 canines). They were taken RT-3DE examination before ligation, 10 minutes, 1 hour and 3 hour after ligation. Then a series of LV parameters, namely, global end diastolic volume (gEDV), regional end diastolic volume (rEDV), global end systolic volume (gESV), regional end systolic volume (rESV), global stroke volume (gSV) , regional stroke volume (rSV), global ejection fraction (gEF) and regional ejection fraction (rEF), were off-line measured by Research-Arena 4D LV-Analysis CAP2.5 software.Results: Changes of LV global systolic function in AMI canine:①In LAD ligation group, 10min and 1h after ligation, gESV and gEDV increase respectively, and the increase last into 3h post-ligation.②In LAD ligation group, 10min after ligation, gEF decrease and last into 1h post-ligation. Three hours after ligation, gEF slightly improve but without statistical significance.③In LCX ligation group, 10min after ligation, gESV increase and last into 3h post-ligation. One hour after ligation, gEDV increase and slightly recover 3h after ligation.④In LCX ligation group, 10min after ligation, gEF decrease and last into 1h post-ligation. Three hours after ligation, gEF improve and with statistical significance.⑤ Ten minutes, 1 hour and 3 hour after ligation, gEF of LAD ligation group are all lower than rEF of LCX ligation group.Changes of LV regional systolic function in AMI canine:①In baseline, regional volume-time curves of canine LV are“U-shaped”and uniform. Corresponding phases of curve peaks are all end diastole, and phases of valleys are in the neighborhood of end systole. Regional EF-time curves of baseline canine are inversely“U-shaped”. The valleys are zero, with corresponding phases being end diastole. The phases of peaks are in the neighborhood of end systole.②After coronary artery ligation, regional LV volume-time curves become disuniform. Curvatures of ischemic segments decrease, curve valleys of ischemic segments are shallow, and coordinates of valleys are disperse. Regional LV EF-time curves show similar changes, becoming disuniform. Curvatures of ischemic segments decrease, curve peak of ischemic segments fall, and coordinates of peaks are disperse.③LAD ligation primarily affect LV anterior, anteroseptal and apical segments.Ten minutes after ligation, rEF of anterior, anteroseptal and apical segments decrease. One hour after ligation, rEF of above segment decrease partly, and rEF of basal lateral, mid lateral and mid septal segments decrease too. Three hours after ligation, rEF in minority of abnormal segments slightly recover.④LCX ligation primarily affect LV basal, inferior and posterior segments. Ten minutes after ligation, rEF of basal segments, mid inferior segment and mid posterior segment decrease. One hour after ligation, rEF of above segment decrease partly, and rEF of mid septal and apical inferior segments decrease too. Three hours after ligation, rEF in minority of abnormal segments slightly recover.Conclusions The new assessment method of RT-3DE combined with semi-automatic boundary detection method can conveniently and accurately measure globe and regional LV systolic function of AMI canine. LAD ligation and LCX ligation affect canine LV global and regional systolic function differently.更多还原