超声心动图结合Flash CT对圆锥动脉干畸形及肺静脉畸形引流诊断价值的应用研究

发布时间：2018-06-09 21:42

  本文选题：圆锥动脉干畸形 + 肺静脉畸形引流　； 参考：《郑州大学》2014年博士论文

【摘要】：第一部分超声心动图结合Flash CT对圆锥动脉干畸形诊断价值的研究 背景和目的 圆锥动脉干畸形（Conotruncal defects，CTD）是一类合并外周血管畸形的复杂型先天性心脏病。一直以来超声心动图以其无创、经济、简便、可重复检查等优势在该类疾病的诊断中始终处于首选检查方法。但是快速发展的螺旋CT技术在诊断外周血管畸形准确率方面优于超声心动图，因而被临床医生所青睐。也因此使超声心动图在CTD诊断准确性方面受到一定的挑战。2010年问世的新双源Flash CT，以其独特的Flash扫描模式，采用大螺距快速扫描，不受心率影响，心脏扫描只需0.25s，实现了亚mSv级的超快速心脏扫描，不仅保证了诊断的准确性，同时也关注到了低剂量辐射等安全问题。本研究通过超声心动图结合Flash CT对CTD诊断价值的对比研究，为今后提高超声诊断该类畸形的准确性及患者术前合理选择检查方法提供参考依据。 材料与方法 96例患者主要包括：永存动脉干17例，肺动脉闭锁22例，主-肺动脉间隔缺损5例，右室双出口18例，法洛四联症18例，完全型大动脉转位16例。将96例患者分别行超声心动图及Flash CT检查。超声心动图重点观察心内结构、大血管连接、心外畸形，估测肺动脉压力，评价瓣膜功能及心功能。Flash CT采用新双源CT前瞻性心电门控Flash扫描模式，扫描结束后，将原始数据进行横断面重建，由一名有经验的放射科医师根据需要进行多平面重建，最大密度投影、曲面重建和三维容积再现和仿真内窥镜等。本研究将不作为分型依据的其他心脏畸形均归为合并畸形。瓣膜关闭不全及肺动脉压不归为合并畸形。检查后采用欧洲CT质量标准指南，记录所有CTD病例的CT剂量指数和剂量长度乘积然后计算出有效辐射剂量。 结果 1．96例CTD患者最终经手术结果或临床确定诊断。超声心动图诊断正确82例，误诊13例，漏诊1例；Flash CT诊断正确92例，误诊4例，漏诊0例。超声心动图和Flash CT对CTD的病因诊断正确率分别为85.42%（82/96）和95.83%（92/96），差异有统计学意义(P＜0.05)。 2.96例CTD患者分型诊断：超声心动图诊断正确64例，误诊15例，未分型17例；Flash CT诊断正确86例，误诊4例，未分型6例。超声心动图和Flash CT对CTD分型诊断正确率分别为66.67%（64/96）和89.58%（86/96），差异有统计学意义(P＜0.01)。 3．96例CTD患者合并畸形249处，超声诊断结果：确诊232处，误诊1处，漏诊16处；Flash CT诊断结果：确诊238处，误诊0处，漏诊11处。超声和FlashCT诊断正确率分别为93.17%（232/249）和95.58%(238/249)，差异无统计学意义(P＞0.05)。 4.射线剂量统计：96例复杂先心患者平均DLP是7.0±1.50mGy*cm（范围：5-10mGy*cm），平均ED值是0.212±0.039mSv (范围：0.144-0.273mSv)。 结论 1．超声心动图对CTD诊断正确率较高，可以作为法洛四联症、完全性大动脉转位、右室双出口、主-肺动脉间隔缺损、永存动脉干及肺动脉闭锁的首选检查方法。 2．超声心动图对于永存动脉干和肺动脉闭锁的分型诊断及鉴别诊断有一定的困难。对于极少数右室双出口的室缺位置及大动脉骑跨率判断会有一定的误差。出现上述两种情况时，建议结合Flash CT协助诊断。 3．Flash CT大螺距扫描技术辐射剂量低，对CTD分型诊断正确率高，是对超声心动图进行补充诊断的最佳检查方法。 第二部分超声心动图结合Flash CT对肺静脉畸形引流诊断价值的研究 背景和目的 肺静脉畸形引流是较为少见的先天性心脏畸形，，由于肺静脉走行部位复杂多变超声检查容易漏诊和误诊。随着螺旋CT技术的快速发展，凭借其对外周血管畸形良好的显示而越来越多的被临床医生所认可。2010年推出的新双源FlashCT，其独特的大螺距快速扫描模式，完全不受心率影响，心脏扫描只需0.25s，实现了亚mSv级的超快速心脏扫描，不仅保证了诊断的准确性，同时也关注到了低剂量辐射等安全问题。本研究运用超声心动图结合Flash CT大螺距扫描技术对肺静脉畸形引流各种类型漏诊、误诊原因进行分析研究，目的在于提高超声心动图在肺静脉畸形引流诊断中的准确率，尽量减少不必要的CT检查，避免射线的危害。当然，对于超声诊断有困难的病例，可以结合低辐射剂量的大螺距CT扫面技术为外科手术提供参考依据。 材料和方法 将71例肺静脉畸形引流患者分为完全性肺静脉畸形引流（T组）和部分性肺静脉畸形引流（P组），每组再分为心上型、心内型、心下型及混合型，所有患者术前均行超声心动图与Flash CT大螺距扫描技术检查，并与手术结果（或临床诊断）对照。另外分别收集正常婴儿20例、婴儿单纯房间隔缺损20例与T组中34例婴儿对照分析；收集20例正常成人、20例成人单纯房间隔缺损与P组中19例成人患者对照分析，分析指标包括左心房、右心室大小、房缺大小，肺动脉压及年龄等。检查后采用欧洲CT质量标准指南，记录所有肺静脉畸形引流病例的CT剂量指数和剂量长度乘积然后计算出有效辐射剂量。 结果 1.完全型肺静脉畸形引流组（T组）44例（包括心上型22例，心内型17例，心下型2例，混合型3例），确诊38例，漏诊4例，误诊2例。CT确诊43例，无漏诊；误诊1例。超声与CT诊断正确率分别为86.36%（38/44）和97.72%（43/44），差异无统计学意义(P＞0.05)。 2. T组合并畸形62处，超声全部确诊，无漏诊及误诊。CT确诊59例，无误诊，漏诊3例。超声与CT诊断正确率分别为100%（62/62）和95.16%（59/62），差异无统计学意义(P＞0.05)。 3. P组27例（包括心上型7例，心内型10例，心下型1例，混合型9例），超声准确诊断20例，误诊2例，漏诊5例。CT确诊26例，漏诊1例。超声与CT诊断正确率分别为74.1%（20/27）和96.3%（26/27）。差异有统计学意义(P＜0.05)。 4. P组合并畸形共计45处，超声确诊44处，漏诊1处。CT正确诊断34处，误诊2处，漏诊8处。超声和CT诊断正确率分别为97.8%（44/45）和75.6%（34/45），差异有统计学意义(P＜0.01)。 5. T组多为婴儿，左心房内径小于房缺组和正常组，差异有统计学意义（（P＜0.05））；右心室、肺动脉压高于房缺组和正常对照组，差异有统计学意义（P＜0.01）；T组婴儿的房间隔缺损大于同龄房缺组，差异有统计学意义(P＜0.05) 6. P组多为成年人，左心房内径低于房缺组和正常组，差异有统计学意义(P＜0.01)，右心室及肺动脉压高于房缺组和正常对照组，差异有统计学意义(P＜0.01)；P组房间隔缺损小于单纯房缺组，差异有统计学意义(P＜0.01) 7.71例肺静脉畸形引流患者，统计其辐射剂量，平均DLP是13.5±3.9mGy*cm（范围：8-30mGy*cm），平均ED值为0.324±0.065mSv（范围：0.182 0.540mSv）。 结论 1．超声心动图诊断肺静脉畸形引流准确率高，可以对瓣膜病变、肺动脉压力及心功能做出全面评价，是一种可以信赖的检查手段。 2．完全性肺静脉畸形引流多见于婴儿，部分性肺静脉畸形引流多见于成人。由于存在血流动力学差异，患者左心房、右心室内径、肺动脉压以及年龄因素可以成为判断部分性或完全性肺静脉畸形引流的敏感指标。尤其适用于房间隔缺损患者。 3．Flash CT大螺距扫描技术对心脏周围血管畸形的诊断具有独特的优势，在不影响诊断准确率的前提下，大大减少了射线的辐射剂量，对超声心动图检查起到了很好的补充诊断作用。
[Abstract]:The Diagnostic Value of First Part Echocardiography Combined with Flash CT in the Diagnosis of Cone Artery Malformations

Background and Purpose

It is a kind of complicated congenital heart disease complicated with peripheral vascular malformation . It has always been the preferred method in the diagnosis of this kind of diseases . However , the rapid development of spiral CT is superior to echocardiography in the diagnosis of the disease .

Materials and Methods

In 96 patients , there were 17 cases of persistent truncus , 22 cases of pulmonary atresia , 5 cases of primary - pulmonary septal defect , 18 cases with right ventricular double - outlet , 18 cases of tetralogy of Fallot , and 16 cases of complete large artery transposition .

Results

1 . 96 CTD patients were diagnosed by surgical results or clinical diagnosis . 82 cases were diagnosed correctly by echocardiography , 13 cases were misdiagnosed , 1 case missed diagnosis ;
The accuracy of diagnosis of CTD was 85.42 % ( 82 / 96 ) and 95.83 % ( 92 / 96 ) respectively , and the difference was statistically significant ( P < 0.05 ) .

2.96 cases of CTD were diagnosed correctly : 64 cases were diagnosed correctly , 15 cases were misdiagnosed and 17 cases were not typed .
The diagnostic accuracy of the CTD typing was 66.67 % ( 64 / 96 ) and 89.58 % ( 86 / 96 ) respectively , and the difference was statistically significant ( P < 0.01 ) .

3.96 patients with CTD were diagnosed at 232 , misdiagnosed as 1 , missed at 16 ;
The diagnostic accuracy of ultrasound and FlashCT was 93.17 % ( 232 / 249 ) and 95.58 % ( 238 / 249 ) respectively .

4 . Ray dose statistics : The mean DLP of 96 patients with complex first heart was 7.0 卤 1.50 mGy * cm ( range : 5 - 10mGy * cm ) , and the mean ED value was 0.212 卤 0.039 ( range : 0.144 - 0.273kJ ) .

Conclusion

1 . The accuracy of the diagnosis of CTD was higher in the diagnosis of CTD , which could be used as the preferred method for the diagnosis of tetralogy of Fallot , transposition of the complete large artery , double - outlet of right ventricle , primary - pulmonary septal defect , persistent arterial trunk and pulmonary atresia .

2 . Echocardiogram is difficult to diagnose and differential diagnosis and differential diagnosis of permanent arterial trunk and pulmonary atresia . It is suggested that the diagnosis should be aided by Flash CT .

3 . The radiation dose of the large - pitch scanning technique of Flash CT is low , and the diagnostic accuracy of CTD typing is high , which is the best method for the supplementary diagnosis of echocardiography .

The value of second part echocardiography combined with Flash CT in the diagnosis of pulmonary venous malformation

Background and Purpose

With the rapid development of spiral CT , a new double - source FlashCT was introduced in 2010 . The new double - source FlashCT , which was introduced in 2010 , has a unique large - pitch fast scan mode , which not only guarantees the accuracy of diagnosis , but also pays attention to the safety problems such as low - dose radiation .

Materials and Methods

71 cases of pulmonary venous malformation were divided into complete pulmonary venous malformation drainage ( T group ) and partial pulmonary venous malformation drainage ( group P ) . Each group was divided into three groups : heart type , heart type , heart type and mixed type . All patients were examined by echocardiography and Flash CT scanning technique before operation and compared with operation result ( or clinical diagnosis ) .
Twenty cases of normal adult , 20 adult simple atrial septal defect and 19 adult patients in the P group were collected . The analysis indexes included left atrium , right ventricle size , atrial septal size , pulmonary artery pressure and age . After examination , the CT dose index and dose length product of all cases of pulmonary venous malformation were recorded and the effective radiation dose was calculated .

Results

1 . There were 44 cases of complete pulmonary venous malformation ( group T ) ( including 22 cases of upper heart type , 17 cases in heart type , 2 cases with heart type , 3 cases of mixed type ) , 38 cases were diagnosed , 4 cases were missed , 2 cases were misdiagnosed .
The accuracy of ultrasonography and CT was 86.36 % ( 38 / 44 ) and 97.72 % ( 43 / 44 ) respectively .

The diagnostic accuracy of ultrasonography and CT was 100 % ( 62 / 62 ) and 95.16 % ( 59 / 62 ) respectively . There was no statistical significance ( P > 0.05 ) .

3 . There were 27 cases of P group ( including 7 cases of heart type , 10 cases in heart type , 1 case with heart type , 9 cases of mixed type ) , 20 cases were diagnosed accurately , 2 cases were misdiagnosed , 5 cases missed diagnosis . 26 cases were diagnosed by CT and 1 case missed diagnosis . The accuracy of ultrasound and CT were 74.1 % ( 20 / 27 ) and 96.3 % ( 26 / 27 ) , respectively .

The diagnostic accuracy of ultrasound and CT was 97.8 % ( 44 / 45 ) and 75.6 % ( 34 / 45 ) , respectively ( P < 0.01 ) .

5.T group was infants , the inner diameter of left atrium was smaller than that of atrial septal defect group and normal group ( P < 0.05 ) .
There was significant difference between right ventricle and pulmonary artery pressure ( P < 0.01 ) .
The atrial septal defect of T - group was higher than that in the same - age group ( P < 0.05 ) .

There was significant difference between the right ventricle ( P < 0.01 ) , the right ventricle and the pulmonary artery pressure ( P < 0.01 ) .
The atrial septal defect in P group was smaller than that in simple atrial septal defect group ( P < 0.01 ) .

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