胎儿左心发育不良综合征血流动力学变化及其右心功能研究

发布时间：2018-06-24 08:45

本文选题：左心发育不良综合征 + 超声心动图　；参考：《中南大学》2014年博士论文

【摘要】：目的：应用超声心动图诊断胎儿左心发育不良综合征(hypoplastic left heart syndrome,HLHS),重点研究HLHS胎儿卵圆孔(FO)、肺静脉(PV)、主动脉峡部(AoI)、大脑中动脉(MCA)和脐动脉(UA)的血流动力学变化,并与胎龄相匹配的正常对照组胎儿进行比较,旨在为深入认识HLHS胎儿复杂而独特的病理生理和循环特点提供更多有用信息,探讨其对于产前早期诊断HLHS和评估胎儿预后的临床意义。应用时间—空间相关成像(spatio-temporal image correlation,STIC)技术结合虚拟器官计算机辅助分析(virtual organ computer-aided analysis,VOCAL)软件测量HLHS胎儿右心室容积,计算出右心功能参数,并与胎龄相匹配的正常对照组胎儿右心室容积及心功能参数进行对比分析,探讨STIC技术评价HLHS胎儿右心室容积和右心功能的可行性、准确性、优越性及临床意义。对象及方法：2007年6月至2013年1月来本院接受常规产前超声检查的49例24+0-37+6孕周HLHS胎儿和180例胎龄相匹配的正常对照组胎儿,均为单胎妊娠。应用Acuson Sequoia512、GE Voluson730Expert和GE Voluson E8彩色多普勒超声诊断仪检测上述胎儿FO、PV‘AoI、MCA和UA血流,并测量其PV、MCA和UA的血流参数,包括：PV的心室收缩波(S波)、心室舒张波(D波)、心房收缩波(A波)、S/D比值、MCA和UA的搏动指数(PI)以及脑/脐血管比值(CPR),然后进行统计学分析比较,并与尸检或产后追踪结果相对照。应用GE Voluson730Expert和GE Voluson E8超声诊断仪的三维容积探头采集上述所有胎儿的STIC心脏动态图像,并结合VOCAL软件进行后期脱机分析。通过回放功能,在房室瓣开放和关闭的瞬间停帧,心脏收缩末期近似为房室瓣即将开放前,心脏舒张末期为房室瓣刚刚关闭后。设定旋转角度为150,对软件自动生成12个旋转层面的右心室内膜面逐层进行手动描记,计算机自动总和各个层面的容积数据得到右心室舒张末期容积(RVEDV)和右心室收缩末期容积(RVESV),从而计算出右心每搏量(RSV)、右心输出量(RCO)和右心射血分数(REF)。根据产前常规超声检查时所测量头围(HC)、腹围(AC)、股骨长度(FL)和胎儿估测体重(EFW)来标准化右心输出量(RCO),然后将所有测量参数进行统计学分析比较。结果：本研究纳入统计分析的46例经尸检证实的HLHS胎儿中,29例(63.04%)FO血流方向正常,为右向左分流；17例(36.96%)FO血流明显异常,其中,14例(30.44%)FO血流反向,为限制性左向右分流；另外3例(6.52%)FO早闭,房间隔完整,房水平无分流。 46例HLHS胎儿的PV血流频谱呈现三种不同类型。29例FO右向左分流和14例FO限制性左向右分流的HLHS胎儿PV血流频谱呈三相波型：心室收缩期前向血流(S波)、心室舒张期前向血流(D波)和心房收缩期反转血流(A波)；3例房间隔完整无分流的HLHS胎儿PV血流频谱呈短而搏动明显的双向来回血流,即：心室收缩期前向血流(S波)和心房收缩期反转血流(A波),心室舒张期血流(D波)缺失。HLHS胎儿组的PV血流频谱A波反转、S波和S/D比值均较胎龄相匹配的正常对照组胎儿明显增高(P0.001)；其中,FO血流异常与FO右向左分流两组HLHS胎儿之间进行比较,前者的PV血流频谱反转A波较后者更高(P0.001)、D波则较后者减低或缺失(P0.001)、S波和S/D比值较后者显著增高(P0.001)。 28例(60.87%)严重HLHS胎儿的AoI出现反向血流。三血管—气管切面彩色多普勒显示主动脉弓部血流主要来自动脉导管经由AoI逆行灌注,血流方向与肺动脉前向血流方向相反,血流色彩不同。 HLHS胎儿组的MCA-PI和CPR均较胎龄相匹配的正常对照组胎儿明显减低(P0.001)、而UA-PI则较正常对照组胎儿明显增高(P0.001)；其中,AoI反向供血与AoI无反向供血两组HLHS胎儿之间进行比较,前者的MCA-PI和CPR较后者更低(MCA-PI：P0.001；CPR：P0.05)。本研究纳入统计分析的226例胎儿中,190例胎儿的STIC心脏动态图像采集满意,并成功应用VOCAL软件分析测量了胎儿的RVEDV和RVESV。其中,HLHS胎儿39例,正常对照组胎儿151例：整体采集分析成功率为84.07%,且可重复性较好。正常对照组胎儿的RVEDV、RVESV、RSV、RCO和根据胎儿生物学参数(HC、AC、FL)分别标准化后的RCO均随孕周增长呈增加趋势,REF和RCO/EFW测值则在一定范围内波动。 HLHS胎儿组的右心室容积较胎龄相匹配的正常对照组胎儿明显增大(P0.001)。其中,左心室腔存在与左心室腔闭锁两组HLHS胎儿右心室容积和心功能参数测值之间的比较并无明显差异(P0.05)；三尖瓣严重返流与轻度返流两组HLHS胎儿之间进行比较,前者的RVEDV和RVESV均较后者增大,而RVESV较后者增大得更明显(RVEDV：P0.05;RVESV：P0.001),前者的RSV、RCO和标准化后的RCO(RCO/EFW、RCO/HC、RCO/AC、RCO/FL)却较后者降低(P0.05),REF测值则较后者降低得更明显(P0.001)；三尖瓣轻度返流组HLHS胎儿的REF测值与胎龄相匹配的正常对照组胎儿比较无明显差异(P0.05),三尖瓣严重返流组HLHS胎儿的REF测值则较胎龄相匹配的正常对照组胎儿明显降低(P0.001)。结论： 1.针对FO限制性左向右分流或房间隔完整无分流的HLHS胎儿,产前尽早明确诊断有助于临床及时开展有效的宫内干预,从而达到最终改善其预后之目的。 2.PV血流频谱可作为一个间接预测左房高压的有用指标。HLHS胎儿PV血流频谱的三种不同类型反映了左房高压的不同严重程度,这些信息对于评估胎儿预后和制定围产期处理方案至关重要。 3.由于AoI反向供血所致三血管—气管切面主动脉弓部与肺动脉血流方向相反的声像特征可为产前诊断HLHS提供重要线索。 4.同时出现AoI反向供血、FO和PV血流异常的HLHS胎儿,病变通常更加严重,应通过产前早期诊断进行及时的临床干预。 5.HLHS胎儿脑血流量明显减少,自动调节机制将促进脑血管代偿性扩张,以使得血管阻力有所降低；故HLHS胎儿MCA-PI和CPR较胎龄相匹配的正常胎儿减低,从而最大限度地满足脑循环血流灌注。这可作为HLHS产前早期诊断的一项辅助性指标。 6.正常胎儿的RVEDV、RESV.RSV、RCO和根据胎儿生物学参数(HC、AC、FL)标准化后的RCO均随孕周增长呈增加趋势,REF和RCO/EFW测值则在一定范围内波动。 7.三尖瓣轻度返流组HLHS胎儿的RVEDV、RVESV、RSV、RCO和标准化后的RCO(RCO/EFW、RCO/HC、RCO/AC、RCO/FL)均较胎龄相匹配的正常对照组胎儿明显增加：提示HLHS胎儿右心室收缩功能代偿性增强。HLHS胎儿左心室腔的大小对其右心室功能的影响不明显。三尖瓣严重返流与轻度返流两组HLHS胎儿之间进行比较,前者的右心室容积较后者增大,而右心功能参数测值却较后者降低：提示三尖瓣严重返流的HLHS胎儿在宫内即出现右心室收缩功能受损,预后极差,临床应及时干预。 8.应用STIC技术能够比较准确、客观地测量胎儿心室容积,有望成为临床评价胎儿心脏功能的重要方法,可为早期评价HLHS胎儿的右心功能提供极为有用信息。
[Abstract]:Objective: to diagnose fetal left heart dysplasia syndrome (hypoplastic left heart syndrome, HLHS) by echocardiography, and to study the changes in blood flow mechanics of HLHS fetal oval foramen (FO), pulmonary vein (PV), aorta isthmus (AoI), middle cerebral artery (MCA) and umbilical artery (UA), and compare with fetal age matched normal control group. The purpose of this study is to provide more useful information for the understanding of the complicated and unique pathophysiology and circulation characteristics of HLHS fetus, and to explore the clinical significance of the early prenatal diagnosis of HLHS and the evaluation of fetal prognosis.
Spatio-temporal image correlation (STIC) technique was used to measure the right ventricular volume of HLHS fetus with the computer aided analysis (virtual organ computer-aided analysis, VOCAL), and the right ventricular function parameters were calculated and the right ventricular volume and heart work in the normal control group matched with the gestational age were matched. The feasibility, accuracy, superiority and clinical significance of STIC technique in evaluating right ventricular volume and right heart function of HLHS fetus were discussed.
Objects and methods: from June 2007 to January 2013, 49 24+0-37+6 gestational HLHS fetuses and 180 normal control groups matched with fetal age were treated with conventional prenatal ultrasound examination, all of which were single pregnancy. Acuson Sequoia512, GE Voluson730Expert and GE Voluson E8 color Doppler ultrasound diagnostic apparatus were used to detect the fetus FO, PV 'A. OI, MCA and UA blood flow, and measure the blood flow parameters of PV, MCA and UA, including: PV ventricular systolic wave (S wave), ventricular systolic wave (D wave), atrial systolic wave (A wave), S/D ratio, MCA and pulsatile index, and the ratio of brain to umbilical blood vessels, then compared statistically and compared with autopsy or postpartum tracing results.
The three-dimensional volume probe of GE Voluson730Expert and GE Voluson E8 ultrasonic diagnostic instrument was used to collect all the STIC cardiac dynamic images of all the above fetus, and combined with the VOCAL software to analyze the later off-line analysis. Through the replay function, the frame of the atrioventricular valve opened and closed, the end of the systole was approximate to the atrioventricular valve opening before the opening of the atrioventricular valve, and the heart diastole was diastolic. After the end of the atrioventricular valve was just closed. The rotation angle was set to 150, and the software automatically generated 12 rotation layers of the right ventricular endocardium by manual tracing. The computer automatically combined the volume data of each level to get the right ventricular end diastolic volume (RVEDV) and the right ventricular end systolic volume (RVESV), thus calculating the right heart stroke volume. (RSV), right cardiac output (RCO) and right cardiac ejection fraction (REF). According to the measured head circumference (HC), abdominal circumference (AC), femur length (FL) and fetal estimation weight (EFW), the right cardiac output (RCO) was standardized by prenatal routine ultrasound examination, and all the measured parameters were compared statistically.
Results: 46 cases of HLHS fetus confirmed by autopsy were included in this study. 29 cases (63.04%) FO blood flow was normal, right to left shunt; 17 (36.96%) FO blood flow was obviously abnormal, of which 14 cases (30.44%) FO blood flow reversed to the restricted left to right shunt; the other 3 cases (6.52%) FO early closed, the atrial septum was intact, the atrial level was no distributary.
The PV blood flow spectrum of 46 cases of HLHS fetus showed three different types of.29 cases FO right to left shunt and 14 cases of FO restrictive left to right shunt of HLHS fetal PV flow frequency spectrum: the anterior ventricular systolic blood flow (S wave), ventricular diastolic forward flow (D wave) and atrial systolic reverse flow (A wave); 3 cases of atrial septal complete and non distributary HLHS. The blood flow of the fetal PV blood flow is short and pulsating, that is, the anterior ventricular systolic blood flow (S wave) and the atrial systolic reverse flow (A wave), the PV flow of the ventricular diastolic blood flow (D wave) in the.HLHS fetal group with the A wave inversion, the S wave and the S/D ratio are significantly higher than those of the normal control group that match the gestational age (P0.001). Among them, FO blood flow abnormal and FO right to left shunt two groups of HLHS fetus were compared, the former PV blood flow reversal A wave is higher than the latter (P0.001), D wave is lower or missing than the latter (P0.001), S wave and S/D ratio is significantly higher than the latter (P0.001).
28 cases (60.87%) of severe HLHS fetus had reverse flow of AoI. Three vascular trachea face color Doppler showed that the aortic arch flow mainly came from the retrograde perfusion of the ductus arteriosus via AoI, and the direction of the blood flow was opposite to the direction of the anterior pulmonary artery, and the color of the blood flow was different.
The MCA-PI and CPR of the HLHS fetal group were significantly lower than those of the normal control group (P0.001), while UA-PI was significantly higher than that of the normal control group (P0.001). Among them, the AoI reverse blood supply and AoI without reverse blood supply were compared between the two groups of HLHS fetus, the MCA-PI and CPR of the former were lower than the latter.
In this study, the STIC cardiac dynamic images of 190 fetuses were collected in 226 fetuses with statistical analysis, and the RVEDV and RVESV. of the fetus were measured by VOCAL software, 39 cases of HLHS fetus and 151 normal controls: the success rate of the whole collection analysis was 84.07%, and the repeatability was better.
RVEDV, RVESV, RSV, RCO, and fetal biological parameters (HC, AC, FL) of normal controls were all increased with the growth of gestational age, and REF and RCO/EFW values fluctuated in a certain range.
The right ventricular volume in the HLHS fetus group was significantly increased (P0.001) in the normal control group matched with the gestational age. There was no significant difference between the left ventricular cavity and the left ventricle atresia in two groups of HLHS fetal right ventricular volume and cardiac function parameters (P0.05); the three apical regurgitation and the mild reflux of two groups of HLHS fetuses were entered. Compared with the latter, the former RVEDV and RVESV were larger than the latter, while RVESV was more obvious than the latter (RVEDV:P0.05; RVESV:P0.001). The former RSV, RCO and the standardized RCO (RCO/EFW, RCO/HC, RCO/AC, RCO/FL) were lower than those of the latter. There was no significant difference between F and fetal age matched normal controls (P0.05). The REF values of HLHS fetus in the three apical regurgitation group were significantly lower than those of the normal control group that matched the gestational age (P0.001).
Conclusion:
1. for the FO restrictive left to right shunt or the complete and distributary HLHS fetus of the atrial septum, the early and clear diagnosis of the prenatal is helpful to the timely and effective intrauterine intervention, so as to achieve the ultimate improvement of the prognosis.
The 2.PV blood flow spectrum can be used as a useful indicator for indirect prediction of left atrial pressure, the three different types of.HLHS fetal PV blood flow spectrum reflect the different severity of left atrial pressure. These information are essential for assessing fetal prognosis and perinatal treatment.
3. the ultrasonographic features of the three vascular endotracheal arch and the opposite direction of the pulmonary artery blood flow can provide an important clue for the prenatal diagnosis of HLHS, due to the reverse blood supply of AoI.
4. at the same time, AoI reverse blood supply, FO and PV abnormal blood flow HLHS fetus, the lesions are usually more serious, we should make timely clinical intervention through prenatal diagnosis.
5.HLHS fetal brain blood flow is significantly reduced. Automatic regulation mechanism will promote cerebral compensatory expansion to reduce vascular resistance, so HLHS fetus MCA-PI and CPR are less matched with fetal age than fetal age, thus maximizing cerebral circulation perfusion. This can be used as an auxiliary indicator of early prenatal diagnosis of HLHS.
6. normal fetal RVEDV, RESV.RSV, RCO, and fetal biological parameters (HC, AC, FL) standardized RCO all increased with the growth of gestational age, and REF and RCO/EFW fluctuated in a certain range.
7. the RVEDV, RVESV, RSV, RCO, and standardized RCO (RCO/EFW, RCO/HC, RCO/AC, RCO/FL) of the HLHS fetus of the three apex regurgitation group were significantly higher than those of the normal control group that matched the gestational age. It suggested that the right ventricular systolic function of the HLHS fetus increased the size of the left ventricular chamber in the fetus of the fetus, and the effect of the right ventricular function was not obvious. Three Compared with the two groups of HLHS fetuses with severe regurgitation and mild reflux, the right ventricular volume of the former was larger than that of the latter, but the right ventricular function parameters were lower than that of the latter. It suggested that the right ventricular systolic function in the HLHS fetus with severe reflux of the tip of the valve was impaired in the uterus, and the prognosis was very poor, and the clinical intervention should be done in time.
8. the application of STIC technology can be more accurate and objective measurement of fetal ventricular volume. It is expected to be an important clinical evaluation of fetal heart function. It can provide very useful information for the early evaluation of the right heart function of HLHS fetus.
【学位授予单位】：中南大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R445.1

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