实时三维超声心动图定量评价主动脉瓣置换患者左心室功能的研究

发布时间：2018-10-15 07:32

【摘要】：背景和目的主动脉瓣疾病（aortic valve disease，AVD）是心脏瓣膜病的一种，发病率较高，发病年龄逐渐年轻化。常见的主动脉瓣疾病有：主动脉瓣狭窄（aortic stenosis，AS），主动脉瓣关闭不全（aortic regurgitation，AR），主动脉瓣混合性病变（mixedaortic valve disease，MAVD），即主动脉瓣狭窄伴中-重度关闭不全或主动脉瓣关闭不全伴中-重度狭窄。常见原因有风湿性炎症、先天性主动脉瓣畸形，，老龄所致的瓣膜退行性变以及与继发于创伤、高血压、动脉瘤等疾病。主动脉瓣疾病因慢性容量负荷或压力负荷及二者共同作用，使左心室形态结构发生改变，引起左心室肥厚，心室收缩及舒张功能受损。主动脉瓣置换（aortic valvereplacement，AVR）是减轻容量负荷和压力负荷的有效方法之一，可使扩大和肥厚的左心室逐渐回归，抑制心室重构，改善心功能。目前有二维及多普勒超声心动图、应变率成像、斑点追踪成像、负荷超声心动图等已用于主动脉瓣病变的超声评价，但都不能真实、直观反映主动脉瓣形态结构及左心室形态。实时三维超声心动图（real-time three-dimensionalechocardiography, RT-3DE）实现了三维技术发展的里程碑式飞跃，实现了心脏结构的动态三维图像实时显示，能从多方位显示腔室容量与形状、瓣膜形态结构和活动、心脏结构的空间关系，对心脏疾病特别是心脏瓣膜病的定量定性诊断、治疗具有重要意义。RT-3DE对于左心室形态方面的研究较多，但对于比较不同主动脉瓣病变患者AVR术前后左心室构型的变化研究较少。本研究的目的是应用RT-3DE评价不同的主动脉瓣病变患者左心室形态结构及功能的价值。材料与方法 1、研究对象2012年8月～2013年10月选取80例在河南省人民医院就诊的患者为研究对象，分为三组：A组：正常对照组，30例，来源于常规体检人群，其中男性18例，女性12例，年龄23～60岁，平均（41.9±12.4）岁，临床及超声心动图等相关检查无异常；选取拟行AVR患者50例：男性29例，女性21例，年龄15～72岁，平均（46.9±16.9）岁，依据病变的类型分为两组，B组：主动脉瓣关闭不全组，28例，除外轻度以上主动脉瓣狭窄，C组：主动脉瓣狭窄组，22例，除外轻度以上主动脉瓣关闭不全。上述行AVR患者均行冠状动脉造影、心电图、超声心动图等相关检查，排除标准：冠心病、高血压、心肌病、糖尿病等疾病。所有AVR患者，分别于术前、术后1周、术后1个月及术后6个月进行RT-3DE检查。 2、RT-3DE检查采用Philips iE33彩色多普勒超声诊断仪， X5-1矩阵三维探头，频率1～5MHz。受检者取左侧卧位，同步连接心电图，行常规超声检查，测量主动脉瓣口峰值流速（Vmax）、主动脉瓣口峰值压差（PPG），启用X5-1探头，置于心尖部，于标准心尖四腔心切面，启用全容积（Full Volume）模式，嘱接受检查者呼气末屏气，收集实时三维容积图像，并将图像保存导出至工作站。脱机后，在工作站中打开Qlab9.0定量分析软件，应用3DQ软件进行定量分析。于左心室舒张末期，选取心尖四腔心及两腔心切面的二尖瓣环水平，手动勾勒出心内膜面及心外膜面，软件自动计算出左心室质量（LVM）。以同样的方法在3DQADV条件下，选取心尖四腔心切面及两腔心切面的二尖瓣环水平，四腔心或两腔心切面的心尖部五点进行心内膜描记，软件自动输出左心室舒张末期容积（LVEDV）、左心室收缩末期容积（LVESV）、左心室射血分数（LVEF）。为了消除身高、体重对测值的影响，以受检者的体表面积(body surface area, BSA)加以校正，计算左室舒张末期容积指数（LVEDVI）=LVEDV/BSA，左室收缩末期容积指数（LVESVI）=LVESV/BSA，左心室质量指数（LVMI）=LVM/BSA，左室重构指数（LVRI）=LVM/LVEDV。 3、统计学分析应用SPSS17.0进行统计分析，数据以均数+标准差（x s），组间、组内比较行单因素方差分析，两两比较行LSD-t检验。相关性分析行Pearson分析法，以P0.05为差异有统计学意义。一致性检验行Bland-Altman绘图分析法。结果 1、组间比较对照组和主动脉瓣病变组比较，两组年龄、身高、体重、体表面积、心率，无统计学差异（P0.05）。AVR患者术前、术后1周、术后1个月及6个月LVMI和LVRI差异有统计学意义（P0.05），B组、C组明显高于A组。术前C组Vmax、PPG高于A组、B组，术后B组及C组高于A组，差异有统计学意义（P0.05）；术前B组LVEDVI、LVESVI高于A组、C组，差异有统计学意义（P0.05），术后1周、术后1个月及6个月A组、B组及C组LVEDVI、LVESVI差异无统计学意义（P0.05）；B组及C组LVRI术前、术后1周比较差异有统计学意义（P0.05）。 2、组内比较术后1周B组LVEDVI、LVESVI、LVMI及C组LVMI、Vmax、PPG均较术前下降，差异有统计学意义（P0.05），术后1周B组、C组LVRI差异有统计学意义（P0.05）。AVR术后1个月，B组LVMI、LVRI较术后1周减小，差异有统计学意义（P0.05），C组LVMI、LVRI与术后1周比较无明显统计学意义（P0.05）。AVR术后6个月，B组、C组各参数与术后1个月相比，差异无统计学意义（P0.05）。 3、相关性分析 AVR置换患者术后1周、1个月及6个月， LVEF与LVMI均呈负相关（分别为r=-0.68，P0.05；r=-0.73，P0.05；r=-0.88，P0.05）。 4、一致性检验 Bland-Altman方法绘图分析结果得出LVMI、LVEDVI、LVRI观察者内部及观察者之间重复性良好。结论 1、应用RT-3DE技术可以定量评价主动脉瓣置换患者左心室重构与功能。 2、主动脉瓣置换术可以逆转不同主动脉瓣病变患者左室重构，AVR对于主动脉瓣关闭不全组的效果优于主动脉瓣狭窄组。 3、AVR术后不同时期LVEF与LVMI均有较高的相关性，说明RT-3DE测量的LVMI可以定量评价AVR术后左心室重构及逆转。
[Abstract]:Background and Purpose Aortic valve disease (AVD) is a kind of valvular heart disease. The common aortic valve disease is aortic stenosis (AS), aortic valve insufficiency (AR), aortic valve disease (MAVD), aortic stenosis with moderate-severe insufficiency or aortic valve insufficiency with moderate-severe Stenosis. Common causes include rheumatic inflammation, congenital aortic valve deformity, degenerative valve degeneration due to aging, and secondary to trauma, hypertension, aneurysm, etc. Disease. Aortic valve disease changes due to chronic capacity load or pressure load and both, resulting in left ventricular hypertrophy, ventricular systolic and diastolic function. Damage. Aortic valve replacement (AVR) is one of the effective methods for reducing capacity load and pressure load, allowing progressive regression of the left ventricle of enlarged and hypertrophic left ventricle, inhibiting ventricular remodeling, and improving heart Functions: Two-dimensional and Doppler echocardiography, strain rate imaging, spot tracking imaging, load echocardiography, etc. have been used in the ultrasonic evaluation of aortic valve diseases, but they can not be true, and the aortic valve morphological structure can be intuitively reflected. Real-time three-dimensional echocardiography (RT-3DE) is a milestone leap in the development of three-dimensional technology, which realizes the real-time display of the dynamic three-dimensional image of the heart structure, which can display the volume and shape of the chamber, the structure and activity of the valve, and the cardiac structure. Quantitative qualitative diagnosis and treatment of heart disease, in particular valvular heart disease, in relation to the spatial relationship of heart disease It is important that RT-3DE has more research on left ventricular morphology, but for comparison of left ventricular configuration before and after AVR in patients with different aortic valve lesions The purpose of this study was to evaluate the left ventricular morphology of patients with different aortic valve lesions using RT-3DE Structure and function The value, material and method of the study were divided into three groups: group A: normal control group and 30 cases. There were 12 female patients, aged 23 to 60 years old and average (41. 9, 12. 4) years old, clinical and echocardiogram were not abnormal; 50 cases were selected for AVR patients: 29 males, 21 females, 15 to 72 years old and average (46. 9 to 16. 9) years old, divided into two groups according to the type of lesion, group B: Aortic insufficiency, 28, with mild or more aortic stenosis, Group C: Aortic stenosis, 22, Minor or more aortic insufficiency. All patients with AVR underwent coronary angiography, ECG, echocardiogram, and so on. Exclusion criteria: coronary heart disease, Hypertension, cardiomyopathy, diabetes, etc. All AVR patients, 1 week after operation, 1 month post-operation and operation RT-3DE inspection was performed in the last 6 months. 2, RT-3DE examination was performed using the GeneE33 color Doppler ultrasound diagnostic instrument, X5-1-matrix three-dimensional probe with frequency of 1-5MHz. The subject takes the left lateral position, synchronously connects the electrocardiogram, performs routine ultrasonic examination, measures the peak flow rate (bpm) of the aortic valve, the peak pressure difference (PPG) of the aortic valve, enables the X5-1 probe to be placed in the apical part, and is enabled on the standard apical four-cavity heart cutting surface. Full Volume mode, which receives the breath end breath of the examiner, and collects the real-time three-dimensional Volume image and export the image to the workstation. After offline, open Qlab9.0 quantitative score in the workstation Analyzing software and applying 3DQ software to analyze quantitatively. At the end of left ventricular end diastole, select the level of mitral annulus of apical four-cavity heart and two-cavity heart-cut plane, hand out the endocardial surface and epicardial surface. Left ventricular mass (LVM) was automatically calculated by software. In the same way, under the condition of 3DQADV, the left ventricular end diastolic volume (LVEDV) was automatically output from the apical four-cavity heart-cut face and the mitral annulus level of the two-cavity heart-cut face, the four-lumen heart or the apical part of the two-cavity heart-cut face. Left ventricular systolic end volume (LVE SV, left ventricular ejection fraction (LVDVI) = LVEDV/ BSA, left ventricular end systolic volume index (LVEVI) = LVEV/ BSA, left ventricular mass index (LVMI) = LVM/ BSA, left ventricular remodeling Number (LVRI) = LVM/ LVEDV. 3. Statistical analysis applied SPSS1.7. 0 for statistical analysis. Data were compared with standard deviation (x s), group, and group. Single-factor analysis of variance, two comparison lines LSD-t test, correlation analysis line Pearso The results of n-analysis showed that the difference was statistically significant with P0.05. Inspection Line Bland Results 1. Compared with the control group and the aortic valve group, the age, height, body weight, body surface area, heart rate and heart rate of the two groups were not statistically different (P <0.05). Before operation, 1 week after operation, 1 month after operation and 6 months after operation. Months LVMI and LV There were significant differences in RI (P0.05), group B and group C were significantly higher than that in group A. In group C before operation, PPG was higher than group A, group B, group B and group C were higher than group A, the difference was statistically significant (P0.05). There was no significant difference in LVEDVI and LVESVI between group B and group C (P0.05). Group LVRI Before and after operation, the difference was statistically significant (P0.05). In group B, LVEDVI, LVESVI, LVMI and LVMI were significantly higher in group B than before operation (P <0.05). The difference of LVMI, LVMI, LVMI in group C was statistically significant (P0.05). There was no significant difference between LVMI and LVRI in group B after AVR (P0.05). Month, Group B, C Compared with 1 month after operation, the difference was not statistically significant (P0.05). 3. The correlation analysis AVR replaced the patients for 1 week, 1 month and 6 months. =-0,68, P0. 05; r =-0.73, P0.05; r =-0.88, P0.05). 4. Consistency check Band-A lt The results of man-method drawing analysis are: LVMI, LVEDVI, LVRI observer; Conclusion 1. RT-3DE technique can quantitatively evaluate left ventricular remodeling and function in patients with aortic valve replacement. 2. Aortic valve replacement can reverse the remodeling of the left chamber of patients with different aortic valves and AVR is superior to aortic valve stenosis in the aortic valve insufficiency group. 3, AV
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R540.45;R542.5

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