多功能超声检测心血管畸形胎儿右心功能的初步研究

发布时间：2018-01-15 10:17

本文关键词：多功能超声检测心血管畸形胎儿右心功能的初步研究　出处：《第三军医大学》2014年硕士论文　论文类型：学位论文

【摘要】：背景卫生部公布的关于2004年全国妇幼卫生监测结果显示：在新生儿出生缺陷中先天性心脏病（congenital heart disease，CHD）居首位。心血管畸形是由于胎儿在胚胎期心血管的发育过程中，多个基因、环境因素两者间的相互影响造成胎儿时期心脏及大血管的发育异常，以至引起局部解剖结构畸形的主要原因，最终影响其心功能。近年来超声分辨率有了很大的提高，胎儿超声心动图技术可以多方位、更全面地检测胎儿的心功能、心脏结构、血流动力学的变化、各种类型心律不齐以及胎儿水肿等进行全面的评价，普遍认为此项技术是评价产前胎儿心脏畸形最为有效的检查方法。由于胎儿时期右心室（Right ventricle，RV）的容量负荷和压力负荷都较左心室(Left ventricular，LV)相对要重，右心系统发挥着关键作用，因此右心室功能的准确评估可以有效地反映胎儿的整体心功能，有助于提高部分CHD胎儿的出生存活率。右室双出口（doubleoutlet right ventricle，DORV）与法洛四联症(tetralogy of fallot，TOF)均属于复杂型先天性心脏病，两者的病理生理有一定的相似性。目的运用脉冲多普勒成像技术（Pulsed wave Doppler，PW）、M型超声(M-modeechocardiography，MME)、实时三维容积超声(real-time three-dimensional volumetricechocardiography，RT-3DE)对DORV及TOF胎儿右心功能进行检测，探讨其在临床的应用价值，为及时早期的发现胎儿心功能异常提供可靠参考。材料与方法 1.分组：病变组（组1），选取于2010年12月～2013年1月期间门诊初次超声诊断为右室双出口或法洛四联症胎儿共32例，孕妇年龄20～39（26.1±3.3）岁，孕周为23～38（29±6.1）周。正常组（组2），另选取同期孕龄相匹配的超声诊断为胎儿心脏未见明显异常者60例胎儿作为正常对照。本研究得到了受检孕妇及其家属的准许，并取得了医院伦理委员会批准。 2.方法：利用飞利浦公司提供的IE33智能心脏彩超检测仪器，具有最新的功能，最专业的临床性能。配有S5-1经胸探头、S8-3经胸高频探头和X3-1经胸实时三维矩阵探头，频率依次为1～5MHz、3～8MHz、1～3MHz，拥有最新的成像模式和最新的Qlab9.0三维容积定量3DQ分析软件；多普勒的扫描速度为100mm/s；运用PW、MME、RT-3DE三种方法，，分别对32例病变组胎儿和60例正常组胎儿心脏的右心室做功指数（Tei指数）、右室舒张末期容积(end-diastolic volume,EDV)、收缩末期容积(end-systolic volume,ESV)、每搏量(stroke volume,SV)和射血分数(ejection fraction,EF)进行测量，三种方法之间进行两两对比分析；整个研究过程中均由一名超声科医生利用三种方法分别测量胎儿心功能指标，最后将三个心动周期的测值进行平均求值；所测得数据均应用SPSS19.0进行统计学的分析，采用平均值±标准差表示（x_±s），病变组与正常组胎儿的心功能测值比较均采用样本t检验，统计结果以p值0.05为差异具有统计学意义，p值0.01为差异显著；利用Pearson相关分析对三种超声心动图方法所测的心功能测值的相关性进行分析；采用ROC曲线进行诊断试验分析比较。结果 1.二维超声心动图测得病变组胎儿的LV/RV比值明显低于正常组[(0.82±0.14)vs（0.95±0.08），P0.001]，病变组胎儿的AO/PA比值明显高于正常组[(1.57±0.75)vs（0.85±0.10），P0.001]； 2. PW检测32例病变组胎儿右心室的Tei指数明显高于60例的正常组胎儿[(0.48±0.09)vs(0.35±0.05), P0.001]； 3. MME与RT-3DE对病变组胎儿右心室的（EDV、ESV和EF）检测结果与正常组进行比较，差异具有显著的统计学意义(P0.05)； 4. Tei指数与RT-3DE所测心功能测值的ROC诊断曲线一致性较好，而与MME测值差异较大。Tei指数与RT-3DE诊断的ROC曲线下面积比较z=1.559，P=0.119，无显著差异，RT-3DE与MME诊断的ROC曲线下面积比较z=0.782，P=0.434；Tei指数EF值的相关系数：MME为（r=-0.449，p＜0.001），RT-3DE为（r=-0.517，p＜0.001），都成负相关，结果提示与RT-3DE的相关性更大，说明Tei指数与RT-3DE诊断更接近，相关性更好，无显著差异。结论胎儿超声心动图可以对复杂型先天性心脏病进行及时有效的诊断，RT-3DE可以不根据任何解剖结构的假设准确可靠地对胎儿时期的右室心功能进行评估，是有效、准确的无创性检查方法，对预测CHD胎儿病情的发展具有重要的临床意义，随着超声技术的不断进步，RT-3DE将向胎儿先天性心脏病的深度和广度两个方向扩展开来。
[Abstract]:background
The Ministry of Health announced on the 2004 National Maternal and child health monitoring results show that: in the neonatal birth defects in congenital heart disease (congenital heart disease, CHD) in the first place. Because of fetal cardiovascular malformations in the developing embryonic cardiovascular system, multiple genes, environmental factors interaction caused by fetal heart and great vessels the main cause of abnormal development, and abnormal structure of local anatomy, ultimately affect cardiac function. In recent years, ultrasonic resolution has been greatly improved, fetal echocardiography can range, a more comprehensive measurement of heart function, fetal heart structure and hemodynamic changes, a comprehensive evaluation of various types of arrhythmia and fetus edema, is generally believed that this technique is the evaluation of fetal heart malformation is the most effective method for the detection of fetal period. Because of the right ventricle (Ri Ght ventricle, RV) the volume load and pressure load are compared with left ventricular (Left ventricular, LV) is relatively heavy, right heart system plays a key role, so the accurate assessment of right ventricular function can effectively reflect the overall fetal heart function, help to improve the CHD part of the fetal survival rate of birth. Outlet of right ventricle (Doubleoutlet right ventricle, DORV) with tetralogy of Fallot (tetralogy of Fallot, TOF) belong to the complex congenital heart disease, there are some similarities between the pathophysiology.
objective
The use of pulsed Doppler imaging technology (Pulsed wave Doppler, PW), M (M-modeechocardiography, MME), ultrasound real-time three-dimensional ultrasonography (real-time three-dimensional volumetricechocardiography, RT-3DE) were used to detect DORV and TOF fetal right heart function, discuss its application value in clinical, timely early detection of fetal cardiac function abnormalities provide reliable reference.
Materials and methods
1. grouping: disease group (group 1), selected from December 2010 to January 2013 during the first outpatient department of ultrasound diagnosis of double outlet right ventricle or a total of 32 cases of tetralogy of Fallot in the fetus, pregnant women aged 20 to 39 (26.1 + 3.3) years of age, gestational age ranged from 23 to 38 (29 + 6.1) normal group (group of 2 weeks.), ultrasound diagnosis of other selected gestational age matched for fetal heart in 60 fetuses served as normal controls. This study has been granted by pregnant women and their families, and obtained the approval of the ethics committee of the hospital.
2. methods: the use of IE33 intelligent cardiac ultrasound detecting instrument provided by PHILPS, with the latest features, the clinical performance of the most professional S5-1. With transthoracic probe, S8-3 transthoracic high-frequency probe and X3-1 probe real-time three-dimensional transthoracic matrix, the frequency was 1 ~ 5MHz, 3 ~ 8MHz, 1 ~ 3MHz, with the most a new imaging mode and the latest Qlab9.0 three-dimensional volumetric quantitative 3DQ analysis software; Doppler scanning speed is 100mm/s; the use of PW, MME, RT-3DE three methods respectively in 32 cases of fetal disease group and normal group 60 cases of fetal heart right ventricular Tei index (Tei index), right ventricular end diastolic volume (end-diastolic volume, EDV), end systolic volume (end-systolic, volume, ESV), stroke volume (stroke, volume, SV) and ejection fraction (ejection fraction, EF) were measured, 22 were compared between the three methods; the whole research process by an ultrasound Doctors of fetal heart function indexes were measured by three methods, the three cardiac cycle measurements of the average evaluation; analysis of the measured data of SPSS19.0 was used, the average standard deviation (x_ + s), fetal heart function lesion group and normal group were measured the sample t test results to the p value is 0.05. The difference was statistically significant, P value of 0.01 is significant difference; correlation between measured values of three echocardiographic methods of measuring the cardiac function by Pearson were analyzed by ROC curve; analysis and comparison of diagnostic tests.
Result
1. two dimensional echocardiography showed that the LV/RV ratio of the fetus in the lesion group was significantly lower than that in the normal group [(0.82 + 0.14) vs (0.95 + 0.08), P0.001], the AO/PA ratio of the fetus in the lesion group was significantly higher than that in the normal group [(1.57 + 0.75) vs (0.85 + 0.10), P0.001].
The Tei index of the right ventricle of the fetus was significantly higher than that of the normal group of 60 cases (0.48 + 0.09) vs (0.35 + 0.05) and P0.001] in the 2. PW test group.
The results of 3. MME and RT-3DE in the right ventricle of the fetus (EDV, ESV and EF) were compared with those of the normal group, and the difference was statistically significant (P0.05).
ROC diagnosis of curve of 4. Tei measured by RT-3DE index and cardiac function measurement is better, and the MME values of ROC curve area differences between the.Tei index and RT-3DE diagnosis under z=1.559, P=0.119, no significant difference, ROC curve of RT-3DE and MME in the diagnosis of the area under the z=0.782, P= 0.434; the correlation coefficient Tei index EF value: MME (r=-0.449, P < 0.001), RT-3DE (r=-0.517, P < 0.001), are negatively correlated, results suggest that the association between RT-3DE and more, Tei index and RT-3DE diagnosis more closely, a better correlation, no significant difference.
conclusion
Fetal echocardiography in complex congenital heart disease were diagnosed timely and effectively can map, RT-3DE can not according to any anatomical structure that accurately and reliably on fetal right ventricular function assessment is an effective, noninvasive method is accurate, it has important clinical significance in predicting fetal development of CHD disease with the continuous progress of technology, ultrasound, RT-3DE to fetal congenital heart disease of the depth and breadth of two directions spread.

【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R445.1;R714.5

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