实时三维超声斑点追踪成像技术评价子痫前期患者左心形态及功能的研究

发布时间：2018-05-13 01:18

本文选题：子痫前期 + 三维　；参考：《郑州大学》2015年博士论文

【摘要】：研究背景妊娠期,孕妇心脏会随心血管负荷的改变出现适应性变化。这些变化对妊娠的顺利进展是必需的,但也有可能给孕妇带来额外的心血管负担。另外,妊娠前原本存在的心脏疾病,如先天性心脏病、风湿性心脏病、心肌病、高血压性心脏病等,由于孕期激素水平变化及心脏负荷的加重,可能进一步发生恶化。不仅如此,合并心血管并发症风险的孕妇数量也呈现逐年上升的趋势。目前,心脏疾病是妊娠期妇女死亡的主要原因,居非产科死亡因素的首位。因此,正确理解和评价孕期妇女心血管系统生理性变化对于全面估测孕期心血管病风险以及妊娠期妇女的心血管临床分级管理是十分重要的。子痫前期(Preeclampsia,PE)是妊娠期特有的疾病,由于血液处于高凝状态,易发生心力衰竭以及肝、肾、脑的继发性损害,PE是造成孕期及围生期母体死亡的主要原因。PE可导致心脏冠状动脉水肿痉挛、造成心绞痛、心肌梗死等心血管疾病。尸检资料表明,PE患者心肌收缩带坏死的发生率是妊娠期其他原因死亡者的10倍以上。然而,目前有关超声心动图评价PE患者心脏损害的报道并不一致。根据疾病发生的时间,PE分为早发型和晚发型。越来越多的证据表明早发型和晚发型PE具有不同的临床特点,应作为两种不同类型的疾病对待。已经有报道发现早发型及晚发型PE的血流动力学不相同,但对于心腔形态及心肌功能是否存在差异未见有详细报道。超声心动图是目前临床首选的心脏影像学检查手段。传统超声心动图检查具有负荷依赖性等诸多不足之处,而妊娠期妇女恰恰正处于心血管负荷急剧变化的时期,因此,传统超声心动图技术对于孕期妇女心脏形态及功能的评价更有局限性。由于使用不同的技术方法、观测指标以及研究对象的不同等原因,目前有关正常妊娠及PE妇女心脏形态及功能的研究结果并不一致。新近的实时三维超声斑点追踪成像技术(three-dimensional speckle-tracking echocardiography,3D STE)是基于超声斑点追踪成像的实时三维超声心动图技术(real time three-dimensional echocardiograph,RT-3DE),该技术通过在三维立体空间内追踪小于入射超声波长的细小结构所产生的声学散射斑点信息,不仅可以显示心脏的三维立体空间,而且可以区分心肌在长轴、轴向、圆周等各方向的主动变形能力及被动运动,在敏感、准确地评价心肌运动以及收缩、舒张功能方面显示出独特的优势。有研究证明,除了测量三个方向上的心肌应变,3D STE还可以通过独特的面积应变指标对左心室整体和局部的功能做出全面的评估,可以克服传统二维超声等技术的缺点,从而更为准确、可靠地评价心脏形态及功能。本课题利用3D STE技术研究PE妇女左心房室重构、心功能及心肌变形能力,对比分析早发型和晚发型PE患者的左心腔形态及心功能差异;评价正常妊娠妇女左心室及左心房的形态、功能特点,建立妊娠妇女在不同孕周心脏结构及功能指标的三维超声心动图正常值范围。这项研究丰富了PE及正常妊娠妇女的心血管相关信息,为该类患者的临床心血管分级管理提供了可靠的参考依据。第一部分3D STE技术评价正常妊娠妇女左心结构及功能的研究1研究目的利用3D STE评估正常妊娠妇女左心室形态、功能以及左心房的容积、功能随着孕周的变化,建立妊娠妇女在不同孕周心脏结构及功能指标的三维超声心动图正常值范围,初步探讨正常妊娠期左心重构的机制,为临床正确评价妊娠妇女左心功能提供影像学依据。2研究方法 2.1研究对象所有研究对象均来源于2012年1月~2013年2月在郑州大学第三附属医院门诊就诊及住院的女性。其中,Na组:健康妊娠妇女68人,分别在妊娠第12~14周、24~27周、36~39周以及分娩后6~9周利用二维超声及3D STE进行左心室形态及功能的研究。Nb组:43例正常Nb组妊娠的孕妇分别在孕11~14周,24~32周和35~39周利用RT-3DE进行左心房容积、功能的研究。Ca组与Cb组分别为30例年龄匹配的健康非孕育龄女性。2.2仪器及图像采集受试者左侧卧位,应用GE vivid E9超声诊断仪,M5S探头行常规二维超声心动图检查,包括胸骨旁及心尖观的脉冲多普勒检查。V4探头进行三维全容积扫查。全部影像数据利用Echo PAC GE Healthcare软件包进行分析。2.3记录指标分别测量二维室间隔厚度、左室后壁厚度、左室壁相对厚度、左室舒张末期内径及收缩末期内径;三维左室舒张末期容积、收缩末期容积、每搏输出量、心输出量、射血分数以及左心室球形指数。Nb组M型超声测量左心房的前后径,进行左心房形态三维重建,获取左心房的最大容积,收缩前容积和最小容积,计算左心房总排空分数、主动及被动排空分数。2.4统计分析描述性数据由均数±标准差(x±s)表现。队列研究采用单因素方差分析结合Bonferroni校正的方法,数值比较采用独立样本t检验。实时三维应变率与二维应变率比较采用配对t检验。3结果1.随着妊娠的延续,Na组心脏指数逐渐升高,左心室发生离心性重构;晚孕期,左室整体心肌纵向应变、圆周应变、面积应变及径向应变轻微下降,伴随左心室射血分数轻微降低(P0.05),但是这些变化在产后均恢复至产前水平。2.Nb组E/e逐渐升高,左心房容量逐渐增大,左心房总排空分数、被动及主动排空分数均逐渐增高;到孕晚期,左心房最大容积及排空分数达到最高值,最小容积达到最低值。4结论随着妊娠进展,正常妊娠妇女心脏生理性肥大,心肌应变轻微下降,左心房容积增大、房泵功能逐渐加强。本部分研究利用3D STE提供了正常妊娠妇女在早、中、晚孕期左心房室形态及功能生理变化的三维超声影像数据以及三维心肌应变的数据。第二部分3D STE技术评价子痫前期患者左心室结构及收缩功能的研究1研究目的旨在利用3D STE研究PE患者左心室形态及功能变化情况,与正常妊娠妇女进行对比分析;并进一步评价早发型和晚发型PE患者是否存在心腔形态及心肌功能差异,为产科临床心血管疾病的分级管理提供参考信息。2研究方法 2.1研究对象所有研究对象均来源于2012年1月~2013年2月在郑州大学第三附属医院门诊就诊及住院的女性。其中,PEa组:84例PE患者,其中,43例早发型PEa(孕周34周)为PEa1组,41例晚发型PEa(发病孕周≥34周)为PEa2组;PE入选标准按照国际妊娠期高血压研究协会的规定执行。从Na组挑选与PEa组年龄、孕周匹配的健康妊娠妇女,分别称为Na1及Na2组。Ca组:30例年龄匹配的健康非孕育龄妇女作为空白对照组。2.2仪器及图像采集受试者左侧卧位,应用GE vivid E9超声诊断仪,M5S探头行常规二维超声心动图检查,包括胸骨旁及心尖观的脉冲多普勒检查。V4探头进行三维全容积扫查。全部影像数据利用Echo PAC GE Healthcare软件包进行分析。2.3记录指标分别测量二维室间隔、左室后壁及左室壁相对厚度,左室舒张末期内径及收缩末期内径;三维左室舒张末期容积、收缩末期容积、每搏输出量、心输出量、射血分数以及左心室球形指数;三维左室整体心肌纵向、圆周、面积及径向应变等指标。2.4统计分析应用SPSS 17.0软件,所有计量资料以均数±标准差(x±s)表示。PEa组、Na组与Ca组数值比较采用独立样本t检验,PEa1与PEa2患者资料的比较采用了协方差分析。数值相关性采用Pearson相关分析。以α=0.05为检验水准。3结果1.PEa组与Na组相比,其左心室的内径及容积增大,左室壁增厚以及室壁相对厚度增加,同时,PE患者的左心室质量指数及球形指数升高;PEa组比Na组左心室射血分数、缩短分数及组织多普勒心肌收缩期运动s峰显著下降,同时三维心肌应变指标出现下降。2.与PEa2组相比,PEa1组患者的左室容积及左心室质量指数增加更明显,三维心肌圆周、面积及径向应变明显降低,而且,发生局部应变减低的心肌节段数目较晚发型多。3.所有的实时三维应变指标与孕周呈相关关系(P0.01);和其他指标相比,GAS与射血分数、球形指数呈较好的相关性(r分别为0.549、0.328),是唯一与左室质量指数相关的指标(r=0.22)。4结论1.PE患者比正常妊娠妇女的心脏后负荷增加,左心室呈离心性肥大;心脏泵功能降低,三维心肌应变减低。2.与晚发型PE相比,早发型PE发生了更严重的左心室重构及心肌损害。第三部分RT-3DE技术定量分析子痫前期患者左心房容积和功能的研究1研究目的本研究使用RT-3DE技术研究PE患者左心房的容积及功能特点;对比分析早发型和晚发型PE的左心房形态和功能差异,并结合左心室舒张功能特点初步探讨PE时左心房重构的机制。2研究方法 2.1研究对象所有研究对象均来源于2012年1月~2013年2月在郑州大学第三附属医院门诊就诊及住院的女性。其中,PEb组:本研究共纳入70例PE患者,其中,36例早发型(PEb1组)和34例晚发型PE(PEb2组)。从Nb组挑选与PEb组年龄、孕周匹配的健康妊娠妇女,分为Nb1组和Nb2组,进行超声心动图和血流动力学检查。30例年龄匹配的健康非孕育龄女性作为空白对照组(Cb组)。2.2仪器及图像采集受试者左侧卧位,应用GE vivid E9超声诊断仪,M5S探头行常规二维超声心动图检查,包括胸骨旁及心尖观的脉冲多普勒检查。V4探头进行三维全容积扫查。全部影像数据利用Echo PAC GE Healthcare软件包进行分析。2.3记录指标分别测量二维室间隔厚度、左室后壁厚度、左室壁相对厚度、左室舒张末期内径及收缩末期内径;三维左室舒张末期容积、收缩末期容积、每搏输出量、心输出量、射血分数以及左心室球形指数。M型超声测量左心房的前后径,进行左心房形态三维重建,获取左心房的最大容积,收缩前容积和最小容积,计算左心房总排空分数、主动及被动排空分数。2.4统计分析描述性数据由均数±标准差(x±s)表现。PEb、Nb与Cb组间数值比较采用独立样本t检验。PEb1与PEb2组资料的比较采用了协方差分析的方法。各参数之间的关系采用Pearson相关系数分析。以α=0.05为检验水准。3结果1.PEb组与Nb组相比,其舒张早期二尖瓣血流E峰流速与组织多普勒二尖瓣环运动速度e的比值,即E/e比值,明显升高;同时,所有左心房容积指数明显增高,排空分数显著降低。2.PEb1与PEb2组相比,其舒张晚期血流速度A波及E/e升高,左心房收缩前容积减小、主动排空分数降低。3.左心房的最大容积和所有排空分数与孕周呈正相关。左心房容积指标与心率、心输出量及二尖瓣环舒张早期运动速度呈负相关;与左心室质量、左心室充盈压呈正相关。然而,左心房排空分数和以上指标的关系恰恰相反。4结论1.PE患者较正常妊娠妇女心室充盈压明显升高、心肌舒张功能障碍,导致左心房的明显扩张和房泵功能降低。2.与晚发型相比,早发型PE患者左心房的容积较小、主动排空的能力明显降低。
[Abstract]:In the study of pregnancy, the heart of the pregnant woman will be adaptable to changes in the cardiovascular load. These changes are necessary for the smooth progress of pregnancy, but it may also bring an extra cardiovascular burden to pregnant women. In addition, the original heart disease, such as congenital heart disease, rheumatic heart disease, cardiomyopathy, and hypertension, is the same. Heart disease, due to changes in hormone levels in pregnancy and aggravation of heart load, may further deteriorate. Not only that, the number of pregnant women with cardiovascular complications is also increasing year by year. At present, heart disease is the main cause of the death of women in pregnancy and is the first factor in non obstetric death. Therefore, it is correctly understood. The physiological changes of cardiovascular system in pregnant women are important for the overall assessment of the risk of cardiovascular disease during pregnancy and the management of cardiovascular clinical grades in pregnant women. Preeclampsia (Preeclampsia, PE) is a special disease of pregnancy. Due to the high coagulation state of blood, it is easy to have heart failure and secondary liver, kidney, and brain. PE is the main cause of maternal death during pregnancy and perinatal period.PE can cause coronary artery edema spasm, angina pectoris, myocardial infarction and other cardiovascular diseases. Autopsy data show that the incidence of myocardial contractile necrosis in PE patients is more than 10 times more than those of other causes of pregnancy. However, current echocardiography is related to echocardiography The assessment of heart damage in PE patients is not consistent. According to the time of the disease, PE is divided into early onset and late onset. More and more evidence suggests that early onset and late onset PE have different clinical characteristics and should be treated as two different types of disease. There have been reports that the hemodynamics of early and late onset PE are different, However, there is no detailed report on the difference of heart cavity shape and cardiac function. Echocardiography is the first choice for clinical examination of cardiac imaging. Acoustic cardiogram is more limited in the evaluation of cardiac shape and function in pregnant women. Due to the use of different technical methods, observation indexes and different research objects, the results of the study on normal pregnancy and PE women's heart form and function are not consistent. Recent real-time three-dimensional ultrasound speckle tracking imaging techniques The technique (three-dimensional speckle-tracking echocardiography, 3D STE) is a real-time three-dimensional echocardiography (real time three-dimensional echocardiograph, RT-3DE) based on ultrasonic speckle tracking imaging (real time three-dimensional echocardiograph, RT-3DE). This technique is used to track the acoustic scattering spots produced by a small structure less than the ultrasonic wavelength in three-dimensional space. Information can not only display the three-dimensional space of the heart, but also distinguish the active deformability and passive motion of the myocardium in all directions, such as the long axis, the axis, the circumference, and so on. It shows unique advantages in sensitive and accurate evaluation of cardiac muscle movement and systolic and diastolic function. 3D STE can also make a comprehensive assessment of the overall and local function of the left ventricle through a unique area strain index, and can overcome the shortcomings of the traditional two-dimensional ultrasound technology, so as to evaluate the heart shape and function more accurately and reliably. This subject uses 3D STE to study the left ventricular remodeling, cardiac function and myocardial deformation of the PE women. Ability to compare the left ventricular shape and cardiac function difference between early and late onset PE patients; to evaluate the morphological and functional characteristics of left and left atrium in normal pregnant women and to establish the normal range of three-dimensional echocardiography of pregnant women in different gestational weeks. This study enriches PE and normal pregnant women. Cardiovascular related information to provide a reliable reference for the clinical cardiovascular management of this type of patients. Part 1 3D STE technique to evaluate the left heart structure and function of normal pregnant women. 1 the purpose of the study was to evaluate the left ventricular shape, function, and the volume of left atrium in normal pregnant women with 3D STE. To establish the normal range of three-dimensional echocardiography of pregnant women in different gestational weeks, to explore the mechanism of left heart remodeling in normal pregnancy, and to provide a correct evaluation of the left heart function of pregnant women in order to provide the correct evaluation of the left heart function of pregnant women. All the subjects of the research object of.2 study 2.1 were all from 2 January 2012. 2 Women in the Third Affiliated Hospital of Zhengzhou University were hospitalized and hospitalized in the Third Affiliated Hospital of Zhengzhou University. Among them, 68 healthy pregnant women were studied at week 12~14, 24~27 weeks, 36~39 weeks and 6~9 weeks after delivery, respectively, using two-dimensional ultrasound and 3D STE to study the left ventricular form and function in group.Nb: 43 cases of normal Nb group pregnant women were at pregnant 11~14, 24~32, respectively. The volume and function of left atrium using RT-3DE at week and 35~39 weeks was studied in group.Ca and group Cb for 30 age matched healthy non pregnant women of childbearing age.2.2 instrument and image acquisition subjects left lateral position, GE vivid E9 ultrasonic diagnostic instrument, and M5S probe routine two-dimensional echocardiography, including sternum and apical pulse Doppler. The.V4 probe was examined for three-dimensional full volume scan. All image data were analyzed by Echo PAC GE Healthcare software package. The thickness of two-dimensional ventricular septum, left ventricular posterior wall thickness, left ventricular wall thickness, left ventricular end diastolic diameter and end systolic diameter, three-dimensional left ventricular end diastolic volume, end systolic volume, were measured respectively. A three-dimensional reconstruction of left atrium was performed for the left atrium, the maximum volume of left atrium, the volume of the left atrium and the minimum volume, the total left atrial emptying score, and the statistical analysis of the active and passive emptying fraction.2.4 for the statistical analysis of the descriptive data of the left atrium, the left atrium was reconstructed in the left atrium by M type ultrasound of the cardiac output, cardiac output, ejection fraction and.Nb group of the left ventricle index group. In the cohort study, the single factor variance analysis combined with Bonferroni correction was used in the cohort study. The independent sample t test was used for numerical comparison. The real-time three-dimensional strain rate and the two-dimensional strain rate were compared with the paired t test.3 results 1. with the continuation of pregnancy, the cardiac index of the Na group increased gradually and the left ventricular remodeling was centrifuged. 1. In the late pregnancy, the longitudinal strain of the left ventricular myocardium, the circumference strain, the area strain and the radial strain were slightly decreased, with the left ventricular ejection fraction slightly decreased (P0.05), but these changes were all restored to the pre natal level of the.2.Nb group, the E/e increased gradually, the left atrium volume increased gradually, the left atrium total emptying fraction, passive and active emptying score were all In the late pregnancy, the maximum volume and emptying score of the left atrium reached the highest value, and the minimum volume reached the lowest value.4. With the progress of pregnancy, the normal pregnancy women had a physiological hypertrophy, a slight decrease in the myocardial strain, the increase of the left atrium volume and the function of the room pump. This part of the study used the 3D STE to provide the normal pregnant women. Three-dimensional echocardiographic data and data of three-dimensional myocardial strain during the early, middle and late pregnancy left atrial ventricular morphology and function. Second 3D STE technique was used to evaluate the left ventricular structure and systolic function of preeclampsia. 1 the purpose of the study was to study the changes of left ventricular form and function in PE patients with 3D STE, and the purpose of the study. Comparative analysis of pregnant women, and further evaluation of the existence of heart cavity morphology and myocardial function differences between early and late onset PE patients, providing reference information.2 research methods for the classification management of clinical cardiovascular disease 2.1 all of the subjects were derived from the Third Affiliated to Zhengzhou University in February January 2012. The PEa group: 84 cases of PE patients, among them, 43 cases of early onset PEa (34 weeks of pregnancy) were group PEa1, 41 cases of late onset PEa (or more than 34 weeks of pregnancy) were group PEa2; PE admission standard was performed according to the international pregnancy hypertension research association. Group Na1 and group Na2, group.Ca, respectively: 30 age matched non pregnant women of childbearing age as the blank control group.2.2 instrument and the left lateral decubitus of the image acquisition subjects, the GE vivid E9 ultrasonic diagnostic instrument, the M5S probe routine two-dimensional echocardiography, including the sternal and apical pulse Doppler examination.V4 probe. All image data were analyzed by Echo PAC GE Healthcare software package. The.2.3 recording index was used to measure the two-dimensional ventricular septum, left ventricular posterior wall and left ventricular wall relative thickness, left ventricular end diastolic diameter and end systolic diameter, three-dimensional left ventricular end diastolic volume, end systolic volume, stroke volume, cardiac output and ejection fraction. As well as the left ventricular globular index, the.2.4 statistical analysis of the longitudinal, circumference, area and radial strain of the whole left ventricular myocardium was applied to the SPSS 17 software. All the data were expressed in.PEa group with mean mean + standard deviation (x + s). The values of Na and Ca were compared by independent sample t, and the covariance analysis was used in the comparison of the data between PEa1 and PEa2 patients. Pearson correlation analysis was used in numerical correlation. With alpha =0.05 as the test level.3 results, the left ventricular diameter and volume of the 1.PEa group increased, the left ventricular wall thickening and the relative thickness of the ventricular wall increased, while the left ventricular mass index and the spherical index of the PE patients increased, and the PEa group shortened the score and tissue of the left ventricular ejection fraction in the group Na. The s peak of myocardial systolic movement of Doppler decreased significantly, and the three dimensional myocardial strain index decreased with.2.. Compared with the PEa2 group, the left ventricular volume and the left ventricular mass index in the PEa1 group were more obvious, the three dimensional myocardial circumference, the area and the radial strain decreased obviously, and the number of myocardial segments with local strain reduction was more.3 in the late period. All real time three-dimensional strain indicators were associated with pregnancy (P0.01). Compared with other indicators, GAS had a better correlation with the ejection fraction and the spherical index (R 0.549,0.328, respectively), and was the only index associated with the left ventricular mass index (r=0.22).4 conclusion that the cardiac afterload of 1.PE patients was higher than that of normal pregnant women, and the left ventricle was centrifuged. Sexual hypertrophy; decreased cardiac pump function and reduced.2. in three-dimensional myocardial strain compared with late onset PE; early onset PE had more serious left ventricular remodeling and myocardial damage. Part third RT-3DE quantitative analysis of left atrial volume and function in preeclampsia patients. 1 research objective to study the volume of left atrium in PE patients using RT-3DE technique The morphological and functional differences of left atrium in early and late onset PE were compared and analyzed, and the mechanism of left atrium remodeling in PE was preliminarily discussed in combination with the characteristics of left ventricular diastolic function. 2.1 the subjects of the study 2.1 subjects were all from the Third Affiliated Hospital of Zhengzhou University in February January 2012. A total of 70 patients with PE were included in this study, including 36 patients with early onset (group PEb1) and 34 late type PE (group PEb2). From group Nb, the age of PEb group and pregnancy matched healthy pregnant women were divided into Nb1 group and Nb2 group. Echocardiography and blood flow mechanics were used to examine.30 age matched non pregnant women of childbearing age. In the blank control group (group Cb), the left lateral position of the.2.2 instrument and the image acquisition subjects was used, the GE vivid E9 ultrasonic diagnostic instrument was used, the M5S probe was examined by the conventional two-dimensional echocardiography, including the sternal and apical pulse Doppler examination.V4 probe for three-dimensional full volume scan. All the image data were carried out by Echo PAC GE Healthcare software package. The thickness of two-dimensional ventricular septum, posterior wall thickness of left ventricle, relative thickness of left ventricular wall, left ventricular end diastolic diameter and end systolic diameter, three-dimensional left ventricular end diastolic volume, end systolic volume, cardiac output, cardiac output, ejection fraction, and left ventricle index.M ultrasound were measured before and after.2.3 recording. Three dimensional reconstruction of left atrial morphology was performed to obtain the maximum volume of the left atrium, the volume and volume of the left anterior chamber.

【学位授予单位】：郑州大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R714.244;R540.45

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