基于心脏CT成像的电生理解剖结构在体研究及临床指导意义

发布时间：2018-10-08 12:49

【摘要】：心律失常是临床常见的疾病,而现代临床电生理技术是应用电生理检查和射频消融术对心律失常进行机制研究、诊断和治疗的有效手段,也是心血管领域迅速发展的一个分支学科。在电生理及射频消融术中,心脏影像由X线投照获得,常常使用多体位结合相应解剖标志对靶结构和相关导管进行定位。获取术中最佳的X线投影并准确定位心脏结构及导管位置可有效增加手术成功率、减少并发症发生。然而,心脏结构的变异,尤其是心脏结构的转位或在体方向的变化(例如房间隔)往往可造成透视影像投影的短缩甚至偏差,。依据经验采用不同投照体位以期满足个体化的需求的方法,尚缺乏有效的理论数据支持。因此,对电生理相关解剖的变异研究有重要的临床意义,可期为我们提供预测变异的方法以及个体化成像及治疗的有用信息。然而,到目前为止,我们对于心脏解剖尤其是电生理相关结构解剖的研究与认识多是经尸检标本得出的统计数据。众所周知,心脏是腔室样结构,在活体由血液填充,故在体、活体心脏中的解剖结构及相互关系可能与尸检和离体标本存在差异。近年来,高分辨CT技术发展迅速,CT的时间分辨率和空间分辨率不断提高,这使得心脏CT研究心脏的解剖结构成为可能。本研究利用心脏CT成像技术对病人在体心脏的电生理解剖结构变异,尤其是对术中成像可能产生影响的转位及方向变化进行探讨,并对术中可能起到指导作用的相关解剖标志例如冠状静脉窦及其开口与相应结构的相互关系进行分析,为个体化成像提供理论依据。研究内容一:应用CT数据探索心脏电生理相关的房间隔转位、术中预测方法及对电生理手术的提示方法:通过筛选纳入115例行心脏CT增强检查的心脏结构正常的病人,应用Pearson相关分析探查卵圆窝方向与心脏位置及冠状窦近段横截面方向之间的关联,进一步应用线性回归分析明确变量之间是否存在预测价值。结果:在入选病人中卵圆窝、心脏位置及冠状窦近段横截面的方向分别是:36.8±7.3°,37.1±8.3°以及37.7±6.6°,变化范围分布分别为:19.1°-53.6°、19.2°-61°以及21.3°-50.1°;卵圆窝的方向和心脏位置之间无明显相关性(P0.05),而卵圆窝方向与冠状窦近段方向之间存在显著的相关性(r=0.928,P0.01),进一步的线性回归得到了线性回归方程:卵圆窝方向=-2.01+1.03*冠状窦方向(R2=0.86,P0.01)。研究内容二:应用CT技术探索Koch’s三角在体临床解剖及射频消融术中投照体位个体化的方法方法:通过筛选纳入行心脏CT检查的病人104例,通过对CT影像及数据的分析,定位Koch’s三角,明确其上部、下部的方向以及冠状窦口的方向。对比Koch’s三角上、下部之间的方向明确其解剖特点,应用Pearson检验检测三角的方向与冠状窦口方向十分相关,建立二者的回归方程,比较传统右前斜投照体位和冠状窦口方向指导的成像投照体位与最佳投照体位即Koch’s三角的方向之间的差别,并应用Bland-Altman分析探索出现差别以及优化投照体位的内在理论原因。结果:Koch’s三角上部、下部及冠状窦口的方向测值分别为57.2±9.5°、58.2±9.1°和52.3±8.4°,而三角的上部和下部方向无统计学差异。Koch’s三角的方向与冠状窦口方向之间呈显著相关(P0.01),根据线性回归结果冠状窦口方向可预测三角的方向(R2=0.78,P0.01)。传统投照角度右前斜30°、右前斜45°及冠状窦口方向指导的投照角度与最佳投照角度(Koch’s三角方向)之间的差别分析提示分别有6.7%、58.7%和99%的病例该差值小于15°。应用Bland-Altman分析显示Koch’s三角方向与冠状窦口方向之间的平均差异为5.88±4.29°,95%一致性上限为14.29°,下限为-2.53°,在临床可接受范围之内。结论:1.房间隔及Koch’s三角等临床电生理相关解剖结构在体的解剖变异尤其是转位及方向变异明显,在相关操作中需要个体化设计成像及操作方案;2.房间隔的转位与方向和心脏位置无明显的相关性,而与冠状窦近段的方向有着相关性,后者可作为转位的预测因子并为个体化手术方案提供术中参考;3.冠状窦口方向与Koch’s三角方向有显著的相关性,且前者是后者的预测因素;4.传统右前斜体位对Koch’s三角进行投照可能使图像发生短缩,而依据解剖信息,我们认为个体化的冠状窦口指导的投照角度可优化投照方法;5.Koch’s三角方向与冠状窦方向的测值差异在临床可接受范围之内,冠状窦方向可考虑成为术中衡量Koch’s三角方向的替代方法;6.心脏CT可用于探索心脏电生理相关结构的解剖变异,并进一步为优化电生理及射频消融术的方案提供理论支持。
[Abstract]:Arrhythmia is a common disease, and modern clinical electrophysiological technique is an effective means of applying electro-physiological examination and radiofrequency ablation to mechanism research, diagnosis and treatment of arrhythmia, as well as a branch subject of rapid development in the cardiovascular field. In electro-physiological and radio-frequency ablation, cardiac images are obtained by X-ray, and the target structure and associated catheter are often positioned using multiple positions combined with corresponding anatomical landmarks. obtaining the optimal X-ray projection in the operation and accurately positioning the heart structure and the catheter position can effectively increase the success rate of the operation and reduce the occurrence of complications. However, variations in cardiac structures, in particular the translocation of cardiac structures or changes in the body direction (e.g., atrial septal) often result in a short contraction or even a deviation of perspective image projections. There is still a lack of effective theoretical data support based on the experience of using different positions with a view to meeting individual needs. Therefore, it is important to study the variation of electro-physiology-related anatomy, which can provide us with the method of predicting variation and the useful information of individualized imaging and treatment. However, so far, our research and understanding of cardiac anatomy, in particular electro-physiological-related structural anatomy, is a statistical data derived from autopsy specimens. As is well known, the heart is a chamber-like structure that is filled with blood in the living body, so the anatomical structures and interrelationships in the body, in-vivo heart, may differ from necropsy and to-body specimens. In recent years, high resolution CT technology has developed rapidly, and the time resolution and spatial resolution of CT are constantly improved, which makes it possible for cardiac CT to study the anatomy of the heart. In this study, cardiac CT imaging technique was used to study the electrophysiological anatomy of the patient's heart, especially the translocation and direction change which might affect the intraoperative imaging. Moreover, the correlation between the relevant anatomical landmarks such as coronary vein thrombosis, its opening and the corresponding structure which may play a guiding role in the operation is analyzed to provide the theoretical basis for the individualized imaging. Study contents 1: To apply CT data to explore the heart electrophysiological related atrial septal transposition, intraoperative prediction method and prompt method for electro-physiological procedure: the patients with normal cardiac structure were screened and included in 115 patients with cardiac CT enhancement. Pearson correlation analysis was applied to explore the association between the direction of the fossa ovalis and the cross-sectional direction of the proximal segment of the coronal section, and further the linear regression analysis was applied to determine the existence of predictive value between the variables. Results: The direction of the cross section of the oval fossa, the heart position and the coronal section of the selected patients were 36. 8, 7. 3 掳, 37. 1, 8. 3 掳 and 37. 7, 6. 6 掳, respectively. The variation range was 19. 1 掳 -53. 6 掳, 19. 2 掳 -61 掳 and 21. 3 掳-50. 1 掳, respectively. There was no significant correlation between the orientation of the fossa and the position of the heart (P0.05), but there was a significant correlation between the direction of the fossa ovalis and the proximal segment of the coronal section (r = 0.928, P0.01). The linear regression equation was obtained: the direction of the fossa ovalis =-2.01 + 1.03 * coronal axis (R2 = 0.986). P0.01). Objective: To explore the method of position individualization in the clinical anatomy and radio frequency ablation of KKK's triangle by using CT technique: 104 cases of patients undergoing cardiac CT examination were screened and analyzed by CT images and data to locate the triangle of Kln's and clarify the upper part of the patients. The direction of the lower part and the direction of the coronal incision. In contrast to the direction of the triangular upper and lower parts of KZS's, the anatomical characteristics of the triangle are compared, and the regression equation of the two regression equations is established by using Pearson's test to detect the direction of the triangle and the direction of coronal incision. To compare the difference between the position of the traditional right anterior oblique projection and the direction of the coronal incision and the direction of the best shot position, i.e., the direction of the KWh's triangle, and apply the Bland-Hellman analysis to explore the difference and the internal theoretical reasons for optimizing the position of the shot. Results: The measured values of the upper and lower parts of the triangular upper part, the lower part and the crown were 57. 2, 9. 5 掳, 58. 2, 9. 1 掳 and 52. 3, respectively, and there was no statistical difference between the upper part and the lower part of the triangle. There was a significant correlation between the direction of KWh's triangle and the direction of coronal incision (P0.01), and the direction of the triangle could be predicted according to the linear regression results (R2 = 0. 78, P 0.01). The difference analysis suggested that the difference between the angle of projection angle and the optimum angle of shot angle (KWh's triangular direction) was 60.7%, 58. 7% and 99% respectively, and the difference was less than 15 掳, respectively. The mean difference between the triangular direction of KH2PO4 's and coronal incision was 5.88% 4.29 掳, the upper limit of 95% consistency was 14.29 掳, and the lower limit was-2.53 掳, within the acceptable range of clinical acceptance. Conclusion: 1. The clinical electrophysiological related anatomical structures, such as atrial septal and Kln's triangle, have obvious anatomical variation, especially translocation and direction variation, and individualized design imaging and operation scheme are needed in the related operation. Translocation of atrial septum has no significant correlation with direction and heart position, but it has a correlation with the direction of the proximal segment of coronary artery, which can be used as predictive factor of translocation and can be referenced in individualized surgical scheme. There is a significant correlation between the coronal incision direction and the triangular direction of KWh's, and the former is the latter's prediction factor. According to the anatomical information, we believe that individual coronal incision guidance can optimize the shooting method according to the anatomical information; 5. The difference between the triangular direction of KMY's and the direction of coronal CT can be within the acceptable range. The coronal scan direction can be considered as an alternative to intraoperative measurement of Kln's triangular direction; 6. Cardiac CT can be used to explore the anatomical variation of electrophysiological-related structures of the heart and provide theoretical support for the optimization of electrophysiological and radio-frequency ablation protocols.
【学位授予单位】：吉林大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R541.7;R813

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