速度向量成像技术在正常妊娠和高危妊娠胎儿心肌力学中的应用研究
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摘要
第一章绪论
胎儿心脏检查包括心脏结构检查和心脏功能的评估。超声对胎儿心脏结构异常的诊断,已经有了比较成熟的经验。然而胎儿心功能评估手段尚在研究中。
速度向量成像技术(velocity vector imaging, VVI),能够提供胎儿局部和整体的心肌功能分析。本文应用VVI技术对正常和高危妊娠状态下胎儿心功能进行研究。旨在找出高危妊娠胎儿心功能的变化规律,发现能够提供胎儿心功能异常变化的早期监测指标,为临床医生提供更多的信息,使胎儿能得到及时关注和及时处理。
第二章速度向量成像技术在正常妊娠胎儿心肌力学中的应用研究
研究目的：应用速度向量成像技术研究正常妊娠胎儿心脏左、右室心肌力学特性以及胎儿发育进程中的心功能变化。
研究方法：
(1)研究对象：研究的对象来自于2008年12月至2011年12月山东大学齐鲁医院产科门诊和产科病房孕妇158例孕妇,其中145例分析成功。采纳的孕周为19周-40周。经超声检查,胎儿双顶径、头围、腹围和股骨长度均符合孕周,胎儿均无明显结构异常,均心律规整,心率正常。孕妇身体健康无糖尿病及高血压等系统性疾病。
(2)研究仪器：本课题采用的超声仪器为Acuson Sequoia512, Acuson Antares彩色多普勒超声诊断仪,探头型号为4C1和6C2。
(3)图像的采集和处理方法：采集胎儿标准四腔心图像动态储存。选定标准四腔心切面后,局部放大,使胎儿心脏至少占据整个屏幕约1/2-1/3。动态图像存储的格式为DICOM,应用频率为30-80Hz。取出图像通过AxiusVVI工作站进行脱机分析。通过M型超声确定心动周期。我们以心室收缩起始作为R波的起始点,选择两个相邻心室收缩起始点,作为一个心动周期。每个胎儿均选择2-3个心动周期,进行检测取其均值。分别于胎儿左室及右室心内膜下描计心内膜下曲线,描计点不少于8个,描计过程中各个点自动连接形成心内膜下曲线,参考点置于心尖处。左室和右室分别分为六个节段。分别获得六个节段的峰值速度、应变和应变率以及整体峰值速度、应变及应变率。
(4)研究思路：
①正常胎儿心肌六个节段速度、应变和应变率及相邻节段间的比较；
②分析正常胎儿心肌整体峰值速度、应变和应变率与孕周的相关性；
③将正常胎儿分为五个妊娠组,比较相邻组间整体峰值速度、应变和应变率的差异；
④比较正常胎儿左、右心室心肌力学的差别；
⑤对本课题参数测定的重复性研究,即进行观察者间和观察者内的差异性分析。
研究结果：
(1)145例正常妊娠胎儿左、右心室收缩期和舒张期六个节段的峰值速度、应变和应变率及相邻节段间比较的结果：无论是左室还是右室,收缩期还是舒张期,游离壁还是室间隔,峰值速度自基底段至心尖段呈梯形递减趋势,即基底段>中间段>心尖段,有统计学差异,p<0.05；无论是收缩期还是舒张期,左心室心肌的应变和应变率在各节段保持均衡,相邻节段间比较无统计学差异,p>0.05；右室心肌游离壁应变和应变率呈递减趋势,部分相邻节段间比较有统计学差异p<0.05。室间隔壁应变和应变率基本保持恒定,p>0.05。
(2)145例正常妊娠胎儿整体峰值速度、应变和应变率与孕周的相关性：无论左室还是右室,收缩期还是舒张期,心肌整体峰值速度,随着孕周的增加而增大,呈中度相关性。无论左室还是右室,收缩期还是舒张期,心肌整体峰值应变和应变率不随孕周增大而改变。
(3)五个妊娠组整体峰值速度、应变和应变率的比较：五个妊娠组间比较,整体峰值速度随孕周增大而逐渐升高,部分相邻妊娠组间比较,可见统计学差异,p<0.05。心肌整体峰值应变和应变率不随孕周增大而改变,相邻妊娠组间比较,未见统计学差异,p>0.05。
(4)左室和右室整体峰值速度、应变和应变率的比较：左室舒张期整体峰值速度小于右室,左室舒张期整体峰值应变率小于右室,p<0.05；左室和右室收缩期整体峰值速度、应变率和应变比较未见统计学差异,p>0.05。
(5)观察者间和观察者内检测参数的重复性检测：节段和整体峰值速度、应变、应变率在观察者间和观察者内的比较,p>0.05,不存在差异。节段峰值速度、应变和应变率平均差异大于心室心肌整体的峰值速度、应变、应变率的平均差异,心室整体值的检测参数有更好的重复性。
结论：(1)速度向量成像技术可以应用于正常胎儿心脏心肌力学的研究。
(2)在正常胎儿中,无论左心室还是右心室,也无论收缩期还是舒张期,心肌的速度自基底段至心尖段均呈梯形递减分布。
(3)无论是收缩期还是舒张期,左室心肌的应变和应变率在各节段保持均衡,右室心肌游离壁应变和应变率呈递减趋势。
(4)在正常胎儿中,无论左心室还是右心室,也无论收缩期还是舒张期,心肌整体峰值速度随孕周增加而增加,应变和应变率在妊娠中晚期保持稳定。
(5)整体心肌力学参数比节段参数具有更好的重复性。
第三章速度向量成像技术在妊娠期糖尿病孕妇胎儿心肌力学中的应用研究
研究目的：应用速度向量成像技术定量分析妊娠糖尿病胎儿左心室及右心室的收缩功能及舒张功能,比较妊娠期糖尿病胎儿和正常妊娠胎儿心肌力学参数的差异。
研究方法：
(1)研究对象：病人来自于2008年12月至2011年12月齐鲁医院门诊及住院孕妇。本研究包括64例正常妊娠胎儿和36例妊娠期糖尿病孕妇胎儿。孕周自21周至38周。据妊娠期糖尿病孕妇的孕周,选取相同孕周的64例正常妊娠孕妇,作为对照组。均为单胎妊娠,超声检查胎儿未见明显结构异常、心律规整、心率正常。两组孕妇均排除了其他系统性疾病。妊娠期糖尿病孕妇经过75g糖耐量试验确诊。
(2)研究仪器：本课题采用的超声仪器为Acuson Sequoia512, Acuson Antares彩色多普勒超声诊断仪,探头型号为4C1和6C2。
(3)图像的采集和处理方法：同第二章。
(4)研究思路：将妊娠期糖尿病孕妇胎儿分为心肌肥厚组和心肌未肥厚组分别进行研究。对照组根据病例组的孕周进行配对。应用峰值速度、应变、应变率及射血分数,比较病例组和对照组的左、右室节段和整体心肌力学的特点及变化规律。
研究结果：
(1)妊娠期糖尿病孕妇胎儿心肌肥厚组2例,因病例数少,未进行配对统计学分析。
(2)妊娠期糖尿病孕妇组胎儿心肌未肥厚组(GDM组)左、右室六个节段和整体峰值速度、应变和应变率以及EF值与对照组比较结果显示：
①GDM组左、右室六个节段峰值速度、应变和应变率与对照组比较：
GDM组和对照组对比,左、右心室收缩期和舒张期节段峰值速度、应变和应变率小于对照组,但部分节段峰值速度存在统计学差异, p＜0.05或p＜0.01,部分节段差异未显示统计学意义,p＞0.05。
②GDM组左、右室整体峰值速度、应变和应变率与对照组比较：
GDM组和对照组对比,左、右心室收缩期和舒张期整体峰值速度、应变和应变率均小于正常对照组,差异均有统计学意义,p＜0.05或p＜0.01。
③GDM组EF值与对照组比较结果：GDM组和对照组左、右心室EF值比较,未见统计学差异,p>0.05。(3)GDM组和对照组胎儿左、右心室整体峰值速度、应变和应变率与孕周相关性：
GDM组和对照组比较,胎儿左、右心室收缩和舒张期整体峰值速度与孕周存在低度或中度相关性,整体峰值应变和应变率与孕周间不存在相关性。
结论：(1)速度向量成像技术能反映妊娠期糖尿病孕妇胎儿心肌力学的变化。
(2)应变和应变率在心肌功能的评价上较EF值敏感。
(3)整体应变和应变率比节段值更敏感地提示妊娠糖尿病孕妇胎儿心肌力学的变化,预警胎儿心肌早期损害的发生。整体测值有望成为评价妊娠糖尿病孕妇胎儿心肌早期病变的指标。
第四章速度向量成像技术在妊娠高血压综合征孕妇胎儿心肌力学中的应用研究
研究目的：应用速度向量成像技术定量分析妊高症胎儿左心室及右心室的收缩功能及舒张功能,比较妊娠高血压综合征胎儿和正常妊娠胎儿心肌力学参数的差异。
研究方法：
(1)研究对象：病人来自2008年12月至2011年12月山东大学齐鲁医院的住院和门诊孕妇。妊高征组共36例孕妇,妊娠25周至36周。根据妊高征孕妇的孕周,选取相同孕周的54例正常妊娠孕妇作为对照组。孕妇排除糖尿病等系统性疾病。妊高征胎儿心脏结构未显示异常,心律规整,心率正常,同时排除胎儿其他先天性畸形。由产科大夫根据孕妇的血压、尿蛋白、水肿及辅助检查综合作出判断并诊断孕妇病情。
(2)研究仪器：本课题采用的超声仪器为Acuson Sequoia512, Acuson Antares彩色多普勒超声诊断仪,探头型号为4C1和6C2。
(3)图像的采集和处理方法：同第二章。
(4)研究思路：根据妊娠妊高征孕妇的孕周,选取相同孕周的正常妊娠孕妇,作为对照组。应用左、右心室收缩期和舒张期六个节段的峰值速度、应变、应变率及整体峰值速度、应变和应变率,评价妊高征孕妇胎儿心肌力学的特点,并与对照组参数进行比较,探讨妊高征组胎儿心肌力学的变化规律。
研究结果：
(1)左、右室六个节段和整体峰值速度、应变和应变率与对照组比较结果：
①妊高征组左、右室六个节段峰值速度、应变和应变率与对照组比较结果：
妊高征组和对照组对比,左、右心室收缩期和舒张期节段峰值速度、应变和应变率小于对照组,但部分节段峰值速度存在统计学差异, p＜0.05或p＜0.01,部分节段差异未显示统计学意义,p>0.05。
②妊高征组左、右室整体峰值速度、应变和应变率与对照组比较结果：妊高征组和对照组对比,左、右心室收缩期和舒张期整体峰值速度、应变和应变率均小于正常对照组,差异均有统计学意义, p＜0.05或p＜0.01。
(2)妊高征组和对照组胎儿左、右心室整体峰值速度、应变和应变率与孕周相关性：
妊高征组胎儿左心室舒张期整体峰值速度与孕周呈低度相关性。妊高征组胎儿左室收缩期、右室收缩期和舒张期整体峰值速度与孕周不存在相关性。
对照组胎儿左、右心室收缩期和舒张期峰值速度与孕周呈低度相关性。
无论妊高征组还是对照组胎儿,左、右心室收缩和舒张期整体峰值应变和应变率与孕周间不存在相关性。
结论：(1)速度向量成像技术能反映妊娠高血压孕妇胎儿心肌力学的变化,提示妊娠高血压孕妇胎儿心肌损害的存在。
(2)与节段应变和应变率比较,心肌整体峰值应变和应变率更敏感,将有望成为评价妊娠高血压孕妇胎儿心肌收缩和舒张功能的有用指标。
创新点
1.首次提出妊娠期糖尿病孕妇胎儿心肌未显示肥厚时,心肌应变和应变率已低于正常胎儿,提示胎儿心脏收缩和舒张功能减弱,预警心肌存在早期损害的可能。应变和应变率比EF值更敏感。
2.首次提出妊娠高血压综合征孕妇胎儿心肌应变和应变率比正常胎儿降低,提示心脏收缩和舒张功能减弱,预警心肌存在损害的可能。
3.整体应变、应变率的检测重复性和敏感性高于节段应变、应变率,有望成为评价胎儿心肌力学的有力指标。
Chapter1Background
Examinations of fetal heart include structure inspection and cardiac function evaluation. In the diagnosis of fetal heart abnormal structure, we have more mature experiences. However, the evaluation of fetal cardiac function is still difficult.
Velocity vector imaging (VVI) could reflect regional and global myocardial mechanics. This paper aims to study fetal myocardial mechanics in normal pregnancy and high-risk pregnancy by VVI, to find out the characteristics and rules. We try to find out more accurate, more sensitive myocardial parameters.
Chapter2Evaluation of fetal myocardial mechanics in normal pregnancy using velocity vector imaging
Objective:Evaluation of fetal left ventricular and right ventricular systolic and diastolic myocardial mechanics in normal pregnancy。
Method:
(1) Materials:The study group consisted of158fetuses with gestational age from19weeks to term without structural abnormalities and arrhythmias, in the department of obstetric of Qilu Hospital Shandong University from Dec2008to Dec2011.145cases were analyzed successfully. All the measurement sizes of body developments were keeping with gestational weeks. Gestational age was calculated using the biparietal diameter, head circumference, abdominal circumference, and femur length, and correlated with LMP gestational age. We excluded fetuses of mothers with systemic diseases, such as diabetes, pregnancy-induced hypertension syndrome.
(2) Ultrasound machines:Acuson Sequoia512, Acuson Antares ultrasound machines. The types of probes were4C1and6C2.
(3) Image collection and processing method:Two-dimensional images of four-chamber view were obtained by a perinatologist with ultrasound machine. Fetal heart was shown at least about1/2-1/3of entire screen. All images, zoomed as large as possible, were stored as digital clip (DICOM), as30-80Hz. The clips were analyzed offline on Axius VVI software. The first step was to definite cardiac cycle by M-mode. R-wave gating was defined at the onset of ventricular systole and the beginning and end of a cardiac cycle, then traced manually the endocardium of the left ventricles. One important step is to check the points along the trace and track the motion in and out, and then edit the trace. The trace was shown on figure1.2or3cardiac cycles which were averaged to obtain VVI data. Parameters used in the software were velocity, strain and strain rate.
(4) Designs:①To analyze the distribution of velocity, strain and strain rate among neighbour segments.
②To analyze the correlations of global velocity, strain and strain rate with gestational weeks, according to the sc cater plot figure.
③All pregnancy women were divided into groups. The contrasts were done in the group and the continuos group.
④Myocardial mechanics between left and right ventricular were compered.
⑤Inter and intraobserver differences were assessed.
Result:
(1) In145normal pregnancy fetuses, the distribution of velocity, strain and strain rate among neighbour segments:
Whether right or left ventricular, systolic or diastolic period, free wall or ventricular septum, peak velocity decrease from the basal segment to apical segment. The velocity tendency was shown as basal segment> mid segment> apical segment, p <0.05. Both systolic and diastolic, left ventricular myocardial strain and strain rate remained balance in each segment. There was no significant differences between contiguous segments, p>0.05; Right ventricular myocardial free wall strain and strain rate showed decreasing tendency. The differences between some adjacent segments had statistically significant p<0.05. The strain and strain rate of right ventricular septal wall mainly had no difference, p>0.05.
(2) The correlations of global velocity, strain and strain rate with gestational weeks:no matter right or left ventricular, systolic or diastolic, myocardial global peak velocity, increases with gestational age, shown moderate correlation. No matter right or left ventricular, systolic or diastolic, there was no correlation between global peak strain, strain rate with gestational age. The global peak strain and strain rate seem stable in the mid and term gestational age.
(3) The comparison among the five pregnancy group in global peak velocity, strain and strain rate:the velocities increase from the first group to the fifth group. There was statistically significant between the group and next group, p<0.05. Global peak strain and strain rate were not found statistical difference between the group and next group, p>0.05.
(4) The comparison in myocardial mechanics between left and right ventricular:Left ventricular diastolic global peak velocity was less than that of right ventricular, p<0.05; left ventricular diastolic global peak strain rate less than that of right ventricular p<0.05; systolic global peak velocity, strain and strain rate had no statistical differences between left and right ventricular, p>0.05.
(5) The repeatability of inter-and intra-observer differences:there were no differences between inter-and intra-observer, p>0.05. The average differences of global peak velocity, strain and strain rate were smaller than segmental velocity, strain and strain rate. The global peak velocity, strain and strain rate had better repeatability.
Conclusion:
(1) VVI can be an effective method to evaluate myocardial function. Whether right or left ventricular, systolic or diastolic period, free wall or ventricular septum, peak velocity decrease from the basal segment to apical segment.
(2) Left ventricular myocardial strain and strain rate remained balance in each segment. Right ventricular myocardial free wall strain and strain rate showed decreasing tendency.
(3) No matter right or left ventricular, systolic or diastolic, myocardial global peak velocity increases with gestational age, showing moderate correlation.
(4) No matter right or left ventricular, systolic or diastolic, the global peak strain and strain rate seem stable in the mid and term gestational age.
(5) The global peak velocity, strain and strain rate had better repeatability than segmental paraments.
Chapter3Evaluation of fetal myocardial mechanics in gestational diabetes mellitus pregnancy using velocity vector imaging
Objective:Evaluation of fetal left ventricular and right ventricular systolic and diastolic myocardial mechanics in gestational diabetes mellitus (GDM) pregnancy.
Method:
(1) Materials:The study group consisted of60normal fetuses and36fetuses which of the pregnant women diagnosed with GDM, from December2008to December2011. The gestational age ranged from21to38weeks. All fetuses were singletons without structural abnormalities and arrhythmias, in the department of obstetric of Qilu Hospital Shandong University. We excluded fetuses of mothers with other systemic diseases, such as pregnancy-induced hypertension syndrome. All the women were diagnosed with75g oral glucose tolerance test.
(2) Ultrasound machines:Acuson Sequoia512, Acuson Antares ultrasound machines. The types of probes were4C1and6C2.
(3) Image collection and processing method:same as chapter2.
(4) Designs:The case group was divided into myocardial hypertrophy group and without myocardial hypertrophy group (called as GDM group). According to the case group gestational weeks, the control group was matched. Peak velocity, strain, strain rate and ejection fraction, were used to evaluate fetal myocardial mechanics between the case group and control group.
Result:
(1) Only2cases were diagnosed as myocardial hypertrophy. The number was less, and we hadn't done statistics analysis.
(2) Fetuses without myocardial hypertrophy group (called as GDM group):
①Segmental peak velocity, strain and strain rate of GDM group compared with control group:
Compered with control group, no matter left or right ventricular, systolic or diastolic, segmental velocity, strain and strain rate of GDM group decreased. There were statistical differences in some of the segments, p<0.05or p<0.01. Some of the segments had not been found statistical differences, p>0.05.
②Global peak velocity, strain and strain rate of GDM group compared with control group:
Compered with control group, no matter left or right ventricular, systolic or diastolic, global velocity, strain and strain rate of GDM group decreased. All the paraments had statistical differences, p<0.05or p<0.01.
③EF value of GDM group compared with control group:
There was no statistical difference in EF value between GDM group and control group, p>0.05.
(3) The correlations of the paraments with gestational age in GDM and control group:
No matter GDM or control group, left or right ventricular, systolic or diastolic, global velocity increased with gestational weeks, showing moderate or low relationship.
No matter GDM or control group, left or right ventricular, systolic or diastolic, global strain and strain rate kept stable in gestational weeks.
Conclusion:
(1) VVI could reflect the fetal myocardial mechanics sensitively in GDM group.
(2) The strain and strain rate were more sensitive than EF, and could reveal the myocardial injured even if lack of the myocardial hypertrophy.
(3) The strain and strain rate may be useful parameters for assessing the fetal myocardial myocardial mechanics of diabetic mothers. Global strain and strain rate may be more sensitive than segmental strain and strain rate.
Chapter4Evaluation of fetal myocardial mechanics in women with pregnancy induced hypertension syndrome using velocity vector imaging
Objective:Evaluation of fetal left ventricular and right ventricular systolic and diastolic myocardial mechanics in women with pregnancy induced hypertension syndrome
Method:
(1) Materials:The study group consisted of54normal fetuses and36fetuses which of women with pregnancy induced hypertension syndrome, from December2008to December2011. The gestational age ranged from25to36weeks. All fetuses were singletons without structural abnormalities and arrhythmias, in the department of obstetric of Qilu Hospital Shandong University. We excluded fetuses of mothers with other systemic diseases, for example GDM. All the women were diagnosed by clinical doctors.
(2) Ultrasound machines:Acuson Sequoia512, Acuson Antares ultrasound machines. The types of probes were4C1and6C2.
(3) Image collection and processing method:same as chapter2.
(4) Designs:According to gestational weeks of women with pregnancy induced hypertension syndrome, we selected fetuses with the same gestational ages at normal pregnancy women, as control group. The right and left ventricular systolic and diastolic segmental peak velocity, strain, strain rate and global peak velocity, strain, strain rate, were used. The paraments were used to evaluate fetal myocardial mechanics between the case group and control group.
Result:
(1) Segmental and global paraments comparison between fetuse of women with pregnancy induced hypertension syndrome (called as hypertensive group) and control group:
CD Segmental peak velocity, strain and strain rate of hypertensive group compared with control group:
Compered with control group, no matter left or right ventricular, systolic or diastolic, segmental velocity, strain and strain rate of hypertensive group decreased. There were statistical differences in some of the segments, p<0.05or p<0.01. Some of the segments had not found statistical differences, p>0.05.
(D Global peak velocity, strain and strain rate of hypertensive group compared with control group:
Compered with control group, no matter left or right ventricular, systolic or diastolic, global velocity, strain and strain rate of hypertensive group decreased. All the paraments had statistical differences, p<0.05or p<0.01.
(2) The correlations of the paraments with gestational age in hypertensive and control group:
In hypertensive group, global peak velocity of left ventricular diastolic period increased with gestational weeks, showing low relationship. Global peak velocity of left ventricular systolic had no relationship with gestation. Global peak velocity of right ventricular systolic and diastolic period had no relationship with gestation.
In control group, no matter left or right ventricular, systolic or diastolic, global velocity increased in the gestation weeks, showing low relationship.
No matter hypertensive or control group, left or right ventricular, systolic or diastolic, global strain and strain rate kept stable in gestational weeks.
Conclusion:
(1) VVI could reflect the fetal myocardial injured in women with pregnancy induced hypertension syndrome.
(2) Global strain and strain rate may be more sensitive than segmental strain an strain rate. Global strain and strain rate may be useful parameters for assessing the fetal myocardial mechanics in women with pregnancy induced hypertension syndrome.
Main Innovative Points
1. This study was the first to find fetal myocardium strain and strain rate decreased even if lack of the myocardial hypertrophy. It means fetal myocardium systolic and diastolic function injured. The strain and strain rate were more sensitive than EF, and could reveal the myocardial injured.
2. This study was the first to find fetal myocardium strain and strain rate decreased in women with pregnancy induced hypertension syndrome. It means fetal myocardium systolic and diastolic function injured.
3. The responsibility and sensitivity of global strain and strain rate were better than segmental strain and strain rate. Global strain and strain rate may be the useful paraments in evaluating fetal myocardial mechanics.
胎儿心脏检查包括心脏结构检查和心脏功能的评估。超声对胎儿心脏结构异常的诊断,已经有了比较成熟的经验。然而胎儿心功能评估手段尚在研究中。
速度向量成像技术(velocity vector imaging, VVI),能够提供胎儿局部和整体的心肌功能分析。本文应用VVI技术对正常和高危妊娠状态下胎儿心功能进行研究。旨在找出高危妊娠胎儿心功能的变化规律,发现能够提供胎儿心功能异常变化的早期监测指标,为临床医生提供更多的信息,使胎儿能得到及时关注和及时处理。
第二章速度向量成像技术在正常妊娠胎儿心肌力学中的应用研究
研究目的：应用速度向量成像技术研究正常妊娠胎儿心脏左、右室心肌力学特性以及胎儿发育进程中的心功能变化。
研究方法：
(1)研究对象：研究的对象来自于2008年12月至2011年12月山东大学齐鲁医院产科门诊和产科病房孕妇158例孕妇,其中145例分析成功。采纳的孕周为19周-40周。经超声检查,胎儿双顶径、头围、腹围和股骨长度均符合孕周,胎儿均无明显结构异常,均心律规整,心率正常。孕妇身体健康无糖尿病及高血压等系统性疾病。
(2)研究仪器：本课题采用的超声仪器为Acuson Sequoia512, Acuson Antares彩色多普勒超声诊断仪,探头型号为4C1和6C2。
(3)图像的采集和处理方法：采集胎儿标准四腔心图像动态储存。选定标准四腔心切面后,局部放大,使胎儿心脏至少占据整个屏幕约1/2-1/3。动态图像存储的格式为DICOM,应用频率为30-80Hz。取出图像通过AxiusVVI工作站进行脱机分析。通过M型超声确定心动周期。我们以心室收缩起始作为R波的起始点,选择两个相邻心室收缩起始点,作为一个心动周期。每个胎儿均选择2-3个心动周期,进行检测取其均值。分别于胎儿左室及右室心内膜下描计心内膜下曲线,描计点不少于8个,描计过程中各个点自动连接形成心内膜下曲线,参考点置于心尖处。左室和右室分别分为六个节段。分别获得六个节段的峰值速度、应变和应变率以及整体峰值速度、应变及应变率。
(4)研究思路：
①正常胎儿心肌六个节段速度、应变和应变率及相邻节段间的比较；
②分析正常胎儿心肌整体峰值速度、应变和应变率与孕周的相关性；
③将正常胎儿分为五个妊娠组,比较相邻组间整体峰值速度、应变和应变率的差异；
④比较正常胎儿左、右心室心肌力学的差别；
⑤对本课题参数测定的重复性研究,即进行观察者间和观察者内的差异性分析。
研究结果：
(1)145例正常妊娠胎儿左、右心室收缩期和舒张期六个节段的峰值速度、应变和应变率及相邻节段间比较的结果：无论是左室还是右室,收缩期还是舒张期,游离壁还是室间隔,峰值速度自基底段至心尖段呈梯形递减趋势,即基底段>中间段>心尖段,有统计学差异,p<0.05；无论是收缩期还是舒张期,左心室心肌的应变和应变率在各节段保持均衡,相邻节段间比较无统计学差异,p>0.05；右室心肌游离壁应变和应变率呈递减趋势,部分相邻节段间比较有统计学差异p<0.05。室间隔壁应变和应变率基本保持恒定,p>0.05。
(2)145例正常妊娠胎儿整体峰值速度、应变和应变率与孕周的相关性：无论左室还是右室,收缩期还是舒张期,心肌整体峰值速度,随着孕周的增加而增大,呈中度相关性。无论左室还是右室,收缩期还是舒张期,心肌整体峰值应变和应变率不随孕周增大而改变。
(3)五个妊娠组整体峰值速度、应变和应变率的比较：五个妊娠组间比较,整体峰值速度随孕周增大而逐渐升高,部分相邻妊娠组间比较,可见统计学差异,p<0.05。心肌整体峰值应变和应变率不随孕周增大而改变,相邻妊娠组间比较,未见统计学差异,p>0.05。
(4)左室和右室整体峰值速度、应变和应变率的比较：左室舒张期整体峰值速度小于右室,左室舒张期整体峰值应变率小于右室,p<0.05；左室和右室收缩期整体峰值速度、应变率和应变比较未见统计学差异,p>0.05。
(5)观察者间和观察者内检测参数的重复性检测：节段和整体峰值速度、应变、应变率在观察者间和观察者内的比较,p>0.05,不存在差异。节段峰值速度、应变和应变率平均差异大于心室心肌整体的峰值速度、应变、应变率的平均差异,心室整体值的检测参数有更好的重复性。
结论：(1)速度向量成像技术可以应用于正常胎儿心脏心肌力学的研究。
(2)在正常胎儿中,无论左心室还是右心室,也无论收缩期还是舒张期,心肌的速度自基底段至心尖段均呈梯形递减分布。
(3)无论是收缩期还是舒张期,左室心肌的应变和应变率在各节段保持均衡,右室心肌游离壁应变和应变率呈递减趋势。
(4)在正常胎儿中,无论左心室还是右心室,也无论收缩期还是舒张期,心肌整体峰值速度随孕周增加而增加,应变和应变率在妊娠中晚期保持稳定。
(5)整体心肌力学参数比节段参数具有更好的重复性。
第三章速度向量成像技术在妊娠期糖尿病孕妇胎儿心肌力学中的应用研究
研究目的：应用速度向量成像技术定量分析妊娠糖尿病胎儿左心室及右心室的收缩功能及舒张功能,比较妊娠期糖尿病胎儿和正常妊娠胎儿心肌力学参数的差异。
研究方法：
(1)研究对象：病人来自于2008年12月至2011年12月齐鲁医院门诊及住院孕妇。本研究包括64例正常妊娠胎儿和36例妊娠期糖尿病孕妇胎儿。孕周自21周至38周。据妊娠期糖尿病孕妇的孕周,选取相同孕周的64例正常妊娠孕妇,作为对照组。均为单胎妊娠,超声检查胎儿未见明显结构异常、心律规整、心率正常。两组孕妇均排除了其他系统性疾病。妊娠期糖尿病孕妇经过75g糖耐量试验确诊。
(2)研究仪器：本课题采用的超声仪器为Acuson Sequoia512, Acuson Antares彩色多普勒超声诊断仪,探头型号为4C1和6C2。
(3)图像的采集和处理方法：同第二章。
(4)研究思路：将妊娠期糖尿病孕妇胎儿分为心肌肥厚组和心肌未肥厚组分别进行研究。对照组根据病例组的孕周进行配对。应用峰值速度、应变、应变率及射血分数,比较病例组和对照组的左、右室节段和整体心肌力学的特点及变化规律。
研究结果：
(1)妊娠期糖尿病孕妇胎儿心肌肥厚组2例,因病例数少,未进行配对统计学分析。
(2)妊娠期糖尿病孕妇组胎儿心肌未肥厚组(GDM组)左、右室六个节段和整体峰值速度、应变和应变率以及EF值与对照组比较结果显示：
①GDM组左、右室六个节段峰值速度、应变和应变率与对照组比较：
GDM组和对照组对比,左、右心室收缩期和舒张期节段峰值速度、应变和应变率小于对照组,但部分节段峰值速度存在统计学差异, p＜0.05或p＜0.01,部分节段差异未显示统计学意义,p＞0.05。
②GDM组左、右室整体峰值速度、应变和应变率与对照组比较：
GDM组和对照组对比,左、右心室收缩期和舒张期整体峰值速度、应变和应变率均小于正常对照组,差异均有统计学意义,p＜0.05或p＜0.01。
③GDM组EF值与对照组比较结果：GDM组和对照组左、右心室EF值比较,未见统计学差异,p>0.05。(3)GDM组和对照组胎儿左、右心室整体峰值速度、应变和应变率与孕周相关性：
GDM组和对照组比较,胎儿左、右心室收缩和舒张期整体峰值速度与孕周存在低度或中度相关性,整体峰值应变和应变率与孕周间不存在相关性。
结论：(1)速度向量成像技术能反映妊娠期糖尿病孕妇胎儿心肌力学的变化。
(2)应变和应变率在心肌功能的评价上较EF值敏感。
(3)整体应变和应变率比节段值更敏感地提示妊娠糖尿病孕妇胎儿心肌力学的变化,预警胎儿心肌早期损害的发生。整体测值有望成为评价妊娠糖尿病孕妇胎儿心肌早期病变的指标。
第四章速度向量成像技术在妊娠高血压综合征孕妇胎儿心肌力学中的应用研究
研究目的：应用速度向量成像技术定量分析妊高症胎儿左心室及右心室的收缩功能及舒张功能,比较妊娠高血压综合征胎儿和正常妊娠胎儿心肌力学参数的差异。
研究方法：
(1)研究对象：病人来自2008年12月至2011年12月山东大学齐鲁医院的住院和门诊孕妇。妊高征组共36例孕妇,妊娠25周至36周。根据妊高征孕妇的孕周,选取相同孕周的54例正常妊娠孕妇作为对照组。孕妇排除糖尿病等系统性疾病。妊高征胎儿心脏结构未显示异常,心律规整,心率正常,同时排除胎儿其他先天性畸形。由产科大夫根据孕妇的血压、尿蛋白、水肿及辅助检查综合作出判断并诊断孕妇病情。
(2)研究仪器：本课题采用的超声仪器为Acuson Sequoia512, Acuson Antares彩色多普勒超声诊断仪,探头型号为4C1和6C2。
(3)图像的采集和处理方法：同第二章。
(4)研究思路：根据妊娠妊高征孕妇的孕周,选取相同孕周的正常妊娠孕妇,作为对照组。应用左、右心室收缩期和舒张期六个节段的峰值速度、应变、应变率及整体峰值速度、应变和应变率,评价妊高征孕妇胎儿心肌力学的特点,并与对照组参数进行比较,探讨妊高征组胎儿心肌力学的变化规律。
研究结果：
(1)左、右室六个节段和整体峰值速度、应变和应变率与对照组比较结果：
①妊高征组左、右室六个节段峰值速度、应变和应变率与对照组比较结果：
妊高征组和对照组对比,左、右心室收缩期和舒张期节段峰值速度、应变和应变率小于对照组,但部分节段峰值速度存在统计学差异, p＜0.05或p＜0.01,部分节段差异未显示统计学意义,p>0.05。
②妊高征组左、右室整体峰值速度、应变和应变率与对照组比较结果：妊高征组和对照组对比,左、右心室收缩期和舒张期整体峰值速度、应变和应变率均小于正常对照组,差异均有统计学意义, p＜0.05或p＜0.01。
(2)妊高征组和对照组胎儿左、右心室整体峰值速度、应变和应变率与孕周相关性：
妊高征组胎儿左心室舒张期整体峰值速度与孕周呈低度相关性。妊高征组胎儿左室收缩期、右室收缩期和舒张期整体峰值速度与孕周不存在相关性。
对照组胎儿左、右心室收缩期和舒张期峰值速度与孕周呈低度相关性。
无论妊高征组还是对照组胎儿,左、右心室收缩和舒张期整体峰值应变和应变率与孕周间不存在相关性。
结论：(1)速度向量成像技术能反映妊娠高血压孕妇胎儿心肌力学的变化,提示妊娠高血压孕妇胎儿心肌损害的存在。
(2)与节段应变和应变率比较,心肌整体峰值应变和应变率更敏感,将有望成为评价妊娠高血压孕妇胎儿心肌收缩和舒张功能的有用指标。
创新点
1.首次提出妊娠期糖尿病孕妇胎儿心肌未显示肥厚时,心肌应变和应变率已低于正常胎儿,提示胎儿心脏收缩和舒张功能减弱,预警心肌存在早期损害的可能。应变和应变率比EF值更敏感。
2.首次提出妊娠高血压综合征孕妇胎儿心肌应变和应变率比正常胎儿降低,提示心脏收缩和舒张功能减弱,预警心肌存在损害的可能。
3.整体应变、应变率的检测重复性和敏感性高于节段应变、应变率,有望成为评价胎儿心肌力学的有力指标。
Chapter1Background
Examinations of fetal heart include structure inspection and cardiac function evaluation. In the diagnosis of fetal heart abnormal structure, we have more mature experiences. However, the evaluation of fetal cardiac function is still difficult.
Velocity vector imaging (VVI) could reflect regional and global myocardial mechanics. This paper aims to study fetal myocardial mechanics in normal pregnancy and high-risk pregnancy by VVI, to find out the characteristics and rules. We try to find out more accurate, more sensitive myocardial parameters.
Chapter2Evaluation of fetal myocardial mechanics in normal pregnancy using velocity vector imaging
Objective:Evaluation of fetal left ventricular and right ventricular systolic and diastolic myocardial mechanics in normal pregnancy。
Method:
(1) Materials:The study group consisted of158fetuses with gestational age from19weeks to term without structural abnormalities and arrhythmias, in the department of obstetric of Qilu Hospital Shandong University from Dec2008to Dec2011.145cases were analyzed successfully. All the measurement sizes of body developments were keeping with gestational weeks. Gestational age was calculated using the biparietal diameter, head circumference, abdominal circumference, and femur length, and correlated with LMP gestational age. We excluded fetuses of mothers with systemic diseases, such as diabetes, pregnancy-induced hypertension syndrome.
(2) Ultrasound machines:Acuson Sequoia512, Acuson Antares ultrasound machines. The types of probes were4C1and6C2.
(3) Image collection and processing method:Two-dimensional images of four-chamber view were obtained by a perinatologist with ultrasound machine. Fetal heart was shown at least about1/2-1/3of entire screen. All images, zoomed as large as possible, were stored as digital clip (DICOM), as30-80Hz. The clips were analyzed offline on Axius VVI software. The first step was to definite cardiac cycle by M-mode. R-wave gating was defined at the onset of ventricular systole and the beginning and end of a cardiac cycle, then traced manually the endocardium of the left ventricles. One important step is to check the points along the trace and track the motion in and out, and then edit the trace. The trace was shown on figure1.2or3cardiac cycles which were averaged to obtain VVI data. Parameters used in the software were velocity, strain and strain rate.
(4) Designs:①To analyze the distribution of velocity, strain and strain rate among neighbour segments.
②To analyze the correlations of global velocity, strain and strain rate with gestational weeks, according to the sc cater plot figure.
③All pregnancy women were divided into groups. The contrasts were done in the group and the continuos group.
④Myocardial mechanics between left and right ventricular were compered.
⑤Inter and intraobserver differences were assessed.
Result:
(1) In145normal pregnancy fetuses, the distribution of velocity, strain and strain rate among neighbour segments:
Whether right or left ventricular, systolic or diastolic period, free wall or ventricular septum, peak velocity decrease from the basal segment to apical segment. The velocity tendency was shown as basal segment> mid segment> apical segment, p <0.05. Both systolic and diastolic, left ventricular myocardial strain and strain rate remained balance in each segment. There was no significant differences between contiguous segments, p>0.05; Right ventricular myocardial free wall strain and strain rate showed decreasing tendency. The differences between some adjacent segments had statistically significant p<0.05. The strain and strain rate of right ventricular septal wall mainly had no difference, p>0.05.
(2) The correlations of global velocity, strain and strain rate with gestational weeks:no matter right or left ventricular, systolic or diastolic, myocardial global peak velocity, increases with gestational age, shown moderate correlation. No matter right or left ventricular, systolic or diastolic, there was no correlation between global peak strain, strain rate with gestational age. The global peak strain and strain rate seem stable in the mid and term gestational age.
(3) The comparison among the five pregnancy group in global peak velocity, strain and strain rate:the velocities increase from the first group to the fifth group. There was statistically significant between the group and next group, p<0.05. Global peak strain and strain rate were not found statistical difference between the group and next group, p>0.05.
(4) The comparison in myocardial mechanics between left and right ventricular:Left ventricular diastolic global peak velocity was less than that of right ventricular, p<0.05; left ventricular diastolic global peak strain rate less than that of right ventricular p<0.05; systolic global peak velocity, strain and strain rate had no statistical differences between left and right ventricular, p>0.05.
(5) The repeatability of inter-and intra-observer differences:there were no differences between inter-and intra-observer, p>0.05. The average differences of global peak velocity, strain and strain rate were smaller than segmental velocity, strain and strain rate. The global peak velocity, strain and strain rate had better repeatability.
Conclusion:
(1) VVI can be an effective method to evaluate myocardial function. Whether right or left ventricular, systolic or diastolic period, free wall or ventricular septum, peak velocity decrease from the basal segment to apical segment.
(2) Left ventricular myocardial strain and strain rate remained balance in each segment. Right ventricular myocardial free wall strain and strain rate showed decreasing tendency.
(3) No matter right or left ventricular, systolic or diastolic, myocardial global peak velocity increases with gestational age, showing moderate correlation.
(4) No matter right or left ventricular, systolic or diastolic, the global peak strain and strain rate seem stable in the mid and term gestational age.
(5) The global peak velocity, strain and strain rate had better repeatability than segmental paraments.
Chapter3Evaluation of fetal myocardial mechanics in gestational diabetes mellitus pregnancy using velocity vector imaging
Objective:Evaluation of fetal left ventricular and right ventricular systolic and diastolic myocardial mechanics in gestational diabetes mellitus (GDM) pregnancy.
Method:
(1) Materials:The study group consisted of60normal fetuses and36fetuses which of the pregnant women diagnosed with GDM, from December2008to December2011. The gestational age ranged from21to38weeks. All fetuses were singletons without structural abnormalities and arrhythmias, in the department of obstetric of Qilu Hospital Shandong University. We excluded fetuses of mothers with other systemic diseases, such as pregnancy-induced hypertension syndrome. All the women were diagnosed with75g oral glucose tolerance test.
(2) Ultrasound machines:Acuson Sequoia512, Acuson Antares ultrasound machines. The types of probes were4C1and6C2.
(3) Image collection and processing method:same as chapter2.
(4) Designs:The case group was divided into myocardial hypertrophy group and without myocardial hypertrophy group (called as GDM group). According to the case group gestational weeks, the control group was matched. Peak velocity, strain, strain rate and ejection fraction, were used to evaluate fetal myocardial mechanics between the case group and control group.
Result:
(1) Only2cases were diagnosed as myocardial hypertrophy. The number was less, and we hadn't done statistics analysis.
(2) Fetuses without myocardial hypertrophy group (called as GDM group):
①Segmental peak velocity, strain and strain rate of GDM group compared with control group:
Compered with control group, no matter left or right ventricular, systolic or diastolic, segmental velocity, strain and strain rate of GDM group decreased. There were statistical differences in some of the segments, p<0.05or p<0.01. Some of the segments had not been found statistical differences, p>0.05.
②Global peak velocity, strain and strain rate of GDM group compared with control group:
Compered with control group, no matter left or right ventricular, systolic or diastolic, global velocity, strain and strain rate of GDM group decreased. All the paraments had statistical differences, p<0.05or p<0.01.
③EF value of GDM group compared with control group:
There was no statistical difference in EF value between GDM group and control group, p>0.05.
(3) The correlations of the paraments with gestational age in GDM and control group:
No matter GDM or control group, left or right ventricular, systolic or diastolic, global velocity increased with gestational weeks, showing moderate or low relationship.
No matter GDM or control group, left or right ventricular, systolic or diastolic, global strain and strain rate kept stable in gestational weeks.
Conclusion:
(1) VVI could reflect the fetal myocardial mechanics sensitively in GDM group.
(2) The strain and strain rate were more sensitive than EF, and could reveal the myocardial injured even if lack of the myocardial hypertrophy.
(3) The strain and strain rate may be useful parameters for assessing the fetal myocardial myocardial mechanics of diabetic mothers. Global strain and strain rate may be more sensitive than segmental strain and strain rate.
Chapter4Evaluation of fetal myocardial mechanics in women with pregnancy induced hypertension syndrome using velocity vector imaging
Objective:Evaluation of fetal left ventricular and right ventricular systolic and diastolic myocardial mechanics in women with pregnancy induced hypertension syndrome
Method:
(1) Materials:The study group consisted of54normal fetuses and36fetuses which of women with pregnancy induced hypertension syndrome, from December2008to December2011. The gestational age ranged from25to36weeks. All fetuses were singletons without structural abnormalities and arrhythmias, in the department of obstetric of Qilu Hospital Shandong University. We excluded fetuses of mothers with other systemic diseases, for example GDM. All the women were diagnosed by clinical doctors.
(2) Ultrasound machines:Acuson Sequoia512, Acuson Antares ultrasound machines. The types of probes were4C1and6C2.
(3) Image collection and processing method:same as chapter2.
(4) Designs:According to gestational weeks of women with pregnancy induced hypertension syndrome, we selected fetuses with the same gestational ages at normal pregnancy women, as control group. The right and left ventricular systolic and diastolic segmental peak velocity, strain, strain rate and global peak velocity, strain, strain rate, were used. The paraments were used to evaluate fetal myocardial mechanics between the case group and control group.
Result:
(1) Segmental and global paraments comparison between fetuse of women with pregnancy induced hypertension syndrome (called as hypertensive group) and control group:
CD Segmental peak velocity, strain and strain rate of hypertensive group compared with control group:
Compered with control group, no matter left or right ventricular, systolic or diastolic, segmental velocity, strain and strain rate of hypertensive group decreased. There were statistical differences in some of the segments, p<0.05or p<0.01. Some of the segments had not found statistical differences, p>0.05.
(D Global peak velocity, strain and strain rate of hypertensive group compared with control group:
Compered with control group, no matter left or right ventricular, systolic or diastolic, global velocity, strain and strain rate of hypertensive group decreased. All the paraments had statistical differences, p<0.05or p<0.01.
(2) The correlations of the paraments with gestational age in hypertensive and control group:
In hypertensive group, global peak velocity of left ventricular diastolic period increased with gestational weeks, showing low relationship. Global peak velocity of left ventricular systolic had no relationship with gestation. Global peak velocity of right ventricular systolic and diastolic period had no relationship with gestation.
In control group, no matter left or right ventricular, systolic or diastolic, global velocity increased in the gestation weeks, showing low relationship.
No matter hypertensive or control group, left or right ventricular, systolic or diastolic, global strain and strain rate kept stable in gestational weeks.
Conclusion:
(1) VVI could reflect the fetal myocardial injured in women with pregnancy induced hypertension syndrome.
(2) Global strain and strain rate may be more sensitive than segmental strain an strain rate. Global strain and strain rate may be useful parameters for assessing the fetal myocardial mechanics in women with pregnancy induced hypertension syndrome.
Main Innovative Points
1. This study was the first to find fetal myocardium strain and strain rate decreased even if lack of the myocardial hypertrophy. It means fetal myocardium systolic and diastolic function injured. The strain and strain rate were more sensitive than EF, and could reveal the myocardial injured.
2. This study was the first to find fetal myocardium strain and strain rate decreased in women with pregnancy induced hypertension syndrome. It means fetal myocardium systolic and diastolic function injured.
3. The responsibility and sensitivity of global strain and strain rate were better than segmental strain and strain rate. Global strain and strain rate may be the useful paraments in evaluating fetal myocardial mechanics.
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