超声斑点追踪成像技术评价完全性大动脉转位患者行Switch手术前后右室局部及整体功能的临床研究
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摘要
完全性大动脉转位(complete transposition of the great arteries, TGA)为紫绀型先天性心脏病,其发病率在紫绀型先天性心脏病中居第二位,仅次于法洛四联症,占所有先天性心脏病的7%-9%,发病率约为2-3/10000,男性约为女性的两倍。定义为心房与心室连接一致,主动脉起自解剖右室,肺动脉起自解剖左室。本病病情复杂,自然存活率极低,如不及时治疗,90%患者在一岁内死亡。
完全性大动脉转位的主要治疗方式是外科手术,手术方式主要包括心房内调转术和大动脉转换术。心房内调转术主要包括：Senning术、Mustard术,该手术方式仅从生理上对大动脉转位进行矫治,其术后远期并发症较高,易产生心律失常、三尖瓣关闭不全、右心扩大、甚至因右心衰竭而死亡,有研究报道,行心房内调转术后的患者右室射血分数普遍降低,并且远期右室功能的下降和上升的死亡率相关。随着近年来外科技术和术后护理的不断提高,大动脉转换术即Switch术,已成为目前治疗新生儿完全性大动脉转位的最佳手术方式,该术式不仅从生理上使血流动力学恢复正常,同时也使错位的大动脉从解剖上进行彻底根治。准确评价完全性大动脉转位患者术前及术后左、右心功能对术前手术方式、手术时机的选择及术后手术疗效的评估、判断预后有着重要意义。目前,国内外公认超声心动图是临床上评价左心功能的首选方法,左室射血分数(left ventricular ejection fraction, LVEF)是最常用的测量指标,因而应用超声心动图评价左心功能已相当完善。然而,右心室解剖形态复杂,临床上应用常规超声心动图评价右心功能具有一定困难。心脏核磁共振成像、心血管造影技术是准确定量评价右心功能的金标准,但由于取图时间长、费用昂贵及有创性,并不能运用于年龄小、病情危重的患儿。近年来发展起来的超声斑点追踪成像技术(speckle tracking imaging, STI)是通过追踪二维超声图像上分布于心肌中的各个斑点,在心动周期中的运动轨迹,从而计算整个感兴趣区内各节段的心肌形变,可真实准确地反映心脏运动情况,并能准确定量评价局部心肌功能及心室整体功能,也可在心脏整体功能出现异常以前,早期发现局部心肌异常,因此许多学者已应用STI技术来广泛评估右室功能,但目前还没有应用STI技术评价完全性大动脉转位患者行Switch手术前后右心功能的报道,基于此背景,本研究分为三部分：
第一部分超声斑点追踪成像技术评价完全性大动脉转位患者右室局部及整体收缩功能
目的应用超声斑点追踪成像技术评价完全性大动脉转位患者右室局部及整体收缩功能。
方法正常对照组16例,完全性大动脉转位患者25例,男19例,女6例。根据室间隔是否完整将其分为室间隔完整型完全性大动脉转位(TGA/IVS)14例和伴室间隔缺损型完全性大动脉转位(TGA/VSD)11例。获取心尖四腔切面,应用超声斑点追踪成像技术测量右室游离壁和室间隔右室面基底段、中间段、心尖段6个节段的纵向收缩期峰值应变(Strain, S).收缩期峰值应变率(Strain rate, SRs),及右室整体纵向收缩期峰值应变(GLS)、应变率(GLSRs),右室整体纵向舒张早期峰值应变率(GLSRe)、右室整体纵向舒张晚期峰值应变率(GLSRa),并比较各期峰值应变、应变率在三组间有无差异。同时测量并分析右室舒张末横径(RVED)、右室射血分数(RVEF)、右室面积变化率(RVPCA)、及三尖瓣环收缩期峰值速度(TVSPV)等指标与右室整体收缩峰值应变的相关性。
结果①完全性大动脉转位两组患者右室游离壁基底段、中间段及心尖段S、SRs较对照组均减低,差异有统计学意义(P均<0.05)；两组患者室间隔基底段、中间段及心尖段S较对照组减低,差异有统计学意义(P均<0.05), TGA/IVS组中室间隔心尖段SRs较对照组减低,差异有统计学意义(P均<0.05),而TGA/IVS组中室间隔基底段、中间段及TGA/VSD组中各节段SRs较对照组稍减低,但差异并无统计学意义(P均>0.05)。②TGA/IVS组患者右室GLS、GLSRs及GLSRe较对照组减低,差异具有统计学意义(P<0.05),而右室GLSRa较对照组稍减低,差异无统计学意义(P>0.05); TGA/VSD组患者右室GLS、GLSRs较对照组减低,差异具有统计学意义(P<0.05),而右室GLSRe、GLSRa较对照组稍减低,差异无统计学意义(P>0.05)。③完全性大动脉患者TGA/IVS组右室局部及整体舒缩功能各相关指标都较TGA/VSD组减低,但两组间差异并无统计学意义(P>0.05)。④TVSPV在TGA/IVS组中,与右室GLS呈相关性(r=0.66,P<0.05),在TGA/VSD组中与右室GLSRs呈相关性(r=-0.75,P<0.05)。
结论完全性大动脉转位患者右室局部及整体功能减低,超声斑点追踪成像技术能够准确定量评价完全性大动脉转位患者右室长轴局部及整体舒缩功能,为临床评价右心功能提供了又一有效方法。
第二部分超声斑点追踪成像技术评价完全性大动脉转位患者术前及行Switch术后早期右室局部及整体功能
目的本研究旨在应用超声斑点追踪成像技术(speckle tracking imaging, STI)评价完全性大动脉转位患者行大动脉转换术(arteries switch operation, ASO)手术前及术后早期右室局部及整体功能,并探讨该类病人术后不同时期右室功能的改变。
方法正常对照组16例,完全性大动脉转位患者25例,男19例,女6例。根据室间隔是否完整将其分为室间隔完整型完全性大动脉转位(TGA/IVS)14例和伴室间隔缺损型完全性大动脉转位(TGA/VSD)11例。于手术前、手术后2周、3月应用STI技术测量右室游离壁和室间隔右室面基底段、中间段、心尖段6个节段的纵向收缩期峰值应变(Strain, S)、收缩期峰值应变率(Strain rate, SRs),及右室整体纵向收缩期峰值应变(GLS)、应变率(GLSRs),并比较TGA患者手术前后右室局部和整体功能改变。
结果①与正常对照组相比,TGA/IVS组患者术前右室GLS、GLSRs及右室游离壁各节段S、SRs均减低,术后2周、3月S逐渐增高,但右室GLS及右室游离壁各节段S仍低于正常水平,而右室GLSRs及右室游离壁各节段SRs增高至正常水平；右室室间隔各节段S、SRs术前较对照组减低,术后2周室间隔基底段S、SRs较术前进一步减低,术后3月又逐渐增高,S仍低于正常水平,但SRs增高至正常水平；右室室间隔中间段、心尖段S、SRs术后2周、3月术前逐步增高,S仍低于正常水平,但SRs增高至正常水平。②与正常对照组相比,TGA/VSD组患者术前右室GLS、GLSRs及右室游离壁各节段S、SRs均减低,术后2周、3月右室GLS、GLSRs逐步降低,术后2周右室游离壁各节段S较术前减低,术后3月增高,但仍低于正常水平,术后2周、3月右室游离壁基底段SRs较术前逐步增高至正常对照组水平,右室游离中间段、心尖段SRs仍处于术前水平；而右室室间隔各节段S、SRs术前较对照组减低,术后2周、术后3月较术前逐步减低。
结论Switch术后早期TGA/IVS组患者右室局部及整体功能有所提高,而TGA/VSD组患者右室局部功能有所提高,右室整体功能仍处于术前水平。应用STI技术可定量分析右室局部及整体功能,从而可早期、敏感识别出TGA患者术后右心局部及整体功能变化,为临床评价手术疗效及判断预后提供重要价值。
第三部分超声斑点追踪成像技术评价完全性大动脉转位患者行Switch术后1年以上右室局部及整体功能
目的本研究旨在应用超声斑点追踪成像技术评价完全性大动脉转位患者行大动脉转换术(arteries switch operation, ASO)后右室局部及整体功能情况。
方法正常对照组20例,行Switch术治疗的完全性大动脉转位(complete transposition of the great arteries, TGA)患者20例,其中男17例,女3例。根据室间隔是否完整将其分为室间隔完整型完全性大动脉转位(TGA/IVS)10例和伴室间隔缺损型完全性大动脉转位(TGA/VSD)10例。获取心尖四腔切面,应用超声斑点追踪成像技术(speckle tracking imaging, STI)测量右室游离壁和室间隔右室面基底段、中间段、心尖段6个节段的纵向收缩期峰值应变(Strain, S)、收缩期峰值应变率(Strain rate, SRs),及右室整体纵向收缩期峰值应变(GLS)、应变率(GLSRs),右室整体纵向舒张早期峰值应变率(GLSRe)、右室整体纵向舒张晚期峰值应变率(GLSRa),并比较各期峰值应变、应变率在两组间有无差异。
结果①行Switch术后,TGA/IVS组患者右室游离壁及室间隔各节段S、SRs与正常对照组相比,差异均无统计学意义(P>0.05)：TGA/IVS组患者右室GLS、GLSRs、GLSRe、GLSRa较正常对照组相比,各指标两组间差异无统计学意义(P>0.05)。②行Switch术后,TGA/VSD组患者右室游离壁基底段、中间段应变率较正常对照组减低,差异有统计学意义(P<0.05),而右室游离壁心尖段与对照组相比,差异无统计学意义(P>0.05),右室游离壁及室间隔各节段应变与正常对照组相比,差异均无统计学意义(P>0.05)；TGA/VSD组患者右室GLSRs、GLSRe、GLSRa等较正常对照组减低,差异均有统计学意义(P<0.05),而右室GLS与正常对照组相比,差异无统计学意义(P>0.05)。
结论完全性大动脉转位TGA/IVS组患者行Switch术后1年以上右室局部及整体功能恢复正常,TGA/VSD组患者行Switch术后1年以上右室局部及整体功能较正常组减低,应用STI技术可早期发现TGA患者术后右室局部及整体功能改变,为临床上评估右室功能提供了一种新方法。
Complete transposition of the great arteries (TGA) is one of the most common cyanotic congenital heart diseases seen in newborns, just second only to Tetralogy of Fallot, represent 7-9% of all congenital heart diseases, corresponding to an incidence of 2 to 3 per 10000 live births.There is a male predominance with a male/female sex ratio that approximately 2:1. In this defect, the aorta arises from the morphological right ventricular, and the pulmonary artery arises from the morphological left ventricular. This disease is very complex, and the natural survival rate is very low, the mortality rate in untreated patients is approximately 90% by the end of the first year.
The primary treatment for complete transposition of the great arteries is surgical repair. The surgical procedures includes:the atrial switch operation and the arterial switch operation. The atrial switch operation includes Mustard and Senning procedures, but these procedures just give physical correction for complete transposition of the great arteries.Long-term follow up is mainly influenced by arrhythmias, tricuspid regurgitation, right ventricular dilatation, systolic dysfunction of the systemic right ventricle in patients with complete transposition of the great arteries after Mustard and Senning procedures, some studies have reported that reduced function of the systemic right ventricle is associated with increased mortality in late stage outlook of these patients. With recent improvement in surgical technique and postoperative care, atterial switch operation is currently the procedure of the best choice for neonates with complete transposition of the great arteries, compared with atrial switch operation, the primary adventages of the arterial switch operation is not only establishment of left ventricle as the systemic ventricle, but also given physical correction for complete transposition of the great arteries. Accurate evaluation of left and right ventricular function in preoperative and postoperative patients with transposition of great arteries, can help to select timing for surgical operation select surgical procedure、assess operative outcomes and prognosis. Currently, echocardiography is the preferred method for clinical evaluation of left ventricular function, the left ventricular ejection fraction (LVEF) is the most common measurement parameter of left ventricular function, using echocardiography in evalution of left ventricular function is substantially perfect. However, assessing the function of the morphological right ventricle by conventional echocardiography is inherently difficult. Severial imaging modalities, such as cardiac magnetic resonance imaging, angiography are the gold standard for accurate quantitative evaluation of right ventricular function, but these technology are not available for neonates. A recent developed ultrasound speckle tracking imaging (STI) technique can trace the speckle spatial motions of myocardium and calculate deformation of the myocardial tissue, and then give accurate quantitative assessment of reginal myocardial function and ventricular globe function, so the STI technique can detect the regional dysfunction of ventricular before the globe dysfunction of ventricular, and it also have been used to assess right ventricular function widely. But so far, there are no reports to evaluate the right function with complete transposition of the great arteries after aterial switch operation by using ultrasound speckle tracking imaging, so the present study was divided into three parts as follows: Part 1 Assessment of right ventricular regional and global function in patients with complete transposition of the great arteries by ultrasound speckle tracking imaging
Objective:Assessment of right ventricular (RV) regional and global function in patients with complete transposition of the great arteries by ultrasound speckle tracking imaging.
Methods:There were 25 patients with complete transposition of the great arteries enrolled in our study,19 males and 6 females. The TGA patients were divided into intact ventricular septum TGA (14 cases) and ventricular septal defect TGA(11 cases) according to the complete of the ventricular septal.16 cases of normal control group were chosen in our study. Two-dimensional strain (2DS) were obtained at the apical four-chamber views and then were analyzed offline by using automated software (EchoPAC,GE Medical). The myocardial logitudinal peak systolic stain were determined at the basal, mid, and apical segment of the righe ventricular free wall and ventricular septum by 2DS, the right ventricular global logitudinal peak systolic stain were also determined by 2DS.Compare the data between three groups. Besides, measuring RV end-diastolic dimension (RVED), RV ejection fractions (RVEF), RV percent change in area (RVPCA) and tricuspid annular systolic peak velocity (TVSPV), and analyzing correlation of these parameters with RV global logitudinal peak systolic stain.
Results:①The right ventricular longitudinal peak systolic strain (S), strain rate (SR) of basal, mid, apical segment in free wall were lower in TGA patients compared with normal controls,the difference was significant (P<0.05). The right ventricular longitudinal S of basal, mid, apical segment in interventricular septum were lower in TGA patients compared with normal controls (P<0.05). The SRs of apical of interventricular septum were lower in TGA/IVS patients compared to controls (P<0.05). The SRs of basal, mid in interventricular septum in TGA/IVS patients and all sigments in interventricular septum in TGA/VSD patients were slightly reduced compared with controls,the difference was no significant.(P>0.05).②The right ventricular GLS、GLSRs and GLSRe in TGA/IVS patients were lower than controls, the difference was significant (P<0.05). The right ventricular GLSRa was slight reduced compared with controls, the difference was no significant(P>0.05). The right ventricular GLS、GLSRs in TGA/VSD patients were lower than controls(P<0.05). The GLSRa were slightly reduced compared with controls(P>0.05).③All the strain parameters in TGA/IVS patients were lower than TGA/VSD patients, but the difference was no significant (P>0.05).④The TVSPV had correlation with right ventricular GLS in TGA/IVS patients (r=0.66, P<0.05), and also had correlation with right ventricular GLSRs in TGA/VSD patients (r=-0.75, P<0.05)
Conclusion:The right ventricular regional and global function reduced in patients with complete transposition of the great arteries. Ultrasound speckle tracking imaging technique can quantitatively assess the right ventricular regional and global function accurately. Ultrasound speckle tracking imaging is an effectively methods for evaluating right ventricular function.
Part 2 Assessment of right ventricular regional and global function in preoperative and early period of postoperative patients with complete transposition of the great arteries after arterial switch operation by ultrasound speckle tracking imaging
Objective:Assessment of right ventricular regional and global function in preoperative and early period of postoperative patients with complete transposition of the great arteries after arterial switch operation by ultrasound speckle tracking imaging.
Methods:There were 25 patients with complete transposition of the great arteries enrolled in our study,19 males and 6 females.16 cases of normal control group were chosen in our study. The TGA patients were divided into 14 cases of intact ventricular septum TGA and 11 cases of ventricular septal defect TGA according to the complete of the ventricular septal. Such indexes were measured by STI before operation,2 weeks after operation,3 months after operation separately, the myocardial logitudinal peak systolic stain were determined at the basal, mid, and apical segment of the righe ventricular free wall and interventricular septum by 2DS, the right ventricular global logitudinal peak stain were also determined by 2DS.
Results:①The right ventricular GLS、GLSRs and S、SRs of all the segments in right ventricular free wall in TGA/IVS patients reduced compared with the controls. These indexes gradually increased 2 weeks and 3 months after operation, but still below normal levels. But, the right ventricular GLSRs and SRs of all the segments in right ventricular free wall increased to normal levels; S、SRs of all segments in right ventricular interventricular septum were lower compared with normal controls before operation, S、SRs of basal segment in right ventricular interventricular septum further reduced compared with preparation 2 weeks after operation, and gradually increased 3 months after operation., the SRs increased to normal level, but S was still lower than normal levels. S、SRs of mid、apical segments in right ventricular interventricular septum, gradually increased 2 weeks and 3 months after operation. S was still lower than normal level, but SRs increased to normal level.②The GLS、GLSRs of the right ventricular and the right ventricular S, SR of all segments in free wall were lower in TGA/VSD patients compared with normal controls, but these indexes gradually decreased 2 weeks and 3 months after operation, S of all segments in right ventricular free wall were lower in 2 weeks after operation than before operation, increased in 3 months after operation, were lower than before operation, but was still lower than normal levels. SRs of basal segment in right ventricular free wall increased gradually to normal levels 2 weeks and 3 months after operation. SRs of mid、apical segments in right ventricular free wall were still at the preoperative level, however, S、SRs of all segments in right ventricular interventricular septum were lower than preoperative level, and gradually reduced compared with preoperative level.
Conclusion:The right ventricular regional and global function increased in TGA/IVS patients at early period after arterial switch operation. The regional ventricular function increased slightly in TGA/VSD patients, but the global ventricular function were still at the preoperative level. STI technique can quantitatively assess the right ventricular regional and global function accurately and it also can detect the changes of cardiac function early and sensitively. In a word, STI can provide important value for clinical evaluation of surgical treatment and prognosis.
Part 3 Assessment of right ventricular regional and global function in patients with complete transposition of the great arteries at least one year after arterial switch operation by ultrasound speckle tracking imaging
Objective:Assessment of right ventricular regional and global function in patients with complete transposition of the great arteries at least one year after arterial switch operation by ultrasound speckle tracking imaging.
Methods:There were 20 patients with complete transposition of the great arteries enrolled in our study,17 males and 3 females.16 cases of normal control group were chosen in our study. The TGA patients were divided into 10 cases of intact ventricular septum TGA and 10 cases of ventricular septal defect TGA according to the complete of the ventricular septal. Two-dimensional strain (2DS) were obtained at the apical four-chamber views and then were analyzed offline by using automated software (EchoPAC,GE Medical). The myocardial logitudinal peak systolic stain were determined at the basal, mid, and apical segment of the righe ventricular free wall and ventricular septum by 2DS, the right ventricular global logitudinal peak systolic stain were also determined by 2DS.Compare the data between three groups. Besides, measuring RV end-diastolic dimension (RVED), RV ejection fractions (RVEF), RV percent change in area (RVPCA) and tricuspid annular systolic peak velocity (TVSPV), and analyzing correlation of these parameters with RV global logitudinal peak systolic stain.
Results:①There were not only no differences of S、SRs of all the segments in the right ventricular free wall and interventricular septum in TGA/IVS patients compared to normal controls after arterial switch operation(P>0.05), but also no differences of the right ventricular GLS、GLSRs、GLSRe. GLSRa in TGA/IVS patients compared to normal controls (P>0.05).②The SRs of basal、mid segment in right ventricular free wall in TGA/VSD patients reduced after artrial swith operation, the difference was significant (P<0.05). There was no significant difference of the SRs of apical segment in right ventricular free wall compared with controls (P>0.05).There were no significant differences of the S of all the segments in right ventricular free wall and interventricular septum compared with normal controls (P>0.05); The right ventricular GLSRs、GLSRe. GLSRa in TGA/VSD patients reduced compared with normal controls, the difference was significant (P<0.05), but the difference of right ventricular GLS compared with normal controls was not significant (P>0.05)
Conclusion:The right ventricular regional and global function returned to normal level in TGA/IVS patients after arterial switch operation for more than 1 year. The right ventricular regional and global function reduced slightly in TGA/VSD patients compared with normal controls after arterial switch operation for more than 1 year. STI technique can detect the function changes of right ventricular regional and global function early and sensitively. STI provide a new method for clinical evaluation of right ventricular function.
完全性大动脉转位的主要治疗方式是外科手术,手术方式主要包括心房内调转术和大动脉转换术。心房内调转术主要包括：Senning术、Mustard术,该手术方式仅从生理上对大动脉转位进行矫治,其术后远期并发症较高,易产生心律失常、三尖瓣关闭不全、右心扩大、甚至因右心衰竭而死亡,有研究报道,行心房内调转术后的患者右室射血分数普遍降低,并且远期右室功能的下降和上升的死亡率相关。随着近年来外科技术和术后护理的不断提高,大动脉转换术即Switch术,已成为目前治疗新生儿完全性大动脉转位的最佳手术方式,该术式不仅从生理上使血流动力学恢复正常,同时也使错位的大动脉从解剖上进行彻底根治。准确评价完全性大动脉转位患者术前及术后左、右心功能对术前手术方式、手术时机的选择及术后手术疗效的评估、判断预后有着重要意义。目前,国内外公认超声心动图是临床上评价左心功能的首选方法,左室射血分数(left ventricular ejection fraction, LVEF)是最常用的测量指标,因而应用超声心动图评价左心功能已相当完善。然而,右心室解剖形态复杂,临床上应用常规超声心动图评价右心功能具有一定困难。心脏核磁共振成像、心血管造影技术是准确定量评价右心功能的金标准,但由于取图时间长、费用昂贵及有创性,并不能运用于年龄小、病情危重的患儿。近年来发展起来的超声斑点追踪成像技术(speckle tracking imaging, STI)是通过追踪二维超声图像上分布于心肌中的各个斑点,在心动周期中的运动轨迹,从而计算整个感兴趣区内各节段的心肌形变,可真实准确地反映心脏运动情况,并能准确定量评价局部心肌功能及心室整体功能,也可在心脏整体功能出现异常以前,早期发现局部心肌异常,因此许多学者已应用STI技术来广泛评估右室功能,但目前还没有应用STI技术评价完全性大动脉转位患者行Switch手术前后右心功能的报道,基于此背景,本研究分为三部分：
第一部分超声斑点追踪成像技术评价完全性大动脉转位患者右室局部及整体收缩功能
目的应用超声斑点追踪成像技术评价完全性大动脉转位患者右室局部及整体收缩功能。
方法正常对照组16例,完全性大动脉转位患者25例,男19例,女6例。根据室间隔是否完整将其分为室间隔完整型完全性大动脉转位(TGA/IVS)14例和伴室间隔缺损型完全性大动脉转位(TGA/VSD)11例。获取心尖四腔切面,应用超声斑点追踪成像技术测量右室游离壁和室间隔右室面基底段、中间段、心尖段6个节段的纵向收缩期峰值应变(Strain, S).收缩期峰值应变率(Strain rate, SRs),及右室整体纵向收缩期峰值应变(GLS)、应变率(GLSRs),右室整体纵向舒张早期峰值应变率(GLSRe)、右室整体纵向舒张晚期峰值应变率(GLSRa),并比较各期峰值应变、应变率在三组间有无差异。同时测量并分析右室舒张末横径(RVED)、右室射血分数(RVEF)、右室面积变化率(RVPCA)、及三尖瓣环收缩期峰值速度(TVSPV)等指标与右室整体收缩峰值应变的相关性。
结果①完全性大动脉转位两组患者右室游离壁基底段、中间段及心尖段S、SRs较对照组均减低,差异有统计学意义(P均<0.05)；两组患者室间隔基底段、中间段及心尖段S较对照组减低,差异有统计学意义(P均<0.05), TGA/IVS组中室间隔心尖段SRs较对照组减低,差异有统计学意义(P均<0.05),而TGA/IVS组中室间隔基底段、中间段及TGA/VSD组中各节段SRs较对照组稍减低,但差异并无统计学意义(P均>0.05)。②TGA/IVS组患者右室GLS、GLSRs及GLSRe较对照组减低,差异具有统计学意义(P<0.05),而右室GLSRa较对照组稍减低,差异无统计学意义(P>0.05); TGA/VSD组患者右室GLS、GLSRs较对照组减低,差异具有统计学意义(P<0.05),而右室GLSRe、GLSRa较对照组稍减低,差异无统计学意义(P>0.05)。③完全性大动脉患者TGA/IVS组右室局部及整体舒缩功能各相关指标都较TGA/VSD组减低,但两组间差异并无统计学意义(P>0.05)。④TVSPV在TGA/IVS组中,与右室GLS呈相关性(r=0.66,P<0.05),在TGA/VSD组中与右室GLSRs呈相关性(r=-0.75,P<0.05)。
结论完全性大动脉转位患者右室局部及整体功能减低,超声斑点追踪成像技术能够准确定量评价完全性大动脉转位患者右室长轴局部及整体舒缩功能,为临床评价右心功能提供了又一有效方法。
第二部分超声斑点追踪成像技术评价完全性大动脉转位患者术前及行Switch术后早期右室局部及整体功能
目的本研究旨在应用超声斑点追踪成像技术(speckle tracking imaging, STI)评价完全性大动脉转位患者行大动脉转换术(arteries switch operation, ASO)手术前及术后早期右室局部及整体功能,并探讨该类病人术后不同时期右室功能的改变。
方法正常对照组16例,完全性大动脉转位患者25例,男19例,女6例。根据室间隔是否完整将其分为室间隔完整型完全性大动脉转位(TGA/IVS)14例和伴室间隔缺损型完全性大动脉转位(TGA/VSD)11例。于手术前、手术后2周、3月应用STI技术测量右室游离壁和室间隔右室面基底段、中间段、心尖段6个节段的纵向收缩期峰值应变(Strain, S)、收缩期峰值应变率(Strain rate, SRs),及右室整体纵向收缩期峰值应变(GLS)、应变率(GLSRs),并比较TGA患者手术前后右室局部和整体功能改变。
结果①与正常对照组相比,TGA/IVS组患者术前右室GLS、GLSRs及右室游离壁各节段S、SRs均减低,术后2周、3月S逐渐增高,但右室GLS及右室游离壁各节段S仍低于正常水平,而右室GLSRs及右室游离壁各节段SRs增高至正常水平；右室室间隔各节段S、SRs术前较对照组减低,术后2周室间隔基底段S、SRs较术前进一步减低,术后3月又逐渐增高,S仍低于正常水平,但SRs增高至正常水平；右室室间隔中间段、心尖段S、SRs术后2周、3月术前逐步增高,S仍低于正常水平,但SRs增高至正常水平。②与正常对照组相比,TGA/VSD组患者术前右室GLS、GLSRs及右室游离壁各节段S、SRs均减低,术后2周、3月右室GLS、GLSRs逐步降低,术后2周右室游离壁各节段S较术前减低,术后3月增高,但仍低于正常水平,术后2周、3月右室游离壁基底段SRs较术前逐步增高至正常对照组水平,右室游离中间段、心尖段SRs仍处于术前水平；而右室室间隔各节段S、SRs术前较对照组减低,术后2周、术后3月较术前逐步减低。
结论Switch术后早期TGA/IVS组患者右室局部及整体功能有所提高,而TGA/VSD组患者右室局部功能有所提高,右室整体功能仍处于术前水平。应用STI技术可定量分析右室局部及整体功能,从而可早期、敏感识别出TGA患者术后右心局部及整体功能变化,为临床评价手术疗效及判断预后提供重要价值。
第三部分超声斑点追踪成像技术评价完全性大动脉转位患者行Switch术后1年以上右室局部及整体功能
目的本研究旨在应用超声斑点追踪成像技术评价完全性大动脉转位患者行大动脉转换术(arteries switch operation, ASO)后右室局部及整体功能情况。
方法正常对照组20例,行Switch术治疗的完全性大动脉转位(complete transposition of the great arteries, TGA)患者20例,其中男17例,女3例。根据室间隔是否完整将其分为室间隔完整型完全性大动脉转位(TGA/IVS)10例和伴室间隔缺损型完全性大动脉转位(TGA/VSD)10例。获取心尖四腔切面,应用超声斑点追踪成像技术(speckle tracking imaging, STI)测量右室游离壁和室间隔右室面基底段、中间段、心尖段6个节段的纵向收缩期峰值应变(Strain, S)、收缩期峰值应变率(Strain rate, SRs),及右室整体纵向收缩期峰值应变(GLS)、应变率(GLSRs),右室整体纵向舒张早期峰值应变率(GLSRe)、右室整体纵向舒张晚期峰值应变率(GLSRa),并比较各期峰值应变、应变率在两组间有无差异。
结果①行Switch术后,TGA/IVS组患者右室游离壁及室间隔各节段S、SRs与正常对照组相比,差异均无统计学意义(P>0.05)：TGA/IVS组患者右室GLS、GLSRs、GLSRe、GLSRa较正常对照组相比,各指标两组间差异无统计学意义(P>0.05)。②行Switch术后,TGA/VSD组患者右室游离壁基底段、中间段应变率较正常对照组减低,差异有统计学意义(P<0.05),而右室游离壁心尖段与对照组相比,差异无统计学意义(P>0.05),右室游离壁及室间隔各节段应变与正常对照组相比,差异均无统计学意义(P>0.05)；TGA/VSD组患者右室GLSRs、GLSRe、GLSRa等较正常对照组减低,差异均有统计学意义(P<0.05),而右室GLS与正常对照组相比,差异无统计学意义(P>0.05)。
结论完全性大动脉转位TGA/IVS组患者行Switch术后1年以上右室局部及整体功能恢复正常,TGA/VSD组患者行Switch术后1年以上右室局部及整体功能较正常组减低,应用STI技术可早期发现TGA患者术后右室局部及整体功能改变,为临床上评估右室功能提供了一种新方法。
Complete transposition of the great arteries (TGA) is one of the most common cyanotic congenital heart diseases seen in newborns, just second only to Tetralogy of Fallot, represent 7-9% of all congenital heart diseases, corresponding to an incidence of 2 to 3 per 10000 live births.There is a male predominance with a male/female sex ratio that approximately 2:1. In this defect, the aorta arises from the morphological right ventricular, and the pulmonary artery arises from the morphological left ventricular. This disease is very complex, and the natural survival rate is very low, the mortality rate in untreated patients is approximately 90% by the end of the first year.
The primary treatment for complete transposition of the great arteries is surgical repair. The surgical procedures includes:the atrial switch operation and the arterial switch operation. The atrial switch operation includes Mustard and Senning procedures, but these procedures just give physical correction for complete transposition of the great arteries.Long-term follow up is mainly influenced by arrhythmias, tricuspid regurgitation, right ventricular dilatation, systolic dysfunction of the systemic right ventricle in patients with complete transposition of the great arteries after Mustard and Senning procedures, some studies have reported that reduced function of the systemic right ventricle is associated with increased mortality in late stage outlook of these patients. With recent improvement in surgical technique and postoperative care, atterial switch operation is currently the procedure of the best choice for neonates with complete transposition of the great arteries, compared with atrial switch operation, the primary adventages of the arterial switch operation is not only establishment of left ventricle as the systemic ventricle, but also given physical correction for complete transposition of the great arteries. Accurate evaluation of left and right ventricular function in preoperative and postoperative patients with transposition of great arteries, can help to select timing for surgical operation select surgical procedure、assess operative outcomes and prognosis. Currently, echocardiography is the preferred method for clinical evaluation of left ventricular function, the left ventricular ejection fraction (LVEF) is the most common measurement parameter of left ventricular function, using echocardiography in evalution of left ventricular function is substantially perfect. However, assessing the function of the morphological right ventricle by conventional echocardiography is inherently difficult. Severial imaging modalities, such as cardiac magnetic resonance imaging, angiography are the gold standard for accurate quantitative evaluation of right ventricular function, but these technology are not available for neonates. A recent developed ultrasound speckle tracking imaging (STI) technique can trace the speckle spatial motions of myocardium and calculate deformation of the myocardial tissue, and then give accurate quantitative assessment of reginal myocardial function and ventricular globe function, so the STI technique can detect the regional dysfunction of ventricular before the globe dysfunction of ventricular, and it also have been used to assess right ventricular function widely. But so far, there are no reports to evaluate the right function with complete transposition of the great arteries after aterial switch operation by using ultrasound speckle tracking imaging, so the present study was divided into three parts as follows: Part 1 Assessment of right ventricular regional and global function in patients with complete transposition of the great arteries by ultrasound speckle tracking imaging
Objective:Assessment of right ventricular (RV) regional and global function in patients with complete transposition of the great arteries by ultrasound speckle tracking imaging.
Methods:There were 25 patients with complete transposition of the great arteries enrolled in our study,19 males and 6 females. The TGA patients were divided into intact ventricular septum TGA (14 cases) and ventricular septal defect TGA(11 cases) according to the complete of the ventricular septal.16 cases of normal control group were chosen in our study. Two-dimensional strain (2DS) were obtained at the apical four-chamber views and then were analyzed offline by using automated software (EchoPAC,GE Medical). The myocardial logitudinal peak systolic stain were determined at the basal, mid, and apical segment of the righe ventricular free wall and ventricular septum by 2DS, the right ventricular global logitudinal peak systolic stain were also determined by 2DS.Compare the data between three groups. Besides, measuring RV end-diastolic dimension (RVED), RV ejection fractions (RVEF), RV percent change in area (RVPCA) and tricuspid annular systolic peak velocity (TVSPV), and analyzing correlation of these parameters with RV global logitudinal peak systolic stain.
Results:①The right ventricular longitudinal peak systolic strain (S), strain rate (SR) of basal, mid, apical segment in free wall were lower in TGA patients compared with normal controls,the difference was significant (P<0.05). The right ventricular longitudinal S of basal, mid, apical segment in interventricular septum were lower in TGA patients compared with normal controls (P<0.05). The SRs of apical of interventricular septum were lower in TGA/IVS patients compared to controls (P<0.05). The SRs of basal, mid in interventricular septum in TGA/IVS patients and all sigments in interventricular septum in TGA/VSD patients were slightly reduced compared with controls,the difference was no significant.(P>0.05).②The right ventricular GLS、GLSRs and GLSRe in TGA/IVS patients were lower than controls, the difference was significant (P<0.05). The right ventricular GLSRa was slight reduced compared with controls, the difference was no significant(P>0.05). The right ventricular GLS、GLSRs in TGA/VSD patients were lower than controls(P<0.05). The GLSRa were slightly reduced compared with controls(P>0.05).③All the strain parameters in TGA/IVS patients were lower than TGA/VSD patients, but the difference was no significant (P>0.05).④The TVSPV had correlation with right ventricular GLS in TGA/IVS patients (r=0.66, P<0.05), and also had correlation with right ventricular GLSRs in TGA/VSD patients (r=-0.75, P<0.05)
Conclusion:The right ventricular regional and global function reduced in patients with complete transposition of the great arteries. Ultrasound speckle tracking imaging technique can quantitatively assess the right ventricular regional and global function accurately. Ultrasound speckle tracking imaging is an effectively methods for evaluating right ventricular function.
Part 2 Assessment of right ventricular regional and global function in preoperative and early period of postoperative patients with complete transposition of the great arteries after arterial switch operation by ultrasound speckle tracking imaging
Objective:Assessment of right ventricular regional and global function in preoperative and early period of postoperative patients with complete transposition of the great arteries after arterial switch operation by ultrasound speckle tracking imaging.
Methods:There were 25 patients with complete transposition of the great arteries enrolled in our study,19 males and 6 females.16 cases of normal control group were chosen in our study. The TGA patients were divided into 14 cases of intact ventricular septum TGA and 11 cases of ventricular septal defect TGA according to the complete of the ventricular septal. Such indexes were measured by STI before operation,2 weeks after operation,3 months after operation separately, the myocardial logitudinal peak systolic stain were determined at the basal, mid, and apical segment of the righe ventricular free wall and interventricular septum by 2DS, the right ventricular global logitudinal peak stain were also determined by 2DS.
Results:①The right ventricular GLS、GLSRs and S、SRs of all the segments in right ventricular free wall in TGA/IVS patients reduced compared with the controls. These indexes gradually increased 2 weeks and 3 months after operation, but still below normal levels. But, the right ventricular GLSRs and SRs of all the segments in right ventricular free wall increased to normal levels; S、SRs of all segments in right ventricular interventricular septum were lower compared with normal controls before operation, S、SRs of basal segment in right ventricular interventricular septum further reduced compared with preparation 2 weeks after operation, and gradually increased 3 months after operation., the SRs increased to normal level, but S was still lower than normal levels. S、SRs of mid、apical segments in right ventricular interventricular septum, gradually increased 2 weeks and 3 months after operation. S was still lower than normal level, but SRs increased to normal level.②The GLS、GLSRs of the right ventricular and the right ventricular S, SR of all segments in free wall were lower in TGA/VSD patients compared with normal controls, but these indexes gradually decreased 2 weeks and 3 months after operation, S of all segments in right ventricular free wall were lower in 2 weeks after operation than before operation, increased in 3 months after operation, were lower than before operation, but was still lower than normal levels. SRs of basal segment in right ventricular free wall increased gradually to normal levels 2 weeks and 3 months after operation. SRs of mid、apical segments in right ventricular free wall were still at the preoperative level, however, S、SRs of all segments in right ventricular interventricular septum were lower than preoperative level, and gradually reduced compared with preoperative level.
Conclusion:The right ventricular regional and global function increased in TGA/IVS patients at early period after arterial switch operation. The regional ventricular function increased slightly in TGA/VSD patients, but the global ventricular function were still at the preoperative level. STI technique can quantitatively assess the right ventricular regional and global function accurately and it also can detect the changes of cardiac function early and sensitively. In a word, STI can provide important value for clinical evaluation of surgical treatment and prognosis.
Part 3 Assessment of right ventricular regional and global function in patients with complete transposition of the great arteries at least one year after arterial switch operation by ultrasound speckle tracking imaging
Objective:Assessment of right ventricular regional and global function in patients with complete transposition of the great arteries at least one year after arterial switch operation by ultrasound speckle tracking imaging.
Methods:There were 20 patients with complete transposition of the great arteries enrolled in our study,17 males and 3 females.16 cases of normal control group were chosen in our study. The TGA patients were divided into 10 cases of intact ventricular septum TGA and 10 cases of ventricular septal defect TGA according to the complete of the ventricular septal. Two-dimensional strain (2DS) were obtained at the apical four-chamber views and then were analyzed offline by using automated software (EchoPAC,GE Medical). The myocardial logitudinal peak systolic stain were determined at the basal, mid, and apical segment of the righe ventricular free wall and ventricular septum by 2DS, the right ventricular global logitudinal peak systolic stain were also determined by 2DS.Compare the data between three groups. Besides, measuring RV end-diastolic dimension (RVED), RV ejection fractions (RVEF), RV percent change in area (RVPCA) and tricuspid annular systolic peak velocity (TVSPV), and analyzing correlation of these parameters with RV global logitudinal peak systolic stain.
Results:①There were not only no differences of S、SRs of all the segments in the right ventricular free wall and interventricular septum in TGA/IVS patients compared to normal controls after arterial switch operation(P>0.05), but also no differences of the right ventricular GLS、GLSRs、GLSRe. GLSRa in TGA/IVS patients compared to normal controls (P>0.05).②The SRs of basal、mid segment in right ventricular free wall in TGA/VSD patients reduced after artrial swith operation, the difference was significant (P<0.05). There was no significant difference of the SRs of apical segment in right ventricular free wall compared with controls (P>0.05).There were no significant differences of the S of all the segments in right ventricular free wall and interventricular septum compared with normal controls (P>0.05); The right ventricular GLSRs、GLSRe. GLSRa in TGA/VSD patients reduced compared with normal controls, the difference was significant (P<0.05), but the difference of right ventricular GLS compared with normal controls was not significant (P>0.05)
Conclusion:The right ventricular regional and global function returned to normal level in TGA/IVS patients after arterial switch operation for more than 1 year. The right ventricular regional and global function reduced slightly in TGA/VSD patients compared with normal controls after arterial switch operation for more than 1 year. STI technique can detect the function changes of right ventricular regional and global function early and sensitively. STI provide a new method for clinical evaluation of right ventricular function.
引文
1朱晓东,张宝仁,主编.心脏外科学.第1版.北京：人民卫生出版社,2007：608
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2 Williams WG, McCrindle BW, Ashburn DA, et al. Outcomes of 829 neonates with complete transposition of the great arteries 12-17 years after repair. Eur J Cardiothorac Surg,2003,24(1):1-9
3 Roos-Hesselink JW, Meijboom FJ, Spitaels SE, et al. Decline in ventricular function and clinical condition after Mustard repair for transposition of the great arteries.Eur Heart J,2004,25:1264-1270
4 Dos L, Teruel L, Ferreira IJ, et al. Late outcome of Senning and Mustard procedures for correction of transposition of the great arteries. Heart, 2005,91:652-656
5 Graham TP, Bernard YD, Mellen BG, et al. Long-term outcome in congenitally corrected transposition of the great arteries:a multi-institutional study. J Am Coll Cardiol.2000,36:255-261
6 Kramer H H, Rammos S, Krian A, et al. Intermediate-term clinical and hemodynamic results of the neonatal arterial switch operation for complete transposition of the great arteries. Int J Cardiol,1992,36(1):13-22
7徐志伟,丁文祥,苏肇伉,等.大动脉转换术治疗新生儿完全性大动脉错位.中华胸心血管外科杂志,2002,18(3)：147-149
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15 Amundsen BH, Helle-Valle T, Edvardsen T, et al. Noninvasive myocardial strain measurement by speckle tracking echocardiography validation against sonomicrometry and tagged magnetic resonance imaging. J Am Coll Cardiol, 2006,47:789-793
16 Pirat B, McCulloch M L, Zoghbi W A, et al. Evaluation of global and regional right ventricular systolic function in patients with pulmonary hypertension using a novel speckle tracking method[J]. Am J Cardiol,2006,98(5):699-704
17 Chow P C, Liang X C, Cheung E W Y, et al.New two-dimensional global longitudinal strain and strain rate imaging for assessment of systemic right ventricular function[J].Heart,2008,94(7):855-859.
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24 Chow P C, Liang X C, Cheung E W Y, et al.New two-dimensional global longitudinal strain and strain rate imaging for assessment of systemic right ventricular function.Heart,2008,94:855-859
25 Andreas PK, Vasiliki VG, Grigorios G, et al. Myocardial deformation imaging of the systemic right ventricle by two-dimensional strain echocardiography in patients with D-Transposition of the great arteries. Hellennic J Cardiol,2009, 50:275-282
26 Michael B, Carmen H, Christina O, et al.The right ventricular response to high afterload:comparison between healthy persons and patients with transposition of the great arteries:A 2D strain study.Echocardiography,2010,27:1256-1262
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2 Williams WG, McCrindle BW, Ashburn DA, et al. Outcomes of 829 neonates with complete transposition of the great arteries 12-17 years after repair. Eur J Cardiothorac Surg,2003,24(1):1-9
3 Roos-Hesselink JW, Meijboom FJ, Spitaels SE, et al. Decline in ventricular function and clinical condition after Mustard repair for transposition of the great arteries.Eur Heart J,2004,25:1264-1270
4 Dos L, Teruel L, Ferreira IJ, et al. Late outcome of Senning and Mustard procedures for correction of transposition of the great arteries. Heart, 2005,91:652-656
5 Graham TP, Bernard YD, Mellen BG, et al. Long-term outcome in congenitally corrected transposition of the great arteries:a multi-institutional study. J Am Coll Cardiol.2000,36:255-261
6 Kramer H H, Rammos S, Krian A, et al. Intermediate-term clinical and hemodynamic results of the neonatal arterial switch operation for complete transposition of the great arteries. Int J Cardiol,1992,36(1):13-22
7徐志伟,丁文祥,苏肇伉,等.大动脉转换术治疗新生儿完全性大动脉错位.中华胸心血管外科杂志,2002,18(3)：147-149
8 Roussin R, Bellie E, Bruniaux J, et al. Surgery for transposition of the great arteries in neonates weighing less than 2000 grams:a consecutive series of 25 patients. Ann Thorac Surg,2007,83(1):173-178
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10 Gelatt M, Hamilton RM, McCrindle BW, et al. Arrhythmia and mortality after the Mustard procedure:a 30-year singlecenter experience.J Am Coll Cardiol.1997,29: 194-201
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12 Wilson NJ, Clarkson PM, Barratt-Boyes BG, et al. Long-term outcome after the Mustard repair for simple transposition of the great arteries.28-year follow-up. J Am Coll Cardiol.1998,32:758-765
13 Losay J, Touchot A, Serraf A, et al. Late outcome after arterial switch operation for transposition of the great arteries. Circulation,2001,104(12):121-126
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15 Amundsen BH, Helle-Valle T, Edvardsen T, et al. Noninvasive myocardial strain measurement by speckle tracking echocardiography validation against sonomicrometry and tagged magnetic resonance imaging. J Am Coll Cardiol, 2006,47:789-793
16 Pirat B, McCulloch M L, Zoghbi W A, et al. Evaluation of global and regional right ventricular systolic function in patients with pulmonary hypertension using a novel speckle tracking method[J]. Am J Cardiol,2006,98(5):699-704
17 Chow P C, Liang X C, Cheung E W Y, et al.New two-dimensional global longitudinal strain and strain rate imaging for assessment of systemic right ventricular function[J].Heart,2008,94(7):855-859.
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24 Chow P C, Liang X C, Cheung E W Y, et al.New two-dimensional global longitudinal strain and strain rate imaging for assessment of systemic right ventricular function.Heart,2008,94:855-859
25 Andreas PK, Vasiliki VG, Grigorios G, et al. Myocardial deformation imaging of the systemic right ventricle by two-dimensional strain echocardiography in patients with D-Transposition of the great arteries. Hellennic J Cardiol,2009, 50:275-282
26 Michael B, Carmen H, Christina O, et al.The right ventricular response to high afterload:comparison between healthy persons and patients with transposition of the great arteries:A 2D strain study.Echocardiography,2010,27:1256-1262
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