超声心动图对室缺患者封堵术前后血流动力学、心腔大小和左心室收缩功能变化的观察
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摘要
目的运用经胸超声心动图(Transthoracic echocardiography, TTE)研究室间隔缺损(Ventricular septal defect, VSD)患者行封堵术介入治疗前后心脏血流动力学、心腔大小和左心收缩功能的近、中期变化。资料与方法收集2010年7月至2011年10月,在广西医科大学第一附属医院心血管研究所住院,经常规超声心动图筛查,选取适宜行室间隔缺损封堵术并成功完成封堵术治疗的VSD患者40例,分别于术前3天、术后3天、术后3个月和术后6个月行超声心动图检查,运用经胸壁超声心动图二维方法于左室长轴切面测量左心房收缩末期前后径、右心室舒张末期前后径、左心室收缩末期和舒张末期前后径；于心尖四腔观切面测量右心房收缩末期横径、右心室舒张末期横径,频谱多普勒方法测量二尖瓣口舒张早期E峰峰值血流速度(Em)和舒张晚期A峰峰值血流速度(Am)；于大动脉短轴观测量主肺动脉内径及运用频谱多普勒测量收缩期肺动脉瓣口峰值血流速度(Vmax)和平均血流速度(Vmean)。于心尖五腔观测量左室流出道收缩期前向血流峰值速度；然后于心尖四腔观切面通过实时三维超声心动图(Real-Time Three-Dimensional Echocardiography, RT-3DE)测量左室舒张末期容积(LVEDV)和左室收缩末期容积(LVESV),并得出左心室射血分数(LVEF)。以上各时间点测得的数据与术前相同指标作配对t检验,当P<0.05时认为差异有统计学意义。结果(1)血流动力学改变：封堵术后原室间隔水平异常分流消失；二尖瓣口Em和Am、肺动脉瓣口Vmax和Vmean术后3天、术后3个月和术后6个月均较术前有明显降低,差异均有统计学意义(均P<0.05)。左室流出道前向峰值血流速度术后3天与术前相比增快(P<0.05),术后3个月和6个月与术前相比均减慢(均P<0.05)。(2)心脏腔室大小变化：(a)左心系统：左房收缩末期前后径术后3天较术前减小(P<0.05),术后3个月和术后6个月较术前进一步减小(均P<0.01)。左室舒张末期内径术后3天较术前减小(P<0.05),术后3个月和术后6个月左室舒张末期内径进一步减小(P<0.01)；左室收缩末期内径术后3天与术前相比无明显差异(P>0.05),术后3个月和术后6个月比术前减小(均P<0.05)。(b)右心系统：右房收缩末期横径术后3天与术前比较无明显变化(P>0.05),术后3个月和6个月与术前比较均减小(均P<0.05)；右室舒张末期前后径术后各时间点测值与术前比较均无明显变化(均P>0.05)。右室舒张末期横径术后3天、术后3个月和术后6个月与术前比较均减小(均P<0.05)。肺动脉内径：术后3天、术后3个月和术后6个月与术前比较均减小(均P<0.05)。(3)左室容积与左心功能的变化：术后3天、3个月和6个月EF与术前EF相比均减小(均P<0.05)。左室舒张末期容积术后3天、术后3个月和6个月均较术前减小(均P<0.05)。左室收缩末期容积术后3天与术前比较无明显变化(P>0.05),术后3个月和6个月均较术前减小(均P<0.05)。结论室间隔缺损封堵术可以完全阻断心内异常分流。随着心内异常分流的阻断,心脏血流动力学得以恢复正常状态,原先代偿增加的左心容量负荷和左心收缩功能也得到恢复。另外,RT-3DE测量室缺患者心腔容积和心功能具有可行性。
Objective To evaluate the changes of hemodynamics, cardiac chamber size and left ventricular systolic function in patients with VSD before and after occlusion in short and middle term using transthoracic echocardiography (Transthoracic echocardiography).Methods40patients with VSD hospitaled in First Affiliated Hospital and cardiovascular Research Institute of Guangxi Medical University were involved in the present study during July2010and October2011. TTE and RT-3DE were performed on patients before occlusion and after three days, three months and six months of occlusion. Left atrial end-systolic diameter was measured using two-dimensional. Right ventricular end-diastolic diameter, left ventricular end-systolic and end-diastolic diameter were evaluate via long axis view. Right atrial end-systolic diameter, right ventricular end-diastolic diameter were measured via apical four-chamber view. The mitral E wave peak velocity (Em) and A wave peak velocity (Am) were measured by spectral doppler. The main pulmonary artery diameter was evaluated via aorta short axis view. Pulmonary artery orifice peak flow velocity (Vmax) and mean blood flow velocity (Vmean) were determined by doppler spectrum. Left ventricular outflow maximum velocity was measured via apical five-chamber view. Real-time three-dimensional echocardiography (RT-3DE) was adopted to measure left ventricular end-diastolic volume (LVEDV) via apical four-chamber view. Left ventricular ejection fraction (LVEF) was automatically calculated by the instrument.All data obtained after occlusion were compared with pre-operation using paired t test, the difference was statistically significant when P<0.05.Results (1) Hemodynamic changes:abnormal shunt disappeared after transcatheter closure of ventricular. After three days, three months and6months of occlusion, the mitral Em, Am, the pulmonary valve orifice Vmax and Vmean were significantly decreased. The difference was statistically significant (P <0.05).(2) Left ventricular cardiac chamber size changes:(A) Left atrial end-systolic diameter was reduced compared with pre-operation (P<0.05). After3days,3months and6months of occlusion, the diameter was further reduced (P <0.01). Left ventricular end-diastolic diameter was reduced after3days of occlusion (P<0.05) compared with pre-operation, but left ventricular end-systolic diameter was not different compared with pre-operation (P>0.05). After3months and6months of occlusion, the left ventricular end-diastolic diameter was further decreased and the left ventricular end-systolic diameter were also reduced (P<0.05).(B) The right heart:There was no difference in right atrial end-systolic diameter obtained at different time points after occlusion (P>0.05). Right ventricular end-diastolic diameter were reduced after3days,3months and6months of occlusion (P<0.05). Pulmonary artery:the diameter of pulmonary artery was decreased after3days,3months and6months of occlusion (P<0.05).(3) Changes in left ventricular volume and left ventricular function:After three days, three months and six months of occlusion, EF was significantly reduced (P<0.05). Compared with pre-operation, left ventricular end-diastolic volume was reduced (P<0.05) after3days,3months and6months of occlusion. The left ventricular end-systolic volume showed no significant changes after three days of occlusion, but was reduced after three months and six months of occlusion (P<0.05).Conclusions It is very helpful to assess the effect of occlusion on patients with VSD by transthoracic echocardiography. The occlusion performed in patients with VSD changed the original abnormal hemodynamic state. Thus, the original increasing compensatory volume in heart chamber was corrected. While improving the shape and configuration of abnormal heart chamber, the left ventricular systolic function was restored. It is feasible and accurate to measure heart volume and cardiac function in patients with VSD by RT-3DE.
Objective To evaluate the changes of hemodynamics, cardiac chamber size and left ventricular systolic function in patients with VSD before and after occlusion in short and middle term using transthoracic echocardiography (Transthoracic echocardiography).Methods40patients with VSD hospitaled in First Affiliated Hospital and cardiovascular Research Institute of Guangxi Medical University were involved in the present study during July2010and October2011. TTE and RT-3DE were performed on patients before occlusion and after three days, three months and six months of occlusion. Left atrial end-systolic diameter was measured using two-dimensional. Right ventricular end-diastolic diameter, left ventricular end-systolic and end-diastolic diameter were evaluate via long axis view. Right atrial end-systolic diameter, right ventricular end-diastolic diameter were measured via apical four-chamber view. The mitral E wave peak velocity (Em) and A wave peak velocity (Am) were measured by spectral doppler. The main pulmonary artery diameter was evaluated via aorta short axis view. Pulmonary artery orifice peak flow velocity (Vmax) and mean blood flow velocity (Vmean) were determined by doppler spectrum. Left ventricular outflow maximum velocity was measured via apical five-chamber view. Real-time three-dimensional echocardiography (RT-3DE) was adopted to measure left ventricular end-diastolic volume (LVEDV) via apical four-chamber view. Left ventricular ejection fraction (LVEF) was automatically calculated by the instrument.All data obtained after occlusion were compared with pre-operation using paired t test, the difference was statistically significant when P<0.05.Results (1) Hemodynamic changes:abnormal shunt disappeared after transcatheter closure of ventricular. After three days, three months and6months of occlusion, the mitral Em, Am, the pulmonary valve orifice Vmax and Vmean were significantly decreased. The difference was statistically significant (P <0.05).(2) Left ventricular cardiac chamber size changes:(A) Left atrial end-systolic diameter was reduced compared with pre-operation (P<0.05). After3days,3months and6months of occlusion, the diameter was further reduced (P <0.01). Left ventricular end-diastolic diameter was reduced after3days of occlusion (P<0.05) compared with pre-operation, but left ventricular end-systolic diameter was not different compared with pre-operation (P>0.05). After3months and6months of occlusion, the left ventricular end-diastolic diameter was further decreased and the left ventricular end-systolic diameter were also reduced (P<0.05).(B) The right heart:There was no difference in right atrial end-systolic diameter obtained at different time points after occlusion (P>0.05). Right ventricular end-diastolic diameter were reduced after3days,3months and6months of occlusion (P<0.05). Pulmonary artery:the diameter of pulmonary artery was decreased after3days,3months and6months of occlusion (P<0.05).(3) Changes in left ventricular volume and left ventricular function:After three days, three months and six months of occlusion, EF was significantly reduced (P<0.05). Compared with pre-operation, left ventricular end-diastolic volume was reduced (P<0.05) after3days,3months and6months of occlusion. The left ventricular end-systolic volume showed no significant changes after three days of occlusion, but was reduced after three months and six months of occlusion (P<0.05).Conclusions It is very helpful to assess the effect of occlusion on patients with VSD by transthoracic echocardiography. The occlusion performed in patients with VSD changed the original abnormal hemodynamic state. Thus, the original increasing compensatory volume in heart chamber was corrected. While improving the shape and configuration of abnormal heart chamber, the left ventricular systolic function was restored. It is feasible and accurate to measure heart volume and cardiac function in patients with VSD by RT-3DE.
引文
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2. J. L. Bass, G. S. Kalra, R. Arora, et al. Initial human experience with the Amplatzer perimembranous ventricular septal occluder device. Catheter Cardiovasc Interv,2003,58:238-245.
3.张军,李军,石晶,等.超声心动图在嵴内型室间隔缺损封堵中的作用.心脏杂志,2005,17：4.
4.李军,张军,段云燕,等.超声心动图与心血管造影在室缺封堵术中的互补价值.中国超声医学杂志,2005,21：3.
5.张华,邵荣龙,孙万峰,等.经胸彩色多普勒超声心动图在室间隔缺损封堵术中的研究.中国临床医学影像杂志,2004,15：2.
6.王凡,汤宝鹏,马依彤,等.应用Amplatzer封堵器介入治疗膜部室缺远期疗效评价.新疆医科大学学报,2004,27：3.
7. G. Derumeaux, P. Mulder, V. Richard, et al. Tissue Doppler imaging differentiates physiological from pathological pressure-overload left ventricular hypertrophy in rats. Circulation,2002,105:1602-1608.
8. M. Galderisi, D. Mele,P. N. Marino. Quantitation of stress echocardiography
by tissue Doppler and strain rate imaging:a dream come true? Ital Heart J,2005,6:9-20.
9. N. L. Greenberg, M. S. Firstenberg, P. L. Castro, et al. Doppler-derived myocardial systolic strain rate is a strong index of left ventricular contractility. Circulation,2002,105:99-105.
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