胸部CT测量左右心室容积比预测肺动脉高压的潜能:与超声心动图估算的肺动脉收缩压有关

目的探讨胸部CT测量的右心室(RV)与左心室(LV)容积比与超声心动图估算的肺动脉收缩压(PASP)之间的相关性。方法 104例[(72.47±13.64)岁,男性39例]病人均行胸部CT与超声心动图,根据其超声心动图PASP25mmHg(1mmHg=0.133kPa)分为两组(高血压组和正常血压组),并计算RV与LV容积比(RVV/LVV)。回归分析得出RVV/LVV与PASP具有相关性。通过计算胸部CT曲线下面积(AUC)来预测肺动脉高压。结果高血压组,平均PASP为(46.29±14.42)mmHg(29～98mmHg),且RVV/LVV与PASP之间具有显著相关性(R=0.82,P<0.001)。观察组内与观察组间RVV/LVV的相关系数为0.990和0.892。高血压组RVV/LVV为1.01±0.44(0.51～2.77),正常血压组为0.72±0.14(0.52～1.11)(P<0.05)。RVV/LVV的分界值为0.9,预测超过40mmHg肺动脉高压的敏感度和特异度分别为79.5%和90%。预测肺动脉高压的曲线下面积为0.87。结论胸部CTRV/LV容积比与超声心动图估算的PASP有很好的相关性,且用来预测超过40mmHg的肺动脉高压具有较高的敏感性和特异性。要点①胸部CT广泛应用于肺动脉高压病人。②胸部CT心室容积比与肺动脉收缩压相关。③R/L心室容积比>0.9常提示肺动脉血压>40mmHg。④常规胸部CT的有效信息有助于预测肺动脉高压。     

The systolic arterial pressure/end-systolic volume relationship in patients with severe left ventricular dysfunction

Performance of the intact left ventricle is well-defined by the end-systolic pressure/end-systolic volume relationship that appears independent of preload and afterload. To determine whether noninvasive measurements of this relationship could distinguish normal from abnormal subjects, we evaluated the relationship between arterial systolic pressure (determined by cuff sphygnonanometry) and radionuclide estimates of end-systolic volume in 12 normal subjects and 24 patients with severe left ventricular dysfunction. Data were acquired at rest, after atropine injection, and then during at least three increments of arterial pressure (average total increase approximately 45 mm Hg) using phenylephrine. The relationship between peak-systolic pressure (SP) and end-systolic volume (ESV) was found to be linear in all subjects (r≧0.91). The slope of this line was steeper in normal subjects than in myopathic patients (73±21.7 vs 20.8±8.7 mm Hg/volume unit/m²,P<0.001) and the zero pressure intercept also was greater (49.8±30 mm Hg vs 27.1±44.2 mm Hg,P<0.01). Similarly, resting ejection fraction (EF) was greater in the normals (0.71±0.88 vs 0.21±0.07%P<0.001) and end-diastolic volume (EDV) was smaller (4.14±0.88 vs 6.58±0.65 volume units,P<0.01). Systolic pressure/end-systolic volume relationship determined by these noninvasive methods was linear in both patients with severely reduced cardiac function and normal control subjects, clearly distinguishing normal from severely impaired left ventricles. This noninvasively determined pressure-volume relationship may be a useful index to identify patients who may benefit from inotropic agents—to regulate their long-term inotropic therapy-and possibly to distinguish inotropic vs vasodilator effects on the heart.     

Repaired tetralogy of fallot: ratio of right ventricular volume to left ventricular volume as a marker of right ventricular dilatation

Purpose: To compare indexed right ventricular (RV) end-diastolic volume (RVEDVi) and the ratio of RV volume to left ventricular (LV) volume (RV/LV ratio) in prediction of significant pulmonary regurgitation (PR) after tetralogy of Fallot (TOF) repair and to assess sex differences in the RV/LV ratio. Materials and Methods: The ethics committee approved this retrospective single-center study, and patients or their parents or guardians signed written informed consent. RVEDVi, RV/LV ratio, and PR were measured with the use of magnetic resonance imaging in 155 consecutive patients with repaired TOF (mean age, 29.2 years ± 10.9 [standard deviation]; 98 [63.2%] male and 57 [36.8%] female patients). PR fraction of 20% or greater was considered significant. The capability of the RVEDVi and that of the RV/LV ratio for prediction of significant PR were compared by using logistic regression analysis and receiver operating characteristic curve analysis. Results: RVEDVi was significantly higher in male (162.8 mL/m(2) ± 50.4) than in female (138.2 mL/m(2) ± 37.5) patients (P = .001). Conversely, the RV/LV ratio was similar in both sexes (1.82 ± 0.56 [male] vs 1.69 ± 0.46 [female], P = .13) both in the entire cohort and after excluding patients with significant (≥ 30 mm Hg) RV outflow tract gradient and/or other residual hemodynamic abnormalities (P = .63). Receiver operating characteristic analysis revealed better discrimination of significant (≥ 20%) from insignificant (< 20%) PR with the use of the RV/LV ratio than with RVEDVi (area under the receiver operating characteristic curve, 0.937 [model 4] vs 0.849 [model 1], P = .01). In multivariate analysis, the only independent predictor of PR fraction was the RV/LV ratio. Conclusion: The RV/LV ratio is more accurate than the RVEDVi in differentiation of significant from insignificant PR. After TOF repair, female and male patients have similar RV/LV ratios despite significant differences in RVEDVi between the sexes. ? RSNA, 2012 Supplemental material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120051/-/DC1.     

法洛四联症修复术后:右心室与左心室容积之比衡量右心室扩张度

摘要目的比较右心室(RV)舒张末期容积(RVEDVi)和RV与左心室(LV)容积比(RV/LV)对于预测法洛四联症(TOF)修复术后的显著肺动脉瓣反流(PR)的价值,并评价RV/LV值的性别差异。     

The ratio of right ventricular volume to left ventricular volume reflects the impact of pulmonary regurgitation independently of the method of pulmonary regurgitation quantification

Background

Previous studies have advocated quantifying pulmonary regurgitation (PR) by using PR volume (PRV) instead of commonly used PR fraction (PRF). However, physicians are not familiar with the use of PRV in clinical practice. The ratio of right ventricle (RV) volume to left ventricle volume (RV/LV) may better reflect the impact of PR on the heart than RV end-diastolic volume (RVEDV) alone. We aimed to compare the impact of PRV and PRF on RV size expressed as either the RV/LV ratio or RVEDV (mL/m²).

Methods

Consecutive patients with repaired tetralogy of Fallot were included (n = 53). PRV, PRF and ventricular volumes were measured with the use of cardiac magnetic resonance.

Results

RVEDV was more closely correlated with PRV when compared with PRF (r = 0.686, p < 0.0001, and r = 0.430, p = 0.0014, respectively). On the other hand, both PRV and PRF showed a good correlation with the RV/LV ratio (r = 0.691, p < 0.0001, and r = 0.685, p < 0.0001, respectively). Receiver operating characteristic analysis showed that both measures of PR had similar ability to predict severe RV dilatation when the RV/LV ratio-based criterion was used, namely the RV/LV ratio > 2.0 [area under the curve (AUC)_PRV = 0.770 vs AUC_PRF = 0.777, p = 0.86]. Conversely, with the use of the RVEDV-based criterion (>170 mL/m²), PRV proved to be superior over PRF (AUC_PRV = 0.770 vs AUC_PRF = 0.656, p = 0.0028].

Conclusions

PRV and PRF have similar significance as measures of PR when the RV/LV ratio is used instead of RVEDV. The RV/LV ratio is a universal marker of RV dilatation independent of the method of PR quantification applied (PRF vs PRV).     

肺动脉高压病人左右心室心肌灌注储备与右心室功能及肺血流动力学之间的相关性

目的应用腺苷负荷MR心肌灌注成像评价肺动脉高压(PAH)病人右心室(RV)与左心室(LV)间心肌灌注储备与心室功能及肺血流动力学的关系。材料与方法本研究符     

组织多普勒超声成像技术评价肺动脉高压患者右室功能的临床应用

目的 应用组织多普勒超声成像技术评价肺动脉高压患者右室收缩功能及舒张功能,研究肺动脉高压患者右室功能的变化.方法 选择90例肺动脉高压患者,根据PH程度分为轻度组、中度组、高度组三个亚组(各30例)和60例正常人作为对照组,测量肺动脉内径,右室前壁厚度,右室腔大小,双平面Simpson法测右室射血分数(RVEF),组织多普勒测量三尖瓣环(前瓣瓣环、后瓣瓣环、隔瓣瓣环)收缩期S波峰值速度(Sm),舒张早期负向E波峰值速度(Em),舒张晚期负向A波峰值速度(Am).结果 肺动脉高压组的右室收缩功能及舒张功能均减低,RVEF、Sm、Em和Em/Am均低于对照组,右室前壁厚度、右室腔大小,Am高于对照组,差异均有显著性意义.结论 肺动脉高压患者右室心肌收缩期峰值速度结合右室RVEF可作为评价右室收缩功能的有效指标,舒张期负向峰值速度Em、Em/Am减低,Am增高可准确的评估右室舒张功能.     

实时三维超声心动图评价高血压左室肥厚患者左室节段收缩功能

目的：应用实时三维超声心动图技术评价高血压性心脏病患者左心室壁节段收缩功能。方法：分别应用实时三维超声心动图测量20例健康者、20例高血压左室肥厚患者的左室壁17节段节段每搏量（rSV）、节段射血分数（rEF）、节段射血率（rPER）。结果：40例检测者均获得了具有清晰内膜边界的实时三维图像和17节段容积-时间曲线;两组间17节段rSV、rEF、rPER测量值间差异有统计学意义（P〈0.05）。结论：高血压左室肥厚患者与正常人左室壁节段收缩功能存在差异,实时三维超声心动图是一种可行的、准确定量评价左室壁节段收缩功能的新技术。     

Response of right ventricular systolic function to exercise stress: Effects of pulmonary vascular resistance on right ventricular systolic function

To elucidate factors influencing responses of right ventricular systolic function to exercise stress, we evaluated the right ventricular ejection fraction and peak ejection rate with two different loading conditions, atrial septal defect and mitral stenosis, at rest and during exercise by means of gated equilibrium blood pool radionuclide ventriculography. In both atrial septal defect and mitral stenosis, strong correlations between changes in the right ventricular ejection fraction with exercise and pulmonary vascular resistance at rest (r = ?0.97, p < 0.001; r = ?0.86, p < 0.0005: respectively) were found. Significant correlations between changes in the right ventricular peak ejection rate with exercise and pulmonary vascular resistance at rest (r = ?0.85, p < 0.05; r = ?0.75, p < 0.01: respectively) were found in atrial septal defect and mitral stenosis. Both the right ventricular ejection fraction and peak ejection rate were lower during exercise than at rest when pulmonary vascular resistance at rest was more than 200 dynes·sec·cm^?5·m² in both atrial septal defect and mitral stenosis. In conclusion, right ventricular systolic function responding to exercise stress was influenced by the pulmonary vascular resistance in both atrial septal defect and mitral stenosis.     

Diastolic and systolic right ventricular diameters for predicting pulmonary hypertension in children with congenital heart disease

Prospective electrocardiography (ECG)-gated cardiac computed tomography angiography (CTA) is widely used for pediatric patients with congenital heart disease (CHD) due to the lower radiation dose compared with the ECG-gated technique. However, functional parameters acquired using ECG-gated cardiac CT to predict pulmonary hypertension (PH) in children with CHD have not yet been reported. This study aimed to investigate the potential of diastolic and systolic right ventricular diameters (RVD) on prospective ECG-gated cardiac CTA to predict PH in children with CHD. A total of 44 children with CHD were divided into two groups: CHD with PH (n = 22) and CHD without PH (n = 22). The association between ECG-gated CTA parameters and PH was evaluated by logistic regression. The receiver operating characteristic curve (ROC) was used to find the best cut-off point for the parameters measured by Youden's index. Patients with higher RVD-BSA [aOR (95% CI) diastolic: 2.76 (1.23–6.23); systolic: 6.15 (1.72–22.06)] had higher risk of PH after adjusting for age and patent ductus arteriosus. The area under the curve (AUC) of D-RVD-BSA was 0.907 and the AUC of S-RVD-BSA was 0.917. Logistic regression showed that patients with D-RVD-BSA over 6.86 or S-RVD-BSA over 5.87 had significantly higher risk of PH after adjustments (aOR = 23.52, 95% CI = 2.89–191.03; aOR = 31.14, 95% CI = 2.75–352.85). In conclusion, in children with CHD, measurements of diastolic or systolic BSA-modified RVDs on prospective ECG-gated CTA are non-invasive markers of PH. BSA-modified D-RVD of 6.86 or BSA-modified S-RVD of 5.87 may be used to identify PH in children with CHD.     

特发性肺动脉高压与先天性心脏病相关肺动脉高压患者右心室心肌葡萄糖代谢的比较研究

目的 比较分析特发性肺动脉高压（IPAH）与先天性心脏病相关肺动脉高压（PAH-CHD）患者右心室心肌葡萄糖代谢的差异。 方法 选取2016年11月至2018年12月在中国医学科学院北京协和医学院阜外医院确诊的26例IPAH患者（IPAH组）[女性17例、男性9例,年龄（28.23±8.92）岁] 和16例PAH-CHD患者（PAH-CHD组） [女性10例、男性6例,年龄（29.19±10.62）岁]。所有患者均行动态18F-FDG PET心肌代谢显像,根据Patlak法计算得出右心室和左心室心肌葡萄糖利用率（rMGU）。显像后1周内患者接受右心导管检查,测定血流动力学指标。采用独立样本t检验比较2组的rMGU等指标;采用Pearson相关分析对2组患者右心室的rMGU与平均肺动脉压力（mPAP）或肺血管阻力的相关性进行分析。 结果 IPAH组与PAH-CHD组患者mPAP之间的差异无统计学意义 [（59.85±16.46） mm Hg 对（69.75±18.93） mm Hg,t=1.79,P=0.81]（1 mm Hg=0.133 kPa）。动态18F-FDG PET心肌代谢显像测得的2组患者右心室rMGU[（0.095±0.074） μmol·g−1·min−1 对（0.135±0.165） μmol·g−1·min−1]与左心室rMGU[（0.057±0.065） μmol·g−1·min−1 对（0.070±0.047） μmol·g−1·min−1] 之间的差异均无统计学意义（t=1.07, P=0.29;t=0.77,P=0.49）。IPAH组患者右心室的rMGU与mPAP存在正相关（r=0.420,P=0.033）,但PAH-CHD组患者右心室的rMGU与mPAP无相关性（r=0.016,P=0.953）。 结论 mPAP无差异的IPAH和 PAH-CHD患者右心室心肌葡萄糖代谢水平无明显差异。     

Quantitative 3D pulmonary MR-perfusion in patients with pulmonary arterial hypertension: correlation with invasive pressure measurements

PURPOSE: Pathological changes of the peripheral pulmonary arteries induce pulmonary arterial hypertension (PAH). Aim of this study was to quantitatively assess the effect of PAH on pulmonary perfusion by 3D-MR-perfusion techniques and to compare findings to healthy controls. Furthermore, quantitative perfusion data were correlated with invasive pressure measurements. MATERIAL AND METHODS: Five volunteers and 20 PAH patients (WHO class II or III) were examined using a 1.5T MR scanner. Measurement of pulmonary perfusion was done in an inspiratory breathhold (FLASH3D; 3.5 mm x 1.9 mm x 4mm; TA per 3D dataset 1.5s). Injection of contrast media (0.1 mmol Gd-DTPA/kg BW) and image acquisition were started simultaneously. Evaluation of 3D perfusion was done using singular value decomposition. Lung borders were outlined manually. Each lung volume was divided into three regions (anterior, middle, posterior), and the following parameters were assessed: Time-to-Peak (TTP), blood flow (PBF), blood volume (PBV), and mean transit time (MTT). In 10 patients invasive pulmonary artery pressure measurements were available and correlated to the perfusion measurements. RESULTS: In both, controls and patients, an anterior-to-posterior gradient with higher PBF and PBV posterior was observed. In the posterior lung region, a significant difference (p<0.05) was found for TTP (12s versus 16s) and MTT (4s versus 6s) between volunteers and patients. PBF and PBV were lower in patients than in volunteers (i.e. dorsal regions: 124 versus 180 ml/100 ml/min and 10 versus 12 ml/100 ml), but the difference failed to be significant. The ratio of PBF and PBV between the posterior and the middle or ventral regions showed no difference between both groups. A moderate linear correlation between mean pulmonary arterial pressure (mPAP) and PBV (r=0.51) and MTT (r=0.56) was found. CONCLUSION: The only measurable effect of PAH on pulmonary perfusion is a prolonging of the MTT. There is only a moderate linear correlation of invasive mPAP with PBV and MTT.     

斑点追踪技术评价肺动脉高压患者右心室舒张功能的研究

目的：应用斑点追踪成像技术评价肺动脉高压患者右心室舒张功能,并与常规多普勒超声心动对比研究。方法：肺动脉高压患者31例,正常对照组33例,二维斑点追踪成像技术获得右心室各个节段舒张期纵向应变率及运动速度。结果：右心室游离壁及室间隔各段舒张早期应变率（SRe）有显著性差异（P〈0．05）;右室游离壁及室间隔舒张早期应变率（SRe）平均值与右室游离壁厚度、肺动脉收缩压相关性较好。结论：舒张早期应变率与右室游离壁厚度及肺动脉收缩压相关性较好,二维斑点追踪成像技术为评价肺动脉高压右室舒张功能提供了一种可行的方法。     

Evaluation of right ventricular volume and ejection fraction by gated 18F-FDG PET in patients with pulmonary hypertension: Comparison with cardiac MRI and CT

Background

Right ventricular (RV) function is a powerful predictor of survival in patients with pulmonary hypertension (PH), but noninvasively assessing RV function remains a challenge. The aim of this study was to prospectively compare gated ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) myocardial imaging (gated PET), cardiac magnetic resonance (CMR), and cardiac computed tomography (CCT) for the assessment of RV volume and ejection fraction in patients with PH.

Methods

Twenty-three consecutive patients aged more than 16 years diagnosed with PH were included. All patients underwent gated PET, CMR, and CCT within 7 days. Right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), and right ventricular ejection fraction (RVEF) were calculated by three imaging modalities. RV ¹⁸F-FDG uptake was determined as RV-corrected standardized uptake value (SUV), and the ratio of RV to left ventricular (LV)-corrected SUV (Corrected SUV R/L).

Results

Gated PET showed a moderate correlation (r = 0.680, P < .001) for RVEDV, good correlation for RVESV (r = 0.757, P < .001) and RVEF (r = 0.788, P < .001) with CMR, and good correlation for RVEDV (r = 0.767, P < .001), RVESV (r = 0.837, P < .001), and RVEF (r = 0.730, P < .001) with CCT. Bland-Altman analysis revealed systematic underestimation of RVEDV and RVESV and overestimation of RVEF with gated PET compared with CMR and CCT. The correlation between RVESV (r = 0.863, P < .001), RVESV (r = 0.903, P < .001), and RVEF (r = 0.853, P < .001) of CMR and those of CCT was excellent; Bland-Altman analysis showed only a slight systematic variation between CMR and CCT. There were statistically significant negative correlations between RV-corrected SUV and RVEF-CMR (r = ?0.543, P < .01), Corrected SUV R/L and RVEF-CMR (r = ?0.521, P < .05), RV-corrected SUV and RVEF-CCT (r = ?0.429, P < .05), Corrected SUV R/L and RVEF-CCT (r = ?0.580, P < .01), respectively.

Conclusion

Gated PET had moderate-to-high correlation with CMR and CCT in the assessments of RV volume and ejection fraction. It is an available method for simultaneous assessing of RV function and myocardial glucose metabolism in patients with PH.     

STI评价原发性高血压与尿毒症左室壁增厚患者的左室纵行心肌应变

目的:应用斑点追踪技术成像(speckle tracking imaging,STI)评价原发性高血压与尿毒症左室壁增厚患者的左室纵行心肌应变。方法:正常对照组20例,原发性高血压组40例,尿毒症组30例。常规心脏数据测量后,连接胸导联心电图,分别采集心尖位3个长轴切面的二维灰阶动态图,取3个连续稳定心动周期,脱机分析18个节段收缩期峰值应变、二腔切面总应变、三腔切面总应变、四腔切面总应变及3个切面的平均总应变,记录并比较各参数测值。结果:正常对照组左室各壁收缩期峰值应变自基底段至心尖段逐渐增加;同一室壁各节段心肌收缩期峰值应变达峰时间基本一致。原发性高血压组左室前间隔中间段、心尖段与后壁中间段、心尖段,后间隔基底段收缩期峰值应变降低,与正常对照组差异有统计学意义,余室壁收缩期峰值应变、二腔切面总应变、三腔切面总应变、四腔切面总应变及3个切面的平均总应变与正常对照组差异无统计学意义;同一室壁各节段心肌应变曲线紊乱,收缩期峰值应变达峰时间一致性差。尿毒症组左室各壁收缩期峰值应变、二腔切面总应变、三腔切面总应变、四腔切面总应变及3个切面的平均总应变明显降低,与另外2组相比差异均有统计学意义;同一室壁各节段心肌应变曲线紊乱,收缩期峰值应变达峰时间一致性差。结论:STI能准确、快速地测定原发性高血压和尿毒症左室壁增厚患者左室局部心肌收缩期峰值应变的减低,提示患者左室整体收缩功能正常情况下存在节段性收缩功能降低。     

组织多普勒测定肺毛细血管楔压评价左室收缩功能的应用研究

目的 探讨应用超声组织多普勒及频谱多普勒综合指标测量肺毛细血管楔压以判定左心功能的可行性.方法 依据二尖瓣瓣环部组织多普勒超声测定各瓣环位点的舒张早期运动速度Ea值,再依据超声血流频谱多普勒测定二尖瓣舒张早期血流速度E峰值,估算出肺毛细血管楔压,据其测量数据将左心功能衰竭的严重程度分为轻、中、重三度,并与患者临床心功能分级进行比较.结果 Ⅰ组患者仅有1例心功能为3级,其余均为2级,占90％,Ⅱ组患者有1例心功能2级,8例心功能为三级占80％,1例心功能为4级,Ⅲ组患者有2例心功能为Ⅲ级,8例心功能为4级,占80％.Ⅰ组和Ⅱ组比较心功能2级和3级差异有显著性意义（P＜0.01）,Ⅱ组和Ⅲ组比较心功能3级和4级差异有非常显著性意义（P＜0.01）.结论 组织多普勒测定肺动脉楔压或肺毛细血管楔压,与临床心功能评价有良好的相关性,是反映左心功能及其前负荷的可靠指标.     

Massive hemoptysis: prediction of nonbronchial systemic arterial supply with chest CT

PURPOSE: To evaluate the diagnostic accuracy of chest computed tomography (CT) in the prediction of a nonbronchial systemic arterial supply in patients with massive hemoptysis. MATERIALS AND METHODS: Forty consecutive patients with massive hemoptysis underwent contrast material-enhanced CT. Massive hemoptysis was defined as the expectoration of 300-600 mL of blood per day. Two CT features were considered to be suggestive of a nonbronchial systemic arterial supply: (a) pleural thickness of more than 3 mm adjacent to the parenchymal lesion and (b) enhancing vascular structures within the extrapleural fat layer. Conventional angiography was used as the standard of reference. CT scans were evaluated by two radiologists in consensus. The CT findings were compared with those of conventional angiography. The sensitivity, specificity, predictive values, and accuracy of CT for predicting the presence of a nonbronchial systemic arterial supply were assessed. RESULTS: In the determination of a nonbronchial systemic arterial supply, CT had a sensitivity of 80%, specificity of 84%, positive predictive value of 73%, negative predictive value of 91%, and accuracy of 84%. Sensitivity was highest for predicting the branches of subclavian and axillary arterial supply and was lowest for predicting the internal mammary arterial supply. Specificity and accuracy were highest for predicting the intercostal arterial supply. CONCLUSION: CT demonstrates acceptable sensitivity, specificity, and accuracy in the prediction of a nonbronchial systemic arterial supply in patients with massive hemoptysis.