小儿二尖瓣反流瓣环三维超声形态及运动分析

目的通过三维超声心动图对二尖瓣环的形态及瓣环在心动周期中的运动进行定量分析,探讨二尖瓣环异常与反流程度的关系。方法使用与上海交通大学图像处理与模式识别研究所合作研发的二尖瓣运动分析软件(CARDIO 4D VIEW),采用人机交互方式,分析所采集的二尖瓣瓣环的三维图像,以标记二尖瓣瓣膜根部附着点为特征点的方式,重建二尖瓣瓣环的三维超声形态。选取二尖瓣瓣环最高点至最低点的距离(Dh-l)、两个最高点的距离(Dh-h)以及两个最低点的距离(Dl-l)为参数,以腹主动脉直径作为标化参数,分别对18例二尖瓣轻度反流患儿、29例中度反流患儿、7例重度反流患儿及21例正常儿童进行测量,并对舒张末期及收缩末期两个时相的参数结果使用SPSS13.0统计软件进行分析。结果正常儿童组21例和不同程度二尖瓣反流组54例患儿,二尖瓣环均呈马鞍形态,并在整个心动周期中始终保持此形态。收缩末期Dh-l值较舒张末期增大(P0.01),Dh-h值及Dl-l值较舒张末期减小(P0.01)。中度反流组、重度反流组舒张末期及收缩末期Dh-h、DI-I测值比正常组大(P0.01),而Dh-I测值则与正常组之间差异无统计学意义(P0.05);轻度反流组和正常组3项参数(Dh-h、DI-l、Dh-l,差异均无统计学意义(P0.05)。结论三维超声心动图对定量评估二尖瓣瓣环形态及运动以及患儿二尖瓣环异常及反流程度有一定意义。     

New quantitative three-dimensional echocardiographic indices of mitral valve stenosis

Background We studied the value of quantitative three-dimensional echocardiography (3DE) in the evaluation of mitral valve stenosis using the measurement of the mitral valve area (MVA) with two new indices: the doming volume and mitral valve volume. Methods and results A total of 45 consecutive patients with mitral valve stenosis were studied. MVA was measured using Doppler with the pressure half-time (PHT) method. Following a diagnostic multiplane transesophageal (TEE) examination, data for 3DE were acquired with a rotational mode of acquisition. MVA was assessed by anyplane echocardiography (APE) and from surface rendered images. Moreover, the doming volume, i.e., the volume subtended by the anterior and posterior mitral valve and annular cut plane was measured by APE. Comparing PHT-derived with 3DE-derived MVA’s, using both APE and surface rendered images, only moderate correlations were observed: PHT-derived MVA versus APE-derived MVA: r = 0.74, P < 0.0001; PHT-derived area versus 3DE-surface rendered MVA: r = 0.70, P < 0.0001. Multiple linear regression analysis showed a relation of atrial fibrillation to the doming volume (P = 0.04), but not to PHT-derived MVA (P = 0.28), APE-derived area (P = 0.33) and mitral valve volume (P = 0.08). Comparison of patients with MVA < 1 cm² and MVA > 1 cm² revealed significant difference in mitral valve volume: mean mitral valve volume in critical stenosis was 3.7 ml versus 1.4 ml in non-critical stenosis (P = 0.04). Conclusions Only moderate correlations between 3DE and Doppler-derived MVA’s were observed. Measurement of the doming volume allows quantification of the 3DE geometry of the mitral apparatus. Patients with conical or funnel-like geometry are more likely to have sinus rhythm, whereas, patients with flat geometry are likely to have atrial fibrillation. Mitral valve volume can be used for the evaluation of mitral stenosis severity. These new 3DE indices might be used for selection of patients for balloon valvuloplasty.     

Detection of prosthetic mitral valve leak: a comparative study using transesophageal echocardiography, transthoracic echocardiography, and auscultation

Paravalvular leakage is a major complication of prosthetic valve dysfunction. Sixty-one subjects with valvular heart disease who had received prosthetic mitral valve replacement 5 months to 5 years before (43 received a porcine prosthesis and 18 received Bjork-Shiley valve prostheses) were evaluated for this complication. Careful auscultation was performed by two experienced cardiologists followed by transthoracic and transesophageal echocardiography. Physiologic leaks were detected in all Bjork-Shiley valves, but in only 30% of porcine valves using transesophageal echocardiography. These regurgitant jets were flame-like, with mean low velocities of 50 +/- 12.3 cm/sec and 48 +/- 18.2 cm/sec in the two types of valves. Neither transthoracic echocardiography nor auscultation could detect physiological regurgitant jets. Ten cases with paravalvular leak were detected by transesophageal echocardiography and subsequently demonstrated by left ventriculography (7 porcine, 3 Bjork-Shiley valves). Pathologic regurgitant jets were seen as high-velocity, systolic-retrograde turbulent flow across the prosthesis. However, only 6 cases of prosthetic valve dysfunction were detected by transthoracic echocardiography, 4 cases of mild paravalvular leakage went undetected. Thirteen of the 61 subjects had an apical systolic murmur and suspected prosthetic valve leakage; in 10 of the 13 cases the findings corresponded to those obtained by transesophageal echocardiography. In 3 cases of double valve replacement with Bjork-Shiley valves the magnitude of the leakage was overestimated by auscultation.     

超声检测二尖瓣对合指数可行性研究及初步结果

目的 探讨采用经食管实时三维超声心动图检测心房颤动患者二尖瓣对合面积及对合指数的可行性.方法 对15例心房颤动患者均行经食管实时三维超声心动图检查,并用Qlab软件对原始数据进行后处理分析.选取舒张早期及收缩末期两个时相,分别手动标记瓣环及瓣叶.计算对合面积和对合指数公式分别为：舒张早期二尖瓣面积-收缩末期二尖瓣面积;[（舒张早期二尖瓣面积-收缩末期二尖瓣面积）/舒张早期二尖瓣面积]×100%.结果 所有15例患者均能成功得到二尖瓣对合面积并可以计算出对合指数这一参数.对合面积范围从119.8～514.5 mm2,平均（293.4±114.0）mm2;对合指数范围16%～42%,平均（23.0±7.0）%.结论 通过Q-lab软件得到二尖瓣对合指数这种方法是可行的.     

经食管实时三维超声心动图检测二尖瓣对合指数的临床应用研究

目的应用经食管实时三维超声心动图对比分析正常与缺血性二尖瓣反流(IMR)患者二尖瓣对合指数,探讨二尖瓣对合指数的临床意义。方法慢性IMR患者11例与无瓣膜疾病且无瓣膜反流的正常对照组12例,均行经食管三维超声心动图检查,应用定量分析软件Qlab7.0对三维数据进行后处理分析。应用以下公式计算二尖瓣对合指数=〔(舒张早期二尖瓣面积-收缩末期二尖瓣面积)/舒张早期二尖瓣面积〕×100%。结果正常对照组二尖瓣对合指数(23.0±7.9)%。慢性IMR患者二尖瓣对合指数(12.6±6.9)%。慢性IMR患者二尖瓣对合指数明显小于正常对照组(P0.05)。结论三维定量分析软件Qlab7.0可以对经食管实时三维超声心动图三维数据进行定量分析得到二尖瓣对合指数。应用二尖瓣对合指数这一指标能够判定二尖瓣对合程度,揭示IMR的发生机制。     

经食管实时三维超声心动图对比研究不同部位缺血致中度及以上二尖瓣反流瓣环形态及功能变化

目的 采用经食管实时三维超声心动图(RT-3D-TEE)对比分析不同部位缺血致中度及以上二尖瓣反流时二尖瓣瓣环形态及功能的变化规律,为外科成形术提供依据.方法选择前壁或下后壁心肌梗死缺血性心肌病伴中度及以上二尖瓣反流患者各11例(前壁病变组/下后壁病变组)和阵发性房颤患者20例(对照组).对所有患者进行RT-3D-TEE检查,获取完整心动周期内的实时三维超声图像,并使用Qlab软件后处理分析计算二尖瓣瓣环最大投影面积A-max、二尖瓣瓣环投影面积变化率A-change、二尖瓣瓣环最大面积出现于R-R间期的时间点AR-R%、二尖瓣瓣环最大周长C-max、二尖瓣瓣环周长变化率C-change、二尖瓣瓣环最大高度H-max、二尖瓣瓣环高度变化率H-change、二尖瓣瓣环在长轴方向最大位移D、二尖瓣瓣环最大前后径DAP、二尖瓣瓣环最大左右径DAIPm及上述两种径线比值DAIPm/DAP.结果 对照组A-change、AR-R%、C-change、D分别为(22.5±5.7)%、(54.6±5.0)%、(13.9±4.2)%、(15.1±1.8)mm,前壁病变组分别为(18.4±4.1)%、(58.8±5.8)%、(12.5±2.9)%、(11.2±1.6)mm;下后壁病变组分别为(16.0±4.1)%、(62.8±7.1)%、(8.0±2.6)%、(11.1±2.3)mm,3组间的差异均有统计学意义(F=6.780、7.245、9.827、22.346,P＜0.05).前壁病变组、下后壁病变组A-change明显低于对照组,差异均有统计学意义(t=-2.23,P=0.032;t=-3.53,P=0.001),但前壁病变组与下后壁病变组之间的差异无统计学意义(t=1.15,P=0.258).对照组、前壁病变组、下后壁病变组的AR-R%均出现在舒张期,下后壁病变组AR-R%出现的时相较其他各组明显延迟.前壁病变组、下后壁病变组AR-R%均高于对照组,且下后壁病变组与对照组之间的差异有统计学意义(t=3.76,P=0.001),但前壁病变组与对照组之间的差异无统计学意义(t=1.91,P=0.063);同时下后壁病变组AR-R%也高于前壁病变组,但差异无统计学意义(t=1.62,P=0.113).前壁病变组、下后壁病变组C-change均低于对照组,且下后壁病变组与对照组之间的差异有统计学意义(t=4.39,P=0.000),但前壁病变组与对照组之间的差异无统计学意义(t=-1.01,P=0.318);同时下后壁病变组C-change也明显低于前壁病变组,差异有统计学意义(t=-2.98,P=0.005).前壁病变组、下后壁病变组的D明显小于对照组,差异均有统计学意义(t=-5.43,P=0.000;t=-5.57,P=0.000),但前壁病变组与下后壁病变组之间的差异无统计学意义(t=0.12,P=0.903).对照组、前壁病变组、下后壁病变组A-max、C-max、H-max、H-change、DAIPm、DAP、DAIPm/DAP的差异均无统计学意义(F=1.340、1.440、0.391、1.421、0.046、0.926、1.107,P均＞0.05).结论 采用RT-3D-TEE定量评价不同部位缺血致二尖瓣反流时二尖瓣瓣环形态及运动变化规律是可行的.下后壁缺血性心肌病致中度及以上二尖瓣反流患者二尖瓣瓣环运动受损相对更明显,外科可进行针对性二尖瓣成形治疗.     

经胸与经食管超声测量心脏瓣环大小的研究

对６６例不同类型的人工心脏瓣膜置换术患者，采用超声检测法，于入院时及术前一周内进行经胸超声心动图（ＴＴＥ）检查，术中进行经食管超声心动图（ＴＥＥ）检查，分别测量瓣环直径与实际置换瓣膜进行比较。结果显示：实际置换瓣膜与入院时ＴＴＥ比较差异有显著性（Ｐ＜０．０５）；与术中ＴＥＥ比较差异无显著性（Ｐ＞０．０５）；与术前一周ＴＴＥ比较差异也无显著性，但Ｘ２值比术中ＴＥＥ大。表明术中ＴＥＥ测量的瓣环大小与置换瓣十分匹配，为减少瓣周漏及术后并发症提供了高度可靠的新技术。在无条件进行ＴＥＥ检查时，也可于术前一周内采用ＴＴＥ测量瓣环大小     

经胸超声心动图引导建立二尖瓣返流动物模型方法学的探讨

目的 :探讨经胸超声心动图引导建立二尖瓣返流 (MR)动物模型的价值。方法 :2 2条犬经股动脉或颈总动脉插管 ,在超声引导下 ,将心肌活检钳经左冠状动脉造影导管引至二尖瓣下 ,咬断二尖瓣前叶一条腱索造成二尖瓣返流。结果 :经股动脉插管 6条犬 ,术中死亡 4条 ,术后死亡 2条。经颈总动脉插管 16条 ,手术成功并存活。彩色多普勒血流图显示二尖瓣返流。频谱多普勒测最大返流速度 (333± 4 4 .3) cm/s,最大压差 (5 .8± 1.8) k Pa。心脏标本示为一级或二级腱索断裂。结论 :经胸超声引导建立 MR动物模型方法简便、安全、成功率较高     

10例二尖瓣成形术的经食管实时三维超声心动图研究

目的采用经食管实时三维超声心动图对二尖瓣成形术前后二尖瓣环及瓣叶三维结构特征进行定量对比研究,确定评价二尖瓣成形术治疗效果的主要形态学指标和关键影响因素。方法 10例二尖瓣脱垂患者在全麻下于二尖瓣成形术前后行经食管实时三维超声心动图(Philips IE33超声心动图成像仪、X7-2t探头)扫查。分别采集二尖瓣环与瓣叶结构的全容积三维动态超声图像以及二尖瓣反流束的彩色多普勒实时三维动态超声图像。运用Qlab7.0MVQ软件对图像进行脱机分析,获得二尖瓣瓣环在二维投影平面中的面积与周长、瓣环的最小三维面积与三维周长、主动脉口二尖瓣环平面夹角、二尖瓣的暴露面积、前叶面积、后叶面积、脱垂高度、脱垂容积等二尖瓣环及瓣叶的各项形态学参数测值,计算二尖瓣对合指数及二尖瓣环与瓣叶各参数在二尖瓣成形术前后的变化值,并进行多元线性回归分析。结果①二尖瓣成形术后,二尖瓣环在二维投影平面中的面积和周长,瓣环的最小三维面积和三维周长,瓣环的前外侧至后内侧直径、前后直径、环的高度及环高度与前外侧至后内侧直径的比率均明显小于术前(P<0.01)。②二尖瓣成形术后,二尖瓣叶的暴露面积、前叶面积、后叶面积、脱垂高度、脱垂容积、前外侧至后内侧接合直径、前外侧至后内侧接合在投影平面内的弧长、投影在近似小叶表面的前外侧至后内侧的接合弧长及非平面小叶角度均明显小于术前(P<0.05),二尖瓣前叶角度、后叶角度及二尖瓣对合指数均明显大于术前(P<0.05)。③将二尖瓣成形术前后二尖瓣环与瓣叶各项形态学参数的变化值与二尖瓣成形术前后二尖瓣对合指数的变化值进行多元线性回归分析,建立多元线性回归模型:Y=11.069-0.059χ1+0.530χ2(Y:二尖瓣成形术前后二尖瓣对合指数的变化值,χ1:二尖瓣成形术前后二尖瓣前叶面积变化值,χ2:二尖瓣成形术前后主动脉口二尖瓣环平面间角度变化值,P=0.002)。结论经食管实时三维超声心动图为定量评价二尖瓣环与瓣叶的三维结构提供了有效的技术手段。二尖瓣对合指数作为评价二尖瓣成形术效果最重要的指标可以通过经食管实时三维超声心动图得到准确测量。二尖瓣成形术要获得较大的对合指数,应尽量保存二尖瓣前叶的面积;二尖瓣成形术对主动脉口二尖瓣环平面间角度的改变应在确保二尖瓣有效对合指数的前提下尽可能使其接近正常的解剖角度。     

二尖瓣关闭不全与左房血栓关系的TEE研究

本文研究目的是为了探讨风湿性二尖瓣疾病患者二尖瓣关闭不全（ＭＲ）对左房血栓形成的影响。经食道超声心动图（ＴＥＥ）检查了６８例风湿性二尖瓣疾病患者。２３例被发现有左房血栓，有血栓组与无血栓组相比，二尖瓣关闭不全的发生率较低（Ｐ＜０．０２），返流束面积较小（Ｐ＜０．０５）。没有明显二尖瓣关闭不全的患者发生左房血栓的风险性较高，因此需要进行抗凝治疗。     

经食管实时三维超声定量评价二尖瓣瓣环在功能性与器质性二尖瓣反流时的形态变化

目的使用经食管实时三维超声(RT-3D-TEE)对比分析正常二尖瓣瓣环与缺血性心肌病、二尖瓣脱垂(器质性瓣膜病)所致中度以上二尖瓣反流(MR)时二尖瓣瓣环的形态及变化规律,探讨不同病因致二尖瓣反流时瓣环变化规律,为外科二尖瓣成形术提供依据。方法对入选10例正常人(对照组)、8例缺血性心肌病(缺血组)及8例二尖瓣脱垂伴中度以上二尖瓣反流病例(脱垂组)进行经食管实时三维超声心动图检查,获取完整心动周期内的实时三维图像,并使用3D-QLAB软件后处理分析二尖瓣瓣环的不同参数。结果 (1)缺血组与对照组在瓣环投影面积变化率、瓣环周长变化率及高度变化率方面差异有统计学意义(P0.05),但在瓣环最大投影面积、瓣环最大高度、瓣环最大周长及瓣环最大内径(前后径及左右径)方面差异无统计学意义;(2)二尖瓣脱垂组与对照组在各瓣环参数方面差异无统计学意义。结论经食管实时三维超声心动图定量评价二尖瓣瓣环形态及运动变化规律是可行的。缺血性二尖瓣反流与二尖瓣脱垂患者二尖瓣瓣环形态运动变化规律有明显不同,RT-3D-TEE能够定量评价二尖瓣瓣环形态及运动变化规律,为外科二尖瓣成形术提供依据。     

实时三维超声心动图对二尖瓣环形态的实验研究

目的探讨实时三维超声心动图(RT-3DE)研究二尖瓣环立体形态的方法和可行性。方法采用RT-3DE获取8只犬冠状动脉左回旋支结扎前和结扎后心脏三维全容积图像,然后于舒张末期对二尖瓣环进行标记,测量二尖瓣环投影面积,观察二尖瓣环的立体形态及其在冠状动脉左回旋支结扎前后的变化。结果通过对二尖瓣环标记,显示二尖瓣环呈“马鞍形”的立体形态;冠状动脉左回旋支结扎后,二尖瓣环发生非对称性扩张,扩张部位主要位于后部瓣环近后内侧连合处,二尖瓣环面积结扎前(17.7±4.6)cm2,结扎后(24.5±7.1)cm2(P<0.05),增加百分比为(31.9±5.6)%,二尖瓣环仍呈“马鞍形”,但形态较结扎前平坦。结论可以采用RT-3DE无创伤性研究不同病理生理状态下二尖瓣环的立体形态,这将有助于深入探讨功能性二尖瓣反流的形成机制。     

Transesophageal Echocardiography in Swine: Establishment of a Baseline

The porcine model is a commonly used animal model in cardiovascular research. Along with new innovative operative techniques, choice of the optimal imaging technique is crucial. Transesophageal echocardiography (TEE) is a reliable imaging tool is highly important in a large number of experimental evaluations. But so far, TEE data for swine are limited, and few standard values have been established for the porcine model. The experience and baseline results for TEE in 45 swine are presented in this study. A full TEE examination was conducted in 45 German landrace or German large white swine, with an average body weight of 49 ± 3 kg, before experimental off-pump mitral valved stent implantation. Additionally hemodynamic measurements were evaluated. The valve implantation procedure was guided solely by real-time 3-D TEE. Baseline values of standard echocardiographic parameters are provided and, where appropriate, compared with human reference values. TEE proved to be an adequate imaging technique in this experimental porcine animal model. The baseline TEE and hemodynamic parameters established for the widely used porcine model can serve as a reference in future studies.     

术中经食管彩色多普勒超声心动图实时评价二尖瓣成形术

本文报告用经食管彩色多普勒超声监测二尖瓣成形术ｌｌ例。１０例二尖瓣术前返流为４级或３级者，术后均降为０～１级；另一例成形术后发生严重狭窄，及时改作瓣膜替换术。作者认为本技术准确可靠，对二尖瓣成形术有指导意义。     

动态三维超声心动图评价二尖瓣关闭不全

本文采取经胸壁及经食道旋转扫描方法获取二维数据，利用总体重建法（ＶｏｌｕｍｉｃＲｅｎｄｅｒｉｎｇＤｉｓｐｌａｙ）对１２例正常人二尖瓣，１４例风心病二尖瓣关闭不全，２０例二尖瓣脱垂患者的二尖瓣解剖结构及二尖瓣返流束进行了动态三维超声心动图重建。重建图像能从左室或左房侧显示二尖瓣装置的整体三维空间结构及动态变化。正常二尖瓣叶光滑平软，舒张期瓣口充分开放，收缩期前后叶对合良好。风心病二尖瓣关闭不全患者瓣叶增厚，收缩期前后叶之间出现裂缝。二尖瓣脱垂时瓣叶某一部分呈“瓢匙”样向左房侧脱出。动态三维超声心动图还能显示二尖瓣关闭不全血液返流束的立体形态及在左房内的空间走向。初步经验表明动态三维超声心动图对二尖瓣关闭不全的诊断有重要临床价值