本文選題：螺旋形心肌帶　切入點：心臟扭轉(zhuǎn)運動　出處：《中國人民解放軍醫(yī)學院》2015年博士論文

【摘要】：目的1.借助磁共振成像追蹤正常人心臟的一個完整心動周期中左心室壁的運動過程,結(jié)合已知的螺旋心肌帶解剖理論對心臟扭轉(zhuǎn)和解旋的各個時期的心室運動進行分析,嘗試揭示心肌帶各節(jié)段與心室運動之間的聯(lián)系。2.采用磁共振技術(shù)研究正常人心尖環(huán)與基底環(huán)在心臟扭轉(zhuǎn)運動中各自相反方向的旋轉(zhuǎn)角度、速率及同步性,進一步分析其發(fā)生機制,并與不同部位心�；颊咝呐K扭轉(zhuǎn)運動的差異進行比較。3.通過對心�；颊呓邮芄跔顒用}旁路移植術(shù)前后的心臟扭轉(zhuǎn)運動變化進行自身比較,嘗試評價心臟扭轉(zhuǎn)角度能否作為心功能評價的敏感指標,并進一步討論其臨床應用價值。材料與方法1.將不同種屬的心臟(豬心、羊心)按照不同時間煮熟后,按照以往心肌帶的研究中所描述的解剖方法進行解剖,將解剖好的心臟自然伸展,對各個節(jié)段進行染色標記并恢復至心臟原形,按照磁共振掃描層面對復原后的心臟進行切開,對橫斷面心肌帶結(jié)構(gòu)進行觀察并分析磁共振同一短軸切面與心肌帶對應關(guān)系。2.采用瞬時速度向量對20例正常人進行磁共振掃描后分析其四腔心切面心肌的運動規(guī)律。使用TOMTEC Imaging System軟件在心臟舒張末期對心內(nèi)膜進行準確描記,將左室內(nèi)膜分為48個節(jié)段并對每個節(jié)段點在完整心動周期內(nèi)每一幀的運動方向進行追蹤,根據(jù)速度矢量的方向及大小分析等容收縮期、扭轉(zhuǎn)運動、等容舒張期及快速舒張期的各個時期室壁各部分的運動順序性。3.對54例不同年齡、不同性別的正常人心臟進行掃描并獲得從心底至心尖的心室二腔切面,根據(jù)之前離體心臟磁共振掃描的解剖定位獲取每位志愿者心底和心尖掃描的同一層面進行分析,同樣對心內(nèi)膜進行準確描記并追蹤每個點在心動周期中的切向運動的最大旋轉(zhuǎn)角度、峰值速率及達峰時間。以逆時針方向作為正向,將心尖與心底的旋轉(zhuǎn)角度差值作為扭曲角度,分析正常人心臟扭轉(zhuǎn)運動的規(guī)律。4.納入心�；颊�33例,其中下壁心梗17例,前壁心梗16例,分別分析兩組患者的心尖環(huán)及心底環(huán)的最大旋轉(zhuǎn)角度、峰值旋轉(zhuǎn)及解旋速率和達峰時間,將結(jié)果與正常人心臟扭轉(zhuǎn)結(jié)果進行比較并分析其差異性。5.對12例既往有心梗病史并接受冠狀動脈旁路移植術(shù)的患者的術(shù)前、術(shù)后MRI進行自身比較,分析心尖環(huán)、心底環(huán)各個扭轉(zhuǎn)指標的變化情況,討論心臟扭轉(zhuǎn)指標對心功能評價的意義。結(jié)果1.采用相對統(tǒng)一的解剖方式,所有心臟均可解剖為一個完整的心肌帶,分為基底環(huán)和心尖環(huán)兩個環(huán),其中基底環(huán)又分為左室段和右室段,心尖環(huán)分為降段和升段;室間隔由降段和升段構(gòu)成,沒有基底環(huán)包繞,而左室游離壁的上三分之二有基底環(huán)覆蓋因而有三層心肌;心內(nèi)膜及室間隔左室面由心肌帶降段構(gòu)成而心外膜及室間隔右室面由升段構(gòu)成,且升段和降段在室間隔的上部與下部構(gòu)成比例不同。2.通過對心肌的速度向量追蹤發(fā)現(xiàn),心臟在收縮前期主要為縮窄及逆時針旋轉(zhuǎn)運動,該時期主要以基底段及降段收縮為主,速度向量觀察發(fā)現(xiàn)室間隔開始運動而側(cè)壁尚未運動；在射血期心尖呈逆時針而心底呈順時針運動,心臟呈“擰毛巾”樣扭轉(zhuǎn)運動,可以觀察到室間隔上部和下部呈扭轉(zhuǎn)運動,并且周圍室壁向心尖靠攏,心室腔明顯縮短;在等容舒張期基底環(huán)和降段停止收縮,而升段仍繼續(xù)收縮,該間期約80-90ms,此時心臟主動抽吸解旋,同時伴隨著心臟整體順時針旋轉(zhuǎn);在舒張期心臟先拉長,繼而變寬,心臟由主動解旋變?yōu)楸粍映溆�。整個心臟運動分為縮窄、扭轉(zhuǎn)、拉伸、變寬四個階段,每個階段的運動是心肌帶各節(jié)段共同運動的結(jié)果所致。3.正常心臟扭轉(zhuǎn)運動中,心尖呈逆時針運動,最大旋轉(zhuǎn)角度約10.2+4.8°,峰值旋轉(zhuǎn)及解旋速度分別為51.1±30.5°/s和-38.6+28.1°/s,達峰時間為234.1+42.3ms;心底呈順時針方向運動,最大旋轉(zhuǎn)角度約7.0+3.3°,峰值旋轉(zhuǎn)及解旋速度-43.1+22.8°/s和29.4+26.9°/s,達峰時間為312.1+56.20ms。心尖旋轉(zhuǎn)角度明顯大于心底,并且心尖解旋早于心底,該時間間隙約78.0±14.0ms,此間隙期間心臟主動舒張解旋運動。4.前壁心�；颊咝募饧盎椎淖畲笮D(zhuǎn)角度明顯下降(P0.05),并且其旋轉(zhuǎn)速度和解旋速率都低于正常組,但差異無統(tǒng)計學意義；前壁心梗組心尖解旋時間明顯延遲,心臟主動解旋間隙消失,表示心臟收縮及舒張功能均受損。下壁心梗患者的心底最大旋轉(zhuǎn)角度及旋轉(zhuǎn)速度均明顯下降(P0.05),而心尖旋轉(zhuǎn)角度及速度與正常組無明顯差異;其主動解旋時間間隙仍存在但較正常組明顯縮短。5.患者接受冠狀動脈旁路移植術(shù)后3個月至1年時,心尖及基底旋轉(zhuǎn)運動明顯改善,旋轉(zhuǎn)及解旋速率明顯提高,心臟收縮功能增強,心臟扭轉(zhuǎn)指標與EF改善相關(guān)性良好,相關(guān)系數(shù)r=0.83,p0.05。結(jié)論1.心肌帶結(jié)構(gòu)及心臟扭轉(zhuǎn)運動在哺乳動物中可能具有普遍性和一致性,本研究首次結(jié)合扭轉(zhuǎn)運動評價的金標準——磁共振技術(shù)對心動周期室壁各個部分在不同時刻的運動進行分析,并發(fā)現(xiàn)心肌帶解剖結(jié)構(gòu)與左室順序性運動密切相關(guān)；2.借助最新的心臟磁共振追蹤技術(shù),我們進一步總結(jié)了正常人心臟扭轉(zhuǎn)運動的規(guī)律,并發(fā)現(xiàn)心尖呈逆時針運動,心底呈順時針運動,心臟呈“擰濕毛巾”運動;并揭示了心尖的解旋時間早于心底,該時間差值約70-80ms,此期間心臟主動舒張解旋抽吸,這一發(fā)現(xiàn)對心臟舒張功能的研究具有重要意義；3.首次將心梗后病理改變下心臟扭轉(zhuǎn)運動與正常人心臟扭轉(zhuǎn)運動進行比較,發(fā)現(xiàn)心尖及心底旋轉(zhuǎn)運動明顯下降,旋轉(zhuǎn)速率及解旋速率明顯降低,且解旋時間延遲,心臟主動解旋抽吸時間明顯縮短甚至消失,心臟舒張功能受損；4.首次采用磁共振評價冠狀動脈旁路移植術(shù)對心臟扭轉(zhuǎn)運動的影響,并發(fā)現(xiàn)心梗患者接受冠狀動脈旁路移植術(shù)后心臟扭轉(zhuǎn)運動明顯提高,包括心尖和心底的旋轉(zhuǎn)運動,初步證明心臟扭轉(zhuǎn)運動指標對心功能改善情況的評估具有一定的敏感性,今后對其他病理改變下心臟扭轉(zhuǎn)運動的評價有可能具有潛在的臨床應用價值。
[Abstract]:1. by means of magnetic resonance imaging tracking of a complete cardiac cycle in normal cardiac left ventricular wall motion, myocardial anatomy with known binding helix theory in different periods of cardiac torsion and untwisting of ventricular motion analysis, try to reveal the myocardial band segments and ventricular motion contact.2. by magnetic resonance imaging normal people and technology tip ring ring in basal rotation angle in each cardiac twist in the opposite direction, speed and synchronization, further analysis of the mechanism, and different parts of myocardial infarction cardiac twist difference were compared by.3. on myocardial infarction in patients undergoing cardiac torsion before and after coronary artery bypass grafting of the movement itself comparison, try a sensitive index for evaluating cardiac torsion angle can be used as the evaluation of cardiac function, and discuss its clinical value and material. 1. different species (pig, sheep heart heart) according to different time after cooked, were dissected according to the anatomical method described in previous studies of myocardial band, the anatomy of good heart naturally stretch, were labeled and restored to the original shape of the heart of each segment, according to MRI in recovery the heart is open, to observe and analyze the magnetic resonance with a short axis and with the relation of.2. by analysis of myocardial motion fourth chamberview myocardial instantaneous velocity vector magnetic resonance imaging was performed in 20 cases of normal people on the cross section structure. Using TOMTEC Imaging myocardial band of System software in the end of diastole of endocardium of accurate recording of left ventricular endocardium, will be divided into 48 segments and each segment of track in the whole cardiac motion direction of each frame period, according to the analysis of the velocity vector direction and magnitude Isovolumic contraction, torsion, motion sequence of each part of the.3. of each period ventricular isovolumic relaxation and diastolic in 54 cases of normal people of different age, different sex heart scan and get from the bottom to the apex of the heart two chamber view, according to the analysis before the anatomical location of cardiac magnetic resonance scanning body for each volunteer heart and apical scanning the same level, the same on endocardial tracings and accurate tracking of each point in the cardiac cycle of the tangential movement of the maximum rotation angle, the peak rate and peak time. In the counterclockwise direction as positive, the rotation angle of the base and apex difference as the twist angle analysis, normal cardiac twist movement.4. included 33 cases of myocardial infarction patients, including 17 cases of myocardial infarction, 16 cases of anterior wall infarction, respectively analysis of the large rotation of apical ring and two groups of patients with heart ring Angle of rotation and peak untwisting rate and peak time, the results with normal cardiac twist results were compared and analyzed the difference of.5. in 12 patients with myocardial infarction and underwent coronary artery bypass grafting in patients with MRI compared with preoperative, postoperative, analysis of apical ring, the change of heart each ring torsion index, discuss the evaluation index on heart function and cardiac twist significance. Results 1. of the anatomical relatively uniform, all the heart can anatomy as a complete myocardial band divided into basal and apical ring, ring two ring, wherein the base ring is divided into the left ventricular and right ventricular apical segment. The ring into the descending and ascending segment; ventricular septal by descending and ascending sections, no basal ring wrapped, and 2/3 of the left ventricular free wall basal ring cover and a three layer of myocardium; left ventricular endocardial and ventricular septal surface by myocardial segments with reduced heart The adventitia and septal right ventricular surface by ascending segments and the ascending segment and descending the proportion of different.2. in the upper and lower chamber through the interval velocity vector on myocardial tracked cardiac contraction in the first major for coarctation and counterclockwise rotation, the period mainly in the basal and descending contraction. The velocity vector observation of ventricular septal and lateral wall movement has not yet started moving; in the ejection period of apical clockwise clockwise movement and the heart, the heart is like "wring a towel" twist, can be observed in the upper and lower septal twisting motion, and the surrounding wall close to the apex, left ventricular cavity was significantly shortened in isovolumic relaxation; basal ring and descending and ascending part of the end of the contraction continued to shrink, the interval of about 80-90ms, at the heart of active suction untwist, accompanied by the whole heart diastolic clockwise rotation; in the first pull long, then change Heart wide, by the active unwinding into passive filling. The heart movement is divided into narrow, twisting, stretching, width of four stages, each stage is the movement of each segment with myocardial common motion results caused by.3. normal cardiac twist, apical clockwise motion, maximum rotation angle of about 10.2+4.8 DEG, peak rotation and untwisting velocity were 51.1 + 30.5 ~ /s and -38.6+28.1 ~ /s, the peak time is 234.1+42.3ms; the heart in a clockwise direction, the maximum rotation angle of about 7.0+3.3 DEG rotation and peak untwisting velocity -43.1+22.8 ~ /s and 29.4+26.9 ~ /s, the peak time of 312.1+56.20ms. apical rotation angle is greater than that in the bottom of my heart and, the apical untwisting early in the heart, the time gap of about 78 + 14.0ms, the gap during the maximum rotation angle of heart diastolic untwisting active.4. anterior myocardial infarction in patients with apical and basal decreased significantly (P0.05), and the rotating speed And the unwinding rate are lower than the normal group, but the difference was not statistically significant; anterior myocardial infarction apical unwinding time was delayed and the active heart untwisting gap disappeared, cardiac systolic and diastolic function that were impaired. The heart maximum rotation angle in patients with myocardial infarction and the rotation speed were significantly decreased (P0.05), while the apex the rotation angle and speed and no significant difference between the normal group; the active unwinding time gap still exists but compared with the normal group was significantly shorter in patients with.5. for 3 months to 1 years after coronary artery bypass grafting, apical and basal rotation significantly improved, rotation and untwisting rate increased significantly, cardiac systolic function enhancement cardiac twist index and EF improve the good correlation, correlation coefficient r=0.83, p0.05. conclusion 1. myocardial band structure and cardiac twist may have universality and consistency in mammals, this study first combined torsional transport The gold standard to assess the dynamic magnetic resonance imaging to cardiac cycle were analyzed in different parts of the ventricular wall movement of the moment, and found that the anatomical structure of left ventricular myocardial band and sequential movements are closely related; 2. with cardiac magnetic resonance tracking the latest technology, we further summarized the normal cardiac twist movement rules, and found the apical clockwise movement, the heart in a clockwise motion, the heart was wrung wet towel "movement; and reveals the apical unwinding time early in the bottom of my heart, the time difference is about 70-80ms, the active diastolic untwisting during heart pumping, this finding has important significance to the study of cardiac diastolic function; 3. for the first time the pathological changes after myocardial infarction cardiac torsion and normal cardiac twist were compared, found that heart apex and rotational motion decreased, rotation rate and untwisting rate decreased obviously, and the solution spinning The delay between the active unwinding, heart pumping time shortened obviously and even disappeared, cardiac diastolic dysfunction; 4. for the first time using magnetic resonance assessment of coronary artery bypass grafting on cardiac twisting motion, and found that the myocardial infarction patients undergoing coronary artery bypass grafting after cardiac twist is improved obviously, rotary motion including apical and heart, preliminary proof heart motion reverse the assessment indicators to improve the situation of cardiac function has certain sensitivity, the other pathological changes of heart torsion evaluation may have potential clinical value.

【學位授予單位】：中國人民解放軍醫(yī)學院
【學位級別】：博士
【學位授予年份】：2015
【分類號】：R654.2

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