【摘要】：目的：應(yīng)用二維應(yīng)變及應(yīng)變率成像技術(shù)對(duì)高海拔缺氧的西藏地區(qū)動(dòng)脈導(dǎo)管未閉患兒在接受導(dǎo)管微創(chuàng)介入治療前后，對(duì)其左、右心室心肌收縮功能進(jìn)行定量分析，以期了解高原低氧環(huán)境下動(dòng)脈導(dǎo)管未閉兒童心肌收縮水平及介入術(shù)后短期內(nèi)心肌收縮功能的恢復(fù)程度。 方法：西藏地區(qū)動(dòng)脈導(dǎo)管未閉（Patent ductus arteriosus,PDA）患兒共31例，其中男11例，女20例，平均年齡8.52±3.00歲，平原地區(qū)動(dòng)脈導(dǎo)管未閉(PDA)患兒共33例，其中男14例，女19例，平均年齡7.70±3.19歲，選擇年齡、性別相匹配的同期因其他疾病在我院住院接受治療或正常查體的兒童共20例為正常組,其中男10例，女10例，平均年齡8.50±2.46歲。采用美國(guó)GE公司生產(chǎn)的Vivid7彩色多普勒超聲檢查儀器，三組兒童入選后常規(guī)查身高、體重、血壓、心率。PDA患兒于術(shù)前1日及術(shù)后7日在血流動(dòng)力穩(wěn)態(tài)情況下行超聲心動(dòng)圖檢查，正常組兒童入選后行超聲心動(dòng)圖檢查，三組兒童分別利用連續(xù)多普勒技術(shù)測(cè)量肺動(dòng)脈收縮壓（PASP）。取二維超聲左心室長(zhǎng)軸切面及心尖四腔切面，心尖四腔切面連續(xù)采集3個(gè)心動(dòng)周期后導(dǎo)入EchoPAC7.0分析軟件，心肌節(jié)段收縮功能測(cè)定包括：PDA患兒分別將術(shù)前及術(shù)后標(biāo)準(zhǔn)心尖四腔切面圖導(dǎo)入分析軟件后，定幀于收縮末期，先手動(dòng)勾勒右心室心內(nèi)膜，將右室游離壁及室間隔各劃分為三個(gè)節(jié)段，測(cè)量其心肌收縮期峰值縱向應(yīng)變（Endsystolic longitudinal strain SL），再手動(dòng)勾勒左心室心內(nèi)膜，測(cè)量左心室游離壁三個(gè)節(jié)段心肌應(yīng)變及應(yīng)變率，分別測(cè)量三次取平均值。再將正常組兒童心尖四腔切面圖像導(dǎo)入軟件重復(fù)上述過程進(jìn)行分析。其中藏區(qū)PDA患兒通過二維測(cè)量其左心室舒張末期左右徑（LVEDd）及右心室舒張末期左右徑（RVEDd）。Simpson法利用公式計(jì)算其左室舒張末期容積（LVEDV）及右室舒張末期容積（RVEDV），計(jì)算左心室射血分?jǐn)?shù)（LVEF），右心室射血分?jǐn)?shù)（RVEF），左心室每搏輸出量（LVSV），每分輸出量（LVCO），心指數(shù)（CI），左室質(zhì)量指數(shù)（LVMI）及左室容積指數(shù)(LVEDVI)。數(shù)值采用SPSS16.0統(tǒng)計(jì)分析軟件進(jìn)行分析處理。 結(jié)果： 1.一般資料比較藏區(qū)組與平原組PDA患兒及正常組兒童在年齡、性別、體重、血壓、心率無統(tǒng)計(jì)學(xué)差異（P0.05），藏區(qū)組患兒身高較平原組及正常組低（P0.01）。藏區(qū)組未閉動(dòng)脈導(dǎo)管的最窄處直徑較平原組寬（P0.01），肺動(dòng)脈壓力較平原組及正常組高（P0.01）。 2.藏區(qū)患兒心室形態(tài)功能變化比較藏區(qū)患兒手術(shù)前及手術(shù)后7天超聲心動(dòng)圖測(cè)量，術(shù)后較術(shù)前左心室舒張末徑(LVEDd)縮短（P0.01），左心室舒張末期容積(LVEDV)縮�。≒0.01）；左心室射血分?jǐn)?shù)（LVEF）減低，但無統(tǒng)計(jì)學(xué)差異（P0.05），左心室每搏輸出量（SV）、每分輸出量（CO）、心指數(shù)（CI）、左室質(zhì)量指數(shù)（LVMI）、左心室舒張末期容積指數(shù)（LVEDVI）均減低（P0.01）。術(shù)后右心室舒張末徑(RVEDd)較術(shù)前增加（P0.01），右心室舒張末期容積(RVEDV)增大（P0.01），右心室射血分?jǐn)?shù)（RVEF）提高，但無顯著性差異（P0.05）。肺動(dòng)脈收縮壓較術(shù)前降低（P0.01）。 3.心肌應(yīng)變及應(yīng)變率比較 3.1藏區(qū)組介入術(shù)后一周左心室游離壁基底段、中間段、心尖段三個(gè)節(jié)段應(yīng)變較術(shù)前減低（P0.01）；室間隔基底段及中間段、右室游離壁基底段、中間段應(yīng)變較術(shù)前增加（P0.01），右室游離壁心尖段應(yīng)變較術(shù)前增加（P0.05），而室間隔心尖段應(yīng)變雖較術(shù)前增加，但無統(tǒng)計(jì)學(xué)差異（P0.05）。藏區(qū)組術(shù)后應(yīng)變率較術(shù)前在左室游離壁基底段、中間段、心尖段均減低，（P0.01），室間隔三個(gè)節(jié)段應(yīng)變率較術(shù)前增加，但無統(tǒng)計(jì)學(xué)差異（P0.05），右室游離壁三個(gè)節(jié)段應(yīng)變率均較術(shù)前增加，其中基底段無統(tǒng)計(jì)學(xué)意義（P0.05），中間段（P0.05），心尖段（P0.01）。 3.2術(shù)前藏區(qū)組左室游離壁三個(gè)節(jié)段應(yīng)變高于正常組，其中左室游離壁基底段（P0.05），左室游離壁中間段、心尖段（P0.01）；室間隔基底段、中間段及心尖段，右室游離壁三個(gè)節(jié)段應(yīng)變均低于正常組，其中室間隔中間段無統(tǒng)計(jì)學(xué)差異（P0.05），室間隔基底段、心尖段（P0.05），右室游離壁三個(gè)節(jié)段（P0.01）。而術(shù)后一周藏區(qū)患兒左室游離壁三個(gè)節(jié)段及室間隔三個(gè)節(jié)段與正常組無統(tǒng)計(jì)學(xué)差異（P0.05），右室游離壁三個(gè)節(jié)段應(yīng)變?nèi)缘陀谡＝M（P0.01）。 3.3藏區(qū)組與平原組介入前在左室游離壁三個(gè)節(jié)段、室間隔三個(gè)節(jié)段兩組應(yīng)變值無明顯差異，均無統(tǒng)計(jì)學(xué)意義（P0.05），右室游離壁三個(gè)節(jié)段藏區(qū)組低于平原組，其中基底段、中間段（P0.01），心尖段（P0.05）。藏區(qū)組與平原組兩組患兒術(shù)前與術(shù)后應(yīng)變變化值在左室游離壁基底段、中間段、心尖段，室間隔基底段、中間段、心尖段及右室游離壁基底段及心尖段八個(gè)節(jié)段比較兩組應(yīng)變改變值，均無統(tǒng)計(jì)學(xué)差異（P0.05），，僅右室游離壁中間段藏區(qū)組的改變大于平原組（P0.05）。 結(jié)論： 1、藏區(qū)患兒介入手術(shù)后短期內(nèi)左室心肌收縮功能可恢復(fù)至正常水平，而右室心肌收縮運(yùn)動(dòng)及肺動(dòng)脈壓力短期內(nèi)仍不能恢復(fù)至正常水平。二維應(yīng)變技術(shù)可無創(chuàng)、定量評(píng)估心肌的收縮功能。 2、西藏地區(qū)PDA患兒肺動(dòng)脈壓力及右室心肌收縮功能較平原地區(qū)患兒受累更加明顯，而左室心肌收縮功能與平原地區(qū)無異。高原PDA介入術(shù)后心肌收縮程度的變化與平原地區(qū)總體無明顯區(qū)別。
[Abstract]:Objective: to analyze the systolic function of left and right ventricular myocardium in children with patent ductus arteriosus in Tibet area with high altitude hypoxia before and after minimally invasive interventional therapy with two dimensional strain and strain rate imaging technique, in order to understand the myocardial contractile level and the short post intervention in children with patent ductus arteriosus under high altitude hypoxia. The degree of recovery of the heart muscle contractile function.
Methods: there were 31 children with Patent ductus arteriosus (PDA) in Tibet, including 11 males and 20 females, with an average age of 8.52 + 3 years. There were 33 cases of patent ductus arteriosus (PDA) in the plain area, including 14 men and 19 women. The average age was 7.70 + 3.19 years, and the age was selected and the sex phase matched the other diseases in our hospital. 20 children who received treatment or normal physical examination were normal group, including 10 male and 10 female, with an average age of 8.50 + 2.46 years. The Vivid7 color Doppler ultrasonic examination instruments produced by GE company were used. The three groups of children were examined for stature, body weight, blood pressure and heart rate.PDA at 1 days before and 7 days after operation. In the downlink echocardiography, the children of the normal group were examined by echocardiography. The three groups of children were measured by continuous Doppler technique to measure the systolic pressure of the pulmonary artery (PASP). The two dimensional echocardiography of the left ventricular long axis and the four cavities of the apex were taken, and the 3 cardiac cycles were collected continuously after the four cavities of the apical four cavities, and the EchoPAC7.0 analysis software was introduced. The measurement of segmental systolic function included: after introducing the analysis software before and after the standard apex four cavities, the PDA children set the frame at the end of the systole, first manually outlined the right ventricular endocardium, and divided the right ventricular free wall and the ventricular septum into three segments, and measured the peak systolic peak longitudinal strain of the myocardium (Endsystolic longitudinal strain S). L), the left ventricular endocardium was manually outlined, and the myocardial strain and strain rate of the left ventricular free wall were measured at the three segment of the left ventricular wall, and the mean values were measured three times respectively. Then the normal group of children's apical four cavity section images were introduced to repeat the process. The left ventricular end diastolic diameter (LVEDd) and the left ventricular diastolic diameter (LVEDd) of the children in the Tibetan area of PDA were measured by two dimension. The right ventricular end diastolic diameter (RVEDd).Simpson method was used to calculate the left ventricular end diastolic volume (LVEDV) and right ventricular end diastolic volume (RVEDV). Left ventricular ejection fraction (LVEF), right ventricular ejection fraction (RVEF), left ventricular stroke output (LVSV), per minute output (LVCO), cardiac index (CI), left ventricular mass index (LVMI) and left ventricle were calculated. Volume index (LVEDVI). Numerical analysis was carried out by SPSS16.0 statistical analysis software.
Result:
1. the general data showed that there was no significant difference in age, sex, weight, blood pressure and heart rate (P0.05) between the Tibetan group and the plain group PDA children and the normal group (P0.05). The height of the children in the Tibetan group was lower than that in the plain group and the normal group (P0.01). The narrowest diameter of the patent ductus arteriosus in the Tibetan group was wider than the plain group (P0.01), and the pulmonary arterial pressure was higher than that in the plain group and the normal group (P 0.01).
2. the ventricular morphological and functional changes in children in Tibetan children were compared before and 7 days after surgery in Tibetan children. The left ventricular end diastolic diameter (LVEDd) was shortened (P0.01), left ventricular end diastolic volume (LVEDV) decreased (P0.01) and left ventricular ejection fraction (LVEF) decreased, but there was no statistical difference (P0.05), and left ventricular stroke output (S). V), the heart index (CI), the left ventricular mass index (LVMI) and the left ventricular end diastolic volume index (LVEDVI) decreased (P0.01). The right ventricular end diastolic diameter (RVEDd) after operation was increased (P0.01), the right ventricular end diastolic volume (RVEDV) increased (P0.01), and the right ventricular ejection fraction (RVEF) increased, but there was no significant difference (P0.05). Pulmonary artery (P0.05). The systolic pressure was lower than that before the operation (P0.01).
3. comparison of myocardial strain and strain rate
3.1 the three segments of the left ventricular free wall basal segment, the middle segment and the apical segment were lower than those before the operation (P0.01), the basal segment and the middle segment of the ventricular septum, the right ventricular free wall basal segment, the middle segment strain increased (P0.01) and the apical apical strain of the right ventricle increased (P0.05), while the apical apex strain was in the ventricular septum, although the strain of the apex in the ventricular septum was higher than that before the operation. Compared with pre operation, there was no statistical difference (P0.05). The strain rate of the Tibetan group after operation was lower than that before operation in the basal segment of the left ventricular wall, the middle segment and the apical segment (P0.01), and the strain rate of the three segments of the interventricular septum increased compared with that before the operation, but there was no statistical difference (P0.05). The strain rates of the three segments of the right ventricular wall were all higher than those before the operation, and the basal segment was not statistically significant. Learning meaning (P0.05), middle segment (P0.05), apical segment (P0.01).
3.2 the three segment strain of left ventricular free wall in the Tibetan group was higher than that of the normal group. The left ventricular free wall basal segment (P0.05), the left ventricular free wall middle segment, the apex segment (P0.01), the interventricular septum basal segment, the middle segment and the apex segment, the right ventricular free wall were all lower than the normal group, and there was no statistical difference between the interventricular septum (P0.05) and the interventricular septum (P0.05). The basal segment, the apical segment (P0.05) and the right ventricular free wall were three segments (P0.01). There was no statistical difference between the three segments of the left ventricular wall and the three segments of the ventricular septum in the left ventricular wall of the children in one week after the operation (P0.05), and the three segments of the free wall of the right ventricle were still lower than those of the normal group (P0.01).
3.3 there were no significant differences between the three segments of the left ventricular free wall and the three segments of the ventricular septum before the intervention of the Tibetan group and the plain group, and there was no significant difference between the two groups of the ventricular septum three segments (P0.05), and the three segments of the right ventricular free wall group were lower than the plain group, including the basal segment, the middle segment (P0.01) and the apex segment (P0.05). The two groups of children in the Tibetan and plain groups should be before and after the operation. In the left ventricular free wall basal segment, the middle segment, the apex segment, the interventricular septum basal segment, the middle segment, the apex segment, the right ventricular free wall basal segment and the apex segment eight segments, there was no statistical difference (P0.05), but the changes in the middle segment of the right ventricular free wall group were more than that of the plain group (P0.05).
Conclusion:
1, the left ventricular systolic function of the children in the Tibetan area can be restored to normal level in the short term, while the right ventricular systolic movement and pulmonary artery pressure can not recover to the normal level in the short term. The two-dimensional strain technique can not be created and quantified the systolic function of the myocardium.
2, the pulmonary arterial pressure and right ventricular systolic function of the children with PDA in Tibet were more obvious than those in the plain, but the systolic function of the left ventricular myocardium was not the same as that in the plain. The changes of myocardial contractility after PDA intervention at high altitude were not significantly different from those in the plain.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2012
【分類號(hào)】：R725.4

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本文編號(hào)：2164046