發(fā)布時間：2018-06-09 21:42

  本文選題：圓錐動脈干畸形 + 肺靜脈畸形引流　； 參考：《鄭州大學(xué)》2014年博士論文

【摘要】：第一部分超聲心動圖結(jié)合Flash CT對圓錐動脈干畸形診斷價值的研究 背景和目的 圓錐動脈干畸形（Conotruncal defects，CTD）是一類合并外周血管畸形的復(fù)雜型先天性心臟病。一直以來超聲心動圖以其無創(chuàng)、經(jīng)濟(jì)、簡便、可重復(fù)檢查等優(yōu)勢在該類疾病的診斷中始終處于首選檢查方法。但是快速發(fā)展的螺旋CT技術(shù)在診斷外周血管畸形準(zhǔn)確率方面優(yōu)于超聲心動圖，因而被臨床醫(yī)生所青睞。也因此使超聲心動圖在CTD診斷準(zhǔn)確性方面受到一定的挑戰(zhàn)。2010年問世的新雙源Flash CT，以其獨(dú)特的Flash掃描模式，采用大螺距快速掃描，不受心率影響，心臟掃描只需0.25s，實(shí)現(xiàn)了亞mSv級的超快速心臟掃描，不僅保證了診斷的準(zhǔn)確性，同時也關(guān)注到了低劑量輻射等安全問題。本研究通過超聲心動圖結(jié)合Flash CT對CTD診斷價值的對比研究，為今后提高超聲診斷該類畸形的準(zhǔn)確性及患者術(shù)前合理選擇檢查方法提供參考依據(jù)。 材料與方法 96例患者主要包括：永存動脈干17例，肺動脈閉鎖22例，主-肺動脈間隔缺損5例，右室雙出口18例，法洛四聯(lián)癥18例，完全型大動脈轉(zhuǎn)位16例。將96例患者分別行超聲心動圖及Flash CT檢查。超聲心動圖重點(diǎn)觀察心內(nèi)結(jié)構(gòu)、大血管連接、心外畸形，估測肺動脈壓力，評價瓣膜功能及心功能。Flash CT采用新雙源CT前瞻性心電門控Flash掃描模式，掃描結(jié)束后，將原始數(shù)據(jù)進(jìn)行橫斷面重建，由一名有經(jīng)驗(yàn)的放射科醫(yī)師根據(jù)需要進(jìn)行多平面重建，最大密度投影、曲面重建和三維容積再現(xiàn)和仿真內(nèi)窺鏡等。本研究將不作為分型依據(jù)的其他心臟畸形均歸為合并畸形。瓣膜關(guān)閉不全及肺動脈壓不歸為合并畸形。檢查后采用歐洲CT質(zhì)量標(biāo)準(zhǔn)指南，記錄所有CTD病例的CT劑量指數(shù)和劑量長度乘積然后計(jì)算出有效輻射劑量。 結(jié)果 1．96例CTD患者最終經(jīng)手術(shù)結(jié)果或臨床確定診斷。超聲心動圖診斷正確82例，誤診13例，漏診1例；Flash CT診斷正確92例，誤診4例，漏診0例。超聲心動圖和Flash CT對CTD的病因診斷正確率分別為85.42%（82/96）和95.83%（92/96），差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。 2.96例CTD患者分型診斷：超聲心動圖診斷正確64例，誤診15例，未分型17例；Flash CT診斷正確86例，誤診4例，未分型6例。超聲心動圖和Flash CT對CTD分型診斷正確率分別為66.67%（64/96）和89.58%（86/96），差異有統(tǒng)計(jì)學(xué)意義(P＜0.01)。 3．96例CTD患者合并畸形249處，超聲診斷結(jié)果：確診232處，誤診1處，漏診16處；Flash CT診斷結(jié)果：確診238處，誤診0處，漏診11處。超聲和FlashCT診斷正確率分別為93.17%（232/249）和95.58%(238/249)，差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。 4.射線劑量統(tǒng)計(jì)：96例復(fù)雜先心患者平均DLP是7.0±1.50mGy*cm（范圍：5-10mGy*cm），平均ED值是0.212±0.039mSv (范圍：0.144-0.273mSv)。 結(jié)論 1．超聲心動圖對CTD診斷正確率較高，可以作為法洛四聯(lián)癥、完全性大動脈轉(zhuǎn)位、右室雙出口、主-肺動脈間隔缺損、永存動脈干及肺動脈閉鎖的首選檢查方法。 2．超聲心動圖對于永存動脈干和肺動脈閉鎖的分型診斷及鑒別診斷有一定的困難。對于極少數(shù)右室雙出口的室缺位置及大動脈騎跨率判斷會有一定的誤差。出現(xiàn)上述兩種情況時，建議結(jié)合Flash CT協(xié)助診斷。 3．Flash CT大螺距掃描技術(shù)輻射劑量低，對CTD分型診斷正確率高，是對超聲心動圖進(jìn)行補(bǔ)充診斷的最佳檢查方法。 第二部分超聲心動圖結(jié)合Flash CT對肺靜脈畸形引流診斷價值的研究 背景和目的 肺靜脈畸形引流是較為少見的先天性心臟畸形，，由于肺靜脈走行部位復(fù)雜多變超聲檢查容易漏診和誤診。隨著螺旋CT技術(shù)的快速發(fā)展，憑借其對外周血管畸形良好的顯示而越來越多的被臨床醫(yī)生所認(rèn)可。2010年推出的新雙源FlashCT，其獨(dú)特的大螺距快速掃描模式，完全不受心率影響，心臟掃描只需0.25s，實(shí)現(xiàn)了亞mSv級的超快速心臟掃描，不僅保證了診斷的準(zhǔn)確性，同時也關(guān)注到了低劑量輻射等安全問題。本研究運(yùn)用超聲心動圖結(jié)合Flash CT大螺距掃描技術(shù)對肺靜脈畸形引流各種類型漏診、誤診原因進(jìn)行分析研究，目的在于提高超聲心動圖在肺靜脈畸形引流診斷中的準(zhǔn)確率，盡量減少不必要的CT檢查，避免射線的危害。當(dāng)然，對于超聲診斷有困難的病例，可以結(jié)合低輻射劑量的大螺距CT掃面技術(shù)為外科手術(shù)提供參考依據(jù)。 材料和方法 將71例肺靜脈畸形引流患者分為完全性肺靜脈畸形引流（T組）和部分性肺靜脈畸形引流（P組），每組再分為心上型、心內(nèi)型、心下型及混合型，所有患者術(shù)前均行超聲心動圖與Flash CT大螺距掃描技術(shù)檢查，并與手術(shù)結(jié)果（或臨床診斷）對照。另外分別收集正常嬰兒20例、嬰兒單純房間隔缺損20例與T組中34例嬰兒對照分析；收集20例正常成人、20例成人單純房間隔缺損與P組中19例成人患者對照分析，分析指標(biāo)包括左心房、右心室大小、房缺大小，肺動脈壓及年齡等。檢查后采用歐洲CT質(zhì)量標(biāo)準(zhǔn)指南，記錄所有肺靜脈畸形引流病例的CT劑量指數(shù)和劑量長度乘積然后計(jì)算出有效輻射劑量。 結(jié)果 1.完全型肺靜脈畸形引流組（T組）44例（包括心上型22例，心內(nèi)型17例，心下型2例，混合型3例），確診38例，漏診4例，誤診2例。CT確診43例，無漏診；誤診1例。超聲與CT診斷正確率分別為86.36%（38/44）和97.72%（43/44），差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。 2. T組合并畸形62處，超聲全部確診，無漏診及誤診。CT確診59例，無誤診，漏診3例。超聲與CT診斷正確率分別為100%（62/62）和95.16%（59/62），差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。 3. P組27例（包括心上型7例，心內(nèi)型10例，心下型1例，混合型9例），超聲準(zhǔn)確診斷20例，誤診2例，漏診5例。CT確診26例，漏診1例。超聲與CT診斷正確率分別為74.1%（20/27）和96.3%（26/27）。差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。 4. P組合并畸形共計(jì)45處，超聲確診44處，漏診1處。CT正確診斷34處，誤診2處，漏診8處。超聲和CT診斷正確率分別為97.8%（44/45）和75.6%（34/45），差異有統(tǒng)計(jì)學(xué)意義(P＜0.01)。 5. T組多為嬰兒，左心房內(nèi)徑小于房缺組和正常組，差異有統(tǒng)計(jì)學(xué)意義（（P＜0.05））；右心室、肺動脈壓高于房缺組和正常對照組，差異有統(tǒng)計(jì)學(xué)意義（P＜0.01）；T組嬰兒的房間隔缺損大于同齡房缺組，差異有統(tǒng)計(jì)學(xué)意義(P＜0.05) 6. P組多為成年人，左心房內(nèi)徑低于房缺組和正常組，差異有統(tǒng)計(jì)學(xué)意義(P＜0.01)，右心室及肺動脈壓高于房缺組和正常對照組，差異有統(tǒng)計(jì)學(xué)意義(P＜0.01)；P組房間隔缺損小于單純房缺組，差異有統(tǒng)計(jì)學(xué)意義(P＜0.01) 7.71例肺靜脈畸形引流患者，統(tǒng)計(jì)其輻射劑量，平均DLP是13.5±3.9mGy*cm（范圍：8-30mGy*cm），平均ED值為0.324±0.065mSv（范圍：0.182 0.540mSv）。 結(jié)論 1．超聲心動圖診斷肺靜脈畸形引流準(zhǔn)確率高，可以對瓣膜病變、肺動脈壓力及心功能做出全面評價，是一種可以信賴的檢查手段。 2．完全性肺靜脈畸形引流多見于嬰兒，部分性肺靜脈畸形引流多見于成人。由于存在血流動力學(xué)差異，患者左心房、右心室內(nèi)徑、肺動脈壓以及年齡因素可以成為判斷部分性或完全性肺靜脈畸形引流的敏感指標(biāo)。尤其適用于房間隔缺損患者。 3．Flash CT大螺距掃描技術(shù)對心臟周圍血管畸形的診斷具有獨(dú)特的優(yōu)勢，在不影響診斷準(zhǔn)確率的前提下，大大減少了射線的輻射劑量，對超聲心動圖檢查起到了很好的補(bǔ)充診斷作用。
[Abstract]:The Diagnostic Value of First Part Echocardiography Combined with Flash CT in the Diagnosis of Cone Artery Malformations

Background and Purpose

It is a kind of complicated congenital heart disease complicated with peripheral vascular malformation . It has always been the preferred method in the diagnosis of this kind of diseases . However , the rapid development of spiral CT is superior to echocardiography in the diagnosis of the disease .

Materials and Methods

In 96 patients , there were 17 cases of persistent truncus , 22 cases of pulmonary atresia , 5 cases of primary - pulmonary septal defect , 18 cases with right ventricular double - outlet , 18 cases of tetralogy of Fallot , and 16 cases of complete large artery transposition .

Results

1 . 96 CTD patients were diagnosed by surgical results or clinical diagnosis . 82 cases were diagnosed correctly by echocardiography , 13 cases were misdiagnosed , 1 case missed diagnosis ;
The accuracy of diagnosis of CTD was 85.42 % ( 82 / 96 ) and 95.83 % ( 92 / 96 ) respectively , and the difference was statistically significant ( P < 0.05 ) .

2.96 cases of CTD were diagnosed correctly : 64 cases were diagnosed correctly , 15 cases were misdiagnosed and 17 cases were not typed .
The diagnostic accuracy of the CTD typing was 66.67 % ( 64 / 96 ) and 89.58 % ( 86 / 96 ) respectively , and the difference was statistically significant ( P < 0.01 ) .

3.96 patients with CTD were diagnosed at 232 , misdiagnosed as 1 , missed at 16 ;
The diagnostic accuracy of ultrasound and FlashCT was 93.17 % ( 232 / 249 ) and 95.58 % ( 238 / 249 ) respectively .

4 . Ray dose statistics : The mean DLP of 96 patients with complex first heart was 7.0 鹵 1.50 mGy * cm ( range : 5 - 10mGy * cm ) , and the mean ED value was 0.212 鹵 0.039 ( range : 0.144 - 0.273kJ ) .

Conclusion

1 . The accuracy of the diagnosis of CTD was higher in the diagnosis of CTD , which could be used as the preferred method for the diagnosis of tetralogy of Fallot , transposition of the complete large artery , double - outlet of right ventricle , primary - pulmonary septal defect , persistent arterial trunk and pulmonary atresia .

2 . Echocardiogram is difficult to diagnose and differential diagnosis and differential diagnosis of permanent arterial trunk and pulmonary atresia . It is suggested that the diagnosis should be aided by Flash CT .

3 . The radiation dose of the large - pitch scanning technique of Flash CT is low , and the diagnostic accuracy of CTD typing is high , which is the best method for the supplementary diagnosis of echocardiography .

The value of second part echocardiography combined with Flash CT in the diagnosis of pulmonary venous malformation

Background and Purpose

With the rapid development of spiral CT , a new double - source FlashCT was introduced in 2010 . The new double - source FlashCT , which was introduced in 2010 , has a unique large - pitch fast scan mode , which not only guarantees the accuracy of diagnosis , but also pays attention to the safety problems such as low - dose radiation .

Materials and Methods

71 cases of pulmonary venous malformation were divided into complete pulmonary venous malformation drainage ( T group ) and partial pulmonary venous malformation drainage ( group P ) . Each group was divided into three groups : heart type , heart type , heart type and mixed type . All patients were examined by echocardiography and Flash CT scanning technique before operation and compared with operation result ( or clinical diagnosis ) .
Twenty cases of normal adult , 20 adult simple atrial septal defect and 19 adult patients in the P group were collected . The analysis indexes included left atrium , right ventricle size , atrial septal size , pulmonary artery pressure and age . After examination , the CT dose index and dose length product of all cases of pulmonary venous malformation were recorded and the effective radiation dose was calculated .

Results

1 . There were 44 cases of complete pulmonary venous malformation ( group T ) ( including 22 cases of upper heart type , 17 cases in heart type , 2 cases with heart type , 3 cases of mixed type ) , 38 cases were diagnosed , 4 cases were missed , 2 cases were misdiagnosed .
The accuracy of ultrasonography and CT was 86.36 % ( 38 / 44 ) and 97.72 % ( 43 / 44 ) respectively .

The diagnostic accuracy of ultrasonography and CT was 100 % ( 62 / 62 ) and 95.16 % ( 59 / 62 ) respectively . There was no statistical significance ( P > 0.05 ) .

3 . There were 27 cases of P group ( including 7 cases of heart type , 10 cases in heart type , 1 case with heart type , 9 cases of mixed type ) , 20 cases were diagnosed accurately , 2 cases were misdiagnosed , 5 cases missed diagnosis . 26 cases were diagnosed by CT and 1 case missed diagnosis . The accuracy of ultrasound and CT were 74.1 % ( 20 / 27 ) and 96.3 % ( 26 / 27 ) , respectively .

The diagnostic accuracy of ultrasound and CT was 97.8 % ( 44 / 45 ) and 75.6 % ( 34 / 45 ) , respectively ( P < 0.01 ) .

5.T group was infants , the inner diameter of left atrium was smaller than that of atrial septal defect group and normal group ( P < 0.05 ) .
There was significant difference between right ventricle and pulmonary artery pressure ( P < 0.01 ) .
The atrial septal defect of T - group was higher than that in the same - age group ( P < 0.05 ) .

There was significant difference between the right ventricle ( P < 0.01 ) , the right ventricle and the pulmonary artery pressure ( P < 0.01 ) .
The atrial septal defect in P group was smaller than that in simple atrial septal defect group ( P < 0.01 ) .

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本文編號：2000925