【摘要】：【目的】房間隔缺損(atrial septal defect,ASD)是常見(jiàn)的先天性心臟病之一,持續(xù)的房水平左向右分流可導(dǎo)致右心室、右心房容量負(fù)荷增加,進(jìn)而導(dǎo)致右心擴(kuò)大以及肺動(dòng)脈高壓。右室增大導(dǎo)致室間隔與左室后壁同向運(yùn)動(dòng),擴(kuò)大的右室壓迫左室,引起左心功能不同程度減低。嚴(yán)重者可導(dǎo)致心力衰竭,甚至死亡。近年來(lái),隨著微創(chuàng)醫(yī)學(xué)的發(fā)展,經(jīng)皮導(dǎo)管介入封堵術(shù)以其創(chuàng)面小、術(shù)后康復(fù)快、住院周期短以及并發(fā)癥少等優(yōu)勢(shì)被臨床認(rèn)為是首選治療。二維斑點(diǎn)追蹤技術(shù)成像(Speckle Tracking Imaging,STI)從縱向、環(huán)向、徑向多個(gè)方面對(duì)心肌力學(xué)特征進(jìn)行多方位的評(píng)價(jià),可以定量評(píng)價(jià)心肌運(yùn)動(dòng)速度、應(yīng)變、應(yīng)變率等,另外可獲得心室的扭轉(zhuǎn)運(yùn)動(dòng)參數(shù),從而評(píng)價(jià)左室整體和區(qū)域心肌收縮功能。本實(shí)驗(yàn)主要是應(yīng)用STI技術(shù)獲得房間隔缺損患者封堵術(shù)前后左心室收縮期圓周應(yīng)變與徑向應(yīng)變以及左心室旋轉(zhuǎn)、扭轉(zhuǎn)的相關(guān)參數(shù)的變化,來(lái)探討房間隔缺損患者封堵手術(shù)前、后左室收縮功能的變化。為評(píng)價(jià)ASD封堵術(shù)前、后左心室收縮功能的評(píng)價(jià)提供新的方法�！痉椒ā窟x取繼發(fā)孔房間隔缺損(asd組)患者30例作為病例組;同期選擇我院性別、年齡相匹配的健康正常人30例作為對(duì)照組(nc組)。分別于術(shù)前、術(shù)后2天、術(shù)后6月常規(guī)測(cè)量右房舒張末內(nèi)徑(rightatrialend-diastolicdiameter,rvdd)、右室舒張末內(nèi)徑(rightventricularend-diastolicdiameter,radd),左室舒張末內(nèi)徑(leftventricularend-diastolicdiameter,lvdd),左室舒張末容積(leftventricularend-diastolicvolume,lvedv)及左室收縮末容積(leftventricularend-systolicvolume,lvesv),并通過(guò)雙平面改良simpson法獲得左心室射血分?jǐn)?shù)(leftventricularejectionfraction,lvef)及左室每搏輸出量(leftventricularstrokevolume,lvsv)。留取左心室短軸三個(gè)水平(基底水平、中部及心尖水平)的動(dòng)態(tài)二維超聲圖像,導(dǎo)入echopac工作站獲取左心室應(yīng)變參數(shù)以及扭轉(zhuǎn)參數(shù)。第一部分:斑點(diǎn)追蹤技術(shù)對(duì)房間隔缺損封堵術(shù)前、后左室短軸應(yīng)變的定量評(píng)價(jià)通過(guò)sti分析后系統(tǒng)自動(dòng)得出左心室各平面各節(jié)段的徑向應(yīng)變(radialstrain,sr)-時(shí)間曲線及圓周應(yīng)變(circumferentialstrain,sc)-時(shí)間曲線。軟件自動(dòng)將左心室短軸分為六個(gè)節(jié)段:前間隔、前壁、側(cè)壁、下壁、后壁及中后間隔。獲取左室短軸各節(jié)段的圓周及徑向應(yīng)變峰值及達(dá)峰時(shí)間,將各節(jié)段應(yīng)變峰值總和后取平均值作為整體應(yīng)變峰值。將得到的數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析。第二部分:二維斑點(diǎn)追蹤技術(shù)對(duì)房間隔缺損封堵術(shù)前、后左心室扭轉(zhuǎn)運(yùn)動(dòng)的定量評(píng)價(jià)同樣經(jīng)過(guò)sti分析后得到基底旋轉(zhuǎn)角度-時(shí)間曲線、心尖旋轉(zhuǎn)角度-時(shí)間曲線及左室扭轉(zhuǎn)-時(shí)間曲線,分別測(cè)量旋轉(zhuǎn)角度峰值、扭轉(zhuǎn)角度的峰值及其對(duì)應(yīng)的達(dá)峰時(shí)間,然后將進(jìn)行統(tǒng)計(jì)學(xué)分析。【結(jié)果】(1)常規(guī)參數(shù)比較:病例組rv及ra術(shù)前舒張末內(nèi)徑大于對(duì)照組(p0.05),術(shù)后2天較術(shù)前組減小(p0.05)并接近對(duì)照組。病例組術(shù)前l(fā)v前后徑、lv左右徑小于對(duì)照組(p0.05),術(shù)后2天增加(p0.05)并接近于對(duì)照組。病例組術(shù)前l(fā)vedv、lvsv組均小于對(duì)照組(p0.05),術(shù)后2天較術(shù)前增大(p0.05),術(shù)后6個(gè)月進(jìn)一步增大(p0.05)并接近于對(duì)照組。病例組lvesv、lvef術(shù)前小于對(duì)照組(p0.05),術(shù)后2天即較術(shù)前增大(p0.05)并接近于對(duì)照組。(2)左室各節(jié)段圓周應(yīng)變比較:病例組封堵術(shù)前各節(jié)段的圓周應(yīng)變峰值均低于對(duì)照組(p0.05)。前間隔、前壁、側(cè)壁、后壁術(shù)后2天較術(shù)前顯著增高(p0.05),亦高于對(duì)照組(p0.05),術(shù)后6個(gè)月減低(p0.05)接近于對(duì)照組。病例組下壁、中后間隔術(shù)后2天即增高(p0.05)并接近于對(duì)照組。(3)左室各節(jié)段徑向應(yīng)變比較:病例組除后壁外余左室各節(jié)段的徑向應(yīng)變峰值均低于對(duì)照組(p0.05),術(shù)后2天增高(p0.05)并接近于對(duì)照組;后壁徑向應(yīng)變術(shù)前高于對(duì)照組(p0.05),術(shù)后2天無(wú)明顯變化,術(shù)后6個(gè)月減低(p㩳0.05),接近于對(duì)照組。(4)左心室整體應(yīng)變的比較:病例組左室整體圓周應(yīng)變術(shù)前低于對(duì)照組(p㩳0.05);封堵術(shù)后2天增高(p㩳0.05),亦高于對(duì)照組(p㩳0.05);術(shù)后6個(gè)月又降低(p㩳0.05)并接近于對(duì)照組。病例組左室整體徑向應(yīng)變術(shù)前與對(duì)照組無(wú)統(tǒng)計(jì)學(xué)差異,封堵術(shù)后2天增高(p㩳0.05),亦高于對(duì)照組(p㩳0.05),術(shù)后6個(gè)月降低(p㩳0.05)至正常。(5)左室基底水平各節(jié)段旋轉(zhuǎn)角度峰值比較:與對(duì)照組比較,病例組術(shù)前左室基底水平除后壁外余各節(jié)段旋轉(zhuǎn)角度峰值顯著減低(p㩳0.05)。術(shù)后2天病例組左室基底水平前壁、側(cè)壁旋轉(zhuǎn)角度峰值較術(shù)前顯著增高(p㩳0.05)并接近于對(duì)照組;前間隔、下壁及中后間隔術(shù)后2天無(wú)顯著變化,至術(shù)后6個(gè)月增高(p㩳0.05)并接近正常水平。病例組左室基底水平后壁旋轉(zhuǎn)角度峰值術(shù)前較對(duì)照組顯著增高(p㩳0.05),術(shù)后2天即減低(p㩳0.05)并接近對(duì)照組。(6)左室心尖水平各節(jié)段旋轉(zhuǎn)角度峰值比較:病例組術(shù)前左室心尖水平各節(jié)段的旋轉(zhuǎn)角度峰值均高于對(duì)照組(p㩳0.05),術(shù)后2天無(wú)明顯變化,術(shù)后6個(gè)月減低(p㩳0.05)并接近于對(duì)照組。(7)左室整體最大扭轉(zhuǎn)角度的比較:病例組左室整體最大扭轉(zhuǎn)角度術(shù)前小于對(duì)照組,術(shù)后2天即較術(shù)前增高(p㩳0.05)并接近于對(duì)照組。(8)左室應(yīng)變達(dá)峰時(shí)間、旋轉(zhuǎn)達(dá)峰時(shí)間及扭轉(zhuǎn)達(dá)峰時(shí)間在病例組與對(duì)照組之間無(wú)統(tǒng)計(jì)學(xué)差異,且這些參數(shù)在病例組封堵術(shù)前、后亦無(wú)統(tǒng)計(jì)學(xué)差異�！窘Y(jié)論】(1)本研究證實(shí)應(yīng)用二維斑點(diǎn)追蹤技術(shù)可以評(píng)價(jià)經(jīng)皮導(dǎo)管介入封堵術(shù)前、后左室各節(jié)段及整體圓周應(yīng)變、徑向應(yīng)變的變化,左室各節(jié)段旋轉(zhuǎn)角度及整體扭轉(zhuǎn)角度的變化。(2)右心容量負(fù)荷增加可引起左室收縮功能不同程度減低。(3)經(jīng)皮導(dǎo)管介入封堵術(shù)阻斷了房水平左向右分流,使得右心容量負(fù)荷減低,室間隔及左室后壁運(yùn)動(dòng)恢復(fù)正常,左室前負(fù)荷增加,擴(kuò)張性增加,左室形態(tài)發(fā)生幾何重構(gòu)和逆轉(zhuǎn)重構(gòu),左室的容積和收縮功能得到改善。(4)封堵術(shù)后左室即刻進(jìn)行幾何重構(gòu),持續(xù)逆轉(zhuǎn)重構(gòu),直至術(shù)后六個(gè)月趨向于穩(wěn)定。
[Abstract]:[Objective] atrial septal defect (ASD) is one of the common congenital heart diseases. The continuous left to right shunt of the atrial level can lead to the increased volume load of the right ventricle and the right atrium, which leads to the enlargement of the right heart and the high pressure of the pulmonary artery. The enlargement of the right ventricle leads to the same movement of the ventricular septum and the left ventricle, and the right ventricle enlarging the left ventricle, In recent years, with the development of minimally invasive medicine, percutaneous transcatheter closure is considered to be the preferred treatment for its advantages of small wound, fast postoperative recovery, short hospital stay and fewer complications. Two-dimensional dot tracking imaging (Speckle Tracking) Imaging, STI) multidimensional evaluation of myocardial mechanical characteristics from longitudinal, circumferential and radial aspects. It can evaluate myocardial velocity, strain, strain rate and so on. In addition, the torsional motion parameters of the ventricle can be obtained, and the systolic function of the whole and regional left ventricular myocardium is evaluated. This experiment is mainly to use STI technique to obtain the atrial septal defect. The changes in the relative parameters of left ventricular systolic circumference and radial strain and left ventricular rotation and torsion before and after occlusion were used to explore the changes in left ventricular systolic function before closure of atrial septal defect in patients with atrial septal defect. A new method was provided to evaluate the systolic function of left ventricle before ASD occlusion. 30 cases of orifice septal defect (Group ASD) were used as case group, and 30 cases of healthy and normal people with matched age were selected as control group (Group NC) at the same time. Before operation and 2 days after operation, the right chamber end diastolic diameter (rightatrialend-diastolicdiameter, rvdd), right ventricular end diastolic diameter (rightventricularend-diastoli) were measured in June after operation (rightventricularend-diastoli Cdiameter, Radd), left ventricular end diastolic diameter (leftventricularend-diastolicdiameter, LVDD), left ventricular end diastolic volume (leftventricularend-diastolicvolume, LVEDV) and left ventricular end systolic volume (leftventricularend-systolicvolume, LVESV), and the left ventricular ejection fraction (leftventricularejectionfrac) was obtained by improved Simpson method by double plane surface (leftventricularejectionfrac). Tion, LVEF) and left ventricular pacing output (leftventricularstrokevolume, lvsv). Dynamic two-dimensional ultrasound images with three levels of the left ventricular short axis (basal, central and apical) were taken, and the echopac workstation was introduced to obtain the left ventricular strain parameters and torsional parameters. Part 1: spot tracking technique was used before the atrial septal defect closure. The quantitative evaluation of left ventricular short axis strain was made by STI analysis. The radial strain (radialstrain, SR) time curve and circumferential strain (circumferentialstrain, SC) time curve of each segment of the left ventricle were automatically obtained. The short axis of the left ventricle was automatically divided into six segments: anterior, anterior, lateral, lower, posterior, and middle and posterior. The circumference and radial strain peak and peak time of each segment of the short axis of the left ventricle were obtained, and the total strain peak value was taken as the peak value of the whole strain. The data obtained were statistically analyzed. The second part: the quantitative evaluation of the left ventricular torsion movement before the occlusion of the atrial septal defect by two-dimensional speckle tracking technique also passed through the quantitative evaluation. After STI analysis, the base rotation angle time curve, the apical rotation angle time curve and the left ventricular torsion time curve were used to measure the peak value of the rotation angle, the peak of the torsion angle and the corresponding peak time respectively, and then the statistical analysis was then carried out. [results] (1) the routine parameters were compared: the internal diameter of the end diastolic end of the case group RV and RA was greater than that of the case group. The control group (P0.05) was less than the control group at 2 days after operation (P0.05). The diameter of LV before and after operation was smaller than that of the control group (P0.05), and increased (P0.05) on the 2 day after operation (P0.05) and was close to the control group. The case group was smaller than the control group before the operation (P0.05), and the 2 day after the operation (P0.05) and 6 months after the operation (P0.05). The case group was less than the control group. The case group LVESV was less than the control group (P0.05) before operation, and 2 days after the operation (P0.05) was increased (P0.05) and was close to the control group. (2) the circumferential strain of each segment of the left ventricle was compared with that of the control group (P0.05). The anterior septum, the anterior wall, the lateral wall and the posterior wall were significantly increased at 2 days after the operation. High (P0.05), and higher than the control group (P0.05), 6 months after the operation decreased (P0.05) close to the control group. The lower wall of the case group, 2 days after the middle and posterior septum increased (P0.05) and close to the control group. (3) the radial strain of each segment of the left ventricle was compared with that of the left ventricular segment of the left ventricle, which was lower than that of the control group (P0.05), and increased at 2 days after the operation (P 0.05) and close to the control group; the posterior wall radial strain was higher than the control group (P0.05), there was no obvious change at 2 days after operation, 6 months after the operation (P? 0.05), close to the control group. (4) the left ventricular overall strain was compared with the left ventricular circumference strain before the operation (P? 0.05), and 2 days after occlusion (P? 0.05), and higher than the control group (P? 0. 0 5); 6 months after the operation (P? 0.05) and close to the control group. There was no statistical difference between the left ventricular radial strain before operation and the control group, 2 days after the occlusion (P? 0.05), and higher than the control group (P? 0.05), and 6 months after the operation (P? 0.05) to normal. (5) the rotation angle peak of the left ventricular basal level was compared: compared with the control group, the disease was compared with the control group. The peak value of the rotation angle of the left ventricular basal level except the posterior wall of the left ventricle in the case group decreased significantly (P 0.05). At the 2 day after the operation, the lateral wall of the left ventricle was significantly higher than that before the operation (P? 0.05) and was close to the control group. The anterior septum, the lower wall and the middle posterior septum were not significantly changed at 2 days after the operation (P? 0.05). The left ventricular base level posterior wall rotation angle peak was significantly higher than the control group (P 0.05) before operation (P? 0.05) and close to the control group at 2 days after operation. (6) the peak value of rotation angle of each segment of the left ventricular apical level was compared with the control group (P? 0.). 05) there was no obvious change at 2 days after operation, 6 months after the operation (P? 0.05) and close to the control group. (7) the maximum torsional angle of the left ventricle was compared: the left ventricular maximum torsion angle was less than the control group before operation, 2 days after the operation (P? 0.05) and close to the control group. (8) the peak time of left ventricular strain, the time of rotation peak and twist There was no statistical difference between the case group and the control group, and there was no statistical difference between the case group and the control group. [Conclusion] (1) this study confirmed the application of two-dimensional speckle tracking technique to evaluate the changes of the left ventricular segment and the overall circumference strain, the change of the radial strain and the left ventricle before transcatheter transcatheter closure of transcatheter closure. (2) the increase of right heart capacity load may cause the left ventricular systolic function to decrease in different degrees. (3) transcatheter transcatheter closure blocking the left to right shunt of the atrial level, reducing the capacity load of the right heart, the movement of the ventricular septum and left ventricle back to normal, the increase of left ventricular preload and dilatation. The left ventricular geometry reconfiguration and reversion reconfiguration, the left ventricular volume and contractile function were improved. (4) the left ventricle was reconstructed immediately after occlusion, and the reconstruction was continued until the six months after the operation.
【學(xué)位授予單位】：第四軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R445.1;R541.1

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