【摘要】：背景和目的 主動(dòng)脈瓣疾病（aortic valve disease，AVD）是心臟瓣膜病的一種，發(fā)病率較高，發(fā)病年齡逐漸年輕化。常見的主動(dòng)脈瓣疾病有：主動(dòng)脈瓣狹窄（aortic stenosis，AS），主動(dòng)脈瓣關(guān)閉不全（aortic regurgitation，AR），主動(dòng)脈瓣混合性病變（mixedaortic valve disease，MAVD），即主動(dòng)脈瓣狹窄伴中-重度關(guān)閉不全或主動(dòng)脈瓣關(guān)閉不全伴中-重度狹窄。常見原因有風(fēng)濕性炎癥、先天性主動(dòng)脈瓣畸形，，老齡所致的瓣膜退行性變以及與繼發(fā)于創(chuàng)傷、高血壓、動(dòng)脈瘤等疾病。主動(dòng)脈瓣疾病因慢性容量負(fù)荷或壓力負(fù)荷及二者共同作用，使左心室形態(tài)結(jié)構(gòu)發(fā)生改變，引起左心室肥厚，心室收縮及舒張功能受損。主動(dòng)脈瓣置換（aortic valvereplacement，AVR）是減輕容量負(fù)荷和壓力負(fù)荷的有效方法之一，可使擴(kuò)大和肥厚的左心室逐漸回歸，抑制心室重構(gòu)，改善心功能。 目前有二維及多普勒超聲心動(dòng)圖、應(yīng)變率成像、斑點(diǎn)追蹤成像、負(fù)荷超聲心動(dòng)圖等已用于主動(dòng)脈瓣病變的超聲評(píng)價(jià)，但都不能真實(shí)、直觀反映主動(dòng)脈瓣形態(tài)結(jié)構(gòu)及左心室形態(tài)。實(shí)時(shí)三維超聲心動(dòng)圖（real-time three-dimensionalechocardiography, RT-3DE）實(shí)現(xiàn)了三維技術(shù)發(fā)展的里程碑式飛躍，實(shí)現(xiàn)了心臟結(jié)構(gòu)的動(dòng)態(tài)三維圖像實(shí)時(shí)顯示，能從多方位顯示腔室容量與形狀、瓣膜形態(tài)結(jié)構(gòu)和活動(dòng)、心臟結(jié)構(gòu)的空間關(guān)系，對(duì)心臟疾病特別是心臟瓣膜病的定量定性診斷、治療具有重要意義。RT-3DE對(duì)于左心室形態(tài)方面的研究較多，但對(duì)于比較不同主動(dòng)脈瓣病變患者AVR術(shù)前后左心室構(gòu)型的變化研究較少。 本研究的目的是應(yīng)用RT-3DE評(píng)價(jià)不同的主動(dòng)脈瓣病變患者左心室形態(tài)結(jié)構(gòu)及功能的價(jià)值。 材料與方法 1、研究對(duì)象2012年8月～2013年10月選取80例在河南省人民醫(yī)院就診的患者為研究對(duì)象，分為三組：A組：正常對(duì)照組，30例，來(lái)源于常規(guī)體檢人群，其中男性18例，女性12例，年齡23～60歲，平均（41.9±12.4）歲，臨床及超聲心動(dòng)圖等相關(guān)檢查無(wú)異常；選取擬行AVR患者50例：男性29例，女性21例，年齡15～72歲，平均（46.9±16.9）歲，依據(jù)病變的類型分為兩組，B組：主動(dòng)脈瓣關(guān)閉不全組，28例，除外輕度以上主動(dòng)脈瓣狹窄，C組：主動(dòng)脈瓣狹窄組，22例，除外輕度以上主動(dòng)脈瓣關(guān)閉不全。上述行AVR患者均行冠狀動(dòng)脈造影、心電圖、超聲心動(dòng)圖等相關(guān)檢查，排除標(biāo)準(zhǔn)：冠心病、高血壓、心肌病、糖尿病等疾病。所有AVR患者，分別于術(shù)前、術(shù)后1周、術(shù)后1個(gè)月及術(shù)后6個(gè)月進(jìn)行RT-3DE檢查。 2、RT-3DE檢查采用Philips iE33彩色多普勒超聲診斷儀， X5-1矩陣三維探頭，頻率1～5MHz。受檢者取左側(cè)臥位，同步連接心電圖，行常規(guī)超聲檢查，測(cè)量主動(dòng)脈瓣口峰值流速（Vmax）、主動(dòng)脈瓣口峰值壓差（PPG），啟用X5-1探頭，置于心尖部，于標(biāo)準(zhǔn)心尖四腔心切面，啟用全容積（Full Volume）模式，囑接受檢查者呼氣末屏氣，收集實(shí)時(shí)三維容積圖像，并將圖像保存導(dǎo)出至工作站。脫機(jī)后，在工作站中打開Qlab9.0定量分析軟件，應(yīng)用3DQ軟件進(jìn)行定量分析。于左心室舒張末期，選取心尖四腔心及兩腔心切面的二尖瓣環(huán)水平，手動(dòng)勾勒出心內(nèi)膜面及心外膜面，軟件自動(dòng)計(jì)算出左心室質(zhì)量（LVM）。以同樣的方法在3DQADV條件下，選取心尖四腔心切面及兩腔心切面的二尖瓣環(huán)水平，四腔心或兩腔心切面的心尖部五點(diǎn)進(jìn)行心內(nèi)膜描記，軟件自動(dòng)輸出左心室舒張末期容積（LVEDV）、左心室收縮末期容積（LVESV）、左心室射血分?jǐn)?shù)（LVEF）。為了消除身高、體重對(duì)測(cè)值的影響，以受檢者的體表面積(body surface area, BSA)加以校正，計(jì)算左室舒張末期容積指數(shù)（LVEDVI）=LVEDV/BSA，左室收縮末期容積指數(shù)（LVESVI）=LVESV/BSA，左心室質(zhì)量指數(shù)（LVMI）=LVM/BSA，左室重構(gòu)指數(shù)（LVRI）=LVM/LVEDV。 3、統(tǒng)計(jì)學(xué)分析應(yīng)用SPSS17.0進(jìn)行統(tǒng)計(jì)分析，數(shù)據(jù)以均數(shù)+標(biāo)準(zhǔn)差（x s），組間、組內(nèi)比較行單因素方差分析，兩兩比較行LSD-t檢驗(yàn)。相關(guān)性分析行Pearson分析法，以P0.05為差異有統(tǒng)計(jì)學(xué)意義。一致性檢驗(yàn)行Bland-Altman繪圖分析法。 結(jié)果 1、組間比較 對(duì)照組和主動(dòng)脈瓣病變組比較，兩組年齡、身高、體重、體表面積、心率，無(wú)統(tǒng)計(jì)學(xué)差異（P0.05）。AVR患者術(shù)前、術(shù)后1周、術(shù)后1個(gè)月及6個(gè)月LVMI和LVRI差異有統(tǒng)計(jì)學(xué)意義（P0.05），B組、C組明顯高于A組。術(shù)前C組Vmax、PPG高于A組、B組，術(shù)后B組及C組高于A組，差異有統(tǒng)計(jì)學(xué)意義（P0.05）；術(shù)前B組LVEDVI、LVESVI高于A組、C組，差異有統(tǒng)計(jì)學(xué)意義（P0.05），術(shù)后1周、術(shù)后1個(gè)月及6個(gè)月A組、B組及C組LVEDVI、LVESVI差異無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）；B組及C組LVRI術(shù)前、術(shù)后1周比較差異有統(tǒng)計(jì)學(xué)意義（P0.05）。 2、組內(nèi)比較 術(shù)后1周B組LVEDVI、LVESVI、LVMI及C組LVMI、Vmax、PPG均較術(shù)前下降，差異有統(tǒng)計(jì)學(xué)意義（P0.05），術(shù)后1周B組、C組LVRI差異有統(tǒng)計(jì)學(xué)意義（P0.05）。AVR術(shù)后1個(gè)月，B組LVMI、LVRI較術(shù)后1周減小，差異有統(tǒng)計(jì)學(xué)意義（P0.05），C組LVMI、LVRI與術(shù)后1周比較無(wú)明顯統(tǒng)計(jì)學(xué)意義（P0.05）。AVR術(shù)后6個(gè)月，B組、C組各參數(shù)與術(shù)后1個(gè)月相比，差異無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）。 3、相關(guān)性分析 AVR置換患者術(shù)后1周、1個(gè)月及6個(gè)月， LVEF與LVMI均呈負(fù)相關(guān)（分別為r=-0.68，P0.05；r=-0.73，P0.05；r=-0.88，P0.05）。 4、一致性檢驗(yàn) Bland-Altman方法繪圖分析結(jié)果得出LVMI、LVEDVI、LVRI觀察者內(nèi)部及觀察者之間重復(fù)性良好。 結(jié)論 1、應(yīng)用RT-3DE技術(shù)可以定量評(píng)價(jià)主動(dòng)脈瓣置換患者左心室重構(gòu)與功能。 2、主動(dòng)脈瓣置換術(shù)可以逆轉(zhuǎn)不同主動(dòng)脈瓣病變患者左室重構(gòu)，AVR對(duì)于主動(dòng)脈瓣關(guān)閉不全組的效果優(yōu)于主動(dòng)脈瓣狹窄組。 3、AVR術(shù)后不同時(shí)期LVEF與LVMI均有較高的相關(guān)性，說(shuō)明RT-3DE測(cè)量的LVMI可以定量評(píng)價(jià)AVR術(shù)后左心室重構(gòu)及逆轉(zhuǎn)。
[Abstract]:Background and Purpose Aortic valve disease (AVD) is a kind of valvular heart disease. The common aortic valve disease is aortic stenosis (AS), aortic valve insufficiency (AR), aortic valve disease (MAVD), aortic stenosis with moderate-severe insufficiency or aortic valve insufficiency with moderate-severe Stenosis. Common causes include rheumatic inflammation, congenital aortic valve deformity, degenerative valve degeneration due to aging, and secondary to trauma, hypertension, aneurysm, etc. Disease. Aortic valve disease changes due to chronic capacity load or pressure load and both, resulting in left ventricular hypertrophy, ventricular systolic and diastolic function. Damage. Aortic valve replacement (AVR) is one of the effective methods for reducing capacity load and pressure load, allowing progressive regression of the left ventricle of enlarged and hypertrophic left ventricle, inhibiting ventricular remodeling, and improving heart Functions: Two-dimensional and Doppler echocardiography, strain rate imaging, spot tracking imaging, load echocardiography, etc. have been used in the ultrasonic evaluation of aortic valve diseases, but they can not be true, and the aortic valve morphological structure can be intuitively reflected. Real-time three-dimensional echocardiography (RT-3DE) is a milestone leap in the development of three-dimensional technology, which realizes the real-time display of the dynamic three-dimensional image of the heart structure, which can display the volume and shape of the chamber, the structure and activity of the valve, and the cardiac structure. Quantitative qualitative diagnosis and treatment of heart disease, in particular valvular heart disease, in relation to the spatial relationship of heart disease It is important that RT-3DE has more research on left ventricular morphology, but for comparison of left ventricular configuration before and after AVR in patients with different aortic valve lesions The purpose of this study was to evaluate the left ventricular morphology of patients with different aortic valve lesions using RT-3DE Structure and function The value, material and method of the study were divided into three groups: group A: normal control group and 30 cases. There were 12 female patients, aged 23 to 60 years old and average (41. 9, 12. 4) years old, clinical and echocardiogram were not abnormal; 50 cases were selected for AVR patients: 29 males, 21 females, 15 to 72 years old and average (46. 9 to 16. 9) years old, divided into two groups according to the type of lesion, group B: Aortic insufficiency, 28, with mild or more aortic stenosis, Group C: Aortic stenosis, 22, Minor or more aortic insufficiency. All patients with AVR underwent coronary angiography, ECG, echocardiogram, and so on. Exclusion criteria: coronary heart disease, Hypertension, cardiomyopathy, diabetes, etc. All AVR patients, 1 week after operation, 1 month post-operation and operation RT-3DE inspection was performed in the last 6 months. 2, RT-3DE examination was performed using the GeneE33 color Doppler ultrasound diagnostic instrument, X5-1-matrix three-dimensional probe with frequency of 1-5MHz. The subject takes the left lateral position, synchronously connects the electrocardiogram, performs routine ultrasonic examination, measures the peak flow rate (bpm) of the aortic valve, the peak pressure difference (PPG) of the aortic valve, enables the X5-1 probe to be placed in the apical part, and is enabled on the standard apical four-cavity heart cutting surface. Full Volume mode, which receives the breath end breath of the examiner, and collects the real-time three-dimensional Volume image and export the image to the workstation. After offline, open Qlab9.0 quantitative score in the workstation Analyzing software and applying 3DQ software to analyze quantitatively. At the end of left ventricular end diastole, select the level of mitral annulus of apical four-cavity heart and two-cavity heart-cut plane, hand out the endocardial surface and epicardial surface. Left ventricular mass (LVM) was automatically calculated by software. In the same way, under the condition of 3DQADV, the left ventricular end diastolic volume (LVEDV) was automatically output from the apical four-cavity heart-cut face and the mitral annulus level of the two-cavity heart-cut face, the four-lumen heart or the apical part of the two-cavity heart-cut face. Left ventricular systolic end volume (LVE SV, left ventricular ejection fraction (LVDVI) = LVEDV/ BSA, left ventricular end systolic volume index (LVEVI) = LVEV/ BSA, left ventricular mass index (LVMI) = LVM/ BSA, left ventricular remodeling Number (LVRI) = LVM/ LVEDV. 3. Statistical analysis applied SPSS1.7. 0 for statistical analysis. Data were compared with standard deviation (x s), group, and group. Single-factor analysis of variance, two comparison lines LSD-t test, correlation analysis line Pearso The results of n-analysis showed that the difference was statistically significant with P0.05. Inspection Line Bland Results 1. Compared with the control group and the aortic valve group, the age, height, body weight, body surface area, heart rate and heart rate of the two groups were not statistically different (P <0.05). Before operation, 1 week after operation, 1 month after operation and 6 months after operation. Months LVMI and LV There were significant differences in RI (P0.05), group B and group C were significantly higher than that in group A. In group C before operation, PPG was higher than group A, group B, group B and group C were higher than group A, the difference was statistically significant (P0.05). There was no significant difference in LVEDVI and LVESVI between group B and group C (P0.05). Group LVRI Before and after operation, the difference was statistically significant (P0.05). In group B, LVEDVI, LVESVI, LVMI and LVMI were significantly higher in group B than before operation (P <0.05). The difference of LVMI, LVMI, LVMI in group C was statistically significant (P0.05). There was no significant difference between LVMI and LVRI in group B after AVR (P0.05). Month, Group B, C Compared with 1 month after operation, the difference was not statistically significant (P0.05). 3. The correlation analysis AVR replaced the patients for 1 week, 1 month and 6 months. =-0,68, P0. 05; r =-0.73, P0.05; r =-0.88, P0.05). 4. Consistency check Band-A lt The results of man-method drawing analysis are: LVMI, LVEDVI, LVRI observer; Conclusion 1. RT-3DE technique can quantitatively evaluate left ventricular remodeling and function in patients with aortic valve replacement. 2. Aortic valve replacement can reverse the remodeling of the left chamber of patients with different aortic valves and AVR is superior to aortic valve stenosis in the aortic valve insufficiency group. 3, AV
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R540.45;R542.5

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