本文關(guān)鍵詞：多功能超聲檢測(cè)心血管畸形胎兒右心功能的初步研究　出處：《第三軍醫(yī)大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 超聲心動(dòng)圖 實(shí)時(shí)三維容積超聲 胎兒 心血管畸形 右心室功能

【摘要】：背景 衛(wèi)生部公布的關(guān)于2004年全國(guó)婦幼衛(wèi)生監(jiān)測(cè)結(jié)果顯示：在新生兒出生缺陷中先天性心臟�。╟ongenital heart disease，CHD）居首位。心血管畸形是由于胎兒在胚胎期心血管的發(fā)育過(guò)程中，多個(gè)基因、環(huán)境因素兩者間的相互影響造成胎兒時(shí)期心臟及大血管的發(fā)育異常，以至引起局部解剖結(jié)構(gòu)畸形的主要原因，最終影響其心功能。近年來(lái)超聲分辨率有了很大的提高，胎兒超聲心動(dòng)圖技術(shù)可以多方位、更全面地檢測(cè)胎兒的心功能、心臟結(jié)構(gòu)、血流動(dòng)力學(xué)的變化、各種類型心律不齊以及胎兒水腫等進(jìn)行全面的評(píng)價(jià)，普遍認(rèn)為此項(xiàng)技術(shù)是評(píng)價(jià)產(chǎn)前胎兒心臟畸形最為有效的檢查方法。由于胎兒時(shí)期右心室（Right ventricle，RV）的容量負(fù)荷和壓力負(fù)荷都較左心室(Left ventricular，LV)相對(duì)要重，右心系統(tǒng)發(fā)揮著關(guān)鍵作用，因此右心室功能的準(zhǔn)確評(píng)估可以有效地反映胎兒的整體心功能，有助于提高部分CHD胎兒的出生存活率。右室雙出口（doubleoutlet right ventricle，DORV）與法洛四聯(lián)癥(tetralogy of fallot，TOF)均屬于復(fù)雜型先天性心臟病，兩者的病理生理有一定的相似性。 目的 運(yùn)用脈沖多普勒成像技術(shù)（Pulsed wave Doppler，PW）、M型超聲(M-modeechocardiography，MME)、實(shí)時(shí)三維容積超聲(real-time three-dimensional volumetricechocardiography，RT-3DE)對(duì)DORV及TOF胎兒右心功能進(jìn)行檢測(cè)，探討其在臨床的應(yīng)用價(jià)值，為及時(shí)早期的發(fā)現(xiàn)胎兒心功能異常提供可靠參考。 材料與方法 1.分組：病變組（組1），選取于2010年12月～2013年1月期間門(mén)診初次超聲診斷為右室雙出口或法洛四聯(lián)癥胎兒共32例，孕婦年齡20～39（26.1±3.3）歲，孕周為23～38（29±6.1）周。正常組（組2），另選取同期孕齡相匹配的超聲診斷為胎兒心臟未見(jiàn)明顯異常者60例胎兒作為正常對(duì)照。本研究得到了受檢孕婦及其家屬的準(zhǔn)許，并取得了醫(yī)院倫理委員會(huì)批準(zhǔn)。 2.方法：利用飛利浦公司提供的IE33智能心臟彩超檢測(cè)儀器，具有最新的功能，最專業(yè)的臨床性能。配有S5-1經(jīng)胸探頭、S8-3經(jīng)胸高頻探頭和X3-1經(jīng)胸實(shí)時(shí)三維矩陣探頭，頻率依次為1～5MHz、3～8MHz、1～3MHz，擁有最新的成像模式和最新的Qlab9.0三維容積定量3DQ分析軟件；多普勒的掃描速度為100mm/s；運(yùn)用PW、MME、RT-3DE三種方法，，分別對(duì)32例病變組胎兒和60例正常組胎兒心臟的右心室做功指數(shù)（Tei指數(shù)）、右室舒張末期容積(end-diastolic volume,EDV)、收縮末期容積(end-systolic volume,ESV)、每搏量(stroke volume,SV)和射血分?jǐn)?shù)(ejection fraction,EF)進(jìn)行測(cè)量，三種方法之間進(jìn)行兩兩對(duì)比分析；整個(gè)研究過(guò)程中均由一名超聲科醫(yī)生利用三種方法分別測(cè)量胎兒心功能指標(biāo)，最后將三個(gè)心動(dòng)周期的測(cè)值進(jìn)行平均求值；所測(cè)得數(shù)據(jù)均應(yīng)用SPSS19.0進(jìn)行統(tǒng)計(jì)學(xué)的分析，采用平均值±標(biāo)準(zhǔn)差表示（x_±s），病變組與正常組胎兒的心功能測(cè)值比較均采用樣本t檢驗(yàn)，統(tǒng)計(jì)結(jié)果以p值0.05為差異具有統(tǒng)計(jì)學(xué)意義，p值0.01為差異顯著；利用Pearson相關(guān)分析對(duì)三種超聲心動(dòng)圖方法所測(cè)的心功能測(cè)值的相關(guān)性進(jìn)行分析；采用ROC曲線進(jìn)行診斷試驗(yàn)分析比較。 結(jié)果 1.二維超聲心動(dòng)圖測(cè)得病變組胎兒的LV/RV比值明顯低于正常組[(0.82±0.14)vs（0.95±0.08），P0.001]，病變組胎兒的AO/PA比值明顯高于正常組[(1.57±0.75)vs（0.85±0.10），P0.001]； 2. PW檢測(cè)32例病變組胎兒右心室的Tei指數(shù)明顯高于60例的正常組胎兒[(0.48±0.09)vs(0.35±0.05), P0.001]； 3. MME與RT-3DE對(duì)病變組胎兒右心室的（EDV、ESV和EF）檢測(cè)結(jié)果與正常組進(jìn)行比較，差異具有顯著的統(tǒng)計(jì)學(xué)意義(P0.05)； 4. Tei指數(shù)與RT-3DE所測(cè)心功能測(cè)值的ROC診斷曲線一致性較好，而與MME測(cè)值差異較大。Tei指數(shù)與RT-3DE診斷的ROC曲線下面積比較z=1.559，P=0.119，無(wú)顯著差異，RT-3DE與MME診斷的ROC曲線下面積比較z=0.782，P=0.434；Tei指數(shù)EF值的相關(guān)系數(shù)：MME為（r=-0.449，p＜0.001），RT-3DE為（r=-0.517，p＜0.001），都成負(fù)相關(guān)，結(jié)果提示與RT-3DE的相關(guān)性更大，說(shuō)明Tei指數(shù)與RT-3DE診斷更接近，相關(guān)性更好，無(wú)顯著差異。 結(jié)論 胎兒超聲心動(dòng)圖可以對(duì)復(fù)雜型先天性心臟病進(jìn)行及時(shí)有效的診斷，RT-3DE可以不根據(jù)任何解剖結(jié)構(gòu)的假設(shè)準(zhǔn)確可靠地對(duì)胎兒時(shí)期的右室心功能進(jìn)行評(píng)估，是有效、準(zhǔn)確的無(wú)創(chuàng)性檢查方法，對(duì)預(yù)測(cè)CHD胎兒病情的發(fā)展具有重要的臨床意義，隨著超聲技術(shù)的不斷進(jìn)步，RT-3DE將向胎兒先天性心臟病的深度和廣度兩個(gè)方向擴(kuò)展開(kāi)來(lái)。
[Abstract]:background
The Ministry of Health announced on the 2004 National Maternal and child health monitoring results show that: in the neonatal birth defects in congenital heart disease (congenital heart disease, CHD) in the first place. Because of fetal cardiovascular malformations in the developing embryonic cardiovascular system, multiple genes, environmental factors interaction caused by fetal heart and great vessels the main cause of abnormal development, and abnormal structure of local anatomy, ultimately affect cardiac function. In recent years, ultrasonic resolution has been greatly improved, fetal echocardiography can range, a more comprehensive measurement of heart function, fetal heart structure and hemodynamic changes, a comprehensive evaluation of various types of arrhythmia and fetus edema, is generally believed that this technique is the evaluation of fetal heart malformation is the most effective method for the detection of fetal period. Because of the right ventricle (Ri Ght ventricle, RV) the volume load and pressure load are compared with left ventricular (Left ventricular, LV) is relatively heavy, right heart system plays a key role, so the accurate assessment of right ventricular function can effectively reflect the overall fetal heart function, help to improve the CHD part of the fetal survival rate of birth. Outlet of right ventricle (Doubleoutlet right ventricle, DORV) with tetralogy of Fallot (tetralogy of Fallot, TOF) belong to the complex congenital heart disease, there are some similarities between the pathophysiology.
objective
The use of pulsed Doppler imaging technology (Pulsed wave Doppler, PW), M (M-modeechocardiography, MME), ultrasound real-time three-dimensional ultrasonography (real-time three-dimensional volumetricechocardiography, RT-3DE) were used to detect DORV and TOF fetal right heart function, discuss its application value in clinical, timely early detection of fetal cardiac function abnormalities provide reliable reference.
Materials and methods
1. grouping: disease group (group 1), selected from December 2010 to January 2013 during the first outpatient department of ultrasound diagnosis of double outlet right ventricle or a total of 32 cases of tetralogy of Fallot in the fetus, pregnant women aged 20 to 39 (26.1 + 3.3) years of age, gestational age ranged from 23 to 38 (29 + 6.1) normal group (group of 2 weeks.), ultrasound diagnosis of other selected gestational age matched for fetal heart in 60 fetuses served as normal controls. This study has been granted by pregnant women and their families, and obtained the approval of the ethics committee of the hospital.
2. methods: the use of IE33 intelligent cardiac ultrasound detecting instrument provided by PHILPS, with the latest features, the clinical performance of the most professional S5-1. With transthoracic probe, S8-3 transthoracic high-frequency probe and X3-1 probe real-time three-dimensional transthoracic matrix, the frequency was 1 ~ 5MHz, 3 ~ 8MHz, 1 ~ 3MHz, with the most a new imaging mode and the latest Qlab9.0 three-dimensional volumetric quantitative 3DQ analysis software; Doppler scanning speed is 100mm/s; the use of PW, MME, RT-3DE three methods respectively in 32 cases of fetal disease group and normal group 60 cases of fetal heart right ventricular Tei index (Tei index), right ventricular end diastolic volume (end-diastolic volume, EDV), end systolic volume (end-systolic, volume, ESV), stroke volume (stroke, volume, SV) and ejection fraction (ejection fraction, EF) were measured, 22 were compared between the three methods; the whole research process by an ultrasound Doctors of fetal heart function indexes were measured by three methods, the three cardiac cycle measurements of the average evaluation; analysis of the measured data of SPSS19.0 was used, the average standard deviation (x_ + s), fetal heart function lesion group and normal group were measured the sample t test results to the p value is 0.05. The difference was statistically significant, P value of 0.01 is significant difference; correlation between measured values of three echocardiographic methods of measuring the cardiac function by Pearson were analyzed by ROC curve; analysis and comparison of diagnostic tests.
Result
1. two dimensional echocardiography showed that the LV/RV ratio of the fetus in the lesion group was significantly lower than that in the normal group [(0.82 + 0.14) vs (0.95 + 0.08), P0.001], the AO/PA ratio of the fetus in the lesion group was significantly higher than that in the normal group [(1.57 + 0.75) vs (0.85 + 0.10), P0.001].
The Tei index of the right ventricle of the fetus was significantly higher than that of the normal group of 60 cases (0.48 + 0.09) vs (0.35 + 0.05) and P0.001] in the 2. PW test group.
The results of 3. MME and RT-3DE in the right ventricle of the fetus (EDV, ESV and EF) were compared with those of the normal group, and the difference was statistically significant (P0.05).
ROC diagnosis of curve of 4. Tei measured by RT-3DE index and cardiac function measurement is better, and the MME values of ROC curve area differences between the.Tei index and RT-3DE diagnosis under z=1.559, P=0.119, no significant difference, ROC curve of RT-3DE and MME in the diagnosis of the area under the z=0.782, P= 0.434; the correlation coefficient Tei index EF value: MME (r=-0.449, P < 0.001), RT-3DE (r=-0.517, P < 0.001), are negatively correlated, results suggest that the association between RT-3DE and more, Tei index and RT-3DE diagnosis more closely, a better correlation, no significant difference.
conclusion
Fetal echocardiography in complex congenital heart disease were diagnosed timely and effectively can map, RT-3DE can not according to any anatomical structure that accurately and reliably on fetal right ventricular function assessment is an effective, noninvasive method is accurate, it has important clinical significance in predicting fetal development of CHD disease with the continuous progress of technology, ultrasound, RT-3DE to fetal congenital heart disease of the depth and breadth of two directions spread.

【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R445.1;R714.5

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