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时间—空间相关成像技术诊断胎儿先天性心脏病的临床研究
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摘要
目的评价联合利用时间—空间相关成像技术(STIC)与灰阶二维显像、彩色多普勒血流显像技术进行胎儿心脏的容积图像采集、正交平面显示及分析应用于正常和先天性心脏病胎儿的可行性和实用性。
     探讨联合利用时间—空间相关成像技术(STIC)与灰阶二维显像、彩色多普勒血流显像、B-flow显像技术进行胎儿心血管的四维重建的实用价值。
     评价能否通过互联网传授STIC采集技术及传送STIC容积数据;STIC容积数据的远程分析(TELE-STIC)能否用于证实或排除典型心脏病。
     方法分别用灰阶二维显像、彩色多普勒血流显像技术对138例正常胎儿和52例先天性心脏病胎儿进行STIC采集,再以正交平面显示、分析。
     分别用灰阶二维显像、彩色多普勒血流显像、B-flow显像技术对160例正常胎儿和56例先天性心脏病胎儿进行STIC采集,再以正交平面显示为指导,用表面模式和反转模式对灰阶二维方式采集的容积图像进行四维重建;用表面模式对B-flow技术采集的容积图像进行四维重建;用彩色模式和透明模式对彩色多普勒技术采集的容积图像进行四维重建。
     由不同医院的两位超声医师共挑选47例孕妇,该两位医师均缺乏详细胎儿超声心动图检查经验。利用互联网传授STIC采集技术、上传采集到的容积数据,由一名有10年胎儿超声心动图检查经验且熟悉STIC后处理与分析的医师完成离线远程分析。
     结果138例正常胎儿与52例先天性心脏病胎儿用两种不同显像技术进行STIC采集,分别成功地采集到231个、98个合格的容积图像,利用正交平面分析所得容积图像,灰阶二维显像技术采集的容积图像对正常及先天性心脏病胎儿心脏各结构或切面显示率分别为91.7%、71.3%,彩色多普勒血流显像技术采集的容积图像对正常及先天性心脏病胎儿心脏各结构或切面显示率分别为95.9%、74.9%。
     160例正常胎儿及56例先天性心脏病胎儿用三种不同显像技术采集到的STIC容积图像均成功地进行了四维重建,其中房室瓣、房室间隔的心腔内正面观、心底冠状切面、3-4条肺静脉同时显示等均是二维超声所无法观察到的。
     通过互联网的远程医疗在所有病例均是可行的。操作者A、B通过互联网分别传输40个、34个STIC容积图像,其对胎儿心脏各结构或切面的总显示率分别为88.3%、81.8%,其中2例先天性心脏病胎儿经TELE-STIC诊断,并与引产后尸体解剖结果相符,1例疑有先天性心脏病的胎儿经TELE-STIC排除。
     结论联合应用灰阶二维、彩色多普勒血流显像技术与STIC进行胎儿心脏的容积图像采集、正交平面显示及分析,可提供某些常规二维超声心动图无法获得的空间结构信息,应用于正常及先天性心脏病胎儿是可行的,且有助于胎儿先天性心脏病的产前诊断。
     联合应用不同显像技术与STIC进行胎儿心脏及大血管的四维重建是可行的,可获取二维超声心动图所无法提供的关于胎儿心脏解剖及病理特点的某些信息,可观察到用以评价胎儿心脏解剖的大部分结构及切面。
     可通过互联网传授STIC采集技术及传输STIC容积图像。分析容积图像,有助于胎儿先天性心脏病的产前诊断、诊治团队间的交流、孕父母的咨询及专业培训。
Objective
     Spatio-temporal image correlation (STIC) is a new four-dimensional (4D) technique allowing the acquisition of a volume of data from the fetal heart that is displayed as a cineloop of a single cardiac cycle. The aim of the study was to examine whether the multiplanar display of STIC volume could produce most of the standard image planes necessary for a comprehensive diagnosis of congenital heart deseases (CHD); to describe a method of 4-dimensional reconstruction of the cardiac septae, valves, chambers and outflow tracts using a combination of STIC, surface mode, inversion mode ,color mode and B-flow imaging; to assess whether STIC acquisition technique can be taught to general obstetricians by e-mail, whether STIC volume datasets can be transmitted over the Internet, and whether STIC volume datasets analyzed offline at a remote setting(TELE-STIC) can be used to confirm or exclude major cardiac defects.
     Methods
     The acquisition was performed in two steps:first,images were acquired by a single,automatic volume sweep, second, the system analyzed the image data according to their spatial and temporal domain and processed an on line dynamic 4D image sequence that was displayed in a multiplanar reformatted cross-sectional display and/or rendered display.
     STIC cardiac images of 138 normal fetuses and 52 CHD fetuses were collected using grey-scale 2-dimensional imaging technique and color Doppler imaging technique, and were displayed and analyzed in multiplanar reformatted cross-sectional display.
     STIC cardiac images of 160 normal fetuses and 56 CHD fetuses were obtained using grey-scale 2-dimensional imaging technique、color Doppler imaging technique and B-flow technique, respectively. Under the guidance of cross-sectional display, images collected with grey-scale 2-dimensional imaging technique were reconstructed using surface mode and inversion mode; images collected with B-flow technique were reconstructed using surface mode and images collected with color Doppler imaging technique were reconstructed using color mode and glassy body mode.
     47 pregnant women were selected by two general obstetricians (operators A and B). Both obstetricians lacked skill in the performance of fetal cardiac examination. The acquisition skill of STIC was taught by e-mail.The acquired volume datasets were uploaded using an Internet broadband connection. Offline analysis was performed by a single investigator experienced in fetal echocardiography (the administrator C).
     Results
     STIC volume data sets were achieved using two different imaging modalities in 138 normal and 52 CHD fetuses, with 231 and 98 qualified volume images, respectively. Displaying rate of cardiac structures or views in normal and CHD fetuses using gray-scale 2-dimensional technique were 91.7%, 71.3%, respectively. Using color Doppler imaging technique, displaying rate of cardiac structures or views in normal and CHD fetuses were 95.9%, 74.9%, respectively.
     All the volume images of 160 normal and 56 CHD fetuses collected using three different imaging modalities were reconstructed successfully. The atria-ventricular valves, intracardiac demonstration of interventricular or interatrial septae, cardiac coronal view at base level that showed in reconstructed images could not be observed using 2-dimensional technique, otherwise, 3 to 4 pulmonary veins could not be seen simultaneously in 2-dimensional images.
     A telemedicine link via the Internet was possible in all cases. Seventy-four volume datasets were sent to the web server. A complete cardiac examination according to set criteria was achieved by the administrator in 88.3% of the cases scanned by one operator and 81.8% by the other operator. Two fetuses had cardiac defects confirmed postnatally, one fetus had extracardiac anomalies and two fetuses had suspected cardiac defects ruled out by TELE - STIC.
     Conclusions
     Volume imaging collection, cross-sectional display and analysis of fetal heart are feasible using grey-scale 2-dimensional technique and color Doppler imaging technique combination with STIC. This novel method may assist in the prenatal diagnosis of congenital heart disease, and can provide more structure information that the 2-dimensioanl imaging can not obtain.
     4-dimensional reconstructions of fetal heart using different imaging modalities combination with STIC are feasible. This new method can provide more morphologic information, and make inter-team communication and parents counseling more convenient.
     STIC volumes can be obtained by operators inexperienced in fetal echocardiography, transmitted via the Internet, and their analysis enables recognition of most of the structures and views necessary to assess fetal cardiac anatomy. The preliminary use of TELE-STIC allowed us to demonstrate that some intracardiac anomalies can be ruled out and others confirmed.
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