室壁瘤外科治疗前后左室功能和形态改变的临床研究——实时三维超声的临床应用
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摘要
第一部分左室室壁瘤外科治疗前后左室功能改变的临床研究
目的和内容：实时三维超声(RT-3DE)通过三维重建反映左室的真实形态,同时检查费用低、具备可移动性等优点,目前临床应用越来越多。左室室壁瘤(LVA)患者左室形态异常,利用二维超声(2DE)和左室造影对左室相关参数测量易与实际值产生偏差。本研究利用RT-3DE测量LVA外科治疗前后左室相关参数,包括首次测量左室局部节段射血分数(EF)。同时,首次利用组织多普勒成像(TDI)评估LVA外科治疗后舒张功能的改变。通过分析,了解LVA外科治疗后左室功能的改变情况,进一步探讨LVA的外科治疗。同时,为RT-3DE的临床应用提供经验。
方法：2009年2月至2010年2月,18例患者确诊为冠状动脉粥样硬化性心脏病合并陈旧性心肌梗死及左室室壁瘤形成。所有患者术前行2DE、RT-3DE及TDI,获得左室相关功能参数。手术治疗后,14例患者完成早中期随访,平均随访4月,随访期间复查2DE、RT-3DE及TDI,获取相同功能参数。同时测量12例正常人的相同功能参数作为正常对照组。利用统计方法进行14例患者术前、术后4月及正常对照组各参数的对比分析。
结果：通过RT-3DE检查显示,术后4月左室收缩末容积指数(LVESVI)从术前57.08±21.26ml／m2减少至34.34±9.90ml／m2,射血分数(EF)从术前34.99%±6.30%增加至44.71%±8.17%,有显著差异。相比正常组,LVESVI、EF尚存在显著差异。术前左室局部EF呈心尖部至基底部方向递增,除下基底段、下侧基底段和前侧基底段外,其余14个节段较正常组显著降低。术后4月,局部EF呈基底部至心尖部方向递增,与正常对照组相同,并且侧壁节段局部EF与正常组无显著差异。同时,术后4月舒张早期跨二尖瓣血流速度峰值／舒张晚期跨二尖瓣血流速度峰值(E／A)、舒张期二尖瓣环侧部和间隔部运动速度峰值平均值(Eam)、舒张期二尖瓣环侧部运动速度峰值(Eal)较术前升高,均有显著差异,其中E／A、Eal、E／Eal与正常组无显著差异。
结论：RT-3DE是评估LVA患者左室收缩功能的有效检查方法。LVA患者手术治疗后早中期左室整体收缩功能和舒张功能明显改善,局部收缩功能恢复正常递增方向,但左室整体和大部分局部节段收缩功能尚未恢复正常,左室舒张功能基本恢复正常。我们推论,LVA外科治疗的关键是去除瘢痕组织,恢复左室局部形态,降低梗死周边区域的应力,然后在此基础上对左室进行减容,降低左室腔压力,使左室功能恢复。
第二部分实时三维超声评价左室室壁瘤外科治疗前后左室形态改变的临床研究
目的和内容：实时三维超声(RT-3DE)能通过三维重建反映左室的真实形态,相比二维超声和左室造影在形态评估方面有其独特优势。左室室壁瘤(LVA)患者左室表现为不同程度的整体和局部形态异常,恢复左室正常形态是LVA外科治疗的重要目的。本研究首次利用RT-3DE评估LVA外科治疗后左室形态改变,除了评估左室球形指数(SI)、锥形指数(CI)两个整体形态参数外,本研究提出新的左室整体形态参数椭球指数(EI),同时针对大部分LVA位于心尖部,致心尖部形态异常,本研究提出新形态参数心尖指数(AI)评估左室心尖局部形态。通过分析左室室壁瘤外科治疗后左室形态改变情况,进一步探讨LVA的外科治疗。
方法：2009年2月至2010年2月,18例患者确诊为冠状动脉粥样硬化性心脏病合并陈旧性心肌梗死及左室室壁瘤形成。所有患者术前行RT-3DE,获得左室形态参数,手术治疗后,14例患者完成术后早中期随访,平均随访4月,随访期间复查RT-3DE,获取相同形态参数。同时测量12例正常人的相同参数作为正常对照组。利用统计方法进行术前、术后4月及正常对照组各参数的对比分析。
结果：术前左室长轴、短轴长度及收缩末SI、CI、EI较正常组增加,有统计学意义。手术治疗后4月,左室长轴、短轴缩短,但仅前者改变有统计学意义,左室整体形态参数SI较术前略有增加,CI、EI较术前降低,局部形态参数收缩末AI较术前下降,但均无统计学意义。与正常组比较,术后4月收缩末AI无显著差异。
结论：RT-3DE能准确评估LVA患者的左室形态。LVA患者术前左室形态明显改变,通过测量左室收缩末形态参数可更准确评估LVA患者术前左室形态。外科治疗后早中期,左室长轴明显缩短,而短轴无明显改变,相比术前,左室整体形态无明显改善,心尖局部形态接近正常。通过研究分析认为,EI是评估左室整体形态的有效参数,AI是评估心尖局部形态的有效参数。
PartⅠ:The changes of left ventricular function after surgical treatment of left ventricular aneurysm
Background and objective:Because left ventricular geometry changes significantly in patients with left ventricular aneurysm (LVA), the accuracy of two dimensional echocardiography and left ventricular angiography is limited in measuring left ventricle volume and other parameters by geometric assumptions. Real-time three-dimensional echocardiography (RT-3DE) is widely used in clinical practice nowadays due to the ability to describe the real geometry by three-dimensional reconstruction of left ventricle, and the advantages of low cost and mobility. In this prospective study, we evaluated left ventricular systolic and diastolic functions, and assessed the changes of left ventricular segment ejection fraction for the first time before and after surgical treatment of LVA by RT-3DE and tissue Doppler imaging (TDI) respectively.
Methods:From February 2009 to February 2010,18 coronary artery disease patients combined with post-myocardial infarction and LVA were included in this study. Forteen patients were followed up for a mean period of 4 months. Left ventricular function was evaluated by by two-dimensional echocardiography, RT-3DE and TDI preoperatively and during follow-up. At the same time,12 healthy persons were included as controls. Statistical analyses of various left ventricular function parameters were carried out among preoperative group, postoperative follow-up group and normal control group.
Results:All patients underwent LVA repair and coronary artery bypass grafting. At postoperative follow-up, RT-3DE showed that left ventricular end-systolic volume index (LVESVI) decreased from 57.08±21.26ml/m2 to 34.34±9.90ml/m2 (P=0.001), ejection fraction (EF) increased from 0.3499±0.063 to 0.4471±0.0817 (P=0.002). There were significant differences in LVESVI and EF among preoperative group, postoperative follow-up group and normal control group. Preoperative regional EF progressively increased from apex to base. Except inferior basal segment, lateral-inferior basal segment and lateral-anterior basal segment, regional EF in the remaining 14 segments were significantly lower than that of control group. At postoperative follow-up, the same to control group, regional EF progressively increased from base to apex, and there was no significant difference between lateral segment regional EF and that of control group. In the assessment of diastolic function, compared to baseline, transmitral Doppler flow echocardiograph showed that the early/late-diastolic filling velocities (E/A) significantly increased in the postoperative early and mid-term follow-up period (P=0.014). TDI also demonstrated that the mean of the early-diastolic lateral and septal mitral annular velocities (Earn) and the early-diastolic lateral mitral annular velocities (Eal) significantly increased postoperatively (P=0.022; P=0.007). Furthermore, there was no significant difference in E/A, Eal, E/Eal between postoperative follow-up group and control group.
Conclusion:RT-3DE is an effective method to assess left ventricular systolic function in patients with LVA. After LVA repair and coronary artery bypass grafting, left ventricular global systolic function improved, regional systolic function restored to the normal direction of progressive increase, but left ventricular global and most regional systolic function did not return to the normal state. Left diastolic function returned to normal. We speculate that the key to surgical treatment of LVA is exclusion of scar tissue, restoration of left ventricular regional geometry and reduction in border zone stress, and furter to reduce left ventricular cavity pressure by decreasing left ventricular volume, which can help left ventricular function recover.
PartⅡ:The clinical study of the changes of left ventricular geometry after surgery in left ventricular aneurysm by RT-3DE
Background and objective:Compared with two-dimensional echocardiography and left ventricular angiography, real-time three-dimensional echocardiography (RT-3DE) has unique advantages in evaluating left ventricular geometry by the real three-dimensional reconstruction. Left ventricular aneurysm (LVA) shows various degrees of left ventricular global and local geometry abnormality, and to restore normal left ventricular geometry is an important part of surgical treatment. In this prospective study, we evaluated left ventricular geometry before and after surgical treatment of LVA by RT-3DE for the first time. In addition, we designed two novel geometric parameters, including ellipsoid index (EI) and apical index (AI), to quantitative left ventricular global and local geometry abnormality respectively, besides sphericity index (SI) and conic index (CI).
Methods:From February 2009 to February 2010,18 coronary artery disease patients combined with post-myocardial infarction and LVA were included in this study. Preoperative and postoperative left ventricular shape was evaluated by RT-3DE and SI, CI, EI and AI were measured. Forteen patients were followed up for a mean period of 4 months. At the same time,12 healthy persons were included as controls. Statistical analyses of various left ventricular geometric parameters were carried out among preoperative group, postoperative follow-up group and normal control group.
Results:Compared with normal control group, the diameters of left ventricular long axis and short axis, end-systolic SI, CI and El increased significantly in preoperative patients. At 4th month after operation, the diameters of left ventricular long axis and short axis decreased, but only significant in the former; in addition, SI increased, CI, El and end-systolic AI decreased, however, there was no significant difference in any of these parameters between preoperative group and postoperative follow-up group. And there was no significant difference in end-systolic AI between postoperative follow-up group and control group.
Conclusion:RT-3DE can assess left ventricular geometry in patients with LVA accurately. The left ventricular shape changed significantly in LVA patients preoperatively. Left ventricular geometric parameters measured at end-systolic phase were more accurate than those in end-diastolic stage to assess the changes of left ventricular shape preoperatively. During follow-up, echocardiography demonstrated that the length of left ventricular long axis decreased significantly, but the length of short axis did not changed significantly. Left ventricular global shape did not improve significantly, and apical shape was close to normal postoperatively. According to our study, we think that El and AI are valid geometric parameters to assess the global left ventricular geometry and the left ventricular apical geometry respectively.
目的和内容：实时三维超声(RT-3DE)通过三维重建反映左室的真实形态,同时检查费用低、具备可移动性等优点,目前临床应用越来越多。左室室壁瘤(LVA)患者左室形态异常,利用二维超声(2DE)和左室造影对左室相关参数测量易与实际值产生偏差。本研究利用RT-3DE测量LVA外科治疗前后左室相关参数,包括首次测量左室局部节段射血分数(EF)。同时,首次利用组织多普勒成像(TDI)评估LVA外科治疗后舒张功能的改变。通过分析,了解LVA外科治疗后左室功能的改变情况,进一步探讨LVA的外科治疗。同时,为RT-3DE的临床应用提供经验。
方法：2009年2月至2010年2月,18例患者确诊为冠状动脉粥样硬化性心脏病合并陈旧性心肌梗死及左室室壁瘤形成。所有患者术前行2DE、RT-3DE及TDI,获得左室相关功能参数。手术治疗后,14例患者完成早中期随访,平均随访4月,随访期间复查2DE、RT-3DE及TDI,获取相同功能参数。同时测量12例正常人的相同功能参数作为正常对照组。利用统计方法进行14例患者术前、术后4月及正常对照组各参数的对比分析。
结果：通过RT-3DE检查显示,术后4月左室收缩末容积指数(LVESVI)从术前57.08±21.26ml／m2减少至34.34±9.90ml／m2,射血分数(EF)从术前34.99%±6.30%增加至44.71%±8.17%,有显著差异。相比正常组,LVESVI、EF尚存在显著差异。术前左室局部EF呈心尖部至基底部方向递增,除下基底段、下侧基底段和前侧基底段外,其余14个节段较正常组显著降低。术后4月,局部EF呈基底部至心尖部方向递增,与正常对照组相同,并且侧壁节段局部EF与正常组无显著差异。同时,术后4月舒张早期跨二尖瓣血流速度峰值／舒张晚期跨二尖瓣血流速度峰值(E／A)、舒张期二尖瓣环侧部和间隔部运动速度峰值平均值(Eam)、舒张期二尖瓣环侧部运动速度峰值(Eal)较术前升高,均有显著差异,其中E／A、Eal、E／Eal与正常组无显著差异。
结论：RT-3DE是评估LVA患者左室收缩功能的有效检查方法。LVA患者手术治疗后早中期左室整体收缩功能和舒张功能明显改善,局部收缩功能恢复正常递增方向,但左室整体和大部分局部节段收缩功能尚未恢复正常,左室舒张功能基本恢复正常。我们推论,LVA外科治疗的关键是去除瘢痕组织,恢复左室局部形态,降低梗死周边区域的应力,然后在此基础上对左室进行减容,降低左室腔压力,使左室功能恢复。
第二部分实时三维超声评价左室室壁瘤外科治疗前后左室形态改变的临床研究
目的和内容：实时三维超声(RT-3DE)能通过三维重建反映左室的真实形态,相比二维超声和左室造影在形态评估方面有其独特优势。左室室壁瘤(LVA)患者左室表现为不同程度的整体和局部形态异常,恢复左室正常形态是LVA外科治疗的重要目的。本研究首次利用RT-3DE评估LVA外科治疗后左室形态改变,除了评估左室球形指数(SI)、锥形指数(CI)两个整体形态参数外,本研究提出新的左室整体形态参数椭球指数(EI),同时针对大部分LVA位于心尖部,致心尖部形态异常,本研究提出新形态参数心尖指数(AI)评估左室心尖局部形态。通过分析左室室壁瘤外科治疗后左室形态改变情况,进一步探讨LVA的外科治疗。
方法：2009年2月至2010年2月,18例患者确诊为冠状动脉粥样硬化性心脏病合并陈旧性心肌梗死及左室室壁瘤形成。所有患者术前行RT-3DE,获得左室形态参数,手术治疗后,14例患者完成术后早中期随访,平均随访4月,随访期间复查RT-3DE,获取相同形态参数。同时测量12例正常人的相同参数作为正常对照组。利用统计方法进行术前、术后4月及正常对照组各参数的对比分析。
结果：术前左室长轴、短轴长度及收缩末SI、CI、EI较正常组增加,有统计学意义。手术治疗后4月,左室长轴、短轴缩短,但仅前者改变有统计学意义,左室整体形态参数SI较术前略有增加,CI、EI较术前降低,局部形态参数收缩末AI较术前下降,但均无统计学意义。与正常组比较,术后4月收缩末AI无显著差异。
结论：RT-3DE能准确评估LVA患者的左室形态。LVA患者术前左室形态明显改变,通过测量左室收缩末形态参数可更准确评估LVA患者术前左室形态。外科治疗后早中期,左室长轴明显缩短,而短轴无明显改变,相比术前,左室整体形态无明显改善,心尖局部形态接近正常。通过研究分析认为,EI是评估左室整体形态的有效参数,AI是评估心尖局部形态的有效参数。
PartⅠ:The changes of left ventricular function after surgical treatment of left ventricular aneurysm
Background and objective:Because left ventricular geometry changes significantly in patients with left ventricular aneurysm (LVA), the accuracy of two dimensional echocardiography and left ventricular angiography is limited in measuring left ventricle volume and other parameters by geometric assumptions. Real-time three-dimensional echocardiography (RT-3DE) is widely used in clinical practice nowadays due to the ability to describe the real geometry by three-dimensional reconstruction of left ventricle, and the advantages of low cost and mobility. In this prospective study, we evaluated left ventricular systolic and diastolic functions, and assessed the changes of left ventricular segment ejection fraction for the first time before and after surgical treatment of LVA by RT-3DE and tissue Doppler imaging (TDI) respectively.
Methods:From February 2009 to February 2010,18 coronary artery disease patients combined with post-myocardial infarction and LVA were included in this study. Forteen patients were followed up for a mean period of 4 months. Left ventricular function was evaluated by by two-dimensional echocardiography, RT-3DE and TDI preoperatively and during follow-up. At the same time,12 healthy persons were included as controls. Statistical analyses of various left ventricular function parameters were carried out among preoperative group, postoperative follow-up group and normal control group.
Results:All patients underwent LVA repair and coronary artery bypass grafting. At postoperative follow-up, RT-3DE showed that left ventricular end-systolic volume index (LVESVI) decreased from 57.08±21.26ml/m2 to 34.34±9.90ml/m2 (P=0.001), ejection fraction (EF) increased from 0.3499±0.063 to 0.4471±0.0817 (P=0.002). There were significant differences in LVESVI and EF among preoperative group, postoperative follow-up group and normal control group. Preoperative regional EF progressively increased from apex to base. Except inferior basal segment, lateral-inferior basal segment and lateral-anterior basal segment, regional EF in the remaining 14 segments were significantly lower than that of control group. At postoperative follow-up, the same to control group, regional EF progressively increased from base to apex, and there was no significant difference between lateral segment regional EF and that of control group. In the assessment of diastolic function, compared to baseline, transmitral Doppler flow echocardiograph showed that the early/late-diastolic filling velocities (E/A) significantly increased in the postoperative early and mid-term follow-up period (P=0.014). TDI also demonstrated that the mean of the early-diastolic lateral and septal mitral annular velocities (Earn) and the early-diastolic lateral mitral annular velocities (Eal) significantly increased postoperatively (P=0.022; P=0.007). Furthermore, there was no significant difference in E/A, Eal, E/Eal between postoperative follow-up group and control group.
Conclusion:RT-3DE is an effective method to assess left ventricular systolic function in patients with LVA. After LVA repair and coronary artery bypass grafting, left ventricular global systolic function improved, regional systolic function restored to the normal direction of progressive increase, but left ventricular global and most regional systolic function did not return to the normal state. Left diastolic function returned to normal. We speculate that the key to surgical treatment of LVA is exclusion of scar tissue, restoration of left ventricular regional geometry and reduction in border zone stress, and furter to reduce left ventricular cavity pressure by decreasing left ventricular volume, which can help left ventricular function recover.
PartⅡ:The clinical study of the changes of left ventricular geometry after surgery in left ventricular aneurysm by RT-3DE
Background and objective:Compared with two-dimensional echocardiography and left ventricular angiography, real-time three-dimensional echocardiography (RT-3DE) has unique advantages in evaluating left ventricular geometry by the real three-dimensional reconstruction. Left ventricular aneurysm (LVA) shows various degrees of left ventricular global and local geometry abnormality, and to restore normal left ventricular geometry is an important part of surgical treatment. In this prospective study, we evaluated left ventricular geometry before and after surgical treatment of LVA by RT-3DE for the first time. In addition, we designed two novel geometric parameters, including ellipsoid index (EI) and apical index (AI), to quantitative left ventricular global and local geometry abnormality respectively, besides sphericity index (SI) and conic index (CI).
Methods:From February 2009 to February 2010,18 coronary artery disease patients combined with post-myocardial infarction and LVA were included in this study. Preoperative and postoperative left ventricular shape was evaluated by RT-3DE and SI, CI, EI and AI were measured. Forteen patients were followed up for a mean period of 4 months. At the same time,12 healthy persons were included as controls. Statistical analyses of various left ventricular geometric parameters were carried out among preoperative group, postoperative follow-up group and normal control group.
Results:Compared with normal control group, the diameters of left ventricular long axis and short axis, end-systolic SI, CI and El increased significantly in preoperative patients. At 4th month after operation, the diameters of left ventricular long axis and short axis decreased, but only significant in the former; in addition, SI increased, CI, El and end-systolic AI decreased, however, there was no significant difference in any of these parameters between preoperative group and postoperative follow-up group. And there was no significant difference in end-systolic AI between postoperative follow-up group and control group.
Conclusion:RT-3DE can assess left ventricular geometry in patients with LVA accurately. The left ventricular shape changed significantly in LVA patients preoperatively. Left ventricular geometric parameters measured at end-systolic phase were more accurate than those in end-diastolic stage to assess the changes of left ventricular shape preoperatively. During follow-up, echocardiography demonstrated that the length of left ventricular long axis decreased significantly, but the length of short axis did not changed significantly. Left ventricular global shape did not improve significantly, and apical shape was close to normal postoperatively. According to our study, we think that El and AI are valid geometric parameters to assess the global left ventricular geometry and the left ventricular apical geometry respectively.
引文
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6. Moustakidis P, Maniar HS, Cupps BP, et al. Altered left ventricular geometry changes the border zone temporal distribution of stress in an experimental model of left ventricular aneurysm:a finite element model study. Circulation,2002,106: I-168-1-175.
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9. Dor V, Kreitmann P, Jourdan J, et al. Interest of physiological closure (circumferential plasty on contractile areas) of left ventricle after resection and endocardectomy for aneurysm or akinetic zone. Comparision with classical technique about a series of left ventricular resections. J.Cardiovasc.Surg,1985,26: 73.
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