全身成像三维量化评估二尖瓣反流体积与实时三维超声心动图及常规超声心动图的对比研究
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摘要
[背景]二尖瓣反流(mitral regurgitation, MR)是常见的瓣膜疾患,如果不施加干预,最终可进展为不可逆转的心力衰竭,导致很高的死亡率,因此及时诊断并准确评估MR的严重程度,对于患者的临床治疗决策尤为重要；但是常规超声心动图评估MR的严重程度仍旧充满挑战。二尖瓣反流体积是评估MR严重程度的重要指标,近来有研究以核磁共振测量的二尖瓣反流体积为标准,发现实时三维超声心动图(real-time3-dimensional echocardiography, RT3DE)测量二尖瓣有效反流口面积(effective regurgitant orifice area, EROA)乘以MR速度时间积分(velocity time integral,VTI)得出的二尖瓣反流体积与其相关性良好,且一致性分析未见两种方法有明显差异。随着超声探头技术及软件技术的进展,全身成像三维量化(General Imaging3-dimensional Quantification, GI3DQ)使得直接测量二尖瓣反流体积成为可能。
[目的]①以RT3DE测量的EROA乘以MR-VTI计算的二尖瓣反流体积作为标准,探讨GI3DQ直接测量二尖瓣反流束体积,用以评估二尖瓣反流体积的可行性和准确性；②同常规超声心动图方法：近端血流等速面(proximal isovelocity surface area,PISA)法及多普勒法测量的二尖瓣反流体积作比较,旨在为临床上评估二尖瓣反流体积寻找一种更为可靠简便的方法。
[方法]①入选93例不同程度的MR患者,其中功能性二尖瓣反流患者61例,器质性二尖瓣脱垂患者32例；根据二尖瓣反流血流束方向,又将患者分为中心性反流41例,偏心性反流52例。②RT3DE测量EROA:在心尖四腔切面采集二尖瓣反流实时三维彩色血流图像,在二尖瓣反流束最大时停帧,调整三维图像上横断切面,使其垂直于二尖瓣反流束,然后自心尖向心底平移切割,直至显示最小二尖瓣反流束横截面,在该横截面的en face切面上手动勾画二尖瓣反流束彩色多普勒信号边缘,得到EROA,然后乘以MR-VTI得出二尖瓣反流体积。③GI3DQ直接测量二尖瓣反流束体积：进入GI3DQ插件,选择实时三维二尖瓣反流血流图像,在反流束最大时停帧,从二尖瓣反流起点到二尖瓣反流终点连线,将二尖瓣反流束分为15等份等厚度薄切片平面,在每一切片的横截面上手动勾画二尖瓣反流束彩色多普勒信号边缘,勾画完15个横截面后,二尖瓣反流束体积计算值将出现在结果中。④PISA法评估二尖瓣反流体积：在心尖四腔切面,将近端血流汇聚区用ZOOM模式局部放大；在20-40cm/s范围内调节Nyquist极限速度,以尽量获取半球形的近端血流等速面形态；冻结图像后,应用回放功能逐帧查看,选择收缩中期最满意的半球形近端血流等速面；测量第一层血流混叠区边缘距反流口的轴向距离得到PISA半径,应用公式：EROA=(2π×r2×Va)/PkVreg得出EROA,式中r指P工SA半径,Va指Nyquist极限速度,PkVreg指连续多普勒测量的MR峰值速度；二尖瓣反流体积由EROA乘以连续多普勒测量的MR-VTI得到。⑤多普勒法评估二尖瓣反流体积：二尖瓣前向血流体积由二尖瓣环前向血流速度时间积分乘以二尖瓣环横截面积得到；主动脉前向血流体积由左室流出道前向血流速度时间积分乘以左室流出道横截面积得到。脉冲多普勒测量前向血流速度时间积分时,取样容积分别放置于二尖瓣环水平和紧邻主动脉瓣下左室流出道水平；左室流出道直径在紧邻主动脉瓣下测量,假设左室流出道为规则的圆形,应用公式π r2/4求出左室流出道横截面积,式中r为左室流出道直径。二尖瓣环直径分别在四腔心切面和两腔心切面测量,由于二尖瓣环几何形态的特殊性,分别假设其为规则的圆形,应用公式πa2/4求出二尖瓣环横截面积,式中a指四腔心切面二尖瓣环直径；假设其为椭圆形,应用公式πab/4求出二尖瓣环横截面积,式中a指四腔心切面二尖瓣环直径,b指两腔心切面二尖瓣环直径；二尖瓣前向血流体积减去主动脉前向血流体积即为二尖瓣反流体积。
[结果]1.G13DQ测量的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积结果比较。
在所有二尖瓣反流患者中,GI3DQ测量的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积相关性良好：r=0.921,p<0.0001,但是一致性分析发现,与RT3DE计算的二尖瓣反流体积比较,GI3DQ法存在低估,平均低估约6.07ml。在功能性二尖瓣反流组中,GI3DQ测量的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积相关性更好：r=0.948,p<0.0001,但一致性分析发现,GI3DQ测量二尖瓣反流体积依然存在低估,平均低估约3.18ml。在器质性二尖瓣脱垂组中,两种方法的相关性为：r=0.911,p<0.001,一致性分析发现,GI3DQ在测量这组二尖瓣反流体积时存在严重低估,平均低估约11.56ml；该组分析结果类似于偏心性二尖瓣反流组中两种方法的比较结果：r=0.914,p<0.0001,平均低估约10.55ml。在中心性二尖瓣反流组中,GI3DQ与RT3DE在测量二尖瓣反流体积时的相关性最好：r=0.956,p<0.0001,虽然一致性分析显示GI3DQ存在轻微低估,平均低估约0.38ml,但无统计学意义(p=0.1114>0.05)。
2.PISA法计算的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积结果比较。
在所有二尖瓣反流患者中,PISA法计算的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积相关性良好：r=0.911,p<0.0001,但是一致性分析发现,与RT3DE计算的二尖瓣反流体积比较,PISA法在总体人群存在低估,平均低估约4.64ml。在偏心性二尖瓣反流组中,两种方法的相关性为：r=0.871,p<0.001,一致性分析发现,PISA法在测量该组二尖瓣反流体积时存在明显低估,平均低估约7.58ml。在中心性二尖瓣反流组中,PISA法与RT3DE在评估二尖瓣反流体积时的相关性最好：r=0.964,p<0.0001,虽然一致性分析显示PISA法在该组人群存在轻度低估,平均低估约0.92ml,但无统计学意义(p=0.5062>0.05)。
3.多普勒法计算的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积结果比较。
①假设二尖瓣环几何形态为圆形：在所有二尖瓣反流患者、偏心性二尖瓣反流组及中心性二尖瓣反流组,多普勒法计算的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积相关性较好,分别为：r=0.813, r=0.759, r=0.725；p值均小于0.0001；一致性分析发现,与RT3DE计算的二尖瓣反流体积比较,多普勒法在这三组人群存在不同程度的高估,平均高估分别约9.82ml、12.79ml、6.06ml:p值均小于0.05。
②假设二尖瓣环几何形态为椭圆形：在所有二尖瓣反流患者、偏心性二尖瓣反流组及中心性二尖瓣反流组,多普勒法计算的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积相关性良好,分别为：r=0.906,r=0.889,r=0.844；p值均小于0.0001；一致性分析发现,与RT3DE计算的二尖瓣反流体积比较,多普勒法在这三组人群均存在轻微的高估,平均高估分别约1.34ml、1.64ml、0.96ml;但未见有明显统计学意义(p值均大于0.05)。
4.G13DQ法测量的二尖瓣反流体积与PISA法及多普勒法计算的二尖瓣反流体积结果比较。
①G13DQ与PISA法：在所有二尖瓣反流患者、偏心性二尖瓣反流组及中心性二尖瓣反流组,配对t检验结果显示,两种方法的测量结果均未见明显差异,p值均大于0.05；一致性分析显示,在前两组人群,GI3DQ较PISA法测量结果存在低估,分别平均低估约1.43ml、2.97m1、但无统计学意义(p>0.05)。在中心性二尖瓣反流组,一致性分析显示,GI3DQ较PISA法测量结果轻微高估约0.54ml,但无统计学意义(p=0.0587>0.05)。
②GI3DQ与多普勒法(椭圆形模型)：在所有二尖瓣反流患者及偏心性二尖瓣反流组,配对t检验结果显示,两种方法的测量结果有明显差异,p值均小于0.0001；一致性分析显示,在这两组人群,GI3DQ较多普勒法测量结果存在明显低估,分别低估约12.19ml。12.19ml,p值均小于0.0001。在中心性二尖瓣反流组,配对t检结果显示,两组方法的测量结果未见明显差异,p=0.3649>0.05；一致性分析显示,GI3DQ较多普勒法测量结果轻微低估约1.34ml,但无统计学意义(p=0.0564>0.05)。
[结论]GI3DQ量化评估二尖瓣反流体积是可行的,且与RT3DE法测量的二尖瓣反流体积相比,二者相关性良好。应用GI3DQ法评估中心性二尖瓣反流体积是准确可行的,在与RT3DE法、PISA法及多普勒法的测量结果比较中,未发现这几种方法有明显差异。
Background Mitral regurgitation (MR) is common valvular lesion that ultimately progresses to irreversible heart failure with high morbidity and mortality. Consequently, timely diagnosis and accurate assessment of severity of MR are of significant importance for appropriate decision making and timing of surgical intervention. Mitral regurgitant volume (MRvol) is a useful and important index of the severity of MR, but MRvol measurement remains challenging. MRvol calculation using effective regurgitant orifice area (EROA) by real-time3-dimensional color Doppler echocardiography multiplied by the velocity time integral of the mitral regurgitant jet on the continuous-wave Doppler has been recently documented as an accurate method. With the development of probe technology and software, General Imaging3-dimensional Quantification (GI3DQ) allows direct measurement of MRvol.
Objectives The aim of this study was to evaluate feasibility and accuracy of GI3DQ method for quantification of MRvol comparison with MRvol using EROA by real-time3-dimensional (3D) color Doppler echocardiography multiplied by the velocity time integral of the mitral regurgitant jet on the continuous-wave Doppler.
Methods1) Ninety-three patients were included,61with functional MR and32with mitral valve prolapse (MVP). The MR was also divided into central MR (n=41) and eccentric MR (n=52).2) EROA by real-time3-dimensional color Doppler echocardiography. To measure EROA, the3D color Doppler datasets were manually cropped by an image plane that was perpendicularly oriented to the jet direction and the cropping plane was then moved along the jet direction as far as the smallest cross-sectional area. The EROA was measured by manual planimetry of the color Doppler signal, tilting the image in an "en face" view and selecting the systolic frame with the most relevant lesion size;the MRvol was calculated as EROA multiplied by the MR time-velocity integral. The MRvol derived from EROA by real-time3D color Doppler echocardiography was used as reference method.3) Direct measurement Of MRvol By GI3DQ. In QLAB workstation, we entered the analysis plug-in of GI3DQ and clicked the initial position and the terminal position of the mitral regurgitant jet to display15slices in the systolic frame with the most relevant lesion size. For each slice in the volume, select one end slice of the regurgitant jet contour and draw along the boundary of the regurgitant jet. The same procedure was performed one after the other until the last slice. Pressed Enter to end the measurement and the MRvol calculation appeared in the results.4) MRvol by PISA. The proximal isovelocity surface of the mitral regurgitant jet was visualized in an image from the apical4-chamber view, using a zoom mode. The position of the transducer was modified to minimize the angle between the centerline of the PISA and the ultrasound beam. We optimized the appearance of the PISA by shifting the color Doppler aliasing velocity from20to40cm/s. For each cardiac cycle, the frame with the largest flow convergence region was selected as coinciding with maximal regurgitant flow. The maximal velocity of the regurgitant jet was determined by continuous-wave Doppler. Effective regurgitant orifice area was calculated by the PISA method as (2×π×r2×Vr)/Vmax, where r is the isovelocity radius measured as the maximal radial distance between the first aliasing contour and the center of the regurgitant orifice at mid-systole, Vr is the aliasing velocity, and Vmax is the maximal velocity of the regurgitant jet. Two-dimensional PISA MRvol was calculated as2D PISA-derived EROA multiplied by the MR time-velocity integral.4)MRvol by Doppler method. Mitral inflow and aortic outflow were calculated as the time-velocity integral of the mitral or aortic inflow multiplied by the cross-sectional area of the mitral annulus (estimates of mitral annulus cross-sectional area were obtained as circular:πa2/4as well as biplane elliptical:πab/4) or aortic annulus(πr2/4),where a is the mitral annular dimension in the four-chamber view,b is the mitral annular dimension in the apical two-chamber view, and r is the left ventricular outflow tract diameter in the parasternal long-axis view(1cm proximal to the aortic annulus). Mitral Rvol was calculated as the difference between mitral and aortic forward stroke volumes.
Results.1. MRvol by the GI3DQ Method Compared with RT3DE Method
In all cases, MRvol measured by GI3DQ was well correlated with MRvol measured by3D color Doppler echocardiography (r=0.921), but with a significant difference between these techniques (mean difference=-6.07ml). Functional MRvol measured by GI3DQ showed better excellent correlation with MRvol measured by3D color Doppler echocardiography (r=0.948) with a lower underestimation (mean difference=-3.18ml). The correlation of MVP MRvol measured by GI3DQ and by3D color Doppler echocardiography was also good(r=0.911), but with a severe underestimation (mean difference=-11.56ml), similar to the result of the eccentric MR (r=0.914, mean difference=-10.55ml). Central MR provided the best correlation and agreement of GI3DQ estimates with3D color Doppler echocardiography (r=0.956, mean difference=-0.38ml).
2. MRvol by the PISA Method Compared with RT3DE Method
In all cases, MRvol measured by PISA was well correlated with MRvol measured by3D color Doppler echocardiography (r=0.911, p<0.001), but with a difference between these techniques (mean difference=-4.64ml). In eccentric MR group, the correlation of MRvol measured by PISA and by3D color Doppler echocardiography was:r=0.871,but with a severe underestimation (mean difference=-7.58ml).Central MR group provided the best correlation and agreement of PISA estimates with3D color Doppler echocardiography(r=0.964, mean difference=-0.92ml).
3. MRvol by the Doppler Methods Compared with RT3DE Method
①Estimates of mitral annulus cross-sectional area as circular.In all cases,eccentric MR group and central MR group, the correlation of MRvol measured by Doppler method and by3D color Doppler echocardiography was respectively:0.813;0.759;0.725. However, the Bland-Altman analysis demonstrated varying degrees of overestimation between these techniques: mean difference (Doppler-RT3DE),respectively,9.82ml;12.79ml;6.06ml (all p values were less than0.05).
②Estimates of mitral annulus cross-sectional area as biplane elliptical.In all cases, eccentric MR group and central MR group, MRvol measured by Doppler method was well correlated with MRvol measured by3D color Doppler echocardiography (r=0.906;0.889;0.844; all p values were less than0.0001) in these three groups and the Bland-Altman analysis demonstrated a slight overestimation between these techniques, mean difference (Doppler-RT3DE)=1.34ml;1.64ml;0.96ml,but no statistical meanings.
4. MRvol by GI3DQ Method Compared with PISA and Doppler Methods
①GI3DQ and PISA method. In all cases, eccentric MR group and central MR group, the t test revealed that there was no significant difference in the measurement of MRvol between these methods in these three groups. In the former two groups, the Bland-Altman analysis demonstrated a slight underestimation between these techniques, mean difference (GI3DQ-PISA), respectively,1.43ml;2.97ml; but no statistical meanings. In the central group, the Bland-Altman analysis demonstrated a slight overestimation between these techniques, mean difference (GI3DQ-PISA)=0.54, p=0.0587>0.05.
②GI3DQ and Doppler method (biplane elliptical).In all cases and eccentric MR group, the t test revealed that there was significant difference in the measurement of MRvol between these methods in these two groups and the Bland-Altman analysis demonstrated a significant underestimation between these techniques,mean difference(GI3DQ-Doppler), respectively,7.41ml;12.19ml.In central group, the t test revealed that there was no significant difference in the measurement of MRvol between these methods and the Bland-Altman analysis demonstrated a slight underestimation between these techniques, mean difference(GI3DQ-PISA)=1.34, p=0.0564>0.05.
Conclusion Quantification of MRvol with GI3DQ was feasible and correlated well with MRvol by3D color Doppler echocardiography. Quantification of central MRvol with GI3DQ was accurate as compared with MRvol by3D color Doppler echocardiography.
[目的]①以RT3DE测量的EROA乘以MR-VTI计算的二尖瓣反流体积作为标准,探讨GI3DQ直接测量二尖瓣反流束体积,用以评估二尖瓣反流体积的可行性和准确性；②同常规超声心动图方法：近端血流等速面(proximal isovelocity surface area,PISA)法及多普勒法测量的二尖瓣反流体积作比较,旨在为临床上评估二尖瓣反流体积寻找一种更为可靠简便的方法。
[方法]①入选93例不同程度的MR患者,其中功能性二尖瓣反流患者61例,器质性二尖瓣脱垂患者32例；根据二尖瓣反流血流束方向,又将患者分为中心性反流41例,偏心性反流52例。②RT3DE测量EROA:在心尖四腔切面采集二尖瓣反流实时三维彩色血流图像,在二尖瓣反流束最大时停帧,调整三维图像上横断切面,使其垂直于二尖瓣反流束,然后自心尖向心底平移切割,直至显示最小二尖瓣反流束横截面,在该横截面的en face切面上手动勾画二尖瓣反流束彩色多普勒信号边缘,得到EROA,然后乘以MR-VTI得出二尖瓣反流体积。③GI3DQ直接测量二尖瓣反流束体积：进入GI3DQ插件,选择实时三维二尖瓣反流血流图像,在反流束最大时停帧,从二尖瓣反流起点到二尖瓣反流终点连线,将二尖瓣反流束分为15等份等厚度薄切片平面,在每一切片的横截面上手动勾画二尖瓣反流束彩色多普勒信号边缘,勾画完15个横截面后,二尖瓣反流束体积计算值将出现在结果中。④PISA法评估二尖瓣反流体积：在心尖四腔切面,将近端血流汇聚区用ZOOM模式局部放大；在20-40cm/s范围内调节Nyquist极限速度,以尽量获取半球形的近端血流等速面形态；冻结图像后,应用回放功能逐帧查看,选择收缩中期最满意的半球形近端血流等速面；测量第一层血流混叠区边缘距反流口的轴向距离得到PISA半径,应用公式：EROA=(2π×r2×Va)/PkVreg得出EROA,式中r指P工SA半径,Va指Nyquist极限速度,PkVreg指连续多普勒测量的MR峰值速度；二尖瓣反流体积由EROA乘以连续多普勒测量的MR-VTI得到。⑤多普勒法评估二尖瓣反流体积：二尖瓣前向血流体积由二尖瓣环前向血流速度时间积分乘以二尖瓣环横截面积得到；主动脉前向血流体积由左室流出道前向血流速度时间积分乘以左室流出道横截面积得到。脉冲多普勒测量前向血流速度时间积分时,取样容积分别放置于二尖瓣环水平和紧邻主动脉瓣下左室流出道水平；左室流出道直径在紧邻主动脉瓣下测量,假设左室流出道为规则的圆形,应用公式π r2/4求出左室流出道横截面积,式中r为左室流出道直径。二尖瓣环直径分别在四腔心切面和两腔心切面测量,由于二尖瓣环几何形态的特殊性,分别假设其为规则的圆形,应用公式πa2/4求出二尖瓣环横截面积,式中a指四腔心切面二尖瓣环直径；假设其为椭圆形,应用公式πab/4求出二尖瓣环横截面积,式中a指四腔心切面二尖瓣环直径,b指两腔心切面二尖瓣环直径；二尖瓣前向血流体积减去主动脉前向血流体积即为二尖瓣反流体积。
[结果]1.G13DQ测量的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积结果比较。
在所有二尖瓣反流患者中,GI3DQ测量的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积相关性良好：r=0.921,p<0.0001,但是一致性分析发现,与RT3DE计算的二尖瓣反流体积比较,GI3DQ法存在低估,平均低估约6.07ml。在功能性二尖瓣反流组中,GI3DQ测量的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积相关性更好：r=0.948,p<0.0001,但一致性分析发现,GI3DQ测量二尖瓣反流体积依然存在低估,平均低估约3.18ml。在器质性二尖瓣脱垂组中,两种方法的相关性为：r=0.911,p<0.001,一致性分析发现,GI3DQ在测量这组二尖瓣反流体积时存在严重低估,平均低估约11.56ml；该组分析结果类似于偏心性二尖瓣反流组中两种方法的比较结果：r=0.914,p<0.0001,平均低估约10.55ml。在中心性二尖瓣反流组中,GI3DQ与RT3DE在测量二尖瓣反流体积时的相关性最好：r=0.956,p<0.0001,虽然一致性分析显示GI3DQ存在轻微低估,平均低估约0.38ml,但无统计学意义(p=0.1114>0.05)。
2.PISA法计算的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积结果比较。
在所有二尖瓣反流患者中,PISA法计算的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积相关性良好：r=0.911,p<0.0001,但是一致性分析发现,与RT3DE计算的二尖瓣反流体积比较,PISA法在总体人群存在低估,平均低估约4.64ml。在偏心性二尖瓣反流组中,两种方法的相关性为：r=0.871,p<0.001,一致性分析发现,PISA法在测量该组二尖瓣反流体积时存在明显低估,平均低估约7.58ml。在中心性二尖瓣反流组中,PISA法与RT3DE在评估二尖瓣反流体积时的相关性最好：r=0.964,p<0.0001,虽然一致性分析显示PISA法在该组人群存在轻度低估,平均低估约0.92ml,但无统计学意义(p=0.5062>0.05)。
3.多普勒法计算的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积结果比较。
①假设二尖瓣环几何形态为圆形：在所有二尖瓣反流患者、偏心性二尖瓣反流组及中心性二尖瓣反流组,多普勒法计算的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积相关性较好,分别为：r=0.813, r=0.759, r=0.725；p值均小于0.0001；一致性分析发现,与RT3DE计算的二尖瓣反流体积比较,多普勒法在这三组人群存在不同程度的高估,平均高估分别约9.82ml、12.79ml、6.06ml:p值均小于0.05。
②假设二尖瓣环几何形态为椭圆形：在所有二尖瓣反流患者、偏心性二尖瓣反流组及中心性二尖瓣反流组,多普勒法计算的二尖瓣反流体积与参考方法RT3DE计算的二尖瓣反流体积相关性良好,分别为：r=0.906,r=0.889,r=0.844；p值均小于0.0001；一致性分析发现,与RT3DE计算的二尖瓣反流体积比较,多普勒法在这三组人群均存在轻微的高估,平均高估分别约1.34ml、1.64ml、0.96ml;但未见有明显统计学意义(p值均大于0.05)。
4.G13DQ法测量的二尖瓣反流体积与PISA法及多普勒法计算的二尖瓣反流体积结果比较。
①G13DQ与PISA法：在所有二尖瓣反流患者、偏心性二尖瓣反流组及中心性二尖瓣反流组,配对t检验结果显示,两种方法的测量结果均未见明显差异,p值均大于0.05；一致性分析显示,在前两组人群,GI3DQ较PISA法测量结果存在低估,分别平均低估约1.43ml、2.97m1、但无统计学意义(p>0.05)。在中心性二尖瓣反流组,一致性分析显示,GI3DQ较PISA法测量结果轻微高估约0.54ml,但无统计学意义(p=0.0587>0.05)。
②GI3DQ与多普勒法(椭圆形模型)：在所有二尖瓣反流患者及偏心性二尖瓣反流组,配对t检验结果显示,两种方法的测量结果有明显差异,p值均小于0.0001；一致性分析显示,在这两组人群,GI3DQ较多普勒法测量结果存在明显低估,分别低估约12.19ml。12.19ml,p值均小于0.0001。在中心性二尖瓣反流组,配对t检结果显示,两组方法的测量结果未见明显差异,p=0.3649>0.05；一致性分析显示,GI3DQ较多普勒法测量结果轻微低估约1.34ml,但无统计学意义(p=0.0564>0.05)。
[结论]GI3DQ量化评估二尖瓣反流体积是可行的,且与RT3DE法测量的二尖瓣反流体积相比,二者相关性良好。应用GI3DQ法评估中心性二尖瓣反流体积是准确可行的,在与RT3DE法、PISA法及多普勒法的测量结果比较中,未发现这几种方法有明显差异。
Background Mitral regurgitation (MR) is common valvular lesion that ultimately progresses to irreversible heart failure with high morbidity and mortality. Consequently, timely diagnosis and accurate assessment of severity of MR are of significant importance for appropriate decision making and timing of surgical intervention. Mitral regurgitant volume (MRvol) is a useful and important index of the severity of MR, but MRvol measurement remains challenging. MRvol calculation using effective regurgitant orifice area (EROA) by real-time3-dimensional color Doppler echocardiography multiplied by the velocity time integral of the mitral regurgitant jet on the continuous-wave Doppler has been recently documented as an accurate method. With the development of probe technology and software, General Imaging3-dimensional Quantification (GI3DQ) allows direct measurement of MRvol.
Objectives The aim of this study was to evaluate feasibility and accuracy of GI3DQ method for quantification of MRvol comparison with MRvol using EROA by real-time3-dimensional (3D) color Doppler echocardiography multiplied by the velocity time integral of the mitral regurgitant jet on the continuous-wave Doppler.
Methods1) Ninety-three patients were included,61with functional MR and32with mitral valve prolapse (MVP). The MR was also divided into central MR (n=41) and eccentric MR (n=52).2) EROA by real-time3-dimensional color Doppler echocardiography. To measure EROA, the3D color Doppler datasets were manually cropped by an image plane that was perpendicularly oriented to the jet direction and the cropping plane was then moved along the jet direction as far as the smallest cross-sectional area. The EROA was measured by manual planimetry of the color Doppler signal, tilting the image in an "en face" view and selecting the systolic frame with the most relevant lesion size;the MRvol was calculated as EROA multiplied by the MR time-velocity integral. The MRvol derived from EROA by real-time3D color Doppler echocardiography was used as reference method.3) Direct measurement Of MRvol By GI3DQ. In QLAB workstation, we entered the analysis plug-in of GI3DQ and clicked the initial position and the terminal position of the mitral regurgitant jet to display15slices in the systolic frame with the most relevant lesion size. For each slice in the volume, select one end slice of the regurgitant jet contour and draw along the boundary of the regurgitant jet. The same procedure was performed one after the other until the last slice. Pressed Enter to end the measurement and the MRvol calculation appeared in the results.4) MRvol by PISA. The proximal isovelocity surface of the mitral regurgitant jet was visualized in an image from the apical4-chamber view, using a zoom mode. The position of the transducer was modified to minimize the angle between the centerline of the PISA and the ultrasound beam. We optimized the appearance of the PISA by shifting the color Doppler aliasing velocity from20to40cm/s. For each cardiac cycle, the frame with the largest flow convergence region was selected as coinciding with maximal regurgitant flow. The maximal velocity of the regurgitant jet was determined by continuous-wave Doppler. Effective regurgitant orifice area was calculated by the PISA method as (2×π×r2×Vr)/Vmax, where r is the isovelocity radius measured as the maximal radial distance between the first aliasing contour and the center of the regurgitant orifice at mid-systole, Vr is the aliasing velocity, and Vmax is the maximal velocity of the regurgitant jet. Two-dimensional PISA MRvol was calculated as2D PISA-derived EROA multiplied by the MR time-velocity integral.4)MRvol by Doppler method. Mitral inflow and aortic outflow were calculated as the time-velocity integral of the mitral or aortic inflow multiplied by the cross-sectional area of the mitral annulus (estimates of mitral annulus cross-sectional area were obtained as circular:πa2/4as well as biplane elliptical:πab/4) or aortic annulus(πr2/4),where a is the mitral annular dimension in the four-chamber view,b is the mitral annular dimension in the apical two-chamber view, and r is the left ventricular outflow tract diameter in the parasternal long-axis view(1cm proximal to the aortic annulus). Mitral Rvol was calculated as the difference between mitral and aortic forward stroke volumes.
Results.1. MRvol by the GI3DQ Method Compared with RT3DE Method
In all cases, MRvol measured by GI3DQ was well correlated with MRvol measured by3D color Doppler echocardiography (r=0.921), but with a significant difference between these techniques (mean difference=-6.07ml). Functional MRvol measured by GI3DQ showed better excellent correlation with MRvol measured by3D color Doppler echocardiography (r=0.948) with a lower underestimation (mean difference=-3.18ml). The correlation of MVP MRvol measured by GI3DQ and by3D color Doppler echocardiography was also good(r=0.911), but with a severe underestimation (mean difference=-11.56ml), similar to the result of the eccentric MR (r=0.914, mean difference=-10.55ml). Central MR provided the best correlation and agreement of GI3DQ estimates with3D color Doppler echocardiography (r=0.956, mean difference=-0.38ml).
2. MRvol by the PISA Method Compared with RT3DE Method
In all cases, MRvol measured by PISA was well correlated with MRvol measured by3D color Doppler echocardiography (r=0.911, p<0.001), but with a difference between these techniques (mean difference=-4.64ml). In eccentric MR group, the correlation of MRvol measured by PISA and by3D color Doppler echocardiography was:r=0.871,but with a severe underestimation (mean difference=-7.58ml).Central MR group provided the best correlation and agreement of PISA estimates with3D color Doppler echocardiography(r=0.964, mean difference=-0.92ml).
3. MRvol by the Doppler Methods Compared with RT3DE Method
①Estimates of mitral annulus cross-sectional area as circular.In all cases,eccentric MR group and central MR group, the correlation of MRvol measured by Doppler method and by3D color Doppler echocardiography was respectively:0.813;0.759;0.725. However, the Bland-Altman analysis demonstrated varying degrees of overestimation between these techniques: mean difference (Doppler-RT3DE),respectively,9.82ml;12.79ml;6.06ml (all p values were less than0.05).
②Estimates of mitral annulus cross-sectional area as biplane elliptical.In all cases, eccentric MR group and central MR group, MRvol measured by Doppler method was well correlated with MRvol measured by3D color Doppler echocardiography (r=0.906;0.889;0.844; all p values were less than0.0001) in these three groups and the Bland-Altman analysis demonstrated a slight overestimation between these techniques, mean difference (Doppler-RT3DE)=1.34ml;1.64ml;0.96ml,but no statistical meanings.
4. MRvol by GI3DQ Method Compared with PISA and Doppler Methods
①GI3DQ and PISA method. In all cases, eccentric MR group and central MR group, the t test revealed that there was no significant difference in the measurement of MRvol between these methods in these three groups. In the former two groups, the Bland-Altman analysis demonstrated a slight underestimation between these techniques, mean difference (GI3DQ-PISA), respectively,1.43ml;2.97ml; but no statistical meanings. In the central group, the Bland-Altman analysis demonstrated a slight overestimation between these techniques, mean difference (GI3DQ-PISA)=0.54, p=0.0587>0.05.
②GI3DQ and Doppler method (biplane elliptical).In all cases and eccentric MR group, the t test revealed that there was significant difference in the measurement of MRvol between these methods in these two groups and the Bland-Altman analysis demonstrated a significant underestimation between these techniques,mean difference(GI3DQ-Doppler), respectively,7.41ml;12.19ml.In central group, the t test revealed that there was no significant difference in the measurement of MRvol between these methods and the Bland-Altman analysis demonstrated a slight underestimation between these techniques, mean difference(GI3DQ-PISA)=1.34, p=0.0564>0.05.
Conclusion Quantification of MRvol with GI3DQ was feasible and correlated well with MRvol by3D color Doppler echocardiography. Quantification of central MRvol with GI3DQ was accurate as compared with MRvol by3D color Doppler echocardiography.
引文
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