血流向量成像技术评价继发孔型房间隔缺损患者右心室流场运动变化及右心功能

Application of new ultrasonic vector flow mapping to evaluate right ventricular hemodynamics and right ventricular function in patients with secundum atrial septal defect

目的应用超声血流向量成像(VFM)技术评价继发孔型房间隔缺损(ASD)右心室内迹线、波前和心室内相对压的变化规律,为定量评估ASD右心室流场运动和功能提供参考。方法选取2019年9月至2020年4月在昆明医科大学附属延安医院就诊的继发孔型ASD患者97例,按照肺动脉高压(PAH)的不同程度进行分组:不伴PAH组[肺动脉收缩压(PASP)≤30 mmHg]30例,轻度PAH组(PASP 30~50 mmHg)25例、中度PAH组(PASP 50~70 mmHg)22例和重度PAH组(PASP>70 mmHg)20例,同期选取健康志愿者29例为对照组。采用VFM技术分析右心室内迹线和波前的变化规律,并定量评估各组间主肺动脉内径(MPA)、右心室前壁厚度(RVAW)、左心室收缩末期偏心指数(LVEIs)、左心室舒张末期偏心指数(LVEId)、左心室射血分数(LVEF)、心室内压差(IVPDs)、右心室横径(RVTD)、右心房横径(RATD)、三尖瓣环收缩期位移(TAPSE)、右心室面积变化率(RVFAC)、Tei指数,三尖瓣E峰流速、A峰流速、E/A,三尖瓣环速度e、a、e/a以及E/e等参数,对以上参数与IVPDs进行相关性分析。结果①对照组、不伴PAH组与轻度PAH组右心室迹线和波前均显示舒张期能顺利到达心尖顶部;中度和重度PAH组整体呈漩涡状不能顺利到达心尖顶部,血流流动效率随PAH压力升高逐渐减低。②各组间MPA、RVAW、LVEIs、LVEId逐渐增大,LVEF逐渐减小(P<0.05);与对照组和不伴PAH组比较,轻度、中度、重度PAH组RVTD、RATD逐渐增大(P<0.05),Tei指数、E/e逐渐增大,TAPSE、RVFAC、E、E/A、e、e/a逐渐减小(P<0.05)。③与对照组和不伴PAH组比较,轻度、中度、重度PAH组IVPDs逐渐降低(P<0.05),IVPDs峰值均出现在快速充盈期。④IVPDs分别与TAPSE、RVFAC、E、e呈正相关(r=0.848、0.735、0.915、0.822,均P<0.05),与Tei指数、E/e呈负相关(r=-0.711、-0.905,均P<0.05)。结论迹线、波前以及相对压成像可为定量评估ASD右心室血流流场变化、PAH压力大小及右心功能提供有价值的参考信息。

Objective To evaluate the changes of right ventricular pathline,wavefront and relative pressure in patients with secundum atrial septal defect(ASD)by vector flow mapping(VFM),and provide a new guidance for quantitative evaluation of ASD right ventricular hemodynamics and function.Methods A selection of 97 patients with secundum ASD admitted to Yan An Hospital Affiliated to Kunming Medical University between September 2019 and April 2020 were grouped according to the guidelines in different degrees of pulmonary arterial hypertension(PAH):30 patients in non PAH group[pulmonary artery systolic pressure(PASP)≤30 mmHg],25 patients in mild PAH group(PASP:30~50 mmHg),22 patients in moderate PAH group(PASP:>50~70 mmHg)and 20 patients in severe PAH group(PASP>70 mmHg).Twenty-nine healthy volunteers served as control group.VFM was used to evaluate the changes of right ventricular patelline and wavefront,the main pulmonary artery(MPA),right ventricular anterior wall(RVAW),left ventricular end-systolic eccentricity index(LVEIs),left ventricular end-diastolic eccentricity index(LVEId),left ventricular ejection fraction(LVEF),intraventricular pressure differences(IVPDs),right ventricular transverse diameter(RVTD),right atrial transverse diameter(RATD),tricuspid annular plane systolic excurtion(TAPSE),right ventricular fractional area change(RVFAC),Tei index and tricuspid valve E peak velocities,A peak velocity,E/A,tricuspid annulus velocities e,a,e/a and E/e and other parameters were also quantitatively evaluated among the groups,and the correlations between the above parameters and IVPDs were analyzed.Results①The right ventricular pathline and wavefront of the control group,the non PAH group and the mild PAH group all showed that they could reach the top of the apex smoothly in diastole.The moderate PAH and severe PAH group showed a vortex and could not reach the top of the apex smoothly,and the blood flow efficiency gradually decreases with the increase of PAH pressure.②The MPA,RVAW,LVEIs,LVEId gradually increased among groups,while the LVEF gradually decrease(P<0.05).Compared with the control group and the non PAH group in the mild,moderate,and severe PAH group,the RVTD and RATD gradually increased(P<0.05).The Tei index and E/e gradually increased among groups,and the TAPSE,RVFAC,E,E/A,e,e/a gradually decreased(P<0.05).③Compared with the control group and the non PAH group in the mild,moderate,and severe PAH group,IVPDs gradually decreased(P<0.05),and the peak value of IVPDs appeared in rapid filling phase.④IVPDs was positively correlated with TAPSE,RVFAC,E and e respectively(r=0.848,0.735,0.915,0.822,P<0.05)and negatively correlated with E/e and Tei index(r=-0.711,-0.905,P<0.05).Conclusions The pathline,wavefront and relative pressure imaging can provide a new reference for quantitative evaluation of ASD right ventricular hemodynamics,PAH pressure and right ventricular function.