實(shí)時(shí)三維經(jīng)食管超聲心動(dòng)圖測(cè)定房間隔缺損最大徑的價(jià)值評(píng)估

郭麗娜， 吳衛(wèi)華， 馬 蘭， 陸 靜， 宮 霞， 謝曉奕

上海交通大學(xué)附屬胸科醫(yī)院超聲科，上海 200030

論 著

實(shí)時(shí)三維經(jīng)食管超聲心動(dòng)圖測(cè)定房間隔缺損最大徑的價(jià)值評(píng)估

郭麗娜， 吳衛(wèi)華*， 馬 蘭， 陸 靜， 宮 霞， 謝曉奕

上海交通大學(xué)附屬胸科醫(yī)院超聲科，上海 200030

目的：探討實(shí)時(shí)三維經(jīng)食管超聲心動(dòng)圖(real-time three-dimensional transesophageal echocardiography, RT3D-TEE)在測(cè)量房間隔缺損(atrial septal defect，ASD)最大徑中的應(yīng)用價(jià)值。方法：前瞻性分析2011年1月至2014年6月單中心篩查的繼發(fā)孔中央型單孔ASD并接受封堵術(shù)患者的臨床資料。比較RT3D-TEE、二維經(jīng)胸超聲心動(dòng)圖(two-dimensional transthoracic echocardiography,2D-TTE)、二維經(jīng)食管超聲心動(dòng)圖(two-dimensional transesophageal echocardiography,2D-TEE) 測(cè)得的ASD最大徑，并將三者與封堵器釋放后的實(shí)際腰部直徑進(jìn)行相關(guān)性分析。結(jié)果：共31例患者入選，經(jīng)RT3D-TEE[(21.81±8.57) mm]、2D-TEE[(20.31±8.50) mm]、2D-TTE[(23.08±10.89) mm]測(cè)得的缺損最大徑與封堵器釋放后實(shí)際腰部直徑[(20.99±8.15) mm]比較，差異均無統(tǒng)計(jì)學(xué)意義。經(jīng)RT3D-TEE、2D-TEE、2D-TTE測(cè)得的缺損最大徑與實(shí)際腰部直徑均高度相關(guān)，相關(guān)系數(shù)(r值)分別為0.902、0.981、0.897(P=0.000)。結(jié)論：RT3D-TEE在測(cè)定ASD最大徑方面較二維超聲并無明顯優(yōu)勢(shì)。

實(shí)時(shí)三維經(jīng)食管超聲心動(dòng)圖；房間隔缺損；最大徑；封堵器

經(jīng)皮介入房間隔缺損(atrial septal defect, ASD)封堵術(shù)因其創(chuàng)傷小、患者恢復(fù)快，逐步替代外科手術(shù)成為繼發(fā)孔、中央型ASD的首選治療方法。術(shù)前準(zhǔn)確測(cè)量缺損大小是封堵手術(shù)成功的關(guān)鍵，能夠指導(dǎo)心臟?？漆t(yī)師選擇合適的封堵器，從而避免如封堵器脫落等嚴(yán)重并發(fā)癥的發(fā)生。目前，二維經(jīng)胸超聲心動(dòng)圖(two-dimensional transthoracic echocardiography，2D-TTE)、二維經(jīng)食管超聲心動(dòng)圖(two-dimensional transesophageal echocardiography，2D-TEE)已成為經(jīng)皮介入封堵術(shù)及外科微創(chuàng)封堵術(shù)術(shù)前測(cè)量ASD最大徑的常規(guī)檢查方法[1-4]。而實(shí)時(shí)三維經(jīng)食管超聲心動(dòng)圖(real-time three-dimensional transesophageal echocardiography, RT3D-TEE)技術(shù)能清晰、直觀地顯示ASD的立體形態(tài)，理論上應(yīng)較上述2種方法在測(cè)量ASD最大徑方面更準(zhǔn)確、更有優(yōu)勢(shì)，但目前尚缺乏相關(guān)數(shù)據(jù)支持。

因此，本研究將這3種方法所測(cè)得的ASD最大徑與封堵器釋放后的實(shí)際腰部直徑進(jìn)行相關(guān)性分析，以期明確RT3D-TEE在ASD最大徑測(cè)量方面的應(yīng)用價(jià)值。

1 資料與方法

1.1 一般資料 選擇2011年1月至2014年6月在上海交通大學(xué)附屬胸科醫(yī)院診治的ASD患者，經(jīng)2D-TTE篩選出繼發(fā)孔、中央型ASD，缺損為單孔，體質(zhì)量>30 kg的患者。排除因其他先天性心臟病需要同期行外科手術(shù)者。共有31例ASD患者入選。其中，男性8例，女性23例；平均年齡(36.5±16.6)歲。31例患者接受微創(chuàng)封堵手術(shù)，均獲成功，并于術(shù)中先后接受2D-TEE及RT3D-TEE檢查。術(shù)后即刻及隨訪期[平均(31.17±11.33)個(gè)月]內(nèi)，TTE檢查均未見殘余分流。所有患者均知情同意并簽署知情同意書。本研究通過醫(yī)院醫(yī)學(xué)倫理委員會(huì)審核。

1.2 超聲圖像分析 采用Philips iE33彩色多譜勒超聲診斷儀，配備S5-1經(jīng)胸探頭(頻率為1～5 MHz)和X7-2t經(jīng)食管探頭(頻率為7～2 MHz)。微創(chuàng)封堵術(shù)在超聲引導(dǎo)下完成。術(shù)前采用2D-TTE觀察胸骨旁大動(dòng)脈短軸觀、心尖四腔觀、劍下腔靜脈觀及胸骨旁四腔觀等，術(shù)中采用2D-TEE在食管中段水平獲取雙心房觀、主動(dòng)脈短軸觀及腔靜脈長(zhǎng)軸觀。于收縮末期分別測(cè)量各切面ASD直徑，取最大值。行RT3D-TEE檢查時(shí)同步記錄心電圖，適當(dāng)調(diào)整增益、時(shí)間增益補(bǔ)償、壓縮控制等設(shè)置，以獲得最佳圖像質(zhì)量，然后在食管中段雙心房觀以3D-Zoom及全容積模式采集實(shí)時(shí)三維圖像。三維影像資料均用DVD儲(chǔ)存，后期導(dǎo)入Qlab 7.1工作站分析，于收縮末期測(cè)量ASD最大徑。患者均先由3位超聲科醫(yī)師(互不知道結(jié)果)分別采用2D-TTE、2D-TEE、RT3D-TEE測(cè)定并記錄 ASD最大徑，然后由第4位醫(yī)師在留存的封堵術(shù)后2D-TEE圖像中測(cè)定并記錄封堵器釋放后的腰部直徑(圖1)。

圖1 不同測(cè)量方法中ASD患者的超聲影像圖

A：2D-TTE顯示心尖四腔觀，測(cè)量ASD最大徑；B：2D-TEE顯示主動(dòng)脈短軸觀，測(cè)量ASD最大徑；C：RT3D-TEE檢查中測(cè)量ASD最大徑；D：封堵器釋放后，2D-TEE檢查中測(cè)量實(shí)際腰部直徑

2 結(jié) 果

2.1 3種超聲心動(dòng)圖測(cè)得的ASD最大徑與放置封堵器后測(cè)得的腰部直徑的比較 經(jīng)RT3D-TEE測(cè)得的ASD平均最大徑為(21.81±8.57)mm，經(jīng)2D-TEE、2D-TTE測(cè)得的ASD平均最大徑分別為(20.31±8.50) mm、(23.08±10.89)mm。31例患者放置封堵器后測(cè)得的實(shí)際腰部直徑平均為(20.99±8.15)mm。3種超聲方法測(cè)得的最大徑與封堵器腰部直徑比較，差異均無統(tǒng)計(jì)學(xué)意義，但是2D-TEE的測(cè)值更接近腰部直徑，而2D-TTE更遠(yuǎn)離腰部直徑(表1)。

表1 3種超聲方法測(cè)得的ASD最大徑與封堵器腰部直徑的比較 n=31

直徑差值為封堵器腰部平均直徑減經(jīng)超聲方法測(cè)得的ASD平均最大徑；差值率為該差值占封堵器腰部平均直徑的百分比

2.2 3種超聲心動(dòng)圖測(cè)得的ASD最大徑與放置封堵器后測(cè)得的腰部直徑的相關(guān)性分析 經(jīng)RT3D-TEE、2D-TEE、2D-TTE測(cè)得的ASD與封堵器腰部直徑均高度相關(guān)，相關(guān)系數(shù)(r值)分別達(dá)0.902、 0.981、 0.897(P=0.000)。相關(guān)性散點(diǎn)圖及布蘭德-奧特曼散點(diǎn)圖(圖2～4)顯示：2D-TEE測(cè)得的ASD最大徑與封堵器腰部直徑差異最小，其次為RT3D-TEE，與2D-TTE的差異最大。

圖3 經(jīng)2D-TEE測(cè)得的ASD最大徑與封堵器腰部直徑的相關(guān)性及一致性分析A：相關(guān)性散點(diǎn)圖；B：布蘭德-奧特曼散點(diǎn)圖

3 討 論

ASD是發(fā)病率位居第二的先天性心臟病。與外科手術(shù)相比，ASD封堵術(shù)由于其創(chuàng)傷性小、住院時(shí)間短、并發(fā)癥發(fā)生率低及中遠(yuǎn)期療效好等優(yōu)勢(shì)而被醫(yī)師和患者廣泛接受。大多數(shù)繼發(fā)孔型ASD可通過介入封堵治療[5]。為了提高封堵治療的成功率、降低并發(fā)癥的發(fā)生率，應(yīng)選擇合適尺寸的封堵器。而術(shù)前準(zhǔn)確測(cè)量ASD最大徑能幫助介入醫(yī)師選擇合適尺寸的封堵器。

球囊伸展直徑(balloon-stretched diameter, SBD)是測(cè)量ASD大小的金標(biāo)準(zhǔn)。國(guó)外研究[6-11]表明，用球囊法測(cè)得的ASD直徑與各種超聲方法(包括2D-TTE、2D-TEE、RT3D-TEE等)的測(cè)值間具有較好的相關(guān)性與一致性。但是，球囊擴(kuò)張法可能會(huì)撐大部分患者的缺損，造成測(cè)值偏大。與之相比，超聲的測(cè)值更準(zhǔn)確，而且超聲能通過引導(dǎo)術(shù)中操作提高手術(shù)成功率[7]，同時(shí)還可減少放射性傷害。

常用的測(cè)量ASD直徑的超聲方法有2D-TTE及2D-TEE。實(shí)時(shí)三維經(jīng)胸超聲心動(dòng)圖(real-time three-dimensional transthoracic echocardiography,RT3D-TTE)及心腔內(nèi)超聲心動(dòng)圖(intracardiac echocardiography, ICE)等技術(shù)由于圖像質(zhì)量欠佳及醫(yī)療成本高等因素，臨床較少使用。而RT3D-TEE技術(shù)因其優(yōu)越的圖像質(zhì)量使臨床醫(yī)師可以更直觀地了解心臟內(nèi)各結(jié)構(gòu)的病理解剖改變，并進(jìn)行三維定量分析，目前已越來越多地應(yīng)用于臨床工作中[1-2]。已有報(bào)道比較了其與2D-TEE在ASD最大徑評(píng)估中的作用。研究結(jié)果[8，12]顯示，RT3D-TEE、2D-TEE兩者間及兩者與封堵器尺寸間的一致性及相關(guān)性均較好。本研究結(jié)果與上述結(jié)果基本一致。本研究未將RT3D-TEE測(cè)得的ASD最大徑與SBD或封堵器尺寸進(jìn)行相關(guān)性分析，主要原因如下：部分ASD患者的SBD法測(cè)值偏大；ASD封堵器的大小選擇范圍較廣，且不同介入醫(yī)師選擇的封堵器的尺寸也會(huì)有差異。

本研究中，RT3D-TEE與2D-TTE、2D-TEE相比較，在ASD最大徑測(cè)量方面并無優(yōu)勢(shì)，可能與以下因素相關(guān)：(1)為了盡可能完整顯示ASD的全貌，RT3D-TEE在圖像采集時(shí)多啟用全容積模式，其是由數(shù)個(gè)心動(dòng)周期的窄角三維圖像融合而成，而這導(dǎo)致圖像質(zhì)量一定程度的下降；(2)應(yīng)用該技術(shù)時(shí)不能直接在三維圖像上進(jìn)行實(shí)時(shí)測(cè)量，而需將數(shù)據(jù)導(dǎo)入工作站后進(jìn)行脫機(jī)分析，這可能會(huì)影響數(shù)據(jù)的準(zhǔn)確性；(3)房間隔在TEE模式下處于圖像近場(chǎng)，如遇小左房或大ASD的患者，三維圖像可能無法完整顯示間隔甚至缺損，造成最大徑測(cè)值誤差。雖然本研究中RT3D-TEE在測(cè)量ASD最大徑方面較其他超聲技術(shù)無優(yōu)勢(shì)，但多項(xiàng)研究[5,13-17]顯示，其能更直觀立體地顯示ASD大小、形狀、數(shù)目及其解剖結(jié)構(gòu)，尤其對(duì)于觀察復(fù)雜ASD更有利，在引導(dǎo)封堵方面也更有效。

本研究中，2D-TEE的測(cè)值與封堵器腰部直徑的相關(guān)性最高，可能是由于2D-TEE檢查能避免氣體及胸壁等因素干擾而可獲得高質(zhì)量的圖像，同時(shí)可使醫(yī)師在任意切面上測(cè)量ASD并獲取最大徑。該結(jié)果與既往研究[9,18-19]相一致。雖然2D-TTE的測(cè)值與封堵器腰部直徑的相關(guān)性在3種超聲方法中最小，但仍與封堵器腰部直徑高度相關(guān)。Bartakian等[18]也發(fā)現(xiàn)，2D-TTE與2D-TEE評(píng)估ASD以及對(duì)于引導(dǎo)ASD封堵術(shù)同樣安全、有效。由于2D-TTE檢查無創(chuàng)、可重復(fù)，在手術(shù)中使用具有操作時(shí)間、X線下暴露時(shí)間短于2D-TEE等優(yōu)勢(shì)，仍應(yīng)作為ASD最大徑的首選測(cè)量方法。此外，McGhie等[20]研究了二維經(jīng)胸實(shí)時(shí)多平面同步成像技術(shù) (simultaneous multiplane imaging, SMPI)在29例繼發(fā)孔ASD封堵術(shù)中的應(yīng)用，結(jié)果顯示，與2D-TEE比較，該技術(shù)評(píng)估繼發(fā)孔ASD及其邊緣大小的結(jié)果可靠，有望在ASD術(shù)前評(píng)估中取代TEE。

綜上所述，雖然RT3D-TEE可以立體顯示房間隔的形態(tài)、部位，進(jìn)而有利于醫(yī)師準(zhǔn)確測(cè)量缺損大小，但本結(jié)果顯示其在測(cè)定ASD最大徑方面較二維超聲并無優(yōu)勢(shì)。本研究的局限性在于：樣本量較少，標(biāo)準(zhǔn)差較大，未比較RT3D-TEE對(duì)不同大小、形狀A(yù)SD直徑的測(cè)值。

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[本文編輯] 姬靜芳

Evaluation of real time three-dimensional transesophageal echocardiography in detecting maximum diameter of atrial septal defect

GUO Li-na, WU Wei-hua*, MA Lan, LU Jing, GONG Xia, XIE Xiao-yi

Department of Ultrasound, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China

Objective：To study the application value of real-time three-dimensional transesophageal echocardiography (RT3D-TEE) in measuring the maximal atrial septal defect (ASD) diameter.Methods：The clinical data of patients diagnosed as central, secundum-type, single-hole ASD and hospitalized for transcatheter closure from January 2011 to June 2014 in a single center were prospectively analyzed.The maximal ASD diameters measured by RT3D-TEE, two-dimensional transthoracic echocardiography (2D-TTE) and two-dimensional transesophageal echocardiography (2D-TEE) were compared.Correlation between the maximal ASD diameters measured by three methods and occluder waist diameter after release were analyzed.Results：A total of 31 ASD patients were included.There was no significant difference between the maximal ASD diameters measured by RT3D-TEE ([21.81±8.57] mm), 2D-TEE ([20.31±8.50] mm), and 2D-TTE ([23.08±10.89] mm) and occluder waist diameter after release ([20.99±8.15] mm).The maximal ASD diameters measured by RT3D-TEE, 2D-TEE, and 2D-TTE were all highly correlated with the occluder waist diameter (r=0.902, 0.981, 0.897, respectively,P=0.000).Conclusions：Compared with two-dimensional echocardiography, RT3D-TEE has no advantage in measuring the maximal ASD diameter.

real-time three-dimensional transesophageal echocardiography; atrial septal defect; maximal diameter; occluder device

2016-09-21[接受日期]2016-10-16

上海市胸科醫(yī)院科技發(fā)展基金重大重點(diǎn)項(xiàng)目(2014YZDH10301).Supported by Science and Technology Development Foundation of Shanghai Chest Hospital (2014YZDH10301).

郭麗娜, 碩士，住院醫(yī)師.E-mail：linaguo85@126.com

*通信作者(Corresponding author).Tel: 021-22200000-1411,E-mail: liu987@vip.sina.com

10.12025/j.issn.1008-6358.2016.20160898

R 540.4+5

A