超声心动图在人工机械瓣卡瓣诊断中的临床应用

目的分析人工机械瓣卡瓣的超声图像特点,探讨超声心动图在人工机械瓣卡瓣诊断中的临床价值。方法 7例人工机械瓣卡瓣患者,超声心动图观察以下内容:1机械瓣瓣叶回声及活动情况;2通过机械瓣口的血流情况;3瓣口血流频谱,估算机械瓣口面积。结果人工机械瓣卡瓣位于二尖瓣6例,主动脉瓣1例。其中6例超声心动图即可清晰显示人工机械瓣叶活动受限,瓣环或瓣叶增厚,回声不光滑,血流束减少或变细,流束与瓣环平面夹角变小。频谱显示瓣口峰值流速及压差较正常增加,瓣口面积减小,术中所见与超声探查结果完全相符。患者均行再次换瓣手术。结论超声心动图是无创、快速诊断人工机械瓣卡瓣的首选方法。     

动态三维超声心动图对正常和病变二尖瓣器的临床研究

目的探讨动态三维超声心动图对二尖瓣器评分的价值。方法通过多平面经食管三维超声心动图容积提取显示法（３ＤＶ）对２０例正常二尖瓣、８例二尖瓣狭窄、１２例二尖瓣关闭不全和１０例二尖瓣位人工机械瓣患者的二尖瓣器进行了评分,并与取自三维数据集的任意切面超声心动图（ＡＰＥ）和多平面经食管二维超声心动图（ＴＥＥ）对照。结果３ＤＶ对正常和病变二尖瓣的活动度、连合部、瓣口面积和与毗邻结构的空间关系的评分显著高于ＴＥＥ和ＡＰＥ（Ｐ＜０．０１和Ｐ＜０．０５）。３ＤＶ对病变二尖瓣的诊断价值更优于正常二尖瓣。它对瓣叶厚度、瓣环和瓣下结构的评分低于ＴＥＥ和ＡＰＥ（Ｐ＜０．０１）。三种检查方法对二尖瓣位人工机械瓣的评分无显著性差异（Ｐ＞０．０５）。结论３ＤＶ对评价正常和病变二尖瓣器提供了一种有特殊价值的新方法。     

超声对二尖瓣位单叶斜蝶瓣功能的评从及检查的护理要点

本文应用Ｍ型二维超声心动图（Ｍ－２Ｄ）脉冲多普勒（ＰＷ）彩色多普勒（ＣＤＦＩ）对１１例二尖瓣位单叶斜蝶瓣置换术后一个月内及半年的随诊观察，发现超声对斜蝶形机械瓣功能的评价有极其独到的作用，尤其是多普勒检测手段，对二尖瓣口面积（ＭＶＡ）二尖瓣口舒张期最大流速（ＶＰ），压差半降时间（ＨＴ），二尖瓣舒张期最大跨瓣压差（ＭＰＧ），平均跨瓣压差的观察较术前有明显改善，是监测机械瓣功能的最佳手段。     

血流会聚法测二尖瓣机械瓣有效面积的价值

本研究通过经食管超声心动图对二尖瓣位机械瓣左房侧血流会聚现象的观察测量，利用血流会聚法对３７例经食管超声检查的二尖瓣换瓣术后患者二尖瓣机械瓣有效面积进行测定，并与压力半降法测定二尖瓣机械瓣有效面积进行比较，结果表明血流会聚法测定的二尖瓣机械瓣有效面积与压力半降法有良好相关（第一等速面ｒ＝０．８７，Ｐ＜０．０５；第二等速面ｒ＝０．７５，ｐ＜０．０５）。作者认为：血流会聚法是一种较有价值的测定二尖瓣机械瓣有效面积的方法。     

多普勒超声心动图评价二尖瓣位人工生物瓣血流动力学性能

应用多普勒超声心动图技术对５５例置换于二尖瓣位的三种不同生物瓣的血流动力学指标进行了观察。结果表明，置换于二尖瓣位三种生物瓣的有效瓣口面积（ＥＯＡ）分别为：ＢＮ型２．６±０．４ｃｍ２，Ｐｅｒｆｅｃｔ型为２．３±０．２ｃｍ２，Ｃａｒｐｅｎｔｉｅｒ－Ｅｄｗａｒｄｓ瓣为２．３±０．６２ｃｍ，其中ＢＮ瓣的ＥＯＡ最大（Ｐ值＜０．０５），后两种瓣间的ＥＯＡ无显著差别（Ｐ值＞０．０５），三种生物瓣的峰值流速（Ｖｍａｘ）、峰值压差（ＰＧ）、及平均压差（ＭＧ）无显著差别（Ｐ值均＞０．０５）。     

血流会聚头测二尖瓣机械瓣有效面积的价值

本研究通过经食管超声心动图对二尖瓣位机械瓣左房侧血流会聚现象的观察测量，利用血流会聚法对３７例经食管超声检查的二尖瓣换瓣术后患者二尖瓣机械瓣有效面积进行测定，并与压力半降法测定二尖瓣机械瓣有效面积进行比较，结果表明血流会聚法测定的二尖瓣机械瓣有效面积与压力半降法有良好相关。作者认为：血流会聚法是一种较有价值的二尖瓣机械瓣有效面积的方法。     

二尖瓣口三维力与左房能量和能量效率关系的研究

目的：研究二尖瓣口充盈力学的三维效应与瓣口狭窄和左房能量的关系。方法：应用牛顿力学定律把力学效应的强度维、时间维和空间维映射到立体坐标系中,按三维模型构筑三维力效应图并求得三维力（３ＤＦ）、另按压力－容积势能理论求得左房总能量（ＴＥ）和能量效效率（ＥＥ）,用二维多普勒超声对自然瓣、狭窄瓣和机械瓣的瓣口冲力（Ｆ）,冲量（Ｉ）、充盈功（Ｗ）和３ＤＦ与瓣口面积（ＭＶＡ）、ＴＥ和ＥＥ作对比研究。结果：三种     

经胸动态三维超声心动图对二尖瓣狭窄患者瓣口面积的评价

采用经胸动态三维超声心动图（３Ｄ－Ｅｃｈｏ）对１５例二尖瓣狭窄（ＭＳ）患者的二尖瓣口面积（ＭＶＡ）进行了定量研究。通过心脏三维重建仪平行切割二尖瓣结构衍生出８个从二尖瓣环至瓣尖的等距离短轴平面，从中能够确定并测量代表最小ＭＶＡ的平面。结果显示３Ｄ－Ｅｃｈｏ测量的ＭＶＡ与多普勒压力半降时间（ＰＨＴ）导出的ＭＶＡ高度相关（ｒ＝０．９７，Ｐ＜０．００１），经胸二维超声心动图（２Ｄ－Ｅｃｈｏ）测量的ＭＶＡ与３Ｄ－Ｅｃｈｏ测量的ＭＶＡ仅中度关连（ｒ＝０．８３，Ｐ＜０．０１），２Ｄ－Ｅｃｈｏ测量的ＭＶＡ平均大于３Ｄ－Ｅｃｈｏ测量的ＭＶＡ为０．３８ｃｍ２，这可能与从胸骨旁短轴切面上难以切扫到最小的瓣口平面有关。本研究表明３Ｄ－Ｅｃｈｏ为定量评价ＭＳ患者的ＭＶＡ提供了一种更准确的全新影像技术。     

经胸和平面经食道超声心动图定量诊断主动脉瓣狭窄

为评价多平面经食道超声心动图（ＭＴＥＥ）定量诊断主动脉瓣狭窄（ＡＳ）的可行性和可靠性，在３２例成年ＡＳ患者中应用经胸超声心动图（ＴＴＥ）测量了主动脉瓣的瓣口面积（ＡＶＡ－ＴＴＥ），最大瞬时压差（ＰＰＧ）和平均压差（ＭＰＧ），应用ＭＴＥＥ测量了瓣口面积（ＡＶＡ－ＴＥＥ）并对手术治疗的患者直接测量了其瓣口面积（ＡＶＡ－ＯＰＥ），结果显示：（１）ＡＶＡ－ＴＥＥ与ＡＶＡ－ＴＴＥ，ＡＶＡ－ＴＥＥ与ＡＶＡ－Ｏ     

多平面经食管三维超声心动图对二尖瓣狭窄的诊断价值

采用多平面经食管三维超声心动图（３Ｄ－Ｅｃｈｏ）对１５例二尖瓣狭窄（ＭＳ）患者的二尖瓣口面积（ＭＶＡ）进行了定量研究。通过心脏三维重建仪平行切割二尖瓣结构衍生出８个从二尖瓣环至瓣尖的等距离短轴平面，能够发现并测量代表最小ＭＶＡ的平面。结果显示３Ｄ－Ｅｃｈｏ测量的ＭＶＡ与多普勒压力半降时间（ＰＨＴ）导出的ＭＶＡ高度相关（ｒ＝０．９８，Ｐ值＜０．００１），经胸两维超声心动图（２Ｄ－Ｅｃｈｏ）的测量的ＭＶＡ与３Ｄ－Ｅｃｈｏ测量的ＭＶＡ仅中度相关（ｒ＝０．８１Ｐ值＜０．０１），２Ｄ－Ｅｃｈｏ测量的ＭＶＡ平均大于３Ｄ－Ｅｃｈｏ测量的ＭＶＡ０．４５ｃｍ２，这可能与从胸骨旁短轴切面上难以切扫到最小的瓣口平面有关。本研究表明３Ｄ－Ｅｃｈｏ为定量评价ＭＳ患者的ＭＶＡ提供一种新的检查方法。     

Quantitative assessment of mechanical prosthetic valve area by 3-dimensional transesophageal echocardiography.

OBJECTIVE: The goal of this study was to assess the geometric orifice area of mechanical valve prostheses by transesophageal 3-dimensional echocardiographic planimetry. METHODS AND RESULTS: Currently used Doppler methods for prosthetic assessment (orifice area-Doppler) were compared with 3D planimetry for orifice area (orifice area-3D) and with manufacturer's values (orifice area-manufacturer) for the corresponding prosthesis types and sizes and with historical controls provided by Doppler literature (orifice area-literature). Twenty-four mechanical valve prostheses (in 22 patients) were studied: 13 in mitral position and 11 in aortic position. Orifice area-manufacturer, orifice area-Doppler, orifice area-literature, and orifice area-3D were 3.6 +/- 1.1 cm(2), 2.3 +/- 0.9 cm(2), 2.4 +/- 0.9 cm(2), and 2.6 +/- 0.7 cm(2), respectively. Orifice area-manufacturer values were significantly larger. Correlation coefficients between orifice area-3D and orifice area-manufacturer, and between orifice area-3D and orifice area-Doppler and orifice area-literature were 0.83, 0.90, and 0.73, respectively (all P < .0001). CONCLUSION: Three-dimensional transesophageal echocardiography is feasible and has good correlation with orifice area-Doppler (in aortic position) and good correlation with orifice area-manufacturer (in aortic and mitral positions) methods.     

实时三维超声心动图在评价人工瓣膜结构和功能中的应用

目的 探讨实时三维超声心动图评价人工瓣膜结构和功能的临床应用价值.方法 应用彩色多普勒超声对33例人工瓣膜置换术后患者进行实时三维超声心动图检查,其中二尖瓣位人工机械瓣19例,生物瓣3例;主动脉瓣位人工机械瓣11例.结果 30例(91%)能够清楚显示人工瓣膜和支架结构及其周邻的解剖结构,其中26例功能正常,4例功能异常,其中3例为二尖瓣机械瓣瓣周漏,另1例为二尖瓣位生物瓣赘生物形成伴瓣叶穿孔破裂.结论 联合应用实时三维和全容积成像模式可以直观、准确地评价人工瓣膜的结构和功能.是对经胸二维超声和经食管超声心动图的有益补充.     

实时三维超声在评价人工机械瓣功能中的应用

目的在二维（2D）基础上应用三维实时超声心动图（RT-3DE）,探讨RT-3DE在评价人工瓣功能方面的临床应用价值。方法应用PhilipsIE33型彩色多普勒超声诊断仪,对23例受检者进行了实时三维超声心动图检查,其中二尖瓣位18例,主动脉瓣位5例。结果23例人工瓣均获得较清晰的三维图像。20例人工瓣功能正常。3例功能异常,其中2例为人工瓣瓣周漏,另有1例为二尖瓣位人工瓣血栓导致梗阻。结论RT-3DE在2DE基础上,可获得更丰富的空间信息,可以对2DE做出有益的补充。     

实时三维超声心动图评价人工瓣膜形态和功能的初步研究

目的评价实时三维超声(Live 3DE)技术观察人工瓣膜形态和功能的可行性和准确性.方法32例行二尖瓣和(或)主动脉瓣以及三尖瓣位人工瓣膜置换的患者,应用Live 3DE的灰阶成像和彩色成像模式,观察人工瓣和支架的结构形态,并评价其相关血流动力学改变.结果Live 3DE灰阶成像可清晰显示二尖瓣位或三尖瓣位上人工瓣膜和支架结构形态以及其空间立体关系,三维成像清晰率为83.33%(15/18);8例二尖瓣合并主动脉瓣置换的患者,受主动脉瓣位机械瓣强回声遮挡的影响,人工二尖瓣的三维成像清晰率为62.5%(5/8);人工主动脉瓣的三维成像清晰率则为50%(7/14).Live 3DE彩色血流成像则可较敏感地显示人工瓣的反流与瓣周漏.结论联合应用Live 3DE的灰阶和彩色成像模式可准确、直观地反映人工瓣膜的形态结构和功能变化,是传统经胸二维超声心动图和经食管超声心动图技术的重要补充.     

Estimation of aortic valve effective orifice area by Doppler echocardiography: effects of valve inflow shape and flow rate.

BACKGROUND: The effective orifice area (EOA) is the standard parameter for the clinical assessment of aortic stenosis severity. It has been reported that EOA measured by Doppler echocardiography does not necessarily provide an accurate estimate of the cross-sectional area of the flow jet at the vena contracta, especially at low flow rates. The objective of this study was to test the validity of the Doppler-derived EOA. METHODS: Triangular and circular orifice plates, funnels, and bioprosthetic valves were inserted into an in vitro aortic flow model and were studied under different physiologic flow rates corresponding to cardiac outputs varying from 1.5 to 7 L/min. For each experiment, the EOA was measured by Doppler and compared with the catheter-derived EOA and with the EOA derived from a theoretic formula. In bioprostheses, the geometric orifice area (GOA) was estimated from images acquired by high-speed video recording. RESULTS: There was no significant difference between the EOA derived from the 3 methods with the rigid orifices (Doppler vs catheter: y = 0.97x +0.18 mm(2), r(2) = 0.98; Doppler vs theory: y = 1.00x -3.60 mm(2), r(2) = 0.99). Doppler EOA was not significantly influenced by the flow rate in rigid orifices. As predicted by theory, the average contraction coefficient (EOA/GOA) was around 0.6 in the orifice plates and around 1.0 in the funnels. In the bioprosthetic valves, both EOA and GOA increased with increasing flow rate whereas contraction coefficient was almost constant with an average value of 0.99. There was also a very good concordance between EOA and GOA (y = 0.94x +0.05 mm(2), r(2) = 0.88). CONCLUSIONS: In rigid aortic stenosis, the Doppler EOA is much less flow dependent than generally assumed. Indeed, it depends mainly on the GOA and the inflow shape (flat vs funnel-shaped) of the stenosis. The flow dependence of Doppler EOA observed in clinical studies is likely a result of a variation of the valve GOA or of the valve inflow shape and not an inherent flow dependence of the EOA derived by the continuity equation.     

二尖瓣修复术后二尖瓣环形态的三维超声研究

目的：评价我院自行研制的新型软质人工二尖瓣成形环的临床应用效果,为软质人工二尖瓣环的推广应用提供理论依据。方法：应用体元模型经食管动态三维超声重建技术研究了１３例接受软质二尖瓣环成形术和９例硬质二尖瓣环成形术者,术后即刻二尖瓣瓣环形态和口径的变化。结果：应用硬质环行二尖瓣修复术后,从左心房向左心室方向观察,二尖瓣环形态被强制成与硬质环相似的“Ｄ”形,且二尖瓣环口径固定,在舒张末期和收缩末期二尖瓣环前后径分别为１．８０±０．１５ｃｍ和１．７７±０．１３ｃｍ（Ｐ＞０．０５）,二尖瓣环面积和周长均无显著性变化（Ｐ＞０．０５）;而应用软质环后,二尖瓣环仍呈椭圆形,在舒张末期和收缩末期二尖瓣前后径分别为２．０９±０．１９ｃｍ和１．８５±０．１３ｃｍ（Ｐ＜０．０１）,且其面积和周长均发生符合生理状态的周期性显著变化（Ｐ＜０．０１）。结论：应用软质二尖瓣成形环可维持人体二尖瓣环生理性的形态和功能。     

Hemodynamic evaluation of normally functioning Sulzer Carbomedics prosthetic valves

The Sulzer Carbomedics prosthetic heart valve (CP) is a commonly used mechanical valve in clinical practice. In the present study, we used conventional and color Doppler echocardiography to assess the hemodynamics of normally functioning CP in the aortic (n = 73) and mitral (n = 127) positions. Our findings demonstrate no significant correlation of Doppler-measured peak and mean pressure gradients and effective orifice area with implanted valve size and actual orifice areas, measured directly by the manufacturer for CPs in both the mitral and aortic positions. However, it is still useful to measure effective orifice area by Doppler because a value in the normal or nonstenotic range points to an unobstructed prosthesis in the aortic or mitral position, in the absence of poor left ventricular ejection fraction. A value in the stenotic range could mean a normally functioning or obstructed prosthesis and, therefore, may need further investigation, such as assessment of valve leaflet motion by transthoracic or transesophageal echocardiography or fluoroscopy. Valve regurgitation as evaluated by color Doppler flow mapping was mild in practically all CPs in the aortic position, and in the majority of CPs in the mitral position.     

实时三维超声心动图评价阵发性心房颤动患者射频消融术后右心房大小和机械功能变化

目的 应用实时三维超声心动图评价阵发性心房颤动患者射频消融术后右房大小和机械功能的变化,并探讨右房与左房大小和机械功能变化之间的相关性.方法 35例阵发性心房颤动患者接受射频消融手术.应用实时三维超声心动图、经胸超声心动图及组织多普勒超声心动图分别于术前、术后1月及术后3月测量右房收缩末期容积及面积、右房射血分数、三尖瓣舒张晚期A峰速度、组织多普勒三尖瓣环舒张晚期A'峰速度、三维右房收缩末期容积、三维右房射血分数、左房收缩末期容积及面积、左房射血分数、二尖瓣舒张晚期A峰速度、组织多普勒二尖瓣环舒张晚期A'峰速度、三维左房收缩末期容积、三维左房射血分数.结果 35例患者均成功获得满意的三维超声心动图及组织多普勒图像.左房收缩末期面积与三维左房收缩末期容积从术后1月开始即出现了明显的缩小[分别为(18.8±6.3)cm2对(21.5±6.2)cm2,(38.8±17.0)ml对(46.1±20.0)ml,均P＜0.05].心房机械功能方面,三维左房射血分数在术后1月较术前明显下降,到术后3月逐步上升接近术前水平[(41.1±13.7)%对(51.7±15.9)%,(41.1±13.7)%对(45.6±18.3)%,P＜0.05].右房的大小与机械功能的所有参数术后与术前相比差异无统计学意义.术后1月与3月时,右房容积及机械功能的变化与左房容积和机械功能的变化无明显相关性(r值分别为0.23,0.26,0.32,0.03,P＞0.05).结论 实时三维超声心动图能精确定量心房的容积和机械功能.阵发性心房颤动患者射频消融术后左房明显缩小,而右房大小及机械功能均无明显改变.

Abstract：

Objective To assess the changes of right atrial size and mechanical function after radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation using real-time threedimensional echocardiography(RT-3DE), and to study the correlation between the changes of left atrial(LA)and right atrial(RA) volume and function. Methods Thirty-five patients with paroxysmal atrial fibrillation were undergone radiofrequency catheter ablation (RFCA) successfully. Transthoracic echocardiography (TTE),tissue Doppler imaging(TDI) and RT-3DE were performed before, 1 month and 3 months after procedure respectively. Late systolic volume and area of RA and LA,ejection fraction(EF) of RA and LA,late diastolic peak velocity of mitral valve inflow, tricuspid valve inflow and late diastolic peak velocity of mitral annulus and tricuspid annulus were recorded. Results The 3DE images of all patients were satisfied.LA max area and 3DE LA max volume were significantly reduced at 1 months and 3 months after procedure compared with basic stage [ ( 18.8 ± 6.3) cm2 vs (21.5 ± 6.2) cm2 , (38.8 ± 17.0) ml vs (46.1 ± 20.0) ml,P ＜ 0.05]. 3DE LA EF also declined markedly at 1 month after RFCA, and restored at 3 months later compared with baseline [(41.1 ± 13.7) % vs (51.7 ± 15.9) %, (41.1 ± 13.7) % vs (45.6 ± 18.3) %, P ＜0.05]. The size and mechanical function of the right atrial after procedure were no obvious changes. There were no evidently correlation between the changes of LA and RA volume and function. Conclusions RT3DE can provide a precise method to quantify the value of atrial volume and function. The LA size and volume are significantly reduced after RFCA in patients with paroxysmal atrial fibrillation, however, the RA size and function are no obvious changes.