- 學位論文
即時三維心臟超音波應用於先天性中隔缺損治療的重要性：評估心房中隔缺損心室中隔缺損及引導治療步驟
The Role of Real-Time Three-Dimensional Echocardiography in Congenital Septal Defects: Assessing and Guiding the Treatment Procedures for Atrial Septal Defect and Ventricular Septal Defect
摘要
前言：結合彩色杜卜勒超音波技術的二維心臟超音波(two-dimensional echocardiography, 2DE)，雖然在功能上已有所提升，但在評估心腔容積及體積時，所能提供正確的定量資訊、區域評估，仍然有顯著的不足。經由多平面的超音波切面，而形成的三維心臟超音波（three-dimensional echocardiography, 3DE）的重建系統，雖然在定量方面已有改善，但卻是相當耗時。即時三維立體心臟超音波（Real-time three-dimensional echocardiography, RT-3DE）與二維切面重建的三維心臟超音波相比，除了能有效的縮短影像重建時間，且可獲得定量、定性的資訊。因此，本研究特別應用即時三維立體心臟超音波，來評估心房中隔缺損及心室中隔缺損之病人。 傳統上應用二維經食道心臟超音波(two-dimensional transesophageal echocardiography, 2D-TEE)以及心臟內超音波(intracardiac echocardiography , ICE)方式來評估病人心房中隔缺損(Atrial septal defect, ASD)的情形，並以此做為介入性心導管置放安普拉茲心房中隔關閉器的參考，但這二種方式不但是侵入性的處置，而且無法完整地描述心房中隔缺損複雜的立體型態。即時三維經胸前心臟超音波（Real-time three-dimensional transthoracic echocardiography, RT3D-TTE），此種不具侵入性的處置能夠提供全面且完整的影像，以了解心房中隔缺損的情形及周邊組織的結構，因此在評估心房中隔缺損治療方面，即時三維經胸前心臟超音波的引用，徹底改變過去以二維經食道心臟超音波或心臟內超音波的觀察模式，而即時三維經胸前心臟超音波已成為心房中隔關閉器放置時的新型指引工具。 本研究目的主要為兩個部份，第一個部份是針對心房中隔缺損病人，應用即時三維經胸前心臟超音波評估心房中隔缺損，並用修正的胸骨旁四腔室切面，作為經導管放置安普拉茲心房中隔關閉器的指引，以評估其可行性及有效性。第二個部份是針對心室中隔缺損病人，將即時三維立體心臟超音波與手術觀察心室中隔缺損結果相比，了解兩者之間的相關性，以評估即時三維立體心臟超音波用於心室中隔缺損之測量，作為日後心室中隔缺損閉合器（目前尚未通過美國藥物食品管理局Food and Drug Administration, FDA許可）選用的依據。 方法：自西元2004年2月至2005年8月之間，共有97位心中隔缺損的病人。其中有59名心房中隔缺損的病人，接受經導管安普拉茲心房中隔關閉器(Transcatheter Amplatzer septal occluder, ASO)治療，這當中有30位病人在施行全身麻醉後，以二維經食道心臟超音波來引導關閉器的置放，其餘29位病人，改採局部麻醉後，以即時三維經胸前心臟超音波來引導關閉器的置放。除了59名心房中隔缺損的病人外，另外有38位確認為心室中隔缺損的病人，藉由即時三維立體心臟超音波，透過TomTec超音波影像工作站，分析心室中隔缺損的三維立體影像，加上二維心臟超音波的測量結果，分別與手術觀察的心室中隔缺損大小相比較，以求其相關性。 結果：在第一部份有關心房中隔缺損病人的研究中，全部病人皆成功完成介入性心導管治療，且沒有合併症，因此可以比較即時三維經胸前心臟超音波及二維經食道心臟超音波的臨床特性。在使用導管室時間方面，即時三維經胸前心臟超音波的時間是39.1±5.4分鐘，二維經食道心臟超音波的時間是78.8±14.1分鐘，兩者間具有顯著性差異（p<0.001）。而在介入性心導管操作的放射線照射時間比較上，即時三維經胸前心臟超音波的時間是7.6±4.2分鐘，二維經食道心臟超音波的時間是15.3±2.9分鐘，兩者間具有顯著性差異（p<0.001），因此使用即時三維經胸前心臟超音波比二維經食道心臟超音波時間來的短，且兩者在治療後六個月的追蹤評估上並無不同。即時三維經胸前心臟超音波與二維經食道心臟超音波在測量心房中隔缺損最大直徑時，與氣球測量導管量測心房中隔缺損直徑之間有著良好的相關性如下：即時三維經胸前心臟超音波與氣球測量導管量測直徑關係y = 0.985x + 0.628, r值達0.924。二維經食道心臟超音波與氣球測量導管量測直徑關係為y = 0.93x + 2.08, r值達0.885。 第二個部份，針對心室中隔缺損病人的研究方面，即時三維立體心臟超音波的測量結果與手術中所測量心室中隔缺損的直徑大小相比，相關係數等同於二維心臟超音波所測量的直徑結果，相關係數分別為r=0.89 vs. r=0.90，在即時三維立體心臟超音波的影像處理分析上，不同觀察者間的分析結果具一致性。 結論：在引導介入性導管置放安普拉茲心房中隔關閉器治療心房中隔缺損方面，即時三維經胸前心臟超音波能提供比二維經食道心臟超音波更可行、安全且有效的評估。另外即時三維立體心臟超音波可增加心室中隔缺損的可視性，並獲得定量、定性的資訊，有效地縮短影像重建時間，且可由左心室面正視心室中隔缺損，提供全新的切面影像，以供評估心室中隔缺損的大小徑長，對於心室中隔缺損的診斷，是一項具有潛力的臨床診斷工具。
並列摘要
Background: Two-dimensional echocardiography (2DE) enhanced by combining with color Doppler technology has significant limitations in providing precise quantitative information, geometric assumptions to calculate chamber volume, mass, and ejection fraction. Reconstructed three-dimensional echocardiographic (3DE) systems (from multiple cross-sectional echocardiographic scans) are still cumbersome and time-consuming. Real-time 3DE (RT3DE) with shorter imaging time than with 3D reconstruction techniques can obtain qualitative and quantitative information on heart disorders. Our purpose was to estimate the patient of Atrial Septal Defect (ASD) and Ventricular Septal Defect (VSD). Transcatheter Amplatzer septal occluder (ASO) device closure of atrial septal defects (ASDs) has traditionally been guided by two-dimensional transesophageal echocardiography (2D-TEE) and intracardiac echocardiography (ICE) modalities. Real-time three-dimensional transthoracic echocardiography (RT3D-TTE) provides rotating images to define ASD and adjacent structures with potential as an alternative to 2D-TEE or ICE for guiding the device closure of ASD. There are two subjects of this study. The first subject was to assess the feasibility and effectiveness of RT3D-TTE in parasternal four-chamber views to guide ASO device closure of ASD. The second subject was to investigate the feasibility and potential value of RT3DE as a means of accurately and quantitatively estimating the size of VSD to correlate with the surgical findings. Materials and Methods: From February 2004 to August 2005, total 97 patients of septal defect were samples. Among in these patients, the 59 patients underwent transcatheter ASO device closure of ASD. The first 30 patients underwent 2D-TEE guidance under general anesthesia and the remaining 29 patients underwent RT3D-TTE guidance with local anesthesia. In addition, the 38 patients with VSD were examined with RT3DE. 3D image data-base was post-processed using TomTec echo 3D workstation. The results were compared with the results measured by 2 DE and surgical findings. Results: The first subject of atrial septal defect patients. All interventions were successfully completed without complications. The clinical characteristics and transcatheter closure variables of RT3D-TTE and 2D-TEE were compared. Echocardiographic visualization of ASD and ASO deployment was found to be adequate when using either methods. Catheterization laboratory time (39.1±5.4 vs 78.8±14.1 minutes, P < 0.001) and interventional procedure length (7.6±4.2 vs 15.3±2.9 minutes, P < 0.001) were shortened by using RT3D-TTE as compared with 2DE-TEE. There was no difference in the rate of closure following either method, assessed after a 6-month follow-up. The maximal diameter measured by RT3D-TTE and 2D-TEE was correlated well with a balloon stretched ASD size (y = 0.985x + 0.628, r = 0.924 vs y = 0.93x + 2.08, r = 0.885, respectively). The second subject of RT3DE produced novel views of VSD and improved quantification of the size of the defect. The sizes obtained from 3DE have equivalent correlation with surgical findings as diameter measured by 2-DE (r = 0.89 vs r = 0.90). Good agreement between blinded observers was achieved by little interobserver variability. Conclusion: RT3D-TTE may be a feasible, safe, and effective alternative to the standard practice of using 2D-TEE to guide ASO deployment. In addition, RT3DE offers intraoperative visualization of VSD to generate a “virtual sense of depth”without extending examining time. From an LV en face projection, the positions, sizes, and shapes of VSDs can be accurately determined to permit quantitative recording of VSD dynamics. It is a potentially valuable clinical tool to provide precise imaging for surgical and catheter-based closure of difficult perimembranous and singular or multiple muscular VSD.
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