超声测量肺循环阻力和体循环阻力比值
作者：蒋国平 康曼丽 何 瑾 夏呈森* 朱卫华*
单位：杭州浙江医科大学附属儿童医院(310003)超声室
关键词：超声心动图；肺循环阻力；先天性心脏病
超声测量肺循环阻力和体循环阻力比值 摘要 探讨超声测量肺循环阻力和体循环阻力比值(PVR/SVR)的方法。超声测量43例先天性心脏病患儿左、右室射血前期(LPEP，RPEP)、射血期(LET，RET)和加速期(LAT，RAT)，同时测量主、肺动脉血流量(Qs, Qp)。进而计算RPEP：Qp、RPEP：ET：Qp、RPEP：AT：Qp、RPEP：Qp/LPEP:Qs、RPEP:ET:Qp/LPEP:ET:Qs和RPEP:AT:Qp/LPEP:AT:Qs。结果：超声测量RPEP：Qp、RPEP：ET：Qp和RPEP：AT：Qp与心导管测量的PVR/m2比较，r分别为0.66、0.65和0.75。超声测量RPEP：Qp/LPEP:Qs、RPEP：ET：Qp/LPEP:ET:Qs和PREP:AT:Qp/LPEP:AT:Qs与心导管测量PVR/SVR比较，r分别为0.78、0.78和0.89。其中RPEP：AT：Qp/LPEP:AT:Qs与PVR/SVR相关最好。超声测量RPEP:AT:Qp/LPEP:AT:Qs能较准确地估测PVR/SVR。
, 百拇医药
Measurement of the Ratio of Pulmonary to
Systemic Vascular Resistance by Echocardiography
Jiang Guoping,Kang Manli,He Jin,et al.
The Children′s Hospital Affiliated to Zhejiang Medical University,Hangzhou,(310003)
Abstract To investigate the method of measuring the ratio of pulmonary to systemic vascular resisitance (PVR/SVR)by echocardiography. The preejection period、ejection time and acceleration time of the left and right ventricules (LPEP、LET、LAT、RPEP、RET and RAT) as well as the volume of pulmonary and systemic blood flow (Qp,Qs) were measured by echocardiogrphy in 43 cases of congenital heart disease. Then the RPEP:Qp、RPEP:ET:Qp、RPEP：AT：Qp、RPEP:Qp/LPEP:Qs、RPEP:ET:Qp/LPEP:ET:Qs and RPEP:AT:Qp/LPEP:AT:Qs were calculated. The LPEP:Qp、 RPEP:ET:Qp and RPEP:AT:Qp measured by echocardiography were compared respectively with PVR/m2 measured by cardiac catheterization. The correlation coefficients were 0.66, 0.65 and 0.75 respectively. The RPEP:Qp/LPEP:Qs、 RPEP:ET:Qp/LPEP:ET:Qs and RPEP:AT:Qp/LPEP:AT:Qs measured by echocardiography were compared respectively with PVR/SVR measured by cardiac catheterization. The correlation coefficients were 0.78, 0.78 and 0.89 respectively. The best correlation was between RPEP:AT:Qp/LPEP:AT:Qs and PVR/SVR. The PVR/SVR can be accurately and extensively estimated by measuring the RPEP:AT:Qp/LPEP:AT:Qs by echocardiography.
, 百拇医药
Key words Echocardiography; Pulmonary vascular resistance; Congenital heart disease
肺循环阻力和体循环阻力比值(PVR/SVR)是评价先天性心脏病血流动力学改变的重要参数，目前主要依赖于有创的心导管检查。本文超声测量43例先天性心脏病患儿的左、右室收缩时间间期(STI)，代替主、肺动脉平均压，结合主、肺动脉血流量(Qs,Qp)计算超声PVR/SVR测值，与心导管测量的PVR/SVR对照，结果报告如下。
资料与方法
研究对象 1995年12月至1998年4月间我院43例住院病人，室间隔缺损(VSD)32例，继发孔型房间隔缺损(ASD)4例，ASD合并肺静脉异位引流1例，ASD合并VSD 2例，心内膜垫缺损4例。所有病例均经超声心动图检查，心导管证实，其中40例已手术。超声与心导管检查间隔时间9.2±8.6天。男性26例，女性17例。年龄3.1±3.2岁。
, http://www.100md.com
研究方法 超声检查仪器为ATLul tramark-9 型超声诊断仪,脉冲多普勒(PWD)在胸骨旁大血管短轴切面肺动脉瓣上获取肺动脉血流频谱,胸骨上主动脉弓长轴或胸骨旁五腔切面主动脉瓣上获取主动脉血流频谱。心电图QRS波起始至主、肺动脉血流频谱开始为左、右室射血前期(LPEP,RPEP),主、肺动脉血流频谱开始至频谱最高峰为左、右室血流加速时间(LAT,RAT),主、肺动脉血流频谱开始至结束为左、右室射血期(LET,RET)。电子游标描绘主、肺动脉频谱边缘,测量主、肺动脉流速时间积分(VTI),结合二维超声测量的主、肺动脉直径计算Qs、Qp。分别计算RPEP:Qp、RPEP:ET:Qp、RPEP:AT:Qp、RPEP:Qp/LPEP:Qs、RPEP:ET:Qp/LPEP:ET:Qs和RPEP:AT:Qp/LPEP:AT:Qs。心导管以直接测压方法测量主、肺动脉压力,Fick′s法计算Qs和Qp,进而计算PVR和PVR/SVR。统计学采用直线相关分析和几何均值t检验。
结 果
, 百拇医药
超声测量43例先天性心脏病患儿RPEP 90.21±19.78msec、RET 250.21±46.63msec、RAT 83.74±17.87msec、Qp14.83±5.78L/min/m2、LPEP107.86±17.97msec、LET 207.84±
36.34msec、LAT 67.79±12.22msec、Qs 5.48±1.72L/min/m2。心导管测量43例患儿肺动脉收缩压6.82±2.55kPa,主动脉收缩压11.05±2.03kPa,肺动脉和主动脉收缩压比值(Pp/Ps)0.62±0.22,Pp/Ps<0.3 2例,Pp/Ps 0.3～0.45 9例,Pp/Ps 0.46～0.75 21例,Pp/Ps>0.75 11例,其中5例Pp/Ps接近或超过1.0。PVR3.82±2.64Woods,其中8例PVR>6.25Woods。PVR/m2 8.52±6.38Woods/m2,SVR 14.18±8.38Woods,PVR/SVR 0.302±0.22与超声测量RPEP:AT:Qp/LPEP:AT:Qs 0.301±0.17相接近,几何均值t检验t=0.3154,P>0.1。超声与心导管测量参数相关分析见表1。
, 百拇医药
表1 超声与心导管参数相关分析
n
r
回归公式
t
P
RPEP:Qp与PVR/m2
43
0.66
Y=1.0142+1.0071X
5.6253
<0.001
, http://www.100md.com
RPEP:ET:Qp与PVR/m2
43
0.65
Y=0.6273+260.54X
5.4768
<0.001
RPEP:AT:Qp与 PVR/m2
43
0.75
Y=0.7587+80.3602X
7.2605
, http://www.100md.com
<0.001
RPEP:Qp/LPEP:Qs与PVR/SVR
43
0.78
Y=-0.0902+1.1158X
7.9811
<0.001
RPEP:ET:Qp/LPEP:ET:Qs与PVR/SVR
43
0.78
Y=-0.0301+1.1028X
, http://www.100md.com
7.9811
<0.001
RPEP:AT:Qp/LPEP:AT:Qs与PVR/SVR
43
0.89
Y=-0.0563+1.1875X
12.4984
<0.001
图1 超声测量RPEP:AT:Qp/LPEP:AT:Qs与心导管PVR/SVR比较
, http://www.100md.com
讨 论
肺动脉平均压和肺循环流量是心导管计算PVR的两大参数,PWD测量右室STI与心导管测量的肺动脉平均压已获良好相关[1～3]。二维超声结合PWD测量的Qp已广泛用于评价肺循环流量[4～6]。近来,Ebeid[7]等人超声测量33例先天性心脏病患儿的PEP/VTI与心导管PVR获良好相关。本文以PWD测量的RPEP：AT代替肺动脉平均压,超声测量的Qp代替肺循环流量,计算的RPEP：AT：Qp测值与心导管测量的PVR/m2对照,r=0.75。表明超声所测RPEP：AT：Qp与PVR/m2之间具有良好的相关关系。
超声测量右室STI和Qp时,患者的心率和检查条件均可影响测量的准确性。本文超声在同一条件下测量左、右室STI和Qs、Qp,计算的PVR/SVR测值与心导管测量的PVR/SVR相关性明显高于超声单一测量PVR测值与心导管PVR/m2的相关性。其中RPEP:AT:Qp/LPEP:AT:Qs测值与心导管PVR/SVR获高度相关(r=0.89)。超声测量的RPEP:AT:Qp/LPEP:AT:Qs测值(0.301±0.17)与心导管PVR/SVR测值(0.302±0.22)结果相近,两者无显著性差异,表明超声在同一条件下测量的RPEP:AT:Qp/LPEP:AT:Qs与PVR/SVR两比值与比值间更具可比性，可直接用于评估PVR/SVR。
, 百拇医药
据报道超声测量肺动脉瓣返流压差与心导管测量的肺动脉平均压获高度相关[8],结合Qp可进而计算PVR。但此方法只适用于肺动脉瓣返流患者,而且舒张期的肺动脉瓣返流量直接影响收缩期Qp的准确测量。本文超声测量的RPEP:AT:Qp/LPEP:AT:Qs评估PVR/SVR方法直接,准确性高,运用范围广泛,适用于大部份先天性心脏病手术前PVR/SVR的估测和手术后远期疗效的随防。
参考文献
[1]Dabestani A,Mahan G,Gardin M,et al.Evaluation of pulmonary artery pressure and resistance by pulsed doppler echocardiography. Am J Cardiol, 1987, 59(1):662～668.
[2]Kosturakis D, Goldberg J, Allen D, et al. Doppler echocardiographic prediction of pulmonary arterial hypertension in congenital heart disease. Am J cardiol, 1984, 53(1):1110～1115.
, 百拇医药
[3]Li W, Du J, Ma Y, et al. Pulmonary artery pressure evaluated by pulsed doppler echocardiography in children with a left-to-right intracardiac shunt. Pediatr Cardiol, 1991, 12(1):17～19.
[4]Hoffman P, Ultrasongraphic evaluation of pulmonary to systemic flow ratio. Kardiol-pol. 1990, 33(1):12～26.
[5]Boehrer D, Lange A, Delles E, et al. Advantages and limitations of methods to defect、 localize quantitate intracardiac left-to-right shunt. Am J Cardiol, 1992, 124(2):448～453.
, 百拇医药
[6]Sabry F, Reller D, Michael G, et al. Comparison of four Doppler echocardiographic methods for calculating pulmonary-to-systemic shunt flow ratios in patients with ventricular septal defect. Am J Cardiology, 1995, 75(15):611～614.
[7]Ebeid M. Doppler echocardiographic evaluation of pulmonary vascular resistance in children with congenital heart disease. J Am Soc Echocardiogr, 1996, 9(6):822～31.
[8]Wiled P. Cardiac ultrasound. Churchill livingstone. New York, 1993, 155.
(1999-01-21收稿)
(1999-02-12修回), 百拇医药(蒋国平 康曼丽 何 瑾 夏呈森* 朱卫华*)
单位：杭州浙江医科大学附属儿童医院(310003)超声室
关键词：超声心动图；肺循环阻力；先天性心脏病
超声测量肺循环阻力和体循环阻力比值 摘要 探讨超声测量肺循环阻力和体循环阻力比值(PVR/SVR)的方法。超声测量43例先天性心脏病患儿左、右室射血前期(LPEP，RPEP)、射血期(LET，RET)和加速期(LAT，RAT)，同时测量主、肺动脉血流量(Qs, Qp)。进而计算RPEP：Qp、RPEP：ET：Qp、RPEP：AT：Qp、RPEP：Qp/LPEP:Qs、RPEP:ET:Qp/LPEP:ET:Qs和RPEP:AT:Qp/LPEP:AT:Qs。结果：超声测量RPEP：Qp、RPEP：ET：Qp和RPEP：AT：Qp与心导管测量的PVR/m2比较，r分别为0.66、0.65和0.75。超声测量RPEP：Qp/LPEP:Qs、RPEP：ET：Qp/LPEP:ET:Qs和PREP:AT:Qp/LPEP:AT:Qs与心导管测量PVR/SVR比较，r分别为0.78、0.78和0.89。其中RPEP：AT：Qp/LPEP:AT:Qs与PVR/SVR相关最好。超声测量RPEP:AT:Qp/LPEP:AT:Qs能较准确地估测PVR/SVR。
, 百拇医药
Measurement of the Ratio of Pulmonary to
Systemic Vascular Resistance by Echocardiography
Jiang Guoping,Kang Manli,He Jin,et al.
The Children′s Hospital Affiliated to Zhejiang Medical University,Hangzhou,(310003)
Abstract To investigate the method of measuring the ratio of pulmonary to systemic vascular resisitance (PVR/SVR)by echocardiography. The preejection period、ejection time and acceleration time of the left and right ventricules (LPEP、LET、LAT、RPEP、RET and RAT) as well as the volume of pulmonary and systemic blood flow (Qp,Qs) were measured by echocardiogrphy in 43 cases of congenital heart disease. Then the RPEP:Qp、RPEP:ET:Qp、RPEP：AT：Qp、RPEP:Qp/LPEP:Qs、RPEP:ET:Qp/LPEP:ET:Qs and RPEP:AT:Qp/LPEP:AT:Qs were calculated. The LPEP:Qp、 RPEP:ET:Qp and RPEP:AT:Qp measured by echocardiography were compared respectively with PVR/m2 measured by cardiac catheterization. The correlation coefficients were 0.66, 0.65 and 0.75 respectively. The RPEP:Qp/LPEP:Qs、 RPEP:ET:Qp/LPEP:ET:Qs and RPEP:AT:Qp/LPEP:AT:Qs measured by echocardiography were compared respectively with PVR/SVR measured by cardiac catheterization. The correlation coefficients were 0.78, 0.78 and 0.89 respectively. The best correlation was between RPEP:AT:Qp/LPEP:AT:Qs and PVR/SVR. The PVR/SVR can be accurately and extensively estimated by measuring the RPEP:AT:Qp/LPEP:AT:Qs by echocardiography.
, 百拇医药
Key words Echocardiography; Pulmonary vascular resistance; Congenital heart disease
肺循环阻力和体循环阻力比值(PVR/SVR)是评价先天性心脏病血流动力学改变的重要参数，目前主要依赖于有创的心导管检查。本文超声测量43例先天性心脏病患儿的左、右室收缩时间间期(STI)，代替主、肺动脉平均压，结合主、肺动脉血流量(Qs,Qp)计算超声PVR/SVR测值，与心导管测量的PVR/SVR对照，结果报告如下。
资料与方法
研究对象 1995年12月至1998年4月间我院43例住院病人，室间隔缺损(VSD)32例，继发孔型房间隔缺损(ASD)4例，ASD合并肺静脉异位引流1例，ASD合并VSD 2例，心内膜垫缺损4例。所有病例均经超声心动图检查，心导管证实，其中40例已手术。超声与心导管检查间隔时间9.2±8.6天。男性26例，女性17例。年龄3.1±3.2岁。
, http://www.100md.com
研究方法 超声检查仪器为ATLul tramark-9 型超声诊断仪,脉冲多普勒(PWD)在胸骨旁大血管短轴切面肺动脉瓣上获取肺动脉血流频谱,胸骨上主动脉弓长轴或胸骨旁五腔切面主动脉瓣上获取主动脉血流频谱。心电图QRS波起始至主、肺动脉血流频谱开始为左、右室射血前期(LPEP,RPEP),主、肺动脉血流频谱开始至频谱最高峰为左、右室血流加速时间(LAT,RAT),主、肺动脉血流频谱开始至结束为左、右室射血期(LET,RET)。电子游标描绘主、肺动脉频谱边缘,测量主、肺动脉流速时间积分(VTI),结合二维超声测量的主、肺动脉直径计算Qs、Qp。分别计算RPEP:Qp、RPEP:ET:Qp、RPEP:AT:Qp、RPEP:Qp/LPEP:Qs、RPEP:ET:Qp/LPEP:ET:Qs和RPEP:AT:Qp/LPEP:AT:Qs。心导管以直接测压方法测量主、肺动脉压力,Fick′s法计算Qs和Qp,进而计算PVR和PVR/SVR。统计学采用直线相关分析和几何均值t检验。
结 果
, 百拇医药
超声测量43例先天性心脏病患儿RPEP 90.21±19.78msec、RET 250.21±46.63msec、RAT 83.74±17.87msec、Qp14.83±5.78L/min/m2、LPEP107.86±17.97msec、LET 207.84±
36.34msec、LAT 67.79±12.22msec、Qs 5.48±1.72L/min/m2。心导管测量43例患儿肺动脉收缩压6.82±2.55kPa,主动脉收缩压11.05±2.03kPa,肺动脉和主动脉收缩压比值(Pp/Ps)0.62±0.22,Pp/Ps<0.3 2例,Pp/Ps 0.3～0.45 9例,Pp/Ps 0.46～0.75 21例,Pp/Ps>0.75 11例,其中5例Pp/Ps接近或超过1.0。PVR3.82±2.64Woods,其中8例PVR>6.25Woods。PVR/m2 8.52±6.38Woods/m2,SVR 14.18±8.38Woods,PVR/SVR 0.302±0.22与超声测量RPEP:AT:Qp/LPEP:AT:Qs 0.301±0.17相接近,几何均值t检验t=0.3154,P>0.1。超声与心导管测量参数相关分析见表1。
, 百拇医药
表1 超声与心导管参数相关分析
n
r
回归公式
t
P
RPEP:Qp与PVR/m2
43
0.66
Y=1.0142+1.0071X
5.6253
<0.001
, http://www.100md.com
RPEP:ET:Qp与PVR/m2
43
0.65
Y=0.6273+260.54X
5.4768
<0.001
RPEP:AT:Qp与 PVR/m2
43
0.75
Y=0.7587+80.3602X
7.2605
, http://www.100md.com
<0.001
RPEP:Qp/LPEP:Qs与PVR/SVR
43
0.78
Y=-0.0902+1.1158X
7.9811
<0.001
RPEP:ET:Qp/LPEP:ET:Qs与PVR/SVR
43
0.78
Y=-0.0301+1.1028X
, http://www.100md.com
7.9811
<0.001
RPEP:AT:Qp/LPEP:AT:Qs与PVR/SVR
43
0.89
Y=-0.0563+1.1875X
12.4984
<0.001
图1 超声测量RPEP:AT:Qp/LPEP:AT:Qs与心导管PVR/SVR比较
, http://www.100md.com
讨 论
肺动脉平均压和肺循环流量是心导管计算PVR的两大参数,PWD测量右室STI与心导管测量的肺动脉平均压已获良好相关[1～3]。二维超声结合PWD测量的Qp已广泛用于评价肺循环流量[4～6]。近来,Ebeid[7]等人超声测量33例先天性心脏病患儿的PEP/VTI与心导管PVR获良好相关。本文以PWD测量的RPEP：AT代替肺动脉平均压,超声测量的Qp代替肺循环流量,计算的RPEP：AT：Qp测值与心导管测量的PVR/m2对照,r=0.75。表明超声所测RPEP：AT：Qp与PVR/m2之间具有良好的相关关系。
超声测量右室STI和Qp时,患者的心率和检查条件均可影响测量的准确性。本文超声在同一条件下测量左、右室STI和Qs、Qp,计算的PVR/SVR测值与心导管测量的PVR/SVR相关性明显高于超声单一测量PVR测值与心导管PVR/m2的相关性。其中RPEP:AT:Qp/LPEP:AT:Qs测值与心导管PVR/SVR获高度相关(r=0.89)。超声测量的RPEP:AT:Qp/LPEP:AT:Qs测值(0.301±0.17)与心导管PVR/SVR测值(0.302±0.22)结果相近,两者无显著性差异,表明超声在同一条件下测量的RPEP:AT:Qp/LPEP:AT:Qs与PVR/SVR两比值与比值间更具可比性，可直接用于评估PVR/SVR。
, 百拇医药
据报道超声测量肺动脉瓣返流压差与心导管测量的肺动脉平均压获高度相关[8],结合Qp可进而计算PVR。但此方法只适用于肺动脉瓣返流患者,而且舒张期的肺动脉瓣返流量直接影响收缩期Qp的准确测量。本文超声测量的RPEP:AT:Qp/LPEP:AT:Qs评估PVR/SVR方法直接,准确性高,运用范围广泛,适用于大部份先天性心脏病手术前PVR/SVR的估测和手术后远期疗效的随防。
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(1999-01-21收稿)
(1999-02-12修回), 百拇医药(蒋国平 康曼丽 何 瑾 夏呈森* 朱卫华*)