一 超声流体动力学方法测定 舒张早期左室流入血流压力阶课件

一、 超声流体动力学方法测定 舒张早期左室流入血流压力阶差 二、 血流向量成像图（VFM）技术 评估慢性心功能不全患者 左心室血流结构的变化,上海同济大学附属东方医院 陈明 苗爱雨 刘怡 张波 张宇辉 郑建华 黄金康 刘盛林 马静 孟凡霞,Department of Ultrasound & Function,超声流体动力学方法测定舒张早期左室流入血流压力阶差,上海同济大学附属东方医院 陈明 苗爱雨 刘怡 张波 张宇辉 郑建华 黄金康 刘盛林 马静 孟凡霞,Department of Ultrasound & Function,Company Logo,心室整体舒张功能测定的局限性,尽管近年来彩超技术进步很快，但是在检测心室舒张功能时仍然采用传统的脉冲多普勒方法，其评估心室整体舒张功能仍有较大的局限性,JACC, 2009, 53(17):1558-1567,Transmitral flow velocities,研究背景,Company Logo,左心室舒张功能的超声方法,都不是二维彩色多普勒超声方法！,Company Logo,PAS：肺动脉收缩压 Valsava动作 Ar-A= AR-A时间间期 LAP：左房压,Sep:室间隔 Lat:左室侧壁 Av:平均值,J Am Soc Echocardiography, 2009, 22(3):107-133.,Recommendations for the Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography,美国超声心动图学会指南,都不是彩色多普勒超声方法！,Company Logo,3D vortex structure at end-diastole found in an idealized ventricle for parameters that correspond to those of a young healthy subject An iso-surface of the 2 meter (intermediate eigenvalue of the squaum of symmetric and antisymmetric parts of the velocity gradient tensor),三维血流结构图,左心室流体结构,Company Logo,VFM显示左心室涡流,Company Logo,Intraventricular pressure gradients,舒张早期二尖瓣开放后，左心室血流波经心底穿越整个左心室，向心尖部传播 左心室的充盈最先发生在心尖部，随即心底部出现的充盈，从而产生了压力梯度。,舒张早期左室流入血流压力阶差（IVPGs）,Company Logo,运用VFM技术，通过超声流体动力学方法判定左心室舒张功能异常？ 超声流体动力学方法测定左心室流入血流压力阶差？,血流速度向量成像（VFM）有用吗？,Company Logo,舒张期左室压、左房压 左室/左房压差 左室流入血流减慢,二尖瓣频谱,心导管左室房压曲线,左室顺应性,等容舒张期,心音图,抽吸作用,左心室内压力阶差的原理,Company Logo,IVPGs = 抽吸,二尖瓣血流,肺静脉血流,左心室、左心房压力曲线,IVPGs发生于二尖瓣开放，左心室解旋率峰值之后，二尖瓣E峰之前,IVPGs,IVPGs = 抽吸,Company Logo,资料与方法,左室舒张功能异常的患者60例（男33例、 女27例），平均年龄（65.5111.02）岁 根据左室舒张功能异常的程度分为： 舒张功能轻度减低亚组（n=39） 限制型舒张功能减低亚组（n=21） 正常对照组（n=30），平均年龄（63.3713.35）岁,Company Logo,仪器与超声方法,日本Aloka公司10 彩超仪，宽频探头频率3.55.0MHz 于心尖四腔观采集左室动态流入血流图，帧频30帧/秒 血流速度向量成像（VFM）软件测定舒张早期左心室流入血流的速度阶差，通过左室心尖部与二尖瓣环部的流速阶差，计算得到左室流入血流的平均压力阶差（Intraventricular pressure gradients, IVPGs）,Company Logo,左心室舒张早期测量指标,谱线流速峰值 谱线流速低值 色阶面积 彩流宽度 左室高流速区流入面积/左室流入总面积 心室内压力梯度（ IVPGs ） 左室充盈流入速率,Company Logo,左室中部及基底部的压力 阶差是心尖部的2-4倍,左室各部的血流速度,Company Logo,VFM测量IVPGs,从心尖部-心底部的血流速度来获得IVPGs,Company Logo,Company Logo,IVPGs 测量方法,？,？,V (cm/sec) = B（心底部） A（心尖部） IVPGs (mmHg) = 4 V2,IVPGs,IVPGs,B,A,左心室内的血流梯度,心尖Apex,中部,心底Base,Company Logo,舒张早期左室流入血流压力阶差（IVPGs）,限制型,轻度减低,对照组,mmHg,P0.001,结 果,Company Logo,正常人的IVPGs,Company Logo,限制型舒张功能减低的IVPGs,Company Logo,舒张功能轻度减低的IVPGs,Company Logo,讨 论,IVPGs = 抽吸 Circulation. 1999;99:2048-2054. 舒张早期左室腔内血流快速充盈从二尖瓣口向左室心尖播散 从房室瓣环/左室心尖部存在着流速差或压力阶差（ IVPGs）。 在左室主动松弛与快速充盈的共同作用下，正常左室产生了负压抽吸作用 JACC 2009，53(17): 1558-1567.,Company Logo,intraventricular pressure gradients (IVPGs),main flow axis line,我们用二维彩色超声分析左室舒张早期二维血流色阶差 沿左室流入道的空间分布方向测量与计算血流参数,超声流体力学的分析方法,Company Logo,左心室彩色多普勒血流信号,main flow axis line,branched flow axis lines,陈明，等. 舒张早期左室流入血流色阶差的二维彩色多普勒超声研究. 中华超声影像学杂志， 2006 ，15(5):340-343.,Company Logo,色阶奇异值Color singular value(CSV),AV指数（色阶变化斜率）：红线为色阶渐进线，AV相当于其斜率，反映色阶变化的整体性 CV 指数（色阶变化积分）：蓝线是实际色阶变化曲线，CV表示其变化的积分，反映色阶变化的细微性,CV 指数（色阶变化积分）,AV指数（色阶变化斜率）,色阶渐进线,色阶变化曲线,Company Logo,Intraventricular pressure gradients (IVPGs) could be obtained from color singular value (CSV) of color Doppler inflow for assessment of LV diastolic function. The method reflected the changes of left ventricular pressure gradients at early diastole, which could describe the total left ventricular function objectively.,奇异值 Color singular value(CSV),AV指数（色阶变化斜率） CV 指数（色阶变化积分）,Company Logo,我们设计用色阶奇异值来表示左室彩色流入血流参数差异的统计值曲线的斜率与积分，用以反映左室流入彩色血流色阶差的整体变化,色阶奇异值(CSV),对照组,心肌梗死,扩张型心肌病,Company Logo,声学造影微泡显示可以减低 左室血流传播速度的测量误差,声学造影微泡显示的左室血流传播速度,Company Logo,显示左心室流入血流：VFM可能是更好的选择,声学造影微泡显示的左室血流传播速度,Company Logo,IVPGs是左心室舒张期传播血流与左心室几何形状变化之间、流入血流与左心室松弛（relaxation）、顺应性（compliance）之间复杂的相互作用下形成的。 左心室舒张时间常数（）、 解旋率、IVPGs均参与了舒张期的活动，目前仍然机理不清。 Am J Physiol Heart Cir Physiol 2008, 294:H505-513.,局限性,Company Logo,结 论,IVPGs 对于维持左室的有效充盈是非常重要的。 IVPGs 对判定各种病理状态下的心肌缺血或左心室功能异常较为敏感的一个标志。 VFM技术所测IVPGs 是一种简单而精确的测定左心室舒张功能方法。,血流向量成像图（VFM）技术评估慢性心功能不全患者左心室血流结构的变化,上海同济大学 附属东方医院 苗爱雨 陈明 刘怡 张波 张宇辉 郑建华 黄金康 刘盛林 马静 孟凡霞,Department of Ultrasound & Function,Company Logo,研究背景,本研究旨在运用VFM技术检测慢性心功能不全（CHF）患者左心室内血流结构的变化 探讨其与左心室收缩功能之间的关系,Company Logo,方法 选取慢性心功能不全患者29例，其中扩张性心肌病5例、陈旧性心肌梗死14例、高血压心脏病2例；男19例，女10例，平均年龄（66.4210.32）岁。 左心室射血分数（EF） 55mm。 正常对照组30例: 男14例，女16例，平均年龄（63.3713.35）岁,Materials and Methods,Company Logo,于心尖三腔观，获取动态彩色多普勒血流图 采用VFM血流涡流图显示模式,Materials and Methods,Company Logo,测定左心室中部的主涡流的以下参数: 涡流最大横径 (Dvor) 涡流边缘血流速度 (Vvor) 左室流出道层流持续时间(Tl） 涡流持续时间（Tvor）,资料与方法,Company Logo,P0.001,Control,CHF,cm/sec,mm,P0.001,CHF,Control,涡流边缘血流速度 (Vvor),涡流最大横径 (Dvor),涡流最大横径与涡流边缘血流速度,Company Logo,左室流出道层流与涡流持续时间间期,涡流持续时间（Tvor）,左室流出道层流状态持续时间(Tl）有效射血时间,P0.001,P0.001,Control,Control,CHF,CHF,ms,ms,Company Logo,结 果,Dvor及Tvor与 EF、Tei等心功能指标呈负相关（r值分别为：与EF：-0.58、-0.43；与Tei：-0.47、-0.41；P0.05） Vvor与EDV、ESV呈正相关（的 r值：0.61、0.44；P0.05）,直线相关性分析,Company Logo,图1：示CHF患者的VFM左心室流线图，收缩早期左心室腔中下部涡流横径较大，边缘血流速度减低（仅 8.5cm/sec）。,结 果,Company Logo,结 果,图2：示正常者的VFN左心室流线图，收缩早期左心室腔中下部涡流横径较小，边缘血流速度较快（达 13.5 cm/sec）。,Company Logo,CHF状态下，左心室主涡流为一个体积大、自身流速缓慢的漩涡，缓慢向左心室出口播散 有别于正常人左心室主涡流体积相对较小、自身流动速度较快的血流结构特征,涡流的大小与传播速度,Company Logo,涡流期：CHF状态下左心室内的主涡流始于左心室舒张晚期，持续于整个等容收缩期，止于收缩早期。，涡流期则可视为射血前期。 左心室射血层流期：左心室于涡流期末即开始射血，此时左心室流出道的血流处于层流状态 CHF组，层流期（Tl）较对照组显著缩短、涡流期Tvor（射血前期）较对照组延长（P0.01）。,有效射血时间与涡流时间间期,Company Logo,血流结构与几何结构对泵功能的作用,提示慢性心衰时，左心室重构与涡流迟缓的传播 可能会降低左心室的机械效率，增加血流传播中的能量消耗，共同使左心室泵功能进一步降低。 从超声动力学的观点来看问题，同步化治疗的目的就是减小涡流的直径、减少涡流形成时间、增加涡流的传播、延长有效射血的层流时间间期。,Company Logo,局限性,由于VFM血流结构图像质量取决于彩色多普勒图像的质量，本文的局限性在于任何影响超声图像质量的因素均能造成血流结构显示的缺失 目前超声仪器提供的二维彩色多普勒帧频仍偏低，导致一些VFM测量信息丢失，影响VFM分析测量的准确性,Company Logo,小结 1: 由VFM 技术测得的IVPGs能够应用于评估左心室舒张功能异常。 小结 2: 左心室涡流的大小、传播速度、有效层流与涡流时间间期可能是左心室衰竭的流体力学特征。 流体力学理论能够在VFM技术的帮助下，应用于测定左心室收缩与舒张功能。,结 论,Company Logo,谢 谢 ,Company Logo,Department of Ultrasound & Function,1. Intraventricular Pressure Gradients（IVPGs） Measured from Left Ventricular Inflow by Vector Flow Mapping (VFM) 2. Echo-dynamographic analysis of Left Ventricular Flow Structure by Vector Flow Mapping,CHEN Ming, MIAO Ai-yu, LIU Yi，ZHANG Bo, ZHANG Yu-hui, ZHENG Jian-hua，MA Jing, LIU Sheng-lin Shanghai East Hospital affiliated to Tongji University，Shanghai 200120 China,Department of Ultrasound & Function,Intraventricular Pressure Gradients（IVPGs） Measured from Left Ventricular Inflow by Vector Flow Mapping (VFM),CHEN Ming, MIAO Ai-yu, LIU Yi，ZHANG Bo, ZHANG Yu-hui, ZHENG Jian-hua，MA Jing, LIU Sheng-lin Shanghai East Hospital affiliated to Tongji University，Shanghai 200120 China,Company Logo,Limitations of current measurement of whole diastolic function of left ventricule,Detection for left ventricular (LV) dysfunction has limited to a small part in the ventricle by traditional echocardiographic methods currently.,JACC, 2009, 53(17):1558-1567,Transmitral flow velocities,Background,Company Logo,Methods for calculation of diastolic function,Without two-dimensional and color Doppler flow mapping,Company Logo,PAS：肺动脉收缩压 Valsava动作 Ar-A= AR-A时间间期 LAP：左房压,Sep:室间隔 Lat:左室侧壁 Av:平均值,J Am Soc Echocardiography, 2009, 22(3):107-133.,From Am Soc Echocardiography,Recommendations for the Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography,Without twodimensional and color Doppler flow mapping,Company Logo,3D vortex structure at end-diastole found in an idealized ventricle for parameters that correspond to those of a young healthy subject An iso-surface of the 2 meter (intermediate eigenvalue of the squaum of symmetric and antisymmetric parts of the velocity gradient tensor),3D Flow Vortex Structure,Flow Structure of Left Ventricle,Company Logo,Vortex inside LV from VFM,Company Logo,Intraventricular pressure gradients,The IVPG is a superposition of pressure decrease due to relaxation and a filling wave, which, for its part is composed of increasing pressure due to filling and a dynamic filling-wave pattern. The IVPGs during filling are the consequence of complex interaction, between on the one hand pressure waves travelling in the LV and, on the other hand, LV geometry, relaxation and compliance.,IVPGs,Company Logo,Do VFM Works in Evaluation of Diastolic Function of Left Ventricle?,Could inflow pattern of echo-dynamography in left ventricle (LV) during early diastole in patients with left ventricular diastolic dysfunction be obtained by Vector Flow Mapping (VFM)? Could IVPGs be used for assessment of LV diastolic function by VFM ?,Company Logo,In LV Diastolic Dysfunction LVEDP LAP LVP/LAP LV inflow ,Spectrum of mitral valve,Pressure of left ventricle & left artium,左室顺应性,Phonogram,suction,Mechanism of IVPGs,Company Logo,IVPGs = Suction,Mitral Flow,Pulmonary Vein Flow,LVP/LAP,IVPGs : After opening of MV and peak rate of untwisting of LV，before E velocity of MV inflow.,IVPGs,IVPGs = Suction,Company Logo,Materials and Methods,Patients with LV diastolic dysfunction : 60 cases（man 33 and lady 27） mean age = 65.5111.02 years. According to degree of LV dysfunction： LV diastolic dysfunction （n=39） Restrictive filling pattern（n=21） Control （n=30）， mean age 63.3713.35 years,Company Logo,Equipment and VFM Analyses,Aloka 10 Echographic machines with Transducer frequecy: 3.55.0MHz LV inflow image from the four-chamber view, frame frequency = 30 frame/sec Intraventricular pressure gradients (IVPGs) from VFM was calculated by the gradient between velocity of apex and velocity of base of LV,Company Logo,Parameters of early diastolic function,Peak velocity of inflow Minimal velocity of inflow Color area of inflow Depth of color inflow Color area of inflow / area of LV inflow IVPGs Filling rate of LV at early diastole,Company Logo,P: 2-4 times in the middle and the base of LV compared with the apex.,Blood Flow in Different Parts of LV,Company Logo,IVPGs from VFM,IVPGs calculated from velocities between apex and the base of LV,Company Logo,Company Logo,Measurement of IVPGs,？,？,V (cm/sec) = Velocity(Base)Velocity(Apex) IVPGs (mmHg) = 4 V2,IVPGs,IVPGs,B,A,左心室内的血流梯度,Apex,middle,Base,Company Logo,Intraventricular pressure gradients （IVPGs）,restrict,Decreased,Control,mmHg,P0.001,Results,Company Logo,IVPGs in a Normal Subject,Company Logo,IVPGs in a Ristrict Patient,Company Logo,IVPGs in LV diastolic dysfunction,Company Logo,Discussion,IVPGs = Diastolic Suction Circulation. 1999;99:2048-2054. IVPGs comes from inflow propagation from mitral valve to apex in the early diastoly. Suction is produced by both active relaxation and pasitive compliance of LV in normal heart. JACC 2009，53(17): 1558-1567.,Company Logo,intraventricular pressure gradients (IVPGs),main flow axis line,Intraventricular pressure gradients (IVPGs) could be obtained from color gradient by color Doppler with distribution of inflow of LV,Echo-Dynamographic Analysis,Company Logo,IVPGs from color Doppler image,main flow axis line,branched flow axis lines,Chen, Ming. et al. Color gradients of early diastolic inflow from two-dimensional color Doppler image. J Chin Ultrasonic Imaging，2006，15(5):340-343.,Company Logo,Color Singular Value ( CSV),AV Index (Slope): Changes of color gradient inside total LV inflow CV Index (integral): Changes of color gradient inside LV inflow in detail,AV Index (Slope),CV Index (integral),Company Logo,Intraventricular pressure gradients (IVPGs) could be obtained from color singular value (CSV) of color Doppler inflow for assessment of LV diastolic function. The method reflected the changes of left ventricular pressure gradients at early diastole, which could describe the total left ventricular function objectively.,Color singular value(CSV),AV Index (Slope) CV Index (integral),Company Logo,Color singular value within the diastolic inflow under pathological conditions might reflect the diastolic dysfunction of LV.,IVPGs from color singular value,Control,AMI,DCM,Company Logo,Speed of contrast within inflow of LV could be calculated by color M-mode echocardiography.,Measurement of propagation by contrast,Company Logo,声学造影微泡显示可以减低 左室血流传播速度的测量误差,Measurement of propagation by contrast,Displaying inflow of LV：VFM may be better,Company Logo,IVPGs is the complex results of relation between LV blood propagation and change of geometry of LV, and relation between LV inflow, relaxation, and compliance. “The correlations between and temporal succession of, isovolmuic pressure decay(), LV untwisting, and IVPGs but does not address a cause and effect relationship between these phenomena.” Am J Physiol Heart Cir Physiol 2008, 294:H505-513.,Limitation,Company Logo,Conclusions,IVPGs is important for maintenan LV filling IVPGs might be sensitive to detect ischemia or dysfunction under different pathological conditions in herat diseases. IVPGs from VFM: a simple and accurate tool for measurement of dysfunction of LV.,MIAO Ai-yu, CHEN Ming, LIU Yi，ZHANG Bo, ZHANG Yu-hui, ZHENG Jian-hua，MA Jing, LIU Sheng-lin Shanghai East Hospital affiliated to Tongji University，Shanghai 200120 China,Department of Ultrasound & Function,Echo-dynamographic Analysis of Left Ventricular Flow Structure by Vector Flow Mapping,Company Logo,Background,To evaluate quantitatively the local flow structure and dynamics using Echo-dynamographic analysis“Vector Flow Mapping, VFM” To investigate the correlation between the vortex and LV systolic function.,Company Logo,Group of CHF : Twenty-nine patients (m=19, f=10, mean age= 66.4210.32 years) with chronic heart failure（ including dilated myocardiopathy 5, myocardial infarction 14, hypertension 2） EF 55mm Controls: Thirty subjects as controls (m=14, f=16, mean age= 63.3713.35 years),Materials and Methods,Company Logo,于心尖三腔观，获取动态彩色多普勒血流图 采用VFM血流涡流图显示模式,Materials and Methods,Company Logo,Main vortex in the middle of left ventricular cavity was measured as: Diameter Flow velocity at border Laminar Interval Duration of vortex,Materials and Methods,Company Logo,Diameter of vortex and flow velocity at border of vortex,P0.001,Control,CHF,Dvor: Maximal Diameter of Vortex,Vvor: Velocity at the border of vortex,cm/sec,mm,P0.001,CHF,Control,Company Logo,Laminar Interval & Vortex duration,Laminary Interval(Ll) Effective ejection duration,P0.001,P0.001,ms,Time of vortex duration (Tvor）,Control,Control,CHF,CHF,ms,Pre-ejection duration,Company Logo,Results,Dvor, Tvor vs EF: r value = -0.58 and -0.43 (P0.05), separately Dvor, Tvor vs Tei Index: r value = -0.47 and -0.41 (P0.05 ), separately,Correlations:,Company Logo,Fig. 1 Image of stream-line mode by VFM in a patient with CHF. A large vortex inside LV was noted and velocity near the border of the vortex was only 8.5 cm/sec.,Results,Company Logo,Fig. 2. Image of stream-line mode by VFM in a healthy subject. Compared with that in patient with CHF, a relative small vortex inside LV was seen and velocity near the border of the vortex was 13.5 cm/sec.,Results,Company Logo,Under the circumstance of CHF, a slowly moving vortex with relative bigger size, which propagated towards left ventricular outflow. Moving fast with higher rate of propagation and with a relative smaller size for normal vortex in control.,Size and rate of propagation of vortex,Company Logo,Duration of the effective ejection：defined as “Laminary Interval (Ll)” . In patients with CHF, the main vortex starts from late-diastole and ends at early-systole. Duration of