基于心臟CT成像的電生理解剖結(jié)構在體研究及臨床指導意義
發(fā)布時間：2018-10-08 12:49
【摘要】：心律失常是臨床常見的疾病,而現(xiàn)代臨床電生理技術是應用電生理檢查和射頻消融術對心律失常進行機制研究、診斷和治療的有效手段,也是心血管領域迅速發(fā)展的一個分支學科。在電生理及射頻消融術中,心臟影像由X線投照獲得,常常使用多體位結(jié)合相應解剖標志對靶結(jié)構和相關導管進行定位。獲取術中最佳的X線投影并準確定位心臟結(jié)構及導管位置可有效增加手術成功率、減少并發(fā)癥發(fā)生。然而,心臟結(jié)構的變異,尤其是心臟結(jié)構的轉(zhuǎn)位或在體方向的變化(例如房間隔)往往可造成透視影像投影的短縮甚至偏差,。依據(jù)經(jīng)驗采用不同投照體位以期滿足個體化的需求的方法,尚缺乏有效的理論數(shù)據(jù)支持。因此,對電生理相關解剖的變異研究有重要的臨床意義,可期為我們提供預測變異的方法以及個體化成像及治療的有用信息。然而,到目前為止,我們對于心臟解剖尤其是電生理相關結(jié)構解剖的研究與認識多是經(jīng)尸檢標本得出的統(tǒng)計數(shù)據(jù)。眾所周知,心臟是腔室樣結(jié)構,在活體由血液填充,故在體、活體心臟中的解剖結(jié)構及相互關系可能與尸檢和離體標本存在差異。近年來,高分辨CT技術發(fā)展迅速,CT的時間分辨率和空間分辨率不斷提高,這使得心臟CT研究心臟的解剖結(jié)構成為可能。本研究利用心臟CT成像技術對病人在體心臟的電生理解剖結(jié)構變異,尤其是對術中成像可能產(chǎn)生影響的轉(zhuǎn)位及方向變化進行探討,并對術中可能起到指導作用的相關解剖標志例如冠狀靜脈竇及其開口與相應結(jié)構的相互關系進行分析,為個體化成像提供理論依據(jù)。研究內(nèi)容一:應用CT數(shù)據(jù)探索心臟電生理相關的房間隔轉(zhuǎn)位、術中預測方法及對電生理手術的提示方法:通過篩選納入115例行心臟CT增強檢查的心臟結(jié)構正常的病人,應用Pearson相關分析探查卵圓窩方向與心臟位置及冠狀竇近段橫截面方向之間的關聯(lián),進一步應用線性回歸分析明確變量之間是否存在預測價值。結(jié)果:在入選病人中卵圓窩、心臟位置及冠狀竇近段橫截面的方向分別是:36.8±7.3°,37.1±8.3°以及37.7±6.6°,變化范圍分布分別為:19.1°-53.6°、19.2°-61°以及21.3°-50.1°;卵圓窩的方向和心臟位置之間無明顯相關性(P0.05),而卵圓窩方向與冠狀竇近段方向之間存在顯著的相關性(r=0.928,P0.01),進一步的線性回歸得到了線性回歸方程:卵圓窩方向=-2.01+1.03*冠狀竇方向(R2=0.86,P0.01)。研究內(nèi)容二:應用CT技術探索Koch’s三角在體臨床解剖及射頻消融術中投照體位個體化的方法方法:通過篩選納入行心臟CT檢查的病人104例,通過對CT影像及數(shù)據(jù)的分析,定位Koch’s三角,明確其上部、下部的方向以及冠狀竇口的方向。對比Koch’s三角上、下部之間的方向明確其解剖特點,應用Pearson檢驗檢測三角的方向與冠狀竇口方向十分相關,建立二者的回歸方程,比較傳統(tǒng)右前斜投照體位和冠狀竇口方向指導的成像投照體位與最佳投照體位即Koch’s三角的方向之間的差別,并應用Bland-Altman分析探索出現(xiàn)差別以及優(yōu)化投照體位的內(nèi)在理論原因。結(jié)果:Koch’s三角上部、下部及冠狀竇口的方向測值分別為57.2±9.5°、58.2±9.1°和52.3±8.4°,而三角的上部和下部方向無統(tǒng)計學差異。Koch’s三角的方向與冠狀竇口方向之間呈顯著相關(P0.01),根據(jù)線性回歸結(jié)果冠狀竇口方向可預測三角的方向(R2=0.78,P0.01)。傳統(tǒng)投照角度右前斜30°、右前斜45°及冠狀竇口方向指導的投照角度與最佳投照角度(Koch’s三角方向)之間的差別分析提示分別有6.7%、58.7%和99%的病例該差值小于15°。應用Bland-Altman分析顯示Koch’s三角方向與冠狀竇口方向之間的平均差異為5.88±4.29°,95%一致性上限為14.29°,下限為-2.53°,在臨床可接受范圍之內(nèi)。結(jié)論:1.房間隔及Koch’s三角等臨床電生理相關解剖結(jié)構在體的解剖變異尤其是轉(zhuǎn)位及方向變異明顯,在相關操作中需要個體化設計成像及操作方案;2.房間隔的轉(zhuǎn)位與方向和心臟位置無明顯的相關性,而與冠狀竇近段的方向有著相關性,后者可作為轉(zhuǎn)位的預測因子并為個體化手術方案提供術中參考;3.冠狀竇口方向與Koch’s三角方向有顯著的相關性,且前者是后者的預測因素;4.傳統(tǒng)右前斜體位對Koch’s三角進行投照可能使圖像發(fā)生短縮,而依據(jù)解剖信息,我們認為個體化的冠狀竇口指導的投照角度可優(yōu)化投照方法;5.Koch’s三角方向與冠狀竇方向的測值差異在臨床可接受范圍之內(nèi),冠狀竇方向可考慮成為術中衡量Koch’s三角方向的替代方法;6.心臟CT可用于探索心臟電生理相關結(jié)構的解剖變異,并進一步為優(yōu)化電生理及射頻消融術的方案提供理論支持。
[Abstract]:Arrhythmia is a common disease, and modern clinical electrophysiological technique is an effective means of applying electro-physiological examination and radiofrequency ablation to mechanism research, diagnosis and treatment of arrhythmia, as well as a branch subject of rapid development in the cardiovascular field. In electro-physiological and radio-frequency ablation, cardiac images are obtained by X-ray, and the target structure and associated catheter are often positioned using multiple positions combined with corresponding anatomical landmarks. obtaining the optimal X-ray projection in the operation and accurately positioning the heart structure and the catheter position can effectively increase the success rate of the operation and reduce the occurrence of complications. However, variations in cardiac structures, in particular the translocation of cardiac structures or changes in the body direction (e.g., atrial septal) often result in a short contraction or even a deviation of perspective image projections. There is still a lack of effective theoretical data support based on the experience of using different positions with a view to meeting individual needs. Therefore, it is important to study the variation of electro-physiology-related anatomy, which can provide us with the method of predicting variation and the useful information of individualized imaging and treatment. However, so far, our research and understanding of cardiac anatomy, in particular electro-physiological-related structural anatomy, is a statistical data derived from autopsy specimens. As is well known, the heart is a chamber-like structure that is filled with blood in the living body, so the anatomical structures and interrelationships in the body, in-vivo heart, may differ from necropsy and to-body specimens. In recent years, high resolution CT technology has developed rapidly, and the time resolution and spatial resolution of CT are constantly improved, which makes it possible for cardiac CT to study the anatomy of the heart. In this study, cardiac CT imaging technique was used to study the electrophysiological anatomy of the patient's heart, especially the translocation and direction change which might affect the intraoperative imaging. Moreover, the correlation between the relevant anatomical landmarks such as coronary vein thrombosis, its opening and the corresponding structure which may play a guiding role in the operation is analyzed to provide the theoretical basis for the individualized imaging. Study contents 1: To apply CT data to explore the heart electrophysiological related atrial septal transposition, intraoperative prediction method and prompt method for electro-physiological procedure: the patients with normal cardiac structure were screened and included in 115 patients with cardiac CT enhancement. Pearson correlation analysis was applied to explore the association between the direction of the fossa ovalis and the cross-sectional direction of the proximal segment of the coronal section, and further the linear regression analysis was applied to determine the existence of predictive value between the variables. Results: The direction of the cross section of the oval fossa, the heart position and the coronal section of the selected patients were 36. 8, 7. 3 擄, 37. 1, 8. 3 擄 and 37. 7, 6. 6 擄, respectively. The variation range was 19. 1 擄 -53. 6 擄, 19. 2 擄 -61 擄 and 21. 3 擄-50. 1 擄, respectively. There was no significant correlation between the orientation of the fossa and the position of the heart (P0.05), but there was a significant correlation between the direction of the fossa ovalis and the proximal segment of the coronal section (r = 0.928, P0.01). The linear regression equation was obtained: the direction of the fossa ovalis =-2.01 + 1.03 * coronal axis (R2 = 0.986). P0.01). Objective: To explore the method of position individualization in the clinical anatomy and radio frequency ablation of KKK's triangle by using CT technique: 104 cases of patients undergoing cardiac CT examination were screened and analyzed by CT images and data to locate the triangle of Kln's and clarify the upper part of the patients. The direction of the lower part and the direction of the coronal incision. In contrast to the direction of the triangular upper and lower parts of KZS's, the anatomical characteristics of the triangle are compared, and the regression equation of the two regression equations is established by using Pearson's test to detect the direction of the triangle and the direction of coronal incision. To compare the difference between the position of the traditional right anterior oblique projection and the direction of the coronal incision and the direction of the best shot position, i.e., the direction of the KWh's triangle, and apply the Bland-Hellman analysis to explore the difference and the internal theoretical reasons for optimizing the position of the shot. Results: The measured values of the upper and lower parts of the triangular upper part, the lower part and the crown were 57. 2, 9. 5 擄, 58. 2, 9. 1 擄 and 52. 3, respectively, and there was no statistical difference between the upper part and the lower part of the triangle. There was a significant correlation between the direction of KWh's triangle and the direction of coronal incision (P0.01), and the direction of the triangle could be predicted according to the linear regression results (R2 = 0. 78, P 0.01). The difference analysis suggested that the difference between the angle of projection angle and the optimum angle of shot angle (KWh's triangular direction) was 60.7%, 58. 7% and 99% respectively, and the difference was less than 15 擄, respectively. The mean difference between the triangular direction of KH2PO4 's and coronal incision was 5.88% 4.29 擄, the upper limit of 95% consistency was 14.29 擄, and the lower limit was-2.53 擄, within the acceptable range of clinical acceptance. Conclusion: 1. The clinical electrophysiological related anatomical structures, such as atrial septal and Kln's triangle, have obvious anatomical variation, especially translocation and direction variation, and individualized design imaging and operation scheme are needed in the related operation. Translocation of atrial septum has no significant correlation with direction and heart position, but it has a correlation with the direction of the proximal segment of coronary artery, which can be used as predictive factor of translocation and can be referenced in individualized surgical scheme. There is a significant correlation between the coronal incision direction and the triangular direction of KWh's, and the former is the latter's prediction factor. According to the anatomical information, we believe that individual coronal incision guidance can optimize the shooting method according to the anatomical information; 5. The difference between the triangular direction of KMY's and the direction of coronal CT can be within the acceptable range. The coronal scan direction can be considered as an alternative to intraoperative measurement of Kln's triangular direction; 6. Cardiac CT can be used to explore the anatomical variation of electrophysiological-related structures of the heart and provide theoretical support for the optimization of electrophysiological and radio-frequency ablation protocols.
【學位授予單位】：吉林大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R541.7;R813
本文編號：2256814
[Abstract]:Arrhythmia is a common disease, and modern clinical electrophysiological technique is an effective means of applying electro-physiological examination and radiofrequency ablation to mechanism research, diagnosis and treatment of arrhythmia, as well as a branch subject of rapid development in the cardiovascular field. In electro-physiological and radio-frequency ablation, cardiac images are obtained by X-ray, and the target structure and associated catheter are often positioned using multiple positions combined with corresponding anatomical landmarks. obtaining the optimal X-ray projection in the operation and accurately positioning the heart structure and the catheter position can effectively increase the success rate of the operation and reduce the occurrence of complications. However, variations in cardiac structures, in particular the translocation of cardiac structures or changes in the body direction (e.g., atrial septal) often result in a short contraction or even a deviation of perspective image projections. There is still a lack of effective theoretical data support based on the experience of using different positions with a view to meeting individual needs. Therefore, it is important to study the variation of electro-physiology-related anatomy, which can provide us with the method of predicting variation and the useful information of individualized imaging and treatment. However, so far, our research and understanding of cardiac anatomy, in particular electro-physiological-related structural anatomy, is a statistical data derived from autopsy specimens. As is well known, the heart is a chamber-like structure that is filled with blood in the living body, so the anatomical structures and interrelationships in the body, in-vivo heart, may differ from necropsy and to-body specimens. In recent years, high resolution CT technology has developed rapidly, and the time resolution and spatial resolution of CT are constantly improved, which makes it possible for cardiac CT to study the anatomy of the heart. In this study, cardiac CT imaging technique was used to study the electrophysiological anatomy of the patient's heart, especially the translocation and direction change which might affect the intraoperative imaging. Moreover, the correlation between the relevant anatomical landmarks such as coronary vein thrombosis, its opening and the corresponding structure which may play a guiding role in the operation is analyzed to provide the theoretical basis for the individualized imaging. Study contents 1: To apply CT data to explore the heart electrophysiological related atrial septal transposition, intraoperative prediction method and prompt method for electro-physiological procedure: the patients with normal cardiac structure were screened and included in 115 patients with cardiac CT enhancement. Pearson correlation analysis was applied to explore the association between the direction of the fossa ovalis and the cross-sectional direction of the proximal segment of the coronal section, and further the linear regression analysis was applied to determine the existence of predictive value between the variables. Results: The direction of the cross section of the oval fossa, the heart position and the coronal section of the selected patients were 36. 8, 7. 3 擄, 37. 1, 8. 3 擄 and 37. 7, 6. 6 擄, respectively. The variation range was 19. 1 擄 -53. 6 擄, 19. 2 擄 -61 擄 and 21. 3 擄-50. 1 擄, respectively. There was no significant correlation between the orientation of the fossa and the position of the heart (P0.05), but there was a significant correlation between the direction of the fossa ovalis and the proximal segment of the coronal section (r = 0.928, P0.01). The linear regression equation was obtained: the direction of the fossa ovalis =-2.01 + 1.03 * coronal axis (R2 = 0.986). P0.01). Objective: To explore the method of position individualization in the clinical anatomy and radio frequency ablation of KKK's triangle by using CT technique: 104 cases of patients undergoing cardiac CT examination were screened and analyzed by CT images and data to locate the triangle of Kln's and clarify the upper part of the patients. The direction of the lower part and the direction of the coronal incision. In contrast to the direction of the triangular upper and lower parts of KZS's, the anatomical characteristics of the triangle are compared, and the regression equation of the two regression equations is established by using Pearson's test to detect the direction of the triangle and the direction of coronal incision. To compare the difference between the position of the traditional right anterior oblique projection and the direction of the coronal incision and the direction of the best shot position, i.e., the direction of the KWh's triangle, and apply the Bland-Hellman analysis to explore the difference and the internal theoretical reasons for optimizing the position of the shot. Results: The measured values of the upper and lower parts of the triangular upper part, the lower part and the crown were 57. 2, 9. 5 擄, 58. 2, 9. 1 擄 and 52. 3, respectively, and there was no statistical difference between the upper part and the lower part of the triangle. There was a significant correlation between the direction of KWh's triangle and the direction of coronal incision (P0.01), and the direction of the triangle could be predicted according to the linear regression results (R2 = 0. 78, P 0.01). The difference analysis suggested that the difference between the angle of projection angle and the optimum angle of shot angle (KWh's triangular direction) was 60.7%, 58. 7% and 99% respectively, and the difference was less than 15 擄, respectively. The mean difference between the triangular direction of KH2PO4 's and coronal incision was 5.88% 4.29 擄, the upper limit of 95% consistency was 14.29 擄, and the lower limit was-2.53 擄, within the acceptable range of clinical acceptance. Conclusion: 1. The clinical electrophysiological related anatomical structures, such as atrial septal and Kln's triangle, have obvious anatomical variation, especially translocation and direction variation, and individualized design imaging and operation scheme are needed in the related operation. Translocation of atrial septum has no significant correlation with direction and heart position, but it has a correlation with the direction of the proximal segment of coronary artery, which can be used as predictive factor of translocation and can be referenced in individualized surgical scheme. There is a significant correlation between the coronal incision direction and the triangular direction of KWh's, and the former is the latter's prediction factor. According to the anatomical information, we believe that individual coronal incision guidance can optimize the shooting method according to the anatomical information; 5. The difference between the triangular direction of KMY's and the direction of coronal CT can be within the acceptable range. The coronal scan direction can be considered as an alternative to intraoperative measurement of Kln's triangular direction; 6. Cardiac CT can be used to explore the anatomical variation of electrophysiological-related structures of the heart and provide theoretical support for the optimization of electrophysiological and radio-frequency ablation protocols.
【學位授予單位】：吉林大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R541.7;R813
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