臺灣博碩士論文加值系統

研究背景
心肌梗塞(myocardial infarction)造成局部的心肌壞死(myocardial necrosis)後，若無適當的治療，左心室會隨著時間進程而產生擴張性再塑型化(ventricular remodeling)及心衰竭(heart failure)，除了會影響當下的心臟收縮和舒張功能外，甚至會惡化而形成左心室血管瘤(left ventricular aneurysm)。過去治療體積較大的左心室血管瘤的方法通常只能選擇風險較大的心外手術，這些手術存在著許多的限制與併發症。目前正在發展的一套嶄新的微創治療稱為：「心室分區裝置」(ventricular partitioning device)，原理是藉由心導管的輔助將其分區裝置放置於左心室內，達到左心室瘤與正常心室隔離的效果，改變心室內容積及血流動力(hemodynamic)，進而改善心臟之收縮及舒張功能，延緩左心室的再塑型化。
材料與方法
本研究利用心臟電腦斷層回溯性評估28位正常人、28位缺血性心衰竭病人與其置放左心室分區裝置後6個月，三族群之左心室容積(left ventricular volume)、收縮功能(systolic function)與舒張功能(diastolic function)變化，藉由評估解剖性與功能性的指標，探討心室分區裝置於左心室重建的機制及其療效。正常族群也被用來驗證電腦斷層評估法之準確性。
結果
由實驗結果發現，病人在放入心室分區裝置後，左心室解剖結構大小相較於術前皆具有顯著性的下降(LVESV: 178.48±61.99 ml vs. 152.72±54.40 ml, p < 0.0001; LVEDV: 256.37±72.34 ml vs. 230.79±59.54 ml, p < 0.001; LV length: 99.85±8.30 mm vs. 91.09±10.66 mm, p < 0.0001)。於收縮功能部份，心搏量並無顯著性差異(stroke volume: 78.71±24.82 ml vs. 78.07±20.60 ml, p = 0.86)；左心室射出分率具有顯著性上升(ejection fraction: 0.31±0.10 vs. 0.35±0.10, p < 0.05)。至於舒張功能部份，二尖瓣血流速(transmitral velocity)之E波血流速度與A波血流速度並無顯著性差異(E velocity: 0.42±0.23 m/s vs. 0.39±0.12 m/s, p = 0.52; A velocity: 0.28±0.18 m/s vs. 0.26±0.14m/s, p = 0.49)；二尖瓣心中膈組織速度(mitral septal tissue velocity)之Ea具有顯著性上升(0.02±0.01 m/s vs. 0.04±0.02 m/s, p < 0.0005)；E/A平均值有下降趨勢但無顯著性差異(2.23±2.09 vs. 2.16±1.56, p = 0.88)；E/Ea具有顯著性下降(21.96±15.58 vs. 13.55±9.86, p < 0.05)。而正常族群之左心室射出分率與舒張功能評估指標(E/A、E/Ea)之平均值皆落於正常範圍內(LVEF > 0.55；1 ≦ E/A < 2；E/Ea ≦ 8)。
討論與結論
本研究成功使用心臟電腦斷層評估此族群之心臟功能指標，且結果顯示電腦斷層具有良好之準確性。藉由置放裝置後6個月後，顯著縮小的左心室容積與改善的收縮與舒張功能，可證實此裝置具有治療效果，並具延緩缺血性心衰竭惡化之能力。

Background
Left ventricular (LV) remodeling after (MI) is characterized by progressive LV dilatation, which if left untreated, may ultimately result in progressive systolic dysfunction, LV aneurysm formation, heart failure and death. Recently, an implantable novel percutaneous device had been developed, aiming for proper isolation of the dysfunctional region of the LV in order to reduce both LV volume and attenuate myocardial wall stress. This study aimed to evaluate whether Parachute LV partitioning system implantation improved LV diastolic function assessed by MDCT.
Material and methods
Twenty eight patients who had cardiac CT images before and 6 months after Parachute device implantation, and twenty eight subjects with normal cardiac CT images were included in this retrospective study. The cardiac functional indexes including left ventricle length, end-diastolic and end-systolic volume as well as systolic function and diastolic function were analyzed by off-line analysis (TeraRecon Aquarius workstation, San Mateo, Calif). The normal group is for the validation of the value of cardiac functional indexes.
Result
The comparison of LV structure variables between baseline, 6 months follow up groups showed a significantly decrease in LV length, LV end-systolic volume, and LV end-diastolic volume; LV systolic function indexes shows a significantly improved in LV ejection fraction (LVEF) (0.31 ± 0.10 vs. 0.35 ± 0.10, respectively, p < 0.01), but there were no significant difference in stroke volume (78.71 ± 24.82 ml vs. 78.07 ± 20.60 ml, respectively, p = NS); LV diastolic function parameters showed a significantly improved in E/Ea (21.96 ± 15.58 ml vs. 13.55 ± 9.86, respectively, p < 0.01), but no significant difference in E/A (2.23 ± 2.09 vs. 2.16 ± 1.56, respectively, p = NS). The result of normal group showed the minimum LV length, LV end-systolic volume, LV end-diastolic volume among the three groups, and LVEF, LV diastolic function parameters which were E/Ea, E/A were all in the normal range (0.73±0.08, 3.70±2.22, 1.36±0.51, respectively).
Discussion and conclusion
This study successfully used cardiac CT images to evaluate these cardiac functional indexes, and the results which in the normal range of normal group were ensured the accuracy of CT measurement. A significant decrease in LV structure and improvement in both systolic and diastolic function occurred after device implantation showed a potential beneficial effect of this novel device in treatment of LV aneurysm.

誌謝 i
中文摘要 ii
英文摘要 iv
目錄 vi
圖目錄 viii
表目錄 x
第一章 緒論 1
1.1冠狀動脈疾病 1
1.2 左心室分區裝置 3
1.3 左心室收縮功能 7
1.4 左心室舒張功能 7
1.5 研究背景 11
1.6 研究目的 11
第二章 文獻回顧 12
2.1 左心室分區裝置之發展與相關研究 12
2.2 心臟電腦斷層評估左心室功能 16
第三章 材料與方法 18
3.1 研究對象 18
3.2 掃描參數 19
3.3 心臟功能評估方法 21
3.3.1 心室容積量測法 21
3.3.2 心室收縮功能量測法 22
3.3.3 心室舒張功能量測法 23
3.3.3.1 二尖瓣血流速量測方法 23
3.3.3.2 二尖瓣左心室中膈速度量測方法 25
3.4 心室功能分級方法 27
3.4.1 收縮功能分級方法 27
3.4.2 舒張功能分級方法 28
3.4.3 紐約心臟學會分級標準 29
3.5統計分析 31
第四章 結果 32
第五章 討論 37
5.1 心室分區裝置造成左心室功能之變化 37
5.2 案例討論 40
5.2.1 正常、術前與術後族群於左心室解剖結構差異 40
5.2.2左心室容積對於舒張功能改善程度之影響 41
5.2.3 影像品質對於量測過程之影響 42
5.2.4 人為因素造成之誤差 47
第六章 結論 50
參考文獻 51

圖目錄
圖1-1、心臟冠狀動脈示意圖 1
圖1-2、冠狀動脈疾病示意圖 2
圖1-3、拉普拉斯定律與擴張性心室再塑型化之關係 3
圖1-4、心室分區裝置系統示意圖 4
圖1-5、左心室分區裝置結構示意圖 5
圖1-6、動態腔室與靜態腔室示意圖 6
圖1-7、置放心室分區裝置後之心導管影像與心臟電腦斷層重組影像 6
圖1-8、左心室舒張期示意圖 8
圖1-9、利用都卜勒超音波量測二尖瓣血流速之結果 8
圖1-10、利用組織都卜勒超音波量測二尖瓣心中膈組織速度之結果 10
圖2-1、動物實驗結果 13
圖2-2、左心室分區裝置第一次人體試驗，分區裝置置放前後圖 13
圖2-3、左心室容積於置放心室分區裝置後之變化 14
圖2-4、3D質點位移分析結果示意圖 15
圖2-5、心肌正常運動、運動不能與運動困難所占心肌範圍比例示意圖 15
圖2-6、使用心臟超音波評估左心室舒張功能 17
圖3-1、心臟電腦斷層掃描搭配心電圖 20
圖3-2、心室舒張末期之心臟電腦斷層影像 20
圖3-3、藉由影像分析軟體半自動圈選各切面左心室面積範圍示意圖 21
圖3-4、相位-容積曲線圖 22
圖3-5、左心室體積變化量曲線圖 24
圖3-6、二尖瓣瓣環開口面積量測示意圖 24
圖3-7、左心室長度示意圖 26
圖3-8、相位-長度曲線圖與相位-二尖瓣心中膈組織速度圖 26
圖4-1、正常人、術前與術後6個月之舒張功能參數盒鬚圖 34
圖4-2、紐約心臟學會分級標準、LVEF與E/Ea之分佈關係圖。 36
圖5-1、正常、術前與術後6個月之左心室心臟電腦斷層影像 41
圖5-2、舒張功能改善程度與術前左心室容積關係圖 42
圖5-3、金屬材質造成心臟電腦斷層影像假影 43
圖5-4、手動修正金屬假影示意圖 43
圖5-5、階梯假影 44
圖5-6、於階梯假影影像上進行量測 45
圖5-7、管電流與雜訊 46
圖5-8、四腔室掃描面重組圖 47
圖5-9、切面選擇造成量測左心室長度之差異 48
圖5-10、切面選擇造成量測二尖瓣面積之差異 49

表目錄
表3-1、缺血性心臟疾病病人與正常族群之特性 19
表3-2、左心室收縮功能評估標準 27
表3-3、左心室舒張功能評估標準 29
表3-4、紐約心臟學會分級標準 30
表4-1、心臟電腦斷層評估術前、術後與正常人之左心室結構與功能 33
表4-2、利用左心室舒張功能分級標準進行術前與術後6個月之分級 35
表4-3、利用多變項線性迴歸分析比較E/Ea、EF與NYHA之關係 36

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