Real-Time Three-Echocardiography For Qunatification Of Heart Volumes And Ejection Fractions Of Thepatients With Coronary Atery Desease And Dilated Cardio Myopacy

BackgroundHeart failure is one of the important dead reasons for cardio ventricular disease. So, it is essential to evaluate cardiac function of the patients with heart diseases for estimating states of illness, treatment and prognosis. For many years, we have known left ventricular ejection fraction is a magnitude guideline. In clinical work, it often exists that the left ventricular (LV) ejection fraction doesn't accord with the patient's symptoms. How to evaluate cardiac function accurately has been always our study topic. Angiocardiography and magnetic resonance imaging are used to evaluate left ventricular function broadly, but these two methods have the shortage of invasion, too expensive and being difficult for repeating exam. Compared to these two methods, echocardiography can estimate the movements of ventricular wall and the changes of cardiac dynamic noninvasionly and can be repeated conveniently. M-echo(ME), two-dimensional echocardiography(2-DE) and acoustic quantification (AQ) need geometry assumption when they were used to evaluate cardiac function.LV globe function lies on regional wall movements. There is significant correlation between ventricular wall movement and cardiac muscle blood supply. When cardiac muscle blood supply decreased, wall movement abnormality would appear first. Thereby, quantitative analysis of regional wall movement is very vital for diagnosis and treatment heart disease. Echocardiography can observe ventricular regional wall movement at real time and find out abnormal zone. M- mode, two-dimensional echo and color kinesis (CK) are frequently used for this purpose.The inability of tomographic techniques to record the complete endocardial surface is a limitation. Tissue Doppler imaging can describe regional wall movement objectively, but it's results are affected by heart displacement. Real-time three-dimensional echocardiography(RT-3DE) can display the whole left ventricular and quantify regional volume and ejection fraction. Objective.1. To evaluate the globe function of left and right atriums and ventricles in patients DCM and MI by RT-3DE.2. To evaluate left ventricular regional volume and ejection fraction in patients with myocardial infarction by RT-3DE.MethodsSixty-nine subjects were studied. Group A included 24 normal in control. 12 males, 12 females, 17-66 years old, with a mean age (47±14) years old, who appear normal in history acquisition, biochemical examination of blood, hepatic and renal examination, ECG, chest fluoroscopy and cardiac echocardiogram. Group B included 16 patients with dilated cardio myopasy (DCM), 9 males and 7 females , with a mean age (52±17) years old, who were definitely diagnosed by history acquisition, physical examination, ECG and cardiac echocardiogram, with II-IV grade cardiac function. Group C included 27 patients with myocardial infarction (MI, who confirmed by coronary artery angiocardiography). 16 males, 11 females, 43-74 years old, with a mean age (54±19) years old. 15 old cardiac infarction(OMI), 12 acute cardiac infarction(AMI), 8 with ventricular aneurysm.PHILIPS SONOS 7500 RT-3DE system was used to acquire 2DE, RT-3DE and AQ data, which has probe S4 and probe X4. RT-3DE data was analyzed using Tom Tec 4D cardio-view and 4D-LV analysis.2DE image acquisition: The LV end diastolic volume (LVEDV), LV end systolic volume (LVESV), LV ejection fraction (LVEF), LA end diastolic volume (LAEDV), LA end systolic volume (LAESV), LA ejection fraction(LAEF), RV end diastolic volume (RVEDV), RV end systolic volume (RVESV), RV ejection fraction (RVEF), RA end diastolic volume(RAEDV), RA end systolic volume (RAESV) and RA ejection fraction(RAEF) of all subjects were measured by 2DE using Simpson's method at apical four chamber view for consecutive three cardiac cycle and then adopted mean values.AQ examination: LVEDV, LVESV, LVEF, LAEDV, LAESV, LAEF, RVEDV,RVESV, RVEF, RAEDV, RAESV, RAEF of all subjects were measured by AQ system at apical four chamber view, when subjects were all at calm respiratory. Pressing AQ function key and adjusting landscape gain and portrait gain in order to make trace line cling the endocardium. Drawing the outline of the interest zone and pressing "Enter" and "Waveform" function keys, we could obtain activate AQ curve. Stop the frame when the curve in right pane grew green, then wrote down the EDV, ESV and EF.RT-3DE examination: (1) image acquisition: the subjects undertook left lateral decubitus position with silent respiration. The transducer was placed on the cardiac apex to record "full volume" image data of LV, LA, RV, RA with ECG was connected. The "full volume" data were saved in compact disc(CD). (2) Image analysis: the "full volume" image data, which were saved in CD were analyzed using 4D Cardio View. First, LV,LA, RV,RA was put in the center of analysis plane respectively. Brightness and contrast were adjusted properly, so that LV, LA, RV,RA endocardium was displayed clearly. LVEDV, LVESV, LVEF, LAEDV, LAESV, LAEF, RVEDV, RVESV, RVEF, RAEDV, RAESV, RAEF of all subjects were measured using apical long axis multiple equiangular rotational planes (bi-, 4-, 8-plane). Meanwhile, LV "full volume" data were analyzed using 4D-LV Analysis software. The cursor was used to orientated mitral valve , aortic valve and apex and 8-plane method was selected. During cineloop, end diastolic image and end systolic image were chosen, then mitral valve, aortic valve and apex were orientated one by one plane. Endocardial outline of 8 planes were drawn and left ventricular wall was carved into 16 regions. Regional end diastolic volumes (REDV), regional end systolic volumes (RESV) and regional ejection fractions (REF) were measured and regional volume curve, regional ejection fraction curve were obtained. Regional stroke volume (RSV), the ratio of regional-global stroke volume (RGSV, %) and regional-global ejection fraction (RGEF, %) can be calculated accordingly.Statistical analysis: PEMS 3.1 statistical analysis software was used. All data were expressed using mean±SEE. No pairing t-test was used to compare two groups and analysis of variance was used in multi-group compare , with P<0.05 as significant discrepancy. Results1. Compare the global function results of normal controls by three echo examinations: there was no significant difference among the data acquired using three echo methods. .2. Compare the global function results of DCM patients measured by three echo methods: volumes of LV, LA, RV, RA measured by 2DE, AQ, 3DE biplane were smaller than those by 3DE 4-, 8-plane (P<0.05). There were no significant differences of ejection fraction results among three echo methods (P>0.05). Three echo methods' results showed diastolic and systolic volumes of LV, LA, RV and RA were all greater than that of the normal (P<0.05), ejection fractions were significantly lower than that of the normal (P<0.05).3. Compare of the results of myocardial infraction(MI) patients measured by three echo methods: the end diastolic volumes(EDV) and the end systolic volumes(ESV) of LV> LA> RV and RA measured by 2DE, AQ and 3DE biplane were significant smaller than those by 3DE 4-, 8-plane (PO.05). There were no significant differences of ejection fraction results among three echo methods (P<0.05) . Three echo methods' results showed diastolic and systolic volumes of LV, LA, RV and RA were all greater than those of the normal(P<0.05), ejection fractions were significantly lower than that of the normal (PO.05).4. Analysis of LV regional function of the normal: the normal regional volume curve and regional ejection fraction curve were regular parabola. There was an decrease trend in regional stroke volume from base to apex. The regional ejection fraction increased from base to apex and decreased in an order of lateral, anterior, posterior and septal wall successively. The ratio of regional-global stroke volume decreased from base to apex and in an order of anterior, laterior, septal and posterior wall. Likely , the regional ejection fraction decreased from base to apex and in an order of anterior, laterior, septal and posterior wall.5. Compare of regional function between group A and C: compared to the normal, the regional volume increased and ejection fraction decreased in the regions with MI and the neighbor zones(P<0.05), but in the remote zones, their was no significant changes in volumes and ejection fractions(P>0.05). The regional-global ejection fraction (RGEF) in the myocardiac infarctional (MI) segments (basal and medium anterior wall, basal anterolateral wall, medium postlateral wall, basal postseptal wall and apical wall ) were significantly lower than that of group A ( PO.05);while RGEF in other MI segments and the remote segments was also lower than that in group A, but there was no statistical significance .The regional stroke volume in MI segments (basal anteroseptal wall and apical anterior wall ) wassignificantly lower than that in group A corresponding segments ( P<0.05 = , but significantly higher in no infarction segments (basal anterior wall and posterior wall, medium anterior, anterseptal, postseptal wall) ( P<0.05). The ratio of regional and global stroke volume (RGSV) was significantly lower in MI segments (basal anterior and anteroseptal wall, medium anteroseptal wall, apical anterior wall) than that in group A corresponding segments (PO.05), but was significantly higher in noninfarction segments (basal and medium postseptal, post and postlateral wall, basal and medium anteroseptal wall, medium and apical anterior wall) (P<0.05).6. The tratriac synchronization of left ventricular wall: there was difference among 16 segments in the time of achieving maximum volume and maximum ejection fraction. It took a period of 7.34%±2.26% of one cardiac cycle from the first segment achieving maximum volume to the last segment achieving maximum volume, started at 86.27%±10.58% and ended at 93.74%±15.09% of one cardiac cycle. Likely, from the first segment achieving maximum ejection fraction to the last segment achieving maximum ejection fraction, it lasted a period of 6.11%±1.49%,started at 31.28%±5.81% and ended at 37.39%±8.57% of one cardiac cycle. The time of achieving maximum volume and maximum ejection fraction was not all the same among 16 segments in MI patients. From the first segment achieving maximum volume to the last segment achieving maximum volume, it lasted a period of 12.42%±4.47% of one cardiac cycle, started at 81.47%±11.43% and ended at 93.89%±12.97% of one cardiac cycle. The period prolonged significantly compared to the normals(P<0.05). From the first segment achieving maximum ejection fraction to the last segment achieving maximum ejection fraction, it took a period of 5.93%±1.25% of one cardiac cycle, started at 32.11%±11.52% and ended at 38.04%±15.63% of one cardiac cycle. In DCM patients, From the first segment achieving maximum volume to the last segment achieving maximum volume, it lasted a period ofl0.13%±3.25% of one cardiac cycle, started at 88.84%±15.36% and ended at98.97%±10.57% of one cardiac cycle. From the first segment achieving maximum ejection fraction to the last segment achieving maximum ejection fraction, it took a period of 17.20%±6.48% of one cardiac cycle, started at 31.55%±19.51% and ended at 48.35%±20.71% of one cardiac cycle. The period prolonged significantly compared to the normals(P<0.05).Conclusions1. In normals, the results was alike among 2DE, AQ and 3DE, when they were used to measure volumes and ejection fractions of atriums and ventricles(P>0.05). In DCM and MI patients with large cardiac cavity, the volumes measured by 2DE, AQ and RT-3DE biplane were underestimated, and those by 3DE 4-, 8-plane were close to the true volume. We suggested 2DE, AQ and 3DE biplane be used in normals in evaluating cardiac function. In patients with large cardiac cavity, 3DE 4-, 8-plane were suggested used.2. RT-3DE can evaluate LV regional volumes and ejection fractions objectively. In the normal, the left ventricular contraction is not uniform and increased from the apex to the base, decreased in turn of anterior, laterior, septal and posterior wall. In MI patients, the regional volume increased in MI segments (P<0.05). The regional contraction decreased in MI segments (PO.05), but increased in non-MI segments (PO.05).3. The study which estimated ventricular synchronization according to regional volume and regional ejection fraction curves indicated that it was not at the same time when every left ventricular wall segments achieves the largest volume and the great ejection fraction. In the patients with DCM and MI, ventricular synchronization fell down.