Preliminary Clinical Studies Of Assessment Of Structural Heart Disease With Echocardiography

BackgroundStructural heart disease summarizes cardiovascular structural abnormality whichresults from different causes, including congenital and developmental abnormality, andacquired structural abnormality. Fatal syncope or cardiac dysfunction frequently wasinduced due to ischemia, supraventricular, ventricular arrhythmias. Therefore, accuratepreoperative diagnosis is extremely important for clinical treatment and prognosis. Atpresent, although two dimension transthoracic echocardiography (2D TTE) and Doppler arethe general methods in diagnosing structural heart disease in adult or fetus, the imagequality and diagnosis accuracy were affected by technology and window. Real-timethree-dimensional transesophageal echocardiography (RT-3D TEE) can provide moreaccurate diagnostic information for clinic because of the more high-quality image in recentyears. Fetal cardiovascular malformations are more mutiple and complex than that ofinfants and adults. Early discovery and diagnosis using prenatal echocardiography are stillthe main research direction for the fetal structural heart disease.Purpose1. To assess the accuracy of RT-3D TEE in diagnosing adult structural heart diseasecontrast with the results of operation.2. To characterize pathomorphology and histopathology of complex structural heartdisease in fetus, prenatal echocardiography and the assay of anatomy and histology wereperformed.Materials and Methods1. Morphology study of structural heart disease by RT-3D TEE in perioperativeperiodSignatures of informed consent of patients [n=94(female:61, male:29), age rangefrom3to64years old] with structural heart disease from January2011to December2012were obtained. 2D TTE and TEE examination were performed using Philips IE33(Philips MedicalSystem, Andover, MA) equipped with an adult2-7MHz phased array transducer of RT-3DTEE and relevant analysis software. We observe the morphology of heart lesion, and therelationship adjacent to tissues, and complete related measurement after collecting theelectrocardiograph. RT-3D TEE database from standard or non standard sections wasobtained and analysed quantificationally. The values were expressed as means±SD.Differences among groups were analyzed by Wilcoxon’s parametric paired t-test usingSPSS19.0software. Statistical significance was reported as P <0.05for95%confidence.2. The study of ultrasonography and pathology of the complex structural heart diseasein fetusThe location of fetus heart and spindle were determined using the Philips IE33(PhilipsMedical System, Andover, MA) equipped with a3-8MHz transducer. And than, theprenatal echocardiographic examination including the sizes of ventricles and atriums,valves position and motion, and Doppler of the fetal heart was completed.After obtaining the signatures of informed consent of family members andapprovement from the ethics committee of the third military medical university,18heartsamples were removed from fetus (the age of pregnant women:19to38years, median age:28years; gestational week:23to33weeks, middle gestational week:27weeks) withcomplex structural heart disease from September2010to May2012, and compared with5normal fetus heart samples.The heart specimens were perfusion-fixed with10%buffered formalin later. At thetime of autopsy, the right atrium appendage (RAA) and RV were opened along the lateralwall to the RV apex and then further along the interventricular septum to the pulmonaryvalve. The left side of the heart was similarly opened according to flow. The operativelyexcised, full-thickness artery wall and myocardial tissue from fetal heart specimens werethen studied. Sections were examined under light microscopy by H&E staining.The values were expressed as means±SD. Differences among groups were analyzedby paired t-test using SPSS19.0software. Statistical significance was reported as P <0.05for95%confidence.Results1. The RT-3DE imaging is more three-dimensional, intuitive, vivid, and clearer compared with that of2DE. Image quality of TEE is more distinct than that of TTEwheather RT-3D imaging or2D imaging. For the measurement of defect sizes, TEE is moreaccurate than TTE. Compared with the measurement of intraoperative, RT-3DE TTE wassignificant statistically (P <0.05).2. The results of prenatal echocardiography are consistent with that of anatomicpathology except one with Hypoplastic right heart syndrome (HRHS) complicating rightaortic arch and vascular ring which was missed diagnosis in fetal structural heart disease.Pathological types include10HRHS,4Tetralogy of Fallot (TOF)(1patient with persistentleft superior vena cava),2single atrium with single ventricle malformations,1completetransposition of great arteries and1endocardial cushion defect (completely endocardialcushion defect combined with persistent left superior vena cava). There are differentdegrees of abnormality in the myocardial cells and vascular wall tissue of fetuses withcomplex structural heart disease compared to that of normal fetal heart samples. Myocardialfibrosis is the most obvious in right ventricular free wall of HRHS and ventricular wall ofsingle ventricle malformations. Significant proliferation of collagen fibers was seen in thepulmonary artery of TOF. The apical myocardial cells showed muddy cytoplasm, swelling,intra-cytoplasmic stripes disappear, nucleus degenerated and the cell spaces became blurred.Left ventricular wall, right ventricular free wall and apical myocardial cells showeddegenerated cytoplasm turbidity, swelling and stripes with different degrees of disappearedof sample with complete transposition of great arteries. Different degrees of fibroiddegeneration in the ventricular tissue of complete endocardial cushion defect were alsofound, but less than that of single atrium with single ventricle malformations.Valve tissue fibroelastosis in single atrium with single ventricle malformations wasdisplayed. Besides, among the specimens of HRHS, transverse diameter and verticaldiameter of right ventricular and pulmonary artery measured values was smaller than thoseof the control group significantly (P<0.05) and tricuspid regurgitation area andregurgitation velocity was significantly greater than in the control group (P<0.05).Conclusion1. The evaluation of the structural heart disease using RT-3DE TEE in peri-operativeperiodBefore surgery, the nature and type of lesion can be confirmed accurately with RT-3DE TEE, and the function of valve and heart can be detected more effectivelycompared to RT-3D TTE. During the surgery, RT-3D TEE can provide more precise andrich cardiovascular information, and guide the operation process. After operation, RT-3DETEE can provide clear3D images and precise function indicators to assess the effect ofoperation effectively.2. Prenatal echocardiography has higher accuracy in diagnosising fetal complexstructural heart disease. The study of pathologic anatomy and histopathology confirmedthat there is obvious histopathological abnormality in many parts of the cardiac muscle orlarge blood vessels in fetal structural heart disease.