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§¸nh gi¸ chøc n¨ngthÊt tr¸i b»ng siªu ©m
Doppler tim
TS.NguyÔn thÞ thu hoµI
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Rèi lo¹n chøc n¨ng thÊt tr¸i: biÕnchøng thêng gÆp ë c¸c bn TM.
HËu qu¶: Suy tim, RL nhÞp tim, tö vong.
Siªu ©m tim lµ ph¬ng ph¸p th¨m dß
h÷u Ých ®Ó ®¸nh gi¸ CNTT, gióp chochÈn ®o¸n vµ tiªn lîng bÖnh ®îc chÝnhx¸c.
Më ®Çu
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1955 - Inge Edler: lÇn ®Çu tiªn nghiªn cøu®¸nh gi¸ chøc năng thÊt tr¸i b»ng siªu
©m A-mode vµ M-mode.
1966 - Harvey Feigenbaum: ®o chøc
năng thÊt tr¸i trªn siªu ©m M-mode víic¸c tÝn hiÖu tõ v¸ch liªn thÊt.
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1976 - Harvey Feigenbaum: ®¸nh gi¸
CNTT trªn siªu ©m M-mode víi thêi gianthùc (real-time).
KQ thu ®îc tõ ph¬ng ph¸p nµy cã t¬ng
quan chÆt chÏ víi ph¬ng ph¸p chôp
buång thÊt tr¸i.
H¹n chÕ: siªu ©m M-mode chØ gióp kh ¶o s¸t kÝch th-
íc ngang cña thÊt tr¸i, kh«ng kh ¶o s¸t ®îc chÝnh
x¸c däc theo chiÒu dµi cña t©m thÊt .
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1974 – 1978: ®Çu dß siªu ©m ®îc c¶i tiÕn
nhiÒu -> gióp quan s¸t h/¶ siªu ©m 2D theo
thêi gian thùc víi gãc 90 ®é -> quan s¸t ®-
îc kh¸ ®Çy ®ñ c¸c cÊu tróc cña tim.
-> tÝnh to¸n ®îc CNTT trªn siªu ©m TM.
Nhîc ®iÓm: Siªu ©m M-mode kh«ng ®¸nh gi¸ ®îcchÝnh x¸c thÓ tÝch cña buång thÊt, nhÊt lµ trong truênghîp TT bÞ biÕn d¹ng (NMCT).
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Nh÷ng n¨m 1980: Ra ®êi c¸c ph¬ngph¸p tÝnh thÓ tÝch thÊt tr¸i theo thiÕt
diÖn vµ chiÒu dµi: Simpson, Cubed…
§é chÝnh x¸c cao khi so s¸nh víi c¸cph¬ng ph¸p tiªu chuÈn vµng: chôp
buång tim, x¹ h×nh c¬ tim
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Siªu ©m DopplerHiÖu øng Doppler:
1884 - Johan Christian Doppler
Ph¬ng tr×nh® é n g h ä cc h Ê t l á n gBernou l l ie :chªnh lÖch
¸p lùc gi÷a 2v Þ t r Ý c Ç nq u a n s ¸ t .
(J Am Coll Cardiol 2006;48: 2012 – 25)
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Siªu ©m Doppler
§¸nh gi¸ CN t©m thu TT: CO, PET, ET,IVCT, VTI (LVOT)…
§¸nh gi¸ CN t©m tr¬ng TT: dßng ch¶y
VHL, dßng ch¶y TMP, IVRT...
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Siªu ©m Doppler m« c¬ tim
1989- Isaac: Siªu ©m Doppler m« xungc¬ tim.
1994- Surtherland: SA Doppler m« mµu
M-mode vµ 2D2000- JD’hood: Doppler søc c¨ng c¬tim (strain vµ strain rate)
Speckle tracking imaging- STI
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®¸nh gi¸ chøc n¨ngt©m thu thÊt tr¸i
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§¸nh gi¸ CN t©m thu TTtrªn siªu ©m TM
-Kho¶ng c¸ch E-VLT
-% co ng¾n sîi c¬:
Dd – Ds
Dd
-Ph©n sè tèng m¸u EF
Vd – Vs
Vd
V= 7D3 /(2,4+D)
EF =
% D =
¸ ¸
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§¸nh gi¸ CN t©m thu TTtrªn siªu ©m TM
¸ ¸ ©
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§¸nh gi¸ CN t©m thu TTtrªn siªu ©m TM
¸ ¸ ©
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§¸nh gi¸ CN t©m thu TTtrªn siªu ©m TM
¸ ¸ ©
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§¸nh gi¸ CN t©m thu TT
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PH¬ng ph¸p simpson
Nguyªn lý : ThÓ tÝch h×nh lín b»ng tæng thÓ tÝch cñac¸c h×nh nhá ®îc chia ra tõ h×nh lín theo trôc däc.Buång TT ®îc chia thµnh nh÷ng h×nh trô (vïng th©n
thÊt tr¸i), vïng mám ®îc coi nh h×nh ellip.
20
V= (h d2/4)
1
V: ThÓ tÝch TT
h: ChiÒu cao cña
mét khèi nhá.
d: §K cña mét
khèi nhá
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PH¬ng ph¸p simpson
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PH¬ng ph¸p simpson
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Siªu ©m 3DNguyªn lý ban ®Çu: t¸I t¹o h×nh ¶nhdùa trªn c¸c h×nh 2D thµnh phÇn.
Siªu ©m 3D thêi gian thùc: cïng métlóc, ®Çu dß ( > 3000 tinh thÓ) thu nhËn ®-îc c¸c d÷ liÖu 3 chiÒu, víi h×nh ¶nh tim®ang co bãp, tõ bÊt cø gãc quÐt nµo.
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Siªu ©m 3D
Am Heart J;130: 812-22Am Heart J;130: 812-22
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Siªu ©m 3D
Circulation 2005 112: 1161 - 1170
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Cung lîng timCO = VTI ®mc x (d/2) 2 x x tÇn sè tim
HoÆc
CO = SV x tÇn sè tim
CO: lîng m¸u b¬m vµo hÖ thèng TH
trong 1 ®v thêi gian.иnh gi¸ CN t©m thu TT : bÖnh van tim,bÖnh c¬ tim, bÖnh m¹ch vµnh, RL huyÕt
®éng.
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C¸c thêi kho¶ng t©m thu
C¸c yÕu tè ¶nh hëng:
TS tim, AL t©m tr¬ng §MC, dÉn truyÒn ®iÖnhäc trong thÊt.
Thêi gian tiÒn tèng m¸u
PET
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C¸c thêi kho¶ng t©m thu
C¸c yÕu tè ¶nh hëng:
TS tim, tiÒn g¸nh, hËu g¸nh
Thêi gian tèng m¸u
herkules.oulun.fi
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Tèc ®é t¨ng ¸p lùc thÊt tr¸I tèi ®a( +dP/dt)
+dP/dt > 1200 mmHg/s: CNTTTT b×nh thêng
+dP/dt 800 – 1200 mmHg/s: CNTTTT gi¶m nhÑ ®Õn võa
+dP/dt < 800 mmHg/s: CNTTTT gi¶m nÆng
Circulation 1989;80;1287-1292 ECHOCARDIOGRAPHY Vol. 24, No. 5, 2007
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Siªu ©m Doppler m« c¬ tim
Am J Cardiol 1989; 64: 66-75
V(S): ph¶n ¸nh CN t©m thu TT BT: V(S) > 9cm/s
V(S) gi¶m: RLCN t©m thu TT, tuæicao.
Cã mèi t¬ng quan tuyÕn tÝnh chÆtchÏ víi EF, +dP/dt
V(S) gi¶m ®I khi cã
thiÕu m¸u c¬ tim côcbé, t¨ng lªn sau t¸I t-í i m ¸ u § M V
S
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®¸nh gi¸ chøc n¨ng t©m thutõng vïng thÊt tr¸i
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Ph©n vïng thÊt tr¸I theo héi Siªu ©m Hoa kú
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Siªu ©m c¶n ©m
European Heart Journal 2008; 29: 299-314
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Siªu ©m Doppler xung m« c¬ tim
Pulsed TDI
S
E
A
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Sù ph©n bè mµu cho thÊy thµnh bªn thÊt tr¸i co bãp muén ( thêigian ®îc x¸c ®Þnh dùa vµo c¸c thêi ®iÓm ®ãng van §MC vµ VHL)
theo dâi vËn ®éng m« c¬ tim(Tissue tracking - TT)
× ¶ å é «
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TSI TT
Thµnh bªn TT cã thêi gian ®at vËn tèc tèi ®a kÐo dµi
t¹o h×nh ¶nh ®ång bé m« c¬ tim
(Tissue Synchronyzation Imaging -TSI)
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4D Tissue Synchronyzation Imaging -TSI
Vïng tríc v¸ch (®á) co bãp muén
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Bax et al JACC 2004 44 1
Strain Rate imaging
B×nh thêng MÊt ®ång bé
Siªu ©m Doppler m« cã m· ho¸ mµu (color coded TDI) møc ®é cobãp tõng vïng c¬ tim.
Tù ®éng tÝnh to¸n chªnh lÖch vÒ vËn tèc gi÷a c¸c vïng c¬ tim, biÓu
diÔn theo TG.
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Theo dâi vËn ®éng m« c¬ tim d¹ng ®èm
(Speckle tracking imaging -STI)
(J Am Coll Cardiol 2006;48:2012 – 25)
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Theo dâi vËn ®éng m« c¬ tim d¹ng ®èm 3D
(3d Speckle tracking imaging – 3DSTI)
Echocardiography, Volume 25, November 2008 p 1167-71
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®¸nh gi¸ chøc n¨ngt©m tr¬ng thÊt tr¸i
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§¸nh gi¸ chøc n¨ng t©m tr¬ngthÊt tr¸i
Siªu ©m TM
Thêi gian gi·n ®ång thÓ tÝch VËn ®éng trong th× t©m tr¬ng cña thµnhsau §MC
Dèc t©m tr¬ng cña van hai l¸ (dèc EF) Kho¶ng c¸ch AC cuèi t©m tr¬ng khi vanhai l¸ ®ãng
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§¸nh gi¸ chøc n¨ng t©m tr¬ngthÊt tr¸i
Siªu ©m TM
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Tû lÖ E/A
Thêi gian gi¶m tèc sãng A
Thêi gian gi·n ®ång thÓ tÝch
Siªu ©m doppler dßng ch¶y vhl
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§Ønh E
Thêi gian gi¶m tècsãng E
§Ønh A
Thêi giansãngA
Siªu ©m Doppler dßng ch¶y VHL
dßng ch¶y qua VHl
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dßng ch¶y qua VHl
B×nh thêng
Gi¶m ®µn håiH¹n chÕ
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Sãng t©m thu.
Sãng t©m tr¬ng.
Dßng trµo ngîc cña nhÜ tr¸i.
Dßng ch¶y tÜnh m¹ch phæi
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S
D
S
D
Dßng ch¶y TM phæi
Khi vËn tèc sãng S < 40% vËn tèc sãng D
-> cã t¨ng ¸p lùc nhÜ tr¸i.
Kh«ng ¸p dông ®îc ë BN rung nhÜ.
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Tèc ®é lan truyÒn cña dßng ®æ ®Çy ®Çut©m tr¬ng (Vp)
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Siªu ©m Doppler m« c¬ tim
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Samer J. Khouri,
(J Am Soc Echocardiogr2004;17:290-7.)
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®¸nh gi¸ chøc n¨ngtoµn bé thÊt tr¸I
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ChØ sè Tei ( Tei - index )
Chuwa Tei - n¨m 1995
ChØ sè Tei (Tei index), chØ sè chøc n¨ng c¬tim (Index of Myocardial Performance)
Ph¬ng ph¸p ®o:
TG gi·n ®ång thÓ tÝch + TG co ®ång thÓ tÝch
Thêi gian tèng m¸u ChØ sè Tei =
®¸nh gi¸ chøc n¨ng toµn bé thÊt tr¸i
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®¸nh gi¸ chøc n¨ng toµn bé thÊt tr¸ib»ng chØ sè Tei
Õ
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Cïng víi sù ph¸t triÓn cña c¸c kü thuËtth¨m dß SA vµ kü thuËt vi xö lý, SA Doppler
tim ngµy cµng chøng tá lµ mét ph¬ng ph¸pcã ®é tin cËy cao, kh«ng x©m nhËp, ®Ó ®¸nhgi¸ chÝnh x¸c t×nh tr¹ng huyÕt ®éng, chøc
n¨ng t©m thu vµ t©m tr¬ng thÊt tr¸i toµn bévµ tõng vïng ë c¸c bÖnh nh©n tim m¹ch.
KÕt luËn
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