Zastosowanie techniki śledzenia markerów akustycznych w ocenie funkcji lewej komory serca. Badania in vivo i in vitro

Olszewski, R.

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Tytuł artykułu

Zastosowanie techniki śledzenia markerów akustycznych w ocenie funkcji lewej komory serca. Badania in vivo i in vitro

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Olszewski R.

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IPPT_Reports_2012_2_R_Olszewski_online_24_October_2012.pdf

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Warianty tytułu

Application of speckle tracking echocardiography in the assessment of left ventricular function. In vivo and in vitro studies

Języki publikacji

Abstrakty

W ciągu ostatniej dekady echokardiografia stała się podstawową metodą obrazowania diagnostycznego serca i naczyń. Szerokie zastosowanie echokardiografii jest możliwe dzięki jej dwóm podstawowym cechom: łatwej dostępności i nieinwazyjności. Otrzymywany w czasie rzeczywistym obraz ultrasonogra?czny doskonale odzwierciedla dynamiczną funkcję serca. Dwuwymiarowa echokardiogra?a (2D) stała się potężnym narzędziem do ciągłego monitorowania rozwoju dysfunkcji mięśnia i chorób serca. Ponadto echokardiogra?a 2D jest metodą relatywnie niedrogą, mającą zastosowanie zarówno w pracowni, jak i bezpośrednio przy łóżku chorego. Echokardiogra?a 2D jest integralną częścią nowoczesnej kardiologii służącą zarówno do oceny wymiarów, funkcji serca, jak również w diagnostyce różnicowej. Skurczowa i/lub rozkurczowa dysfunkcja lewej komory (LK) serca jest cechą charakterystyczną dla większości chorób serca. Jednakże echokardiograficzna ocena LK napotyka również na wiele ograniczeń; np. obrazowanie M-mode i 2D jest zależne od umiejętności osoby badającej, a obliczenia objętości i frakcji wyrzutowej opierają się na wzorach geometrycznych, które nie opisują w sposób wystarczający powiększonej czy zniekształconej w trakcie remodelingu LK. Dopplerowskie obrazowanie prędkości ruchu tkanek (DTI) jest echokardiograficzną metodą, której zastosowanie było dokładnie badane w różnych chorobach serca. Poprzez zastosowanie odpowiednich technik filtracji, poza wizualizacją przepływu krwi, stał się również możliwy pomiar prędkości ruchu tkanki, charakteryzujący się wysoką amplitudą sygnału w zakresie bardzo małych częstotliwości. Jednakże ponieważ prędkość ruchu danego obszaru mięśnia sercowego jest mierzona w stosunku do punktu odniesienia umieszczonego w głowicy ultradźwiękowej na zewnątrz klatki piersiowej, to pomiar prędkości danego obszaru techniką DTI nie jest wolny od wpływu przemieszczenia się całego mięśnia sercowego oraz od jego pociągania pasywnego przez sąsiednie segmenty. Ponadto wadą tej metody jest również zależność wartości prędkości miokardialnych od kąta padania wiązki ultradźwięków oraz niskie małe wartości prędkości w segmentach koniuszkowych. Poprawa wizualizacji wsierdzia LK przez podanie środka kontrastowego ułatwia rozpoznanie odcinkowych zaburzeń kurczliwości. Niestety, mimo to, również echokardiografia z podaniem środka kontrastującego ma pewne ograniczenia, np. konieczność uzyskania odpowiedniego okna akustycznego, ruch oddechowy płuc oraz zjawiska fizyczne, jak tłumienie sygnału ultradźwiękowego czy efekt cieniowania. Mimo rozwoju nowych metod służących poprawie jakości uzyskanego obrazu i ocenie odkształcenia mięśnia sercowego właściwa ocena funkcji LK ciągle pozostaje wyzwaniem echokardiograficznym. Technika śledzenia markera akustycznego (ang. speckle tracking - 2D-TMSA) jest ostatnio wprowadzoną techniką do precyzyjnego obliczania odkształcenia mięśnia sercowego poprzez analizę ruchu markerów akustycznych w obrazie echograficznym 2D, rutynowo uzyskanym w trakcie badania. 2D-TMSA jest metodą pozwalającą na pomiar ruchu mięśnia sercowego we wszystkich kierunkach, ponieważ jest wolna od zależności kątowej ruchu ściany i kierunku padania wiązki ultradźwiękowej. W tej technice możemy mierzyć takie parametry mięśnia sercowego, jak jego odkształcenie (strain) i prędkość odkształcenia miokardium (strain rate). Technika 2D-TMSA wyznaczania obu wielkości, odkształcenia i szybkości odkształcenia ma ograniczenia związane z przemieszczaniem się całego serca w trzech wymiarach. Wielkość odkształcenia miokardium obliczana w technice 2D-TMSA opiera się na wartościach otrzymanych w płaszczyźnie dwuwymiarowej, ignorując trójwymiarowy ruch serca (3D). Najnowsza technologia śledzenia przemieszczania się markerów akustycznych 3D-TMSA przełamuje te potencjalne ograniczenia. Cel pracy 1. Opracowanie modelu matematycznego lewej komory serca oraz numerycznego modelu wizualizacji ultrasonograficznej. 2. Stworzenie wzorca echokardiograficznego lewej komory serca do analizy różnych stanów fizjologicznych i patologicznych w nowej technice 2DTSMA. 3. Ocena zgodności prędkości ruchu środkowych segmentów lewej komory serca w technikach 2D-TSMA i MRI dla osób uprawiających wyczynowo wioślarstwo. 4. Wyznaczenie zakresu prawidłowych wartości odkształcenia ściany lewej komory serca (strain) w technice 3D-TSMA dla zdrowych osób uprawiających sport. Metody Do badania zastosowano matematyczny model ruchu "ziarna" - markerów akustycznych związany z kurczliwością lewej komory serca. Powstał on na podstawie obserwacji akcji rzeczywistego serca, obrazowanego przez ultrasonograf w projekcji poprzecznej, przymostkowej, w obrazowaniu 2D - w celu numerycznego modelowania obrazów ultrasonograficznych ścian serca, a zwłaszcza zachowania się markerów akustycznych i odkształcenia radialnego środkowych segmentów lewej komory. Do badań echokardiograficznych opracowano i zbudowano dwa wzorce lewej komory. Pierwszy wzorzec ultrasonograficzny LK (WGP) dla badania przemieszczania się markerów akustycznych w trakcie skurczu i rozkurczu oraz drugi model zawału lewej komory (WZLK). WGP został wykonany z gąbki poliuretanowej, w postaci wydrążonego walca o długości 10 cm, średnicy zewnętrznej 5 cm, średnicy wewnętrznej 3 cm i o grubości ściany 1 cm, a drugi WZLK - z materiału alkoholu poliwinylowego w postaci elastycznej rurki o długości 12 cm, grubości ściany 1 cm i średnicy zewnętrznej 5 cm. We wzorcu WZLK obszar odpowiadający dwóm segmentom poddano procesowi obróbki termicznej (suszenia), co skutkowało jego usztywnieniem. Następnie wzorce ultrasonogra?czne podłączono do komputerowo sterowanej, hydraulicznej pompy tłokowej firmy (Vivitro Inc.TM). Wzorce LK zanurzono w wodzie i badano ich odkształcenie (strain) i tempo odkształcenia (strain rate), przy zastosowaniu dostępnych komercyjnie algorytmów 2D-TMSA. Przyjęto następujące parametry: wpompowywanie objętości wody 12-50 ml z częstością cykli pracy: 40, 60, 100, 120 na minutę, dla kąta padania wiązki ultradźwiękowej 90st. i 65st. w stosunku do osi wzorca. W części klinicznej badaniu echokardiograficznemu poddano dwie grupy ochotników (n = 118). U 14 zdrowych mężczyzn w wieku 23 3,2 lat uprawiających wyczynowo wioślarstwo wykonano badanie echokardiograficzne techniką 2D aparatem ?rmy IE 33 (Philips Medical System, Andover, MA, USA) i badanie serca techniką MRI, gdzie zastosowano skaner 1,5-T MR (Simens, Erlangen, Niemcy). Prędkości radialne środkowych segmentów LK obliczano techniką 2D-TMSA w projekcji przymostkowej w osi krótkiej, podobnie jak w MRI. Dla porównania wartości prędkości uzyskanych metodą echokardiograficzną i MRI użyto liniowej regresji, analizę zgodności przeprowadzono testem Bland-Altmana. Drugą analizowaną grupę stanowiło 104 ochotników uprawiających amatorsko sport, w wieku 19-60 lat; średnia 46,6. Badania wykonywano za pomocą echokardiografu firmy Toshiba Artida, Toshiba Medical Systems, Tokio, Japonia. Stosując automatyczną trójwymiarową analizę 3D-TMSA, obliczono dla poszczególnych segmentów maksymalne wartości odkształcenia strain dla ruchupodłużnego, okrężnego, radialnego i trójwymiarowego LK. Wartości współczynnika zmienności pomiarów, de?niowanego jako iloraz odchylenia standardowego do wartości średniej pomiędzy dwoma badaczami, przedstawiono dla każdego z odkształceń. Wyniki Matematyczny model ultrasonograficznej wizualizacji jest realizacją w pełni kontrolowanego środowiska diagnostycznego. Zaproponowany matematyczny model LK w pełni opisuje odkształcenie radialne ściany modelu lewej komory, podobny do obserwowanego w sercu ludzkim. Pozwala on na testowanie obecnie dostępnych algorytmów śledzenia markerów akustycznych, jak również na ich ulepszanie. Uzyskane obrazy wzorców lewej komory doskonale naśladowały echogram LK w obrazowaniu 2D w projekcji przymostkowej w osi krótkiej. We wszystkich przypadkach pomiarów odkształcenia radialnego i okrężnego, jak również tempa odkształcenia radialnego i okrężnego, niezależnie od prędkości pracy wzorca i objętości wpompowywanej krwi, nie zaobserwowano znamiennie istotnych różnic pomiędzy seriami pomiarowymi dla dwóch kątów ustawienia głowicy ultradźwiękowej względem wzorca ultrasonograficznego. WZLK pozwala naśladować obszar LK objęty zawałem. W grupie uprawiających wyczynowo wioślarstwo uwidoczniono wszystkie 84 badane segmenty, a automatycznej analizie 2D-TMSA poddano 92% segmentów. Pozostałe 8% segmentów wymagało korekcji ręcznej. Maksymalna wartość uzyskanej prędkości ruchu środkowych segmentów dla poszczególnych segmentów LK, uzyskanych metodą 2D-TMSA, mieściła się w przedziale 3,61-5,22 cm/s. W badaniu MRI 96% segmentów analizowano automatycznie, a 4% wymagało korekcji ręcznej. Maksymalna wartość uzyskanej prędkości ruchu środkowych segmentów dla poszczególnych segmentów LK uzyskanych w MRI mieściła się w przedziale 3,48-4,94 cm/s. Uzyskane wyniki wskazują na duży poziom zgodności dla obu technik, współczynnik korelacji bliski r = 0;9. W trójwymiarowym badaniu echokardiograficznym analizie metodą 3D-TMSA poddano odkształcenie strain przy podziale LK na 16 segmentów. Spośród analizowanych segmentów 83% segmentów koniuszkowych, 87,3% środkowych i 87,5% podstawnych było poddane pełnej, prawidłowej analizie automatycznej 3D-TMSA. Średni czas badania wynosił 4,1 1,2 min. Maksymalna wartość odkształcenia radialnego segmentów podstawnych obliczona techniką 3D-TMSA była znamiennie (p < 0;001) wyższa od maksymalnej wartości odkształcenia segmentów koniuszkowych. Odkształcenia: 3D, radialne, podłużne i okrężne dla LK w technice 3D-TMSA wynosiły odpowiednio: 35,1 15,4%; 33,6 15,3%; 17,4 6,1%; 25,3 8,3%. Współczynnik zmienności pomiarów wynosił: 6% dla pomiarów odkształcenia radialnego, 8% odkształcenia okrężnego i 8,5% dla pomiarów odkształcenia podłużnego, a dla odkształcenia globalnego 3D - 4%. Wnioski 1. Opisany matematyczny model lewej komory serca w pełni odzwierciedla odkształcenia radialne ścian zachodzące w ludzkim sercu. 2. Proponowany przez autora model numeryczny wizualizacji ultrasonograficznej jest realizacją w pełni kontrolowanego środowiska diagnostycznego, opartego na różnych typach aparatów echokardiograficznych. 3. Matematyczny model lewej komory serca w opisanym środowisku wizualizacji ultrasonograficznej pozwala testować algorytmy śledzące i analizujące rozkłady markerów akustycznych, a także doskonalić istniejące algorytmy lub wspierać konstrukcje nowych. 4. Opracowane i wykonane wzorce lewej komory serca, jak i wzorzec zawału serca, wykazały w pełni ich przydatność do badań nad nową echokardiograficzną techniką 2D-TMSA. 5. Przedstawione wzorce ultrasonograficzne mogą służyć do analizy odkształceń ścian lewej komory serca zarówno w stanach fizjologicznych, jak i patologicznych. 6. Wyniki przeprowadzonych badań wskazują na przydatność zastosowanego materiału do konstrukcji lewej komory serca, czego dowodzi model zawału serca, a to z uwagi na osiągnięcie porównywalnego, radialnego przemieszczania ścian i porównywalnej wartości odkształceń niezależnie od kąta padania wiązki ultradźwiękowej. 7. Maksymalne wartości prędkości skurczowej dla środkowych segmentów lewej komory u osób uprawiających wioślarstwo, otrzymane metodą 2DTMSA, są zgodne z wartościami prędkości otrzymanymi metodą MRI. 8. Metoda śledzenia markerów akustycznych 2D-TMSA daje właściwą informację o ruchu środkowych segmentów lewej komory u osób uprawiających wioślarstwo. Jest nową, obiecującą techniką pozwalającą na szersze jej zastosowanie do analizy prędkości ruchu segmentów lewej komory w dalszych badaniach klinicznych. 9. Wykazano, że technika 3D-TMSA jest prostą metodą do wyznaczania wartości odkształcenia lewej komory serca.

The thesis reports the research report aimed at the application of speckle tracking echocardiography (TMSA) in the assessment of left ventricular function (LV). It is devoted to four particular aspects: to work out a mathematical model of the LV as well as a numerical model of ultrasonographic visualization, create an echocardiographic model of the LV enhancing the in vitro analysis of various physiological and pathological conditions, estimate the congruity of the velocity of movement for mid-segments of the LV using 2D-TMSA and magnetic MRI techniques for athletes who engage in rowing and finally, to determine the range of correct values for the LV strain in the 3D-TMSA technique for healthy subjects who engage in sports. The monograph consists of eight chapters. In the beginning the author provides the abbreviations and symbols, and next addresses the objectives and backgrounds of echocardiography and systolic function of LV. The current knowledge about Tissue Doppler, TMSA and the echocardiographic parameters of deformation like strain rate and strain in the 2D-TMSA, are described in detail in Chapters 2 and 3. Chapters 4–6 report the novel part of the research. These Chapters present the original contribution of the author. The aims of the research, methods and results are described The dedicated mathematical model of speckle displacement accompanying the ventricular contraction was also discussed. Both tracking the position of acoustic markers during cardiac cycle in the mid-segments of LV and radial strain were modeled. In Chapter 5 the description of two novel dynamic ultrasonic phantoms of the LV to imitate a beating heart is given. Next, two groups of healthy volunteers used in vivo studies are described. Chapter 6 reports the final results both for in vivo and in vitro experiments. The final Chapters 7 and 8 conclude the monograph and recapitulate the main achievements of the reported research and provide discussion of the original results.

Słowa kluczowe

ultrasonografia echokardiografia lewa komora serca markery akustyczne

echocardiography two-dimensional speckle tracking speckle modeling ultrasound phantoms ventricular systolic function strain strain rate three-dimensional speckle tracking

Wydawca

Instytut Podstawowych Problemów Techniki PAN

Czasopismo

IPPT Reports on Fundamental Technological Research

Rocznik

2012

Tom

nr 2

Strony

5--161

Opis fizyczny

Bibliogr. 364 poz.

Twórcy

autor

Olszewski R.

Bibliografia

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