The Echocardiography Quantitative Analysis And Clinical Evaluation Of Atrial Septal Defect With Normal Pulmonary Artery Pressure And Right To Left Shunt

Objective： To understand the right to left shunt in atrial level from simplesecundum atrial septal defect by echocardiography quantitative analysis,and evaluaterelevant factors which may be have the clinical significance.Methods： First,20patients of simple secundum atrial septal defect(ASD)diagnosed by echocardiography and suspected right to left shunt during May2013-2014April in our hospital had been collected. By TTE(transthoracicechocardiography) in the apical four-chamber view raw right heart contrastechocardiography,to clear the positive rate of right to left shunt in the times of calmbreathing、Valsalva movement and coughing phase, and then based on the test resultsthe20cases of simple secundum atrial septal,according to whether the patients hadright to left shunt and pulmonary hypertension,were divided into four groups: group1(healthy people,n=10); group2(simple secundum atrial septal defect no pulmonaryhypertension and no right to left shunt,n=5); group3(simple secundum atrial septaldefect with pulmonary hypertension and no right to left shunt, n=9); group4(simplesecundum atrial septal defect with pulmonary hypertension and right to left shunt, n=6).By TTE to check the above cases,First we measured all facets of missing atrialseptal defect diameter by using two-dimensional and color Doppler ultrasound,andfound out the maximum; secondly,in the conventional two-dimensional Dopplerultrasound we measured RVEF(right ventricular ejection fraction), TAPSE(tricuspidannular plane systolic excursion), aortic root diameter (A), pulmonary artery (P) and theratio between the two,the longer right atrial diameter,RVEDA(right ventricularend-diastolic area), RVESA(right ventricular end-systolic area), and then calculated theRVFAC(right ventricular fractional area change)=(RVEDA-RVESA)/RVEDA.Wecollected IVCT(isovolumetric contraction time)、IVRT(isovolumic relaxation time)、ET(ejection time)at RVW(right ventricular free wall) by tissue Doppler ultrasound, andthen calculated RIMP (right ventricular index of myocardial performance)=(IVCT+IVRT)/ET, namely Tei index.Results:1.The result of echocardiography microbubble contrast examination displayed thatthe right to left shunt had the highest positive rate (75%)by the Valsalva maneuverfollowed by quiet breathing state (70%).2.The difference of four groups in clinical datacompared with group1,the age of group4increased significantly (P <0.05);group2compared with group3、group4,the duration had statistical difference (P <0.05).3.The comparison of ultrasound-related indicators among the four groups(1)To compare the maximum of the missing diameter,group2、group3,、group4-pairwise comparison were significantly different(P<0.05),in group4were significantlyhigher.(2)Group1, group2, group3compared with group4, aortic root diameter (A)/pulmonary artery (P)was significantly different,and pair-wise comparison had notstatistically significant (P>0.05); four groups of the mean of longer right atrial diametergradually increased, the longest of all was group4.(3)Groups2、3compared with group4, PASP was significantly increased (P (4)Group1、group2compared with group3, group4,Tei index was significantlydifferent (P <0.05).Compared with group1、2、3,IVCT、IVRT of the group4weresignificantly longer,ET of group4was significantly shorter. IVRT, IVCT of four groupshad a gradually extend trend, ET had a shorting trend.(5)Compared with group4, RVEF, RVFAC, TAPSE of group1、2、3wereobviously reduced(P <0.01).4.Correlation and regression analysis of right to left shunt in atrial levelsTei index, PASP with other indicators (TAPSE, A/P, the longer right atrialdiameter, the largest missing diameter,RVEF, RVFAC) had good correlation, betweenthe two indicators also had a positively correlation (r=0.6, P <0.05).The longer rightatrial diameter was positively correlated with the maximum missing diameter (r=0.775,P <0.05), the correlation between longer right atrial diameter、 the largest missingdiameter and RVEF、 RVFAC were r=-0.7（P <0.05). Tei index、TAPSE、 A/P、thelonger right atrial diameter、 the largest missing diameter、RVEF、 RVFAC、 PASP allcan affect the shunt direction in atrial level.Regression analysis showed that theseindicators were not affected right to left shunt in atrial level as an independent factor.Conclusion:1.Right heart contrast echocardiography is the most common method to judge rightto left shunt of atrial septal defect in atrial level,which has a higher accuracy andsensitivity. During the times of calm breathing, Valsalva movement, coughing,Valsalvaproduced the highest positive rate.2.Pulmonary hypertension and Tei index, the longer right atrial diameter, thelargest missing diameter, TAPSE, RVEF, RVFAC, aortic diameter (A)/pulmonaryartery (P)had good correlation, but was not the independent indicators.3.When PASP is normal, the increase of the longer right atrial diameter, the largestmissing diameter、Tei index and the decline of aortic diameter (A)/pulmonary artery(P) ratio, TAPSE, RVEF were all the factors of affecting whether right to left shunt inatrial level is absent, but were all not independent indicators.These can be used asindicators of comprehensive assessment of shunt direction in atrial level. The longer right atrial diameter was positively correlated with the maximum missing diameter, thelonger right atrial diameter,and the largest missing diameter had negatively correlationwith RVEF、 RVFAC.4.The extend of Tei index is an early sensitive indicators to assess right ventricularsystolic and diastolic dysfunction, specifically the extend of isometric contraction(IVCT) and isovolumic relaxation (IVRT)and the short of ejection period (ET), the totalisovolumic time (IVRT+IVCT) was prolonged, which IVRT had the most obviouslyextension.5.The secundum atrial septal defect patients who had been found right to left shuntin atrial level by right heart contrast echocardiography,while color Doppler displayedonly the left-to-right shunt,could be to surgery.But these patients need to give activelyanticoagulant therapy, closely followed up,to prevent the migraine of embolismperformance.