The Diagnostic Value of Dual-source CT in Adult Atrial Septal Defect with Pulmonary Hypertension
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摘要:
目的：探讨双源CT评价成人房间隔缺损（ASD）合并肺动脉高压（PAH）的诊断价值。方法：回顾性分析我院75例成人ASD患者，根据右心导管（RHC）检查术所得肺动脉平均压（mPAP）是否≥25 mmHg分为PAH组（40例）和无PAH组（35例）。所有患者均在术前1周内行DSCT先天性心脏病检查，测量升主动脉直径（AAD）、主肺动脉直径（MPAD）、右肺动脉干直径（RPAD）、左肺动脉干直径（LPAD）、右下肺动脉直径（RLPAD）、双心室短轴最大内径（RVD、LVD）、脊柱室间隔夹角、ASD直径，计算MPAD与AAD比值（rPA）、RVD与LVD比值（RVD/LVD）。采用t检验评价两组患者临床资料、RHC检查指标、CT心血管参数差异；使用ROC曲线确定双源CT对成人ASD合并PAH的诊断效能；使用Pearson等级相关系数分析CT参数与mPAP、PVR的相关性。结果：两组间差异有统计学意义的CT指标有MPAD、RPAD、LPAD、RLPAD、RVD、脊柱室间隔夹角、rPA、RVD/LVD、ASD直径，其中RPAD、LPAD、脊柱室间隔夹角、rPA、RVD/LVD、ASD直径对PAH具有中等强度的诊断效能（AUC均>0.7）；MPAD、rPA、ASD直径与mPAP呈中度正相关，MPAD、rPA、RVD/LVD与PVR呈中度正相关，ASD直径与PVR呈高度正相关。结论：双源CT对成人ASD合并PAH具有一定的诊断价值，可以为临床治疗前综合评估、长期随访与管理提供较好的依据。
Abstract:Objective: To investigate the diagnostic value of dual-source CT (DSCT) in evaluating adults with atrial septal defect (ASD) with pulmonary hypertension (PAH). Methods: Seventy-five adult patients with ASD in our hospital were retrospectively analyzed. The study sample was divided into 2 groups (PAH group (n=40) and non-PAH group (n=35 cases)) according to the mean pulmonary artery pressure (mPAP) obtained by right cardiac catheterization (RHC) (PAH: ≥ 25 mmHg). All patients were examined for congenital heart disease by DSCT one week before RHC. The ascending aorta diameter (AAD), main pulmonary artery diameter (MPAD), right pulmonary artery diameter (RPAD), left pulmonary artery diameter (LPAD), right lower pulmonary artery diameter (RLPAD), the maximum diameter of the short axis of both the ventricles (RVD, LVD), included the angle of the spinal ventricular septum and ASD diameter, were measured on the image. The MPAD to AAD ratio (rPA) and the RVD to LVD ratio (RVD/LVD) were calculated. Differences between the two groups in terms of clinical data, RHC indexes, and CT cardiovascular parameters were evaluated by a t-test. The ROC curve was used to determine the diagnostic efficacy of DSCT in adults with ASD and PAH. Pearson correlation coefficient was used to analyze the association between the CT parameters, mPAP, and PVR. Results: The statistically significant CT indexes between the two groups were MPAD, RPAD, LPAD, RLPAD, RVD including the angle of the spinal ventricular septum, rPA, RVD/LVD, and ASD diameter. Of these, the RPAD and LPAD including the angle of the spinal ventricular septum, rPA, RVD/LVD, and ASD diameter demonstrated moderate diagnostic efficacy for PAH (AUC>0.7). The MPAD, rPA, and ASD diameter with mPAP were moderately positively correlated. The MPAD, rPA, and RVD/LVD with PVR were also mildly positively correlated. Furthermore, the ASD diameter and PVR were highly positively correlated. Conclusion: DSCT is diagnostically valuable for the evaluation of adults with ASD complicated with PAH. In particular, DSCT may be used to provide a comprehensive evaluation before clinical treatment, as well as for long-term follow-up and management.
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图 1 女，57岁，ASD合并PAH，mPAP=41.0 mmHg
Figure 1. Female, 57 years old, atrial septal defect with pulmonary hypertension, mPAP=41.0 mmHg
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图 2 女，57岁，ASD不合并PAH，mPAP=16.0 mmHg
Figure 2. Female, 57 years old, atrial septal defect without pulmonary hypertension, mPAP=16.0 mmHg
表 1 两组间临床基线资料及RHC指标比较
Table 1 Comparison of clinical baseline data and right heart catheterization indexes between the two groups
项目 组别 P 无PAH组（n=35） PAH组（n=40） 年龄/岁 40.49±16.99 44.68±12.28 0.22 男性/（n，％） 11.00（31.43） 10.00（25.00） 0.54 BSA/m2 1.65±0.11 1.67±0.14 0.59 NYHA分级 <0.05 Ⅰ～Ⅱ级（n，％） 35.00（100.00） 31.00（77.50） Ⅲ～Ⅳ级（n，％） 0.00（0.00） 9.00（22.50） PASP/mmHg 38.03±12.78 50.85±20.76 <0.05 PADP/mmHg 16.12±6.80 20.98±8.80 <0.05 mPAP/mmHg 17.97±2.75 34.00±11.08 <0.05 PVR（Wood） 1.38±0.67 5.70（3.24～15.12） <0.05 
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表 2 两组间CT心血管参数测量值比较
Table 2 Comparison of CT cardiovascular parameters between the two groups
心血管参数 组别 P 无PAH组（n=35） PAH组（n=40） AAD 28.91±4.74 28.41±4.81 0.652 MPAD/mm 31.14±6.27 36.34±8.52 <0.05 RPAD/mm 23.66±5.28 27.91±6.23 <0.05 LPAD/mm 23.05±5.24 27.30±5.84 <0.05 RLPAD/mm 14.24±2.78 16.49±3.75 <0.05 RVD/mm 43.22±9.72 48.43±8.75 <0.05 LVD/mm 35.97±5.77 34.87±7.89 0.499 脊柱室间隔夹角/° 51.93±12.83 61.87±11.68 <0.05 rPA 1.08±0.18 1.31±0.38 <0.05 RVD/LVD 1.21±0.24 1.43±0.29 <0.05 ASD直径/mm 17.28±4.43 24.95±5.32 <0.05
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表 3 CT心血管参数预测PAH的ROC曲线分析
Table 3 ROC curve analysis of CT cardiovascular parameters predicting PAH
心血管参数 AUC值（95％CI） P 截断值 敏感度/％ 特异度/％ 约登指数 MPAD/mm 0.68（0.55～0.80） <0.05 35.00 0.58 0.74 0.32 RPAD/mm 0.71（0.59～0.83） <0.05 21.95 0.88 0.51 0.39 LPAD/mm 0.72（0.60～0.83） <0.05 23.50 0.80 0.60 0.40 RLPAD/mm 0.68（0.56～0.81） <0.05 16.95 0.45 0.91 0.36 脊柱室间隔夹角/° 0.72（0.61～0.84） <0.05 63.35 0.53 0.86 0.38 rPA 0.70（0.58～0.82） <0.05 1.20 0.63 0.83 0.45 RVD/LVD 0.71（0.59～0.82） <0.05 1.22 0.83 0.51 0.34 ASD直径/mm 0.85（0.77～0.93） <0.05 22.32 0.68 0.89 0.56
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表 4 mPAP与CT心血管测量参数相关性分析
Table 4 Correlation analysis of mPAP and CT cardiovascular measurement parameters
心血管参数 r P MPAD/mm 0.51 <0.05 RPAD/mm 0.45 <0.05 LPAD/mm 0.44 <0.05 RLPAD/mm 0.47 <0.05 脊柱室间隔夹角/° 0.36 <0.05 rPA 0.61 <0.05 RVD/LVD 0.47 <0.05 ASD直径/mm 0.62 <0.05
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表 5 PVR与CT心血管测量参数相关性分析
Table 5 Correlation analysis of PVR and CT cardiovascular measurement parameters
心血管参数 r P MPAD/mm 0.56 <0.05 RPAD/mm 0.48 <0.05 LPAD/mm 0.47 <0.05 RLPAD/mm 0.44 <0.05 脊柱室间隔夹角/° 0.39 <0.05 rPA 0.63 <0.05 RVD/LVD 0.52 <0.05 ASD直径/mm 0.81 <0.05
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表 6 CT心脏参数测量值相关性分析
Table 6 Correlation analysis of CT cardiac parameter measurements
相关系数 RVD LVD RVD/LVD 脊柱室间隔夹角 RVD 1.00 LVD 0.49** 1.00 RVD/LVD 0.45** -0.06 1.00 脊柱室间隔夹角 0.52** -0.47** 0.50** 1.00 注：**-在0.01级别（双尾），相关性显著。
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