심초음파를 이용한 출생 전후 좌심실 이완 기능 변화에 대한 평가 = Echocardiographic Assessment of Left Ventricular Diastolic Function in Transitional Circulation Period

다국어 초록 (Multilingual Abstract)

Background and Objectives：During the transitional period from fetal to neonatal life, there are dramatic changesin the newborn circulation. Among these changes, the left ventricular diastolic function can be easily assessed byDoppler measurement of the mitral inflow. However, there are many physiologic and hemodynamic factors responsiblefor the mitral inflow. This study was designed to evaluate several parameters that represent the left ventricularfunction during the transitional circulation period. Subjects and Methods：Eighteen normal full-terminfants were studied by serial two-dimensional, Doppler and color flow echocardiography within 24 hours beforeand after birth, between 2 days and 6 days after birth and between 7 days and 30 days after birth). Results：Oneday after birth, the mitral valve (MV) E velocity and E/A increased (37.9±7.5 vs. 60.3±9.0 and 0.8±0.1 vs.1.1±0.1, p<0.01, respectively), but the MV A velocity, the velocity of propagation (Vp), the LV isovolumic relaxationtime (IVRT), the corrected IVRT and the tissue Doppler ventricular septum e’ and s’ did not change.Although Vp/E and a’ decreased (1.2±0.3 vs. 0.7±0.2 and 8.2±1.8 vs. 6.5±1.7, p<0.05, respectively), the E/e’and the systolic and diastolic pulmonary venous flow velocities increased after birth (6.3±1.9 vs. 11.6±2.9, and26.1±6.7 vs. 64.5±9.6, and 20.9±4.1 vs. 63.5±17.2, p<0.05, respectively). Conclusion：Increased preloadplays a key role for the increased MV E/A ratio after birth. Other unknown factors (and possibly including pericardialrestriction) may be also responsible for left ventricular diastolic function. (Korean Circulation J 2006;36:652-660)

국문 초록 (Abstract)

출생 직후 관찰되는 승모판 E/A비의 현저한 증가는 신생아의 전부하 증가가 주요 원인으로 생각되며, 출생 직후 좌심실 충만을 제한하는 어떤 요인이 작용하는 것으로 생각되며 심낭 제한의 가능성이 높은 것으로추측된다. 그러나 이러한 가설은 출생 전후 발생하는 다른 여러 심 폐 요소들의 변화 등을 고려하지 않은 것이어서 앞으로보다 많은 연구를 통해 승모판 E/A비 증가의 원인이 규명되어야 할 것으로 생각된다.요 약배경 및 목적：태아기에서 신생아기로 이행하는 시기에는 신생아의 순환기에 현저한 변화가 발생한다. 이러한 변화 중 좌심실의이완 기능은 승모판의 혈류를 도플러로 측정함으로써 쉽게파악할 수 있다. 그러나 좌심실의 기능변화 이외의 많은 생리적, 혈역학적 변수들이 승모판 혈류에 영향을 미친다. 이에 본 연구는 출생 전후 승모판의 혈류 분석과 동시에 좌심실부하와 이완 기능을 시사하는 다른 지표를 조사하여 이 기간의 좌심실 기능 변화에 대해 좀더 자세한 자료를 얻고자하였다.방 법：18명의 신생아에 대해 연속적으로(출생 하루 전, 출생 후Fig. 6. The change of pulmonary vein folw velocity waveform. Systolicand diastolic pulmonary venous flow velocities increased significantlyafter birth.Systolic velocity of pulmonary vein010 20 30 40 50 60 70 8090Fetal D1 D2-D6 D>7Day of examinationcm/sec.ADiastolic velocity of pulmonary vein flow010 2300 405060 7080 90100Fetal D1 D2-D6 D>7Day of examinationcm/sec.BJoon-Seok Hong, et al：Left Ventricular Diastolic Function from Fetus to Neonate·65924시간 이내, 생후 2~6일 사이, 생후 7일에서 1개월 사이)심초음파 검사를 시행하였다.
결 과：
출생 전 검사와 비교하였을 때 생후 1일 검사에서 승모판
의 E파 높이와 E/A 비는 유의하게 상승하였다(37.9±7.5 vs.
60.3±9.0, and 0.8±0.1 vs. 1.1±0.1, p<0.01, respectively).
그러나 승모판의 A파 높이, 초기 확장기 좌심실 혈류 전파
속도(Vp)와 좌심실 등용적 이완기(IVRT) 및 심박수로 교정
한 IVRTc(IVRT/ RR interval), 초기 승모판륜 속도(e ’)와
수축기 심근 수축속도(s ’)는 출생 전후에 큰 변화가 없었다.
Vp/E 비와 후기 승모판륜 속도(a ’)는 출생 전 검사보다
생후 1일 검사에서 유의하게 감소하였다(1.2±0.3 vs. 0.7±
0.2 and 8.2±1.8 vs. 6.5±1.7, p<0.05, respectively). 그러
나 E/e ’와 수축기 및 이완기의 이완기의 폐 정맥 혈류 속도
도 출생 전 검사보다 생후 1일 검사에서 유의하게 상승하였다
(6.3±1.9 vs.11.6±2.9, and 26.1±6.7 vs. 64.5±9.6, and
20.9±4.1 vs. 63.5±17.2, p<0.05, respectively).
결 론：
출생 직후 관찰되는 승모판 E/A비의 증가는 신생아의 전부
하 증가가 주요 원인으로 생각되며, 심낭의 제한 등이 출생
직후 좌심실 이완 기능에 부분적인 역할을 하는 것으로 추
측된다.

참고문헌 (Reference)

• 1 "Use ofValsalva maneuver to unmask left ventricular diastolic functionabnormalities by Doppler echocardiography in patients withcoronary artery disease or systemic hypertension" 68 : 515-519, 1991
• 2 "Transesophagealecho-Doppler echocardiographic assessment of pulmonaryvenous flow patterns" 4 : 457-64, 1991
• 3 "Tissue Doppler image-derivedmyocardial performance(Tei Index)as a simple assessment ofglobal cardiac function in adults" 35 : 315-321, 2005
• 4 "The usefulness of Doppler tissue image in evaluationof left ventricular systolic and diastolic dysfunction" 32 : 99-105, 2002
• 5 "The neonatal transitionalcirculation:a combined noninvasive assessment" 9 : 29-37, 1992
• 6 "Serialechocardiographic and Doppler evaluation of left ventricularsystolic performance and diastolic filling in premature infants" 54 : 169-180, 1999
• 7 "Relation of transmitral flowvelocity patterns to left ventricular diastolic function:new insightsfrom a combined hemodynamic and Doppler echocardiographicstudy" 12 : 426-40, 1988
• 8 "Referencecharts of gestation-specific tissue Doppler imagingindices of systolic and diastolic functions in the normal fetalheart" 150 : 750-755, 2005
• 9 "Quantitative assessmentof right ventricular function using Doppler tissue imagingin fetuses without heart failure" 36 : 652-, 2006
• 10 "Pulsed wave Doppler tissueechocardiography assessment of the long axis function of theright and left ventricles during the early neonatal period" 90 : 175-180, 2004
• 11 "Nongeometricquantitative assessment of right and left ventricular function:myocardial performance index in normal children and patientswith Ebstein anomaly" 11 : 849-856, 1998
• 12 "Influence of heart rate on left ventricular isovolumicrelaxation time:a Doppler study in healthy newborns" 17 : 330-331, 2004
• 13 "Impact of dardiac growthon Doppler tissue imaging velocities:a study in healthy children" 17 : 212-221, 2004
• 14 "From ‘Emax’ to pressure-volume relations:a broader view" 77 : 1203-12, 1988
• 15 "Efficiency of leftventricular diastolic function increases in healthy full-terminfants during the first months of life:a prospective follow-upstudy" 57 : 49-59, 2000
• 16 "Effects ofpostural changes on cardiac function in healthy subjects" 4 : 196-201, 2003
• 17 "Effect of heart rate onleft ventricular diastolic filling patterns assessed by Dopplerechocardiography in normal infants" 76 : 634-636, 1995
• 18 "Echocardiographic indices associated with left ventricular enddiastolicpressure" 32 : 872-877, 2002
• 19 "Dynamicdeterminants of left ventricular diastolic pressure-volume relationsin man" 51 : 317-23, 1975
• 20 "Doppler flowparameters of left ventricular filling in infants:how long doesit take for the maturation of the diastolic function in a normalleft ventricle to occur?" 25 : 482-491, 2004
• 21 "Doppler evaluationof left and right ventricular diastolic function:a technical guidefor obtaining optimal flow velocity recordings" 10 : 271-292, 1997
• 22 "Doppler echocardiographic evaluation of left ventricularoutput and left ventricular diastolic filling changes in the firstday of life" 35 : 506-9, 1994
• 23 "Diastolic ventricularfunction in children:a Doppler echocardiographic studyestablishing normal values and predictors of increased ventricularend-diastolic pressure" 73 : 616-628, 1998
• 24 "Development of left ventricular systolic and diastolic functionin preterm infants during the first month of life:a prospectivefollow-up study" 139 : 539-545, 2001
• 25 "Changes in the pulmonarycirculation during birth-related events" 27 : 372-8, 1990
• 26 "Canadian consensusrecommendations for the measurement and reporting of diastolicdysfunction by echocardiography:from the Investigatorsof Consensus on Diastolic Dysfunction by Echocardiography" 9 : 736-760, 1996
• 27 "Assessment of mitral annulusvelocity by Doppler tissue imaging in the evaluation of left ventriculardiastolic function" 30 : 474-480, 1997
• 28 "Assessment of left ventriculardiastolic pressures with pulmonary venous flow andtransmitral inflow by Doppler echocardiography" 27 : 312-317, 1997
• 29 "Are contraction andrelaxation coupled in patients with and without congestive heartfailure" 2132-9, circulation1992
• 30 "A practicalguide to assessment of ventricular diastolic function using Dopplerechocardiography" 27 : 1753-1760, 1996