좌우 심전류의 혈력학적 변화에 따르는 폐혈관상의 X선학적 고찰

Abstract

[한글]

비정상적인 심장 기능의 방사선학적 추측 방법에 있어서 과거에는 심장 윤곽의 변화, 폐부종등의 소견에만 국한되었으나, 최근 Modichsel(1948), Campbell(1951), Simon(1961)등에 의하여 폐야에서의 폐맥관 저항 증가, 죄심부전등의 소견이 기술되었고, 폐맥관상의

유용성을 강조하였다. 대체로 단순 흉부 사진상 혈력학적 변화를 특징짓는 일정한 폐맥관 변화가 있음을 쉽게 확인할 수 있으나, 혈력상태와의 양적인 상관성에 있어서는 의견이 일치되지 못하고 있다.

이 연구는 좌우 전류를 가진 선천성 심장병을 대상으로, 단순 흉부 사진상 폐맥관의 변화와 심도자술에서 측정된 혈력학치를 비교하였으며, 폐맥관상에 의거한 혈력 상태 추정의 기준에 대하여 검토하였다.

대상 및 방법

1966년부터 본 병원에서 심도자술에 의하여 단일의 좌우 전류가 확인되었고, 적당한 흉부 사진을 얻을 수 있었던, 심방 중격 결손 21명, 심실 중격 결손 34명, 개방성 동맥관 28명, 총 83명을 대상으로 하였다.

각각의 경우에는 단순 흉부 사진상 폐맥관 확장의 정도와 중심화 현상 및 우측 하강 폐동맥의 단면적을 관찰하고 심도자술상 얻은 Qp/Qs ratio, 평균 폐동맥압 및 폐맥관 저항치와 비교하였다.

성적

1. 폐맥관 저항이 정상인 경우에서 폐맥관 확장은 심방 중격 결손과 개방성 동맥관의 경우에서 Qp/Qs ratio와 유의한 연관을 찾을 수 있었는데, 정상내지 상폐야에만 다혈증이 국한된 경우와 전 폐야에 다혈증이 온 경우로 나누면 Qp/Qs ratio가 약 2:1 이하와 그

이상으로 구별될 수 있다. 심실 중격 결손의 경우는 Qp/Qs ratio에 따른 폐맥관 확장의 정도가 일정치 못하였다.

폐맥관 저항이 증가된 경우에서는 폐맥관 확장의 정도와 Qp/Qs ratio와 상관을 찾을 수 없었고, 폐맥관 확장이 같은 정도인 저항이 정상인 경우에 비해 Qp/Qs ratio가 적은 경향을 보인다.

2. 폐맥관의 중심화 현상이 있음은 폐맥관 저항의 상승을 가르키는 좋은 지침이 된다.

폐맥관 저항이 높을수록, 또는 Qp/Qs ratio가 많을수록 폐맥관의 중심화를 나타내는 경향을 보인다. 그러나 중심화의 인지율이 다만 44%이었음은 단순 흉부 사진상 좌우 전류의 혈력상태 추정에 가장 큰 장애가 될 것이다.

3. 폐동맥압은 중심화가 있을 경우 폐동맥 고혈압의 존재를 추측할 수 있으나 그외 폐동맥압의 수준을 추측할 직접적인 기준은 폐맥관상에서 찾을 수 없었다.

4. 단위 체표면적당 우측 하강 폐동맥의 단면적은 저항성 폐동맥 고혈압이 없는 심방 중격 결손과 동맥관의 경우에서 Qp/Qs ratio와 비교적 높은 상관을 보였다. 싱실 중격 결손에서는 우측 하강 폐동맥과 Qp/Qs ratio와의 사이에 유의한 상관을 찾을 수 없었다.

저항성 고혈압의 경우, 심방 중격 결손에서는 폐맥관 저항이 정상인 군에 비해 전례에서 뚜렷이 큰 우측 하강 폐동맥을 보이나 개방성 동맥관과 싱실 중격 결손의 예에서는 확실히 구별되는 차이를 보이지 않았다.

RADIOLOGICAL EVALUATION OF PULMONARY VASCULAR PATTERN CORRELATED WITH HEMODYNAMIC

CHANGES IN LEFT TO RIGHT SHUNT

KYOO OK CHOE

Department of Medical Science, The Graduate School Yonsei University

(Directed by Professor Byung Sook Choi, M.D., Chang Yun Park, M.D.)

In the early years of radiology, roentgenologic diagnosis of abnormal cardiac

function was confined to changes of the cardiac sihlouette and pulmonary edema.

Recently, Campbell(1951), and Simmon(1961) described changes of increased vascular

resistence or left heart failure in the lungs by pulmonary vascular patterns.

It is generally accepted that roentgenologic changes characteristic of

hemodynamic abberaion are usually present and can be redognized with relative ease,

but there is by no means agreement as to whether a quantitative correlation exist

between hemodynamic and roentgenologic parameters.

At the present it is the goals of this study to determine the acceptable criteria

to predict hemodynamic status in plain chest in the cases of congenital heart

disease with left to right shunt, and findings of vascular changes of the plain

chest are compared with hemodynamic datas of cardiac catheterization.

METHOD AND MATERIALS:

Plain chese x-ray were reviewed in 83 congenital heart disease with pure left to

right shunt, including 21 cases of interatrial septal defect, 34 cases of

interventricular septal defect and 28 cases of patent ductus arteriosus, confirmed

by cardiac catheterization at Severance Hospital. In each patients, the degree of

pulmonary vessel distention, centralization of pulmonary vessels and

cross-sectional area of right descending pulmonary artery per unit body surface

area were evaluate on plain chese roentgenograms and were correlated with

hemodynamic data, including Qp/Qs ratio, mean pulmonary arterial pressure and

pulmonary vascular resistence.

RESULTS:

1. When the pulmonary vascular resistence is normal, there is noted relatively

good correlation between the degree of pulmonary vessel distention and Qp/Qs ratio

in the cases of interatrial septal defect and patent ductus arteriosus. If vessel

distention is absent or limited to upper lung field, the Qp/Qs ratio is generally

less than 2:1, and if present in all lung zones, the ratio is above 2:1.

In the cases of interventricular septal defect, the pulmonary vessel distention

appears to be very variable without significant relation to Qp/Qs ratio.

When the pulmonary vascular resistence is elevated, the degree of pulmonary

vessel distention is not correlated to Qp/Qs ratio, and similarly distended vessel

have low Qp/Qs ratio compared to the vessel with normal resistence.

2. The presence of centralization of pulmonary vessel is a good index for

evidence of increased pulmonary vascular resistence. Higher Qp/Qs ratio or higher

pulmonary vascular resistence seems to have a higher probability of centralization

of pulmonary vessels. However, presence of centralization is only 44% among cases

of increased resistence so this poor result is a big barrier in this study; the

cases having resistence hypertension without centralization of pulmonary vessel

constitute the major portion of error in estimating hemodynamic changes from plain

film.

3. Pulmonary arterial hypertension is presumable present when the centralization

of pulmonary vessel is present. However, there is no direct radiologic criteria to

determine the level of pressure in left to right shunt.

4. When pulmonary vascular resistence is normal range, the cross-sectional area

of right descending pulmonary artery per unit body surface area is well correlated

with Qp/Qs ratio in the cases of interatrial septal defect and patent ductus

arteriosus, but in cases of interventricular septal defect there is no significant

correlation.

When pulmonary vascular resistence is elevated, the size of right descending

pulmonary artery is constantly larger than that of normal resistence in interatrial

septal defect. But in interventricular septal defect and patent ductus arteriosus,

no apparent difference in size of right descending pulmonary artery whether the

resistence is normal or elevated.

[영문]

In the early years of radiology, roentgenologic diagnosis of abnormal cardiac function was confined to changes of the cardiac sihlouette and pulmonary edema.

Recently, Campbell(1951), and Simmon(1961) described changes of increased vascular resistence or left heart failure in the lungs by pulmonary vascular patterns.

It is generally accepted that roentgenologic changes characteristic of hemodynamic abberaion are usually present and can be redognized with relative ease, but there is by no means agreement as to whether a quantitative correlation exist

between hemodynamic and roentgenologic parameters.

At the present it is the goals of this study to determine the acceptable criteria to predict hemodynamic status in plain chest in the cases of congenital heart disease with left to right shunt, and findings of vascular changes of the plain chest are compared with hemodynamic datas of cardiac catheterization.

METHOD AND MATERIALS:

Plain chese x-ray were reviewed in 83 congenital heart disease with pure left to right shunt, including 21 cases of interatrial septal defect, 34 cases of interventricular septal defect and 28 cases of patent ductus arteriosus, confirmed by cardiac catheterization at Severance Hospital. In each patients, the degree of pulmonary vessel distention, centralization of pulmonary vessels and cross-sectional area of right descending pulmonary artery per unit body surface area were evaluate on plain chese roentgenograms and were correlated with

hemodynamic data, including Qp/Qs ratio, mean pulmonary arterial pressure and pulmonary vascular resistence.

RESULTS:

1. When the pulmonary vascular resistence is normal, there is noted relatively good correlation between the degree of pulmonary vessel distention and Qp/Qs ratio in the cases of interatrial septal defect and patent ductus arteriosus. If vessel

distention is absent or limited to upper lung field, the Qp/Qs ratio is generally less than 2:1, and if present in all lung zones, the ratio is above 2:1.

In the cases of interventricular septal defect, the pulmonary vessel distention appears to be very variable without significant relation to Qp/Qs ratio.

When the pulmonary vascular resistence is elevated, the degree of pulmonary vessel distention is not correlated to Qp/Qs ratio, and similarly distended vessel have low Qp/Qs ratio compared to the vessel with normal resistence.

2. The presence of centralization of pulmonary vessel is a good index for evidence of increased pulmonary vascular resistence. Higher Qp/Qs ratio or higher pulmonary vascular resistence seems to have a higher probability of centralization of pulmonary vessels. However, presence of centralization is only 44% among cases of increased resistence so this poor result is a big barrier in this study; the cases having resistence hypertension without centralization of pulmonary vessel constitute the major portion of error in estimating hemodynamic changes from plain

film.

3. Pulmonary arterial hypertension is presumable present when the centralization of pulmonary vessel is present. However, there is no direct radiologic criteria to determine the level of pressure in left to right shunt.

4. When pulmonary vascular resistence is normal range, the cross-sectional area of right descending pulmonary artery per unit body surface area is well correlated with Qp/Qs ratio in the cases of interatrial septal defect and patent ductus

arteriosus, but in cases of interventricular septal defect there is no significant correlation.

When pulmonary vascular resistence is elevated, the size of right descending pulmonary artery is constantly larger than that of normal resistence in interatrial septal defect. But in interventricular septal defect and patent ductus arteriosus,

no apparent difference in size of right descending pulmonary artery whether the resistence is normal or elevated.