Original Articles 자동경계탐지 (Automated Border Detection) 심초음파도를이용한좌심방면적및기능의평가 김현주 주승재 임진형 정효균 이영수 유호대 차태준 이재우 Abstract On-line Assessment of Le

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1 Original Articles 자동경계탐지 (Automated Border Detection) 심초음파도를이용한좌심방면적및기능의평가 김현주 주승재 임진형 정효균 이영수 유호대 차태준 이재우 Abstract On-line Assessment of Left Atrial Area and Function by Automated Border Detection Echocardiography Hyun-Joo Kim, M.D., Seung-Jae Joo, M.D., Jin-Hyung Lim, M.D., Hyo-Gyun Chung, M.D., Young-Su Lee, M.D., Ho-Dae Yoo, M.D., Tae-Joon Cha, M.D., Jae-Woo Lee, M.D. Department of Internal Medicine, Kosin Medical College, Pusan, Korea BackgroundAutomated border detectionabd echocardiography is a convenient and objective tool in the estimation of left atrialla area and function when compared to the off-line, twodimensional echocardiographic method that requires manual tracing of the endocardial border. In addition, the applicability of the ABD system to instantaneously derive LA area and function may provide a noninvasive method to assess the diastolic interaction between the left ventricle and the left atrium. Method53 patients with normal sinus rhythm and an apical four chamber view of LA areain which at least 75% of the endocardium was clearly visible were selected for this study. The on-line echocardiographic assessment of LA areas and functions with automated boundary detection was performed and compared with the off-line estimation. From the instantaneous cavity area displayed by the ABD system, the extent of left atrial area decrease resulting from rapid ventricular fillingd and atrial contractionac were measured. The DAC ratio was compared with the transmitral Doppler flow velocity EA ratio. Results1 The end-systolic areaesa and the end-diastolic areaeda of the left atrium, the diastolic atrial emptying indexaemi and the systolic atrial expansion indexaexi with the ABD system were not different from those with the off-line, manually traced method. 2 ESA, EDA, AEMI and AEXI determined by the ABD system and the off-line method showed strong correlationsr 0.87, 0.79, 0.52 and 0.49 respectively. 3 The DAC ratio with the ABD system correlated significantly with the transmitral Doppler velocity EA ratior0.70. 교신저자 237

2 ConclusionThe ABD system may be used in the assessment of LA area and LA function and the diastolic interaction between the left atrium and the left ventricle. KEY WORDSAutomated border detectionabd echocardiography Left atrial area and function. 서 론 연구대상및방법 1. 연구대상 2. 연구방법 238

3 경계면이 붉은 선으로 나타나도록 하고, 이 붉은선을 이면성 심초음파도에서 육안으로 확인 가능한 심내 막의 경계와 일치시키기 위해서 transmit power와 time gain compensation을 조절하였다20-22). 필요시 에서 구한 수치를 각각 비교하였다. ESA-EDA ESA-EDA AEMI AEXI ESA EDA lateral gain control을 사용하였다. ABD 시스템을 껐 또한, ABD 시스템으로부터 얻은 좌심방 면적 변화 다, 켰다를 반복하여 ABD 시스템의 심내막 경계와 곡선에서 확장기시 급속 심실 충만에 의한 면적 감소 이면성 심초음파도에서 육안으로 확인 가능한 경계와 (D rapid ventricular filling)와 좌심방 수축에 의한 일치시켰다. 이 상태에서 승모판을 기준으로 관심 영 면적 감소(AC atrial contraction)를 구한 후, D/AC 역(region of interest)을 설정하면 SONOS 1500에 비를 계산하였다(Fig. 1). 이후 심첨 4방 단면도에서 내장된 프로그램에 의해서 좌심방 수축기말 면적 및 cursor를 승모판막 끝에 위치하여 간헐파형 도플러 확장기말 면적이 매 심박동마다 연속적으로 계산되었 심초음파도로 승모판 유입 혈류를 기록한 후 확장기 으며(Fig. 1), 이것을 video tape에 녹화한 후 재생시 초기 최고 혈류 속도(E 속도)와 확장기 후기 최고 혈류 켜서 5cycles 이상의 평균치를 취하고 off-time 시 속도(A 속도)를 측정하고, E/A 비를 계산하여 D/AC 스템에서 얻은 수치와 서로 비교하였다. 좌심방 기능을 비와 비교하였다. 평가하기 위해서 확장기 좌심방 박출 지수(AEMI 모든 통계치는 평균±표준 편차로 나타내었고, 통계 atrial emptying index)와 수축기 좌심방 팽창 지수 처리에 SPSS for windows를 이용하였다. On-line (AEXI atrial expansion index)를 다음의 공식에 측정치와 off-line 측정치의 비교는 paired t-test, 의해서 계산한 후, off-line system과 on-line system 두 방법 간의 일치 한계와 상관 계수는 각각 Bland- Fig. 1. Echocardiographic automated border detection image with the region of interest drawn around the left atrium(la) and the instantaneous cavity area displayed. End-systolic area(esa), end-diastolic area(eda) and the extents of LA area decrease resulting from rapid ventricular filling(d A-B) and atrial contraction (AC B-C) were measured. 239

4 결과 Table 1. ESA, EDA, AEMI, and AEXI by two different methods Manual tracing ABD p Value ESAcm EDAcm AEMI AEXI Values are mean±sd. ESA;End-systolic area of the left atrium EDA;End-diastolic area of the left atrium AEMI;Atrial emptying index AEXI;Atrial expansion index ABD;Automated border detection Fig. 4. Plots of left atrial end-diastolic area(eda) as measured with automated border detection system (EDA on) versus the off-line trackball operatortraced method(eda off). Fig. 2. Plots of left atrial end-systolic area(esa) as measured with automated border detection system (ESA on) versus the off-line trackball operatortraced method(esa off). Fig. 3. Limits of agreement of left atrial end-systolic area (ESA) determined by automated border detection system(esa on) and the off-line trackball operator-traced method(esa off). Fig. 5. Limits of agreement of left atrial end-diastolic area (EDA) determined by automated border detection system(eda on) and the off-line trackball operator-traced method(eda off). Table 2. Differences(off-line manual tracing-abd system) in ESA, EDA, AEMI and AEXI using two different methods Mean difference SD Limits of agreement mean2sd ESAcm EDAcm AEMI AEXI ABD;Automated border detection ESA;End-systolic area of the left atrium EDA;End-diastolic area of the left atrium AEMI;Atrial emptying index AEXI;Atrial expansion index 240

5 Fig. 6. Plots of diastolic left atrial emptying index(aemi) as measured with automated border detection system(aemi on) versus the off-line trackball operator-traced method(aemi off). Fig. 8. Plots of systolic left atrial expansion index(aexi) as measured with automated border detection system(aexi on) versus the off-line trackball operator-traced method(aexi off). Fig. 7. Limits of agreement of diastolic left atrial emptying index(aemi) determined by automated border detection system(aemi on) and the off-line trackball operator-traced method(aemi off). Fig. 9. Limits of agreement of systolic left atrial expansion index(aexi) determined by automated border detection system(aexi on) and the off-line trackball operator-traced method(aexi off). 고안 241

6 Fig. 10. Plots of the ratio of early diastolic change in left atrial area to change caused by left atrial contraction(d/ac) measured with automated border detection system versus the transmitral Doppler flow velocity E/A ratio. 242

면 좌심방 용적이 거의 연속적으로 감소하여 수동적 ABD 시스템에서는 심초음파도 화면 영상의 질, 초 수축과 능동적 수축에 의한 용적 감소를 구별할 수 없 음파와 평행하게 놓였을 때 심내막의 영상이 감소되 는 경우가 있다6). 거나 소실되는 측벽의 echo drop out18), gain 조절에 A B Fig. 11.

7 면 좌심방 용적이 거의 연속적으로 감소하여 수동적 ABD 시스템에서는 심초음파도 화면 영상의 질, 초 수축과 능동적 수축에 의한 용적 감소를 구별할 수 없 음파와 평행하게 놓였을 때 심내막의 영상이 감소되 는 경우가 있다6). 거나 소실되는 측벽의 echo drop out18), gain 조절에 A B Fig. 11. A Instantaneous left atrial cavity area change in diastole showed a small change in area during rapid ventricular filling(a-b) and a relatively large component of atrial contraction(b-c). B Corresponding transmitral Doppler flow velocity recording in the same patient demonstrated corresponding small E and large A wave component. 243

8 따른 심내막의 위치 변화, 승모판윤의 이동에 따른 관 이상 구분되는 환자만을 대상으로 하고, echo drop 심 영역의 변화, 호흡 등에 의해서 오차가 생길 수 있 out을 극복하기 위해서 lateral gain control을 사용 다20,21,25). 본 연구에서 좌심방 심내막의 경계가 75% 했음에도 불구하고, 약간의 transmit power와 time A B Fig. 12. A Instantaneous left atrial cavity area change in diastole showed a large change in area during rapid ventricular filling (A-B) and a relatively small component of atrial contraction(b-c). B Corresponding transmitral Doppler flow velocity recording in the same patient demonstrated corresponding large E and small A wave component. 244

9 요약 연구배경 : 방법 : 결과 : 결론 : 245

10 References 1) Grant C, Bunnell IL, Greene DG:The reservoir function of the left atrium during ventricular systole:an angiographic study of atrial stroke volume and work. Am J Med 37:36, ) Williams JF, Sonnenblick EH, Braunwald E:Determinants of atrial contractile force in the intact heart. Am J Physiol 209:1061, ) Murray JA, Kennedy JW, Figley MM:Quantitative angiocardiography:ii. The normal left atrial volume in man. Circulation 37:800, ) Stott DK, Marpole DGF, Bristow JD, Kloster FE, Griswold HE:The role of left atrial transport in aortic and mitral stenosis. Circulation 41:1031, ) Rahimtoola SH, Ehsani A, Sinno MZ, Loeb HS, Rosen KM, Gunnar RM:Left atrial transport function in myocardial infarction:importance of its booster pump function. Am J Med 59:686, ) Hitch DC, Nolan SP:Descriptive analysis of instantaneous left atrial volume-with special reference to left atrial function. J Surg Res 30:110, ) Bough EW, Gandsman EJ, Shulman RS:Measurement of normal left atrial function with gated radionuclide angiography. Am J Cardiol 48:473, ) Matsuda Y, Toma Y, Ogawa H, Matsuzaki M, Katayama K, Fujii T, Yoshino F, Moritani K, Kumada T, Kusukawa R:Importance of left atrial function in patients with myocardial infarction. Circulation 67:566, ) Matsuzaki M, Tamitani M, Toma Y, Ogawa H, Katayama K, Matsuda Y, Kusukawa R:Mechanism of augmented left atrial pump function in myocardial infarction and essential hypertension evaluated by left atrial pressuredimension relation. Am J Cardiol 67:1121, ) Appleton CP, Hatle LK:The natural history of left ventricular filling abnormalities:assessment by twodimensional and Doppler echocardiography. Echocardiography 9:437, ) Hirata T, Wolfe SB, Popp RL, Helmen CH, Feigenbaum H:Estimation of left atrial size using ultrasound. Am Heart J 78:43, ) Schabelman S, Schiller NB, Silverman NH, Ports TA: Left atrial volume estimation by two dimensional echocardiography. Cathet Cardiovasc Diagn 7:165, ) Gutman J, Wang YS, Wahr D, Schiller NB:Normal left atrial function determined by 2-dimensional echocardiography. Am J Cardiol 51:336, ) Hofstetter R, Bartz-Bazzanella P, Kentrup H, von Bernuth G:Determination of left atrial area and volume by crosssectional echocardiography in healthy infants and children. Am J Cardiol 68:1073, ) Prez JE, Waggoner AD, Barzilai B, Melton HE, Miller JG, Sobel BE:On-line assessment of ventricular function by automatic boundary detection and ultrasonic backscatter imaging. J Am Coll Cardiol 19:313, ) Vandenberg BF, Rath LS, Stuhlmuller P, Melton HE, Skorton DJ:Estimation of left ventricular cavity area with an on-line, semiautomated echocardiographic edge detection system. Circulation 86:159, ) Prez JE, Klein SC, Prater DM, Fraser CE, Cardona H, Waggoner AD, Holland MR, Miller JG, Sobel BE: Automated, on-line quantification of left ventricular dimensions and function by echocardiography with backscatter imaging and lateral gain compensation. Am J Cardiol 70:1200, ) Cahalan MK, Ionescu P, Melton HE, Adler S, Kee LL, Schiller NB:Automated real-time analysis of intraoperative transesophageal echocardiograms. Anesthesiology 78:477, ) Lindower PD, Rath L, Preslar J, Burns TL, Rezai K, Vandenberg BF:Quantification of left ventricular function with an automated border detection system and comparison with radionuclide ventriculography. Am J Cardiol 73: 195, ) 최현묵 김영우 이금희 이신화 박능화 지상근 차태준 주승재 이재우 : 자동경계탐지 (Automated Border Detection) 심초음파도를이용한좌심실용적및구혈율의측정. 순환기 25:614, ) 김대현 김용수 김동옥 차태준 주승재 이재우 : 자동경계탐지 (Automated Border Detection) 심초음파도를이용한좌심실기능의평가 :Gated cardiac blood pool scintigraphy 와의비교. 순환기 26: 637, ) 이준철 이병건 김동옥 김용수 차태준 주승재 이재우 :M 형심초음파도 / 심음도와자동경계탐지심초음파도를이용한좌심실수축기기능의평가. 순환기 26:992, ) Waggoner AD, Barzilai B, Miller JG, Prez JE:On-line assessment of left atrial area and function by echocardiographic automatic boundary detection. Circulation 88: 1142, ) Bland JM, Altman DG:Statistical methods for assessing agreement between two methods of clinical measurement. Lancet i:307, ) Bednarz JE, Marcus RH, Lang RM:Technical guidelines for performing automated border detection studies. J Am Soc Echocardiogr 8:293,

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<4D F736F F F696E74202D20BFA1C4DA5FC0D3BBF3C3CAC0BDC6C42E BC8A3C8AF20B8F0B5E55D> 심장 (Heart) 심초음파 서울대병원내과 김용진 심장은평생몇번이나뛸까요? 1) 3 백만번 2) 3 천만번 3) 3 억번 4) 30 억번 30 억박동, 2 억리터의혈액 Cause 심장질환 6.2 12.4 11.1 16.2 뇌졸중 4.3 8.5 7.7 11.3 기타심혈관질환 2.6 5.1 6.0 8.8 심혈관질환 13.1 26.0 24.8 36.3 총사망 50.4