摘要
血流动力学因素直接作用于血管内皮细胞，对内皮细胞的生理和病理功能具有调节作用。研究发现，在血管分叉、弯曲、动脉瓣膜等部位存在异常和不均匀的血流动力学因素，包括流动分离、涡流、高压、低壁面切应力、振荡剪切应力、长粒子滞留时间、二次流等。这些异常的血流动力学因素能够引起血管内膜增生、内皮细胞损伤等，导致血管壁面处动脉粥样硬化斑块的形成，被普遍认为是血管病变产生与发展的重要原因，称为粥样硬化危险性血流动力学因素。
危险性血流动力学因素除发生在上述特定血管部位之外，在心血管搭桥手术局部位置也存在，可能会导致手术部位的血管内膜增生，造成术后血管再狭窄、移植血管病变等临床症状，影响着手术的成败及长期有效性。因此，在心血管疾病的手术过程中，也必须充分考虑血流动力学因素。心血管疾病治疗的手术规划就是在术前通过对各种手术方案可能产生的血流动力学因素进行预测和比较，避免危险性血流动力学因素，从而优化术后的血流动力学，为手术决策提供依据。
本论文以优化手术血流动力学，辅助心血管手术决策为目的，开展了单心室、Fallot四联症和冠状动脉狭窄三种心血管疾病的血流动力学研究，从搭桥手术几何多样性角度研究了不同手术方式的血流动力学特征，评估了不同搭桥几何对手术效果的影响，为临床手术决策和疾病预防提供了理论依据。
论文的研究内容包括以下几方面：
（1）个性化心血管手术建模研究：主要包括两部分工作，一是基于医学图像的个性化解剖模型三维重建；二是基于重建模型，利用虚拟现实技术开发心血管手术虚拟建模工具，实现心血管手术虚拟操作，构建了血流动力学仿真所需的个性化手术模型。
（2）单心室手术模型的血流动力学数值研究：研究了治疗单心室疾病的Fontan手术的三个步骤，主要研究了不同搭桥位置、角度、血管直径等几何因素对血流动力学的影响，寻找最优化的搭桥几何结构，达到分离体循环和肺循环、减小手术后的能量损失、实现肝静脉血向两肺的平均分流、实现腔静脉血向左右肺动脉的平均灌注、减少涡流及低壁面切应力等危险性血流动力学现象的目的，提高手术的长期有效性。
（3）法洛氏四联症手术模型的血流动力学数值研究：研究了两种常用的体肺分流术，即改良的BT手术和中央分流术。着重分析了搭桥管的局部血流动力学内环境，定量分析了主动脉向肺动脉的血液灌注比，搭桥后左、右肺动脉的分流比等，指导临床医生更好的认识体肺分流术，辅助临床体肺分流术的决策。
（4）冠状动脉狭窄手术模型的血流动力学数值研究：研究了冠状动脉不同狭窄率时竞争流对搭桥管内血流动力学的影响，探索竞争流与搭桥管失败之间的关系；研究了传统冠状动脉搭桥术后血管内的血流动力学，发明了一种双移植管搭桥方式来增加手术后的血管通透性，减小冠状动脉再狭窄的发生几率。
论文通过血流动力学因素的优化来优化搭桥血管几何结构，建立了一套医学图像三维重建-虚拟心血管手术建模-血流动力学计算与评估相结合的心血管疾病手术规划理论和方法，对促进血流动力学的临床应用、提高心血管手术的科学化水平具有理论意义和潜在的应用价值。
Hemodynamic factors directly impact on vascular endothelial cells, and playimportant roles on the physiological and pathological function of endothelial cells. Ithas been found that abnormal or uneven hemodynamic factors, including the flowseparation, vortex, high pressure, low wall shear stress, oscillatory shear stress, longparticle residence time, second flow and so on, always appear at the artery bifurcation,bending and valve. These abnormal hemodynamic factors, which are also calledatherosclerotic-dangerous hemodynamic factors, can cause arterial intimal hyperplasiaor endothelial cell damage, and lead to the formation of atherosclerotic plaque nearthe wall. Therefore, these factors have been widely thought to be closely related withthe cause and development of arterial diseases.
Except for the above-mentioned areas, dangerous hemodynamic factors are alsoobserved at the cardiovascular bypass regions. These factors can cause intimalhyperplasia at local bypass regions and result in post-operational restenosis or graftdiseases, which have serious influences on the surgery and long-term effectiveness.Therefore, hemodynamics must be considered in the cardiovascular surgery.Cardiovascular surgical planning is trying to optimize the post-operationalhemodynamics and assist surgical decisions before the surgery by predicting andevaluating the hemodynamics of possible surgical options based on the principle ofavoiding dangerous hemodynamic factors.
Three cardiovascular diseases, including single ventricle heart defect, tetralogy ofFallot and coronary artery stenosis, were studied with the objective of optimizingsurgical options based on hemodynamic optimization. Hemodynamic parameters werecalculated in each surgery from the view point of geometrical bypass-diversity, andthe influences of different bypass geometries on the surgical outcomes were evaluatedto help cardiovascular surgical decision.
The research contents consist of the following aspects:
1. Patient-specific cardiovascular surgery modeling. It mainly consists of two parts.One part is the three-dimensional reconstruction of patient-specific anatomy based onmedical slices, and the other is to develop a virtual cardiovascular modeling tool byusing virtual reality technology, with which to establish the computational models.
2. Hemodynamic study of surgeries for single ventricle heart defect. The threestages of the Fontan procedure were studied according to different bypass offsets,angles and diameters based on hemodynamic optimization with the aims of separatingsystemic circulatory and pulmonary circulatory, saving energy, achieving balancedflow to both longs, and avoiding dangerous hemodynamic performances such asvortex, low wall shear stress and so on.
3. Hemodynamic study of surgeries for tetralogy of Fallot. Two common systemicto pulmonary shunts, including modified B-T shunt and central shunt, were studied byanalyzing the hemodynamic performance inside of the bypass graft, the blood flowrate from aorta to both lungs and the flow rate of both pulmonary arteries to help thesurgical decision of systemic to pulmonary shunt.
4. Hemodynamic study of surgeries for coronary artery stenosis. The influence ofcompetitive flow caused by different coronary artery stenosis on bypass graft wasevaluated from the view point of hemodynamics. A new coronary artery bypass graftdesign called double-bypass graft design was developed to enhance the long-termpatency of coronary artery and reduce the risk of coronary artery stenosis.
This study tried to optimize the geometry of the bypass graft through hemodynamicoptimization and established a cardiovascular planning strategy by coupling medicalimage processing, virtual cardiovascular operation and hemodynamic evaluationtogether. This study has potential value to promote the application of cardiovascularsurgical planning and enhance the scientific level of cardiovascular surgery.
引文
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