法洛氏四重症是一種常見的發紺先天性心臟疾病，心臟主要有四種變異，肺動脈狹窄、右心室肥大、主動脈橫跨左右心室以及心室中膈缺損。手術後，慢性的肺動脈逆流會造成右心室體積負荷超載，心室心律不整和心臟衰竭。已有報告顯示持續性的肺動脈逆流以及右心室擴張和左心室功能變差是有相關的。因此如何早期診斷出病人右心室功能惡化是個很重要的議題。此篇研究目的是探討法洛氏四重症病人不正常的肺動脈血流對心肌造成不利的相互影響。
我們徵求了47名法洛氏四重症患者和43名年紀相符的健康受試者進行檢查。使用4D MRI定量肺動脈血流參數和組織相位圖評估左右心室的心肌運動。
法洛氏四重症患者有較高的肺動脈逆流、脈動指數和較長的右心室舒張徑向到達峰值速度的時間。病人的肺動脈逆流和脈動指數與右心室舒張徑向到達峰值速度的時間及左心室舒張縱向到達峰值速度的時間皆有正向關連性，右心室舒張徑向到達峰值速度的時間和左心室舒張縱向到達峰值速度的時間之間也有顯著的相關性。此外，右心室的射出分率和肺動脈脈動指數、逆流、右心室舒張徑向到達峰值速度的時間和左心室舒張縱向到達峰值速度的時間皆有正相關。肺動脈血流截面積與逆流顯示出有正相關，肺動脈血流截面積分率與血流壓力差則呈現負相關。
本研究中的參數與系統性的相關性分析有助於在法洛氏四重症患者早期全面地評估心臟功能。

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. The disease consists of the following heart malfunctions: (1) pulmonary stenosis, (2) right ventricular hypertrophy, (3) overriding aorta, and (4) ventricular septal defect. Even after surgery, chronic pulmonary regurgitation (PR) is a major residual lesion contributed to right ventricular (RV) volume overload, ventricular arrhythmia and heart failure. Previous studies have demonstrated proceeding PR and RV dilatation associate with impaired left ventricular (LV) function. These make early detection of deteriorated right ventricular function in repaired Tetralogy of Fallot (rTOF) is an important issue.
In our study, we aim to investigate the abnormal pulmonary artery flow and adverse interaction with regional myocardial motion in rTOF patients with preserved LV ejection fraction (LVEF).
We recruited 47 rTOF patients and 43 age-matched normal volunteers. We use 4D flow magnetic resonance imaging (MRI) to qualify flow-related parameters and tissue phase mapping (TPM) to measure RV and LV regional myocardial motion. rTOF patients showed higher PR fraction, pulsatility index (PI) and RV diastolic time to peak (TTPr). Pulmonary PR fraction and PI in rTOF patients were correlated with RV diastolic TTPr and LV diastolic TTPz, respectively. The correlation between RV diastolic TTPr and LV diastolic TTPz were also significant. Moreover, the illustrated positively correlation between RVEF and pulmonary PI, PR fraction, ,RV diastolic TTPr and LV diastolic TTPz. Patients showed significantly positive correlation between pulmonary PR fraction and cross-section area. The pulmonary pressure difference have negatively correlation with cross-section area ratio.
In conclusion, the systemic correlation between myocardial motion and pulmonary flow can exhaustive evaluate the cardiac function in rTOF patients in early disease stage.

ABSTRACT 2
Chapter 1 Introduction 11
1.1 Tetralogy of Fallot 11
1.2 Treatment and Surveillance of Tetralogy of Fallot 13
1.2.1 Treatment in Tetralogy of Fallot 13
1.2.2 Echocardiography 14
1.2.3 Tissue Doppler imaging 17
1.2.4 Cardiac Computed Tomography 18
1.2.5 Cardiac Magnetic Resonance Imaging 20
1.3 Motivation 23
1.4 Orientation of Dissertation 24
Chapter 2 Theory 26
2.1 Phase-Contrast MRI 26
2.2 4D Flow MRI 27
2.3 Tissue Phase Mapping 30
Chapter 3 Materials and Methods 32
3.1 Study Cohort 32
3.2 MRI Acquisition 33
3.2.1 Cine Short-Axis View 33
3.2.2 4D Flow MRI 34
3.2.3 Tissue Phase Mapping 35
3.3 Data Analysis: Cardiac Volumetric Index 36
3.4 Data Analysis: Pulmonary Artery 36
3.4.1 Area and Area Ratio 36
3.4.2 Flow Parameter 37
3.4.3 Pulmonary Pressure Difference 38
3.6 Data Analysis: Myocardial Motion 39
3.7 Statistics 40
Chapter 4 Results 41
4.1 Demographic Characteristics 41
4.2 Pulmonary Area and Area Ratio 44
4.3 Pulmonary flow 45
4.3.1 PR Fraction and Pulsatility Index 45
4.3.2 Pressure Difference 46
4.4 Myocardial Motion 46
4.4.1 Time Course of Myocardial Motion 46
4.4.2 Myocardial Velocity 54
4.4.3 Myocardial Time to Peak 57
4.5 Correlation 60
4.5.1 Correlation Analysis: Pulmonary Flow 60
4.5.2 Correlation Analysis: Myocardial Motion 60
4.5.3 Correlation Analysis: Pulmonary Flow and Myocardial Motion 65
4.5.4 Correlation Analysis: RVEF, Pulmonary Flow and Myocardial Motion 72
4.5.5 Correlation Analysis: Pulmonary Area and PR Fraction 72
4.5.6 Correlation Analysis: Pulmonary Area Ratio and Pulmonary Pressure Difference 73
4.5.7 Correlation Analysis: RVEF and Pulmonary Pressure Difference 74
4.6 ROC Curve 、 Multivariable Regression and Collinearity Statistics 75
4.6.1 Multivariable Regression and collinearity statistics 75
4.6.2 ROC Curve 92
Chapter 5 Discussion 94
5.1 Cardiac Volumetric Index, Pulmonary Flow, and Myocardial Motion 94
5.2 Interaction of Cardiac Volumetric Index, Pulmonary Flow, and Myocardial Motion 95
5.2.1 Correlation Analysis: Myocardial Motion 95
5.2.2 Correlation Analysis: RVEF, Pulmonary Flow and Myocardial Motion 96
5.2.3 Correlation Analysis: Pulmonary Area and PR Fraction 97
5.2.4 Correlation Analysis: Pulmonary Area Ratio and Pressure Difference 98
5.3 ROC Curve、Multivariable Regression and Collinearity Statistics 98
5.4 Limitations 99
Chapter 6 Conclusions 101
6.1 Conclusions 101
6.2 Future Work 102
Chapter 7 References 103
Chapter 8 Appendix 110
AppendixⅠ: Abbreviation List 110
Appendix Ⅱ: Response to defense committee members 113

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