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Zagazig University

Faculty of Medicine
Department of Pediatrics

Myocardial Function In Patients With


Sickle Cell Disease:
A Tissue Doppler And Speckle Tracking
Echocardiographic Study
A Protocol of Thesis
Submitted For Partial Fulfillment of Master
Degree
In Pediatrics

By
Mohamed Abd-Elmonem Ismail
M.B; B.CH.;
Faculty of Medicine, Al Azhar University

Under Supervision of
Dr. Soad Abd-Elsalam Shedeed
Professor of Pediatrics
Faculty of Medicine - Zagazig University

Dr. Ahmed Abd-Elsamad Elhewala


Assistant Professor of Pediatrics
Faculty of Medicine - Zagazig University

Zagazig University
Faculty of Medicine
- 2019 -
INTRODUCTION
The word sickle cell disease (SCD) describes inherited
hemoglobin disorders. The SCD patients have abnormal hemoglobin
in the RBCs, called hemoglobin S or sickle hemoglobin, because of
adenine-to-thymine substitution in the sixth codon in the beta globin
gene, replacing glutamic acid with valine in the beta-globin chain
(Moor et al., 2016).

The disease is characterized by complications such as anemia,


pulmonary hypertension, lungs, kidneys, spleen, and brain injuries due
to deprived tissues and organs from oxygen-rich blood. The left
ventricular hypertrophy (LVH) is the main clinical symptoms of SCD.
This occurs because of high cardiac output caused by developed
chronic anemia in patients with SCD; particularly the SCD cases
experience abnormal systolic and diastolic ventricular functions (Niss
et al., 2016).

The major reasons for death in SCD patients are cardiovascular


disorders and the relevant complications. The most common
impairments observed in such patients are diastolic dysfunction in the
left ventricle and pulmonary hypertension (Sachdev et al., 2007).

There are also unusual but more likely complications in the SCD
patients, such as myocardial infarction, arrhythmia and
cardiomyopathy (De Montalembert et al., 2004).

Diastolic and systolic dysfunction can be evaluated by tissue Doppler


echocardiography and speckle tracking imaging. Speckle tracking is
considered an angle-independent technique in the evaluation of
myocardial performance (Cameli et al., 2013).

The echocardiographic modalities such as two-dimensional, M-


mode, Doppler and tissue Doppler echocardiography (TDE) are
employed to assess the cardiac function (Eddine et al., 2012), so that
the device display the myocardial motion as color Doppler velocity
maps and pulsed Doppler spectral display as well as provides the
possibility of checking myocardial velocities within heart cycle
(Ghaderian et al., 2015).

The diastolic function can be assessed quantitatively due to the


pulsed-wave spectral Doppler display of the tissue velocity. In
addition, pulsed-wave Doppler of the lateral mitral valve annulus is
commonly recruited to investigate the function of left ventricle,
resulting in the spectral display required to evaluate the diastolic
function (Ghaderian et al., 2015).

The regional wall motion at any point of the ventricular


myocardium can be achieved via the TDE. Also subclinical
myocardial dysfunction can be found by TDE often not evident on M-
mode, two-dimensional (2D) or spectral Doppler studies. The
ventricular function in myocardial disease can be evaluated using TDE
via LV filling pressures (Marwick, 2003).

Preload changes influence the TDE outcomes with low probability


like in chronic anemia (Van de Veire et al., 2008).

The MPI (myocardial performance index) or the Tei- index estimated


by TDE can be used to measure at the same time the systolic and
diastolic components (Ghaderian et al., 2015).
The isovolumic contraction time (ICT) along with the isovolumic
relaxation time (IRT) resulting from the ejection time (ET) is Tei-
index to calculate simultaneously the atrioventricular inflow and
ipsilateral semi-lunar outflow Doppler velocities, as well as to assess
the systolic and diastolic functions. The cardiac function index in
cardiac catheterization and magnetic resonance derived right
ventricular ejection fraction is also associated with the Tei-index

( Dabirian et al., 2015).

Speckle tracking echocardiography is a new mean of evaluating


cardiac function. The principle of speckle tracking is to measure
myocardial strain, based on local shortening, lengthening and
thickening of the muscles.

It has been proposed that the left ventricle global longitudinal


strain (LV-GLS) could be a useful tool for the detection of early
systolic dysfunction in patients under cardiotoxic chemotherapy
(Thavendiranathan et al., 2014).

Moreover, the high reproducibility of the LV-GLS represents an


advantage over the left ventricle ejection fraction (LVEF) (King et al.,
2016 and Medvedofsky et al., 2017).

Compared to the LVEF, the LV-GLS is less affected by changes in


loading conditions, which makes it a potentially useful tool in patients
with sickle cell disease (SCD), due to the chronic overload associated
with SCD. However, in this population, studies are rare and results are
conflicting (Ahmad et al., 2012; Sengupta et al., 2012; Barbosa
et al., 2014 and Hammoudi et al., 2014).
Rationale:
There is limited information on echocardiographic myocardial
functions findings in the SCD patients. In the SCD patients also, one
of the sensitive ventricular function markers to complement
conventional echocardiography can be the tissue Doppler
echocardiography and Speckle tracking.

According to the mentioned issues, the present study will be therefore


conducted to evaluate the cardiac functions and structure using tissue
Doppler and Speckle tracking among patients suffering from SCD
compared to normal subjects.

Research questions:

 Is myocardial function abnormal in patients with SCD?

 Can tissue Doppler and Speckle tracking detect reliably


myocardial abnormalities in SCD?
AIM OF WORK
The aim of this study is to evaluate myocardial function in
children with SCD by using tissue Doppler and Speckle tracking
echocardiography.

OBJECTIVES
 Evaluation of myocardial function in children with SCD
using tissue Doppler.

 Evaluation of myocardial function in children with SCD


using Speckle tracking.

 Evaluate the relationship between tissue Doppler and


Speckle tracking in children with SCD.

 Evaluate the relationship between myocardial function in


patients with SCD and each of demographic, clinical and
laboratory data of patients as well as other disease
complications.
PATIENTS & METHODS
I. Technical design:
A:type of study:

case control study.

B: Site of the study:


This study will be carried out in pediatric cardiology and
pediatric hematology units of Zagazig university hospitals.

B: Study groups:
Comprehensive sample will be taken including all cases with
sickle cell disease during period of 6 months (5cases/month).
Sample will be equal to 30 cases (as all follow up cases in hematology
unit are 30 cases) and an equal number of control participants.

Inclusion criteria:
1. Age: 6 to 15 years.
2. Sex: both sexes are included
3. Children who were previously diagnosed with SCD

Exclusion criteria:

­ Inability to obtain adequate 2D image quality. 

­  Children with hypertension 

­ Newly diagnosed or treated patients. 
­ symptoms   of   heart   failure   or   LV   dysfunction   defined   as

ejection fraction <50%

­  Children with arrhythmia which may affect the image analysis

2. Operational Design:
Steps of performance:

All patients will undergo the followings:

 A questionnaire interview: with care taking for collection of


personal data, sociodemographic data and complete history taking
with particular emphasis on age, sex, birth weight and duration of
illness.

 Previous hospital admission, symptoms suggestive of heart


failure cough, dyspnea, haemoptsis, oedema of lower limbs, co-
morbid diseases and drug history.

 General and local examination:

General features laying stress on:

1. Anthropometric measurements including:

 Body weight: Weight will be calculated using the SECA scale


and expressed in kilograms.

 Height : standing height in cm

 BMI: Published international age and gender specific


reference values for BMI in infants and children and the task
force recommended the use of BMI (calculated as weight in
kilograms divided by height in meters square) derived
normative percentile for the diagnosis of underweight if BMI
is less than the 5th percentile , over weight if BMI is at least
85th percentile but less than 95th percentile for age and sex and
obesity if BMI is at least the 95th percentile for age and sex.

BMI= weight (kg) / length (m2) .

2. Vital signs including

 Blood pressure: measurement using appropriate cuff size for


each child with an inflatable bladder width that is at least 40
percent of arm circumference at a point midway between the
olecranon and acromion .

 Heart rate and Respiratory rate assessment: calculated


over one minute.

3. General, skeletal and abdominal features of sickle cell disease

4. Local examination of the heart by

 Inspection and palpation for pulsation, bulging &


retractions.

 Auscultation of heart sounds, murmurs either systolic or


diastolic & additional sounds as s3 gallop.

5. Laboratory investigations:

­ CBC

­ Hemoglobin electrophoresis

­ Liver and kidney functions tests


­ Serum ferritin

6. Echocardiographic Evaluation:

A. Conventional Echocardiographic examination: will be


performed for all subjects by using esaotie MyLab class C device
esaotie Europe SPA Genoa Italy. All cases will be examined using
multiple frequencies transducer ranging from 3 to 8 MHZ. with
simultaneous electrocardiographic recording to allow timing of
flow. The imaging planes consisted of the parasternal long- and
short-axis views followed by the apical four and two-chamber
views. Cardiac dimensions: Aortic and left atrial dimensions, the
interventricular septum (IVS), the left ventricular posterior wall
(LVPW), thickness, the left ventricular end diastolic (LVED), and
end systolic (LVES) will be measured. Left ventricular ejection
fraction and fraction shortening will be estimated from M-mode
tracings.
B. Diastolic function assessment:

Pulsed Doppler interrogation of the mitral valve was performed with


simultaneous synchronized ECG monitoring to determine the left
ventricular diastolic functions (Bajraktari etal., 2018)

The E-wave to A-wave (E/A) ratio is a commonly used index of


diastolic function

The following variables will be obtained:

1. Peak early diastolic flow velocity, measured as the height of the


early peak of flow velocity (E wave).
2. Peak velocity at the time of atrial contraction, measured as the
height of the late peak of flow velocity (A wave).

Ratio between the early and the late peaks of flow velocity (E /A ratio).

B. Tissue doppler study:


After completion of the conventional echocardiogram, apical images
(2 and 4-chambers) with <200 frames/s are acquired and digitalized for the
quantitative analysis of TDI. Offline measurements will be performed. The
tissue Doppler Parameters are set in pulsed wave doppler mode. A 3-5 mm
sample volume is positioned at the lateral mitral annulus (Alam et al.,
2000)

Two major negative velocities are recorded with the movement of the
annulus to the base of the heart during diastole: one during the early phase
of diastole (Em) and another during the late phase of diastole (Am). A
major systolic velocity (S) will be recorded with the movement of the
annulus toward the cardiac apex during systole. The peak myocardial
systolic velocity are defined as the maximum velocity during systolic. All
velocities are recorded for 3 consecutive cardiac cycles at end expiration,
and results will be averaged. (Dokainish et al., 2004).

The positive systolic wave (S) represented myocardial contraction.


The negative waves represented the early diastolic myocardial relaxation
(Em) and active atrial contraction in late diastole (Am). The time to peak S
velocity will be measured .

Tissue Doppler_derived Tei index, isovolaemic contraction and


relaxation periods are identified. Pulsed wave TDI velocity measurements
will be obtained by placing the sample volume at the lateral mitral annular
level denoting S, Em & Am waves.
The time interval from the end to the onset of mitral annular velocity
wave during diastole (a) and the duration of the Sm (b) are measured. Tei
index will be calculated as isovolumetric contraction time (IVCT) plus
isovolumetric relaxation time (IVRT) divided by ET:
(IVCT+IVRT)/ET=(a-b)/b. Tei index will calculated using the average
values of three consecutive cardiac cycles (Lakoumentas et al., 2005; Su
et al., 2007.

C. Speckle tracking Strain analysis is based on combined speckle


tracking algorithms applied on high-frequency ultrasound images.
By definition, strain indicates how much the myocardial tissue has
deformed, i.e. Strain (S) = ΔL/L0 = (L1-L0)/L0, and strain rate (SR)
reflects how fast the myocardial tissue is deforming, i.e. SR = S/Δt
= ΔL/L0/Δt (Fernandes et al., 2008). Therefore, strain and SR can
reflect the regional and global systolic and diastolic function. Strain
and SR will be quantified in the longitudinal, radial, and
circumferential axes by speckle tracking of 2D grayscale
echocardiographic images acquired from the parasternal long- and
short-axis views. Strain analyses are conducted by the same trained
investigator on My LabSix work station. In brief, B-mode cine
loops will be selected from 2D echocardiographic images, and then
three to four consecutive cardiac cycles are selected to analyze the
strain and SR. Tracing of the endocardial borders will be performed.
Then the strain and SR are analyzed so that regional and global
measures are acquired, respectively (Griffin et al., 2001). Long
axis or short axis view of the left ventricle (LV) myocardium will be
automatically divided into six segments for regional speckle
tracking. The peak of regional strain are obtained from the six
standard segments. At the same time, the global peak of strain are
also acquired

Data analysis:

1. Collected data will be tabulated in tables and suitable graphs


and analyzed according to standard statistical methods.

2. Discussion is done on results and compared to related relevant


literature and scientific researches.

3. Conclusions and recommendations will be derived from the


findings of the study.

3. Administrative Design :
 Approval will be asked from Zagazig university institution
reviewer board.

 Approval of Pediatric department, Zagazig university.

 Informed consent will be obtained from study participants


and /or their cases givers.
Results :
Collected data will be presented in tables and suitable graphs
and analyzed using appropriate statistical methods.

Discussion :
Discussion will be done on result compared to related
relevant literatures and scientific researches to explain the reason
for getting such results

Conclusion and Recommendations:


Conclusion and recommendations will be derived from the
findings of the study.
REFERENCES

Moor VJA, Pieme CA, Chemegne BC, Manonji H, Nono BLN,


Mamiafo CT, et al. Oxidative profile of sickle cell
patients in a Cameroonian urban hospital. BMC Clin
Pathol. 2016;16(1):15

Niss O, Quinn CT, Lane A, Daily J, Khoury PR, Bakeer N, et al.


Cardiomyopathy with restrictive physiology in sickle cell
disease. JACC: Cardiovasc Img. 2016;9(3):243–52.

Sachdev V, Machado RF, Shizukuda Y, Rao YN, Sidenko S, Ernst


I, et al. Diastolic dysfunction is an independent risk factor
for death in patients with sickle cell disease. J Am Coll
Cardiol. 2007;49(4):472–9.

De Montalembert M, Maunoury C, Acar P, Brousse V, Sidi D,


Lenoir G. Myocardial ischaemia in children with sickle
cell disease. Arch Dis Child. 2004;89(4):359–62.

Cameli M, Lisi M, Righini FM, Focardi M, Lunghetti S,


Bernazzali S, et al. Speckle tracking echocardiography as
a new technique to evaluate right ventricular function in
patients with left ventricular assist device therapy. J Heart
Lung Transplant. 2013;32:424–30

Eddine AC, Alvarez O, Lipshultz SE, Kardon R, Arheart K,


Swaminathan S. Ventricular structure and function in
children with sickle cell disease using conventional and
tissue Doppler echocardiography. Am J Cardiol.
2012;109(9):1358–64.
Ghaderian M, Keikhaei B, Heidari M, Salehi Z, Malamiri R.
Tissue Doppler echocardiographic findings of left
ventricle in children with sickle-cell anemia. J Tehran
Heart Cent. 2015;7(3):106–10.

Marwick T. Clinical applications of tissue Doppler imaging: a


promise fulfilled. Heart. 2003;89(12):1377–9

Van de Veire NR, De Sutter J, Bax JJ, Roelandt JR. Technological


advances in tissue Doppler imaging echocardiography.
Heart. 2008;94(8):1065–74.

Dabirian M, Jalalian R, Karami H, Kowsarian M, Ahmadi A,


Shokohi L, et al. Evaluation of diagnostic power of
Tissue Doppler Echocardiography for assessment of
cardiac iron overload in patients with thalassemia major.
Int J Hematol Oncol Stem Cell Res. 2015;6(4):14–9

Thavendiranathan, P., Poulin, F., Lim, K.D., Plana, J.C., Woo, A.


& Marwick, T.H. (2014) Use of myocardial strain
imaging by echocardiography for the early detection of
cardiotoxicity in patients during and after cancer
chemotherapy. A systematic review. Journal of the
American College of Cardiology, 63, 2751–2768

King, A., Thambyrajah, J., Leng, E. & Stewart, M.J. (2016) Global
longitudinal strain: a useful everyday measurement? Echo
Research and Practice, 3, 85–93.
Ahmad, H., Gayat, E., Yodwut, C., Abduch, M.C., et al (2012)
Evaluation of myocardial deformation in patients with
sickle cell disease and preserved ejection fraction using
three‐dimensional speckle tracking echocardiography.
Echocardiography, 29, 962–969.

Barbosa, M.M., Vasconcelos, M.C., Ferrari, T.C., et al. (2014)


Assessment of ventricular function in adults with sickle
cell disease: role of two dimensional speckle‐tracking
strain. Journal of the American Society of
Echocardiography, 27, 1216–1222.

Hammoudi, N., Arangalage, D., Djebbar, M., et al(2014)


Subclinical left ventricular systolic impairment in steady
state young adult patients with sickle‐cell anemia.
International Journal of Cardiovascular Imaging, 30,
1297–1304.

Sengupta, S.P., Jaju, R., Nugurwar, A., Caracciolo, G. &


Sengupta, P.P. (2012) Left ventricular myocardial
performance assessed by 2-dimensional speckle tracking
echocardiography in patients with sickle cell crisis. Indian
Heart Journal, 64, 553–558.

Bajraktari G, Pugliese NR, D'Agostino A, et al ( 2018): Echo- and


B-Type Natriuretic Peptide-Guided Follow-Up versus
Symptom-Guided Follow-Up: Comparison of the Outcome
in Ambulatory Heart Failure Patients. E PUB 1: 30.
‫الملخص العربى‬
‫المقدمة‪:‬‬
‫أنأيميا الخلياا النمجليه هي شكل موروث من النأيميا – هي حالة من عدم توافر ما ياكفي من‬
‫خلياا الدم الحمراء لحمل ما ياكفى من الكأسجين للجسم كله‪.‬‬
‫عادة تكون خلياا الدم الحمراء مرنأة ومستديارة وتتحرك بسهولة عبر الوعية الدموية‪ .‬في‬
‫حالة أنأيميا الخلياا النمجلية تصبح خلياا الدم الحمراء جامدة ولزجة وتتشكل مثل النماجل‬
‫أو الهللا‪ .‬يامكن لهذه الخلياا غير منمتظمة الشكل أن تعلق في أوعية الدم الصغيرة وهو ما‬
‫قد يابطئ أو يسد تدفق الدم والكأسجين لجزاء الجسم‪.‬‬
‫ياتميز الرض بمضاعفات مثل فقر الدم وإرتفاع ضغط الدم الرئوي وإصابات مختلفة‬
‫بالرئتين والكلى والطحالا والسكتة الدماغية بسبب حرمان النأسجة والعضاء من الدم‬
‫الغني بالكأسجين‪.‬‬
‫من الضاعفات التي يامكن أن تحدث أياضا تضخم البطين اليسر )‪ (LVH‬ويحدث هذا‬
‫بسبب الزيادة في جهد عضلة القلب النماتج عن فقر الدم الزمن في مرضضى أنأيميا الخلياا‬
‫النمجلية؛ ويعتبر القصور في وظائف القلب والضاعفات النماجمة عنمه أحد أشهر أسباب‬
‫الوفاة في مرضضي أنأيميا الخلياا النمجلية‪.‬‬
‫لذلك يستخدم تخطيط صدي القلب للتصوير بالوجات فوق الصوتية القياسية ثنمائية‬
‫البعاد وثلثية البعاد والدوبلر لنأشاء صور للقلب تساعد في تشخيص ومتابعة أي‬
‫مضاعفات قلبية مشتبه في حدوثها ويمكن أن ياوفر الكثير من العلومات مثل حجم وشكل‬
‫القلب وقدرة الضخ وموقع ومدى أى تلف في النأسجة‪ .‬كأما يامكن أن ياوفر تقديارات أخرى‬
‫لوظائف القلب مثل حساب النمتاج القلبي والجزء القذوف والوظيفة النأبساطية‪.‬‬
‫يامكن بإستخدام دوبلر النأسجة للتصوير بالوجات فوق الصوتية )‪ (TDE‬إكأتشاف الحالة‬
‫ما قبل الكلينيكية لى ضعف في عضلة القلب والتي قد تكون غير واضحة في كأثير من‬
‫الحيان عنمد إستخدام نأظام إم )‪ ،(M-mode‬وثنمائي البعاد )‪ (2D‬أو دراسات الدوبلر‬
‫الطيفية حيث يامكن تقييم وظيفة البطين في إعتللا عضلة القلب بإستخدام )‪ (TDE‬عبر‬
‫قياس ضغط ضخ الدم في البطين اليسر‪ .‬كأما ياصعب تأثره بالتغيرات في الدورة الدموية‬
‫ما قبل القلبية )‪(preload‬مثلما ياحدث في فقر الدم الزمن‪.‬‬
‫أخيرا يعد التتبع الرقطي بالوجات فوق الصوتية )‪(speckle tracking echocardiography‬‬
‫ا‬
‫طريقة حدياثة لتقييم وظيفة القلب‪ .‬ويعتبر القل تأثرا بالتغيرات في زيادة الجهد )‬
‫‪ ،(preload‬مما ياجعله أكأثر إفادة في الرضضى الذيان يعانأون من مرض أنأيميا الخلياا النمجلية‬
‫)‪ ،(SCD‬بسبب الزيادة الزمنمة ف الجهد الرتبطة بمرض أنأيميا الخلياا النمجلية ‪.‬‬
‫سؤال البحث‪:‬‬

‫ه ييل تعت ييبر وظيف يية عض ييلة القل ييب غي يير طبيعي يية ف ييي الرضض ييى ال ييذيان يع ييانأون م يين م ييرض أنأيمي ييا‬
‫الخلياا النمجلية ؟‬
‫هي ييل بامكي ييان دوبلي يير النأسي ييجة للتصي ييوير بالوجي ييات في ييوق الصي ييوتية والتتبي ييع الرقطي ييي اكأتشي يياف‬
‫الضاعفات التي يامكن حدوثها لعضلة القلب في مرضضي أنأيميا الخلياا النمجلية ؟‬

‫الهدف من العمل‬
‫اله ييدف م يين ه ييذه الدراس يية ه ييو تقيي ييم وظيف يية عض ييلة القل ييب ف ييي الطف ييالا ال ييذيان يع ييانأون م يين‬
‫مييرض أنأيميييا الخلياييا النمجلييية عيين طريييق دوبليير النأسييجة للتصييوير بالوجييات فييوق الصييوتية‬
‫والتتبع الرقطي‪.‬‬

‫الهأداف‬
‫• تقييييم وظيفيية عضييلة القلييب فييي الطفييالا الييذيان يعييانأون ميين مييرض أنأيميييا الخلياييا النمجلييية‬
‫بإستخدام دوبلر النأسجة للتصوير بالوجات فوق الصوتية‪.‬‬
‫• تقييييم وظيفيية عضييلة القلييب فييي الطفييالا الييذيان يعييانأون ميين مييرض أنأيميييا الخلياييا النمجلييية‬
‫باستخدام التتبع الرقطي‪.‬‬
‫• تقييييم العلقيية بييين دوبليير النأسييجة للتصييوير بالوجييات فييوق الصييوتية والتتبييع الرقطييي يفييي‬
‫الطفالا الذيان يعانأون من مرض أنأيميا الخلياا النمجلية‪.‬‬
‫• تقييم العلقة بين وظيفة عضلة القلب في الطفالا الذيان يعانأون من مرض أنأيميا الخلياا‬
‫النمجلييية وكييل ميين البيانأييات الدياموغرافييية والسييريرية والخبريايية لهييم‪ ،‬فضييل عيين مضيياعفات‬
‫الرض الخرى‪.‬‬
‫المرضى والطرق‬

‫التصميم الفني‪:‬‬
‫موقع الدراسة‬
‫سيييتم إجيراء هييذه الدراسيية فييي قسييم العيييادات الخارجييية لميراض القلييب وأميراض الييدم لييدى‬
‫مستشفيات جامعة الزقازيق‬
‫مجموعات الدراسة‪:‬‬
‫سيتم أخذ عينمة شاملة لجميع الطفالا الذيان يعانأون من مرض أنأيميا الخليايا النمجليية مين‬
‫العيادة الخارجيية لميراض اليدم وأميراض القليب والذيان يعيانأون مين مضياعفات لهيذا الرض‬
‫تؤثر على وظائف عضلة القلب‪.‬‬
‫وستكون مساوية لا ‪ 30‬حالة )‪ 5‬حالت ‪/‬شهر(‪.‬‬
‫ا‬ ‫سييوف نأقييوم أيا ا‬
‫ضييا بتضييمين ‪ 30‬طفل ياتمتعييون بصييحة جيييدة مييع العميير والجنييس التطييابقين‬
‫كأمجموعة ضابطة‪.‬‬
‫ج‪ :‬الطرق‪:‬‬
‫سيخضع جميع الرضضى ل ي ي‬
‫‪ -1‬الخاتب ش ششارات الروتيني ش ششة لتش ش ششخيص ومتابع ي يية م ي ييرض أنأيمي ي ييا الخليا ي ييا النمجلي ي يية وفق ي ييا‬
‫لعايايرنأا الحليه بما في ذلك ‪:‬‬
‫صوردة دم كاملة‬
‫الفصل الكهرباءي للهيموجلوبين‬
‫وظائف كأبد ووظائف كألي‬
‫نأسبة الفيرياتين بالدم‬
‫‪ -2‬سيييتم التحقييق ميين كأفيياءة وظييائف عضييلة القلييب عيين طريييق إسييتخدام دوبليير الشييعة‬
‫للتصوير بالوجات فوق الصوتية والتتبع الرقطي‪.‬‬
‫التصميم التشغيلي‪:‬‬
‫تصميم الدراسة‪ :‬دراسة الحالة‬
‫خطوات الداء‪:‬‬
‫سيتم جمع البيانأات وفقا للتى ‪:‬‬
‫‪ -1‬من خللا دراسة التاريخ الرضضي‪.‬‬
‫‪ -2‬من خللا الفحص السريري‪.‬‬
‫‪ -3‬فحوص ييات روتيني يية لتش ييخيص ومتابع يية ت ييأثير م ييرض أنأيمي ييا الخليا ييا النمجلي يية عل ييى وظيف يية‬
‫عضلة القلب‪.‬‬
‫‪ -4‬الفحص القلبي باستخدام‪:‬‬
‫‪ ‬دوبلر النأسجة للتصوير بالوجات فوق الصوتية‪.‬‬
‫‪ ‬التتبع الرقطي‪.‬‬

‫‪ -5‬سيييتم تجميييع البيانأييات الجممعيية فييي جييداولا ورسييوم بيانأييية منماسييبة وتحليلهييا وفاقييا للطييرق‬
‫الحصائية القياسية‬
‫‪ -6‬تتم منماقشة النمتائج ومقارنأتها بالمراجع والبحوث العلمية ذات الصلة‬
‫‪-‬سوف تستمد الإستنتاجات والتوصيات من النمتائج التي توصلت إليها الدراسة‬

‫التصميم الدإارى ‪:‬‬


‫‪ ‬أخذ الموافقات من الجهات الحكومية‪.‬‬
‫‪ ‬موافقة لجنة أخلقايات المهنة‪.‬‬
‫‪ ‬موافقة الفرادإ الخاضعين للبحث‪.‬‬
‫النتـــــائــج‬
‫بعد جمع البيانات سيتم تحليلها بإستخدام طرق الحإصاء‬
‫القياسية وعرضها فى شكل جداول وأشكال بيانية‪.‬‬

‫المناقاشـــة‬
‫سوف تناقاش نتائج البحث بالستعانة بالمراجع المحلية‬
‫والعالمية مع تفسير ظهور النتائج وإيضاح سبب اختلفها‬
‫عن بعض المراجع‪.‬‬

‫الخلصاـــة والتوصاـــيات‬
‫سوف تستخلص من نتائج البحث‪.‬‬
‫جامعة الزقاازيق‬
‫كلية الطب‬
‫قاسم طب الطفال‬

‫وظيفة عضلة القلب في مرضي‬


‫أنيميا الخلياا المنجلية‬
‫‪ :‬دراسة بالموجات فوق الصوتية‬
‫على القلب باستخدام دوبلر‬
‫النسجة والتتبع الرقطي‬
‫بروتوكول رسالة‬
‫توطئة للحصول على دإرجة الماجستير فى طب‬
‫الطفال‬
‫مقدم من‬
‫ط‪ /‬محمد عبدالمنعم اسماعيل‬
‫بكالوريوس الطب والجراحإة‬

‫تحت إشراف‬
‫دإ‪ /.‬سعادإ عبد السلم شديد‬
‫أستاذ طب الطفال‬
‫كلية الطب ــ جامعة الزقاازيق‬

‫دإ‪ /.‬أحإمد عبد الصمد حإوالة‬


‫أستاذ مساعد طب الطفال‬
‫كلية الطب ــ جامعة الزقاازيق‬
‫كلية الطب‬
‫جامعة الزقاازيق‬
‫‪- 2019 -‬‬