心脏核磁共振钆剂延迟增强显像在评价扩张型心肌病中的临床应用价值

发布时间：2017-12-27 04:26

本文关键词：心脏核磁共振钆剂延迟增强显像在评价扩张型心肌病中的临床应用价值　出处：《大连医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:扩张型心肌病(DCM)定义为在没有严重冠心病及反常负荷(未控制的高血压、心脏瓣膜病或先天性心脏病)的情况下出现左心室或左、右心室同时扩张和心脏收缩功能障碍的一种心肌病。扩张型心肌病是多个病因学的最终结果,包括不同患者间的多种心室重构倾向及临床转归。目前的危险分层仍旧主要依据左心室射血分数(LVEF)及临床症状的评估,这很具有挑战性,尤其对于心律失常及心脏性猝死的预测。多数研究发现心肌纤维化是心肌病发展的重要病理生理过程,与患者的心室重构及预后不良密切相关。而心脏核磁共振钆剂延迟增强(LGE-CMR)可通过钆喷酸葡胺(GD-DPTA)造影剂在心肌成像中的显像无创的评估心肌纤维化情况,已成为各种心脏疾病的重要诊断工具,拥有广泛的应用前景。本研究的目的是探讨心脏核磁共振钆剂延迟增强显像在评价扩张型心肌病患者左心系统结构及功能中的临床应用价值。方法:入选2016-2017年于大连医科大学附属第一医院采用GE Signa HDxt 3.0T磁共振机行平扫及增强检查的扩张型心肌病患者,根据心肌成像结果中有无钆剂延迟增强显像分为LGE阳性(有钆剂延迟增强显像)组和LGE阴性(无钆剂延迟增强显像)组,分析两组间扩张型心肌病患者的各个临床特征。应用中文版SPSS19.0统计软件进行统计学分析,对两组计量资料进行独立样本t检验,计数资料进行χ2检验或Fisher确切概率法,以P0.05为有统计学意义。结果:近1年间入住我院有完整临床资料且于住院期间行心脏核磁共振平扫及增强检查的扩张型心肌病患者共有31例,排除重度主动脉瓣病变的1例和配合欠佳至图像不清的1例,剩余29例患者均符合本研究的入选标准。其中男性24例(82.8%),女性5例(17.2%);年龄29-73岁,平均55.6±12.5岁。原发性扩张型心肌病患者22例(75.9%),心肌致密化不全患者4例(13.8%),酒精性心肌病患者3例(10.3%)。29例患者临床上均表现为进行性加重的心力衰竭,根据纽约心脏协会(New York Heart Association,NYHA)心功能分级标准,其中9例(31.0%)患者心功能II-III级,20例(69.0%)患者心功能III-IV级。所有入选的扩张型心肌病患者均有左室弥漫性运动减低,LVEF范围18-44%;入选患者均有相对性瓣膜关闭不全,以二尖瓣和三尖瓣相对关闭不全为主。23例(79.3%)患者超声下表现为左心系统增大,5例(17.2%)患者表现为全心普大。所有入选患者中有钆剂延迟增强显像的患者17例(58.6%),无钆剂延迟增强显像的患者12例(41.4%)。LGE阳性组有持续性室速或非持续性室速(SVT/NSVT)的患者8例(47.1%),LGE阴性组有SVT/NSVT病史的患者4例(33.3%),两组之间相比无统计学差异(P=0.703)。LGE阳性的患者中,14例患者的延迟增强显像图形为左室壁心肌中膜条形延迟强化影,占LGE阳性组的比例为82.4%;2例患者为斑片状和点状延迟强化影,占LGE阳性组的比例为11.8%;1例为心内膜下延迟强化影,占LGE阳性组的比例为5.9%。延迟增强显像位于左室壁的区域各有不同,其中包括有间隔壁的14例(82.4%),下壁4例(23.5%),侧壁3例(17.6%),心尖部1例(5.9%)。11例患者的心脏核磁共振结果提示有心肌灌注减低,在左室心肌分布的区域有:间隔壁(8例)、侧壁(8例)、下壁(4例),其中4例为心内膜下心肌灌注减低。同时也评价了左房舒张末期内径(LAEDD)、左室舒张末期内径(LVEDD)、左室舒张末期容积(LVEDV)及左室收缩末期容积(LVESV)、左室质量(LVmass)和左室射血分数(LVEF)等左室结构和功能的变化,这些数据在LGE阳性和LGE阴性两组之间的差异均无统计学意义。结论:1.心肌中膜条形钆剂延迟增强(LGE)显像是扩张型心肌病的显著性特点,以室间隔LGE显像较多见,其余节段比例基本相同,多分布在心脏基底部或中间部,心尖部不易受累。2.扩张型心肌病LGE阳性和LGE阴性两组患者间的左心系统结构和功能无明显差别。3.DCM心肌纤维化发展过程中可能伴有微血管功能异常,从而导致心肌血流储备降低和缺血性改变,因此在无严重冠状动脉供血异常和冠心病临床表现的情况下可出现局部心肌钆剂延迟增强显像或灌注异常。
[Abstract]:Objective: dilated cardiomyopathy (DCM) is defined as a cardiomyopathy with no serious coronary heart disease and abnormal load (uncontrolled hypertension, valvular heart disease or congenital heart disease). Dilated cardiomyopathy is the final result of multiple etiology, including a variety of ventricular remodeling trends and clinical outcomes among different patients. The current risk stratification is still mainly based on the evaluation of left ventricular ejection fraction (LVEF) and clinical symptoms, which is very challenging, especially for the prediction of arrhythmia and sudden cardiac death. Most studies have found that myocardial fibrosis is an important pathophysiological process in the development of cardiomyopathy, which is closely related to ventricular remodeling and poor prognosis in patients. The cardiac magnetic resonance gadolinium delayed enhancement (LGE-CMR) can be used to evaluate myocardial fibrosis by noninvasive evaluation of gadolinium gluconate (GD-DPTA) contrast agent in myocardial imaging. It has become an important diagnostic tool for various heart diseases, and has wide application prospects. The purpose of this study is to explore the clinical value of gadolinium delayed enhancement imaging in evaluating the structure and function of left ventricular system in patients with dilated cardiomyopathy. Methods: the patients with 2016-2017 in the First Affiliated Hospital of Dalian Medical University by GE Signa HDxt 3.0T magnetic resonance machine and enhanced scan of patients with dilated cardiomyopathy, according to myocardial imaging results in no late gadolinium enhanced imaging were divided into LGE positive (with late gadolinium enhanced imaging) and LGE negative group (no late gadolinium enhanced imaging) group, analysis of clinical characteristics of all two groups of patients with dilated cardiomyopathy. Statistical analysis was done by Chinese version of SPSS19.0 statistical software. Independent samples t test was performed on two sets of measurement data, and chi square test or Fisher exact probability method were used to count data. P0.05 was statistically significant in the 2 groups. Results: in the past 1 years in our hospital with complete clinical data and hospitalization for cardiac magnetic resonance scan and enhanced scan in patients with dilated cardiomyopathy were excluded in 31 cases, severe aortic valve disease and 1 cases with poor to the image is not clear in 1 cases, the remaining 29 cases were accord with the study the selected standard. There were 24 males (82.8%), 5 women (17.2%) and 29-73 years old, with an average of 55.6 + 12.5 years. There were 22 cases of primary dilated cardiomyopathy (75.9%), 4 patients with myocardial densification (13.8%), 3 patients with alcoholic cardiomyopathy (10.3%). All 29 patients were progressive progressive heart failure. According to the New York Heart Association (NYHA) cardiac function classification standard, 9 patients (31%) had cardiac function II-III level and 20 patients (69%) had cardiac function III-IV level. All of the 9 patients had progressive heart failure. All the patients with dilated cardiomyopathy had decreased left ventricular diffuse motion and LVEF range 18-44%. All patients had relative valve regurgitation, and mitral and three cuspid valves were relatively closed. In 23 cases (79.3%), the left heart system was enlarged under ultrasound and 5 cases (17.2%) were full of heart. Of all the selected patients, there were 17 patients (58.6%) with gadolinium delayed enhancement imaging and 12 patients (41.4%) with gadolinium - free delayed enhanced imaging. There were 8 cases (47.1%) with persistent ventricular tachycardia or non sustained ventricular tachycardia (SVT/NSVT) in the LGE positive group, 4 patients (33.3%) had SVT/NSVT history in the LGE negative group, and there was no significant difference between the two groups (P=0.703). LGE positive patients, 14 cases of patients with delayed enhancement imaging graphics for left ventricular wall membrane strip delayed enhancement, accounting for LGE positive ratio was 82.4%; 2 patients were patchy and punctate delay enhancement, accounting for LGE positive ratio was 11.8%; 1 cases of subendocardial delayed enhancement shadow, accounted for the proportion of 5.9% LGE positive group. There are different areas of delayed enhancement imaging in the left ventricular wall, including 14 cases (82.4%) with septal walls, 4 cases (23.5%) of the inferior wall, 3 cases (17.6%) of the lateral walls, and 1 cases (5.9%) of the apical part. The results of cardiac magnetic resonance imaging in 11 patients suggested that myocardial perfusion was reduced, and the areas in the left ventricular myocardium were: interseptal wall (8 cases), lateral wall (8 cases), inferior wall (4 cases), and 4 cases of hypoperfusion of myocardium. At the same time to evaluate left atrial end diastolic diameter (LAEDD), left ventricular end diastolic diameter (LVEDD), left ventricular end diastolic volume (LVEDV) and left ventricular end systolic volume (LVESV), left ventricular mass (LVmass) and left ventricular ejection fraction (LVEF) changes of left ventricular structure and function these data, there were no significant differences in LGE positive and negative LGE between the two groups. Conclusion: 1.. Delayed enhancement (LGE) imaging of myocardium medium strip gadolinium is a significant feature of dilated cardiomyopathy. LGE is more frequently seen in the ventricular septum. The proportion of other segments is basically the same. Most of them are distributed in the basal or middle part of the heart, and the apex is not easy to be involved. There was no significant difference in the structure and function of left heart system between 2. dilated cardiomyopathy LGE positive and LGE negative groups. Microvascular dysfunction may be associated with the development of 3.DCM in myocardial fibrosis, resulting in reduced myocardial flow reserve and ischemic changes, so in the absence of serious coronary artery abnormalities and clinical manifestations of coronary heart disease in case of local myocardial late gadolinium enhanced imaging and perfusion abnormalities.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R542.2;R445.2

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