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CMR心肌灌注和延迟增强扫描对儿童病毒性心肌炎的诊断价值

发布时间:2018-02-24 21:42

  本文关键词: 心脏磁共振 儿童 病毒性心肌炎 延迟增强扫描 出处:《山东大学》2013年硕士论文 论文类型:学位论文


【摘要】:目的 病毒性心肌炎(VMC)是儿童最常见的心肌炎类型,心内膜心肌活检被认为是诊断VMC的“金标准”,有创性和低敏感度限制了其在临床中的应用。目前VMC的主要诊断方法包括心肌标记物、心电图、超声心动图等。心脏磁共振(CMR)具有无创性、高分辨率、大视野、多方位成像等特点,是心血管疾病的新型影像学诊断方法,尤其是心肌灌注和延迟增强扫描技术在病毒性心肌炎中的应用近年来备受关注,但其在儿童病毒性心肌炎中的应用国内外文献报道较少,本研究旨在探讨CMR心肌灌注和延迟增强扫描对儿童病毒性心肌炎的诊断价值。 方法 选择2011年7月至2013年3月于山东省立医院门诊及住院治疗的28例病毒性心肌炎患儿作为VMC组,其中男18例,女10例,年龄5岁-16岁,平均年龄9.6岁;选择7例原发性扩张型心肌病患儿作为扩心组,其中男5例,女2例,年龄1.2岁-10岁,平均年龄6.2岁;同时选择儿科门诊查体的13名健康儿童作为对照组,其中男8例,女5例,年龄6岁-12岁,平均年龄8.9岁。诊断标准参照1999年全国心肌炎心肌病学术研讨会上制定的病毒性心肌炎和心肌病诊断标准,其中出现急性心功能不全、心源性休克或心脑综合征的VMC患儿诊断为重症VMC,而仅表现为胸闷、乏力等的VMC患儿诊断为普通VMC。所有儿童先抽取外周血检测肌钙蛋白T、肌酸激酶同工酶质量、N端脑钠肽前体,做心电图和经胸超声心动图检查。然后在急性期完成CMR检查,内容包括平扫、电影成像、心肌灌注和延迟增强扫描,分析心脏形态、心肌动度、左室射血分数、心肌灌注和延迟期信号变化。将CMR结果与心肌损伤标记物、心电图、超声心动图结果对比,5例VMC患儿于恢复期复查CMR,并将结果与急性期CMR结果进行对比。 结果 1.28例VMC患儿均于发病前1至3周有呼吸道或肠道病毒感染史,其中9例诊断为重症VMC,包括3例急性心力衰竭,3例阿斯综合征发作,2例Ⅲ度房室传导阻滞,1例心源性休克;其余19例诊断为普通VMC。 2.所有儿童中年龄最小者为1.2岁,均顺利完成CMR检查,无一例出现对比剂过敏及其他并发症,心率在120次/分以下,平均检查时间为40分钟至1小时。 3.VMC组共有19例患儿出现CMR异常,主要表现为:(1)心腔扩大者7例,局部心肌变薄者12例,室间隔心肌增厚者2例;(2)心肌动度减低者8例,左室EF减低者4例,为44%-49%;(3)T2加权像出现高信号者1例,出现心肌延迟强化者17例,心肌延迟强化信号主要分布在左心室侧壁和下壁,部分患儿多个心肌部位受累,重症VMC主要为异常明显的弥漫性强化,普通VMC主要为轻中度散在斑片状强化。 4.CMR延迟增强扫描在VMC组的敏感度明显高于扩心组(60.71%vs0%,P0.01),并且对重症VMC的敏感度明显高于普通VMC(100%vs42.11%,P0.01),特异度均为100%。 5.心电图上出现缺血样ST-T图形的VMC患儿中,70%的患儿在相应部位出现CMR延迟强化信号;超声心动图上出现心肌变薄或心肌动度减低的VMC患儿中,68.75%的患儿在相应部位出现CMR延迟强化信号。 6.5例患儿分别于急性期和恢复期行CMR,其中3例患儿恢复期CMR延迟期强化信号消失,2例患儿延迟期强化信号强度较急性期减弱、范围较急性期减小。 结论 1.心脏磁共振是儿童病毒性心肌炎十分安全有效的无创性检查手段。 2.病毒性心肌炎在心脏磁共振上表现为心脏扩大,局部心肌变薄、动度减低,左室射血分数减低,延迟增强扫描时病灶区出现强化信号是其特异性表现。 3.磁共振心肌延迟增强扫描对重症心肌炎敏感度高于对普通心肌炎的敏感度,并具有较高的特异度。 4.磁共振心肌延迟增强扫描可以动态观察心肌炎症的变化,可用于病情随访。
[Abstract]:objective
Viral myocarditis (VMC) is the most common type of myocarditis, endomyocardial biopsy was considered as the "gold standard" for diagnosis of VMC, noninvasive and low sensitivity to limit its clinical application. At present, the main method for the diagnosis of VMC include cardiac markers, electrocardiogram, echocardiography and cardiac magnetic resonance. (CMR) is a noninvasive, high resolution, wide field, imaging features, diagnosis method is a new imaging of cardiovascular disease, especially myocardial perfusion and delayed enhancement scanning technology in viral myocarditis applications has attracted much attention in recent years, but in the children with viral myocarditis in the application of domestic and foreign literatures less, this study aimed to investigate the CMR myocardial perfusion and delayed enhancement examination in diagnosis of viral myocarditis in children.
Method
From July 2011 to March 2013 in Shangdong Province-owned Hospital outpatient and inpatient treatment of 28 cases of viral myocarditis were selected as VMC group, 18 cases were male, 10 were female, aged 5 -16 years, mean age 9.6 years; 7 cases of idiopathic dilated cardiomyopathy in children as the expansion of the heart group, 5 cases were male, 2 were female 1.2, age -10 years old, the average age of 6.2 years; 13 healthy children at the same time the outpatient department of Pediatrics examination as the control group, 8 cases were male, 5 were female, aged 6 -12 years old, the average age of 8.9 years. The diagnosis standard of viral myocarditis and cardiomyopathy diagnosis standard of the 1999 National Academic Seminar on myocarditis cardiomyopathy the formulation of the acute heart failure, cardiogenic shock or cardio cerebral syndrome VMC patients diagnosed as severe VMC, and showed only a weak chest, VMC in diagnosis for the detection of troponin blood all children from peripheral ordinary VMC. White T, CK mbmass, N terminal pro brain natriuretic peptide, electrocardiogram and transthoracic echocardiography. Then complete the CMR examination in acute period, including plain film imaging, myocardial perfusion and delayed enhancement scanning, analysis of cardiac morphology, myocardial motion, left ventricular ejection fraction, cardiac perfusion and delayed signal changes. The results of CMR and myocardial injury markers, electrocardiogram, echocardiography results, 5 cases of VMC in the recovery period after CMR, and compare the results with the acute phase of CMR results.
Result
1.28 children with VMC had history of respiratory or enterovirus infection 1 to 3 weeks before onset. 9 of them were diagnosed as severe VMC, including 3 cases of acute heart failure, 3 cases of ASA attack, 2 cases of third degree atrioventricular block, 1 cases of cardiogenic shock, and the other 19 cases diagnosed as ordinary VMC..
2. of all children, the youngest age group was 1.2 years old. All the patients completed the CMR examination successfully. No contrast agent allergy and other complications occurred. The heart rate was below 120 times / minute. The average time to check was 40 minutes to 1 hours.
The 3.VMC group had a total of 19 patients with CMR appear abnormal, mainly as follows: (1) heart enlargement in 7 cases, 12 cases of local myocardial thinning, 2 cases of ventricular septal myocardial thickening; (2) 8 cases with reduced myocardial mobility, reduce left ventricular EF in 4 cases, 44%-49% (; 3) T2 weighted image high signal in 1 cases, there were 17 cases of myocardial delayed enhancement, myocardial delayed enhancement signal mainly in the left ventricular lateral wall and inferior wall, part of the children involved multiple myocardial site, severe VMC was mainly abnormal obvious diffuse enhancement, VMC mainly for mild to moderate enhancement in scattered spots flake.
The sensitivity of 4.CMR delayed enhancement scan in VMC group was significantly higher than that in the extended heart group (60.71%vs0%, P0.01), and the sensitivity to severe VMC was significantly higher than that in common VMC (100%vs42.11%, P0.01), and the specificity was 100%..
5. of the VMC children who had blood ST-T like pattern on the electrocardiogram, 70% of them had CMR delayed enhancement signal at the corresponding location. 68.75% of the VMC children who had myocardial thinning or decreased myocardial activity on echocardiography showed delayed signal enhancement in the corresponding location.
In 6.5 children, CMR was performed in the acute phase and recovery stage respectively. Of them, 3 patients recovered during the recovery phase, and the delayed signal intensity disappeared in 2 cases. The signal intensity of the 2 children in the delayed phase was weaker than that in the acute phase, and the range was smaller than that in the acute phase.
conclusion
1. cardiac magnetic resonance (MRI) is a very safe and effective noninvasive method for children with viral myocarditis.
2. viral myocarditis in cardiac MRI is manifested as cardiac enlargement, local myocardial thinning, reduced mobility and reduced left ventricular ejection fraction. Delayed enhancement scanning is a specific manifestation of enhanced signal in lesion area.
The sensitivity of 3. MRI myocardial delayed enhanced scan to severe myocarditis was higher than that of ordinary myocarditis with high specificity.
4. MRI myocardial delayed enhanced scan can dynamically observe the changes of myocarditis and can be used for the follow-up of the disease.

【学位授予单位】:山东大学
【学位级别】:硕士
【学位授予年份】:2013
【分类号】:R725.4

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