第二代双源CT对复杂型先天性心血管病的临床应用研究

  本文关键词：第二代双源CT对复杂型先天性心血管病的临床应用研究，，由笔耕文化传播整理发布。

        第一部分：新的对比剂注射方法结合大螺距扫描技术在复杂型先天性心血管病成像中的临床可行性研究背景和目的：近几年来,有关复杂型先天性心血管病的CT临床应用研究甚多,以往研究较多的是多排螺旋CT(multi-detector spiral computed tomography,MDCT)回顾性心电门控扫描,其最大的弊端是辐射剂量大,虽然可以通过降低管电流、管电压等措施降低辐射剂量,但辐射剂量及对比剂剂量较大仍然是不可忽视的问题。随着二代双源CT的诞生,其先进的设备(两套球管、两套探测器)及扫描模式(Flash扫描模式)为心脏CT成像开创了空前的快速低剂量扫描,其辐射剂量可以达到亚mSv,堪称“绿色CT”,其快速扫描间接减少了对比剂的用量。第二个问题,图像质量问题,以往对于心脏成像,无论是冠脉疾病或是先天性心血管疾病,对比剂注射方法均采用双筒单流注射,即先高流率快速注射对比剂,再低流率慢速注射对比剂,最后注射生理盐水的注射方法,该方法产生的上腔静脉伪影较大,对部分结构及畸变不能很好的显示。然而,众所周知,先天性心血管病不同于冠脉病变,前者心脏及与心脏相连的大血管的任何一个结构都有可能畸变,故其对图像要求更高,最好是能够消除上腔静脉伪影,使得心脏、冠脉及与心脏相连的大血管都能够均匀显影,不能单纯看冠脉的显示。基于该出发点的研究,国内外甚少报道。本研究即是探讨新双源Flash CT应用于复杂型先天性心血管疾病的成像技术和方法,探索最合理的扫描方法和技术,以期达到降低辐射剂量、降低对比剂剂量及消除上腔静脉伪影、提高图像质量的目的。材料与方法：43例(平均分成A、B两组)复杂型先天性心脏病患儿,均接受新双源FlashCT(西门子炫速双源CT,德国)检查及手术治疗。A组(18例)为Flash CT常规注药方式及扫描组,对比剂的注药方式及扫描参数设置均采用常规用量及用法；B组(25例)为优化注药方式及扫描组,对比剂注药方式及扫描参数设置采用优化方案。将所有病例的图像根据需要进行多平面重建(1nultiple planar reformation, MPR),曲面重建(curve planar reformation,最大密度投影(maximum intensity projeetion,MIP)和三维容积再现(volume rendering,VR)等后处理分析。对A、B两组间的图像质量、对比剂用量及辐射剂量进行比较,并将结果进行统计学分析。结果：两组间图像质量的评价参数是一致的,上腔静脉、右心房、右心室、肺动脉、左心房、左心室、升主动脉及降主动脉的增强CT值,A组高于B组(P>0.05),心腔及大血管不同部位CT差值,两者之间比较有显著性统计学差异(P=0.00),其中上腔静脉、右心房的图像质量B组明显优于A组(P<0.05),而肺动脉、左心房、左心室、主动脉的图像质量A组明显优于B组(P<0.05),两组间的有效辐射剂量相比,B组明显低于A组(W=350,P=0.00)。A组的对比剂用量明显多于B组(t=3.56,P=0.038)。结论：1.进行复杂型先天性心血管病检查时应将图像质量、诊断质量以及射线剂量进行综合考虑,采用最合理的检查方法。2.第二代双源CT Flash(?)剂量扫描技术在复杂型先天性心血管病的诊断中在不丢失诊断信息的情况下最大限度的降低了辐射剂量,是值得推广的扫描方法。3.新的对比剂注射方法有效的降低了上腔静脉伪影、减少了对比剂剂量,在某种意义上提高了图像质量,值得推广应用。第二部分：新的对比剂注射方法结合大螺距扫描成像技术对复杂型先天性心血管病的诊断价值研究——与超声心动图及手术结果对照背景和目的：一直以来,超声心动图(echocardiograph,ECHO)对复杂型先天性心血管病的诊断在临床上都处于主导地位。然而,多排螺旋CT (multi-detector spiral computed tomography, MDCT)对复杂型先天性心血管病的临床应用已有多年历史,在诊断复杂型先心病中体现出很大的优势。本研究的目的旨在通过研究新的对比剂注射方法结合大螺距扫描技术对复杂型先天性心血管病的诊断应用,并将结果同超声心动图及手术结果进行对照,评价新的对比剂注射方法结合大螺距扫描CT成像技术对复杂型先天性心血管病的诊断价值及对手术治疗的指导意义。材料与方法：将43例患者随机分成两组：常规组(A组)、优化组(B组),分别进行MDCT (Flash CT)和ECHO检查,所有患者均接受外科手术治疗,术中记录病变的位置及测量大小。扫描原始数据需要进行多平面重建,最大密度投影、曲面重建和三维容积再现等后处理。由两位有经验的放射科医师对图像进行分析。对结果进行对照研究,将所有病变畸形分为心脏内部畸形、心脏血管连接部畸形及心脏周围血管畸形三部分。Flash CT两种检查方法的结果、ECHO结果均同手术结果对照。结果：心脏内部畸形共102处,与手术结果对照,Flash CT检查诊断正确87处,诊断不正确15处,ECHO诊断正确99处,诊断不正确3处,Flash CT和ECHO对心脏畸形的诊断准确性分别为85.29%(87/102)和97.06%(99/102),两组比较差异具有统计学意义(χ2=9.437,P=0.0038)。心脏血管连接部及心脏周围血管畸形共69处,与手术结果对照,Flash CT检查诊断正确67处,诊断不正确2处,ECHO诊断正确49处,诊断不正确20处,Flash CT和ECHO对心脏血管连接部及心脏周围血管畸形的诊断准确性分别为97.10%(67/69)和71.01%(49/69),两组比较差异具有统计学意义(χ2=16.704,P=0.000)。Flash CT对全部171处心血管畸形诊断正确154处,诊断不正确17处,诊断准确性为90.06%(154/171),ECHO对全部171处心血管畸形诊断正确148处,诊断不正确23处,诊断准确性为87.72%(148/171),两者比较差异没有统计学意义(χ2=0.095,P=-0.567)。结论：1. ECHO作为心脏畸形的首选检查手段,其诊断准确性高,是可以信赖的一种检查手段,但是对于心脏内部畸形缺损较小、局部血液分流不明显或合并多种畸形(尤其是心脏大血管连接部畸形及心外畸形)时ECHO检查容易漏诊。2.原始轴位图像仍是Flash CT诊断复杂型先天性心血管疾病的分析基础,通过原始轴位图像发现病变后,再结合多种三维后处理重建技术能够更好的显示病变的大小、位置,指导临床手术治疗。3. Flash CT扫描速度快、空间分辨率高,对于心脏血管连接处及心外畸形的诊断有其明显优势。4. Flash CT与ECHO检查对复杂型先心病的诊断没有显著差异,两者各有其优势,Flash CT对心脏血管连接部及心外血管畸形的诊断优于ECHO,而ECHO对心内畸形尤其是瓣膜病变的诊断价值要好于Flash CT。

    Part I:Clinical application research of the new technique of contrast injection with High-pitch spiral Acqusition by Dual-source Computed Tomography to view complex congenital cardiovascular diseaseBackground and objective:Recently, the clinical application of multi-detector spiral computed tomography (MDCT) in diagnosing for complex congenital cardiovascular disease has been increasing. However,retrospective electrocardiography (ECG)-gated technique was generally adopted. Retrospective ECG-gated spiral CT is widely used for the evaluation of thoracic and cardiovascular deformities in patients with congenital heart disease. Retrospective ECG-gated CT is associated with relatively high radiation dose for its low pitch and overlapping data acquisition although the integration of the dose-saving features of heart rate adaptive pitch and ECG-controlled tube-current modulation can reduce the effective dose for patients with congenital heart disease, higher radiation dose is still the limitation for retrospective ECG-gated CT. Recently, the second generation dual-source CT (DSCT) system has offered a high-pitch spiral mode, data acquisition is also prospectively triggered with the ECG, the radiation dose could been reduced obviously. So, the second generation dual-source CT (DSCT) is called "Green CT". The second question, at present, there hasn’t been an agreed project on contrast injection in dynamic computed tomography to view the congenital heart disease in children, the program of coronary artery CTA was mostly used in patients with congenital heart disease. Before, named "optimization group note technology"---contrast agent and saline is injected separately, contrast agent is injected first, then saline, but the imaging quality was unsatisfactory, either hardening beam artifact in superior vena cava is large, or contrast agent isn’t homogenously distributed Consequently, how to get the pefect image with minimum of contrast agent dosage and lowermost radiation dose on MDCT scanning is one of the hot spot questions that studies currently. This research was to evaluate the technique and method of individuation scanning scheme in Flash CT appling to complex congenital cardiovascular disease.Materials and methods:Forty-three patients (divided into group A and group B) suspected with complex congenital heart disease underwent Flash CTA with optimizing mode and conventional mode. All patients accepted surgical treatment. All icons of cases according to carry on multiple planar reformation(MPR), maximum intensity projection (MIP), curve planar reformation(CPR) and volume rendering(VR) etc. CT image quality, contrast medium dosage and radiation dose were evaluated and the results were carried on statistics analysis.Results:There was no significant difference in diagnostic accuracy (x2=0.384, P=0.594) between group A and group B. All evaluation parameters of image quality were agreed. The CT value in superior vena cava, the right atrium, right ventricle, the main pulmonary artery, left atrium, left ventricle, ascending and the descending aorta in the two groups was statistical significance(P<0.05, respectively). The difference of the CT value between two groups was statistical significance(P=0.000).The image quality of superior vena cava, the right atrium was significantly better in group A than in group B (P<0.05, respectively). The mean effective dose and contrast agent doses in group A was significantly lower (P<0.05) than that in group B.Conclusions:1. We should use the most reasonable method of examination for paitients with complex congenital cardiovascular disease. The image quality, radiation dose and clear diagnosis should be comprehensive considered.2. The prospectively ECG-gated-flash CTA scanning mode is worth extending scanning methods in diagnosis of complex congenital cardiovascular disease because information is not lost under the condition of the radiation dose could been reduced obviously3. Using the new technique of contrast injection, eliminated beam hardening artifact in superior vena cava and right atrium, also lowered the contrast agent dose. It is expected to be widely applied for diagnosis of complex congenital heart disease. Part II:The diagnostic value of new technique of contrast injection with High-pitch spiral Acqusition in complex congenital cardiovascular disease-echocardiographic and surgical results controlsBackground and objective:Echocardiography (ECHO) for the diagnosis of congenital heart disease in clinical has been the initial choice for patients. But multi-detector spiral computed tomography (MDCT) has many years history in diagnosis of complex congenital heart disease and reflects huge advantage. The purpose of this study aims to study the diagnostic accuracy of new technique of contrast injection with High-pitch spiral Acqusition for all the congenital heart disease and compare with the echocardiography and surgical results, then evaluate the diagnostic value of new technique of contrast injection with High-pitch spiral Acqusition for diagnosing complex congenital heart disease and guiding for surgical treatment.Materials and methods:Forty-three patients who were divided into two parts (Conventional group-group A and Optimizing group-groupB) underwent the Flash CT and ECHO examination separately. All the patients accepted surgical treatment and record the size and location of the lesions during operation. The scanning data according to needing to carry on multiple planar reformation(MPR), maximum intensity projeetion(MIP), curve planar reformation(CPR) and volume rendering(VR) etc. Two experienced radiologists analyzed image.Results:All of102lesions of the cardiac anomaly, compared with the surgery results,87lesions were correct and15lesions were incorrect in Flash CT diagnosing. There were99correct lesions and3incorrect lesions in ECHO diagnosing. The diagnosis accuracy of Flash CT and ECHO in diagnosing cardiac anomaly were85.29%(87/102) and97.06%(99/102) respectively, two groups are statistical difference (x2=9.437, P=0.0038). All of69lesions of the cardiovascular fitting and peripheral vascular anomaly,67lesions were correct diagnosis and2lesions were incorrect diagnosis in Flash CT. There were correct diagnosis49lesions and incorrect diagnosis20lesions in ECHO. The accuracy of Flash CT and ECHO in diagnosing cardiovascular fitting and peripheral vascular anomaly were97.10%(67/69) and71.01%(49/69) respectively, the difference of two groups was statistical significant (X2=16.704, P=0.000). The diagnosis accuracy of all the171lesions in Flash CT and ECHO were90.06%(154/171) and87.72%(148/198), the difference was statistical significant (x2=0.095, P=0.567).Conclusions:1. ECHO has been the initial choice for patients with congenital heart disease, because of its superiority in showing intracardiac anatomy and hemodynamic information, it may not be the perfect diagnostic tool because when cardiac anomalies defect lesser, local blood bypass around bigger or not obvious maybe cause the misdiagnosis.2. Axis images is foundation in diagnosing the complex congenital heart disease, find the lesions according to the foundation,then combine with appropriate three-dimensional post-processing reconstruction technique to show the lesions. 3. Flash CT which has fast scanning and high spatial resolution is superior for diagnosing for cardiovascular fitting and heart peripheral vascular anomaly.4. There is no obvious difference in diagnosing for congenital heart disease between Flash CT and ECHO, for peripheral vascular anomaly, Flash CT is better than ECHO,but for cardiac anomalies, ECHO is better than Flash CT.

第二代双源CT对复杂型先天性心血管病的临床应用研究

摘要4-8Abstract8-12目录13-15中英文对照表15-16前言16-21    参考文献19-21第一部分：新的对比剂注射方法结合大螺距扫描技术在复杂型先天性心血管病成像中的临床可行性研究21-39    前言21-22    材料与方法22-25    结果25-32    讨论32-36    结论36-37    参考文献37-39第二部分：新的对比剂注射方法结合大螺距扫描成像技术对复杂型先天性心血管病的诊断价值研究——与超声心动图及手术结果对照39-53    前言39-40    材料与方法40-41    结果41-47    讨论47-50    结论50-51    参考文献51-53综述 影像学检查方法对复杂型先天性心血管病的临床应用概况53-69    参考文献66-69个人简历及在研期间发表论文69-70致谢70

  本文关键词：第二代双源CT对复杂型先天性心血管病的临床应用研究，由笔耕文化传播整理发布。