核素心肌显像在冠心病诊断与冠状动脉慢性完全闭塞性病变中的应用研究

发布时间：2018-06-15 19:52

本文选题：冠状动脉疾病 + 侧支循环　；参考：《北京协和医学院》2017年硕士论文

【摘要】：第一部分冠状动脉左前降支慢性完全闭塞病变中侧支循环与心肌存活的心肌放射性核素显像研究目的:评价冠状动脉侧支循环与心肌存活在冠状动脉左前降支慢性完全闭塞病变中的作用。方法:研究纳入101例于我院临床确诊为冠状动脉左前降支慢性完全闭塞病变患者。所有患者均行99mTc-甲氧基异丁基异腈(MIBI)心肌灌注显像和门控18F-氟代脱氧葡萄糖(FDG)心肌代谢显像,且在前后3个月内接受过冠状动脉造影术。将心肌灌注图像与心肌代谢显像进行同机重建,使用QPS软件分别得到静息心肌灌注总积分(SRS)、心肌灌注异常面积(TPD)、心肌灌注/代谢不匹配(存活心肌)面积、心肌灌注/代谢匹配(无存活心肌)面积,利用QGS软件对心肌代谢图像进行分析,得到左心室舒张末期容积(LVEDV)、左心室收缩末期容积(LVESV)、左心室射血分数(LVEF)。根据冠状动脉造影术结果分为有侧支循环组(n=39)、无侧支循环组(n=62),比较两组之间SRS、TPD、心肌灌注/代谢不匹配面积、心肌灌注/代谢匹配面积、门控心功能参数(LVEDV、LVESV、LVEF)之间的差异;进一步根据患者有无陈旧性心肌梗死、左前降支慢性完全闭塞部位各分为4个亚组,比较上述各项参数的差异,从而探讨侧支循环在其中的作用。结果:101例[男性86例,女性15例,平均年龄(59.9±11.4)岁]。患者中有侧支循环组39例(38.6%),无侧支循环组62例(61.4%);两组静息灌注总积分[(21.2±9.7)vs.(28.6±8.8)]、灌注异常面积(30.0± 13.7)%vs.(40.4±12.5)%相比,差异均有统计学意义(P均0.05)。有侧支循环组心肌灌注/代谢不匹配面积(21.8±13.1)%、心肌灌注/代谢匹配面积(8.3±8.6)%,与无侧支循环组心肌灌注/代谢不匹配面积(13.7±9.2)%、灌注/代谢匹配面积(27.4±13.0)%相比,差异均有统计学意义(P均0.05)。两组 LVEDV[(109.8±30.0)ml vs.(173.7±57.7)ml]、LVESV[(62.8±22.4)ml vs.(123.5±51.7)ml]、LVEF[(43.9±8.5)%vs.(31.0±8.3)%]相比,差异均有统计学意义(P均0.05)。结论:本研究初步发现,对于冠状动脉左前降支慢性完全闭塞病变的患者,冠状动脉侧支循环可以维持左心室静息心肌血流灌注、维持心肌存活、保护左心室心功能。第二部分心肌灌注显像、CT衰减校正和冠状动脉钙化积分一站式检查诊断冠心病心肌缺血的价值目的:探讨放射性核素心肌灌注显像(MPI)与CT衰减校正(CTAC)MPI在图像质量及诊断心肌缺血效能方面的差异;进一步探讨MPI、CTAC、冠状动脉钙化积分(CACS)及三者“一站式”检查对心肌缺血诊断的价值。方法:前瞻性对148例可疑冠心病或已确诊冠心病患者行SPECT/CTMPI,前后三个月内行冠状动脉造影检查,根据有无进行CT衰减校正,分为CTACMPI与没有进行CT衰减校正(NO AC)MPI两组,分析两者在左心室各节段放射性计数百分比[性别、体重指数(BMI)]、图像质量、心肌灌注及左心室心功能参数间的差异;以冠状动脉造影结果显示管腔最大狭窄≥70%为“金标准”,比较两者对心肌缺血诊断效能间的差异。对其中54例患者进行SPECT/CT MPI和CACS 一站式检查,同样以冠状动脉造影显示管腔最大狭窄≥70%为“金标准”,用受试者工作特征(ROC)曲线评价CACS、NO AC MPI、CTAC MPI及三者联合对心肌缺血的诊断效能。结果:(1)CTAC图像在左心室下壁、间壁的放射性计数明显高于NOAC图像(p0.001),心尖段、前壁明显低于NOAC(p0.05),侧壁在两者间无明显统计学差异(p0.05);(2)男性患者下壁、侧壁CTAC和NO AC图像放射性计数百分比的差异明显低于女性患者(p均0.05);(3)正常BMI患者左心室间壁CTAC和NO AC图像放射性计数百分比明显低于高BMI患者(p均0.05),与此相一致的还有运动心肌灌注显像中左心室下壁、侧壁,而在左心室心尖段、前壁、静息心肌灌注显像下壁及侧壁,正常BMI患者与高BMI患者间无明显统计学差异(p均0.05);(4)CTAC MPI所获得的SRS、SDS、运动试验TPD数值均高于NO AC MPI(p0.05);SSS与静息TPD则明显低于NO AC MPI(p0.001);(5)图像质量方面,CTAC MPI获得的图像质量评分(3.6±0.5)高于NO AC MPI(3.1±0.4),p0.05;(6)CTACMPI 与 NO AC MPI 诊断心肌缺血达到 82.4%(61/74)一致性。CTAC MPI诊断心肌缺血的ROC曲线下面积为0.66(95%可信区间:0.54-0.79);NO AC MPI图像诊断心肌缺血的ROC曲线下面积为0.67(95%可信区间:0.54-0.79),未见明显统计学差异(p0.05);(7)对54例患者进行MPI、CT衰减校正、CACS一站式检查。CACS诊断心肌缺血的ROC曲线下面积为0.71(95%可信区间:0.57-0.85),依据ROC曲线获得CACS诊断心肌缺血的最佳界值为109.6分,以此作为CACS阳性标准;CACS联合MPI诊断心肌缺血的ROC曲线下面积为0.75(95%可信区间:0.62-0.88);CACS联合CTAC MPI诊断心肌缺血的ROC曲线下面积为0.67(95%可信区间:0.53-0.82);CACS联合NO AC MPI、CTAC MPI诊断心肌缺血的ROC曲线下面积为0.73(95%可信区间:0.60-0.87),差异具有统计学意义(p0.05)。结论:(1)CT衰减校正的SPECT心肌灌注显像图像质量优于传统SPECT心肌灌注图像,增加左心室下壁、间壁的放射性分布,同时降低左心室心尖部、前壁放射性分布,而对侧壁没有影响;(2)NO AC MPI与CTAC MPI诊断心肌缺血达到82.4%的一致性,与冠状动脉造影结果相比较,两者在ROC曲线下面积相近,CTAC图像相对NO AC图像在增加诊断特异度的同时,降低了敏感度;(3)CACS会影响MPI对心肌缺血的诊断,CACS、CT衰减校正、MPI三者联合“一站式”检查可以同时获得冠状动脉功能学信息和解剖学信息,做到优势互补减少误诊或漏诊,但同时降低诊断特异度和提高阴性预测值;(4)结合所有优缺点,本研究的观点为正确看待CT衰减校正技术,不推荐作为常规进行心肌灌注显像。
[Abstract]:Part I study of myocardial radionuclide imaging of collateral circulation and myocardial survival in chronic complete occlusion of coronary artery left anterior descending branch Objective: To evaluate the role of coronary collateral circulation and myocardial survival in chronic complete occlusion of the left anterior descending coronary artery. Methods: 101 cases were clinically diagnosed as coronal in our hospital. The patients with chronic complete occlusion of the left anterior descending artery were treated with 99mTc- methoxy isobutyl isobutyl nitrile (MIBI) myocardial perfusion imaging and gated 18F- fluorodeoxyglucose (FDG) myocardial metabolism imaging, and underwent coronary angiography within 3 months and before. Myocardial perfusion images were reconstructed with myocardial metabolism imaging. QPS software was given the total score of resting myocardial perfusion (SRS), abnormal area of myocardial perfusion (TPD), myocardial perfusion / metabolic mismatch (surviving myocardium) area, myocardial perfusion / metabolic matching (no survival myocardium) area, and QGS software was used to analyze myocardial metabolism image, and the left ventricular end diastolic volume (LVEDV) and left ventricular end systolic volume were obtained. (LVESV), left ventricular ejection fraction (LVEF). According to the results of coronary angiography, there were collateral circulation group (n=39), no collateral circulation group (n=62), SRS, TPD, myocardial perfusion / metabolic mismatch area, myocardial perfusion / metabolic area, gated cardiac function parameters (LVEDV, LVESV, LVEF) between the two groups were compared. No old myocardial infarction, the chronic complete occlusion of the left anterior descending branch was divided into 4 subgroups. Compared the differences of the above parameters, the role of the collateral circulation was discussed. Results: 101 cases [86 men, 15 women, 59.9 + 11.4 years old]. There were 39 cases (38.6%) in the collateral circulation group, 62 in the non collateral circulation group (61.4%); two. The total score of group resting perfusion [(21.2 + 9.7) vs. (28.6 + 8.8)], abnormal perfusion area (30 + 13.7)%vs. (40.4 + 12.5)%, was statistically significant (P 0.05). There were myocardial perfusion / metabolic mismatched area (21.8 + 13.1)% of collateral circulation group (21.8 + 13.1), myocardial perfusion / metabolic area (8.3 + 8.6)%, and no myocardial perfusion / metabolism in non collateral circulation group. The matching area (13.7 + 9.2)%, perfusion / metabolic matched area (27.4 + 13)%, the difference was statistically significant (P 0.05). Two group LVEDV[(109.8 + 30) ml vs. (173.7 + 57.7) ml], LVESV[(62.8 + 22.4) ml vs. (123.5 +%) ml], LVEF[(P)% vs. (P all)%]. Conclusion: This study is preliminary. It was found that in patients with chronic complete occlusion of the left anterior descending coronary artery, the coronary collateral circulation could maintain left ventricular myocardial perfusion, maintain myocardial survival and protect the left ventricular function. Second partial myocardial perfusion imaging, CT attenuation correction and coronary artery calcification integral one station examination were used to diagnose myocardial ischemia of coronary heart disease. Objective: To explore the difference between radionuclide myocardial perfusion imaging (MPI) and CT attenuation correction (CTAC) MPI in image quality and diagnosis of myocardial ischemia, and further explore the value of MPI, CTAC, coronary artery calcification integral (CACS) and three "one station" examination for the diagnosis of myocardial ischemia. Methods: a prospective study of 148 cases of suspected coronary heart disease. Coronary angiography (SPECT/CTMPI), or three months before and after the diagnosis of coronary heart disease, was performed within three months of coronary angiography. According to whether CT attenuation correction was performed, it was divided into CTACMPI and MPI two without CT attenuation correction (NO AC). The radioactivity count percentage [sex, body mass index (BMI)], image quality, myocardial perfusion and left heart were analyzed in the left ventricular segments. The difference between the ventricular cardiac function parameters and the results of coronary angiography showed that the maximum stenosis of the lumen more than 70% was "gold standard". The difference between the two patients was compared. 54 patients were examined by SPECT/CT MPI and CACS one station, and the coronary angiography showed that the maximum stenosis of the lumen was more than 70% "gold standard". The diagnostic efficacy of CACS, NO AC MPI, CTAC MPI, and three were evaluated by the subjects' working characteristic (ROC) curve. Results: (1) the radioactivity count of CTAC image in the lower left ventricle was significantly higher than that of the NOAC image (p0.001), the apical segment and the anterior wall were lower than NOAC (P0.05), and there was no significant difference in the lateral wall between the two sides. (2) The percentage difference between the lower wall, the lateral wall CTAC and the NO AC images was significantly lower than that of the female patients (P 0.05). (3) the percentage of CTAC and NO AC images in the left ventricular septum in normal BMI patients was significantly lower than those in the high BMI (P 0.05), and the lower left ventricular wall and lateral wall of the myocardial perfusion imaging were consistent with this. There was no significant difference in the inferior wall and lateral wall of the left ventricular apical segment, anterior wall and resting myocardial perfusion imaging. There was no significant difference between the normal BMI patients and the high BMI patients (P 0.05). (4) the SRS, SDS, and the TPD value of CTAC MPI were higher than NO AC MPI (P0.05); (5) the image quality was obtained. The image quality score (3.6 + 0.5) was higher than that of NO AC MPI (3.1 + 0.4), P0.05, and (6) CTACMPI and NO AC MPI in the diagnosis of myocardial ischemia reached 82.4% (61/74) conformance.CTAC MPI diagnosis of myocardial ischemia under the ROC curve area of 0.66 (95% confidence interval), which was 0.67 (95% confidence interval: 0.54: 95% confidence interval). -0.79), there was no significant statistical difference (P0.05); (7) 54 patients were treated with MPI, CT attenuation correction, and CACS one-stop.CACS diagnosis of myocardial ischemia was 0.71 (95% confidence interval: 0.57-0.85), and the best boundary value of CACS to diagnose myocardial ischemia was 109.6 points according to the ROC curve. The area under the ROC curve of myocardial ischemia was 0.75 (95% confidence interval: 0.62-0.88); the area under the ROC curve of CACS combined with CTAC MPI for the diagnosis of myocardial ischemia was 0.67 (95% confidence interval: 0.53-0.82); CACS combined NO AC MPI, and 0.73 (95% confidence interval) for the diagnosis of myocardial ischemia (95% confidence interval), the difference has statistical significance. Conclusions: (1) the quality of CT attenuation corrected SPECT myocardial perfusion imaging is superior to that of the traditional SPECT myocardial perfusion image, increasing the radionuclide distribution of the lower left ventricle and the wall, reducing the radioactivity of the left ventricular apex, the anterior wall radioactivity and the lateral wall, and (2) the consistency between the NO AC MPI and the CTAC MPI for the diagnosis of myocardial ischemia is 82.4%, and the coronary artery is coronal. Compared with the results of arteriography, the area of the two is similar under the ROC curve. The CTAC image relative to the NO AC image reduces the sensitivity while increasing the diagnostic specificity. (3) CACS will affect the diagnosis of myocardial ischemia, CACS, CT attenuation correction, and the combination of MPI three "one station" examination can simultaneously obtain the information and anatomy of coronary artery function. Information, do the complementary advantages to reduce misdiagnosis or missed diagnosis, but at the same time reduce the diagnostic specificity and improve negative predictive value; (4) combined with all the advantages and disadvantages, this study view the correct view of the CT attenuation correction technique, not recommended as a routine myocardial perfusion imaging.
【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.4;R816.2

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