SPECT心肌灌注与PET心肌代谢显像在肥厚型心肌病中的应用

发布时间：2018-06-24 22:19

本文选题：肥厚型梗阻性心肌病 + 门控静息SPECT心肌灌注显像　；参考：《北京协和医学院》2014年博士论文

【摘要】：目的：肥厚型梗阻性心肌病(hypertrophic obstruction cardiomyopathy, HOCM)是一种不明原因的心室肌不均匀肥厚的心肌病,主要是以左心室(或)右心室肥厚为特征,常为不对称性肥厚并且累及室间隔,以左心室血液充盈受阻、舒张期顺应性下降为基本病态的特发性心肌病。经皮室间隔化学消融术(percutaneous transluminal septal myocardial ablation, PTSMA)是治疗HOCM的新技术。本研究旨在利用门控静息SPECT心肌灌注显像评价HOCM患者在PTSMA治疗前、后左心室心肌血流灌注及左心室功能的变化。方法：35例HOCM患者,其中男性24例(68.5%),女性11例(31.4%),平均年龄48±11岁。对所有患者行PTSMA治疗,并且在PTSMA术前4±10天(术前),术后4.7±1.0天(术后早期)以及术后15.5±8.2个月(术后中期)对所有患者行门控静息SPECT心肌灌注显像。图像分析采用17节段5分制半定量评分法(评分越高心肌血流灌注越差),评价化学消融术前、术后患者左心室各室壁节段的血流灌注情况。应用QGS软件计算左心室功能参数：即左心室射血分数(left ventricular ejection fraction, LVEF)、左心室室壁运动(left ventricular wall motion, WM),左心室室壁增厚率(left ventricular wall thickening, WT)等。比较35例患者PTSMA术前、术后早期及术后中期心肌灌注显像17节段灌注评分、左心室室壁运动、室壁增厚率及左心室整体射血分数。结果：PTSMA术前,33例(94%)HOCM患者左心室心肌可见放射性摄取增高,2例(6%)患者左心室心肌未见明显放射性异常分布。PTSMA术后早期,所有患者间隔部放射性分布均出现不同程度的减低至缺损,室间隔血流灌注评分明显高于PTSMA术前(1.28±1.53比-0.82±0.40,P0.001)。PTSMA术后中期后间隔血流灌注评分分数较PTSMA术后早期有明显的降低(1.77±1.11比2.23±1.06,P0.05),但是与PTSMA术前相比,后间隔血流灌注评分分数仍明显高于PTSMA术前(1.77±1.11比-0.70±0.46,P0.001)。患者PTSMA术后中期平均LVEF明显低于术前(59.7±8.6%比62.2±9.7%,P0.05),术后早期及中期患者LVEF未见明显变化。PTSMA术后,患者前壁基底段、间隔基底段及下后壁基底段左心室局部室壁运动较PTSMA术前明显减弱(P0.05),室间隔(尤其是后间隔基底段及间隔中段)左心室室壁增厚率较术前也明显减低(P0.05)。结论：门控静息SPECT心肌灌注显像可以显示PTSMA术前、术后HOCM患者左心室心肌血流灌注及左心室功能,因此评价PTSMA的疗效。目的：肥厚型心肌病(hypertrophic cardiomyopathy, HCM)是一种复杂而常见的遗传性心脏疾病,发病原因尚不明确,在人群中的患病率大约为1/500,由于HCM的高猝死率对病人危害极大,如何准确识别高危猝死患者一直是临床关注的重点。因此,本研究的目的是采用18F-FDGPET心肌葡萄糖代谢显像,评价HCM患者空腹及糖负荷状态下心肌葡萄糖代谢的变化,并与心脏磁共振延迟强化结果比较,以进一步揭示HCM的病理生理改变,为今后患者的预后分析提供帮助。方法：36例HCM患者,其中男性28例(78%),女性8例(22%),平均年龄41±12岁。对所有患者行心脏磁共振显像(CMR)和空腹±糖负荷状态18F-FDG PET心肌葡萄糖代谢显像。图像分析采用17节段5分制法进行半定量评分,评价患者左心室心肌葡萄糖代谢情况,将每位患者17节段的评分相加,得到代谢总评分。应用QGS软件计算左心室功能参数：即左心室射血分数(left ventricular ejection fraction, LVEF)及左心室舒张末期容积(left ventricular end-diastolic volume, LVEDV)等。结果：HCM患者空腹及糖负荷状态下,其葡萄糖代谢显像表现明显的不均一性。空腹状态下,左心室各心肌节段均未见放射性摄取5例(14%),各心肌节段均完整显影3例(8%),心肌某一或某些节段可见放射性摄取28例(78%)；在糖负荷状态下,左心室显像清晰,各心肌节段均可见放射性摄取30例(83%),部分心肌节段有放射性摄取6例(17%)。根据CMR将患者分为延迟强化组(24例)及非延迟强化组(12例),发现在空腹状态下延迟强化组患者左心室心肌代谢总评分较非延迟强化组明显减低(23.7±7.0比36.2±14.2,P0.05),提示延迟强化组患者放射性摄取增高；糖负荷状态下,两组患者代谢总评分未见明显统计学差异。比较患者空腹及葡萄糖负荷下心肌代谢显像的变化,发现部分心肌节段(42个)在空腹状态下放射性摄取较其它心肌节段增高,而糖负荷状态下放射性摄取较其他心肌节段稀疏或缺损。根据上述发现将36例HCM患者分为两组,组1患者是包括上述42个心肌节段的11例患者,组2为其余25例患者；与组2患者相比,组1患者室间隔厚度明显增加(24.6±3.9mm比21.3±5.9mm,P0.05),左心室后壁厚度明显增加(98.3±29.1mm比94.4±16.3mm,P0.05),延迟强化的心肌节段数明显增多[83(44.5%)比52(12.2%),P0.001],LVEF明显减低(67.4±15.5%比73.1±5.8%,P0.05)。结论：肥厚型心肌病F-FDGPET心肌葡萄糖代谢显像表现明显的不均一性,在空腹显影时左心室某一或某些心肌节段放射性摄取较其它节段增高而糖负荷显影时其放射性摄取稀疏或缺损,可能与HCM患者CMR显像延迟强化存在一定的关系,因此可能可以作为HCM患者危险度分层的指标。目的：门控单光子发射计算机断层(SPECT)心肌灌注显像(MPI)不仅可以评价左心室心肌血流灌注,亦可评价左心室心功能,测定左心室心腔容积,而运动／药物负荷试验MPI是目前非介入性影像学检查中最常用、准确的冠心病诊断方法。本研究的目的是评价腺苷负荷后患者左心室功能的变化(心肌顿抑)及其与冠心病心肌缺血的关系。方法：前瞻性分析了2010年1月1日至2010年12月31日因疑诊冠心病(coronary artery disease, CAD)住院的患者70例(男性39例,女性31例,年龄38-78岁),平均年龄59±10岁。所有患者均行2日法腺苷负荷试验+静息门控SPECT心肌灌注显像。于腺苷注射3min时静脉注射显像剂99mTc-甲氧基异丁基异腈(99mTc-MIBI)740-925MBq,注射显像剂15-30min后服脂肪餐,90分钟后行心肌断层SPECT显像,间隔48-72h后行静息心肌灌注显像。所有患者均行冠状动脉造影检查。心肌灌注显像图像分析采用17节段5分制法进行半定量评分,得到负荷灌注总评分(summed stress score, SSS)、静息灌注总评分(summed rest score, SRS)及心肌缺血总评分(summed difference score, SDS)。应用QGS软件计算左心室功能参数：即左心室射血分数(left ventricular ejection fraction, LVEF)、左心室舒张末期容积(left ventricular end-diastolic volume, LVEDV)及左心室收缩末期容积(left ventricular end-systolic volume, LVESV)等结果：根据腺苷负荷试验+静息门控心肌灌注显像所测得的LVEF将患者分为两组：腺苷负荷试验LVEF较静息状态下LVEF降低≥5%的患者组(16例)及腺苷负荷试验LVEF较静息降低5%的患者组(54例)。与LVEF降低5%组的患者相比,LVEF降低≥5%组的患者冠状脉狭窄程度及病变范围更严重(冠脉狭窄90%～100%：38%比11%,P0.05；多支病变：50%比26%,P0.05)；LVEF降低≥5%组患者的SSS及SDS明显大于LVEF降低5%组(9.1±6.8比5.6±4.5,P0.05；6.6±3.8比3.6±4.0,P0.05),即心肌灌注缺损程度更严重。结论：门控腺苷负荷试验心肌灌注显像检测患者有无CAD心肌缺血,应同时关注左心室功能的变化(即是否存在心肌顿抑),腺苷负荷试验LVEF的严重降低(≥5%)对诊断CAD有着较高的特异性,负荷LVEF明显降低可增加CAD心肌缺血及心脏事件发生可能性。腺苷负荷试验后LVEF较静息明显降低(≥5%)可作为诊断冠心病的一个重要而有效的证据。
[Abstract]:Objective: hypertrophic obstructive cardiomyopathy (hypertrophic obstruction cardiomyopathy, HOCM) is an unknown cause of ventricular inhomogeneous hypertrophic cardiomyopathy. It is characterized by left ventricular (or) right ventricular hypertrophy, often asymmetrical hypertrophy and interventricular septum involving left ventricular blood filling and diastolic compliance decline. Basic pathological idiopathic cardiomyopathy. Percutaneous transluminal septal myocardial ablation (PTSMA) is a new technique for the treatment of HOCM. The aim of this study was to evaluate the changes of left ventricular myocardial perfusion and left ventricular function in the left ventricular myocardium before PTSMA treatment by gated resting SPECT myocardial perfusion imaging.
Methods: 35 cases of HOCM, including 24 males (68.5%) and 11 females (31.4%), were 48 + 11 years old. All patients were treated with PTSMA, and 4 + 10 days before PTSMA (preoperative), 4.7 + 1 days after operation (early postoperative) and 15.5 + 8.2 months after operation (middle period after operation), all patients were subjected to gated SPECT myocardial perfusion imaging. The 17 segment 5 score semi quantitative score (higher score of myocardial perfusion) was used to evaluate the blood flow perfusion in the left ventricular wall segment of the left ventricle before chemical ablation. The left ventricular function parameters were calculated by QGS software: the left ventricular ejection fraction (left ventricular ejection fraction, LVEF), and the left ventricular wall movement (left VE). Ntricular wall motion, WM), the thickening rate of left ventricular wall (left ventricular wall thickening, WT). Compared with 35 patients before PTSMA, 17 segments perfusion score, left ventricular wall motion, ventricular wall thickening and left ventricular ejection fraction were compared before and after operation.
Results: before PTSMA, the left ventricular myocardium was increased in 33 cases (94%) of HOCM, and 2 cases (6%) had no obvious radiation-induced abnormal distribution of left ventricular myocardium in the early period of.PTSMA operation. All the radionuclide distributions in the septum of all patients were reduced to varying degrees to the defect, and the ventricular septal perfusion score was significantly higher than that before PTSMA (1.28 + 1). The mid-term posterior septal perfusion score of.53 was significantly lower than that of -0.82 after PTSMA (1.77 + 1.11 / 2.23 + 1.06, P0.05) after.PTSMA, but the score of posterior septal perfusion score was still significantly higher than that before PTSMA (1.77 + 1.11 / -0.70 + 0.46, P0.001). It was significantly lower than before (59.7 + 8.6%, 62.2 + 9.7%, P0.05). After the operation of LVEF, the anterior wall of the anterior wall, the basal segment of the basal segment and the basement of the lower posterior wall decreased significantly after the operation (P0.05), and the ventricular septum (especially the posterior septum and the middle interval) left ventricular wall. The thickening rate was significantly lower than that before operation (P0.05).
Conclusion: gated SPECT myocardial perfusion imaging can show the left ventricular myocardial perfusion and left ventricular function in HOCM patients before PTSMA, and therefore evaluate the curative effect of PTSMA.
Objective: hypertrophic cardiomyopathy (HCM) is a complex and common genetic heart disease. The cause of the disease is not clear, the prevalence rate in the population is about 1/500, and the high sudden death rate of HCM is very harmful to the patients. Therefore, how to identify the patients with high risk of sudden death is the focus of clinical attention. The aim of this study was to evaluate the changes of glucose metabolism in HCM patients under the fasting and glucose load condition by 18F-FDGPET myocardial glucose metabolism imaging, and to compare the results with the delayed enhancement of cardiac magnetic resonance (MRI) in order to further reveal the pathophysiological changes of HCM and provide help for the post analysis of the patients in the future.
Methods: 36 patients with HCM, including 28 males (78%) and 8 women (22%), were 41 + 12 years old. The cardiac magnetic resonance imaging (CMR) and 18F-FDG PET myocardial glucose metabolism imaging were performed on all patients. The image analysis was conducted by the 17 segment 5 score method to evaluate the glucose metabolism in the left ventricular myocardium. The score of 17 segments of each patient was added to the total metabolic score. The left ventricular function parameters were calculated by QGS software: the left ventricular ejection fraction (left ventricular ejection fraction, LVEF) and left ventricular end diastolic volume (left ventricular end-diastolic volume, LVEDV) and so on.
Results: the glucose metabolism imaging of HCM patients showed significant heterogeneity under the condition of fasting and sugar loading. No radioactivity was found in 5 cases (14%) in all segments of left ventricle, 3 cases (8%), 28 cases (78%) of radioactivity in one or some segments of the myocardium, and left in the glucose load state. Radionuclide uptake was clear in 30 cases (83%) in all segments of myocardium and 6 cases (17%) of radioactive uptake in partial segments of myocardium. The patients were divided into delayed intensification group (24 cases) and non delayed strengthening group (12 cases) according to CMR. The total score of left ventricular myocardial metabolism in delayed intensification group was significantly lower than that in non delayed enhancement group. 23.7 + 7 to 36.2 + 14.2, P0.05), suggesting that the patients in the delayed intensification group had increased radioactivity, and there was no significant difference in the total metabolic score between the two groups. Compared with the changes in the cardiac metabolism of the patients under the empty stomach and glucose load, some myocardial segments (42) were exposed to other hearts in the fasting state. 36 cases of HCM patients were divided into two groups according to the above findings. In the group 1 patients were included in 11 patients with 42 myocardial segments above, and 2 of the other 25 patients. Compared with the group 2, the interval thickness of the 1 patients was significantly increased (24.6 + 3.9mm than 21.3 +. 5.9mm, P0.05), the thickness of left ventricular posterior wall increased significantly (98.3 + 29.1mm ratio 94.4 + 16.3mm, P0.05). The number of delayed enhanced myocardial segments increased significantly, [83 (44.5%) was 52 (12.2%), P0.001], LVEF decreased significantly (67.4 + 15.5% than 73.1 + 5.8%, P0.05).
Conclusion: the glucose metabolism imaging of F-FDGPET myocardium in hypertrophic cardiomyopathy shows a distinct heterogeneity. The radioactivity uptake of one or some of the left ventricles in the left ventricle is higher than that of the other segments while the glucose load development is sparse or defect, which may be related to the delayed enhancement of CMR imaging in patients with HCM. This may be used as an indicator of risk stratification in HCM patients.
Objective: gated single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) can not only evaluate left ventricular myocardial perfusion, but also evaluate left ventricular cardiac function and determine the volume of left ventricular heart cavity. Motion / drug load test MPI is the most commonly used and accurate diagnosis of coronary heart disease in non interventional imaging examination. The aim of this study was to evaluate the changes of left ventricular function (myocardial stunning) and its relationship with myocardial ischemia in patients with coronary heart disease after adenosine loading.
Methods: a prospective analysis of 70 patients (39 males, 31 females, 38-78 years old) with a mean age of 59 + 10 years old for coronary artery disease (CAD) from January 1, 2010 to December 31, 2010. All patients were treated with 2 day adenosine load test and resting gated SPECT myocardial perfusion imaging. Static adenosine injection of 3min was static. Pulse injection imaging agent 99mTc- methoxy isobutyl isonitrile (99mTc-MIBI) 740-925MBq, 15-30min after injection of imaging agent to take fat meal, 90 minutes after myocardial SPECT imaging, interval 48-72h after resting myocardial perfusion imaging. All patients were performed coronary angiography. Myocardial perfusion imaging analysis using the 17 segment 5 points method for half The total score of summed stress score (SSS), the total score of resting perfusion (summed rest score, SRS) and the total myocardial ischemia score (summed difference score, SDS) were obtained. Left ventricular end-diastolic volume (LVEDV) and left ventricular end systolic volume (left ventricular end-systolic volume, LVESV) and so on.
Results: according to the adenosine load test and resting gated myocardial perfusion imaging, the LVEF patients were divided into two groups: the adenosine load test LVEF was more than 5% in the resting state (16 cases) and the LVEF in the adenosine load test was 5% in the resting group (54 cases). Compared with the 5% group of LVEF, the patients with the adenosine load test were lower than the 5% group. The degree and extent of coronary artery stenosis were more serious (90% to 100%:38% ratio of coronary stenosis, P0.05, P0.05; 50% to 26%, P0.05); SSS and SDS in LVEF decreased more than 5% groups (9.1 + 6.8, 5.6 + 4.5, P0.05; 6.6 + 3.8, 3.6 +, P0.05), that is, the degree of myocardial perfusion defect was more serious.
Conclusion: gated adenosine load test myocardial perfusion imaging can detect myocardial ischemia in patients with CAD, and should pay attention to the changes of left ventricular function (that is, whether there is myocardial stunning). The severe reduction of LVEF in adenosine load test (> 5%) has a high specificity for the diagnosis of CAD, and a significant decrease in load LVEF can increase CAD myocardial ischemia and cardiac events. The possibility of LVEF decreased significantly after the adenosine stress test (over 5%). It can be used as an important and effective evidence for the diagnosis of coronary heart disease.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R542.22;R816.2

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