本文關(guān)鍵詞： 心臟磁共振 兒童 病毒性心肌炎 延遲增強掃描　出處：《山東大學(xué)》2013年碩士論文　論文類型：學(xué)位論文

【摘要】：目的 病毒性心肌炎(VMC)是兒童最常見的心肌炎類型,心內(nèi)膜心肌活檢被認為是診斷VMC的“金標準”,有創(chuàng)性和低敏感度限制了其在臨床中的應(yīng)用。目前VMC的主要診斷方法包括心肌標記物、心電圖、超聲心動圖等。心臟磁共振(CMR)具有無創(chuàng)性、高分辨率、大視野、多方位成像等特點,是心血管疾病的新型影像學(xué)診斷方法,尤其是心肌灌注和延遲增強掃描技術(shù)在病毒性心肌炎中的應(yīng)用近年來備受關(guān)注,但其在兒童病毒性心肌炎中的應(yīng)用國內(nèi)外文獻報道較少,本研究旨在探討CMR心肌灌注和延遲增強掃描對兒童病毒性心肌炎的診斷價值。 方法 選擇2011年7月至2013年3月于山東省立醫(yī)院門診及住院治療的28例病毒性心肌炎患兒作為VMC組,其中男18例,女10例,年齡5歲-16歲,平均年齡9.6歲；選擇7例原發(fā)性擴張型心肌病患兒作為擴心組,其中男5例,女2例,年齡1.2歲-10歲,平均年齡6.2歲；同時選擇兒科門診查體的13名健康兒童作為對照組,其中男8例,女5例,年齡6歲-12歲,平均年齡8.9歲。診斷標準參照1999年全國心肌炎心肌病學(xué)術(shù)研討會上制定的病毒性心肌炎和心肌病診斷標準,其中出現(xiàn)急性心功能不全、心源性休克或心腦綜合征的VMC患兒診斷為重癥VMC,而僅表現(xiàn)為胸悶、乏力等的VMC患兒診斷為普通VMC。所有兒童先抽取外周血檢測肌鈣蛋白T、肌酸激酶同工酶質(zhì)量、N端腦鈉肽前體,做心電圖和經(jīng)胸超聲心動圖檢查。然后在急性期完成CMR檢查,內(nèi)容包括平掃、電影成像、心肌灌注和延遲增強掃描,分析心臟形態(tài)、心肌動度、左室射血分數(shù)、心肌灌注和延遲期信號變化。將CMR結(jié)果與心肌損傷標記物、心電圖、超聲心動圖結(jié)果對比,5例VMC患兒于恢復(fù)期復(fù)查CMR,并將結(jié)果與急性期CMR結(jié)果進行對比。 結(jié)果 1.28例VMC患兒均于發(fā)病前1至3周有呼吸道或腸道病毒感染史,其中9例診斷為重癥VMC,包括3例急性心力衰竭,3例阿斯綜合征發(fā)作,2例Ⅲ度房室傳導(dǎo)阻滯,1例心源性休克；其余19例診斷為普通VMC。 2.所有兒童中年齡最小者為1.2歲,均順利完成CMR檢查,無一例出現(xiàn)對比劑過敏及其他并發(fā)癥,心率在120次／分以下,平均檢查時間為40分鐘至1小時。 3.VMC組共有19例患兒出現(xiàn)CMR異常,主要表現(xiàn)為：(1)心腔擴大者7例,局部心肌變薄者12例,室間隔心肌增厚者2例；(2)心肌動度減低者8例,左室EF減低者4例,為44%-49%；(3)T2加權(quán)像出現(xiàn)高信號者1例,出現(xiàn)心肌延遲強化者17例,心肌延遲強化信號主要分布在左心室側(cè)壁和下壁,部分患兒多個心肌部位受累,重癥VMC主要為異常明顯的彌漫性強化,普通VMC主要為輕中度散在斑片狀強化。 4.CMR延遲增強掃描在VMC組的敏感度明顯高于擴心組(60.71%vs0%,P0.01),并且對重癥VMC的敏感度明顯高于普通VMC(100%vs42.11%,P0.01),特異度均為100%。 5.心電圖上出現(xiàn)缺血樣ST-T圖形的VMC患兒中,70%的患兒在相應(yīng)部位出現(xiàn)CMR延遲強化信號；超聲心動圖上出現(xiàn)心肌變薄或心肌動度減低的VMC患兒中,68.75%的患兒在相應(yīng)部位出現(xiàn)CMR延遲強化信號。 6.5例患兒分別于急性期和恢復(fù)期行CMR,其中3例患兒恢復(fù)期CMR延遲期強化信號消失,2例患兒延遲期強化信號強度較急性期減弱、范圍較急性期減小。 結(jié)論 1.心臟磁共振是兒童病毒性心肌炎十分安全有效的無創(chuàng)性檢查手段。 2.病毒性心肌炎在心臟磁共振上表現(xiàn)為心臟擴大,局部心肌變薄、動度減低,左室射血分數(shù)減低,延遲增強掃描時病灶區(qū)出現(xiàn)強化信號是其特異性表現(xiàn)。 3.磁共振心肌延遲增強掃描對重癥心肌炎敏感度高于對普通心肌炎的敏感度,并具有較高的特異度。 4.磁共振心肌延遲增強掃描可以動態(tài)觀察心肌炎癥的變化,可用于病情隨訪。
[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.

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2013
【分類號】：R725.4

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