本文關鍵詞：第二代雙源CT對復雜型先天性心血管病的臨床應用研究，，由筆耕文化傳播整理發(fā)布。

        第一部分：新的對比劑注射方法結合大螺距掃描技術在復雜型先天性心血管病成像中的臨床可行性研究背景和目的：近幾年來,有關復雜型先天性心血管病的CT臨床應用研究甚多,以往研究較多的是多排螺旋CT(multi-detector spiral computed tomography,MDCT)回顧性心電門控掃描,其最大的弊端是輻射劑量大,雖然可以通過降低管電流、管電壓等措施降低輻射劑量,但輻射劑量及對比劑劑量較大仍然是不可忽視的問題。隨著二代雙源CT的誕生,其先進的設備(兩套球管、兩套探測器)及掃描模式(Flash掃描模式)為心臟CT成像開創(chuàng)了空前的快速低劑量掃描,其輻射劑量可以達到亞mSv,堪稱“綠色CT”,其快速掃描間接減少了對比劑的用量。第二個問題,圖像質量問題,以往對于心臟成像,無論是冠脈疾病或是先天性心血管疾病,對比劑注射方法均采用雙筒單流注射,即先高流率快速注射對比劑,再低流率慢速注射對比劑,最后注射生理鹽水的注射方法,該方法產生的上腔靜脈偽影較大,對部分結構及畸變不能很好的顯示。然而,眾所周知,先天性心血管病不同于冠脈病變,前者心臟及與心臟相連的大血管的任何一個結構都有可能畸變,故其對圖像要求更高,最好是能夠消除上腔靜脈偽影,使得心臟、冠脈及與心臟相連的大血管都能夠均勻顯影,不能單純看冠脈的顯示。基于該出發(fā)點的研究,國內外甚少報道。本研究即是探討新雙源Flash CT應用于復雜型先天性心血管疾病的成像技術和方法,探索最合理的掃描方法和技術,以期達到降低輻射劑量、降低對比劑劑量及消除上腔靜脈偽影、提高圖像質量的目的。材料與方法：43例(平均分成A、B兩組)復雜型先天性心臟病患兒,均接受新雙源FlashCT(西門子炫速雙源CT,德國)檢查及手術治療。A組(18例)為Flash CT常規(guī)注藥方式及掃描組,對比劑的注藥方式及掃描參數(shù)設置均采用常規(guī)用量及用法；B組(25例)為優(yōu)化注藥方式及掃描組,對比劑注藥方式及掃描參數(shù)設置采用優(yōu)化方案。將所有病例的圖像根據(jù)需要進行多平面重建(1nultiple planar reformation, MPR),曲面重建(curve planar reformation,最大密度投影(maximum intensity projeetion,MIP)和三維容積再現(xiàn)(volume rendering,VR)等后處理分析。對A、B兩組間的圖像質量、對比劑用量及輻射劑量進行比較,并將結果進行統(tǒng)計學分析。結果：兩組間圖像質量的評價參數(shù)是一致的,上腔靜脈、右心房、右心室、肺動脈、左心房、左心室、升主動脈及降主動脈的增強CT值,A組高于B組(P>0.05),心腔及大血管不同部位CT差值,兩者之間比較有顯著性統(tǒng)計學差異(P=0.00),其中上腔靜脈、右心房的圖像質量B組明顯優(yōu)于A組(P<0.05),而肺動脈、左心房、左心室、主動脈的圖像質量A組明顯優(yōu)于B組(P<0.05),兩組間的有效輻射劑量相比,B組明顯低于A組(W=350,P=0.00)。A組的對比劑用量明顯多于B組(t=3.56,P=0.038)。結論：1.進行復雜型先天性心血管病檢查時應將圖像質量、診斷質量以及射線劑量進行綜合考慮,采用最合理的檢查方法。2.第二代雙源CT Flash(?)劑量掃描技術在復雜型先天性心血管病的診斷中在不丟失診斷信息的情況下最大限度的降低了輻射劑量,是值得推廣的掃描方法。3.新的對比劑注射方法有效的降低了上腔靜脈偽影、減少了對比劑劑量,在某種意義上提高了圖像質量,值得推廣應用。第二部分：新的對比劑注射方法結合大螺距掃描成像技術對復雜型先天性心血管病的診斷價值研究——與超聲心動圖及手術結果對照背景和目的：一直以來,超聲心動圖(echocardiograph,ECHO)對復雜型先天性心血管病的診斷在臨床上都處于主導地位。然而,多排螺旋CT (multi-detector spiral computed tomography, MDCT)對復雜型先天性心血管病的臨床應用已有多年歷史,在診斷復雜型先心病中體現(xiàn)出很大的優(yōu)勢。本研究的目的旨在通過研究新的對比劑注射方法結合大螺距掃描技術對復雜型先天性心血管病的診斷應用,并將結果同超聲心動圖及手術結果進行對照,評價新的對比劑注射方法結合大螺距掃描CT成像技術對復雜型先天性心血管病的診斷價值及對手術治療的指導意義。材料與方法：將43例患者隨機分成兩組：常規(guī)組(A組)、優(yōu)化組(B組),分別進行MDCT (Flash CT)和ECHO檢查,所有患者均接受外科手術治療,術中記錄病變的位置及測量大小。掃描原始數(shù)據(jù)需要進行多平面重建,最大密度投影、曲面重建和三維容積再現(xiàn)等后處理。由兩位有經驗的放射科醫(yī)師對圖像進行分析。對結果進行對照研究,將所有病變畸形分為心臟內部畸形、心臟血管連接部畸形及心臟周圍血管畸形三部分。Flash CT兩種檢查方法的結果、ECHO結果均同手術結果對照。結果：心臟內部畸形共102處,與手術結果對照,Flash CT檢查診斷正確87處,診斷不正確15處,ECHO診斷正確99處,診斷不正確3處,Flash CT和ECHO對心臟畸形的診斷準確性分別為85.29%(87/102)和97.06%(99/102),兩組比較差異具有統(tǒng)計學意義(χ2=9.437,P=0.0038)。心臟血管連接部及心臟周圍血管畸形共69處,與手術結果對照,Flash CT檢查診斷正確67處,診斷不正確2處,ECHO診斷正確49處,診斷不正確20處,Flash CT和ECHO對心臟血管連接部及心臟周圍血管畸形的診斷準確性分別為97.10%(67/69)和71.01%(49/69),兩組比較差異具有統(tǒng)計學意義(χ2=16.704,P=0.000)。Flash CT對全部171處心血管畸形診斷正確154處,診斷不正確17處,診斷準確性為90.06%(154/171),ECHO對全部171處心血管畸形診斷正確148處,診斷不正確23處,診斷準確性為87.72%(148/171),兩者比較差異沒有統(tǒng)計學意義(χ2=0.095,P=-0.567)。結論：1. ECHO作為心臟畸形的首選檢查手段,其診斷準確性高,是可以信賴的一種檢查手段,但是對于心臟內部畸形缺損較小、局部血液分流不明顯或合并多種畸形(尤其是心臟大血管連接部畸形及心外畸形)時ECHO檢查容易漏診。2.原始軸位圖像仍是Flash CT診斷復雜型先天性心血管疾病的分析基礎,通過原始軸位圖像發(fā)現(xiàn)病變后,再結合多種三維后處理重建技術能夠更好的顯示病變的大小、位置,指導臨床手術治療。3. Flash CT掃描速度快、空間分辨率高,對于心臟血管連接處及心外畸形的診斷有其明顯優(yōu)勢。4. Flash CT與ECHO檢查對復雜型先心病的診斷沒有顯著差異,兩者各有其優(yōu)勢,Flash CT對心臟血管連接部及心外血管畸形的診斷優(yōu)于ECHO,而ECHO對心內畸形尤其是瓣膜病變的診斷價值要好于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.

第二代雙源CT對復雜型先天性心血管病的臨床應用研究

摘要4-8Abstract8-12目錄13-15中英文對照表15-16前言16-21    參考文獻19-21第一部分：新的對比劑注射方法結合大螺距掃描技術在復雜型先天性心血管病成像中的臨床可行性研究21-39    前言21-22    材料與方法22-25    結果25-32    討論32-36    結論36-37    參考文獻37-39第二部分：新的對比劑注射方法結合大螺距掃描成像技術對復雜型先天性心血管病的診斷價值研究——與超聲心動圖及手術結果對照39-53    前言39-40    材料與方法40-41    結果41-47    討論47-50    結論50-51    參考文獻51-53綜述 影像學檢查方法對復雜型先天性心血管病的臨床應用概況53-69    參考文獻66-69個人簡歷及在研期間發(fā)表論文69-70致謝70

  本文關鍵詞：第二代雙源CT對復雜型先天性心血管病的臨床應用研究，由筆耕文化傳播整理發(fā)布。