本文選題：冠狀動(dòng)脈疾病 + 側(cè)支循環(huán)��； 參考：《北京協(xié)和醫(yī)學(xué)院》2017年碩士論文

【摘要】：第一部分冠狀動(dòng)脈左前降支慢性完全閉塞病變中側(cè)支循環(huán)與心肌存活的心肌放射性核素顯像研究目的:評價(jià)冠狀動(dòng)脈側(cè)支循環(huán)與心肌存活在冠狀動(dòng)脈左前降支慢性完全閉塞病變中的作用。方法:研究納入101例于我院臨床確診為冠狀動(dòng)脈左前降支慢性完全閉塞病變患者。所有患者均行99mTc-甲氧基異丁基異腈(MIBI)心肌灌注顯像和門控18F-氟代脫氧葡萄糖(FDG)心肌代謝顯像,且在前后3個(gè)月內(nèi)接受過冠狀動(dòng)脈造影術(shù)。將心肌灌注圖像與心肌代謝顯像進(jìn)行同機(jī)重建,使用QPS軟件分別得到靜息心肌灌注總積分(SRS)、心肌灌注異常面積(TPD)、心肌灌注/代謝不匹配(存活心肌)面積、心肌灌注/代謝匹配(無存活心肌)面積,利用QGS軟件對心肌代謝圖像進(jìn)行分析,得到左心室舒張末期容積(LVEDV)、左心室收縮末期容積(LVESV)、左心室射血分?jǐn)?shù)(LVEF)。根據(jù)冠狀動(dòng)脈造影術(shù)結(jié)果分為有側(cè)支循環(huán)組(n=39)、無側(cè)支循環(huán)組(n=62),比較兩組之間SRS、TPD、心肌灌注/代謝不匹配面積、心肌灌注/代謝匹配面積、門控心功能參數(shù)(LVEDV、LVESV、LVEF)之間的差異;進(jìn)一步根據(jù)患者有無陳舊性心肌梗死、左前降支慢性完全閉塞部位各分為4個(gè)亞組,比較上述各項(xiàng)參數(shù)的差異,從而探討側(cè)支循環(huán)在其中的作用。結(jié)果:101例[男性86例,女性15例,平均年齡(59.9±11.4)歲]�；颊咧杏袀�(cè)支循環(huán)組39例(38.6%),無側(cè)支循環(huán)組62例(61.4%);兩組靜息灌注總積分[(21.2±9.7)vs.(28.6±8.8)]、灌注異常面積(30.0± 13.7)%vs.(40.4±12.5)%相比,差異均有統(tǒng)計(jì)學(xué)意義(P均0.05)。有側(cè)支循環(huán)組心肌灌注/代謝不匹配面積(21.8±13.1)%、心肌灌注/代謝匹配面積(8.3±8.6)%,與無側(cè)支循環(huán)組心肌灌注/代謝不匹配面積(13.7±9.2)%、灌注/代謝匹配面積(27.4±13.0)%相比,差異均有統(tǒng)計(jì)學(xué)意義(P均0.05)。兩組 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,差異均有統(tǒng)計(jì)學(xué)意義(P均0.05)。結(jié)論:本研究初步發(fā)現(xiàn),對于冠狀動(dòng)脈左前降支慢性完全閉塞病變的患者,冠狀動(dòng)脈側(cè)支循環(huán)可以維持左心室靜息心肌血流灌注、維持心肌存活、保護(hù)左心室心功能。第二部分心肌灌注顯像、CT衰減校正和冠狀動(dòng)脈鈣化積分一站式檢查診斷冠心病心肌缺血的價(jià)值目的:探討放射性核素心肌灌注顯像(MPI)與CT衰減校正(CTAC)MPI在圖像質(zhì)量及診斷心肌缺血效能方面的差異;進(jìn)一步探討MPI、CTAC、冠狀動(dòng)脈鈣化積分(CACS)及三者“一站式”檢查對心肌缺血診斷的價(jià)值。方法:前瞻性對148例可疑冠心病或已確診冠心病患者行SPECT/CTMPI,前后三個(gè)月內(nèi)行冠狀動(dòng)脈造影檢查,根據(jù)有無進(jìn)行CT衰減校正,分為CTACMPI與沒有進(jìn)行CT衰減校正(NO AC)MPI兩組,分析兩者在左心室各節(jié)段放射性計(jì)數(shù)百分比[性別、體重指數(shù)(BMI)]、圖像質(zhì)量、心肌灌注及左心室心功能參數(shù)間的差異;以冠狀動(dòng)脈造影結(jié)果顯示管腔最大狹窄≥70%為“金標(biāo)準(zhǔn)”,比較兩者對心肌缺血診斷效能間的差異。對其中54例患者進(jìn)行SPECT/CT MPI和CACS 一站式檢查,同樣以冠狀動(dòng)脈造影顯示管腔最大狹窄≥70%為“金標(biāo)準(zhǔn)”,用受試者工作特征(ROC)曲線評價(jià)CACS、NO AC MPI、CTAC MPI及三者聯(lián)合對心肌缺血的診斷效能。結(jié)果:(1)CTAC圖像在左心室下壁、間壁的放射性計(jì)數(shù)明顯高于NOAC圖像(p0.001),心尖段、前壁明顯低于NOAC(p0.05),側(cè)壁在兩者間無明顯統(tǒng)計(jì)學(xué)差異(p0.05);(2)男性患者下壁、側(cè)壁CTAC和NO AC圖像放射性計(jì)數(shù)百分比的差異明顯低于女性患者(p均0.05);(3)正常BMI患者左心室間壁CTAC和NO AC圖像放射性計(jì)數(shù)百分比明顯低于高BMI患者(p均0.05),與此相一致的還有運(yùn)動(dòng)心肌灌注顯像中左心室下壁、側(cè)壁,而在左心室心尖段、前壁、靜息心肌灌注顯像下壁及側(cè)壁,正常BMI患者與高BMI患者間無明顯統(tǒng)計(jì)學(xué)差異(p均0.05);(4)CTAC MPI所獲得的SRS、SDS、運(yùn)動(dòng)試驗(yàn)TPD數(shù)值均高于NO AC MPI(p0.05);SSS與靜息TPD則明顯低于NO AC MPI(p0.001);(5)圖像質(zhì)量方面,CTAC MPI獲得的圖像質(zhì)量評分(3.6±0.5)高于NO AC MPI(3.1±0.4),p0.05;(6)CTACMPI 與 NO AC MPI 診斷心肌缺血達(dá)到 82.4%(61/74)一致性。CTAC MPI診斷心肌缺血的ROC曲線下面積為0.66(95%可信區(qū)間:0.54-0.79);NO AC MPI圖像診斷心肌缺血的ROC曲線下面積為0.67(95%可信區(qū)間:0.54-0.79),未見明顯統(tǒng)計(jì)學(xué)差異(p0.05);(7)對54例患者進(jìn)行MPI、CT衰減校正、CACS一站式檢查。CACS診斷心肌缺血的ROC曲線下面積為0.71(95%可信區(qū)間:0.57-0.85),依據(jù)ROC曲線獲得CACS診斷心肌缺血的最佳界值為109.6分,以此作為CACS陽性標(biāo)準(zhǔn);CACS聯(lián)合MPI診斷心肌缺血的ROC曲線下面積為0.75(95%可信區(qū)間:0.62-0.88);CACS聯(lián)合CTAC MPI診斷心肌缺血的ROC曲線下面積為0.67(95%可信區(qū)間:0.53-0.82);CACS聯(lián)合NO AC MPI、CTAC MPI診斷心肌缺血的ROC曲線下面積為0.73(95%可信區(qū)間:0.60-0.87),差異具有統(tǒng)計(jì)學(xué)意義(p0.05)。結(jié)論:(1)CT衰減校正的SPECT心肌灌注顯像圖像質(zhì)量優(yōu)于傳統(tǒng)SPECT心肌灌注圖像,增加左心室下壁、間壁的放射性分布,同時(shí)降低左心室心尖部、前壁放射性分布,而對側(cè)壁沒有影響;(2)NO AC MPI與CTAC MPI診斷心肌缺血達(dá)到82.4%的一致性,與冠狀動(dòng)脈造影結(jié)果相比較,兩者在ROC曲線下面積相近,CTAC圖像相對NO AC圖像在增加診斷特異度的同時(shí),降低了敏感度;(3)CACS會(huì)影響MPI對心肌缺血的診斷,CACS、CT衰減校正、MPI三者聯(lián)合“一站式”檢查可以同時(shí)獲得冠狀動(dòng)脈功能學(xué)信息和解剖學(xué)信息,做到優(yōu)勢互補(bǔ)減少誤診或漏診,但同時(shí)降低診斷特異度和提高陰性預(yù)測值;(4)結(jié)合所有優(yōu)缺點(diǎn),本研究的觀點(diǎn)為正確看待CT衰減校正技術(shù),不推薦作為常規(guī)進(jìn)行心肌灌注顯像。
[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.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R541.4;R816.2

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