本文選題：肥厚型梗阻性心肌病 + 門控靜息SPECT心肌灌注顯像��； 參考：《北京協(xié)和醫(yī)學(xué)院》2014年博士論文

【摘要】：目的：肥厚型梗阻性心肌病(hypertrophic obstruction cardiomyopathy, HOCM)是一種不明原因的心室肌不均勻肥厚的心肌病,主要是以左心室(或)右心室肥厚為特征,常為不對(duì)稱性肥厚并且累及室間隔,以左心室血液充盈受阻、舒張期順應(yīng)性下降為基本病態(tài)的特發(fā)性心肌病。經(jīng)皮室間隔化學(xué)消融術(shù)(percutaneous transluminal septal myocardial ablation, PTSMA)是治療HOCM的新技術(shù)。本研究旨在利用門控靜息SPECT心肌灌注顯像評(píng)價(jià)HOCM患者在PTSMA治療前、后左心室心肌血流灌注及左心室功能的變化。 方法：35例HOCM患者,其中男性24例(68.5%),女性11例(31.4%),平均年齡48±11歲。對(duì)所有患者行PTSMA治療,并且在PTSMA術(shù)前4±10天(術(shù)前),術(shù)后4.7±1.0天(術(shù)后早期)以及術(shù)后15.5±8.2個(gè)月(術(shù)后中期)對(duì)所有患者行門控靜息SPECT心肌灌注顯像。圖像分析采用17節(jié)段5分制半定量評(píng)分法(評(píng)分越高心肌血流灌注越差),評(píng)價(jià)化學(xué)消融術(shù)前、術(shù)后患者左心室各室壁節(jié)段的血流灌注情況。應(yīng)用QGS軟件計(jì)算左心室功能參數(shù)：即左心室射血分?jǐn)?shù)(left ventricular ejection fraction, LVEF)、左心室室壁運(yùn)動(dòng)(left ventricular wall motion, WM),左心室室壁增厚率(left ventricular wall thickening, WT)等。比較35例患者PTSMA術(shù)前、術(shù)后早期及術(shù)后中期心肌灌注顯像17節(jié)段灌注評(píng)分、左心室室壁運(yùn)動(dòng)、室壁增厚率及左心室整體射血分?jǐn)?shù)。 結(jié)果：PTSMA術(shù)前,33例(94%)HOCM患者左心室心肌可見放射性攝取增高,2例(6%)患者左心室心肌未見明顯放射性異常分布。PTSMA術(shù)后早期,所有患者間隔部放射性分布均出現(xiàn)不同程度的減低至缺損,室間隔血流灌注評(píng)分明顯高于PTSMA術(shù)前(1.28±1.53比-0.82±0.40,P0.001)。PTSMA術(shù)后中期后間隔血流灌注評(píng)分分?jǐn)?shù)較PTSMA術(shù)后早期有明顯的降低(1.77±1.11比2.23±1.06,P0.05),但是與PTSMA術(shù)前相比,后間隔血流灌注評(píng)分分?jǐn)?shù)仍明顯高于PTSMA術(shù)前(1.77±1.11比-0.70±0.46,P0.001)。患者PTSMA術(shù)后中期平均LVEF明顯低于術(shù)前(59.7±8.6%比62.2±9.7%,P0.05),術(shù)后早期及中期患者LVEF未見明顯變化。PTSMA術(shù)后,患者前壁基底段、間隔基底段及下后壁基底段左心室局部室壁運(yùn)動(dòng)較PTSMA術(shù)前明顯減弱(P0.05),室間隔(尤其是后間隔基底段及間隔中段)左心室室壁增厚率較術(shù)前也明顯減低(P0.05)。 結(jié)論：門控靜息SPECT心肌灌注顯像可以顯示PTSMA術(shù)前、術(shù)后HOCM患者左心室心肌血流灌注及左心室功能,因此評(píng)價(jià)PTSMA的療效。 目的：肥厚型心肌病(hypertrophic cardiomyopathy, HCM)是一種復(fù)雜而常見的遺傳性心臟疾病,發(fā)病原因尚不明確,在人群中的患病率大約為1/500,由于HCM的高猝死率對(duì)病人危害極大,如何準(zhǔn)確識(shí)別高危猝死患者一直是臨床關(guān)注的重點(diǎn)。因此,本研究的目的是采用18F-FDGPET心肌葡萄糖代謝顯像,評(píng)價(jià)HCM患者空腹及糖負(fù)荷狀態(tài)下心肌葡萄糖代謝的變化,并與心臟磁共振延遲強(qiáng)化結(jié)果比較,以進(jìn)一步揭示HCM的病理生理改變,為今后患者的預(yù)后分析提供幫助。 方法：36例HCM患者,其中男性28例(78%),女性8例(22%),平均年齡41±12歲。對(duì)所有患者行心臟磁共振顯像(CMR)和空腹±糖負(fù)荷狀態(tài)18F-FDG PET心肌葡萄糖代謝顯像。圖像分析采用17節(jié)段5分制法進(jìn)行半定量評(píng)分,評(píng)價(jià)患者左心室心肌葡萄糖代謝情況,將每位患者17節(jié)段的評(píng)分相加,得到代謝總評(píng)分。應(yīng)用QGS軟件計(jì)算左心室功能參數(shù)：即左心室射血分?jǐn)?shù)(left ventricular ejection fraction, LVEF)及左心室舒張末期容積(left ventricular end-diastolic volume, LVEDV)等。 結(jié)果：HCM患者空腹及糖負(fù)荷狀態(tài)下,其葡萄糖代謝顯像表現(xiàn)明顯的不均一性�？崭�?fàn)顟B(tài)下,左心室各心肌節(jié)段均未見放射性攝取5例(14%),各心肌節(jié)段均完整顯影3例(8%),心肌某一或某些節(jié)段可見放射性攝取28例(78%)；在糖負(fù)荷狀態(tài)下,左心室顯像清晰,各心肌節(jié)段均可見放射性攝取30例(83%),部分心肌節(jié)段有放射性攝取6例(17%)。根據(jù)CMR將患者分為延遲強(qiáng)化組(24例)及非延遲強(qiáng)化組(12例),發(fā)現(xiàn)在空腹?fàn)顟B(tài)下延遲強(qiáng)化組患者左心室心肌代謝總評(píng)分較非延遲強(qiáng)化組明顯減低(23.7±7.0比36.2±14.2,P0.05),提示延遲強(qiáng)化組患者放射性攝取增高；糖負(fù)荷狀態(tài)下,兩組患者代謝總評(píng)分未見明顯統(tǒng)計(jì)學(xué)差異。比較患者空腹及葡萄糖負(fù)荷下心肌代謝顯像的變化,發(fā)現(xiàn)部分心肌節(jié)段(42個(gè))在空腹?fàn)顟B(tài)下放射性攝取較其它心肌節(jié)段增高,而糖負(fù)荷狀態(tài)下放射性攝取較其他心肌節(jié)段稀疏或缺損。根據(jù)上述發(fā)現(xiàn)將36例HCM患者分為兩組,組1患者是包括上述42個(gè)心肌節(jié)段的11例患者,組2為其余25例患者；與組2患者相比,組1患者室間隔厚度明顯增加(24.6±3.9mm比21.3±5.9mm,P0.05),左心室后壁厚度明顯增加(98.3±29.1mm比94.4±16.3mm,P0.05),延遲強(qiáng)化的心肌節(jié)段數(shù)明顯增多[83(44.5%)比52(12.2%),P0.001],LVEF明顯減低(67.4±15.5%比73.1±5.8%,P0.05)。 結(jié)論：肥厚型心肌病F-FDGPET心肌葡萄糖代謝顯像表現(xiàn)明顯的不均一性,在空腹顯影時(shí)左心室某一或某些心肌節(jié)段放射性攝取較其它節(jié)段增高而糖負(fù)荷顯影時(shí)其放射性攝取稀疏或缺損,可能與HCM患者CMR顯像延遲強(qiáng)化存在一定的關(guān)系,因此可能可以作為HCM患者危險(xiǎn)度分層的指標(biāo)。 目的：門控單光子發(fā)射計(jì)算機(jī)斷層(SPECT)心肌灌注顯像(MPI)不僅可以評(píng)價(jià)左心室心肌血流灌注,亦可評(píng)價(jià)左心室心功能,測(cè)定左心室心腔容積,而運(yùn)動(dòng)／藥物負(fù)荷試驗(yàn)MPI是目前非介入性影像學(xué)檢查中最常用、準(zhǔn)確的冠心病診斷方法。本研究的目的是評(píng)價(jià)腺苷負(fù)荷后患者左心室功能的變化(心肌頓抑)及其與冠心病心肌缺血的關(guān)系。 方法：前瞻性分析了2010年1月1日至2010年12月31日因疑診冠心病(coronary artery disease, CAD)住院的患者70例(男性39例,女性31例,年齡38-78歲),平均年齡59±10歲。所有患者均行2日法腺苷負(fù)荷試驗(yàn)+靜息門控SPECT心肌灌注顯像。于腺苷注射3min時(shí)靜脈注射顯像劑99mTc-甲氧基異丁基異腈(99mTc-MIBI)740-925MBq,注射顯像劑15-30min后服脂肪餐,90分鐘后行心肌斷層SPECT顯像,間隔48-72h后行靜息心肌灌注顯像。所有患者均行冠狀動(dòng)脈造影檢查。心肌灌注顯像圖像分析采用17節(jié)段5分制法進(jìn)行半定量評(píng)分,得到負(fù)荷灌注總評(píng)分(summed stress score, SSS)、靜息灌注總評(píng)分(summed rest score, SRS)及心肌缺血總評(píng)分(summed difference score, SDS)。應(yīng)用QGS軟件計(jì)算左心室功能參數(shù)：即左心室射血分?jǐn)?shù)(left ventricular ejection fraction, LVEF)、左心室舒張末期容積(left ventricular end-diastolic volume, LVEDV)及左心室收縮末期容積(left ventricular end-systolic volume, LVESV)等 結(jié)果：根據(jù)腺苷負(fù)荷試驗(yàn)+靜息門控心肌灌注顯像所測(cè)得的LVEF將患者分為兩組：腺苷負(fù)荷試驗(yàn)LVEF較靜息狀態(tài)下LVEF降低≥5%的患者組(16例)及腺苷負(fù)荷試驗(yàn)LVEF較靜息降低5%的患者組(54例)。與LVEF降低5%組的患者相比,LVEF降低≥5%組的患者冠狀脈狹窄程度及病變范圍更嚴(yán)重(冠脈狹窄90%～100%：38%比11%,P0.05；多支病變：50%比26%,P0.05)；LVEF降低≥5%組患者的SSS及SDS明顯大于LVEF降低5%組(9.1±6.8比5.6±4.5,P0.05；6.6±3.8比3.6±4.0,P0.05),即心肌灌注缺損程度更嚴(yán)重。 結(jié)論：門控腺苷負(fù)荷試驗(yàn)心肌灌注顯像檢測(cè)患者有無CAD心肌缺血,應(yīng)同時(shí)關(guān)注左心室功能的變化(即是否存在心肌頓抑),腺苷負(fù)荷試驗(yàn)LVEF的嚴(yán)重降低(≥5%)對(duì)診斷CAD有著較高的特異性,負(fù)荷LVEF明顯降低可增加CAD心肌缺血及心臟事件發(fā)生可能性。腺苷負(fù)荷試驗(yàn)后LVEF較靜息明顯降低(≥5%)可作為診斷冠心病的一個(gè)重要而有效的證據(jù)。
[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.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2014
【分類號(hào)】：R542.22;R816.2

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