运动-静息门控心肌断层显像中冠心病预后参数与灌注缺损关系的初步探讨

运动静息门控心肌断层显像中冠心病预后参数与灌注缺损关系的初步探讨郭烽1,李思进2,赵文锐1,梁英魁1,武志芳2摘要:目的分析左室暂时性扩大(TID)及肺摄取增加相关指标与灌注缺损的关系㊂方法回顾性分析2004年1月 2009年12月在山西医科大学第一医院核医学科行99m Tc MIBI运动静息门控单光子计算机断层扫描心肌灌注显像的可疑冠心病患者共170例,男103例,女67例,年龄51.8岁ʃ12.7岁㊂根据显像结果,以17节段靶心图模型对运动心肌灌注显像图像进行评分,获取各个节段评分之和,即运动总积分(SSS)㊂左室功能参数及左室暂时性扩大比率(TID ratio)由ECToolbox软件自动处理获得㊂依据SSS结果将患者分为四组:G1组(SSSɤ3,血流灌注正常)㊁G2组(4ɤSSSɤ8,血流灌注轻度异常)㊁G3组(9ɤSSSɤ13,血流灌注中度异常)及G4组(SSSȡ14,血流灌注重度异常)㊂结果行冠状动脉造影的12例患者中,G1组中有4例;G2组中有1例;G3组中有2例;G4组中有5例㊂TID ratio㊁SVR(5)随SSS的增加而增高,在G4组中,二者均较G1组明显增高(分别为1.10ʃ0.19与0.99ʃ0.13,1.12ʃ0.39与0.92ʃ0.16,P<0.008);在G3组中,SIVR(5)亦较G1组明显增高.而TID ratio较G1组无统计学意义㊂随着SSS的增加运动LHR及静息LHR均逐渐升高,在G3组㊁G4组中二者均较G1组明显增高;运动LHR与静息LHR相比,在G3(0.32ʃ0.08与0.31ʃ0.04,P<0.05)及G4组(0.35ʃ0.07与0.32ʃ0.06,P<0.05)中有统计学意义㊂结论运动负荷中心腔一过性扩大及肺摄取增加均与心肌缺血及冠脉病变关系密切㊂SIVR(5)及运动LHR在检测心肌缺血方面较TID ratio及静息LHR更为灵敏,有一定的临床应用价值㊂关键词:左室腔暂时性扩大;肺心比;心肌缺血;收缩末期容积中图分类号:R541.4R81文献标识码:B d o i:10.3969/j.issn.16721349.2014.11.017文章编号:16721349(2014)11133403Relationship between Prognostic Parameters for CAD and Gated SPECT Myocardial Perfusion ImagingGuo Feng,Li Sijin,Zhao Wenrui,et alDepartment of Nuclear Medicine,Navy General Hospital,PLA(Beijing100048),China Abstract:Objective To analysis the relationship between transient ischemia dilation(TID),increased lung uptake related indi-cators,and perfusion defects in Gated SPECT and prognosis of coronary artery disease(CAD),explore its preliminary clinical appli-cation.Methods Stress and rest99mTc MIBI Gated SPECT were performed in170patients with suspect coronary artery disease (67female and103male patients were included).Semiquantitative summed stress scores(SSS)were determined using a17seg-ment,5point model,which was calculated by summing all regions where radial plot activity fell below the normal limits.The left cardi-ac function and transient ischemia dilation ratio(TID ratio)were processed automatically by the ECToolbox software.Lung/heart ra-tio(LHR)was calculated by left lung ROI average pixel counts/myocardium ROI average pixel counts.In addition,the stress in-duced volume ratio(5)[SIVR(5)]defined as stress to rest ratio,was calculated.All patients were divided into four groups ac-cording to the SSS:The G1(SSSɤ3),G2(4ɤSSSɤ8),G3(9ɤSSSɤ13),and G4(SSSȡ14).Results1.Twelve patients un-derwent angriscopy,4patients were divided in G1,1in G2,2in G3,and5in G4.2.The TID ratio and SIVR(5)were getting higher with the increasing of SSS.In G4,TID ratio and SIVR(5)were significantly greater than G1(1.10ʃ0.19vs0.99ʃ0.13,1.12ʃ0.39vs 0.92ʃ0.16,P<0.008).Comparing the TID ratio and SIVR(5)between G3and G1,an obstructive difference was seen in SIVR (5),but not in TID ratio.According with the increasing of SSS,sLHR and rLHR were grown too higher.especially in G4,the values of two were more higher than in GI,a significant different was also seen in sLHR between G3and pared sLHR and rLHR within each group,we found that there were significantly difference in G3and G4(0.32ʃ0.08vs0.31ʃ0.04,0.35ʃ0.07vs0.32ʃ0.06,P<0.05).Conclusion TID and increased lung uptake are closely related with myocardial ischemia and coronary artery pared with TID ratio and rLHR,SIVR(5)and sLHR are more sensitive in detecting myocardial ischemia,and have an im-portant value in clinical application.Key words:transient ischemia dilation;lung/heart ratio;myocardial ischemia;end Systolic Volume门控心肌灌注显像作为一种安全无创的显像方法,已广泛应用于临床㊂一些与运动MPI相关的异常结果,如左室腔暂时性扩大㊁肺摄取增加等已成为预测冠心病的独立高危因素,与冠心病患者的预后密切相关[1]㊂目前,多种指标可以反映此类异常结果,本研究旨在分析此类指标与灌注缺损的关系,探讨其初步临床应用价值㊂1资料与方法1.1临床资料2004年1月 2009年12月在山西医科大学第一医院核医学科行99m Tc MIBI运动静息门控单光子计算机断层扫描(GSPECT)心肌灌注显像的可疑冠心病患者173例,男113例,女60例,年龄作者单位:1.海军总医院核医学科(北京100048)E mail:guofeng_ gf84@;2.山西医科大学附属第一医院核医学科(太原030001)51.8岁ʃ12.7岁㊂除外有心律失常㊁左束支传导阻滞㊁植入心脏起搏器㊁急性冠脉综合征㊁近1个月内行冠脉搭桥或血管成形术的患者㊂1.2仪器及方法1.2.1采集使用GSPECT技术仪器为美国ADAC 公司产VERTEX双探头SPECT,使用低能高分辨(LEHR)准直器,能峰140keV,窗宽20%,矩阵64ˑ64,放大倍数1.28㊂患者取仰卧位,双上臂抱头并固定,探头贴近胸壁,从右前斜(RAO)45ʎ至左后斜(LPO)45ʎ旋转采集180ʎ,每3ʎ采集一帧,共采集60帧,采集速度为35秒/帧㊂1.2.2图像重建采用滤波反投影法,滤波函数采用Butterworth,截止频率和陡度因子分别为0.5和9,获得垂直长轴㊁水平长轴及短轴图像㊂在三维重建的基础上,采用17阶段模型,分左室各壁为17节段,得出㊃4331㊃C H I N E S EJ O U R N A L O FI N T E G R A T I V E M E D I C I N E O N C A R D I O/C E R E B R O V A S C U L A R D I S E A S E N o v e m b e r2014 V o l.12 N o.11缺损评分靶形图㊂每个节段评分由0~4分,0为无显像剂分布缺损,1分为有轻度显像剂分布缺损,2分为有中度显像剂分布缺损,3分为有重度显像剂分布缺损,4分为无显像剂分布㊂用软件自动处理,获得运动总积分(summed stress scores,SSS),依据SSS结果将患者分为四组:G1组(SSSɤ3分,血流灌注正常)㊁G2组(4分ɤSSSɤ8分,血流灌注轻度异常)㊁G3组(9分ɤSSSɤ13分,血流灌注中度异常)及G4组(SSSȡ14分,血流灌注重度异常)㊂1.2.3心功能参数左室舒张末期容积(EDV)㊁收缩末期容积(ESV)㊁射血分数(LVEF)及TID ratio由ECToolbox软件自动计算出㊂1.2.4运动诱导体积比(SIVR)根据Thomas等[2]数学模型,SIVR(5)为运动静息比(ESVˑ5+EDV) 1.2.5肺心比(LHR)在原始图像的第16帧(前位),分别在左室心肌前壁及肝脏显像剂浓聚最高处勾画相同大小(3ˑ3=9pixels)的感兴趣区(region of in-teresting,ROI),分别在左室心肌放射性最强的部位勾画相同大小(3ˑ3=9pixels)的感兴趣区,将其复制(保证ROI相同大小),移至左上肺计数最高的部位,距心肌边缘至少5个像素(避免心脏对其影响),软件自动计算两区域的平均计数,重复勾画3次,取平均数,计算肺心比值㊂1.3统计学处理采用SPSS11.5统计软件包处理,计量资料以均数ʃ标准差(xʃs)表示,两两比较用t 检验㊂组间比较用方差分析(ANOVA),P<0.05为差异有统计学意义㊂符合方差齐性,且方差分析有差别,可进一步用LSD法进行多组间两两比较㊂2结果2.1各组一般资料情况(见表1)表1各组一般资料比较组别n年龄(岁)性别(例)男女G1组7249.6ʃ12.13834G2组4651.7ʃ12.32917G3组2452.0ʃ10.6186G4组3150.2ʃ12.02011 2.212例患者行冠脉造影检查结果(见表2)行冠状动脉造影的12例患者中,G1组4例(冠脉三支95%狭窄1例,右冠优势2例,正常1例);G2组1例(右冠优势);G3组2例(1例为左前降支85%狭窄,1例为右冠中段65%狭窄及左前降支近端不规则病变);G4组5例(均为冠脉三支病变)㊂表212例患者冠脉造影结果例类别G1组G2组G3组G4组合计冠脉造影阳性10258冠脉造影阴性31004合计4125122.3各组心肌断层显像指标结果2.3.1TID ratio㊁SVR(5)比较TID ratio㊁SVR(5)随SSS的增加而增高㊂在重度组中,TID ratio㊁SVR (5)较正常组明显增高(P<0.008)㊂而SVR(5)在中度组中亦较正常组高㊂详见表3㊂表3TID ratio及SIVR(5)与运动总积分的关系(xʃs)项目G1组G2组G3组G4组TID ratio0.99ʃ0.130.98ʃ0.130.97ʃ0.101.10ʃ0.191)2)3) SIVR(5)0.92ʃ0.160.93ʃ0.101.01ʃ0.2011)2)1.12ʃ0.391)2)3)与G1组比较,1)P<0.05;与G2组比较,2)P<0.05;与G3组比较,3)P<0.05㊂2.3.2各组sLHR及rLHR比较随着SSS的增加sLHR及rLHR均逐渐升高,在重度组中二者均较正常组明显增高,而sLHR在中度组中亦较正常组高;比较各组内sLHR及rLHR,中㊁重度组中,sLHR较rLHR 有统计学意义㊂详见表4㊂表4sLHR及rLHR与运动总积分的关系(xʃs)项目正常轻度中度重度sLHR0.30ʃ0.040.31ʃ0.050.32ʃ0.081)2)0.35ʃ0.071)2) rLHR0.30ʃ0.030.31ʃ0.050.31ʃ0.040.32ʃ0.061)2)与正常比较,P<0.05;与轻度比较,2)P<0.05㊂3讨论GSPECT运动负荷MPI不仅对诊断冠心病具有重要价值[3],而且可以对冠心病进行准确的预后判断及危险度分层[4]㊂运动试验时左室暂时性扩大与肺摄取增加是预后不良的重要指征,也是多支冠状动脉病变的指标[5]㊂国外文献报道[6],广泛且严重的灌注缺损是冠状动脉多支病变的显著指征㊂当SSSȡ14分时,与冠脉多支病变密切相关㊂本研究发现,6例冠脉多支病变患者中,有5例在G4(SSSȡ14分),与国外报道基本一致㊂但由于本研究中行冠脉造影患者较少,需要进一步加大样本量进行证实㊂本研究中有1例冠脉多支病变患者(三支冠脉狭窄均为95%),MPI正常,可能的解释是由于其冠脉病变程度相似,从而在MPI中表现为 平衡缺血 ,左室各壁显像剂分布呈均匀性的减㊃5331㊃中西医结合心脑血管病杂志2014年11月第12卷第11期低,肉眼及半定量分析中表现为正常[7]㊂在MPI中, TID被定义为负荷后左室心腔较静息时增大㊂1980年stolzenberg等[8]首次应用201Tl MPI在3例CAD患者的MPI中记录了TID,并认为其为CAD患者的高危因素㊂随后大量的临床研究对TID的发生及其意义进行了探讨,发现其与多支冠状动脉病变密切相关,并且可以增加CAD患者心脏事件发生率,甚至在MPI正常患者中也可见到㊂目前评价TID的主要指标为TID比率㊂有TID患者较无TID的患者有更高的SSS㊂本研究也发现随着SSS的增加,TID比率逐渐增高,且在重度中(SSSȡ14分),TID比率较其他三组明显增高,提示其与冠脉多支病变关系非常密切㊂Thomas等[2]经过数学模型研究,认为SIVR(5)亦可反映TID,且认为其与缺血关系更为密切,Besteti 等[9]研究结果也表明,99m Tc MIBI MPI中,SIVR(5)值与缺血的程度有关,冠脉缺血越重(SSS越高),其值越高㊂Satoshi等[10]通过分析113例CAD患者,发现冠脉多支病变患者(62例)的SIVR(5)较正常或单支冠脉病变患者(57例)明显增高(1.21ʃ0.14vs1.02ʃ0.10;P<0.0001)㊂本研究在SIVR(5)与灌注缺损关系分析中发现,不仅重度组中SIVR(5)值明显高于正常及轻度组,且中度组中其值亦较正常组高,可能预示SIVR(5)值较TID比率能更好㊁更灵敏反应心肌缺血㊂肺摄取是反映CAD患者冠脉病变严重程度和左室舒张功能的指标[11]㊂运动后肺摄取201Tl增加与运动后诱发左室功能障碍有关,而静息肺摄取201Tl增加也与左室功能障碍㊁严重冠心病及静息灌注缺损有关[12]㊂本研究观察4组中运动㊁静息LHR与血流灌注异常的关系,发现随着血流灌注异常的增加,运动和静息LHR都逐渐增高,且在重度组中sLHR与rLHR均较其余3组明显增高㊂在一组109例行99m Tc MIBI 运动MPI及冠脉造影的患者中,以sLHR>0.44作为异常诊断标准,对重度冠脉病变的诊断敏感性和特异性分别为63%和81%[13]㊂且多因素分析表明LHR高的患者有较高的SSS㊂此外,本研究发现在中度组中,sLHR较正常及轻度组亦明显增高㊂而rLHR较正常及轻度组屋明显差异,因此,sLHR与rLHR相比,与灌注缺损更为密切,可能预示其在心肌缺血检测中作用更大㊂在各组内sLHR与rLHR比较中,在重度组中,sLHR均较rLHR增高,究其原因可能为,随着心肌血流灌注异常加重导致左室功能下降及肺毛细血管压力升高有关,且运动后更为明显㊂运动负荷后左室腔暂时性扩大及肺摄取增加均与心肌缺血及冠脉病变关系密切㊂SIVR(5)及sLHR在检测心肌缺血方面较TID ratio及rLHR更为灵敏,有一定的临床应用价值㊂参考文献:[1]Patel GM,Hauser TH,Parfer JA,et al.Quantitative relationshipof stress Tc99m sestamibi lung uptake with resting T1201lung uptake and with indices of left ventricular dysfunction andcoronary artery disease[J].J NucL Cardiol,2004,11(4):408413.[2]Thomas F,Sigg DM.Quantifying transient ischemic dilation usinggated SPECT[J].J Nucl Med,2005,46:19901996. 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[13]Bacher Stier C,Sharir T,Kavanagh PB,et al.Postexecise lunguptake of99mTc MIBI determined by a new automatic tech-nique:validation and application in detection of server and ex-tensive coronary artery disease and reduced left ventricularfunction[J].J Nucl Med,2000,4(7):11901197.(收稿日期:20140729)(本文编辑王雅洁)㊃6331㊃C H I N E S EJ O U R N A L O FI N T E G R A T I V E M E D I C I N E O N C A R D I O/C E R E B R O V A S C U L A R D I S E A S E N o v e m b e r2014 V o l.12 N o.11。