心脏融合显像定量评价功能相关冠状动脉狭窄的临床研究

doi:10.3969/j.issn.1006-7795.2013.01.007

摘要/Abstract

摘要：

目的利用无创性融合影像技术对冠状动脉粥样硬化性心脏病(以下简称冠心病)进行筛选诊断,旨在评价心脏融合显像MPI/CCTA用于鉴别功能相关冠状动脉(以下简称冠脉)狭窄性病变的诊断效能及其临床价值。方法选取怀疑或确诊为冠心病的患者78例,均行常规两日法腺苷负荷/静息心肌灌注显像(myocardial perfusion imaging,MPI)和同机冠状动脉CT成像(coronary computed tomography angiography,CCTA),30 d内完成冠脉造影(coronary angiography, CAG)。MPI:采用心肌15分段法对心肌血供做定性及半定量评价;CAG和CCTA:按常规将冠脉狭窄≥50%定义为临床有意义。以MPI/CAG作为标准对MPI/CCTA对冠脉狭窄致心肌血供异常的诊断效能进行评价。结果 78例患者中,MPI结果显示正常/异常为6/72例,其中66例为心肌缺血,6例为心肌梗死;根据3支主要冠脉血管的相应供血心肌节段划分,有可逆性缺损的节段:左前降支(left anterior descending artery,LAD) 55段、左旋支(left circumflex artery, LCX)14段、右冠状动脉(right coronary artery, RCA) 11段,有固定性缺损的节段:LAD 4段、RCA 3段。CCTA结果显示:冠脉正常/异常为22/56例,78例患者共有234支主要冠脉,其中有74支冠脉狭窄≥50%,106支冠脉正常。MPI/CCTA融合影像结果显示:冠脉正常/异常(存在功能相关冠脉狭窄)为22/56例,与MPI/CAG对照,得到敏感度、特异度、准确度、阳性预测值、阴性预测值分别为94.33%、72.00%、87.18%、87.71%、85.71%。基于234支主要冠脉,MPI/CCTA融合影像与MPI/CAG对照,均异常(真阳性)55段/支,MPI/CCTA 正常而MPI/CAG异常(假阴性)7段/支,MPI/CCTA异常而MPI/CAG正常(假阳性)13 段/支,MPI/CCTA及MPI/CAG均正常(真阴性)159段/支,诊断敏感度、特异度、准确度、阳性预测值、阴性预测值分别为 88.71%、92.44%、91.45%、80.89%、95.78%。46例施行冠脉血管重建术患者均确定有功能相关冠脉狭窄,但是在67支行冠脉血管重建术的冠脉中,有25支(冠脉搭桥术CABG:8/22,36.36%;冠脉支架术PCI:17/45,37.80%)冠脉明显狭窄部位与心肌缺血区域并不匹配。结论本研究显示心脏融合影像(MPI/CCTA)用于评价功能相关冠脉狭窄具有较高的诊断效能,其优势在于可无创性评价冠脉解剖结构和功能状态,明确冠脉狭窄与其功能之间的关系,有望成为冠心病诊断,指导治疗方案的决策的首选方法。

关键词: 冠心病, 核素心肌灌注显像, 心脏融合影像, 心肌缺血

Abstract:

Objective To evaluate the diagnostic accuracy of a combined non-invasive assessment of coronary artery disease with coronary computed tomography angiography (CCTA) and myocardial perfusion imaging (MPI) for the detection of flow-limiting coronary stenoses and its potential as a gatekeeper for invasive examination and treatment. Methods A total of 78 patients with known or suspected coronary artery disease (CAD) were examined by adenosine stress/rest MPI and coronary angiography (CAG) within one month, at the same time these patients underwent CCTA with the same SPECT/CT facility. MPI was evaluated by semi- quantitative visual interpretation using a 15-segment model. According to CAG and CCTA standard, a significant stenosis was defined as a diameter reduction of ≥50%. Detection of flow-limiting stenoses (justifying revascularization) by the combination of CCTA and MPI (MPI/CCTA) was compared with the combination of CAG plus MPI (MPI/CAG), which served as standard of reference.Results In 78 patients, MPI image revealed 66 reversible, 6 fixed and 6 normal.The distribution of the perfusion defects among the different coronary artery territories was as follows: reversible perfusion defects: left anterior descending artery(LAD)(n=55), left circumflex artery (LCX)(n=14), right coronary artery(RCA)(n=11); fixed perfusion defects: LAD(n=4); RCA(n=3). CCTA image analysis revealed a stenosis in 74/234 coronary arteries of 56/78 patients. MPI/CCTA image analysis revealed a stenosis in 56/78 patients. The diagnostic sensitivity, specificity, accuracy, positive and negative predictive values by MPI/CCTA vs MPI/CAG for the detection of flow-limiting coronary stenosis on patient-based and vessel-based analysis were 94.33%, 72.00%, 87.18%, 87.71%, 85.71% and 88.71%, 92.44%, 91.45%, 80.89%, 95.78%. All of revascularization procedures (46,100%) were associated with ischemia on MPI, but more than a third(25/67,37%)of revascularized vessels were not associated with ischemia on MPI. Conclusion The combined non-invasive approach MPI/CCTA has an excellent acuracy to detect flow-limiting coronary stenoses compared with MPI/CAG. Its advantage lies in the non-invasive evaluation of coronary anatomy and function, and its use as a gatekeeper appears to make a substantial part of revascularization procedures redundant.

Key words: coronary artery disease, myocardial perfusion imaging, fusion imaging technique, myocardial ischemia

中图分类号:

R541.4

谷珊珊, 王蒨, 董薇, 焦建, 苏航, 付瑛. 心脏融合显像定量评价功能相关冠状动脉狭窄的临床研究[J]. 首都医科大学学报, 2013, 34(1): 36-42.

GU Shanshan, WANG Qian, DONG Wei, JIAO Jian, SU Hang, FU Ying. Clinical study on coronary computed tomography angiography and myocardial perfusion imaging in quantitative assessment of flow-limiting stenoses[J]. Journal of Capital Medical University, 2013, 34(1): 36-42.

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