放射性核素显像在心血管疾病方面的临床应用研究

【作者】 王丽；

【导师】 何作祥；

【作者基本信息】 北京协和医学院 ， 影像医学与核医学， 2013， 博士

【摘要】 第一部分门控心肌代谢18F-FDG PET/CT相位分析与门控心肌灌注99mTc-MIBI SPECT相位分析在评价冠心病患者左心室同步性方面的比较目的：比较门控心肌代谢18F-FDG PET/CT相位分析与门控心肌灌注99mTc-MIBI SPECT相位分析测量冠心病患者左心室不同步参数间是否存在差异,测定两种方法的相关性和一致性,评价门控心肌代谢18F-FDG PET/CT相位分析测量左心室同步性的准确性。方法：回顾性分析连续收集的100例冠心病患者,所有患者均己行门控心肌代谢18F-FDG PET/CT显像与门控心肌灌注99mTc-MIBI SPECT显像。应用QGS心脏相位分析技术分别对重建后的门控心肌代谢18F-FDG PET/CT图像与门控心肌灌注99mTc-MIBI SPECT图像进行分析,获得左心室不同步参数,即相位直方图带宽(phase histogram bandwidth, BW)和相位标准差(standard deviation, SD)。分别计算门控心肌代谢18F-FDG PET/CT与门控心肌灌注99mTc-MIBI SPECT相位分析获得的BW值和SD值的相关性和一致性,并比较这两种方法分别测得的心肌活性以及最晚激动位点的一致性。结果：相关性分析显示门控心肌代谢18F-FDG PET/CT相位分析与门控心肌灌注99mTc-MIBI SPECT相位分析所得的Bw及SD值为中等相关(Bw：r=0.60;SD：r=0.58;p均<0.0001)。门控心肌代谢18F-FDG PET/CT相位分析测得Bw值及SD值均高于门控心肌灌注SPECT相位分析的结果(BW22.0。±46.8°；SD：6.4°±14.3。),门控心肌代谢18F-FDG PET/CT相位分析过高估计左心室不同步。多因素Logistic回归分析示：与门控心肌代谢18F-FDG PET/CT相位分析高估左心室不同步相关的因素有左心室是否发生显著重构、左心室功能参数(左心室收缩末期容积,ESV；左心室舒张末期容积,EDV;左心室射血分数,EF)以及心肌和心血池I8F-FDG摄取的比值(SUVT/B)。门控心肌代谢18F-FDG PET/CT与门控99mTc-MIBI SPECT显像在评估左心室最晚激动位点方面具有67.1%的一致性,与心肌灌注99mTc-MIBI SPECT显像相比,心肌代谢18F-FDG PET/CT显像可多检测出5.2%的存活心肌。结论：门控心肌代谢18F-FDG PET/CT相位分析与门控心肌灌注99mTc-MIBI SPECT相位分析在测量冠心病患者左心室同步性方面具有中等相关性。对于发生明显的左心室重构、左心室功能严重受损、以及心肌摄取18F-FDG较差的冠心病患者,应谨慎应用门控心肌代谢18F-FDG PET/CT相位分析技术评价左心室同步性。第二部分门控静息心肌灌注99BTc-MIBI SPECT相位分析测量左心室同步性在评价扩张型心肌病患者预后的临床价值目的：评价门控静息心肌灌注99mTc-MIBI SPECT显像预测扩张型心肌病患者预后的临床价值。方法：回顾性分析48例连续纳入的扩张型心肌病患者。所有患者均已行门控静息心肌灌注99mTc-MIBI SPECT显像。应用QGS心脏相位分析技术分别对重建后的门控静息心肌灌注99mTc-MIBI SPECT图像进行分析,获得左心室不同步参数,即相位直方图带宽(phase histogram bandwidth, BW)和相位标准差(standard deviation, SD)。对所有入选患者进行随访,以心脏性死亡作为观测终点事件。应用Cox回归分析找到对扩张型心肌病患者预后具有重要预测作用的因素。结果：所有患者随访期间(22.7±5.1月),12名患者(25.0%)发生心脏性死亡。与存活患者相比,发生心脏性死亡的患者的BW值(157.0°±37.9°vs.105.4°±58.1°,P<0.05)和SD值均显著增高(44.0°±11.0°vs.29.0°±15.9°,P<0.05)。单因素COX回归分析结果示体重指数(BMI)、QRS波时限>120ms以及重度左心室不同步三个因素是预测扩张型心肌病患者发生心脏性死亡事件的独立因子。多因素COX回归分析结果示重度左心室不同步(风险比值：9.607,95%可信区间：2.064-44.713,P=0.004)和BMI(风险比值：0.851,95%可信区间：0.732-0.989,P=0.036)可独立预测心脏性死亡事件的发生。左心室严重不同步的患者累计心脏性死亡率显著高于无左心室不同步的患者(55.6%vs.6.7%,P<0.0001)。正常体重指数组(BMI<25kg/m2)的累计心源性死亡率显著高于超重组(BMI≥25kg/m2)患者(36.7%vs5.6%,P=0.018)。结论：门控静息心肌灌注99mTc-MIBI SPECT相位分析测得左心室不同步以及患者体重指数对药物保守治疗的扩张型心肌病患者发生心脏性死亡事件具有重要的预测价值。第三部分18F-FDG PET心脏代谢显像与心脏磁共振成像在测定心力衰竭患者左心室功能参数方面的比较目的：左心室功能是评价心力衰竭患者预后的重要因子。本研究的目的在于比较18F-FDG PET心肌代谢显像与心脏磁共振成像测量心力衰竭患者左心室功能参数(左心室舒张末期容积、左心室收缩末期容积和左心室射血分数)的差异,计算两种方法的相关性和一致性,评价18F-FDG PET显像测量左心室功能的准确性。方法：89例(男69例,女20例,年龄(55±13)岁)确诊为心力衰竭的患者,并于一周内均行心脏18F-FDG PET心肌代谢显像和心脏磁共振成像。18F-FDG PET心脏代谢显像分别应用门控心肌显像QGS软件与4D-MSPECT软件测量左心室舒张末期容积(LVEDV).左心室收缩末期容积(LVESV)以及左心室射血分数(LVEF),与心脏磁共振成像测得的左心室功能参数进行相关性检验以及Bland-Al tman一致性检验。结果：18F-FDG PET显像(分别应用QGs软件、4D-MSPECT软件)与心脏磁共振成像在左心室容积及左心室射血分数方面相关性良好(QGS:LVEDV:r=0.92:LVESV: r=0.92:LVEF:r=0.76:4D-MSPECT:LVEDV:r=0.93:LVESV:r=0.94:LVEF: r=0.75:p均<0.001).18F-FDG PET显像应用QGS软件所得LVEDV及LVESV(LVEDV192.3±91.4ml;LVESV140.3±85.8ml)低于心脏磁共振成像所得结果(LVEDV220.3±90.7ml:LVESV158.9±85.8ml),均具有统计学意义(p均<0.05)。结论：18F-FDG PET心脏代谢显像与心脏磁共振成像在测定心力衰竭患者左心室功能参数方面相关性良好,但是两种方法测定左心室功能参数方面具有一定的差异,不能完全互相代替。临床应用18F-FDG PET心脏代谢显像测量左心室功能参数时应谨慎参考。更多还原

【Abstract】 PartⅠPhase analysis by gated F-18FDG PET/CT for left ventricular dyssynchrony assessment:comparison with gated Tc-99m sestamibi SPECTPurpose:To investigate the value of gated F-18FDG PET/CT on left ventricular (LV) dyssynchrony assessment in comparison with gated Tc-99m sestamibi SPECT in patients with coronary artery disease (CAD).Methods:The data of100consecutive CAD patients who underwent both gated myocardial Tc-99m sestamibi SPECT and F-18FDG PET/CT imaging were analyzed. Phase standard deviation (SD) and histogram bandwidth (BW) were derived from phase analysis using Cedars software package. The correlation and agreement of SD and BW between Tc-99m sestamibi SPECT and F-18FDG PET/CT were examined. Myocardial viability and the site of latest activation assessed by the two imaging methods were compared as well.Results:A moderate correlation for SD (r=0.58, p<0.0001) and BW (r=0.60, p<0.0001) was found between gated SPECT and gated F-18FDG PET/CT. Bland-Altman analysis revealed an overestimation of SD and BW (6.4°±14.3°and22.0°±■46.8°) by gated F-18FDG PET/CT. Multivariate logistic regression analysis identified that significant LV remodeling on SPECT imaging, LV functional parameters and F-18FDG uptake ratio of myocardium to blood pool (SUVM/B) were associated with the overestimation. Myocardial SPECT and F-18FDG PET/CT had a67.1%identity in determining the latest activation site and5.2%more viable myocardium was detected by18F-FDG PET/CT than SPECT.Conclusion:Gated F-18FDG PET/CT moderately correlated with gated Tc-99m sestamibi SPECT in assessing LV dyssynchrony. Gated F-18FDG PET/CT phase analysis should be cautiously applied in CAD patients with significant LV remodeling on SPECT imaging, severe LV functional impairment or poor myocardial F-18FDG uptake. Part ⅡPrognostic significance of left ventricular dyssynchrony by phase analysis of gated SPECT in medically treated patients with dilated cardiomyopathyPurpose:The study aimed to investigate the value of clinical variables and rest gated single photon emission computed tomography (SPECT) in predicting cardiac deaths in medically treated dilated cardiomyopathy (DCM) patients.Methods:This is a retrospective study. Fifty-six consecutive hospitalized DCM patients who underwent rest gated SPECT myocardial perfusion imaging (MPI) were initially recruited. Patients were further excluded for receiving heart transplantation, cardiac resynchronization treatment (CRT) and non-cardiac death during follow-up. The remaining48medically treated DCM patients were selected into the final analysis. Phase analysis of gated SPECT was conducted to identify LV dyssynchrony. Cardiac death during follow-up was considered as the only endpoint. Univariate and multivariate Cox proportional hazards regression analysis were performed to identify the independent predictors of cardiac death. Kaplan-Meier cumulative survival analysis with stratification was performed, and survival curves were compared by Log-rank test.Results:The mean age was47.5±15.8years (range,15-76y) and85.4%were men. The mean LV ejection fraction (LVEF) was22.2±7.7%. During the follow-up period (22.7±5.1months),12(25.0%) cardiac deaths occurred. Compared to survivors, patients with cardiac death had lower body mass index (BMI, P=0.010), higher percent of prolonged QRS duration (QRSD, P=0.043) and severe LV dyssynchrony (P=0.002). Multivariate Cox analysis demonstrated that severe LV dyssynchrony (hazard ratio=9.607,95%confidential interval,95%CI2.064-44.713, P=0.004) and BMI (hazard ratio=0.851,95%CI0.732-0.989, P=0.036) were predictive of cardiac death.Conclusion:Left ventricular dyssynchrony assessed by phase analysis of gated SPECT and BMI are predictive of cardiac death in medically treated DCM patients. Part IIIGated F-18FDG PET for assessment of left ventricular volumes and ejection fraction using QGS and4D-MSPECT in patients with heart failure:comparison with cardiac MRIPurpose:Ventricular function is a powerful predictor of survival in patients with heart failure (HF). However, so far, studies on gated F-18FDG PET for assessment of the cardiac function are fairly rare. The aim of this study is to prospectively compare gated F-18FDG PET and cardiac MRI for assessment of ventricular volume and ejection fraction (EF) in patients with HF.Methods:Eighty-nine patients with diagnosed HF who underwent both gated F-18FDG PET/CT and cardiac MRI within3days were included. Left ventricular (LV) end-diastolic volume (EDV), end-systolic volume (ESV) and EF were obtained from gated F-18FDG PET/CT using Quantitative Gated SPECT (QGS) and4D-MSPECT software, respectively.Results:LV EDV and ESV measured by QGS were significantly lower than those of cardiac MRI (both P<0.0001), whereas the corresponding values of LV EDV for4D-MSPECT showed no statistical significance (P=0.595) and LV ESV showed an underestimation in borderline significance in comparison with cardiac MRI (P=0.047, respectively). LV EF measured by QGS showed no statistical significance in comparison with cardiac MRI (P=0.95) whereas the corresponding values for4D-MSPECT were lower than those of cardiac MRI (P<0.0001). The correlations of LV EDV, ESV and EF between gated F-18FDG PET/CT and cardiac MRI were excellent for both QGS (R=0.92,0.92and0.76, respectively) and4D-MSPECT (R=0.93,0.94and0.75, respectively). Bland-Altman analysis revealed significant systemic error that LV EDV (-27.9±37.0mL; bias significantly different from0, P=0.004) and ESV (-18.6±33.8mL; bias significantly different from0,P=0.01) were underestimated by QGS.Conclusion:For patients with HF, despite gated F-18FDG PET/CT correlated well with cardiac MRI in assessment of ventricular volumes and EF, variability between the two techniques did exist. Hence, in comparison with cardiac MRI, the two imaging techniques should not be used interchangeably and LV volumes and LV EF by gated F-18FDG PET/CT should be cautiously interpreted.更多还原