肺栓塞与心力衰竭的放射性核素显像研究

【作者】 王峰；

【导师】 何作祥； 方纬； 田月琴； 杨敏福；

【作者基本信息】 中国协和医科大学 ， 影像医学与核医学， 2009， 博士

【摘要】 目的:比较核素肺灌注/通气（ventilation/perfusion,V/Q）显像或核素肺灌注显像结合胸片（chest radiography,CR）与CT肺动脉造影（computed tomographypulmonary angiography,CTPA）诊断肺栓塞（pulmonary embolism,PE）的效能,并在肺段水平分析核素肺灌注显像和CTPA检测PE的一致性。方法:从2005年10月至2007年2月前瞻性收录82例连续性疑似PE的患者。所有患者均行核素肺灌注显像、CTPA及CR检查。28例患者尚进行了核素肺通气显像。核素肺显像和CTPA分别由2位有经验的核医学医师或放射学医师阅片,阅片结果经2位医师讨论后得出。核素肺显像阅片是将肺灌注显像与肺通气显像或CR相结合进行盲法阅片。核素肺显像与CTPA间隔的时间为1-3天。最终诊断采用临床综合诊断,即在综合所有临床资料、所有实验室检查结果、所有影像学检查结果及负责治疗的医师的意见之后所得出的诊断作为最终诊断。采用Kappa检验分析两种显像方法之间的一致性;采用配对或非配对x2检验分析两种显像方法之间的差异是否有显著统计学意义。P<0.05视为有显著统计学差异。结果:最终有42例（42/82,51.2%）患者被诊断为PE。对于所有的82例患者,在排除7例（7/82,8.5%）核素肺显像或CTPA为“不能诊断”的患者之后,V/Q显像或肺灌注显像结合CR的敏感度、特异度、阳性预测值及阴性预测值分别为:89.2%、92.1%、91.7%及89.7%,CTPA分别为:97.3%,97.4%,97.3%及97.4%。两种显像方法的准确性之间无显著统计学差异（x2检验,P=NS）。对于28例有肺通气显像的患者,在排除2例（2/28,7.1%）V/Q显像为“不能诊断”的患者之后,V/Q显像的敏感度、特异度、阳性预测值及阴性预测值分别为:91.7%、92.9%、91.7%及92.9%,CTPA分别为:91.7%、100.0%、100.0%及93.3%。两种显像方法的准确性之间无显著统计学差异（x2检验,P=NS）。对于54例无肺通气显像的患者,以CR替代肿通气显像。在排除5例（5/54,9.3%）核素肺显像或CTPA为“不能诊断”的患者之后,肺灌注显像结合CR的敏感度、特异度、阳性预测值及阴性预测值分别为:88.0%、91.7%、91.7%及88.0%,CTPA分别为:100.0%、95.8%、96.2%及100.0%。两种显像方法的准确性之间无显著统计学差异（x2检验,P=NS）。对于42例最终诊断为PE的患者,在排除5例（5/42,11.9%）核素肺显像或CTPA为“不能诊断”的患者之后,肺灌注显像发现了70个肺叶灌注稀疏或缺损、174个肺段灌注稀疏或缺损、59个亚肺段灌注稀疏或缺损;CTPA发现31个栓子位于主肺动脉、74个栓子位于叶动脉、164个栓子位于肺段动脉、10个栓子位于亚肺段动脉。本研究总共分析了629个肺段,肺灌注显像共发现457个肺段有灌注稀疏或缺损,CTPA共发现407个肺段所对应的肺动脉内有栓子,肺灌注显像和CTPA在肺段水平的符合率为69.5%（Kappa值=0.30,P<0.05）,肺灌注显像所发现的亚肺段异常显著多于CTPA（59与10,x2检验,P<0.05）。结论:V/Q显像或肺灌注显像结合CR及CTPA对于PE均有较高的诊断效能,V/Q显像或肺灌注显像结合CR的诊断效能与CTPA相近。肺灌注显像与CTPA在肺段水平为中度符合。（一）、静息门控SPECT心肌灌注显像对CHF患者的诊断和预后价值目的:调查静息门控单光子发射式计算机断层（single photon emission computedtomography,SPECT）心肌灌注显像对慢性心力衰竭（chronic heart failure,CHF）患者的诊断及预后价值。方法:2007年8月至2008年10月,从阜外心血管病医院心力衰竭诊治中心前瞻性初步收录141例连续性CHF患者,其均为因CHF而首次入阜外心血管病医院的患者。18例患者因符合排除标准、3例患者因失访而被排除,最终120例患者被纳入研究进行分析,其中男性患者94例,女性患者26例,平均年龄为52±16岁（年龄范围:12-79岁）。所有患者均行静息门控SPECT心肌灌注显像,显像剂为^99m锝-甲氧基异丁基异腈(^99mTc-methoxyisobutylisonitrile,^99mTc-MIBI)。所有患者均在门控SPECT心肌灌注显像完成后6-11个月进行随访,共分为4个批次,采用电话或邮件随访,联系患者本人或其亲属。研究终点为:心脏性死亡、需心脏移植、因CHF或急性冠状动脉综合征需再次住院治疗或需行心脏手术治疗。平均随访时间为236±94天。本研究采用自动分析软件QGS（quantitative gated SPECT）和QPS（Quantitative Perfusion SPECT）对门控SPECT心肌灌注显像进行分析,获得左心室射血分数（left ventricularejection fraction,LVEF）、心指数（cardiac index,CI）、静息灌注总评分（summed rest score,SRS）、室壁运动总评分（summed motion score,SMS）、室壁增厚总评分（summed thickening score,STS）、高峰充盈率（peak fillingrate,PFR）及高峰充盈时间（time to peak filling,TTPF）等指标,分析患者的显像特点,并运用生存分析方法调查研究因素与CHF患者预后的关系。结果:120例CHF患者中包括缺血性CHF患者39例,非缺血性CHF患者81例。静息门控SPECT心肌灌注显像结果显示:120例CHF患者的LVEF平均值为25.7%±12.2%,SRS平均值为10.2±10.4;缺血性CHF患者中静息心肌血流灌注异常（SRS≥4）的患者所占比例显著高于非缺血性CHF患者（84.6%与58.0%,x2检验,P<0.05）,缺血性CHF患者的SRS显著高于非缺血性CHF患者（19.0±12.5与6.0±5.5,t检验,P<0.05）。当以SRS≥4作为诊断缺血性CHF的阳性阈值时,其诊断缺血性CHF的敏感度和阴性预测值分别为84.6%和85.0%。120例CHF患者的LVEF中位值为22%,LVEF<22%的患者的SRS显著高于LVEF≥22%的患者（13.4±12.4与7.4±7.2,t检验,P<0.05）,说明LVEF低的患者其静息心肌血流灌注受损较严重。经随访,120例患者中有39例（39/120,32.5%）患者发生心脏事件:3例（3/120,2.5%）患者死亡,23例（23/120,19.2%）患者因CHF再次住院,4例患者因急性冠脉综合征住院（4/120,3.3%）,1例患者行血运重建术（1/120,0.8%）,1例患者行左心室减容术（1/120,0.8%）,7例患者行心脏移植术（7/120,5.8%）。COX回归模型分析结果显示:对于120例CHF患者,SRS≥9（RR=2.86,p<0.05）和Def Ext≥14%（RR=2.71,p<0.05）是预后的显著预测因素。结论:此初步研究的结果显示:静息门控SPECT心肌灌注显像对缺血性与非缺血性CHF具有鉴别诊断价值,而且其对CHF预后具有重要预测价值。（二）、门控SPECT心肌灌注显像检测左心室收缩功能和容积的准确性—与MRI对比研究目的:调查静息门控单光子发射式计算机断层（single photon emission computedtomography,SPECT）心肌灌注显像检测扩张型心肌病（dilatedcardiomyopathy,DCM）患者左心室射血分数（left ventricular ejectionfraction,LVEF）、舒张末期容积（end diastolic volume,EDV）及收缩末期容积（end systolic volume,ESV）的准确性,并与心脏磁共振显像（magneticresonance imaging,MRI）对比。此外,调查门控SPECT软件:QGS（QuantitativeGated SPECT）、ECTB（Emory Cardiac Tool Box）及4D-MSPECT各自的特点。方法:分析36例DCM患者的静息门控^99mTc-MIBI甲氧基异丁基异腈(^99mTc-methoxyisobutylisonnitrile)SPECT心肌灌注显像,采用软件QGS、ECTB及4D-MSPECT计算LVEF、EDV及ESV,并与心脏MRI对比。结果:门控SPECT与MRI之间,EDV的相关性好:R=0.872（QGS）、R=0.879（ECTB）及R=0.869（4D-MSPECT）;ESV的相关性好:R=0.908（QGS）、R=0.897（ECTB）及R=0.880（4D-MSPECT）;LVEF的相关性亦好:R=0.794（QGS）、R=0.763（ECTB）及R=0.710（4D-MSPECT）。QGS所测的EDV和ESV与MRI无显著统计学差异（t检验,p均=NS）,而ECTB和4D-MSPECT所测的EDV和ESV均显著高于MRI（t检验,p均<0.05）。QGS、ECTB及4D-MSPECT所测的LVEF均显著高于MRI（t检验,p均<0.05）。结论:对于DCM患者,门控SPECT所测的LVEF、EDV及ESV与MRI的相关性均好,但在临床应用时需注意不同软件和不同显像方法之间所测数值的差异。更多还原

【Abstract】 PartⅠComparison of Lung Scintigraphy with Multi-slice Spiral CT in the Diagnosis of Pulmonary EmbolismPurpose:To compare the diagnostic efficacy of lung perfusion scan combined with lung ventilation（V/Q） scan and/or chest radiography with contrast-enhanced multi-slice spiral computed tomography pulmonary angiography（CTPA） in diagnosing pulmonary embolism（PE）.Furthermore, perfusion scan was compared with CTPA on a segment-by-segment basis.Methods:Eighty-two consecutive patients with suspected PE were enrolled. All patients underwent CTPA,lung perfusion imaging,and chest radiography.Twenty-eight patients underwent lung ventilation imaging. The final diagnosis was made using a composite reference test.Results:For all 82 patients,the sensitivity,specificity,positive predictive value（PPV） and negative predictive value（NPV） were 89.2%, 92.1%,91.7%and 89.7%respectively for V/Q scan or perfusion scan combined with chest radiography,and 97.3%,97.4%,97.3%and 97.4% respectively for CTPA,excluding 7（8.5%） patients with non-diagnostic results.For the 28 patients with V/Q scan,the sensitivity,specificity, PPV and NPV were 91.7%,92.9%,91.7%and 92.9%respectively for V/Q scan, and 91.7%,100.0%,100.0%and 93.3%respectively for CTPA,excluding 2（7.1%） patients with non-diagnostic results.For the 54 patients without ventilation scan,chest radiography was used instead.Five（9.3%） patients with non-diagnostic results were excluded.The sensitivity, specificity,PPV and NPV were 88.0%,91.7%,91.7%and 88.0%respectively for perfusion scan combined with chest radiography,and were 100.0%, 95.8%,96.2%and 100.0%respectively for CTPA.In the 42 patients with PE,five（11.9%） patients with non-diagnostic results were excluded. For the remaining 37 patients,perfusion scan showed 70 lobar perfusion defects,174 segmental perfusion defects,and 59 sub-segmental perfusion defects;CTPA revealed emboli in 31 main arteries,in 74 lobar arteries,in 164 segmental arteries,and in 10 sub-segmental arteries. In the segment-based analysis,a total of 629 segments were evaluated. The segmental agreement rate between perfusion scan and CTPA was 69.5% （Kappa=0.30,p<0.05）.Perfusion scan revealed significantly more sub-segmental abnormalities than CTPA（59 vs.10,Test x²,p<0.05）.Conclusions:V/Q scan,perfusion scan combined with chest radiography and CTPA all show high efficacy in diagnosing PE.V/Q scan or perfusion scan combined with chest radiography is as accurate as CTPA.The concordance between perfusion scan and CTPA was intermediate on the segmental basis. PartⅡ1.Diagnostic and Prognostic Value of Gated SPECT in Patients with Chronic Heart FailurePurpose:To evaluate the diagnostic and prognostic value of quantitative rest electrocardiogram-gated single photon emission computed tomography（SPECT） with^99m Tc-sestamibi（99mTc-MIBI） in patients with chronic heart failure（CHF）.Methods:One hundred and forty-one consecutive patients who had CHF were enrolled prospectively between August 2007 and October 2008.Eighteen patients were excluded for meeting exclusion criteria and three patients were excluded for lost to follow up.Finally,120 patients were included （male,94,female,26,mean age,56±16 years）.The diagnosis of CHF was made by physicians based upon the patients’ symptoms,signs, laboratory recorders,imaging tests,and medical history.All patients underwent rest gated SPECT myocardial perfusion imaging.During the mean follow-up period of 236±94 days,the patients or their relatives were contacted using telephone or mail.The study endpoints were defined as cardiac death,or acute coronary syndrome（ACS）,or CHF requiring hospitalization,or clinical need for cardiac surgery.Gated SPECT images were analyzed by Quantitative Gated SPECT（QGS） and Quantitative Perfusion SPECT（QPS）,and then the left ventricular ejection fraction （LVEF）,cardiac index（CI）,summed rest scores（SRS）,summed motion score（SMS）,summed thickening score（STS）,peak filling rate（PFR）, and time to peak filling（TTPF） were calculated.Gated SPECT imaging results were analyzed,and survival analyses were performed using the Cox proportional-hazards model to establish the combined risk of cardiac events or disease progression for the variables assessed.Results:Among the 120 patients with CHF,39 patients were ischemic cardiomyopathy,81 patients were non-ischemic cardiomyopathy.Mean LVEF was 25.7%±12.2%and mean SRS was 10.2±10.4 for all patients on gated SPECT.SRS of the patients with ischemic cardiomyopathy were significantly higher than the patients with non-ischemic cardiomyopathy （19.0±12.5 vs 6.0±5.5,t test,p<0.05）.During follow-up,there were three cases of cardiac death,four cases of ACS,23 cases of hospitalization for CHF,and nine cases of cardiac surgery.Cox regression demonstrated that SRS≥9（RR=2.86,p<0.05） and Def Ext≥14%（RR=2.71,p<O.05） were independent predictors of cardiac events.Conclusions:These preliminary data suggest potential diagnostic utility of gated SPECT for ischemic cardiomyopathy in CHF,and important value for prognosis of CHF. PartⅡ2.Evaluation of Left Ventricular Volumes and Ejection Fraction by Gated SPECT and Cardiac MRI in Patients with Dilated CardiomyopatyPurpose:The goal of this study was to evaluate the accuracy of gated single-photon emission computed tomography（SPECT） in the assessment of left ventricular（LV） end-diastolic/end-systolic volumes（EDV,ESV） and ejection fraction（LVEF） in patients with dilated cardiomyopathy, using cardiac magnetic-resonance imaging（MRI） as the reference method. Furthermore,software-specific characteristics of QGS,ECTB and 4D-MSPECT were analyzed.Methods:Thirty-six patients with dilated cardiomyopathy who underwent gated technetium-99m methoxyisobutylisonitrile SPECT and cardiac MRI were included.LV EDV,ESV and LVEF values of gated SPECT were calculated using QGS,ECTB and 4D-MSPECT.Results:Correlation between the results of gated SPECT and cardiac MRI was excellent for EDV[R=0.872（QGS）,R=0.879（ECTB）,R=0).869（4D-MSPECT）], ESV[R=0.908（QGS）,R=0.897（ECTB）,R=0.880（4D-MSPECT）]and LVEF [R=0.794（QGS）,R=0.763（ECTB）,R=0.710（4D-MSPECT）].EDV and ESV by QGS did not differ significantly from those by cardiac MRI（all p=NS）, whereas EDV and ESV were overestimated by ECTB and 4D-MSPECT compared with cardiac MRI（all p=0.05）.LVEF was overestimated by QGS,ECTB and 4D-MSPECT compared with cardiac MRI（all p<0.05）.Conclusions:The correlation between gated SPECT and cardiac MRI is excellent for LV volume and LVEF values calculated by QGS,ECTB and 4D-MSPECT in patients with dilated cardiomyopathy.However, algorithm-varying over-or underestimation of LV volumes and LVEF should be accounted for in the clinical context.更多还原