【作者】 马青；

【导师】 王东；

【作者基本信息】 河北医科大学 ， 外科学， 2009， 硕士

【摘要】 目的:冠状动脉粥样硬化性心脏病( coronary atherosclerotic heart disease)指冠状动脉粥样硬化使得血管管腔狭窄或阻塞,或(和)因冠状动脉功能性改变(痉挛)导致心肌缺血缺氧或坏死引起的心脏病,统称冠状动脉性心脏(coronary heart disease),简称冠心病。冠心病外科治疗主要是冠状动脉搭桥术(coronary artery bypass graft, CABG)为缺血心肌重建血运通道,改善心肌供血供氧,缓解和消除心绞痛症状,改善心肌功能,延长寿命。CABG术后复查主要以X线下的选择性冠状动脉造影(conventional coronaryangiography,CAG)为准,但是该检查费用高、风险大,难以被多数患者所接受。近年随着CT技术的迅速发展,CT冠状动脉成像(computed tomography coronary angiography,CTA)逐渐成为学术界的研究热点之一,它对通过图像重组可以有效地显示冠状动脉血管树,并准确显示冠状动脉病变。特别是64排螺旋CT(64-slice computed tomography,64-SCT),它对心脏扫描的时间更快,功能软件更完善,对CABG术后患者的危险程度和发展趋势有一定的评估,诊断价值会更大。方法:选取我院2007年6月～2009年3月门诊复查的CABG术后患者共27例,男17例,女10例,年龄49～78岁,平均(63.6±7.9)岁。搭桥时间至CTA检查时间间隔30～121月,平均(59±18.7)月。所有患者均行64排螺旋CT冠状动脉扫描(64-slice computed tomography coronary angiography,64-SCTA)检查冠状动脉以及冠状动脉术后搭桥血管的病变情况,其中共有10例患者在64-SCTA之后行CAG,5例当时行经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI),1例再次行CABG,其余患者主要以药物治疗为主。参照美国心脏病协会(American Heart Association,AHA)冠状动脉节段划分法,将冠状动脉分为9段,冠状动脉搭桥术治疗后的病人桥血管分为5～6段,血管狭窄依程度分为四级:⑴正常;⑵狭窄程度25～50%为轻度狭窄;⑶狭窄程度50%～75%为中度狭窄;⑷狭窄程度≥75%为重度狭窄。对比分析64-SCTA和CAG的结果。64-SCTA结果由一组影像学专家来分析,以狭窄部位两端的血管直径作为参考值,评价桥血管病变情况,对狭窄程度进行分析及评价。CAG由一组心内科医师报告结果。64-SCTA和CAG两组之间都不知道对方的结果。64-SCTA诊断准确性以CAG结果作为标准,由此计算出敏感性、特异性、阳性预测值、阴性预测值和准确性,并做X2检验比较两种方法的诊断有无差别,计算kappa值查看其一致性。结果:27例患者均成功接受检查,每位患者大约需要10～15 min完成检查。27例患者均无心律失常,心率为52～85次/分。CTA扫描时间(9.0±1.2)s,屏气时间为12～14s。共发现桥血管78根,其中大隐静脉桥52根,动脉桥23根。共发现427段血管,其中能够满足影像学评价的共392段(占91.80%),35段(占8.20%)无法评价,其中运动伪影10段、严重钙化12段、金属夹伪影13段。LIMA-LAD桥、AO-LAD桥、AO-RCA桥和AO-LCX桥的可评价率分别为(103/115)89.57%、(18/18)100%、(139/150)92.67%、(132/144)91.67%。10例同期行64-SCTA及冠状动脉造影,两者诊断桥血管通畅、轻度狭窄、中度狭窄、重度狭窄的符合率分别为: 97.94%、88.24%、92.31%、90.00%。64-SCTA显示轻度以上狭窄(≥25%)的敏感度和特异度分别为100%和97.94%,准确度为98.51%;64-SCTA显示中度以上狭窄(≥50%)的敏感度和特异度分别为100%和100%,准确度为100%。重度狭窄(≥75%)的敏感度和特异度分别为90.00%和100%,准确度为99.25%。X2检验,得出0.95<P<0.975,按α=0.05水准,还不能认为两种检查方法对于桥血管通畅、轻度狭窄、中度狭窄、重度狭窄的诊断有区别。计算kappa=0.9350,认为两种检查方法检测搭桥术后桥血管狭窄的结果具有较高的一致性。结论:64-SCTA在评价冠心病病人冠状动脉病变及CABG术后桥血管通畅、狭窄和闭塞方面,有很高的准确性,敏感性和特异性,虽然64-SCTA还不能完全取代CAG,但其无创性、简便性,性价比高且易于接受等优点,适于对CABG术后患者桥血管通畅率进行评价,可以广泛用于患者术后复查。更多还原

【Abstract】 Objective:Coronary atherosclerotic heart disease is ischemia and hypoxia of heart muscle because of stenosis or occlusion of coronary artery caused by atherosclerosis or(and) functional change(spasm).It is called by a joint name,coronary heart disease,which is also called CHD for short.The main surgical treatment of CHD is coronary artery bypass graft(CABG).CAB G can reconstruct blood supply and improve oxygen supply of ischemia of heart muscle.It also can release symptom of stenocardia and improve function of cardiac muscle and prolong longevity.The main way of rechecking the patient who was operated CABG is conventional coronary angiography(CAG) which is more expensive and more risky and more unacceptable for the most patient.In recent years,computed tomography coronary angiography is gradually becoming a hot spot in academic study.It display the tree of coronary artery and pathological changes of coronary artery efficiently. 64-slice computed tomography (64-SCT) is especially faster and better in functional software.The diagnostic value of 64-SCTA is bigger because of it’s evaluation of danger-degree and development- tendency of patient who was operated CABG.Method: From June 2007 to March 2009,choose 27 patients rechecked from out-patient clinic in Tangshan Woker Hospital(17 males and 10 females; age range 49-78 years;mean age: 63.6±7.9years).(after CABG time:from 30-121months , mean time 59±18.7months).All of 27 patients underwent 64-SCTA.10 of them underwent CAG at same time. 5 of them previously underwent procedure of PCI with stent implantation. 1 of them underwent coronary artery bypass surgery (CABG).Others were treated by drugs.According to the suggestion of American Heart Association,the coronary arteries were devided to 9 segment.Bypass grafts were devided to 5-6 segment.The degree of bypass grafts stenosis divided into 4 classes:1, normol ; 2, slight stenosis (﹤50%) ;3, midrange stenosis(50%-75%) ;4, serious stenosis (≥75 % ) .The 64-SCTA’results were analyzed based on the CAG results.The results of the two methods were analyzed by a group of imageologic expert and cardiologists. Considering the blood vessel diameter of two sides of stenosis,Pathological changes and degree of stenosis of coronary artery was evaluated.Two groups do not kown the results of each other. The accuracy and sensitivity and specificity and positive predictive value and negative predictive value of 64-SCTA for diagnosis of stenosis of bypass grafts was evaluated,based on the CAG as a golden standard.Checking difference and consistency between two ways of diagnosis of bypass grafts by Chi-square test and Kappa value.Results:27 patients were operated 64-SCTA successfully.Each process takes 10～15min.There was no arrhythmia in 27 patients.(heart rate:52～85/min;CTA time: 9.0±1.2s; breath holding time:12～14s)There are Among the 427 coronary arteries segments in 78 bypass grafts,392(91.80%) were evaluated by 64-SCT successfully.(great saphenous vein:52;arterial bridge:23)35(8.20%) were unevaluated (movement shadow: 10 , serious calcification: 12 , metal clips-shadow:13). Evaluable-rate in each kind of bypass grafts: LIMA-LAD(103/115)89.57%, AO-LAD(18/18)100%, AO-RCA(139/150)92.67%, AO-LCX(132/144)91.67%.At the same time,10 of 27 patients were operated CAG.Two kind ways of diagnosis coincidence for 4 stenosis classes were 97.94%,88.24%,92.31%,90.00%. Sensitivity and specificity and accuracy in each groups,stenosis (stenosis≥25%),Up midrange stenosis(stenosis≥50%),Serious stenosis(stenosis≥75%),are 100% 97.94% 98.51% , 100% 100% 100% , 90.00% 100% 99.25%.In Chi-square test(α=0.05),0.95﹤p﹤0.975,we can not consider two ways of diagnosis of bypass grafts are different.Kappa=0.9350,we can consider there is high consistency between two ways of diagnosis of bypass grafts。Conclution:In evaluation of normal and stenosis and occlusion of coronary artery and bypass grafts, 64-SCTA takes more accuracy and sensitivity and specificity.It suit to evaluate bypass grafts of patient who was operated CABG because of the good quality of no-traumatic occlusion and convenience and low-price et al,although 64-SCTA can not replace CAG totally.更多还原