陳軍紅,李東野,韓曙光,徐通達(dá), 王超凡,王曉瑛
冠心病研究
小劑量多巴酚丁胺負(fù)荷下超聲斑點(diǎn)追蹤技術(shù)與磁共振延遲增強(qiáng)顯像技術(shù)評(píng)價(jià)陳舊性心肌梗死存活性研究
陳軍紅,李東野,韓曙光,徐通達(dá), 王超凡,王曉瑛
目的:比較磁共振延遲增強(qiáng)顯像(DE-MRI)技術(shù)與小劑量多巴酚丁胺負(fù)荷斑點(diǎn)追蹤超聲 (LDDS-STE) 技術(shù)評(píng)價(jià)陳舊性心肌梗死患者存活心肌方面的敏感性和特異性。
方法:選取30例本院住院陳舊性心肌梗死患者為研究對(duì)象。上述患者接受經(jīng)皮冠狀動(dòng)脈介入治療(PCI)術(shù)前進(jìn)行心臟核磁共振檢查及超聲心動(dòng)圖檢查,LDDS-STE方法分析靜息和負(fù)荷條件下左心室室壁運(yùn)動(dòng)異常節(jié)段短軸徑向應(yīng)變(RS)及應(yīng)變率(RSr),術(shù)后1,3,6個(gè)月復(fù)查超聲心動(dòng)圖,觀察室壁運(yùn)動(dòng)反常節(jié)段運(yùn)動(dòng)是否改善或恢復(fù),以室壁運(yùn)動(dòng)分?jǐn)?shù)改善作為判斷存活心肌的金標(biāo)準(zhǔn)。
結(jié)果: 30例患者共獲得510個(gè)左心室可分析節(jié)段,超聲心動(dòng)圖判定室壁運(yùn)動(dòng)異常節(jié)段201個(gè)。與金標(biāo)準(zhǔn)比較,靜息狀態(tài)下左心室徑向應(yīng)變(RSrest)預(yù)測(cè)陳舊性心肌梗死患者存活心肌受試者工作特征(ROC)曲線下面積為0.636,敏感性為60.0%,特異性為60.5%;小劑量多巴酚丁胺負(fù)荷條件下左心室徑向應(yīng)變(RSLDDS)預(yù)測(cè)存活心肌ROC曲線下面積0.806,敏感性和特異性分別為79.1%及82.7%。靜息狀態(tài)下左心室徑向應(yīng)變率(RSrrest)預(yù)測(cè)陳舊性心肌梗死患者存活心肌敏感性為60.0%,特異性為60.5%,ROC曲線下面積0.646;小劑量多巴酚丁胺負(fù)荷條件下左心室徑向應(yīng)變率(RSrLDDS)預(yù)測(cè)存活心肌敏感性和特異性較靜息狀態(tài)下明顯提高,分別為80.0%及83.7%,ROC曲線下面積0.808。DE-MRI技術(shù)預(yù)測(cè)存活心肌的敏感性和特異性分別為90.8%和87.1%,準(zhǔn)確性89.5%,ROC曲線下面積為0.901。
結(jié)論:DE-MRI與LDDS-STE方法均能準(zhǔn)確識(shí)別梗死后存活心肌, 但DE-MRI方法檢測(cè)存活心肌的價(jià)值稍高于LDDS-STE,且準(zhǔn)確率及重復(fù)性高,耗時(shí)短,為臨床預(yù)測(cè)陳舊性心肌梗死患者PCI術(shù)的療效及治療策略的選擇提供重要依據(jù)。
心肌梗死;磁共振成像;超聲心動(dòng)描記術(shù);存活心肌
存活心肌是心肌缺血后的一種特殊存在形式,特點(diǎn)為有效的血運(yùn)重建可使其功能部分或完全恢復(fù),改善臨床癥狀及預(yù)后。如無(wú)存活心肌,即使經(jīng)有效的血運(yùn)重建,局部心肌也不會(huì)恢復(fù)功能。如何前瞻性地確定心肌是否存活、心功能異常是否可逆對(duì)冠心病患者尤其是陳舊性心肌梗死患者臨床治療方案的選擇、危險(xiǎn)程度及預(yù)后評(píng)估有重要的臨床意義。磁共振延遲增強(qiáng)顯像(DE-MRI)技術(shù)可準(zhǔn)確識(shí)別心肌梗死后壞死透壁的心肌疤痕組織[1,2],超聲心動(dòng)圖是傳統(tǒng)評(píng)價(jià)心肌存活性的重要工具之一。本研究擬比較兩種方法在檢測(cè)陳舊性心肌梗死存活心肌上不同,擬為臨床提供一種經(jīng)濟(jì)有效評(píng)價(jià)存活心肌的方法。
臨床資料:收集本院2014-02至2016-12收治的陳舊性心肌梗死患者30例,其中男性19例,女性11例,年齡35~70(56.2±14.6)歲,臨床資料見(jiàn)表1。所有患者均簽署知情同意書(shū),試驗(yàn)過(guò)程中無(wú)不良事件發(fā)生。排除標(biāo)準(zhǔn):嚴(yán)重的心律不齊及心律失常,嚴(yán)重的瓣膜病,肥厚型心肌病,慢性阻塞性肺病,心力衰竭急性期,不能配合檢查者。
表1 30例受試者臨床一般資料[例(%)]
DE-MRI掃描技術(shù)及方法:采用philips Intera 1.5T超導(dǎo)型磁共振掃描系統(tǒng),磁場(chǎng)梯度為30 mT/m和60 mT/m,梯度切換率150mT/(m·ms),配有心臟專用5單元相位陣列線圈。在患者呼氣末15 s心電向量門控觸發(fā)掃描,心臟電影采用亮血序列,是回顧性心電門控真實(shí)穩(wěn)態(tài)自由進(jìn)動(dòng)梯度回波序列(True FISP),分別行左心室兩腔心長(zhǎng)軸、四腔心長(zhǎng)軸、左心室流出道切面以及6~8層左心室短軸電影。釓延遲增強(qiáng)磁共振掃描心肌首過(guò)灌注以0.1 mmol/kg體重,4~5 ml/s流速注入對(duì)比劑增強(qiáng)劑(即釓噴酸葡胺),完成以后追加20 ml生理鹽水,注射與掃描同時(shí)開(kāi)始,采用TSENSE EPI GRE序列。心肌灌注完成以后立即以2 ml/s的流速追加0.1~0.15 mmol/kg體重的對(duì)比劑,同時(shí)追加20 ml生理鹽水,15 min以后行相位敏感反轉(zhuǎn)恢復(fù)的T1WI掃描(PSIR),包括6~8層左心室短軸切面,左心室兩腔心切面以及四腔心切面均各1層。脫機(jī)分析Philips Achieva Extended MR Workspace 2.6.3.1工作站心臟軟件包,定量計(jì)算運(yùn)動(dòng)異常的心肌節(jié)段延遲增強(qiáng)的透壁程度。手動(dòng)勾畫左心室各延遲增強(qiáng)節(jié)段強(qiáng)化區(qū)域以及該節(jié)段室壁全層心肌的輪廓,并計(jì)算其面積,分別記為延遲強(qiáng)化區(qū)域面積(Ahyperenhancement)與室壁全層心肌面積(Amyocardium),室壁延遲增強(qiáng)透壁程度可按下面的公式計(jì)算[3]:延遲增強(qiáng)透壁程度(%)= 延遲強(qiáng)化區(qū)域面積/室壁全層心肌面積×100,見(jiàn)圖1。左心室各心肌節(jié)段延遲增強(qiáng)采用以下5等級(jí)分法[3,4]:0分:正常,無(wú)延遲增強(qiáng);1分:延遲增強(qiáng)透壁程度 1%~25%;2分:延遲增強(qiáng)透壁程度 26%~50%;3分:延遲增強(qiáng)透壁程度 51%~75%;4分:延遲增強(qiáng)透壁程度 76%~100%。目前磁共振成像(MRI)評(píng)價(jià)存活心肌的標(biāo)準(zhǔn)[5,6]:延遲增強(qiáng)透壁程度≤50%則是DE-MRI判斷存活心肌的標(biāo)準(zhǔn)。
負(fù)荷斑點(diǎn)追蹤超聲心動(dòng)圖技術(shù)與方法:采用Philip iE33彩色超聲診斷儀,S5-1探頭,頻率1~5 MHz,受檢者左側(cè)臥位,連接血壓與12導(dǎo)聯(lián)心電圖監(jiān)護(hù),采集并存儲(chǔ)連續(xù)3個(gè)心動(dòng)周期胸骨旁左心室二尖瓣環(huán)、乳頭肌、心尖水平短軸切面及胸骨旁左心室長(zhǎng)軸切面。幀頻維持在60~70 幀頻/秒,采用美國(guó)超聲心動(dòng)圖協(xié)會(huì)左心室17節(jié)段分法。檢查前24 h內(nèi)停用β受體阻滯劑、鈣離子拮抗劑及硝酸酯類等抗心絞痛藥物和其他影響心肌收縮力的藥物。靜息狀態(tài)圖像錄入后,微量注射泵靜脈注入小劑量多巴酚丁胺10 μg/(kg·min)5 min后,同樣記錄、存儲(chǔ)上述左心室短軸切面。QLAB 8.1脫機(jī)分析軟件沿二尖瓣瓣環(huán)及心尖部描記左心室心內(nèi)膜,手工調(diào)節(jié)心內(nèi)膜邊界,獲得含一定心肌厚度的感興趣區(qū)(ROI),計(jì)算機(jī)逐幀追蹤ROI內(nèi)斑點(diǎn)組織的運(yùn)動(dòng),得到二尖瓣環(huán)、乳頭肌及心尖部水平左心室短軸切面每一節(jié)段收縮期峰值徑向應(yīng)變(RS), 徑向應(yīng)變率(RSr),每一個(gè)數(shù)值取3個(gè)心動(dòng)周期的平均值。
圖1 磁共振延遲增強(qiáng)透壁程度計(jì)算圖
以超聲心動(dòng)圖心內(nèi)膜運(yùn)動(dòng)和室壁增厚率作為室壁運(yùn)動(dòng)評(píng)分,計(jì)算局部室壁運(yùn)動(dòng)異常(RWMA)節(jié)段數(shù)與評(píng)分。心內(nèi)膜運(yùn)動(dòng)幅度≥5 mm或室壁收縮期增厚率≥25 %視為運(yùn)動(dòng)正常,記1分;心內(nèi)膜運(yùn)動(dòng)幅度<5 mm或增厚率<25 %視為運(yùn)動(dòng)減弱,記2分;心內(nèi)膜運(yùn)動(dòng)和室壁收縮期增厚率消失視為無(wú)運(yùn)動(dòng),記3分;收縮期室壁變薄,向外運(yùn)動(dòng)為反常運(yùn)動(dòng)記4分;室壁瘤記為5分。金標(biāo)準(zhǔn)判定:以超聲心動(dòng)圖經(jīng)皮冠狀動(dòng)脈介入治療(PCI)術(shù)前及術(shù)后左心室室壁運(yùn)動(dòng)分?jǐn)?shù)改善作為判斷存活心肌的金標(biāo)準(zhǔn)[7,8], PCI術(shù)后1、3及6個(gè)月復(fù)查超聲心動(dòng)圖,有一次原來(lái)運(yùn)動(dòng)異常的節(jié)段室壁收縮期增厚率比術(shù)前靜息時(shí)增加>10%或室壁運(yùn)動(dòng)記分減少1分以上,則認(rèn)為是存活心肌,否則是壞死或瘢痕心肌。但反常運(yùn)動(dòng)轉(zhuǎn)為無(wú)運(yùn)動(dòng)則判定為室壁運(yùn)動(dòng)無(wú)改善。
統(tǒng)計(jì)學(xué)分析:采用SPSS 16.0統(tǒng)計(jì)分析軟件,所有數(shù)據(jù)以均數(shù)±標(biāo)準(zhǔn)差( ±s)表示,存活心肌與非存活心肌間參數(shù)檢驗(yàn)采用獨(dú)立樣本t檢驗(yàn)。受試者工作特征曲線(ROC曲線)計(jì)算不同狀態(tài)RS和RSr參數(shù)的曲線下面積(AUC)及診斷存活心肌的最佳截?cái)帱c(diǎn)、敏感性、特異性和準(zhǔn)確性。率的組間比較則采用卡方檢驗(yàn)。P<0.05視為差異具有統(tǒng)計(jì)學(xué)意義。
術(shù)前30例確診為陳舊性心肌梗死患者,均接受冠狀動(dòng)脈造影及PCI術(shù),手術(shù)順利完成。30例患者共獲得510左心室可分析節(jié)段,傳統(tǒng)超聲心動(dòng)圖方法判定左心室室壁運(yùn)動(dòng)異常節(jié)段201個(gè)。PCI術(shù)后1、3及6個(gè)月復(fù)查超聲心動(dòng)圖,對(duì)201個(gè)節(jié)段進(jìn)行隨訪,金標(biāo)準(zhǔn)檢出存活心肌131個(gè),非存活心肌70個(gè),其靜息和負(fù)荷條件下應(yīng)變及應(yīng)變率變化見(jiàn)表2。靜息狀態(tài)下左心室徑向應(yīng)變(RSrest)預(yù)測(cè)存活心肌ROC曲線下面積為0.636,敏感性為60.0%,特異性為60.5%;小劑量多巴酚丁胺負(fù)荷條件下左心室徑向應(yīng)變(RSLDDS)預(yù)測(cè)存活心肌ROC曲線下面積0.806,敏感性和特異性較靜息條件下明顯提高,分別為79.1%及82.7%,見(jiàn)圖2A。靜息狀態(tài)下左心室徑向應(yīng)變率(RSrrest)預(yù)測(cè)存活心肌ROC曲線下面積0.646,敏感性為60.0%,特異性為60.5%,小劑量多巴酚丁胺負(fù)荷條件下左心室徑向應(yīng)變率(RSrLDDS)預(yù)測(cè)存活心肌ROC曲線下面積0.808,敏感性和特異性較靜息條件下明顯提高,分別為80.0%及83.7%,見(jiàn)圖2B。
表2 金標(biāo)準(zhǔn)檢出存活心肌與非存活心肌靜息及負(fù)荷條件下徑向應(yīng)變及應(yīng)變率參數(shù)變化( ±s)
圖2 靜息和負(fù)荷條件下斑點(diǎn)追蹤超聲及磁共振延遲增強(qiáng)技術(shù)預(yù)測(cè)陳舊性心肌梗死患者存活心肌ROC曲線
DE-MRI方法分析上述201個(gè)室壁運(yùn)動(dòng)異常節(jié)段,結(jié)果發(fā)現(xiàn)其中延遲增強(qiáng)透壁程度為1%~25% 1分的節(jié)段有56個(gè),延遲增強(qiáng)透壁程度為26%~50% 2分的節(jié)段有72個(gè),延遲增強(qiáng)透壁程度為51%~75% 3分的節(jié)段有41個(gè),延遲增強(qiáng)透壁程度為76%~100% 4分的節(jié)段有32個(gè)。DEMRI根據(jù)延遲增強(qiáng)的程度判定其中128個(gè)節(jié)段判定為存活心肌,73個(gè)節(jié)段為非存活心肌,敏感性、特異性和準(zhǔn)確性分別為90.8%、87.1%和89.5%,見(jiàn)表3,根據(jù)不同透壁程度繪制ROC曲線,見(jiàn)圖2C。
表3 DE-MRI評(píng)價(jià)陳舊性心肌梗死患者201個(gè)室壁運(yùn)動(dòng)異常節(jié)段存活心?。ɡ?/p>
心肌梗死是心血管內(nèi)科的急癥,預(yù)后差,是心血管疾病最常見(jiàn)的死亡原因。研究證實(shí)心肌梗死后的局部室壁運(yùn)動(dòng)異常區(qū)域除壞死心肌外,尚有部分存活心肌,如冬眠心肌或頓抑心肌[9,10]。再血管化治療早期識(shí)別存活心肌對(duì)冠心病患者心肌梗死后冠狀動(dòng)脈血運(yùn)重建術(shù)的療效判斷、預(yù)后判斷起重要作用。判斷存活心肌的金標(biāo)準(zhǔn)主要有正電子發(fā)射斷層顯像(PET)和超聲心動(dòng)圖等方法,PET因其檢查費(fèi)用昂貴,且難以劃分心內(nèi)膜下心肌梗死或心肌梗死透壁程度,目前在臨床難以廣泛普及。故我們選擇目前國(guó)內(nèi)外公認(rèn)的以PCI術(shù)后超聲室壁運(yùn)動(dòng)改善作為判定存活心肌的金標(biāo)準(zhǔn)。
斑點(diǎn)追蹤超聲(STE)技術(shù)因其可對(duì)高幀頻二維圖像的斑點(diǎn)回聲進(jìn)行逐幀追蹤,無(wú)角度依賴性,能較準(zhǔn)確地反映局部及整體心肌功能,因此檢測(cè)存活心肌有較高的價(jià)值,前期研究表明超聲心動(dòng)圖結(jié)合10 μg/(kg·min)多巴酚丁胺對(duì)存活心肌的檢出率與雙核素單光子發(fā)射計(jì)算機(jī)斷層攝影術(shù)(DISASPECT)相當(dāng)[11],故我們采取LDDS-STE方法與DE-MRI方法進(jìn)行比較。
DE-MRI由于具有良好的空間分辨率及高度的組織特定性能力,其檢測(cè)存活心肌的準(zhǔn)確性及特異性較高,越來(lái)越引起臨床醫(yī)生的關(guān)注[12]。DE-MRI是通過(guò)檢測(cè)細(xì)胞膜的完整性來(lái)評(píng)估心肌血流灌注,通過(guò)計(jì)算收縮功能障礙的心肌節(jié)段延遲增強(qiáng)的透壁程度來(lái)判斷是否存在存活心肌[13,14]。急性心肌梗死歸咎于細(xì)胞膜的完整性被破壞,造影劑得以滲透至細(xì)胞外,這種機(jī)制往往用于解釋急性心肌梗死造影劑延遲增強(qiáng),但對(duì)于陳舊性心肌梗死,其機(jī)理則不盡相同,心肌梗死隨著時(shí)間進(jìn)展,梗死區(qū)域心肌細(xì)胞密度顯著降低,膠原纖維含量大幅增加,細(xì)胞外基質(zhì)擴(kuò)大。已經(jīng)有研究表明陳舊性心肌梗死是由于重構(gòu)的微血管側(cè)支循環(huán)和殘存擴(kuò)張的血管允許造影劑的轉(zhuǎn)運(yùn),疤痕心肌內(nèi)微血管通透性增加允許細(xì)胞外造影劑如釓噴酸葡胺滲透至細(xì)胞外間隙。另外進(jìn)展的瘢痕組織中增加的細(xì)胞外基質(zhì)擴(kuò)大了細(xì)胞外間隙也是造影劑聚集的一個(gè)重要因素[15,16]。所以DEMRI可以明確的顯示心肌梗死或纖維化的心肌瘢痕,可以直觀的顯示其壞死心肌的透壁程度。
研究證實(shí)心臟延遲磁共振評(píng)價(jià)心肌梗死的范圍和血運(yùn)重建術(shù)后運(yùn)動(dòng)異常心肌的恢復(fù)密切相關(guān)[17,18]。Fieno等[19]發(fā)現(xiàn)DE-MRI可以區(qū)分可逆的和非可逆的心肌損傷,并且可以明確其梗死的時(shí)間,是否有再灌注的血流,梗死的范圍等情況。同樣DE-MRI在急性的心肌細(xì)胞缺血時(shí)可以區(qū)分心肌細(xì)胞壞死和心肌細(xì)胞水腫[20],相比于其他的傳統(tǒng)檢查方法,它有著許多潛在的優(yōu)勢(shì)。
本研究證實(shí)DE-MRI在評(píng)價(jià)陳舊性心肌梗死存活性方面明顯優(yōu)于靜息及負(fù)荷斑點(diǎn)追蹤超聲,且較正電子發(fā)射斷層顯像價(jià)格低廉,重復(fù)性好,對(duì)患者無(wú)輻射。如患者心功能可耐受,對(duì)于陳舊性心肌梗死存活心肌的判斷,急性心肌梗死水腫帶范圍及微血管阻塞程度判定,對(duì)PCI效果及預(yù)后有重要指導(dǎo)意義。本試驗(yàn)主要研究對(duì)象為陳舊性心肌梗死患者,因?yàn)榇蟛糠旨毙孕募」K阑颊哂绕涫乔氨谛募」K阑颊呒毙云诖蠖啻嬖趪?yán)重心功能不全,患者不能耐受核磁共振完整過(guò)程檢查。目前市場(chǎng)現(xiàn)有的冠狀動(dòng)脈藥物涂層支架為第二代、第三代藥物支架,因其含鐵量小,尤其是第三代藥物涂層支架,在3.0T以下場(chǎng)強(qiáng)進(jìn)行磁共振掃描證實(shí)是安全的。DE-MRI應(yīng)用對(duì)于非急診PCI術(shù)心肌梗死患者及其他類型冠心病患者治療方案的選擇、危險(xiǎn)程度及預(yù)后評(píng)估有重要的臨床意義,在臨床可廣泛推廣。
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2017-04-25)
(編輯:汪碧蓉)
Assessment of Myocardial Viability by Low-dose Dobutamine Stress Speckle Tracking Echocardiography and Delayed Enhancement MRI in Patients With Old Myocardial Infarction
CHEN Jun-hong, LI Dong-ye, HAN Shu-guang, XU Tong-da, WANG Chao-fan, WANG Xiao-ying.
Department of Cardiology, Aff i liated Hospital of Xuzhou Medical University, Xuzhou (221000), Jiangsu, China
LI Dong-ye, Email: Dongyeli@medmail.com.cn
Objective: To compare the sensitivity and specificity between low dose dobutamine stress speckling tracking echocardiography (LDDS-STE) and delayed enhancement MRI (DE-MRI) for assessing viable myocardium (VM) in patients with old myocardial infarction (OMI).
Methods: A total of 30 in-hospitalized OMI patients were enrolled, all patients received cardiac MRI and LDDSSTE prior percutaneous coronary intervention (PCI). Radial peak systolic strain (RS) and strain rate (RSr) were analyzed by LDDS-STE at both resting and loading conditions, echocardiography was performed at 1, 3 and 6 months after PCI to observe the cardiac wall motion changes and the improvement of wall motion score was taken as golden standard of VM.
Results: 510 left ventricular segments were obtained for analysis in 30 patients and echocardiography indicated 201 segments with abnormal wall motion. Compared with golden standard, the area under ROC curve of RSrestfor detecting VM was 0.636 with the sensitivity at 60.0% , specif i city at 60.5% and the area under ROC curve of RSLDDSfor detecting VM was 0.806 with the sensitivity at 79.1%, specif i city at 82.7%; the area under ROC curve of RSrrestfor detecting VM was 0.646 with the sensitivity at 60.0% , specif i city at 60.5% and the area under ROC curve of RSrLDDSfor detecting VM was 0.808 with the sensitivity at 80.0%, specif i city at 83.7% which were obviously improved than RSrrest. By DE-MRI, the area under ROC curve for detecting VM was 0.901 with the sensitivity at 90.8%, specif i city at 87.1% and accuracy at 89.5%.
Conclusion: Both DE-MRI and LDDS-STE can recognize VM in OMI patients; while DE-MRI had the better accuracy and repeatability, cost less time which may provide important basis for predicting the eff i cacy of PCI and for making the treatment strategy.
Myocardial infarction; Magnetic resonance imaging; Echocardiography; Viable myocardium
221000 江蘇省徐州市,徐州醫(yī)科大學(xué)附屬醫(yī)院 心內(nèi)科(陳軍紅、徐通達(dá)、王超凡、王曉瑛),心血管病研究所(李東野),放射科(韓曙光)
陳軍紅 副教授 博士 研究方向?yàn)闊o(wú)創(chuàng)心功能評(píng)價(jià) Email:cjh1029@sina.com 通訊作者:李東野 Email:Dongyeli@medmail.com.cn
R541
A
1000-3614(2017)11-1066-05
10.3969/j.issn.1000-3614.2017.11.006
(Chinese Circulation Journal, 2017,32:1066.)