冠心病患者冠状动脉侧支循环形成的形态学特点分析

目的:分析国人冠状动脉侧支循环的形态学特点。方法:将265例冠心病病人的冠状动脉造影结果进行分析,按Levin的方法进行分类,并与之比较。结果:不同狭窄程度两组间侧支循环开放率差别有高度统计学意义(X2=14.43,P<0.001)。三支血管间侧支循环开放率差别均有统计学意义(X2=3.96,X2=4.28,P<0.05)。东、西方组冠状动脉各支病变的侧支分布的比较差别有高度统计学意义(右冠状动脉X2=9.68,P<0.01;左冠状动脉X2=41.73,P<0.001;左冠状动脉旋支X2=8.54,P<0.01。结论:冠状动脉侧支循环的形成与冠状动脉狭窄程度及病变血管有关。中国人的冠状动脉侧支循环具有独特性。     

Multiple coronary artery-left ventricular fistulas: A pattern of anomalous coronary microvascularization

Fistulas between the coronary artery and the left heart chambers are exceptionally rare, especially those emptying into the left ventricle. We know of 33 cases of coronary artery-left ventricular fistulas reported in the literature, 7 of which had multiple communications. The findings in 6 additional patients with multiple coronary artery-left ventricular fistulas are reported. Three of the 6 patients had fistulas communicating to the left ventricle from all three major coronary arteries. It is important to recognize this anomaly as it may be the source of angina in patients without angiographic evidence of major atherosclerotic coronary artery disease.     

Non-invasive assessment of coronary artery geometry using coronary CTA

AimTo assess the association of coronary artery geometry with the severity of coronary artery disease (CAD).Methods73 asymptomatic individuals at increased risk of CAD due to peripheral vascular disease (18 women, mean age 63.5 ± 8.2 years) underwent coronary computed tomography angiography (coronary CTA) using first generation dual-source CT. Curvature and tortuosity of the coronary arteries were quantified using semi-automatically generated centerlines. Measurements were performed for individual segments and for the entire artery. Coronary segments were labeled according to the presence of significant stenosis, defined as >70% luminal narrowing, and the presence of plaque. Comparisons were made by segment and by artery, using linear mixed models.ResultsOverall, median curvature and tortuosity were, respectively, 0.094 [0.071; 0.120] and 1.080 [1.040; 1.120] on a per-segment level, and 0.096 [0.078; 0.118] and 1.175 [1.090; 1.420] on a per-artery level. Curvature was associated with significant stenosis at a per-segment (p < 0.001) and per-artery level (p = 0.002). Curvature was 16.7% higher for segments with stenosis, and 13.8% higher for arteries with stenosis. Tortuosity was associated with significant stenosis only at the per-segment level (p = 0.002). Curvature was related to the presence of plaque at the per-segment (p < 0.001) and per-artery level (p < 0.001), tortuosity was only related to plaque at the per-segment level (p < 0.001).ConclusionCoronary artery geometry as derived from coronary CTA is related to the presence of plaque and significant stenosis.     

Three-dimensional teaching model for coronary angiography

In order to improve the understanding and interpretation of cine coronary arteriograms obtained in various angled projections, a three-dimensional wire model was constructed. The main coronary arteries and most important muscular branches are simulated by a wire skeleton. The model can be rotated to simulate the standard right and left anterior oblique and left lateral projections. The degree of rotation is indicated on the base of the model. By tilting the model, cephalad and caudad tube angulation can be simulated. By placing the model in front of the cine projector, the shadows of the wires can be superimposed upon the projected cine coronary arteriogram. This simple, inexpensive model has greatly improved the three-dimensional understanding of the coronary arterial tree in various angled and nonangled views and in our practice had led to the development of additional useful projections.     

双源CT诊断冠脉狭窄的价值—与冠状动脉造影对照分析

目的:探讨双源CT冠脉成像评价冠脉中度及中度以上狭窄的准确性及可行性。方法:入选60例临床高度怀疑或已确诊冠脉疾病的患者,行双源CT扫描,扫描过程中患者心率平稳,未出现心率不齐及心律失常。患者于1周内行经皮选择性冠状动脉造影,并以冠状动脉造影作为标准,从冠脉节段及冠脉分支角度分别评价双源CT诊断冠脉中度及中度以上狭窄的准确性、敏感性、特异性、阳性预测率及阴性预测率。结果:以冠脉节段为基础分析,双源CT诊断冠脉明显狭窄的敏感性、特异性、阳性预测率、阴性预测率、准确性分别为81.14%、97.57%、85.34%、96.74%、95.13%;以冠脉分支为基础分析,双源CT诊断冠脉明显狭窄的敏感性、特异性、阳性预测率、阴性预测率、准确性分别为84.21%、93.79%、89.88%、90.06%、90.0%。双源CT与选择性冠脉造影对发现冠脉狭窄节段及检查冠脉分支病变的能力进行卡方检验,χ2分别0.625、1.041;P0.05,双源CT与选择性冠脉造影比较在发现冠脉明显狭窄差异上无统计学意义。结论:双源CT在诊断冠脉明显狭窄时有很高的准确性,可作为无创性评价冠脉狭窄及疾病的手段。     

拟诊冠心病患者心电图与冠状动脉造影结果分析

 目的通过对178例拟诊冠心病患者的静息心电图(ECG)与冠状动脉造影结果进行回顾性分析,评价静息心电图(ECG)对冠心病诊断和预后的价值.方法选择有冠心病典型症状及危险因素的患者,男109例、女69例,年龄62.5(61.5±11.1)岁.其中,99例患者ECG有心肌缺血表现(ECG阳性组),79例无心肌缺血表现(ECG阴性组).对所有拟诊患者进行冠状动脉造影(CAG)检查.结果静息ECG阳性与阴性组患者,CAG阳性率无显著性差异(54.5%vs 59.5%,P＞0.05);静息ECG对冠心病诊断的敏感性为56.4%,特异性为36.8%;静息ECG阳性组多支病变率明显高于ECG阴性组(66.7%vs 44.7%,P=0.029);静息ECG阴性组单支病变率明显高于ECG阳性组(55.3%vs 33.3%,P=0.026).静息ECG阳性组高血压患病率明显高于ECG阴性组(P=0.042).结论静息ECG阳性对诊断冠心病的特异性和敏感性低,对多支、多危险因素的高危冠心病患者具有一定的提示意义.     

CT冠状动脉成像在冠心病诊断中的应用

目的:研究CT冠状动脉成像在冠心病早期诊断冠状动脉狭窄定性定量判读的作用。方法:对34例临床未发生急性冠脉综合征的冠心病患者,先后进行冠状动脉造影、128排双源CT冠状动脉成像。以冠状动脉造影为"金标准",计算CT冠状动脉成像敏感性、特异性、阳性预测值、阴性预测值。结果:①与冠状动脉造影相比,CT冠状动脉成像的敏感性为68%,特异性为97%,阳性预测值为89%,阴性预测值为90%。②CT冠状动脉成像有65个血管段图像质量差,约占12%,造成图像质量差的原因主要为钙化,心跳、呼吸伪影,少部分为管腔显示不良。结论:冠心病早期诊断中,CT冠状动脉成像可用作冠状动脉造影前筛选,CT冠状动脉成像阴性的患者不必行冠状动脉造影检查;CT冠状动脉成像阳性的患者,可行冠状动脉造影进一步确认病变。     

冠状动脉粥样硬化性心脏病血管造影分析

目的 :探讨冠心病患者的冠状动脉病变特点及其危险因素。方法 :根据冠状动脉造影结果将 164例分为硬化组 12 2例和非硬化组 42例 ,分析冠状动脉病变特点、心电图特点及其危险因素。结果 :冠状动脉病变者 12 2例 ,累积病变血管 2 45支 ,其中左前降支 98支 (40 % )、右冠状动脉 72支 (2 9.4% )、左回旋支 60支 (2 4.5% )、左主干 15支 (6.1% ) ;单支50例 (41% )、双支和三支各 3 6例 (2 9.5% ) ;狭窄程度以 75%～ 94%占大多数 10 4支 (42 .4% )、95%～ 10 0 %占次位 75支(3 0 .6% )。ECG对冠心病诊断存在假阳性 (9.5%～ 3 0 .9% )。硬化组的年龄、吸烟、合并高血压、糖尿病、合并TC、TG、LDL C异常及GLU、TC、LDL C、SBP、DBP值与非硬化组之间均有显著差异 (P <0 .0 5)。 2组间的饮酒 ,HDL C、APOA和APOB值之间无显著性差异 (P >0 .0 5)。但 2组的TG水平均高于异常临床界值 ,TG >1.7mmol/L。结论 :冠心病的危险因素从高到低的顺序为年龄、高血压、糖尿病、高TC、TG和LDL C水平、吸烟     

Role of 320-slice multislice computed tomography coronary angiography in the assessment of coronary artery stenosis

Objective

To evaluate the effectiveness of the multislice CT coronary angiography, as a non-invasive imaging tool in assessment of coronary artery stenosis.

Patients and methods

The study included 50 patients who were referred for MSCT coronary angiography followed by catheter coronary angiography. Patients with previous coronary bypass grafts and those with coronary stents were excluded. History of contrast allergy, renal impairment and severe chest conditions were exclusion criteria. The coronary angiographic CT studies were performed using a 320 CT scanner. The catheter coronary angiographic studies were performed via femoral arterial puncture. The results of CT angiography were compared with the gold standard catheter angiography.

Results

The positive predictive value and negative predictive value of MSCT coronary angiography in detection of coronary artery stenosis were 94% and 100%, respectively.

Conclusion

In conclusion, MSCT coronary angiography is a very helpful and rapid non-invasive coronary imaging modality that was able to detect and grade coronary artery stenosis better than other noninvasive examinations used to detect CAD, such as exercise stress testing. Due to its very high negative predictive value, it may eliminate the need for invasive coronary procedures in the presence of normal coronary imaging.     

脊神经刺激对冠脉内皮功能及血流储备的影响

目的观察脊神经刺激对冠脉内皮功能及血流储备的影响。方法小型猪10只,用冠脉造影的方法,测量左冠脉主干的内径。同时插入5F塑型后的右冠造影管到冠状静脉窦。在胸椎3～4间隙椎旁2cm,分别进针3．5cm,电麻仪刺激30分钟。刺激后立即做冠脉造影,并同时分别抽取冠状动静脉血各1ml送检,测量其NO、ET含量。结果刺激脊神经可以改善内皮功能,促进内皮细胞释放NOx同时减少ET的释放,增加冠状动脉直径。结论脊神经刺激疗法能改善冠脉内皮功能及血流储备。     

Use of digital video coronary arteriography in the performance of percutaneous transluminal coronary angioplasty

Digital video coronary arteriography (DVCA) was used in 59 cases of percutaneous transluminal coronary angioplasty (PTCA) and found to be useful for (1) display of imagery to facilitate choice of approach to a setnotic lesion; (2) providing a “road map,” simplifying guide wire manipulation and selective catheterization of vessels during PTCA; and (3) archival of pre- and post-PTCA images. Use of DVCA for real-time display inside the catheterization laboratory expedites the successful performance of PTCA and is a convenient means of image archival.     

心肌桥和壁冠状动脉多层螺旋CT与冠状动脉造影诊断对照

目的 探讨多层螺旋CT（MSCT）和冠状动脉造影（CAG）诊断心肌桥-壁冠状动脉（MB—MCA）的能力。方法 对76例先后进行MSCT和CAG检查者，CT诊断和CAG诊断医师分别判断MB—MCA的有无，载MB—MCA血管形态特征。（1）采用双盲法MSCT和CAG分别独立阅片；（2）相互参照另1种检查结果后再次阅片。应用卡方统计分析方法，判断2种方法发现MB—MCA和判断血管迂曲有无差异。结果 双盲法MSCT发现MB—MCA27例29处，CAG发现2例2处（X^2=24．55，P〈0，05），MSCT发现22处（75．86％）载MB—MCA冠状动脉节段迂曲，CAG发现1处（X^2=28，82，P〈0．05），2种方法差异有统计学意义。相互对照后再次评价，MSCT发现MB—MCA数量同前，CAG新发现7例7处，位置与MSCT一致，2种方法差异仍有统计学意义（X^2=10．52，P〈0．05）。对22例MSCT诊断局部迂曲者，CAG也可证实，2种方法差异无统计学意义（X^2=0．33，P〉0．05）。结论 MSCT较CAG容易发现MB—MCA，CAG发现局部血管迂曲对MB—MCA有提示作用。     

冠心病合并2型糖尿病患者临床和冠脉造影特点分析

目的探讨冠心病（CHD）合并2型糖尿病（DM）患者的临床和冠脉造影特点。方法选择经冠脉造影证实的冠心病患者515例，根据是否合并糖尿病将其分为糖尿病组（353例）和非糖尿病组（162例），比较两组患者的临床和冠脉造影资料。结果合并2型糖尿病的冠心病患者发生高血压和急性心肌梗死的比例明显高于非糖尿病的冠心病患者（P〈0．01），前者血甘油三酯水平也明显高于后者（P〈0．01）。冠心病合并2型糖尿病患者多发生多支病变，左主干病变也明显高于非糖尿病者（P〈0．01）。结论冠心病合并2型糖尿病患者临床和冠脉病变复杂。     

Evaluation of coronary bypass grafts

Coronary artery bypass graft (CABG) surgery is in widespread use. Bypass graft angiography continues to be an integral part of the evaluation of the post-CABG patient. Future methods may include computed tomography and digital subtraction angiography to assist in this evaluation.     

The behavior of collateral circulation after coronary artery bypass surgery

The changes in coronary collateral circulation after bypass surgery were analyzed in 50 patients with coronary disease. The demonstration of collateral circulation was found to be dependent upon the severity of the coronary heart disease and the patency of the bypass. When the graft was patent, it was usually not possible to visualize the collateral circulation demonstrated preoperatively. When the bypass was occluded, the same collateral circulation as before surgery was frequenctly found.     

The accuracy of coronary CT angiography in patients with coronary calcium score above 1000 Agatston Units: Comparison with quantitative coronary angiography

BackgroundHigh amounts of coronary artery calcium (CAC) pose challenges in interpretation of coronary CT angiography (CCTA). The accuracy of stenosis assessment by CCTA in patients with very extensive CAC is uncertain.MethodsRetrospective study was performed including patients who underwent clinically directed CCTA with CAC score >1000 and invasive coronary angiography within 90 days. Segmental stenosis on CCTA was graded by visual inspection with two-observer consensus using categories of 0%, 1–24%, 25–49%, 50–69%, 70–99%, 100% stenosis, or uninterpretable. Blinded quantitative coronary angiography (QCA) was performed on all segments with stenosis ≥25% by CCTA. The primary outcome was vessel-based agreement between CCTA and QCA, using significant stenosis defined by diameter stenosis ≥70%. Secondary analyses on a per-patient basis and inclusive of uninterpretable segments were performed.Results726 segments with stenosis ≥25% in 346 vessels within 119 patients were analyzed. Median coronary calcium score was 1616 (1221–2118). CCTA identification of QCA-based stenosis resulted in a per-vessel sensitivity of 79%, specificity of 75%, positive predictive value (PPV) of 45%, negative predictive value (NPV) of 93%, and accuracy 76% (68 false positive and 15 false negative). Per-patient analysis had sensitivity 94%, specificity 55%, PPV 63%, NPV 92%, and accuracy 72% (30 false-positive and 3 false-negative). Inclusion of uninterpretable segments had variable effect on sensitivity and specificity, depending on whether they are considered as significant or non-significant stenosis.ConclusionsIn patients with very extensive CAC (>1000 Agatston units), CCTA retained a negative predictive value ​> ​90% to identify lack of significant stenosis on a per-vessel and per-patient level, but frequently overestimated stenosis.     

Radiation dose optimization in coronary angiography and percutaneous coronary intervention (PCI). II. Clinical evaluation

In a previous part of this study, the fluoroscopy dose rate was reduced in a cardiac catheterization laboratory. The objectives of the present study were to evaluate the effects in a clinical population undergoing percutaneous coronary intervention (PCI) of the dose-reducing measures detailed previously. Kerma area-product (KAP) values were first recorded for 154 patients undergoing PCI. Then, the fluoroscopy KAP rate was reduced from 44 to 16 mGy cm²/s by increasing filtration and reducing the image intensifier dose request. After this optimization, KAP was recorded for another 138 PCI procedures. After adjustment for differing proportions of combined procedures (coronary angiography+PCI), the total KAP was reduced to 67% of the original value with a 95% confidence interval from 57 to 78%, statistically significant. The mean total KAP values were 93.6 Gy cm² before and 69.1 Gy cm² after optimization. The KAP for digital acquisition did not change significantly. It is possible to make a large dose reduction in PCI by reducing the fluoroscopy dose rate. This dose reduction is beneficial for both patients and staff. Electronic Publication     

Radiation dose optimization in coronary angiography and percutaneous coronary intervention (PCI). I. Experimental studies

The objectives of this study were to evaluate the influence on image quality and dose to the patient and operator of various equipment settings for percutaneous coronary intervention (PCI), and to optimize the set-up. With an Alderson phantom, different settings, such as projection, protective screens, filtration, image intensifier size and collimation, were evaluated. Kerma-area product (KAP) was recorded as a measure of patient dose and scattered radiation was measured with an ionization chamber. Effective dose for a standardized PCI procedure was measured with thermoluminescent dosimeters inside the phantom. Image quality was evaluated with a contrast-detail phantom. Based on these findings, the equipment set-up was optimized to a low fluoroscopy dose rate with a sufficient image quality. Several operating parameters affected dose, particularly scattered radiation. The optimization reduced the fluoroscopy KAP rate from 44 to 16 mGy cm(2)/s using 15 cm of acrylic. The effective dose was reduced from 13 to 4.6 mSv for a standardized PCI procedure. Radiation dose to patient and operator in PCI is heavily dependent on both equipment set-up and operating parameters which can be influenced by the operator. With a careful optimization, a large reduction of radiation dose is possible.