静脉心肌声学造影观察心肌微血管缺血再灌注损伤的实验研究

为探讨急性心肌缺血再灌注后心肌微血管状态，观察了三条开胸犬关降支阻断前后，心肌声学造影显示的心肌微血管对Ａｃｈ反应情况。结果表明；ＬＡＤ阻断３０ｍｉｎ再开放后，心肌微血管灌注于血流重建后９０ｍｉｎ才恢复。说明心肌微血管内皮损伤是心肌顿抑的原因之一。     

犬局部心肌顿抑动物模型的制备

目的为研究和治疗局部心肌顿抑制备在体动物模型。方法杂种犬36条,冠状动脉左前降支阻断15min后,再灌注30min.分别于冠脉阻断前、冠脉阻断5、10、15min及再灌注5、10、20、30、60min测定血流动力学指标,并于再灌注后30mid取左、右心室标本送电子显微镜检查.结果心率在缺血／再灌注过程中均明显增快;平均动脉压在冠脉阻断期间稍下降(P＜0.05),再灌注后升至基础水平;冠脉阻断后心排血量、每搏量、左室收缩功指数均迅疾下降,再灌注5min略有上升,之后又呈进行性下降;冠脉阻断后心律失常发生率为56．7％,再灌注心律失常发生率40％,其中3例冠脉开放突发室颤死亡.心肌超微结构再灌注30min心肌纤维肿胀,间质明显水肿,毛细血管淤血,线粒体大量空泡.结论犬LAD阻断15min,再灌注后出现明显的心肌顿抑;缺血／再灌注心律失常发病率高,治疗困难.     

局部心肌顿抑对全身血流动力学及心肌氧供需平衡的影响

目的观察局部心肌顿抑对全身血流动力学及心肌氧供需平衡的影响.方法杂种犬33条,常温下LAD阻断15 min,观察再灌注后全身血流动力学、冠脉流量及缺血心肌氧供需平衡的变化.结果 MAP在冠脉阻断期间稍下降,再灌注后升至基础水平;HR在缺血/再灌注过程中均明显增快;冠脉阻断后,CO、SV、LVSWI均迅疾下降,再灌注5 min略有升高,之后进行性下降;再灌注后SVR及PVR均呈进行性增高;再灌注5 min冠脉流量、MDO2和MVO2均显著升高,然后同步下降;MERO2在缺血/再灌注过程中无明显变化.电镜检查:再灌注30 min,心肌纤维肿胀,间质明显水肿,毛细血管淤血,线粒体大量空泡.结论局部心肌顿抑可引起明显的血流动力学变化;再灌注初期存在明显的氧耗反常,而再灌注后期心肌氧供、氧耗基本相配.     

The effects of atorvastatin on myocardial no-reflow after ischemia/reperfusion in rats.

目的 观察阿托伐他汀对大鼠心肌缺血再灌注后无复流的影响,探讨其可能机制.方法 56只雄性SD大鼠随机分为4组:(1)假手术组,左前降支冠脉(LAD)穿线不结扎180 min;(2)缺血再灌注组,结扎LAD 60 min后再灌注120min;(3)阿托伐他汀组,结扎LAD前给予阿托伐他汀20 mg/(kg·d)灌胃3 d;(4)阿托伐他汀+L-硝基精氨酸(L-NNA)组,L-NNA 15mg/kg结扎LAD前15min尾静脉注入,阿托伐他汀处理同上,后两组缺血再灌注处理同缺血再灌注组.实验结束后测血清CK-MB及心肌一氧化氮(NO)水平;心肌染色法区分缺血区、无复流区及梗死区;免疫组化法检测心肌及血管中eNOS、iNOS含量;电镜下观察微血管及心肌线粒体等超微结构改变.结果 与假手术组比较,缺血再灌注组心肌及血管iNOS表达增加,eNOS表达无变化,心肌NO水平下降,微血管及心肌线粒体损伤明显;与缺血再灌注组比较,阿托伐他汀能抑制iNOS表达,诱导eNOS表达,增加NO水平,减轻微血管及心肌线粒体损伤,减少心肌梗死及无复流.一氧化氮合酶抑制剂L-NNA可阻断阿托伐他汀上述作用.结论 阿托伐他汀通过eNOS/iNOS-NO途径,激活线粒体ATP敏感钾通道和减轻微血管损伤,减少心肌梗死及无复流.     

阿托伐他汀对大鼠心肌缺血再灌注后无复流的影响

目的观察阿托伐他汀对大鼠心肌缺血再灌注后无复流的影响,探讨其可能机制。方法 56只雄性SD大鼠随机分为4组:(1)假手术组,左前降支冠脉(LAD)穿线不结扎180 min;(2)缺血再灌注组,结扎LAD60 min后再灌注120 min;(3)阿托伐他汀组,结扎LAD前给予阿托伐他汀20 mg/(kg.d)灌胃3 d;(4)阿托伐他汀+L-硝基精氨酸(L-NNA)组,L-NNA 15 mg/kg结扎LAD前15 min尾静脉注入,阿托伐他汀处理同上,后两组缺血再灌注处理同缺血再灌注组。实验结束后测血清CK-MB及心肌一氧化氮(NO)水平;心肌染色法区分缺血区、无复流区及梗死区;免疫组化法检测心肌及血管中eNOS、iNOS含量;电镜下观察微血管及心肌线粒体等超微结构改变。结果与假手术组比较,缺血再灌注组心肌及血管iNOS表达增加,eNOS表达无变化,心肌NO水平下降,微血管及心肌线粒体损伤明显;与缺血再灌注组比较,阿托伐他汀能抑制iNOS表达,诱导eNOS表达,增加NO水平,减轻微血管及心肌线粒体损伤,减少心肌梗死及无复流。一氧化氮合酶抑制剂L-NNA可阻断阿托伐他汀上述作用。结论阿托伐他汀通过eNOS/iNOS—NO途径,激活线粒体ATP敏感钾通道和减轻微血管损伤,减少心肌梗死及无复流。     

无创性心肌声学造影评价急性心肌梗死再灌注后冠脉微循环的实验研究

目的:应用经静脉心肌声学造影(MCE)评价急性心肌梗死血管再通后的心肌微循环灌注情况.方法:30只中华小型猪,通过心导管介入法阻断前降支(LAD)120min,再灌注180min.在LAD闭塞及开通后分别行MCE,测定再灌注前后缺血心肌节段和正常心肌节段的视频强度值及心肌充盈缺损面积,计算无复流与危险区心肌面积比值(NRA/RA).进行心肌病理染色,计算NRA/RA.结果:LAD开通后TIMI血流均为3级.再灌注180min后,缺血心肌节段的视频强度较闭塞时有所增加(P<0.01),但仍明显低于正常心肌(P<0.01),可见充盈缺损区.MCE和病理染色测定的NRA/RA分别为39.68±23.06%和31.07±14.25%,结果无显著性差异(P>0.05),相关系数r=0.715.结论:MCE可作为一种准确、无创评价心肌微循环灌注的有效方法.     

MCE评价格列苯脲在硝酸甘油诱导心肌缺血再灌注损伤的保护作用

目的采用心肌声学造影(MCE)评价格列苯脲在硝酸甘油诱导心肌缺血再灌注损伤的延迟保护作用.方法24只犬左冠状动脉前降支(LAD)阻断180 min,再灌注120 min,分别于结扎前,结扎后即刻,180 min,再灌注后即刻、60 min、120 min时于左股静脉弹丸式注入MCE剂,分4组: A组(缺血再灌注组,6只),B组(硝酸甘油组,6只), C组(硝酸甘油+KATP拮抗剂组,6只),D组(KATP拮抗剂组,6只).MCE评价峰值声强度和曲线下面积.结果再灌注后即刻,四组心肌峰值声强度及曲线下面积明显减低;随着再灌注时间的延长,峰值声强度逐渐恢复.结论硝酸甘油对缺血再灌注损伤心肌微循环、微血管内皮功能具有延迟保护作用;硝酸甘油可能通过激活K离子通道诱导对缺血再灌注损伤心肌微循环灌注,微血管内皮功能的延迟保护.     

普鲁泊福对犬急性缺血再灌注心肌代谢和超微结构的影响

目的：研究不同剂量的普鲁泊福对犬急性缺血再灌注损伤心肌代谢和超微结构的影响。方法：杂种犬18只（11-14kg）,随机分3组：生理盐水对照组(NS组)用量为2ml/(kg.h), 高剂量普鲁泊福组(HP组)用量为11.2mg/(kg.h), 低剂量普鲁泊福组(LP组)用量为5.6mg/(kg.h)。开胸阻断左冠状动脉前降支（LAD）90min后再灌注200 min;于注药前、注药60min、阻断LAD血流90min以及再灌注60,120和180min时,抽心大静脉血测乳酸脱氢酶(LDH)含量和超氧化物歧化酶(SOD)活力;于再灌注200min时取再灌注区心肌组织做电镜观察。结果：再灌注后各时间点NS组LDH含量明显高于HP组和LP组（P<0.05）,SOD活力明显低于HP组和LP组（P<0.05）。NS组心肌超微结构再灌注损伤明显重于HP组和LP组。结论：普鲁泊福具有一定抗氧化能力和保护线粒体作用,可减轻犬急性心肌缺血再灌注损伤。     

用硝酸镧检测心肌顿抑兔微血管的超微结构改变及呋喃丙吡啶的保护作用

观察心肌顿抑后微血管可逆性损伤的超微结构改变，以及钙拮抗剂呋喃丙吡啶对微血管损伤是否具有保护作用．方法：建立兔心肌顿抑模型，采用镧醛灌注固定法制备电镜样品．缺血再灌注前用呋喃丙吡啶预防性给药．结果：闭塞15min再灌注15min时，血管扩张，间隙水肿，血管内外附着大量的镧颗粒．再灌注30min时损伤进一步加重，但血管膜结构完整，直至再灌注120min血管通透性损伤基本恢复正常．预防性给予呋喃丙吡啶后，闭塞15min再灌注15min，血管内皮结构完整，仅在血管腔内有镧颗粒附着在血管壁上，血管外间隙水肿减轻．结论：心肌顿抑时微血管通透性增加，血管内膜结构完整，随着再灌注时间延长，血管通透性恢复正常．缺血再灌注前预先应用呋喃丙吡啶防治可以限制微血管顿抑．     

缺血后处理对糖尿病大鼠缺血再灌注心肌的保护作用

目的 探讨缺血后处理对糖尿病大鼠缺血再灌注心肌的保护作用.方法 通过尾静脉注射2％链脲佐菌素溶液(45mg/kg)建立糖尿病大鼠模型,并将大鼠随机分为4组(每组12只):正常组:正常大鼠自由饲食水,不做任何手术处理;假手术组:糖尿病大鼠开胸后在冠状动脉左前降支(LAD)下穿线,不结扎;缺血再灌注(IR)组:结扎糖尿病大鼠LAD造成缺血30min,再灌注2h;缺血后处理(IPostC)组:结扎糖尿病大鼠LAD 30 min,再灌注30 s,阻断30 s,重复3次,再灌注2h.采用TTC法检测心肌梗死面积,TUNEL法检测心肌细胞凋亡.结果 与IR组比较,IPostC组大鼠心肌梗死面积及凋亡指数明显减小,差异有统计学意义(P＜0.05).结论 缺血后处理能够减小心肌梗死面积,减少心肌细胞凋亡,对糖尿病大鼠缺血再灌注心肌具有保护作用.     

Intracoronary adenosine improves myocardial perfusion in late reperfused myocardial infarction

Background Myocardial perfusion associates with clinical syndromes and prognosis.Adenosine could improve myocardial perfusion of acute myocardial infarction within 6 hours,but few data are available on late perfusion of myocardial infarction (MI).This study aimed at quantitatively evaluating the value of intracoronary adenosine improving myocardial perfusion in late reperfused MI with myocardial contrast echocardiography(MCE).Methods Twenty-six patients with anterior wall infarcts were divided randomly into 2 groups:adenosine group(n=12) and normal saline group(n=14).Their history of myocardial infarction was about 3-12 weeks.Adenosine or normalsaline was given when the guiding wire crossed the lesion through percutaneous coronary intervention(PCI),then the balloon was dilated and stent(Cypher/Cypher select)was implanted at the lesion.Contrast pulse sequencing MCE with Sonovue contrast via the coronary route was done before PCI and 30 minutes after PCI.Video densitometry and contrast filled-blank area were calculated with the CUSQ off-line software.Heart function and cardiac events were followed up within 30 days.Results Perfusion in the segments of the criminal occlusive coronary artery in the adenosine group was better than that in the saline group(5.71±0.29 vs 4.95±1.22,P＜0.05).Ischemic myocardial segment was deminished significantly afterPCI,but the meliorated area was bigger in the adenosine group than in the saline group((1.56±0.60)cm2 vs(1.02±0.56) cm2,P＜0.05).The video densitometry in critical segments was also improved significantly in the adenosine group (5.53±0.36 vs 5.26±0.35,P＜0.05).Left ventricular ejection fraction(LVEF)was improved in all patients after PCI,but EF was not significant between the two groups((67±6)% vs(62±7)%,P＞0.05).There was no in-hospital or 30-day major adverse cardiac event(MACE)in the adenosine group but 3 MACE in the saline group in 30 days after PCI.Conclusions Adenosine could improve myocardial microvascular perfusion in the late reopening of an occluded infarct reIaled artery(3 to 12 weeks after AMI)and clinical outcome in the follow-up period,and myocardial microvascular perfusion is a powerful predictor of clinical events.     

Intracoronary adenosine improves myocardial perfusion

Background Myocardial perfusion associates with clinical syndromes and prognosis. Adenosine could improve myocardial perfusion of acute myocardial infarction within 6 hours, but few data are available on late perfusion of myocardial infarction （MI）. This study aimed at quantitatively evaluating the value of intracoronary adenosine improving myocardial perfusion in late reperfused MI with myocardial contrast echocardiography （MCE）.
Methods Twenty-six patients with anterior wall infarcts were divided randomly into 2 groups： adenosine group （n=12） and normal saline group （n=-14）. Their history of myocardial infarction was about 3-12 weeks. Adenosine or normal saline was given when the guiding wire crossed the lesion through percutaneous coronary intervention （PCI）, then the balloon was dilated and stent （Cypher/Cypher select） was implanted at the lesion. Contrast pulse sequencing MCE with Sonovue contrast via the coronary route was done before PCI and 30 minutes after PCI. Video densitometry and contrast filled-blank area were calculated with the CUSQ off-line software. Heart function and cardiac events were followed up within 30 days.
Results Perfusion in the segments of the criminal occlusive coronary artery in the adenosine group was better than that in the saline group （5.71：L-0.29 VS 4.95±1.22, P〈0.05）. Ischemic myocardial segment was deminished significantly after PCI, but the meliorated area was bigger in the adenosine group than in the saline group （（1.56±0.60） cm^2 vs （1.02±0.56） cm^2, P〈0.05）. The video densitometry in cntical segments was also improved significantly in the adenosine group （5.53±0.36 VS 5.26±0.35, P〈0.05）. Left ventricular ejection fraction （LVEF） was improved in all patients after PCI, but EF was not significant between the two groups （（67±6）% vs （62±7）%, P〉0.05）. There was no in-hospital or 30-day major adverse cardiac event （MACE） in the adenosine group but 3 MACE in the saline group in 30 days after     

Non-invasive assessment of myocardial risk and infarct area incanine model of myocardial reperfusion by intravenouscontrast echocardiography

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实时心肌超声造影评价糖尿病早期心肌血流灌注改变的实验研究

目的：探讨实时心肌超声造影（RT-MCE）技术检测糖尿病（DM）早期大鼠心肌血流灌注异常的价值。方法：24只雄性SD大鼠中随机选取12只通过腹腔注射链脲佐菌素建立DM模型（DM组）,剩余12只大鼠作为对照,腹腔注射等量枸橼酸缓冲液。模型建成8周后,在静息状态下,对两组大鼠行RT-MCE检查,检测两组大鼠乳头肌水平左室壁感兴趣区的峰值声学强度（A）以及造影剂的灌注速度（β）,并计算出心肌血流量（A×β）。RT-MCE检查结束后,处死大鼠取心肌组织,行CD31免疫组织化学染色检测心肌微血管密度（MVD）,然后对DM组A与MVD进行相关分析。结果：与对照组比较,在静息状态下DM组的A及A＆#215;β较对照组明显减低,差异具有统计学意义（P＜0.01）,β较对照组减低,但差异无统计学意义（P＞0.05）。DM组的MVD较对照组明显减低（P＜0.01）。DM组A与MVD呈线性正相关（r=0.903,P＜0.01）。结论：DM早期即可发生心肌血流灌注的异常,RT-MCE在检测DM早期心肌血流灌注异常方面具有重要的应用价值。     

Assessment of coronary artery disease with second harmonic myocardial perfusion contrast echocardiography

Objectives To assess the relationship between myocardial regional perfusion using second harmonic myocardial contrast echocardiography (MCE) by venous injection of Levovist and coronary artery stenosis detected by coronary angiography to determine whether MCE can be used to detect coronary artery disease (CAD) and its sensitivity and specificity for detecting CAD.Methods Thirty-six patients who underwent coronary artery angiography and MCE formed the study groups.Ten myocardial segments (5 each in the apical two- and four-chamber views) from the images were scored for detecting myocardial perfusion as follows: 1, normal perfusion; 2, decreased perfusion; and 3, perfusion defect.The arteries were classified as normal or diseased.The diseased arteries were classified into three groups according to the perfusion scores.Results There were significant differences in coronary diameter stenosis among the different perfusion score groups (P&lt;0.001).There were 10 total occluded arteries, and the myocardial perfusion scores were different because of different collateral circulation.In the normal perfusion group (Group A), the coronary diameter stenosis was 65%±12%, and the myocardial perfusion score index was 1±0.00.In the decreased perfusion group (Group B), the average coronary diameter stenosis was 82%±8%, and the myocardial perfusion score was 1.93±0.16.The diameter stenosis was less than 85% in 63 % of the coronary arteries (including diameter stenosis ≤75% in 12% of the vessels).The diameter stenosis was 85%-90% in 22% of the coronary arteries and &gt;90% in 15% of the arteries.In the perfusion defect group (Group C), the average diameter stenosis was 90%±6%, and the myocardial perfusion score index was 2.89±0.24.The diameter stenosis was　≥85% in 94% of the coronary arteries, and the diameter stenosis was &lt;85% and &gt;75% only in 6% of the coronary arteries.The overall sensitivity and specificity of MCE in identifying angiographic coronary diameter stenosis was 67% and 100%, respectively.The false negative rate was 32.6% for the 108 coronary arteries.Further subdivided analysis showed the sensitivities in Groups A, B and C were 0, 100%, and 100%, respectively.The sensitivity increased with increased lumen diameter stenosis of coronary arteries.Conclusions There is a close relationship between coronary artery stenosis and MCE perfusion scores.MCE with venous injection of new generation contrast can define the presence of CAD and lesion graded classifications.Some disagreements between perfusion score and coronary diameter of stenosis may indicate other factors such as different collateral circulation, which should be further investigated.As artery stenosis increases, the sensitivity of MCE is increased.     

地尔硫卓对猪急性心肌梗死再灌注后无再流的影响

目的评价地尔硫卓防治猪急性心肌梗死(AMI)再灌注后无再流的作用。方法实验动物随机分成对照组、地尔硫卓组(2mg/min冠脉内)和假手术组。前两组行冠状动脉结扎3h,松解1h制备AMI再灌注模型。AMI前、后和再灌注后均行血流动力学测定和心肌声学造影(MCE)检查,最终行病理学分析。结果与AMI前相比,对照组AMI后3h、左室收缩压(LVSP)、心排量(CO)和左心室内压最大收缩和舒张变化速率(±dp/dtmax)均显著下降(均P<0.05,P<0.01),左室舒张末压(LVEDP)显著升高(P<0.01);再灌注后1h仅LVSP显著恢复(P<0.05),然而±dp/dtmax继续显著下降(P<0.05);而地尔硫卓组AMI后3h各项指标变化与对照组相同;但再灌注后1h LVEDP、±dp/dtmax和CO均显著恢复(均P<0.05),且比对照组更显著(均P<0.05)。对照组MCE和病理染色所测的冠脉结扎区心肌范围(LA)高度一致(P>0.05),再灌注后无再流范围(ANR)分别为78.5%和82.3%,心肌坏死范围(NA)占LA的98.5%;而地尔硫卓组两方法所测LA均与对照组相当(均P>0.05),但ANR仅分别为20.6%和19.9%,NA又与对照组差异无统计学意义(P>0.05)。对照组再灌注即刻和再灌注后1h冠脉血流量仅占AMI前的45.8%和50.6%(均P<0.01),而地尔硫卓组冠脉血流量分别提高到80.4%和79.3%,比对照组增加均有统计学意义(均P<0.01)。结论     

心肌声学造影对急性心肌梗死急诊介入术后心肌灌注及预后评估

目的 通过实时心肌声学造影(MCE)评估急性心肌梗死（AMI）急诊介入术后微循环灌注情况及其对AMI预后的评估价值。方法纳入108例AMI且行急诊介入手术患者,术后3～5 d行心肌声学造影,记录患者左室射血分数（LVEF）、室壁运动评分指数（WMSI）、左室收缩末期容量（LVESV）、左室舒张末期容量（LVEDV）、左室舒张末期内径（LVIDd）、二尖瓣E峰速度（MVE）、二尖瓣A峰速度（MVA）、左室质量指数（Lvmassi）及造影剂评分指数（CSI）。出院后1年对108例患者进行电话随访,根据是否发生不良心血管事件（MACE）分为MACE组和非MACE组。结果（1）MACE组患者WMSI、CSI、LVESV更高,而LVEF则较低,两组差异有统计学意义(P<0.05)。（2）前壁心肌梗死MACE事件的发生和更多的心肌灌注缺损有关系。（3）CSI可以作为AMI急诊介入术后MACE事件发生的独立危险因素;（4）CSI≥1.58较 CSI<1.58的AMI患者1年后MACE事件发生率更高(45% vs. 9% P=0.001)。结论MCE能评估AMI急诊介入术后患者微循环灌注情况; CSI能独立预测AMI患者急诊介入术后MACE事件,从而对该类人群进行危险分层,尽早识别高危患者,规避恶性事件发生。     

超声心动图观察左室肥厚对评价高血压心肌微血管病变的价值

OBJECTIVE: To investigate the value of the echocardiographic observation of the left ventricular hypertrophy (LVH) in diagnosing myocardial microvascular damage in patients with essential hypertension (EH). METHODS: After intravenous injection with Quanfuxian (a contrast agent consisting of albumin and C3F8 prepared by Nanfang Hospital), the values of A (the maximum number of microbubbles accumulating in the local tissues for assessing the density of local microvessels), beta (the filling velocity of contrast agent for evaluating local blood flow velocity) and A x beta (the product of A and beta for estimating local myocardial blood flow) at rest and after dipyridamole injection were measured by intermittent harmonic imaging with myocardial contrast echocardiography (MCE). The ratios of A and beta along with the microvascular coronary flow velocity reserve (CFVR) were also calculated. RESULTS: Compared with the control group, the rest values of A, beta and A.beta in EH patients were higher, especially in those with LVH. After dipyridamole injection, the values of A, beta, A x beta and the ratios of A and beta, along with CFVR as well, were significantly lowered (P <0.01), and the reductions were especially obvious in LVH cases. As the hypertension exacerbated, the values of A and A x beta tended to increase in positive correlation with systolic and diastolic blood pressure (P <0.01), while the ratio of A and CFVR were decreased, the latter was inversely correlated with diastolic blood pressure (r=-0.55, P <0.01). Positive correlations were noted of the values of A and A x beta with the left ventricular mass and left ventricular mass index (P <0.01). CONCLUSION: EH patients, especially those with LVH, are characterized by increased rest myocardial microvascular blood flow, impaired myocardial microvascular flow reserve and endothelium independent vasodilation relaxing ability, and reduced capillary density, and these conditions tend exacerbate as the disease worsens. Microvascular function impairment should be suspected when complication of LVH arises in the EH patients. As a new important noninvasive technique, MCE can be a promising modality for diagnosing microvascular disease in essential hypertension.     

心肌声学造影在经皮冠脉成形术中的应用

为探讨心肌声学造影（MCE）在经皮冠状动脉成形术（PTCA）中的应用价值，对14例冠心病人于PTCA术前后经冠状动脉完成MCE，观察心肌影象增强计分，心肌灰阶峰值强度（PI）和心肌节段半径缩短率（D％）等指标的变化。结果：心绞痛病人20个心肌节段术前有7个节段MCE计为1分者，术后仍为1分，术前13个节段为0．5分者术后有8个节段升级为三分，PI及△D％均有相应改善（P＜0.01）；7例心肌梗塞病人共分析了16个心肌节段，术前有12个节段MCE计分为0者，术后有9个节段的MCE计分升级，PI及△D％也得到改善，提示有存活心肌。联合观察3项指标可从心肌灌注水平评价PTCA效果。     

心肌声学造影对冠脉狭窄临界病变的功能性诊断价值

目的 探讨心肌声学造影对冠脉狭窄临界病变功能性评价的有效性及可靠性.方法 前瞻性纳入2017年6-10月本院心内科经冠状动脉造影证实冠脉狭窄介于50％～70％的患者70例,行心肌声学造影(myocardial contrast echocardiography,MCE)检查并以金标准血流储备分数(fractional flow reserve,FFR)为自身对照,结合其心脏结构、血脂、肾功、糖化血红蛋等生化指标进行对比分析.结果 ①70例患者中共78支血管为临界病变,其中左前降支(the left anterior descending,LAD)病变53处(67.9％),左回旋支(the left circumflex coronary artery,LCX)病变13处(16.7％),右冠状动脉(right coronary artery,RCA)病变12处(15.4％),其中FFR阴性(FFR值＞0.8)的53处(67.9％);FFR阳性(FFR值≤0.8)的25处(32.1％).②MCE检出49例患者存在节段性室壁运动异常,其中19例同时提示心肌灌注异常.MCE结果提示LAD病变56处,LCX病变12处,RCA病变18处.③FFR阳性的25处病变MCE全部为阳性,MCE阴性的29处病变FFR全部为阴性.FFR阴性的53处病变中,MCE阳性24处,MCE阴性29处.与金标准FFR相比,MCE诊断冠脉临界病变功能性狭窄的敏感性为100％,特异性为55％,阳性似然比为2.2,阴性似然比为0.④FFR阴性的病变中,MCE阳性组的静息FFR值[(0.94 ±0.02)vs(0.96 ±0.02),P＜0.05]和负荷FFR值[(0.84 ±0.04)vs(0.88 ±0.04),P＜0.05]均明显低于MCE阴性组.两组间年龄、左室舒张末期内径、室间隔厚度、左室射血分数、总胆固醇、甘油三酯、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇、糖化血红蛋白、肌酐、估算肾小球滤过率差异均无统计学意义(P＞0.05).结论 MCE评价冠脉狭窄临界病变具有极高的敏感性和阴性预测价值,但特异性偏低,是否存在冠脉微血管病变或是其主要影响因素.