超声造影技术对成人体外循环中肾脏微循环灌注状态的初步研究

目的 探讨体外循环转流对成人肾脏微循环灌注的影响。方法 纳入择期行体外循环心脏手术成人患者6例和非心脏手术的成人患者12例,分别于体外循环建立30 min和麻醉诱导结束生命体征稳定5 min后获取肾脏超声造影图像,采用超声造影技术分析比较成人非搏动性体外循环与麻醉诱导后的肾脏微循环灌注。分析比较两种条件下肾脏不同区域的灌注时间强度曲线（TIC）的相关参数:上升支斜率( α )、达峰时间（TTP）、峰值强度（PI）、曲线下面积（AUC）。结果 与全身麻醉状态相比,体外循环下肾脏浅层皮质、深层皮质和髓质锥体区域TIC的AUC均降低（ PAUC低于同条件下的浅层皮质以及深层皮质的AUC P<0.05）。所有患者均未出现超声微泡造影剂相关的不良事件。结论 体外循环下肾脏各个区域的微循环灌注出现了明显下降,其中以髓质区域下降最为明显。超声造影技术可用于监测心脏手术期间肾脏微循环灌注状态。     

心肌声学造影对急性心梗PCI术后心肌灌注的评价

目的:通过心肌声学造影(MCE)对急性心梗经皮冠状动脉支架术(PCI)后心肌灌注的情况进行判断,了解其对左心功能及左室重构的影响.方法:采用病例对照的研究方法,根据PCI术后1周的MCE检查,将急性心梗患者分为灌注正常组、灌注稀疏组和灌注缺失组,并随访检查3个月、6个月的左室射血分数(LVEF)及左室舒张末内径(LVDd)的变化情况,比较组内及组间不同时段LVEF与LVDd的变化.结果:PCI术后3个月灌注稀疏组LVEF恢复到正常;灌注缺损组PCI术后LVEF的平均水平随时间变化而逐渐降低;灌注缺损组患者的LVEF低于灌注稀疏组和灌注正常组(P<0.05);术后6个月灌注缺损组LVDd平均水平高于灌注正常组和灌注稀疏组(P<0.05),灌注缺损组随时间的变化左室内径逐渐增大(P<0.05).结论:急性心梗患者PCI术后心肌微循环较差时,其左室射血分数降低,左室内径增大;MCE有利于对急性心梗患者PCI术后左心功能及左室重构评估.     

双核素心肌显像检测心肌梗死患者存活心肌的临床价值

目的研究(~(18)F-FDG)心肌代谢显像联合99锝m-甲氧异腈(~(99m)Tc-MIBI)心肌灌注显像的价值,通过双核素心肌显像诊断心梗患者心肌梗死区的坏死心肌或存活心肌,从而判定此项技术对心梗患者血运重建术(冠脉搭桥及冠脉支架术)的临床价值。方法126例经心脏冠脉造影证实的至少一支以上冠状动脉闭塞以及临床明确诊断为心肌梗塞的冠心病患者,在两日内分别行~(99m)Tc-MIBI心肌灌注显像及~(18)F-FDG心肌代谢显像,其图像分为显像剂分布减低、明显减低和缺损。其中,心肌灌注显像与心肌代谢显像不匹配为心肌存活,心肌灌注显像与心肌代谢显像匹配为心肌无存活。将纳入研究的心肌梗死患者分为3组:心肌存活组、部分心肌存活组和无心肌存活组。3组冠心病心梗患者在血运重建术前及术后均行心脏超声心动图检查并获得左室射血分数(LVEF)等心功能指标。结果 126例心肌梗死患者病例中剔除6例死亡患者,其中3例无心肌存活患者,2例部分心肌存活患者,1例有心肌存活患者。其余120例心梗患者均在血运重建术前及术后行超声心动图检查。其中,57例心肌存活组患者LVEF值(40.81±8.91)%,经过血运重建术后,LVEF值提高至(52.71±9.23)%,t=-5.23,心功能改善明显,统计学意义显著(P0.05)。部分心肌存活组36例患者LVEF值(38.61±9.91)%经过血运重建术后提高至(44.71±9.73)%,t=-5.45,心功能改善尚可,有统计学意义(P0.05)。无心肌存活组患者27例,LVEF值(35.11±7.91)%,经过血运重建术后LVEF值提高至(39.71±9.23)%,t=-5.89,心功能改善不佳,无统计学意义(P0.05)。结论 ~(18)F-FDG心肌代谢显像联合~(99m)Tc-MIBI心肌灌注显像可以从心肌血流灌注和心肌葡萄糖代谢两个方面同时观察心肌状态,判断心肌梗死患者梗死区存在的坏死心肌或存活心肌,对冠心病心梗患者的血运重建术有重要的临床指导意义。     

实时心肌声学造影评价2型糖尿病患者心肌微循环的研究

目的应用经静脉实时心肌声学造影，观察2型糖尿病患者心肌微循环灌注的情况。方法选择射血分数大于50％，无冠心病病史，负荷超声或者冠状动脉造影正常，无瓣膜病变，无心房颤动和其他严重心律失常，无先天性心脏病，并排除合并高血压病、肾病、甲状腺功能减退的38例患者作为研究对象；正常对照组20例。经体检、心电图和超声心动图检查无心脏疾患，无高血压病、肾病及甲状腺功能减退病史。均进行实时心肌声学造影，图像存储。结果2型糖尿病患者心肌造影剂灌注的峰值强度A与反映心肌血流速度的k值较正常对照组低（P〈0．01），反映心肌血流量的A·k乘积也明显低于正常对照组（P〈0．01）。结论实时心肌声学造影技术可定量评价2型糖尿病患者心肌微循环灌注的改变。     

ATP负荷MR心肌灌注成像对缺血性心脏病心肌血流储备的评价

目的：探讨缺血性心脏病ATP负荷前、后MR心肌灌注成像的影像学特点,分析应用该方法评估心肌血流储备的效果。方法：采用1.5T MR成像设备对20例健康志愿者和30例临床按ISFC/WHO标准确诊为冠心病并经冠脉造影证实有心肌缺血的患者进行ATP负荷MR心肌灌注成像, 对心肌灌注储备的相关参数进行定量分析,并与冠状动脉造影（CAG）进行比较。结果：ATP负荷后时间-信号强度曲线的最大上升斜率(slope)明显增加,负荷后与负荷前slope的比值（slope +/-）正常组明显高于病例组(P<0.05);slope +/- 的正常参考值范围为2.040±0.395;与CAG的对比分析表明,ATP负荷MR心肌灌注成像诊断心肌缺血的符合率为89%。 结论：ATP负荷MR心肌灌注成像能够准确地评估心肌血流储备的异常。     

~(201)Tl-GIK溶液心肌灌注显像对陈旧性心肌梗塞患者存活心肌的判断

采用２０１Ｔｌ ＧＩＫ溶液（２０１铊 葡萄糖 胰岛素 氯化钾）心肌灌注显像，对２８例陈旧性心肌梗塞患者的梗塞区域心肌的存活性进行研究。输注ＧＩＫ溶液后再次心肌断层显像，结果：在２８例陈旧性心肌梗塞患者的１１９个梗塞节段中有４５个节段（３７．８％）有存活心肌。１５例做经皮冠状动脉内气囊扩张术或冠状动脉搭桥术的患者，术前７６个梗塞节段中有２８个节段于输注ＧＩＫ溶液后显像证明有存活心肌（３６．８％）；术后复查静态２０１Ｔｌ心肌断层显像有３２个节段存活（４２％），两者间符合率为８７．５％（２８／３２）。本研究证明在陈旧性心肌梗塞区内仍有存活心肌存在。     

心肌声学造影的研究进展

心肌声学造影,也称心肌造影超声心动图(Myocardialcon trastechocardiography ,简称MCE) ,是诊断微循环水平心肌灌注的新技术,它采用特制的微气泡造影剂直接经冠状动脉或外周静脉注入,随冠脉血流灌注到心肌微血管床时,应用二维乃至三维或多普勒超声技术增强含血心肌的显像,从而     

急性心肌梗塞心肌再灌注心电图定量研究

本文对１７例接受尿激酶（溶栓组）、２５例接受极化液（非溶栓组）治疗的急性心肌梗塞患者运用心电定量心肌梗塞面积。用药前采用ＳＴ段运算法预计梗塞面积，住院７２ｈ后用ＱＲＳ积分法计算实际梗塞面积，二者之差为梗塞缩小面积，并以此计算梗塞心肌存活率，大于－２０％者为再灌注。结果显示溶栓组平均心肌梗塞面积缩小６．７％，梗塞区心肌存活率－２９．２％，早期溶栓（〈３ｈ）４例（４／５）符合心肌再灌注标准；晚期溶栓（     

急性心肌梗塞心肌再灌注心电图定量研究

本文对１７例接受尿激酶（溶栓组）、２５例接受极化液（非溶栓组）治疗的急性心肌梗塞患者运用心电定量心肌梗塞面积。用药前采用ＳＴ段运算法预计梗塞面积，住院７２ｈ后用ＱＲＳ积分法计算实际梗塞面积，二者之差为梗塞缩小面积，并以此计算梗塞心肌存活率，大于－２０％者为再灌注。结果显示溶栓组平均心肌梗塞面积缩小６．７％，梗塞区心肌存活率－２９．２％，早期溶栓（＜３ｈ）４例（４／５）符合心肌再灌注标准；晚期溶栓（３～８ｈ）６例（６／１２）符合再灌注标准。而非溶栓组无一例符合再灌注标准。故认为溶栓治疗是急性心肌梗塞的首选方法。     

实时超声心肌声学造影对冠心病患者心肌灌注的临床研究

目的应用实时心肌声学造影半定量评价冠心病患者心肌灌注状况和心肌微循环状况。方法 20例冠脉造影左前降支冠脉狭窄>75%以上的冠心病患者和20例健康对照组行静息状态下实时心肌声学造影检查,并进行左室显影效果评分及造影声像半定量分析,来评价冠心病患者心肌灌注状况和心肌微循环状况。结果 MCE技术不但可对左室显影效果及心肌造影进行直观评价,而且能同时显示心肌增厚率和室壁运动,可以作为评价冠心病患者心肌血流灌注及心肌微血管病变的最佳选择。结论心肌超声造影有望成为冠心病的常规检查方法。     

磁共振心肌灌注成像评价心肌梗死PTCA治疗前后心肌存活

目的 评价磁共振心肌灌注成像(MRMPI) 检测心肌梗死存活心肌的作用. 方法 选择心肌梗死患者51 例.采用1.5 T MR扫描仪,反转恢复快速小角度激励( IR-turbo FLASH) 序列,全部患者均在静脉注射钆喷替酸葡甲胺(Gd-DTPA) 0.1 mmol/kg、MRMPI 首过期及5~30 min 延迟期成像.21 例行静息、负荷99锝单光子发射计算机体层摄影术( single photon emission computed tomography, SPECT) 进行对照研究.首过期行短轴面成像,延迟期行短轴面及长轴面成像.结果 51例心肌梗死患者,42 例(82.3%) 首过期显示灌注减低;50 例(98%) 延迟增强.在21例168个心肌段SPECT诊断无活性心肌段48个,MRMPI 示梗死区均有延迟增强,SPECT诊断存活心肌段120 个,MRMPI 示97段无延迟增强.以静息、负荷99m锝SPECT 作为参考标准,MRMPI 的敏感度、特异度分别为100%、80.8%. 结论 MRMPI 可有效地检测心肌梗死的存活和非存活心肌,以及其程度和范围.     

Acute myocardial infarction: myocardial salvage assessment

Primary coronary revascularization by means of percutaneous coronary intervention(PCI)is a highly effective treatment of acute myocardial infarction re-establishing coronary perfusion and stopping the ongoing necrosis in the dependent myocardium.Single-photon emission computed tomography(SPECT)is the most widely used modality assessing myocardial salvage as the difference between the acute perfusion defect before intervention and the remaining scar size measured in a second scan several days after the event.SPECT allows quantification of area at risk(AAR)and final infarct size(FIS)by tracer injection prior to revascularization and after 1 month,respectively.SPECT provides the most validated measure of myocardial salvage and has been utilized in multiple randomizedclinical trials.However,SPECT is logistically challenging,expensive,and includes radiation exposure.More recently,a large number of studies have suggested that cardiac magnetic resonance(CMR)can determine salvage in a single examination by combining measures of myocardial oedema in the AAR exposed to ischaemia reperfusion with FIS quantification by late gadolinium enhancement.     

Acute myocardial infarction due to myocardial bridge

Myocardial bridge (MB) is regarded as a common anatomic variant rather than a congenital condition anomaly,defined as the intramyocardial course of a portion of the coronary artery.It was first mentioned by Rayman in 1737 and first described by Grainicianu in the early 1920s.The current gold standard for diagnosing     

Evaluation of Myocardial Viability after Myocardial Infarction with Intravenous Real-time Myocardial Contrast Echocardiography

The myocardial viability after myocardial infarction was evaluated by intravenous myocardial contrast echocardiography. Intravenous real-time myocardial contrast echocardiography was performed on 18 patients with myocardial infarction before coronary revascularization. Follow-up echocardiography was performed 3 months after coronary revascularization. Segmental wall motion was assessed using 18-segment LV model and classified as normal, hypokinesis, akinesis and dyskinesis. Viable myocardium was defined by evident improvement of segmental wall motion 3 months after coronary revascularization. Myocardial perfusion was assessed by visual interpretation and divided into 3 conditions： homogeneous opacification; partial or reduced opaciflcation or subendocardial contrast defect; contrast defect. The former two conditions were used as the standard to define the viable myocardium. The results showed that 109 abnormal wall motion segments were detected among 18 patients with myocardial infarction, including 47 segments of hypokinesis, 56 segments of akinesis and 6 segments of dyskinesis. The wall motion of 2 segments with hypokinesis before coronary revascularization which showed homogeneous opacification, 14 of 24 segments with hypokinese and 20 of 24 segments with akinese before coronary revascularization which showed partial or reduced opaciflcation or subendocardial contrast defect was improved 3 months after coronary revascularization. In our study, the sensitivity and specificity of evaluation of myocardial viability after myocardial infarction by intravenous real-time myocardial contrast echocardiography were 94.7% and 78.9%, respectively. It was concluded that intravenous real-time myocardial contrast echocardiography could accurately evaluate myocardial viability after myocardial infarction.     

水飞蓟素通过抑制心肌细胞凋亡减轻心肌梗死

目的：观察水飞蓟素对心肌梗死小鼠的血流动力学、梗死面积及梗死边缘区凋亡蛋白表达情况。方法：将60只小鼠随机分为心肌梗死组、假手术组、心肌梗死+水飞蓟素组和心肌梗死溶剂组。建模成功4周后检测小鼠血流动力学变化,进行心脏超声检查,评价梗死面积、细胞凋亡指数以及凋亡蛋白Bcl-2、Bax、Cleaved-Caspase3的表达。结果：与心肌梗死组小鼠相比,水飞蓟素可显著减轻心肌梗死,改善心梗小鼠心功能,降低心肌细胞凋亡指数,增强Bcl-2蛋白表达和减弱Bax和Cleaved-Caspase3蛋白表达。结论：水飞蓟素能够减轻心肌梗死,改善心梗小鼠心室收缩功能,保护心肌,减少心肌细胞的凋亡,其机制与升高Bcl-2蛋白、降低Bax和Cleaved-Caspase3蛋白表达水平有关。     

“肾阳虚证”下心肌梗死模型与单纯心肌梗死模型大鼠心肌形态学、心肌酶学及血液流变学的比较

目的：建立大鼠“肾阳虚证”下心肌梗死模型,探讨其与单纯心肌梗死模型大鼠在心肌形态学、心肌酶学及血液流变学方面的差异,为评价治疗胸痹心痛中药的药效学提供理论依据。方法：60只Wistar大鼠随机分为空白对照组、肾阳虚模型组、心肌梗死假手术组、单纯心肌梗死模型组及“肾阳虚证”下心肌梗死模型组,每组12只。在大鼠 “肾阳虚”情况下复制急性心肌梗死模型,测定各组大鼠心肌梗死面积 (MIS),血清天门冬氨酸氨基转化酶（AST）、肌酸磷酸激酶（CK）及乳酸脱氢酶（LDH）活性,同时测定血小板黏附率（PAR）、血小板聚集率（PAG）、红细胞沉降率（ESR）、红细胞压积（HCT）、体外血栓长度、血栓干重与湿重以及血栓弹力图等参数。结果： 大鼠“肾阳虚证”下心肌梗死模型与单纯心肌梗死模型在MIS,血清AST、CK及LDH活性,PAR、PAG、ESR及HCT增加程度差异无统计学意义（P>0.05）;肾阳虚模型组、单纯心肌梗死模型组及“肾阳虚证”下心肌梗死模型组大鼠体外血栓干重及长度均明显增加（P<0.05或P<0.01）,“肾阳虚证”下心肌梗死模型组的增加程度大于单纯心肌梗死模型组及肾阳虚模型组,但三者之间差异无统计学意义（P>0.05）;尽管“肾阳虚证”下心肌梗死模型组大鼠血栓弹力图r、k值的缩短程度及ma值的增大程度高于单纯心肌梗死模型组,但2组之间差异无统计学意义（P>0.05）。结论：大鼠“肾阳虚证”下心肌梗死模型与单纯心肌梗死模型心肌梗死面积、血清心肌酶学、红细胞压积、血沉、血小板功能、体外血栓重量及血栓弹力图等指标均无明显差异。     

Relation of myocardial bridge to myocardial infarction: a meta-analysis

Background Small case series have suggested an association of coronary myocardial bridge （MB） with myocardial infarction （MI）.However,the relationship between MB and major adverse cardiac events （MACE） remains largely unknown.The aim of this study was to assess the relationship between MB and MACE involving MI.Methods We performed a systematic search of MEDLINE,PreMEDLINE,and all EMB Reviews as well as a reference list of relevant articles according to the SPICO （Study design,Patient,Intervention,Control-intervention,and Outcome） criteria using the following keywords：myocardial bridging,myocardial bridge,intramural coronary artery,mural coronary artery,tunneled coronary artery,coronary artery overbridging,etc.Bibliographies of the retrieved publications were additionally hand searched.Studies were included for the meta-analysis if they satisfied the following criteria：（1） they evaluate the association of MB with cardiovascular endpoint event; （2） they included individuals with MB and those without MB; 3） they excluded individuals with obstructive coronary artery disease （CAD）.Studies were reviewed by a predetermined protocol including quality assessment.Dates were pooled using a random effect model.Results Seven observational studies that followed 5 486 patients eligible for the enrolled criteria were included from 7 136 initially identified articles.The prevalence of MB was 24.8％ （1 363/5 486）.During 0.5-7.0 years of follow-up of this cohort of population,crude outcome rates were 8.0％ in the MB group and 7.7％ in the non-MB group.The odds ratio of overall MACE and MI were 1.34 （95％ confidence interval （CI）：0.57-3.17,P=0.51,n=7 studies） and 2.75 （95％ CI：1.08-7.02,P ＜0.03,n=5 studies） respectively for subjects of MB compared to non-MB.Conclusion Relationship between MB and MI appears to be a real one,although the study did not reveal a connection of MB to MACE,suggesting whether the necessity of antiplatelet therapy needs to be further studied in a larger cohort of patients with MB prospectively.     

Self-induced myocardial infarction

A case of acute myocardial infarction and peripheral vascular insufficiency following overdose with ergotamine is described.