应激性心肌病的临床特征及影像诊断

目的分析和总结应激性心肌病的临床和影像特征，旨在提高对该病的认识。方法71岁女性患者，入院前1d生气后突发胸闷、胸痛伴胸骨后烧灼。先后行心电图、超声心动图、冠状动脉和左室造影、核素心肌灌注（代谢）显像和MR扫描。结果急诊心电图示V1～V4导联sT段抬高和T波倒置，1周后出现病理性Q波，1个月后Q波消失：代之为巨大倒置的T波。心肌酶正常或仅轻度升高。急诊左室造影示左室巨大室壁瘤形成，约占左室容积3／4，左室射血分数（LVEF）约30％，但选择性冠状动脉造影未发现与之对应的冠状动脉病变；1个月后复查造影，示左室室壁瘤明显缩小，左室功能基本恢复，LVEF63．6％。发病1周内心肌核素检查示相应区域灌注和代谢不匹配，提示心肌存活。MRI示左室心尖部巨大室壁瘤形成，但受累节段既无灌注缺损又未见明显延迟强化，提示无坏死心肌。结论极度心理打击发生的短暂性左室心尖球状扩张可称为应激性心肌病。核素心肌灌注（代谢）显像以及MRI心肌灌注延迟显像能够提示病变区存活心肌，可指导临床治疗。     

核素心肌断层显像诊断心尖肥厚型心肌病

目的　探讨核素心肌断层显像对心尖肥厚型心肌病 (AHCM)的诊断价值。方法　 32例有特殊心电图改变、疑为AHCM的患者行超声心动图 (UCG)、99Tcm 甲氧基异丁基异腈 (MIBI)心肌断层显像、冠状动脉造影及左室造影等检查。结果　 32例患者中确诊为AHCM者 2 9例 ,UCG与核素心肌断层显像诊断灵敏度分别为 93.1%和 89.7% ,两者差异无显著性 (P >0 .0 5 )。结论　99Tcm MIBI心肌断层显像是诊断AHCM一种有效无创的方法。     

核素显像鉴别缺血性和扩张性心肌病的综合评价

介绍了核素心肌灌注、心肌代谢、核素心室显像在缺血性心肌病(CAD-CM)和扩张性心肌病(DCM)鉴别诊断中的意义。扩张性心肌病患者心肌灌注显像多表现为放射性分布不均匀,无灌注缺损,代谢显像常与灌注显像一致,核素心室显像表现为弥漫性的室壁运动异常。缺血笥心肌病患者心肌灌注显像多表现严重的灌注异常,有灌注缺损且呈节段性分布,灌注与代谢显像不匹配多见,核素心室显像表现为节段性的定壁运动减低。     

核素显像鉴别缺血性和扩张性心肌病的综合评价

介绍了核素心肌灌注、心肌代谢、核素心室显像在缺血性心肌病（ＣＡＤ－ＣＭ）和扩张性心肌病（ＤＣＭ）鉴别诊断中的意义。扩张性心肌病患者心肌灌注显像多表现为放射性分布不均匀,无灌注缺损,代谢显像常与灌注显像一致,核素心室显像表现为弥漫性的室壁运动异常。缺血笥心肌病患者心肌灌注显像多表现严重的灌注异常,有灌注缺损且呈节段性分布,灌注与代谢显像不匹配多见,核素心室显像表现为节段性的定壁运动减低。     

心电图异常Q波患者

目的分析临床心电图(ECG)出现异常Q波而核素心肌显像正常的原因.方法 69例患者分别行ECG和201Tl心肌显像.其中男52例,女17例,45岁以下28例.结果 25例ECG表现为前间壁心肌梗死,33例表现为下壁心肌梗死,5例表现为前间壁+下壁心肌梗死,4例表现为侧壁心肌梗死,2例表现为正后壁心肌梗死;误诊为前间壁或下壁心肌梗死共60例,占87%.经心脏超声、ECG等检查,69例中9例为心室内传导障碍,7例为扩张型心肌病,5例为肥厚型心肌病,2例为风湿性心脏病主动脉瓣关闭不全,共23例,占33.3%,其余各种检查未见明显异常.结论依靠ECG诊断陈旧性心肌梗死应慎重;核素心肌断层显像应为诊断心肌梗死的常规检查方法.     

术前^99mTc—MIBI心肌灌注显像了解瓣膜患者心肌缺血的诊 …

目的：评价＾９９ｍＴｃ－ＭＩＢＩ心肌灌注显像术前了解瓣膜患者心肌缺血的诊断价值。材料与方法：８１例瓣膜患者行术前核素心肌断层显像，并与冠状动脉造影，超声心动图及手术后结果进行对比。７２例瓣膜患者做瓣膜置换术，其中９例同时做冠状动脉搭桥术。结果：４１例做冠状动脉造影检查，结果阳性符合率９５．５％，阴性符合率１００％，提示病变部位一致率８５．７％，总符合率９７．６％。结论：４０岁以上风湿必瓣膜病患者工     

心电图异常Q波患者201Tl心肌显像分析

目的　分析临床心电图 (ECG)出现异常Q波而核素心肌显像正常的原因。方法　 6 9例患者分别行ECG和2 0 1 Tl心肌显像。其中男 5 2例 ,女 17例 ,4 5岁以下 2 8例。结果　 2 5例ECG表现为前间壁心肌梗死 ,33例表现为下壁心肌梗死 ,5例表现为前间壁 下壁心肌梗死 ,4例表现为侧壁心肌梗死 ,2例表现为正后壁心肌梗死 ;误诊为前间壁或下壁心肌梗死共 6 0例 ,占 87%。经心脏超声、ECG等检查 ,6 9例中 9例为心室内传导障碍 ,7例为扩张型心肌病 ,5例为肥厚型心肌病 ,2例为风湿性心脏病主动脉瓣关闭不全 ,共 2 3例 ,占 33 3% ,其余各种检查未见明显异常。结论　依靠ECG诊断陈旧性心肌梗死应慎重 ;核素心肌断层显像应为诊断心肌梗死的常规检查方法。     

左心室及冠状动脉造影诊断心尖肥厚型心肌病

目的:探讨左心室及冠状动脉造影诊断心尖肥厚型心肌病的价值.材料和方法:147例心电图异常患者,行UCG,冠状动脉及左心室造影,21患者进一步行MRI检查确诊为心尖肥厚型心肌病.结果:147例中, UCG发现67例心尖部肥厚.左心室造影示126例左心室舒张期形态均呈"黑桃"样改变,诊断阳性率85.7%.冠状动脉造影示19例冠状动脉有狭窄.结论:左心室及冠状动脉造影是诊断心尖肥厚型心肌病较好的方法,并能了解冠状动脉病变情况.     

颈动脉超声、核素心肌显像与冠状动脉造影诊断冠心病的对比研究

 目的 探讨颈动脉超声、核素心肌灌注显像对冠心病的诊断价值.方法 对88例疑有冠心病者,以冠状动脉造影结果 作为诊断标准, 进行颈动脉超声检查和核素心肌灌注断层显像两种检查,并将结果 进行对比分析.结果 颈动脉超声诊断冠心病的敏感性为65.5%,特异性为73.3%.核素心肌灌注显像诊断冠心病的敏感性为86.2%,特异性为66.7%.结论 颈动脉超声结合核素心肌灌注显像诊断冠心病,敏感性与特异性较高,对冠心病的无创性诊断具有重要价值.     

民航飞行员T波倒置随访10年一例并文献复习CSCD

目的：探讨体检中ECG出现T波倒置的飞行员的航空健康管理和航空医学鉴定。方法回顾性分析1例民航飞行员10年的T波倒置ECG变化、临床诊断及医学鉴定情况,复习相关文献。结果本例飞行员ECG有心尖肥厚型心肌病ECG改变,胸导联电压逐年升高,ST 段压低逐年显著,T波倒置程度逐年加深,间断进行冠状动脉造影和心脏彩色超声无明显异常。2013年踏板运动试验提示ECG ST‐T改变明显,运动恢复期出现频发房性早搏。考虑其ECG变化进展明显,临时停飞查明原因。心脏彩色超声检查诊断为心尖肥厚型心肌病,心脏核磁共振诊断：心尖部心肌广泛增厚,考虑心尖肥厚型心肌病。未行治疗。考虑飞行员存在肥厚性非梗阻性心肌病,无其他明显的心脑血管疾病,现特许飞行。结论 ECG警示心尖部肥厚型心肌病比心脏彩色超声早;当ECG出现倒置T波,排除冠状动脉病变时,应考虑肥厚性心肌病可能;每年鉴定应行心脏彩色超声检查,再次行冠状动脉造影检查时应加做左室造影和心脏核磁共振检查,以尽早发现疾病。     

Stress functional MRI: detection of ischemic heart disease and myocardial viability.

Breath-hold gradient-echo magnetic resonance imaging (MRI) in conjunction with pharmacologic dobutamine stress has become a practical tool to investigate patients with chest pain. The presence of high-grade coronary artery stenoses can be detected more accurately than with stress echocardiography. The main diagnostic advantage of MRI is in patients with suboptimal echocardiographic image quality. Depiction of left ventricular anatomy and function at rest and during low-dose dobutamine stress is also clinically useful for evaluating patients with severely impaired left ventricular function for the presence of residual myocardial viability. Recovery of regional and global left ventricular function can be accurately predicted by stress functional MRI. J. Magn. Reson Imaging 1999;10:667-675, 1999.     

Diffuse subendocardial ischemia in a patient with aortic valve stenosis without coronary artery disease by exercise 201Tl SPECT]

A case of aortic valve stenosis without coronary artery disease was confirmed to have diffuse subendocardial ischemia by exercise Thallium-201 myocardial single photon emission computed tomography. A 72-year-old woman, who had been diagnosed as aortic valve stenosis, was admitted because of chest pain during exercise. In cardiac catheterization findings, the patient angiographically had normal coronary arteries and no asynergy of left ventricular wall motion. The peak flow velocity in continuous wave Doppler echocardiography was about 5.0 m/sec at aortic valve level, providing a pressure drop of 100 mmHg across a stenotic valve with calculating on a modified Bernoulli equation (PG = 4V2). Thallium-201 myocardial SPECT images during exercise showed a transient "dilation and a widespread wall thinning" of left ventricle with apical perfusion defect. Simultaneous electrocardiogram showed further ST depression and the patient had chest pain. In 6 months after aortic valve replacement the patient no longer demonstrated both apical perfusion defect and "wall thinning" in postoperative thallium-201 myocardial SPECT images and also had neither ST depression nor chest pain. Thus; a transient "dilation and wall thinning" of left ventricle in this patient is suspected to be a sign of diffuse subendocardial ischemia.     

Impact of diabetes mellitus on prediction of clinical outcome after coronary revascularization by 18F-FDG SPECT in patients with ischemic left ventricular dysfunction.

Nuclear imaging using (18)F-FDG is an established method for the noninvasive assessment of myocardial viability. Data on the value of (18)F-FDG imaging in patients with diabetes mellitus are scarce. The aim of this study was to assess whether, in patients with diabetes mellitus and ischemic left ventricular (LV) dysfunction, (18)F-FDG imaging can predict improvement of LV function and heart failure symptoms after coronary revascularization. METHODS: A total of 130 consecutive patients with ischemic LV dysfunction who were already scheduled for surgical revascularization were studied; 34 of the patients had diabetes mellitus. All patients underwent radionuclide ventriculography to assess left ventricular ejection fraction (LVEF), resting 2-dimensional echocardiography to identify dysfunctional myocardial tissue, and dual-isotope (18)F-FDG/(99m)Tc-tetrofosmin SPECT after oral administration of acipimox. Nine to 12 mo after coronary revascularization, radionuclide ventriculography and echocardiography were repeated. An improvement in LVEF by at least 5% was considered significant. RESULTS: (18)F-FDG SPECT demonstrated that 610 (50%) of 1,212 dysfunctional segments were viable. Patients with and without diabetes mellitus had a comparable number of dysfunctional but viable segments per patient. Also, the number of patients with a substantial amount of dysfunctional but viable myocardium (>or=4 viable segments) was comparable between the groups with and without diabetes mellitus. The presence of substantial viability on (18)F-FDG SPECT was predictive of improvement in LVEF and heart failure symptoms postoperatively (sensitivity and specificity of 82% and 89%, respectively, in patients with diabetes and 83% and 93%, respectively, in patients without diabetes; not statistically significant). CONCLUSION: (18)F-FDG SPECT is practical for routine assessment of myocardial viability in patients with ischemic LV dysfunction with or without diabetes mellitus. Patients with substantial myocardial viability on (18)F-FDG SPECT have a high probability of improvement of LV function and symptoms after coronary revascularization, irrespective of the absence or presence of diabetes mellitus.     

Noninvasive assessment of myocardium at risk by Tl-201 SPECT imaging in a child with Kawasaki disease. A case report.

Serial two-dimensional echocardiograms documented the formation of giant aneurysms, measuring from 0.55 to 3.1 cm in diameter, in the distribution of the left and right coronary arteries, in a 2 1/2-year-old boy with Kawasaki disease. His global left ventricular function, assessed by M-mode echocardiography, was normal, and no significant wall motion abnormalities could be detected on two-dimensinal evaluation. Cardiac catheterization showed multiple aneurysms with no evidence of stenosis. Although he had no clinical symptoms or electrocardiographic evidence of ischemia, pharmacologic stress and delayed Tl-201 SPECT images revealed prominent stress-induced myocardial ischemia in the left ventricle. A resting gated blood pool study showed hypokinesia in corresponding regions of the left ventricle. This case demonstrates the usefulness of Tl-201 myocardial SPECT imaging and resting gated blood pool studies in the management of coronary artery disease in children with Kawasaki disease.     

Assessment of myocardial viability by MRI.

Assessment of myocardial viability has become an important issue in patients presenting with either acute myocardial infarction or presenting with chronic ischemic left ventricular dysfunction. In patients with viable myocardium recovery of left ventricular function can be anticipatedm, spontaneously in patients with acute myocardial infarction or following revascularization in patients with ischemic cardiomyopathy. In contrast, patients without viable tissue are not likely to improve in left ventricular function. Currently, nuclear imaging techniques and dobutamine stress echocardiography are used for assessment of viability; recent studies with magnetic resonance imaging (MRI) have however demonstrated the potential usefulness of this technique for the assessment of viability. Various parameters, derived from resting MRI, can be used as markers of myocardial viability, including the end-diastolic wall thickness, systolic wall thickening and signal intensity without contrast-enhancement. Other studies have combined the information from resting MRI with the assessment of contractile reserve during dobutamine stimulation. Finally, recent studies have evaluated the use of contrast-enhanced MRI to detect viable myocardium. All of these parameters are potentially useful and MRI provide an alternative approach for the assessment of viable myocardium.     

Echocardiographic and magnetic resonance methods for diagnosing hibernating myocardium

Hibernating myocardium refers to regions of impaired left ventricular function at rest due to coronary artery disease that is reversible with revascularization. The accurate identification and assessment of myocardial viability is a critical aspect of the management of the patient with coronary artery disease and left ventricular dysfunction. Several non-invasive methods exist to assist the clinician in distinguishing those patients with significant regions of hibernating myocardium from those who have non-viable scar. This is important not only to identify those patients who would most benefit from percutaneous intervention or surgery, but also to spare the latter group from the morbidity and mortality associated with a revascularization procedure that would provide little benefit. While nuclear medicine imaging is the most widely used means for evaluating myocardial viability, alternative modalities have emerged and have gained increasing acceptance in recent years. This article will review the echocardiographic and magnetic resonance imaging (MRI) methods that are currently available or under investigation to assess myocardial viability. These techniques include rest and stress echocardiography, myocardial contrast echocardiography, stress MRI, contrast-enhanced MRI and magnetic resonance spectroscopy (MRS).     

Uncommon and dynamic changes detected by123I-15-(p-iodophenyl)-3-R,S-methylpentadecanoic acid myocardial single photon emission computed tomography in a stunned myocardium induced by coronary microvascular spasm

A 55-yr-old man underwent surgery. Soon after the procedure was finished, the patient complained of chest pain, and the electrocardiogram showed increase in the ST-segment in some leads. Emergency angiography showed normal coronary arteries, but there was asynergy in the left ventricle, and delayed filling of contrast medium was observed in the LCA. An intracoronary infusion of isosorbide dinitrate did not improve the delayed filling of contrast medium or ST segment increase in the electrocardiogram. Soon after nicorandil was injected into the LCA, the patient's symptoms, electrocardiogram, and delayed filling of contrast medium dramatically improved. On the second day, initial imaging by 123I-BMIPP myocardial SPECT showed a moderate increase in tracer uptake in the apico-anteroseptal region and a moderate decrease in tracer uptake in the lateral region, in which the first left ventriculography showed akinesis, and delayed imaging revealed a moderate increase in tracer uptake in the apical region and a high washout of 123I-BMIPP in the anteroseptal and lateral regions. On the sixth day, initial imaging by 123I-BMIPP myocardial SPECT showed a moderate decrease in tracer uptake in the apical and lateral regions and a mild decrease in tracer uptake in the anteroseptal region, and delayed imaging revealed a moderate increase in tracer uptake in the apical region and a high washout of 123I-BMIPP in the anteroseptal and lateral regions. By the 30th day, 123I-BMIPP myocardial SPECT had normalized. We consider that these dynamic changes in 123I-BMIPP myocardial SPECT imaging may reflect metabolic changes in fatty acids in the ischemic state, the size of the triacylglycerol pool, and the degree of turnover in the triacylglycerol pool.     

Magnetic Resonance Imaging of Transient Left Ventricular Apical Ballooning Related to Emotional Stress: a Case Report

Transient left ventricular apical ballooning is characterized by transient wall motion abnormalities involving the left ventricular apex and mid-ventricle in the absence of coronary arterial occlusion. A 66-year-old woman presented to the emergency department with chest pain that mimicked acute myocardial infarction. An aortogram showed akinesis from the mid to apical left ventricle with sparing of the basal segments. Four days later, she underwent MRI, which demonstrated characteristic apical contractile dysfunction, the same as the aortogram, without evidence of myocardial infarction on the MRI. Two weeks later, her symptoms were resolved and follow-up echocardiography showed normal ventricular function.     

Assessment of myocardial viability in patients with heart failure.

The prognosis for patients with chronic ischemic left ventricular dysfunction is poor, despite advances in different therapies. Noninvasive assessment of myocardial viability may guide patient management. Multiple imaging techniques have been developed to assess viable and nonviable myocardium by evaluating perfusion, cell membrane integrity, mitochondria, glucose metabolism, scar tissue, and contractile reserve. PET, (201)Tl and (99m)Tc scintigraphy, and dobutamine stress echocardiography have been extensively evaluated for assessment of viability and prediction of clinical outcome after coronary revascularization. In general, nuclear imaging techniques have a high sensitivity for the detection of viability, whereas techniques evaluating contractile reserve have a somewhat lower sensitivity and a higher specificity. MRI has a high diagnostic accuracy for assessment of the transmural extent of myocardial scar tissue. Patients with a substantial amount of dysfunctional but viable myocardium are likely to benefit from coronary revascularization and may show improvements in regional and global contractile function, symptoms, exercise capacity, and long-term prognosis.     

Resting “solar polar” map pattern and reduced apical flow reserve: Characteristics of apical hypertrophic cardiomyopathy on SPECT myocardial perfusion imaging

BACKGROUND: Patients with apical hypertrophic cardiomyopathy (ACM) are often referred for myocardial perfusion single photon emission computed tomography (SPECT) as a result of marked T-wave inversion and chest pain syndromes. Stress perfusion defects have been reported in ACM, but the characteristic SPECT pattern as well as the typical findings on volume-weighted polar maps has not been described. METHODS AND RESULTS: Dual-isotope rest (thallium 201) and exercise or adenosine stress (technetium 99m tetrofosmin) myocardial perfusion SPECT was performed in 11 patients with ACM, including 8 with either normal coronary arteriography (n = 5) or a low pretest probability of coronary artery disease (CAD) (n = 3), and 14 control patients with concentric left ventricular hypertrophy. An 8-pixel-diameter circular region of interest was used to quantitatively compare apical and septal counts on CEqual volume-weighted polar maps. A characteristic "Solar Polar" map pattern resulting from the increased apical counts was present in each ACM patient at rest, with a mean apical-septal ratio of 1.39 +/- 0.17 (range, 1.23-1.62, P <.01 vs concentric left ventricular hypertrophy group). With stress, there was a significant decrease in the apical-septal ratio (0.96 +/- 0.18, P <.001 vs rest) in the ACM subgroup without CAD. CONCLUSION: Patients with ACM demonstrate a newly described "Solar Polar" map pattern at rest, as well as relative apical ischemia on the stress images even in the absence of CAD.