隐藏在钙化病变下的蜂巢现象1例报告

正1临床资料患者男,67岁。因"间断胸闷、气短2个月"于2018年12月1日收入河北医科大学第二医院心内科。患者于2个月前劳累后出现胸闷、胸痛,无肩背部放射痛,症状持续不缓解,就诊于当地医院,诊断为急性心肌梗死。行冠状动脉造影示:左主干(left main coronary artery,LM)未见异常,左前降支(left anterior descending artery,LAD)近端钙化,自近端起急性完全闭塞,左回旋支(left circumflex,LCX)多发斑块浸润,未见明显狭窄,右冠状动脉(right coronary artery,RCA)弥漫斑块浸润,未见明显狭窄,未行介入治疗,经药物治疗后症状好转出院。出院后规律服用抗血小板、     

右冠状动脉狭窄程度对左冠状动脉狭窄患者左室射血分数的影响

目的研究右冠状动脉不同程度狭窄对左冠状动脉狭窄患者左室射血分数（LVEF）的影响。方法根据左冠状动脉病变部位不同,将1 000例左冠状动脉狭窄患者分为左前降支（LAD）狭窄,左回旋支（LCX）狭窄,左主干（LM）狭窄,左前降支+左回旋支（LAD+LCX）狭窄4个系列。每个系列再根据右冠状动脉（RCA）病变程度不同分为RCA正常组（直径狭窄<50%）、RCA非闭塞组（99%>直径狭窄≥50%）和RCA闭塞组（直径狭窄≥99%）,比较分析3组间LVEF的差异。结果在LAD,LCX,LM,LAD+LCX狭窄时,与RCA正常组LVEF相比,RCA非闭塞组LVEF分别下降0.9%,0.3%,3.4%和2.8%;RCA闭塞组LVEF分别下降10.9%,3.7%,6.5%和5.2%。LAD狭窄时,RCA非闭塞组和RCA闭塞组之间LVEF有统计学差异（P<0.01）。结论右冠状动脉病变可在左冠状动脉狭窄的基础上使左室射血分数进一步下降;当左冠状动脉狭窄为闭塞性病变时,影响更为明显。     

冠状动脉瘘的CT血管成像表现

目的 分析冠状动脉瘘的CT血管成像表现.方法 回顾性分析12717例行冠状动脉多排螺旋CT血管成像检查病例,其中诊断冠状动脉瘘66例.综合多种后处理图像,记录冠状动脉瘘的起源、瘘口、冠状动脉有无斑块及狭窄.其中14例患者行冠状动脉造影,比较两种检查方法结果的异同.结果 66例冠状动脉瘘中,起源于双侧冠状动脉21例,左冠状动脉26例,右冠状动脉19例;而瘘口在肺动脉41例,左心房10例,右心房8例,左心室4例,冠状静脉2例,右心室1例.14例患者冠状动脉造影显示的瘘管起源和瘘口部位均与多排螺旋CT血管成像一致.31例冠状动脉瘘同时伴冠状动脉斑块形成,其中狭窄程度≥50%者7例.结论 双侧冠状动脉起源的冠状动脉瘘并不少见,且瘘口在肺动脉者最多.CT血管成像可作为冠状动脉瘘的首选检查手段,可为该病的治疗提供重要的术前信息.

Abstract：

Objective To analyzed the computed tomography angiography (CTA) features of the coronary artery fistulas. Methods Sixty-six coronary artery fistulas were diagnosed out of 12 717 patients underwent the coronary artery multiple detector CTA examination. The origin and drainage site of the coronary artery fistulas and the plaque and stenosis of the coronary artery were observed by post-processing analysis on various images. Coronary artery angiography was performed in 14 out of 66 coronary artery fistulas patients. Results Coronary artery fistulas arose from bilateral coronary artery system in 21 cases, from left coronary artery in 26 cases and from right coronary artery in 19 cases. The majority of coronary artery fistulas entered into pulmonary artery (41 cases). The rest drainage sites included left atrium (10 cases), right atrium (8 cases),left ventricle (4 cases), coronary sinus (2 cases) and right ventricle (1 case). The findings of CTA and coronary artery angiography were consistent in 14 patients with DSA examination. Coronary artery plagues were evidenced in 31 cases and stenosis was greater than 50% in 7 coronary artery fistulas patients. Conclusions Multiple coronary artery fistulas are not rare, and pulmonary artery is the most frequent drainage site. When suspecting the coronary artery fistulas, coronary artery CTA can be the first choice of diagnose. CTA can supply adequate information for therapy.     

融合影像技术评价冠状动脉病变功能改变及临床价值

目的:探讨同机心肌灌注显像和冠状动脉计算机断层摄影术(CT)成像融合影像技术评价冠状动脉病变的功能改变,及其在冠心病诊断中的临床价值。方法:30例可疑或确诊冠心病患者行同机负荷心肌灌注(myocardial perfusion imaging,MPI)和冠状动脉CT成像(coronary tomography coronary angiography,CTCA),负荷心肌灌注和CTCA按常规方法完成,利用融合软件整合冠状动脉解剖与心肌灌注功能影像,所有患者1个月内完成冠状动脉造影。负荷心肌灌注、CTCA和冠状动脉造影图像分别由2位以上有经验的核医学科和影像科、心内科和影像科医师判读;负荷-静息心肌灌注显示心肌"可逆性"缺损判为心肌缺血,显示心肌"不可逆性"缺损判为心肌梗死;冠状动脉造影及CTCA冠状动脉管腔狭窄≥50%定义为有临床意义。结果:基于冠状动脉血管及相应心肌供血区的对应关系,以冠状动脉造影或冠状动脉造影联合负荷心肌灌注作为标准对照,CTCA诊断冠心病的敏感性89.29%(25/28),特异性88.71%(55/62),阳性预测值78.13%(25/32),阴性预测值94.83%(55/58),准确性88.89%(80/90)。MPI诊断冠心病的敏感性70.73%(29/41),特异性81.63%(40/49),阳性预测值76.32(29/38),阴性预测值76.92%(40/52),准确性76.67%(69/90)。MPI/CTCA融合显像诊断冠心病,评价冠状动脉病变功能改变的敏感性96.43%(27/28),特异性90.32%(56/62),阳性预测值81.82%(27/33),阴性预测值98.25%(56/57),准确性92.22%(83/90)。结论:心肌灌注显像和CTCA融合影像技术评价冠状动脉病变功能改变,与单一影像技术比较,可明显提高冠心病及冠状动脉病变功能异常的诊断效能,并同时提供冠状动脉解剖及心肌血供功能信息,对冠状动脉疾病诊疗有较高的临床价值。     

超声对老年急性心肌梗死患者左心室心肌总应变及左心室重构的研究

目的探讨应用超声技术评价老年急性心肌梗死(AMI)患者左心室心肌总应变,及其与左心室重构的相关性。方法选择心肌梗死患者104例,根据冠状动脉造影结果分为左回旋支(LCX)和(或)右冠状动脉(RCA)病变组(LCX/RCA组)31例、单纯左前降支(LAD)病变组(LAD单支组)34例、包含LAD的2支或3支病变组(多支组)39例,另选择性别、年龄相匹配的同期健康体检者40例为对照组。应用二维超声斑点追踪成像测算左心室各节段心肌及整体总应变矢量(ε)及其与左心室短轴平面间的角度(θ),应用实时三维超声心动图测算左心室重构指数(LVRI)。结果与对照组比较,LCX/RCA组左心室前壁ε,LAD单支组下侧壁、下壁ε未见明显减低(P0.05),LCX/RCA组、LAD单支组、LAD多支组其余不同心肌节段ε明显减低(P0.05),且LCX/RCA组下侧壁、下壁θ,LAD单支组前间隔、前壁θ及多支组各部位θ明显升高(P0.05)。与对照组比较,LCX/RCA组、LAD单支组和LAD多支组整体ε、LVRI均显著降低,整体θ显著升高(P0.05)。LCX/RCA组、LAD单支组和多支组整体ε(r=-0.815,P=0.014;r=-0.747,P=0.031;r=-0.768,P=0.024)、θ(r=-0.719,P=0.043;r=-0.763,P=0.021;r=-0.753,P=0.029)均与LVRI呈显著负相关。结论老年AMI患者左心室心肌ε大小及θ能反映局部及整体的心肌应变能力,整体ε、θ与LVRI均呈负相关性。     

腺苷负荷心肌灌注显像正常女性中心电图呈缺血改变35例分析

目的:探讨腺苷负荷心电图(ECG)呈缺血性改变而核素心肌灌注显像(MPI)正常的女性患者,MPI和冠状动脉CT(CTCA)结果对冠心病(CAD)诊断的临床价值。方法:回顾性分析2008年5月至2011年11月疑诊冠心病行腺苷负荷/静息MPI的4 142例女性患者资料,将其中35例〔年龄39～76岁,平均年龄(55.74±9.43)岁〕腺苷负荷ECG呈缺血改变,但MPI正常者作为研究对象,35例患者均利用SPECT/CT行MPI和同机CTCA检查,其中1例患者在1个月内行冠状动脉造影(CAG)检查。结果:35例患者静息状态ECG均正常,腺苷负荷ECG则出现ST段水平或下斜型下移≥0.1 mV,停止负荷1 min后ECG恢复正常,提示心肌缺血改变,随后的负荷/静息MPI均未见心肌缺血改变。同机CTCA结果示:27例冠状动脉正常(27/35,77.1%),7例冠状动脉粥样硬化性改变(7/35,20.0%),1例(2.9%)为3支冠状动脉狭窄性病变,程度均≥50%,其CAG显示:LAD近段狭窄75%,LCX中段狭窄90%,RCA近中段狭窄95%。结果提示:此组患者中97.1%的冠状动脉是正常或仅呈硬化性改变,而无心肌缺血存在。结论:女性患者易出现负荷ECG"假阳性";负荷MPI是评价此类患者有无冠心病的重要手段;同机CTCA则是避免冠状动脉3支病变而MPI"假阴性"的弥补手段,因此,利用SPECT/CT施行同机MPI/CTCA是对此类患者进行冠心病筛查的准确性较高的无创性评价手段。     

老年人冠状动脉左主干病变手术与一般介入治疗效果比较

一般而言,冠状动脉左主干的闭塞会导致左心室的血供减少75％左右。因此,左主干狭窄的患者属高危患者。临床上把左前降支(left anterior descending,LAD)及左回旋支(left circumflex,LCX)     

256层螺旋CT在冠状动脉疾病诊断及左心功能评价中的临床价值

目的探讨256层螺旋CT在冠状动脉疾病诊断及左心功能评价中的临床价值。方法本组104例研究对象选自2016年1月至9月来我科室进行检查的疑似冠状动脉疾病患者。104例患者均应用256层螺旋CT行心脏冠状动脉CT成像(CTCA),二维经胸超声心动图(2D-TTE)检查,及冠状动脉造影(CAG)。对比分析心脏冠状动脉CT成像(CTCA)与冠状动脉造影(CAG)对冠状动脉狭窄的检出情况;并对比分析心脏冠状动脉CT成像(CTCA)与二维经胸超声心动图(2D-TTE)检查对患者LV-EDV、LV-ESV、LVEF各项心功能参数的评价情况。结果通过对患者左冠主支、左回旋支、左前降支、右冠动脉等340支血管进行检查,CTA检出146支冠状动脉狭窄,CAG检出134支冠状动脉狭窄,两种方式均显示狭窄的冠状动脉共计128支,两种检查方式冠状动脉狭窄检出情况比较差异不存在统计学意义P0.05。经CTCA与2D-TTE检查患者的LV-EDV、LV-ESV、LVEF等心功能参数的评价情况,比较差异不存在统计学意义P0.05。结论 256层螺旋CT冠状动脉成像在冠状动脉狭窄方面的诊断与常规冠状动脉造影检查结果具有较高的一致性,同时其对患者左心功能的评价具有较高的准取性,且该检查方式还具有操作简单、安全无创的优点,因此该检查方式可作为目前临床进行冠状动脉疾病诊断的首先方式。     

LAD纵深型心肌桥形态与CT-FFR的关系研究

目的:通过冠状动脉CT血管造影(coronary CT angiography, CCTA)检查探讨左冠状动脉前降支(left anterior descending coronary artery, LAD)纵深型心肌桥(myocardial bridging, MB)形态与CT血流储备分数(CT-FFR)的关系。方法:回顾性分析2018年1月—2022年4月包头医学院第一附属医院影像科323例LAD纵深型MB患者的解剖学信息，并以CT-FFR≤0.80为心肌缺血的指标，将患者分为CT-FFR正常组(237例)及CT-FFR异常组(86例)。采用t检验分析比较2组各MB参数的差异，采用岭回归模型分析CT-FFR值的影响因素，通过ROC曲线分析差异有统计学意义的参数。结果:2组MB入口处位置、出口处位置、长度、肌肉指数、收缩期压迫程度及壁冠状动脉(mural coronary artery, MCA)最狭窄处面积、入口处面积、出口处面积差异均有统计学意义(P<0.05)。岭回归方程显示，MB出口位置、长度及肌肉指数对CT-FFR值具有负向影响(P<0.05),MCA面积对C...     

右冠状动脉介入治疗多重并发症成功处置一例

患者　男性 ,5 5岁 ,因“阵发胸痛 1年 ,加重 1月”入院。 2 0 0 0年 1 1月 1 5日冠状动脉造影显示右冠状动脉 (RCA)中段 90 %狭窄 ,远段 70 %狭窄 (图 1 ) ,左前降支 (LAD)不光滑 ,左旋支 (LCX)中段 6 0 %狭窄 ,左室收缩功能正常 ,因故未即刻行介入治疗。于3周后 (1 2月 5日 )     

Congenital absence of the left circumflex coronary artery and an unusually dominant course of the right coronary artery

Congenital absence of the left circumflex artery (LCX) is a very rare congenital anomaly of the coronary circulation, and only a few cases have been reported in the literature. We report on a 55-year-old female with atypical chest pain. Routine coronary angiography showed a normal left anterior descending coronary artery (LAD), no LCX and a dominant right coronary artery (RCA), which continued beyond the crux, running the full course of the LCX and terminating in the left atrial branch. Neither aortography nor pulmonary angiography showed a separate ostium for the LCX. There were no atherosclerotic lesions in the coronary arteries, or ischaemia on stress myocardial perfusion imaging. Multidetector row computed tomography (MDCT) was performed to confirm the diagnosis.     

急性下壁心肌梗死患者心电图胸前导联ST段改变的临床意义

目的探讨急性下壁心肌梗死患者心电图胸前导联ST段改变与冠状动脉造影(CAG)所见冠状动脉病变部位的关系及其临床意义。方法 187例急性下壁心肌梗死患者,按入院时18导心电图胸前导联ST段改变分为3组,ST段无变化组(47例),ST段抬高组(16例),ST段压低组(124例);所有患者均行CAG。结果急性下壁心肌梗死伴胸前导联ST段抬高时多为右冠状动脉(RCA)近段闭塞(14例,82.3%),尤其是伴圆锥支动脉闭塞,与RCA中远端闭塞(2例,5.9%)比较差异有统计学意义(P0.01),且14例(73.7%)伴有右心功能不全和血流动力学障碍。下壁心肌梗死胸前导联ST段压低者可见于RCA、回旋支(LCX)闭塞及RCA、LCX闭塞与前降支(LAD)、对角支(D)病变的不同组合,其中LCX闭塞伴RCA病变者多表现为朐前ST V_4～V_6的压低,RCA闭塞伴LAD近端病变多有胸前ST V_1～V_6的压低,RCA伴D病变胸前ST V_1～V_3压低,与对照组比较差异有统计学意义(P0.05)。结论急性下壁心肌梗死合并胸前导联ST段抬高表明为RCA近段或丌口闭塞且多伴右心室心肌梗死和心功能不全;下壁心肌梗死伴胸前导联ST段压低提示为多支病变,ST V_1～V_3压低多伴有对角支严重狭窄,STV_1～V_6压低多伴有前降支的严重狭窄。     

青年冠心病患者危险因素及冠状动脉病变的临床分析

目的探讨青年冠心病（CHD）患者危险因素及病变特点。方法选择冠状动脉造影确诊的青年CHD患者97例,男性94例,女性3例,回顾性分析危险因素、冠状动脉病变特点及支架置入资料。结果急诊住院42例（43．30％）,急性及陈旧性心肌梗死35例（36．08％）。各危险因素阳性率依次为：吸烟78．35％,高甘油三酯血症59．79％,严重超重53．61％,高血压43．30％,高胆固醇血症27．84％,家族史22．68％,酗酒18．56％,糖尿病12．37％;具有3个以上危险因素者51例（52．58％）。冠状动脉单支病变56例（57．73％）、双支病变27例（27．84％）、三支病变14例（14．43％）。病变血管狭窄〉75％者152支,左前降支（IAD）57．89％,回旋支（LCX）13．82％,右冠状动脉（RC）27．63％,左主干（LM）0．07％。支架置入术干预血管127支,支架的大小及长度为：LAD（3．25±0．34）mm×（23．47±4．36）mm,LCX（3．01±0．32）mm×（23．27±5．87）mm,RC（3．60±0．43）mm×（26．83±4．43）mm。结论多数青年CHD患者发病突然,病变严重,约半数患者病变累及LAD。吸烟、高甘油三酯血症、严重超重、高血压等是最重要的危险因素。     

Differential coronary artery calcification detected by electron beam computed tomography as an indicator of coronary stenosis among patients with stable angina pectoris.

BACKGROUND: The detection of coronary artery calcification by electron beam computed tomography (EBCT) has been suggested as an indicator of atherosclerosis and coronary artery disease (CAD). There is no consensus on the correlation between coronary calcification and angiographically significant stenosis on an artery-by-artery basis. OBJECTIVE: To examine the relationship between coronary calcification score (CCS) and the presence of significant CAD on an artery-by-artery basis in patients with stable angina pectoris. METHODS AND RESULTS: EBCT and coronary angiogram (CAG) were evaluated in 71 patients with stable angina and in nine control subjects. The CCSs of each of the four major coronary arteries were highest in patients with significant CAD (n=43), followed by patients with insignificant CAD (n=5), patients with syndrome X (n=23) and control subjects, respectively. Calcification scores of the four major coronary arteries appeared to have different predictive power for significant stenosis on the same vessel. For left main (LM) and left anterior descending (LAD) coronary arteries, CCSs of vessels with significant stenoses were not different from those without significant stenoses (values expressed as medians: LM 0 versus 1; LAD 98.5 versus 70; not significant). Calcification scores of left circumflex (LCX) and right coronary arteries (RCA) were significantly higher in vessels with significant stenosis (LCX 49.5 versus 0; RCA 53 versus 1; P<0.05). CCSs appeared to be moderately useful to predict significant stenoses in these two vessels (areas under receiver operating characteristic curves: LCX 0.68+/-0.08, 95% CI 0.52 to 0.81; RCA 0.71+/-0.08, 95% CI 0.55 to 0.84). CONCLUSIONS: The CCSs of RCA and LCX arteries, but not those of LM and LAD arteries, may predict significant angiographic stenosis on an artery-by-artery basis among patients with stable angina pectoris.     

Semi-quantitative planar scintigraphy using thallium 201 for detection and localization of coronary artery disease: correlation with coronary angiography.

Thallium 201 exercise redistribution planar myocardial perfusion scan using semiquantitative technique was performed in 80 symptomatic patients undergoing coronary angiography. Out of the 240 vessels studied by angiography, more than 70% luminal narrowing was detected in 87 vessels, borderline stenosis was found in 49 arteries and the remaining 104 vessels were normal. Thallium scan correctly identified the significant stenosis in 76 vessels and the absence of stenosis in 102 vessels. In addition, perfusion abnormality was found in relation with 21 vessels of borderline stenosis. The sensitivity and specificity of Thallium scan were estimated as 92% and 95% for left anterior descending artery (LAD), 79% and 98% for left circumflex artery (LCX), 88% and 100% for right coronary artery (RCA) and 87% and 98% for all coronary arteries combined together (ACA).     

The diameter of coronary artery is enlarged in patients with dilated cardiomyopathy

Background Dilated cardiomyopathy(DCM) is a primary cardiomyopathy characterized by the enlargement of left ventricle or biventricular and left ventricular systolic dysfunction, without any obvious stenosis of coronary arteries. However, it remains unclear that whether the diameter of coronary artery is different from those of normal population, because few studies directly assessed the diameter of the coronary artery in patients with DCM. The study aimed to evaluate the diameter of coronary arteries in DCM patients and its influence on prognosis for DCM patients. Methods Fifty-seven DCM patients and fifty-nine patients presenting with atypical chest pain and normal coronary angiography were enrolled in the study. A coronary angiography image analysis system was used to measure the diameters at 5 mm from the opening of the left main coronary artery(LM), left anterior descending(LAD) and left circumflex coronary(LCX) arteries, and the right coronary artery(RCA) of both groups. Follow-up study through telephone over a period of 2 years was performed. Spearman rank correlation and logistic regression were used to evaluate the correlations of the diameter of coronary arteries with the risk of nonfatal heart failure event. Results Diameters of the LM, LAD, LCX, and RCA in DCM group were significantly larger than those of the control group(P 0.001). During a follow-up of 2 years, the nonfatal heart failure event occurred in 9 patients of DCM group, but not in control group. Spearman rank correlation analysis showed diameters of the LM, LAD, and LCX were correlated with the risk of nonfatal heart failure event, respectively(P 0.05). While the diameter of RCA showed no correlation with the risk of nonfatal heart failure event(P =0.583). Whereas logistic regression analysis showed there were no correlation between diameters of the LM,LAD, LCX, and RCA and the risk of nonfatal heart failure event(P 0.05). Conclusions The coronary arteries of DCM patients show a larger diameter without any obvious stenosis, which may not correlate with the risk of heart failure event.     

急性心肌梗死患者不同冠状动脉病变对介入术后预后的影响

目的探讨急性心肌梗死经皮冠状动脉介入治疗患者不同冠状动脉病变对预后的影响。方法将117例接受急诊经皮冠状动脉介入治疗的急性心肌梗死患者根据罪犯血管不同分为左前降支组51例、左回旋支组27例、右冠状动脉组39例。比较3组患者术后ST段回落〉70％的梗死相关导联数、TIMI血流分级、住院期间及出院后1年内主要心脏不良事件发生率。结果与左回旋支组和右冠状动脉组比较,左前降支组术后ST段完全回落的梗死相关导联数和左室射血分数显著降低（P〈0．05）,心源性死亡率及总主要心脏不良事件率显著升高（P〈0．05）。结论左前降支病变者术后心电图ST段回落更缓慢、左心功能不全更严重、主要心脏不良事件发生率更高、预后更差。     

右冠状动脉病变对左冠状动脉狭窄患者左心室功能的影响

目的　探讨右冠状动脉病变对左冠状动脉狭窄患者左心室功能的影响及其机制。方法　对比分析左冠状动脉狭窄患者在合并与不合并右冠状动脉病变时的左心室射血分数。结果　与相应部位单纯左冠状动脉狭窄患者相比 ,合并右冠状动脉病变患者左心室射血分数均呈不同程度地下降 ,其中在左前降支、左前降支 +左回旋支狭窄基础上合并右冠状动脉病变时左心室射血分数下降有统计学意义 (P <0 .0 5或 0 .0 1) ,左主干合并右冠状动脉狭窄患者下降幅度最大 ,但无统计学意义。结论　右冠状动脉病变可在单纯左冠状动脉狭窄的基础上使左心室收缩功能进一步恶化 ;当左冠状动脉狭窄部位为左前降支、左主干或左前降支 +左回旋支时 ,对左心室收缩功能影响更为严重