基于第二代追踪冻结技术重建冠状动脉CT造影图像所测冠状动脉跨狭窄CT血流储备分数差值与冠状动脉狭窄风险及心肌损伤指标的相关性

目的 观察基于第二代追踪冻结(SSF2)技术重建冠状动脉CT造影(CCTA)图像所测冠状动脉跨狭窄CT血流储备分数(CT-FFR)差值(ΔCT-FFR)与冠状动脉狭窄风险及心肌损伤指标的相关性。方法 回顾性分析41例疑诊冠心病并接受CCTA患者,分别以标准算法及SSF2算法重建图像;比较不同方法重建CCTA显示左前降支(LAD)、左回旋支(LCX)及右冠状动脉(RCA)的图像质量,评估LAD、LCX及RCA狭窄程度,分析基于SSF2算法重建CCTA所测最窄CT-FFR及ΔCT-FFR与冠状动脉疾病报告和数据系统(CAD-RADS)分类、肌钙蛋白I(cTnI)及肌酸激酶同工酶MB(CK-MB)的相关性。结果 SSF2重建CCTA图像显示LAD、LCX及RCA质量评分均高于标准算法(P均＜0.05)。LAD、LCX及RCA的CAD-RADS分类分别为2(1,3)、1(1,3)及1(1,3),其最窄CT-FFR分别为0.77±0.13、0.79±0.16及0.78±0.14,ΔCT-FFR分别为0.16±0.10、0.13±0.07及0.14±0.09。冠状动脉上述3分支最窄CT-FFR与CAD-RADS分类、cTnI、CK-MB均呈负相关,ΔCT-FFR与CAD-RADS分类、cTnI、CK-MB均呈正相关(P均＜0.05)。结论 基于SSF2重建CCTA图像所测冠状动脉跨狭窄ΔCT-FFR与CAD-RADS评分和心肌损伤指标均呈正相关。     

冠状动脉CT血管造影评估冠状动脉慢性完全性闭塞

目的 观察冠状动脉CT血管造影(CCTA)评估冠状动脉慢性完全闭塞(CTO)的可靠性。方法 回顾性分析201例经有创冠状动脉造影(ICA)确诊的CTO患者共207处病变的CCTA资料,观察CCTA与ICA显示CTO特征的一致性、差异及符合率,包括冠状动脉闭塞段头端形态(钝形/锥形),闭塞段内有无钙化、纡曲、近端分支及闭塞段长度是否≥20 mm。结果 CCTA与ICA检出冠状动脉闭塞段头端钝形(Kappa=0.50)、闭塞段内有无钙化(Kappa=0.48)、闭塞段近端有无分支(Kappa=0.56)及病变长度≥20 mm(Kappa=0.53)与否的结果具有中度一致性(P均＜0.01),二者判断闭塞段是否纡曲的一致性好(Kappa=0.80,P＜0.01)。CTA与ICA对冠状动脉闭塞段钙化[38.65%(80/207)vs.21.74%(45/207)]及闭塞近端分支[31.40%(65/207)vs.43.48%(90/207)]的检出率差异有统计学意义(P均＜0.01),对闭塞段头端钝形[35.75%(74/207)vs.36.71%(76/207)]、闭塞段纡曲[20.29%(42/207)vs.23.19%(48/207)]及病变长度≥20 mm[38.65%(80/207)vs.41.06%(85/207)]的检出率差异均无统计学意义(P均＞0.05)。CCTA与ICA检出冠状动脉闭塞段头端钝形、钙化、纡曲、近端存在分支及长度≥20 mm的符合率分别为76.81%(159/207)、77.29%(160/207)、93.24%(193/207)、79.23%(164/207)及77.29%(160/207)。结论 利用CCTA能可靠评估CTO病变特征。     

静息心率对CTA评价冠状动脉弹性及病变的影响

目的观察静息心率(RHR)对冠状动脉CTA(coronary CTA, CCTA)评价冠状动脉弹性及病变的影响。方法回顾性分析180例接受CCTA检查患者,按RHR分组,A组RHR≤60次/分,B组60次/分RHR80次/分,C组RHR≥80次/分,每组60例;根据CCTA结果分为正常亚组(CTA未发现明显病灶)和病变亚组(CTA发现冠状动脉软/硬斑块)。重建R-R间期10%～90%时相(间隔5%R-R间期),评价图像质量,获得右冠状动脉(RCA)、左前降支(LAD)及左回旋支(LCX)最佳收缩期及舒张期重建时相。于3组最佳时相测量正常亚组RCA、LAD及LCX血管扩张系数(DC),计数各病变亚组斑块数目。结果 A组RCA、LAD、LCX最佳重建时相均为40%R-R间期、70%或75%R-R间期,B组RCA、LAD、LCX最佳重建时相均为45%、75%R-R间期,C组RCA、LAD、LCX均为45%或50%、75%或80%R-R间期。3组正常亚组RCA、LAD、LCX血管弹性DC值差异均有统计学意义(P均0.05),其中C组RCA、LAD、LCX的DC值均低于A组,LAD、LCX均低于B组(P均0.05),A、B组间差异均无统计学意义(P均0.05)。3组病变亚组RCA、LAD、LCX斑块数差异均有统计学意义(P均0.05),其中C组RCA、LAD、LCX斑块数均多于A组,LAD斑块数多于B组(P均0.05),A、B组间差异均无统计学意义(P均0.05)。结论 CCTA检查中,患者RHR过高可致血管弹性降低及血管斑块数增加。     

临床-影像学模型预测冠状动脉狭窄患者基于冠状动脉CT造影所获无创血流储备分数≤0.8

目的 建立临床-影像学模型,观察其预测冠状动脉狭窄患者基于冠状动脉CT造影所获无创血流储备分数(CT-FFR)≤0.8的效能。方法 回顾性分析114例接受冠状动脉CT造影(CCTA)并获取CT-FFR的冠状动脉狭窄患者,将其分为缺血组(CT-FFR≤0.8,n=69)和非缺血组(CT-FFR>0.8,n=45);以单因素及多因素logistic回归分析筛选CT-FFR≤0.8的独立影响因素,构建临床-影像学模型,评价其预测CT-FFR≤0.8的效能。 结果 单因素及多因素logistic回归分析结果显示,典型心绞痛、重度狭窄、管状病变及弥漫性病变为冠状动脉狭窄患者CT-FFR≤0.8的独立影响因素;基于上述因素建立的临床-影像学模型的数据拟合(P=0.45)及泛化能力(Kappa=0.46)均可,预测概率接近实际概率线及理想线,其预测冠状动脉狭窄患者CT-FFR≤0.8的曲线下面积为0.86[95%CI(0.79,0.93)],敏感度为78.34%,特异度为82.22%。结论 基于心绞痛类型、狭窄程度和病变类型的临床-影像学模型预测冠状动脉狭窄患者CT-FFR≤0.8的效能较佳。     

不同屏气方式对冠状动脉CT血管成像辐射剂量和图像质量的影响

目的 观察不同屏气方式对冠状动脉CT血管成像（CCTA）辐射剂量和图像质量的影响。方法 将150例疑诊冠心病患者随机分为3组（每组50例）,对A组于深吸气末屏气、B组于平静呼吸下屏气、C组于深呼气末屏气下行CCTA检查;记录扫描前平静呼吸时心率（基础心率）、扫描时屏气心率及容积扫描长度,比较各组辐射剂量和图像质量差异。结果 147例顺利完成检查,3例C组患者因图像模糊、无法评价而被排除。3组患者扫描时屏气心率均明显低于基础心率（P均<0.01）。B、C组容积扫描长度、剂量长度乘积（DLP）及有效剂量（ED）均低于A组（P均<0.05）,B、C组间差异均无统计学意义（P均>0.05）。A组共评估698个冠状动脉节段,其中4分678个,3分20个;B组共评估696个冠状动脉节段,其中4分682个,3分14个;C组共评估656个冠状动脉节段,其中4分615个,3分41个;3组图像质量评分差异无统计学意义（P>0.05）。结论 于平静呼吸屏气下行CCTA可在保证图像质量的同时降低容积扫描长度及辐射剂量。     

颈动脉斑块常规超声及超声造影预测颈动脉狭窄患者缺血性脑卒中

目的 观察常规超声及超声造影(CEUS)评估颈动脉斑块、预测颈动脉狭窄患者缺血性脑卒中的价值。方法 回顾性分析115例经超声证实的颈动脉斑块致狭窄(狭窄率≥50%)患者,根据近6个月内有无缺血性脑卒中将其分为症状组(n=53)及无症状组(n=62)。以单因素分析及多因素logistic回归分析筛选颈动脉狭窄患者发生缺血性脑卒中的颈动脉斑块超声特征,建立回归模型,绘制受试者工作特征(ROC)曲线,评估其预测患缺血性脑卒中的效能。结果 单因素分析显示,组间颈动脉狭窄率、斑块表面形态及斑块内新生血管分级差异均有统计学意义(P均<0.05)。多因素logistic回归分析显示,斑块表面形态及斑块内新生血管分级为颈动脉狭窄患者发生缺血性脑卒中的独立预测因素,建立回归模型Y=－4.914+2.272X₁+2.354X₂(X₁为斑块表面形态,X₂为斑块内新生血管分级),其预测缺血性脑卒中的曲线下面积为0.886。结论 常规超声联合CEUS评估颈动脉狭窄患者颈动脉斑块有助于预测缺血性脑卒中。     

加速康复外科在关节镜下半月板损伤修复围术期护理中的应用

目的 探讨加速康复外科（enhanced recovery after surgery, ERAS）优化方案在关节镜下半月板损伤修复围术期护理的应用效果。方法 选取2017年1月至6月在北京积水潭医院运动医学科收治的膝关节半月板损伤病人90例,按照随机数字表法分为ERAS组和常规组,每组45例。ERAS组围术期在常规护理方法的基础上,给予改进的ERAS优化护理方案。比较两组病人术后疼痛视觉模拟量表（visual analogue score, VAS）评分、膝关节活动度恢复时间、Lysholm膝关节评分（Lysholm knee score scale, LKSS）、住院时间和费用、术后并发症及术后满意度情况。结果 两组病人术前至术后48 h各时间点的VAS评分均呈下降趋势（F_ERAS组=14.355,F_常规组=5.728,P均＜0.05）,从各个时间点看,ERAS组的VAS评分值显著低于常规组（F_组间=11.937,P_组间=0.001）,不同时间点与分组之间存在交互作用（F_交互=16.571,P_交互＜0.001）;ERAS组术后膝关节活动度恢复至30°、60°、90°及120°时间明显早于常规组（P＜0.001）,且病人住院时间短（t=-5.181,P＜0.001）、住院费用低（t=-3.263,P=0.002）、术后Lysholm膝关节评分更佳（t=10.682,P＜0.001）;ERAS组病人术后恶心、呕吐、尿潴留、关节积液等并发症发生率较常规组低（P＜0.05）,总体满意度明显高于常规组（Z=-2.455,P=0.014）。结论 ERAS优化方案应用于关节镜下半月板损伤修复的围术期护理中效果显著,可明显降低病人术后疼痛程度,缩短住院时间,减少住院总费用和并发症发生率,有效改善病人早期及远期膝关节活动情况,提高病人治疗综合满意度。     

双层光谱CT评估非小细胞肺癌Ki-67表达水平的可行性

目的 探讨双层光谱CT相关参数评估非小细胞肺癌(NSCLC)Ki-67表达水平的可行性。方法 纳入50例NSCLC患者,根据Ki-67表达水平将其分为低表达组(n=23,Ki-67≤30%)及高表达组(n=27,Ki-67＞30%),比较组间光谱定量参数的差异。采用Spearman相关性分析评价光谱定量参数与Ki-67表达水平的相关性;绘制受试者工作特征曲线,分析各参数评估Ki-67表达水平的效能。结果 低表达组CT_{40 keV}、曲线斜率、等效原子序数、碘密度和无水碘密度均高于高表达组(P均＜0.05)。NSCLC患者CT_{40 keV}、CT_{70 keV}、曲线斜率、碘密度及无水碘密度均与Ki-67表达呈负相关(r_s=-0.28、-0.18、-0.37、-0.29、-0.33,P均＜0.05),等效原子序数与Ki-67表达呈正相关(r_s=0.32,P＜0.05)。根据CT_{40 keV}、曲线斜率、等效原子序数、碘密度及无水碘密度评估NSCLC Ki-67表达水平的曲线下面积分别为0.72、0.75、0.70、0.72及0.75。结论 双层光谱CT定量参数可用于评估NSCLC Ki-67表达水平。     

同时多层采集技术结合分段读出平面回波成像序列弥散加权成像评估直肠腺癌病理分化程度

目的 观察不同层加速因子同时多层(SMS)采集技术结合分段读出平面回波成像序列(rs-EPI)弥散加权成像(DWI)评估直肠腺癌病理分化程度的可行性。方法 回顾性分析59例经术后病理证实的直肠腺癌患者,均接受直肠常规rs-EPI序列(DWI₁)、层加速因子为2的SMS技术结合rs-EPI序列(DWI₂)及层加速因子为3的SMS技术结合rs-EPI序列(DWI₃)DWI检查,采集时间分别为137、60、51 s,获得相应表观弥散系数(ADC)。根据术后组织病理学所见将病灶分为高、中、低分化,比较不同分化程度直肠腺癌之间ADC,以及相同分化程度内ADC的差异,分析ADC与直肠腺癌分化程度的相关性。结果 高、中分化与低分化直肠腺癌间ADC₁、ADC₂、ADC₃差异均有统计学意义(P均＜0.05);高、中分化直肠腺癌间ADC差异均无统计学意义(P均＞0.05)。高分化直肠腺癌ADC₁、ADC₂及ADC₃总体差异无统计学意义(P=0.08);中、低分化直肠腺癌ADC₃值均低于ADC₁及ADC₂(P均＜0.01),ADC₁与ADC₂差异均无统计学意义(P均＞0.05)。直肠腺癌病理分化程度与ADC₁(r_s=0.49,P＜0.01)、ADC₂(r_s=0.51,P＜0.01)及ADC₃(r_s=0.40,P＜0.05)均呈正相关。结论 以层加速因子为2的SMS技术结合rs-EPI采集的DWI可用于评估直肠腺癌病理分化程度。     

柔性减影CE-Boost技术对CT肺动脉造影图像质量的影响

目的 观察柔性减影CE-Boost技术对CT肺动脉造影(CTPA)图像质量的影响。方法 回顾性分析66例疑诊肺栓塞(PE)患者的肺部CT平扫及CTPA资料,对平扫期和增强动脉期图像进行薄层重建,以Sure-Subtraction Lung软件行柔性减影,获得CE-Boost序列图像。将重建后增强动脉期图像(A组)与CE-Boost图像(B组)上传至Toshiba Vitrea后处理工作站,测量肺动脉及其分支CT值,计算信噪比(SNR)及对比噪声比(CNR);并由2名影像科医师采用5分法对图像质量进行主观评分。结果 B组肺动脉主干,左、右肺动脉干,左、右上肺动脉分支及左、右下肺动脉分支的CT值、SNR值及CNR值均高于A组(P均＜0.001)。B组图像主观评分5(4,5)分,高于A组的2(1,2)分(Z=－4.980,P＜0.001),且2名医师对A、B组图像质量评分的一致性较高(Kappa=0.896)。结论 柔性减影CE-Boost技术可提高CTPA图像质量。     

Intraoperative assessement of coronary flow and coronary vascular resistance during coronary bypass surgery

The measurement of coronary graft flow rates is a well-established method of assessing graft function intraoperatively. In order further to understand the dynamics of graft function, the resistance to the flow was considered a desirable measurement intraoperatively. The coronary vascular resistance (CVR) was estimated by applying the Poiseuille-Hagen equation. The CVR was estimated at zero cardiac work (during cardioplegic arrest) using fixed perfusion flow rates and estimating the pressures produced. After going off cardiopulmonary bypass (CPB), the bypass graft flow (F) was estimated by a standard ultrasound Doppler technique. The perfusion pressure over the perfused coronary graft was then determined and the CVR in the working heart ascertained. The CVR was studied in 178 vein grafts in 59 patients undergoing coronary bypass surgery. The mean CVR in the cardioplegic heart (c-CVR) varied from 0.81 to 2.3 mmHg/ml/min for various coronary artery diameters and was significantly higher in small diameter arteries compared with larger arteries (p < 0.0002). Consequently significant high flows were found in the large vessels compared with the smaller ones (p < 0.0001). The mean c-CVR during cardioplegia of 1.57 +/- 0.06 increased significantly to 1.75 +/- 0.07 mmHg/ml/min after the procedure (p-CVR) and was attributed to the dynamic resistance of the working heart. The post-CPB graft flow was significantly and negatively correlated to the c-CVR of the arrested heart. The measurement of coronary vascular resistance reveals coronary beds at potential high risk for inadequate perfusion. Such areas are usually fed by small vessels with low flows. The working heart, in turn, increases the coronary resistance following cardioplegia during the surgical procedure.     

Status of percutaneous coronary intervention and coronary artery bypass.

At present a rapid and profound change in myocardial revascularization has evolved from the work of Gruentzig. The recent technological advances have been so fast paced that there has not been ample time to fully assess each new facet of technology and pharmaceutics before another arrives. The interface between percutaneous intervention (PCI) and coronary artery bypass (CAB) is not well defined as previously so that continental, national and regional differences exist. The progress in PCI from balloon angioplasty to drug eluting stents has seen a progressive decline in restenosis and reintervention but relief of symptoms has not equaled that attained with CAB. Survival benefit for CAB over PCI has not been demonstrated in the many randomized clinical trials which are limited by selection of only 5-12% of potential patients so that higher risk patients and those with more extensive and complex coronary disease are excluded. These excluded patients are included in the registries where survival benefit for CAB over PCI is clearly evident. Situations less amenable to PCI include: left main disease; three vessel disease; vessels that are smaller, diffusely diseased or with distal lesions which are frequently associated with diabetes; ostial and bifurcation lesions; and coronary arteries that are tortuous, calcified or with very long lesions. It is in these situations that PCI does not provide revascularization equivalent to CAB. Surgeons must appreciate the success of PCI, acknowledge their reduced role in revascularization and strive to provide the best operation possible when the clinical situation demands it.     

Cystic medionecrosis of the coronary arteries and fatal coronary vasospasm

The histopathological basis of coronary vasospasm is not well defined. We report a patient with directly observed coronary artery spasm in whom cystic medionecrosis of the coronary arteries and great vessels and myxomatous degeneration of the mitral valve were evident. We suggest that myxoid connective tissue lesions of the heart may be linked to coronary vasospasm.     

Extensive coronary dissection treated with endarterectomy and coronary reconstruction

Acute coronary dissection is an uncommon event, usually not related to typical coronary risk factors, usually in women, and usually diagnosed at autopsy. This report describes a young woman with extensive left anterior descending coronary artery (LAD) dissection, refused for intervention since there was no lesion to angioplasty and no artery to bypass. A long arteriotomy was made, removing under direct vision all of the torn and dissected tissue, just as would be done for extensive LAD endarterectomy. A vein was split and attached to reconstruct the artery. Normal left ventricular function was restored.     

多排螺旋CT冠脉成像与冠脉造影对冠心病诊断的对比研究

目的:初步评价MSCT在冠状动脉成像中的临床应用价值。方法:18例疑诊冠状动脉狭窄患者行MSCT扫描,利用影像曲面重建,3D重建,了解冠状动脉病变情况,并与冠状动脉造影对比。结果:18例76支血管同时经MSCT和CAG成像。冠状动脉造影发现狭窄27支,其中左前降支(LAD)病变11支,回旋支(LCA)病变3支,左主干(LMA)2支,右冠(RCA)病变9支,桥支病变2支。MSCT发现狭窄23支,其中左前降支病变11支,回旋支病变3支,左主干病变1支,右冠病变9支,桥支病变2支。MSCT成像的敏感性为81．5％(22／27),特异性100％,阳性推测值91．7％,阴性推测值94．2％。结论:在控制心率的情况下,MSCT可作为冠状动脉狭窄的一种无创筛选检查方法。     

Survival difference between coronary bypass surgery and percutaneous coronary intervention

Abstract

Objectives. To assess whether the previously observed lower death rate with coronary artery bypass surgery compared with percutaneous coronary intervention in subsets of patients with coronary artery disease persists in more recent years. Design. Retrospective study from Feiring Heart Clinic database of survival in 17739 patients followed for 5 years after coronary revascularization. The cohorts treated in 1999–2005 and 2006–2011 were compared using Cox regression and propensity score analyses. Results. Cox regression and propensity score analyses revealed no difference in survival in either time period in one- and two-vessel diseases. In three-vessel disease, the hazard ratios between bypass surgery and percutaneous intervention were 0.62 (95% confidence interval [CI]: 0.53–0.71, p <0.001) and 0.59 (95% CI: 0.47–0.73, p < 0.001), respectively, in the two time periods, indicating persistent higher survival with bypass surgery. Conclusions. The previously observed lower death rate of coronary artery bypass surgery compared with percutaneous intervention in patients with three-vessel disease is persistent in more recent years and indicates that bypass surgery still should be the standard treatment for these patients.