心血管影像学在预防医学中的价值和发展前景

冠状动脉粥样硬化性心脏病（简称冠心病）的防治已成为全球关注的重大公共卫生问题。传统的基于风险评分的一级预防能否准确识别高危人群仍存在争议。先进的影像学技术不仅能检出亚临床动脉粥样硬化病变,并且可以评估其性质及血流动力学意义,有助于优化病人的危险分层,有很大的潜力应用于心血管疾病的二级预防。随着近年临床影像学与预防医学交叉融合的深入,影像学的作用越来越大,就心血管影像学在疾病预防中的价值及发展方向进行综述。     

Molecular cardiovascular imaging using scintigraphic methods

Molecular cardiovascular imaging plays an increasingly important role both in basic research and in clinical diagnosis. Scintigraphic methods have long been used to study pathophysiological changes on a cellular and molecular level, and they are likely to remain important molecular imaging modalities in the foreseeable future. This article provides an overview over current developments in cardiovascular molecular imaging using scintigraphic methods. The focus lies on imaging of cardiac innervation, plaque instability, hypoxia and angiogenesis, gene expression and stem and progenitor cell migration and proliferation.     

心血管核医学分子影像研究进展

心血管分子影像研究是一项崭新且具有巨大临床应用前景的课题,核医学影像是目前分子影像学的主流技术之一,具有无创伤性、灵敏度高、合乎生理条件、可定量等优点,代表了分子影像学发展的前沿.近年来,核医学在心血管分子影像的研究中取得了突出成绩,为心血管疾病的病理生理过程研究以及基因治疗的监测开辟了广阔的空间.     

IgG4-related cardiovascular disease. The emerging role of cardiovascular imaging

Immunoglobulin 4-related disease (IgG4-related disease) is a systemic inflammatory disease that presents with increases of serum IgG4. It may affect various systems, including the cardiovascular (CV) system. Assessment of serum IgG4 levels and involved organ biopsy are necessary for diagnosis. IgG4-related disease is characterized by fibrosclerosis, lymphocytic infiltration and presence of IgG4-positive plasma cells. The disease usually responds to treatment with corticosteroids and/or immunosuppressive medication.CV involvement may manifest as cardiac pseudotumors, inflammatory periaortitis, coronary arteritis and/or pericarditis. IgG4-related cardiovascular disorders can severely affect patient prognosis. Various imaging techniques, including echocardiography, Computed Tomography (CT), 18FDG-PET, Cardiovascular Magnetic Resonance (CMR) and cardiac catheterisation, have been successfully used for early disease detection and follow-up.Echocardiography and vascular ultrasound are the most commonly used non-invasive, non-radiating imaging techniques for the evaluation of IgG4-related CV disease. Periaortitis/periarteritis can be also assessed by CT, showing a soft tissue thickening around arteries. Coronary artery aneurysms can be easily diagnosed by coronary CT. In case of active periarterial or coronary artery inflammation, 18FDG-PET will show FDG uptake at the area of the lesion.CMR, due to its capability to perform function and tissue characterisation, can offer an integrated imaging of aorta, coronary arteries and the heart, assessment of disease acuity, extent of fibrosis and guide further treatment. However, multimodality imaging may be necessary for assessment of disease activity and fibrosis extent in those cases with multifocal CV involvement.     

心血管MR成像在缺血性心脏病中的应用

缺血性心脏病（IHD）不同阶段的病理组织学改变与病人预后和生活质量密切相关。心血管MR（CMR）成像技术具有多参数、多成像序列,能对IHD进行早期诊断,评价微血管阻塞、心肌内出血、瘢痕心肌和舒张末期心室壁厚度,通过对急慢性心肌梗死进行早期诊断和远期风险评估,为病人的早期治疗及降低预后风险提供信息。就CMR在急慢性IHD心肌组织特征、风险评估和病人远期预后方面的应用予以综述。     

Appropriateness of cardiovascular computed tomography and magnetic resonance imaging in patients with conotruncal defects

BackgroundTo promote the rational use of cardiovascular imaging in patients with congenital heart disease, the American College of Cardiology developed Appropriate Use Criteria (AUC), but its clinical application and pre-release benchmarks have not been evaluated. We aimed to evaluate the appropriateness of indications for cardiovascular magnetic resonance (CMR) and cardiovascular computed tomography (CCT) in patients with conotruncal defects and to identify factors associated with maybe or rarely appropriate (M/R) indications.MethodsTwelve centers each contributed a median of 147 studies performed prior to AUC publication (01/2020) on patients with conotruncal defects. To incorporate patient characteristics and center-level effects, a hierarchical generalized linear mixed model was used.ResultsOf the 1753 studies (80% CMR, and 20% CCT), 16% were rated M/R. Center M/R ranged from 4 to 39%. Infants accounted for 8.4% of studies. In multivariable analyses, patient- and study-level factors associated with M/R rating included: age <1 year (OR 1.90 [1.15–3.13]), truncus arteriosus (vs. tetralogy of Fallot, OR 2.55 [1.5–4.35]), and CCT (vs. CMR, OR 2.67 [1.87–3.83]). None of the provider- or center-level factors reached statistical significance in the multivariable model.ConclusionsMost CMRs and CCTs ordered for the follow-up care of patients with conotruncal defects were rated appropriate. However, there was significant center-level variation in appropriateness ratings. Younger age, CCT, and truncus arteriosus were independently associated with higher odds of M/R rating. These findings could inform future quality improvement initiatives and further exploration of factors resulting in center-level variation.     

新型冠状病毒肺炎心血管并发症的影像学研究进展

新型冠状病毒肺炎（COVID-19）可累及心血管系统引起心肌炎或其他心血管并发症,导致病人死亡率显著增加。超声心动图、心脏MR（CMR）、CT等多种无创性影像技术在COVID-19心血管并发症的诊断、治疗指导和预后评估中发挥了重要作用,特别是CMR不仅能评估心脏形态、结构方面的变化,还能判断COVID-19病人的心肌组织学异常,为预后提供新的影像学指标。就COVID-19心血管并发症的影像学研究进展予以综述。     

Role of cardiac magnetic resonance imaging in the diagnosis and management of COVID-19 related myocarditis: Clinical and imaging considerations

There is a growing evidence of cardiovascular complications in coronavirus disease 2019 (COVID-19) patients. As evidence accumulated of COVID-19 mediated inflammatory effects on the myocardium, substantial attention has been directed towards cardiovascular imaging modalities that facilitate this diagnosis. Cardiac magnetic resonance imaging (CMRI) is the gold standard for the detection of structural and functional myocardial alterations and its role in identifying patients with COVID-19 mediated cardiac injury is growing. Despite its utility in the diagnosis of myocardial injury in this population, CMRI’s impact on patient management is still evolving. This review provides a framework for the use of CMRI in diagnosis and management of COVID-19 patients from the perspective of a cardiologist. We review the role of CMRI in the management of both the acutely and remotely COVID-19 infected patient. We discuss patient selection for this imaging modality; T1, T2, and late gadolinium enhancement imaging techniques; and previously described CMRI findings in other cardiomyopathies with potential implications in COVID-19 recovered patients.     

Highly accelerated cardiovascular MR imaging using many channel technology: concepts and clinical applications

Cardiovascular magnetic resonance imaging (CVMRI) is of proven clinical value in the non-invasive imaging of cardiovascular diseases. CVMRI requires rapid image acquisition, but acquisition speed is fundamentally limited in conventional MRI. Parallel imaging provides a means for increasing acquisition speed and efficiency. However, signal-to-noise (SNR) limitations and the limited number of receiver channels available on most MR systems have in the past imposed practical constraints, which dictated the use of moderate accelerations in CVMRI. High levels of acceleration, which were unattainable previously, have become possible with many-receiver MR systems and many-element, cardiac-optimized RF-coil arrays. The resulting imaging speed improvements can be exploited in a number of ways, ranging from enhancement of spatial and temporal resolution to efficient whole heart coverage to streamlining of CVMRI work flow. In this review, examples of these strategies are provided, following an outline of the fundamentals of the highly accelerated imaging approaches employed in CVMRI. Topics discussed include basic principles of parallel imaging; key requirements for MR systems and RF-coil design; practical considerations of SNR management, supported by multi-dimensional accelerations, 3D noise averaging and high field imaging; highly accelerated clinical state-of-the art cardiovascular imaging applications spanning the range from SNR-rich to SNR-limited; and current trends and future directions.     

轻链型心脏淀粉样变影像研究进展

心脏淀粉样变指淀粉样物质沉积于心脏组织,轻链型心脏淀粉样变是最常见且预后最差的类型。因各种心脏淀粉样变的治疗手段不一致,早期、准确诊断心脏淀粉样变在临床中尤为关键。近年来,多种影像检查手段已应用于轻链型心脏淀粉样变的诊断。综述心脏MRI、超声及核素显像等技术在轻链型心脏淀粉样变中的研究进展。     

Left ventricular thrombus formation after acute myocardial infarction as assessed by cardiovascular magnetic resonance imaging

Introduction

Left ventricular (LV) thrombus formation is a feared complication of myocardial infarction (MI). We assessed the prevalence of LV thrombus in ST-segment elevated MI patients treated with percutaneous coronary intervention (PCI) and compared the diagnostic accuracy of transthoracic echocardiography (TTE) to cardiovascular magnetic resonance imaging (CMR). Also, we evaluated the course of LV thrombi in the modern era of primary PCI.

Methods

200 patients with primary PCI underwent TTE and CMR, at baseline and at 4 months follow-up. Studies were analyzed by two blinded examiners. Patients were seen at 1, 4, 12, and 24 months for assessment of clinical status and adverse events.

Results

On CMR at baseline, a thrombus was found in 17 of 194 (8.8%) patients. LV thrombus resolution occurred in 15 patients. Two patients had persistence of LV thrombus on follow-up CMR. On CMR at four months, a thrombus was found in an additional 12 patients. In multivariate analysis, thrombus formation on baseline CMR was independently associated with, baseline infarct size (g) (B = 0.02, SE = 0.02, p < 0.001). Routine TTE had a sensitivity of 21–24% and a specificity of 95–98% compared to CMR for the detection of LV thrombi. Intra- and interobserver variation for detection of LV thrombus were lower for CMR (κ = 0.91 and κ = 0.96) compared to TTE (κ = 0.74 and κ = 0.53).

Conclusion

LV thrombus still occurs in a substantial amount of patients after PCI-treated MI, especially in larger infarct sizes. Routine TTE had a low sensitivity for the detection of LV thrombi and the interobserver variation of TTE was large.     

神经母细胞瘤的影像学诊断

神经母细胞瘤是儿童颅外最常见的实体瘤,占儿童肿瘤的10%。其预后与肿瘤的分级密切相关。影像学的诊断能为临床的治疗和随访提供有价值的信息。核医学显像主要展示肿瘤及其转移灶的功能状况,而X线计算机体层摄影术和磁共振成像在结构方面能提供更详细和确切的资料。每一种方法都有独到之处,起互补作用。     

MR-based full-body preventative cardiovascular and tumor imaging: technique and preliminary experience

Recent improvements in hardware and software, lack of side effects, as well as diagnostic accuracy make magnetic resonance imaging a natural candidate for preventative imaging. Thus, the purpose of the study was to evaluate the feasibility of a comprehensive 60-min MR-based screening examination in healthy volunteers and a limited number of patients with known target disease. In ten healthy volunteers (7 men, 3 women; mean age, 32.4 years) and five patients (4 men, 1 woman; mean age, 56.2 years) with proven target disease we evaluated the performance of a comprehensive MR screening strategy by combining well-established organ-based MR examination components encompassing the brain, the arterial system, the heart, the lungs, and the colon. All ten volunteers and five patients tolerated the comprehensive MR examination well. The mean in-room time was 63 min. In one volunteer, insufficient colonic cleansing on the part of the volunteer diminished the diagnostic reliability of MR colonography. All remaining components of the comprehensive MR examination were considered diagnostic in all volunteers and patients. In the five patients, the examination revealed the known pathologies [aneurysm of the anterior communicating artery (n=1), renal artery stenosis (n=1), myocardial infarct (n=1), and colonic polyp (n=2)]. The outlined MR screening strategy encompassing the brain, the arterial system, the heart, the lung, and the colon is feasible. Further studies have to show that MR-based screening programs are cost-effective in terms of the life-years saved.     

The ACR imaging network: A retrospective on 5 years of conducting multicenter trials in radiology and plans for the future

The ACR Imaging Network (ACRIN) provides a complete infrastructure to conduct multicenter clinical trials of medical imaging technologies as they relate to cancer. During its first 5 years of National Cancer Institute funding, ACRIN initiated work on 18 trials, a number of which are closed, in analysis, with results approaching publication. During its next funding cycle, ACRIN intends to pursue a more strategic approach to its selection of trials, focusing on key clinical questions in which imaging can improve the care of cancer patients. ACRIN represents a critical resource for the specialty in which all interested parties can participate. The results of ACRIN trials will improve the appropriateness of the use of imaging and benefit both those with cancer and those who are concerned that they might have the disease.     

《心血管成像电离辐射优化使用安全性和效能的 最佳实践专家共识》解读

目前心血管成像技术在临床应用越来越多,随之而来的电离辐射损伤成为备受关注的重要问题,优化辐射剂量是大势所趋。2018年美国心脏病学会等多家学会联合推出了《心血管成像电离辐射优化使用的安全性和效能的最佳实践专家共识》,汇集并解释了当前与使用电离辐射有关的心血管成像知识,提出了安全性和有效性的最佳实践指南。     

Radionuclide angiography and magnetic resonance imaging: complementary non-invasive methods in the diagnosis of constrictive pericarditis

Constrictive pericarditis presents with a suggestive clinical picture, and its diagnosis is based on a haemodynamic pattern revealing impaired ventricular filling. In this study of 15 patients with pure isolated constrictive pericarditis, we attempted to evaluate the diagnostic value of two non-invasive methods not usually employed in this indication: radionuclide angiography (RNA) and magnetic resonance imaging (MRI). Whilst RNA permits analysis of the functional pattern of the global and segmental left ventricular filling impairment, MRI allows measurement of the thickness of the pericardium. RNA revealed increased early diastolic filling as evidenced by a shorter one-third filling time (TFl/3;P<0.0001 with respect to a normal population), a higher peak filling rate (PFR;P<0.01) and its early occurrence (P<0.001), increased one-third and mid diastolic filling fractions (P<0.01), and the ratio of the PFR over the peak ejection rate (P<0.01). During late diastole, the atrial filling fraction decreased (NS). The patients with constrictive pericarditis also showed a decrease in the physiological filling asynchrony, as assessed by segmental evaluations. Seven patients underwent MRI. The pericardium was thickened in all the patients, varying from 6 to 14 mm (normal: 2.5±0.7 mm), without any systolo-diastolic variation. Pericardial thickening appeared as a dark low-intensity signal band, demonstrating the fibrocalcific nature of the pericardial contents. Sagittal and coronal cross-sections were particularly well-suited to show the non-uniformity of the pericardial thickening. These results indicate that RNA and MRI are complementary non-invasive methods, and can provide the functional and anatomical information required for the diagnosis of constrictive pericarditis.     

Confident non-invasive diagnosis of pseudolesions of the liver using diffusion-weighted imaging at 3T MRI

Purpose

Pseudolesions of the liver including focal steatosis or non-steatosis and THID (transient hepatic intensity differences) are often challenging, especially when imaging patients with underlying malignant disease. We evaluated the efficacy of diffusion-weighted imaging (DWI) in the diagnostic work-up of pseudolesions.

Materials and methods

Forty-eight patients with pseudolesions of the liver were consecutively examined and the images were retrospectively analyzed. MRI was performed on a clinical 3 T scanner using T1-GRE in-phase and opposed phase images, T2-TSE-FS, diffusion-weighted sequences (b-value 50, 300, 600), ADC mapping, and dynamic post-contrast T1-VIBE-FS sequences (32 patients received Gd-EB-DTPA and 16 patients received gadolinium chelates). All images were analyzed by two experienced radiologists in consensus. As a standard of reference, we used the T1-w GRE, in-phase and out of phase, and the contrast enhanced series, as well as long-term follow-up.

Results

In the 48 patients, a total of 116 liver lesions were found. Of these, 40 were benign and eleven were malignant focal lesions. Benign lesions included one FNH, 26 simple cysts, and twelve hemangiomas. In addition, 65 pseudolesions (20 focal steatosis, 13 focal non-steatosis, and 32 THIDs) were found. All pseudolesions could be identified either on the T1-GRE in-phase and opposed phase images or on the contrast-enhanced series, or on both. However, none of them were visible on the diffusion-weighted images.

Conclusion

Pseudolesions are invisible on DWI (negative predictive value = 1); therefore, DWI can be used as an additional sequence to significantly increase diagnostic confidence in the differentiation between pseudolesions and other focal liver lesions.     

碰撞癌的临床影像学表现及病理分析

目的:探讨碰撞癌的临床影像学表现、发病机制与病理特点。方法:回顾性分析20例碰撞癌的临床影像学资料并结合文献复习,总结其患病率、发病年龄、性别比、好发部位、临床影像学表现、治疗手段、病理特点。结果:碰撞癌罕见,好发年龄大于58岁,男性发病多见,好发部位为食管-贲门,食管-胃底等。临床表现无特殊,术前影像学检查多不能明确诊断,术后病理诊断是唯一的确诊方法。治疗以手术为主,辅以化疗或放疗。病理特点为同一宿主同一部位或器官2个不同类型肿瘤的结合,瘤组织间没有移行和混合,有各自的转移途径,碰撞癌以鳞癌和腺癌的碰撞为主。结论:碰撞癌是一种罕见的恶性肿瘤结合,临床特点有待进一步总结,影像学综合诊断有助于提高其确诊率。     

肺动脉栓塞的影像学诊断

肺动脉栓塞的发病率较高,容易漏诊及误诊,故死亡率高,迅速准确的诊断是治疗成功及取得良好预后的关键。X线胸片是必要的筛选检查手段;超声心动图检查有助于排除心脏疾患;核素肺显像是传统的常规检查,诊断准确性很高;螺旋CT及MRI检查不但具有一定的确诊价值,而且是良好的指导治疗和评价疗效的手段。但是,当非侵入性检查不能确诊时,应该进行肺血管造影。