心肌声学造影对冠脉狭窄临界病变的功能性诊断价值

目的 探讨心肌声学造影对冠脉狭窄临界病变功能性评价的有效性及可靠性.方法 前瞻性纳入2017年6-10月本院心内科经冠状动脉造影证实冠脉狭窄介于50％～70％的患者70例,行心肌声学造影(myocardial contrast echocardiography,MCE)检查并以金标准血流储备分数(fractional flow reserve,FFR)为自身对照,结合其心脏结构、血脂、肾功、糖化血红蛋等生化指标进行对比分析.结果 ①70例患者中共78支血管为临界病变,其中左前降支(the left anterior descending,LAD)病变53处(67.9％),左回旋支(the left circumflex coronary artery,LCX)病变13处(16.7％),右冠状动脉(right coronary artery,RCA)病变12处(15.4％),其中FFR阴性(FFR值＞0.8)的53处(67.9％);FFR阳性(FFR值≤0.8)的25处(32.1％).②MCE检出49例患者存在节段性室壁运动异常,其中19例同时提示心肌灌注异常.MCE结果提示LAD病变56处,LCX病变12处,RCA病变18处.③FFR阳性的25处病变MCE全部为阳性,MCE阴性的29处病变FFR全部为阴性.FFR阴性的53处病变中,MCE阳性24处,MCE阴性29处.与金标准FFR相比,MCE诊断冠脉临界病变功能性狭窄的敏感性为100％,特异性为55％,阳性似然比为2.2,阴性似然比为0.④FFR阴性的病变中,MCE阳性组的静息FFR值(0.94 ±0.02)vs(0.96 ±0.02),P＜0.05]和负荷FFR值(0.84 ±0.04)vs(0.88 ±0.04),P＜0.05]均明显低于MCE阴性组.两组间年龄、左室舒张末期内径、室间隔厚度、左室射血分数、总胆固醇、甘油三酯、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇、糖化血红蛋白、肌酐、估算肾小球滤过率差异均无统计学意义(P＞0.05).结论 MCE评价冠脉狭窄临界病变具有极高的敏感性和阴性预测价值,但特异性偏低,是否存在冠脉微血管病变或是其主要影响因素.

Clinical value of myocardial contrast echocardiography for functional diagnosis in patients with intermediate lesions of coronary stenosis

Objective To explore the effectiveness and reliability of myocardial contrast echocardiography (MCE) in the functional evaluation of the patients with intermediate coronary lesions.Methods A total of 70 patients with 50％ to 70％ stenosis in the coronary artery who admitted in our cardiological department from June to October in 2017 were prospectively recruited in this study.MCE was performed,and the results were analyzed with the gold standard,blood fractional flow reserve (FFR) as selfcontrol.Cardiac structure indicators,blood lipid,renal function,glycosylated hemoglobin and other biochemical indicators were compared and analyzed at the same time.Results ①Among the 70 patients,78 vessels were identified with intermediate lesions,including 53 lesions (67.9％) in the left anterior descending coronary artery (LAD),13 lesions (16.7％) in the left circumflex coronary artery (LCX),and 12 lesions (15.4％) in the right coronary artery (RCA).There were 53 lesions (67.9％) of FFR negative (FFR value ＞0.8) and 25 lesions (32.1％) positive (FFR value ≤0.8).②MCE results showed that 45 patients had ventricular wall motion abnormalities (including 19 patients having abnormal myocardial perfusion at the same time).The results showed there were 56 lesions in LAD,12 lesions in LCX and 18 lesions in RCA.③ The 25 FFR-positive lesions were all positive to MCE,and 29 MCE-negative lesions were all negative to FFR.For the other 53 FFR-negative lesions,24 were positive to MCE and 29 were negative.Compared with FFR,MCE showed a sensibility of 100％ and a specificity of 55％ for diagnosis of intermediate lesions of coronary stenosis,with a positive likelihood ratio of 2.2 and a negative likelihood ratio of 0.④ For the FFR negative lesions,the resting FFR value (0.94 ± 0.02 vs 0.96 ± 0.02,P ＜ 0.05) and loaded FFR value (0.84 ± 0.04vs 0.88 ± 0.04,P ＜ 0.05) were significantly lower in the lesions of positive MCE than those of negative MCE.But,there was no significantly statistical differences in the age,left ventricular end diastolic diameter (LVD),interventricular septal thickness (IVS),left ventricular ejection fraction (LVEF),total cholesterol (TC),triglyceride (TG),high density lipoprotein cholesterol (lDL-C),low density lipoprotein cholesterol (LDL-C),glycosylated hemoglobin (HBA1C％),creatinine (Cr) and estimated glomerular filtration rate (eGFR) between the 2 groups (P ＞ 0.05).Conclusion MCE has very high sensitivity and negative predictive value for intermediate lesion of coronary stenosis,but the specificity is quite low.The main influencing factor might be the presence of coronary microvascular lesions.