不同心肌显像测定左心室功能参数对左心室室壁瘤患者临床诊疗决策及预后评估的价值  

Left ventricular function parameters determined by different myocardial imaging for treatment decision and estimation of prognosis in patients with left ventricular aneurysm

作　　者：王伟学 张晓丽[2,3] WANG Wei-xue;ZHANG Xiao-li(Department of Traditional Chinese Medicine,the Affiliated Hospital of Guilin Medical College,Guilin 541001,Guangxi,China;Department of Nuclear Medicine,State Key Laboratoryof Cardiovascular Disease,Fu Wai Hospital,National Center for Cardiovascular Diseases,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100037,China;Department of Nuclear Medicine,Beijing Anzhen Hospital,Capital Medical University,Beijing 100029,China)

机构地区：[1]桂林医学院附属医院中医科,桂林541001 [2]北京协和医学院中国医学科学院国家心血管病中心,阜外医院核医学科,北京100037 [3]首都医科大学附属北京安贞医院核医学科,北京100029

出　　处：《中国临床医学》2019年第4期518-523,共6页Chinese Journal of Clinical Medicine

基　　金：国家自然科学基金(81571717);北京市科技计划首都临床特色应用研究(Z131107002213181)~~

摘　　要：目的:探讨门控SPECT心肌灌注显像、门控PET心肌代谢显像和心脏磁共振显像(CMR)测定的左心室重构及心肌存活参数对左心室室壁瘤(LVA)患者临床诊疗决策及预后评估的价值。方法:连续纳入126例左心室室壁瘤患者,2周内行门控SPECT心肌灌注显像、门控PET心肌代谢显像和CMR,测定左心室重构及心肌存活参数,包括:舒张末期容积(EDV)、收缩末期容积(ESV)、左室射血分数(LVEF)、心肌灌注-代谢不匹配分(mismatch score,MMS)等,EDV、ESV经中国成人体表面积校正后获得舒张末期容积指数(EDV index,EDVI)和收缩末期容积指数(ESV index,ESVI)。根据上述方法测定的心肌存活性(MMS≥2.0,室壁瘤存活)和左心室重构(门控PET-ESVI>60 mL/m^2)情况,将患者分为3组:组1(室壁瘤存活-/左心室重构-,n=50),组2(室壁瘤存活-/左心室重构+,n=37)和组3(室壁瘤存活+/左心室重构+/-,n=39),平均随访(3.9±1.5)年,比较各组患者的预后及心源性死亡发生情况。采用单因素、多因素Cox回归分析探讨LVA患者预后相关影响因素。结果:最后共入选126例患者,包括111例男性和15例女性,平均年龄(56.9±9.6)岁。随访期间,21例(16.7%)发生心源性死亡。多变量Cox回归分析显示,门控PET-ESVI(HR 1.024,95%CI 1.011~1.037,P=0.000 4)与室壁瘤MMS(HR 1.284,95%CI 1.051~1.577,P=0.015)是预测LVA患者心源性死亡的独立危险因子(P<0.05)。与药物治疗相比,再血管化治疗可明显改善组3患者的长期生存率(P<0.01),但在组1和组2间差异无统计学意义。结论:门控PET-ESVI是预测LVA患者心源性死亡的阳性独立危险因子;室壁瘤心肌存活患者心源性死亡风险高,再血管化治疗可明显改善其长期预后;室壁瘤无心肌存活且无心室重构的LVA患者长期预后佳,与药物治疗相比,再血管化治疗并没有明显改善其长期预后。Objective:To compare the prognostic value of left ventricular(LV)remodeling parameters determined by gated single photon emission computed tomography(SPECT),gated positron emission tomography(PET)and cardiac magnetic resonance(CMR)in patients with LV aneurysm,and to evaluate the impact of myocardial viability and LV remodeling on the long-term cardiac survival in patients with LV aneurysm.Methods:One hundred and twenty-six consecutive patients underwent gated SPECT myocardial perfusion imaging,gated PET metabolic imaging,and CMR within two weeks,with a mean follow-up of(3.9±1.5)years were enrolled.Patients were divided into three groups by aneurysmal viability(MMS of aneurysm≥2.0)and LV remodeling(ESVI by gated-PET>60 mL/m 2).Group 1(viability-,LV remodeling-);Group 2(viability-,LV remodeling+)and Group 3(viability+,LV remodeling+/-).Results:ESVI by gated-PET(HR 1.024,95%CI 1.011-1.037,P=0.000 4),MMS of aneurysm(HR 1.284,95%CI 1.051-1.577,P=0.015)by interaction analysis were shown to be independent predictors for cardiac death(P<0.05).The long-term cardiac survival was significantly improved by revascularization in comparison with medical therapy in Group 3(P<0.01),but did not significantly differ between Groups 1 and2.Conclusions:ESVI by gated-PET showed a significant positive predictive value for cardiac death.Patients with viable myocardial aneurysm were most likely at increased risk for cardiac death and coronary revascularization was significantly associated with improved long-term cardiac survival.In contrast,the long-term cardiac survival of patients without LV remodeling and without aneurysmal viability was promising and,thus,could be treated by medical therapy.

关 键 词：缺血性心脏病 急性心肌梗死 正电子发射型计算机断层显像 左心室重构 室壁瘤 心肌存活 生存率 

分 类 号：R541[医药卫生—心血管疾病]