动态CT心肌灌注对支架置入术后心肌缺血的诊断价值  

Diagnostic value of dynamic CT myocardial perfusion in myocardial ischemia after stenting

作　　者：赵润涛 纪欣强 刘子暖 单冬凯[3] 沈建 于建辉[2] 杨俊杰[3] 王凡[2] ZHAO Runtao;JI Xinqiang;LIU Zinuan;SHAN Dongkai;SHEN Jian;YU Jianhui;YANG Junjie;WANG fan(Chinese PLA Medical School,Beijing 100853,China;Department of Cardiology,the Second Medical Center&National Clinical Research Center for Geriatric Diseases,Chinese PLA General Hospital,Beijing 100853,China;Senior Department of Cardiology,the Sixth Medical Center,Chinese PLA General Hospital,Beijing 100048,China)

机构地区：[1]解放军医学院,北京100853 [2]解放军总医院第二医学中心心血管内科,国家老年疾病临床研究中心,北京100853 [3]解放军总医院第六医学中心心血管病医学部,北京100048

出　　处：《解放军医学院学报》2022年第11期1138-1145,共8页Academic Journal of Chinese PLA Medical School

基　　金：解放军总医院医疗大数据与人工智能研发项目(2019MBD-035)。

摘　　要：背景冠状动脉支架置入术是治疗急性心肌梗死的重要手段,然而支架置入术后患者可能出现支架内再狭窄(in-stent restenosis,ISR)及非靶病变进展(nontarget lesions,NTLs),并引起心肌缺血。目前常用的无创检测ISR的技术手段主要为冠状动脉CT血管造影(computed tomographic angiography,CCTA),然而该技术容易受到金属伪影影响。动态CT心肌灌注(computed tomographic myocardial perfusion imaging,CTP)技术能无创诊断心肌缺血且不受金属伪影影响,对ISR及NTLs的临床诊疗具有重要指导意义。目的以有创冠状动脉造影(invasive coronary angiography,ICA)联合有创血流储备分数(fractional flow reserve,FFR)为标准,评价动态CTP技术对冠状动脉支架置入术后患者发生ISR或NTLs的诊断价值。方法前瞻性纳入在2019年10月-2021年12月于解放军总医院就诊,在冠状动脉支架置入术后出现可疑心绞痛的患者113例,其中男性93例(82.3%),女性20例(17.7%),平均年龄(64.56±8.46)岁。所有患者均接受动态负荷动态CTP联合CCTA检查,并在1周内接受ICA检查并测量FFR。由两名医师独立采用CTP和CCTA工作站分析数据,计算心肌血流量(myocardial blood flow,MBF)和CCTA直径狭窄率(diameter stenosis,DS)。以ICA狭窄≥90%或FFR≤0.80作为心肌缺血的诊断标准,比较缺血心肌和非缺血心肌MBF差异,绘制受试者操作特征曲线并计算曲线下面积(area under the curve,AUC)。采用最大约登指数计算MBF判断心肌缺血的最佳临界值,分别在患者水平和血管水平上计算DS≥50%、MBF以及两者联合诊断心肌缺血的诊断效能。结果经ICA或FFR检查发现其中62例(54.9%)共96支冠状动脉(30.4%)发生ISR或NTLs。不论在患者水平或是血管水平,DS≥50%联合MBF诊断心肌缺血的诊断效能均显著优于单纯采用DS≥50%(AUC:0.80 vs 0.60,P<0.001;0.85 vs 0.68,P<0.001)。在无支架置入的血管中(n=145),DS≥50%联合MBF较DS≥50%以及MBF诊断效能进一步提�Background Coronary stent implantation is an important method for the treatment of acute myocardial infarction.However,in-stent restenosis(ISR)and nontarget lesions(NTLs)may occur in patients after stent implantation,then causing myocardial ischemia.At present,the commonly used noninvasive technique for detecting ISR is computed tomography angiography(CCTA).However,this technique is susceptible to metal artifacts.Computed tomographic myocardial perfusion imaging(CTP)technique can non-invasively diagnose myocardial ischemia and is not affected by metal artifacts,which has important guiding significance for the clinical diagnosis and treatment of ISR and NTLs.Objective To evaluate the diagnostic value of dynamic CTP technique in patients with ISR or NTLs after coronary stent implantation,with invasive coronary angiography(ICA)combined with fractional flow reserve(FFR)using as the criteria.Methods A total of 113 patients(mean age of 64.56±8.46 years)with angina pectoris after coronary stent implantation in Chinese PLA General Hospital from October 2019 to December 2021 wereprospectively included,including 93 males(82.3%)and 20 females(17.7%).All patients were examined by dynamic load dynamic CTP combined with CCTA,and ICA and FFR were measured within one week.CTP and CCTA data were independently analyzed by two physicians,and myocardial blood flow(MBF)and CCTA diameter stenosis rate(DS)were calculated.ICA stenosis≥90%or FFR≤0.80 were considered functionally significant.The differences of MBF between ischemic and non-ischemic myocardium were compared,the subject operating characteristic curve was drawn and the area under the curve(AUC)was calculated.The cut-off value of MBF was calculated by the most approximate index,and the diagnostic efficacy of DS≥50%,MBF and the combination of DS and MBF were calculated at patient level and vascular level,respectively.Results A total of 62 patients(54.9%)with 96 coronary arteries(30.4%)were found to have ISR or NTLs by ICA or FFR examination.No matter at patient level or

关 键 词：计算机体层摄影术 动态CT心肌灌注成像 冠状动脉疾病 心肌缺血 支架内再狭窄 

分 类 号：R541.4[医药卫生—心血管疾病]