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冠心病是我国第一位致死性疾病,其发病率呈逐年上升趋势,目前,心血管病死占城乡居民总病死原因的首位,心血管病的疾病负担日渐加重,已成为重大的公共卫生问题[1]。冠状动脉CT成像(coronary computed tomography angiography,CCTA)以其检查的无创性、较高的准确率和快捷性等优点而成为检测冠状动脉狭窄的重要手段[2-3],但伴随而来的较高的辐射剂量问题也引起了人们的关注。传统的多排螺旋CCTA对人体的电离辐射较高,且由于时间分辨率所限,CCTA易受心率和呼吸运动的影响产生伪影[4],进而会降低诊断冠心病的准确率。第3代双源CT可使患者在自然呼吸并且无心率干预下完成高质量扫描,并且有效辐射剂量极低。本研究应用第3代双源CT Turbo Flash模式进行冠状动脉成像,并与传统冠状动脉造影(coronary angiography,CAG)进行比较,评价该方法诊断冠状动脉狭窄的准确性、图像质量及有效辐射剂量。
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所有患者均顺利完成CCTA和CAG检查,无任何严重不良反应。
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由表 1可见,1003例患者所有可诊断血管节段:右冠状动脉图像质量为1分的节段占右冠状动脉节段的99.20% (3968/4000) (图 1)、2分的节段占0.55% (22/4000)、3分的节段占0.25% (10/4000)、不可诊断的血管节段为0;左冠状动脉主干及前降支图像质量为1分的节段占左冠状动脉节段的99.78% (5612/5624)、2分的节段占0.16% (9/5624)、3分的节段占0.05% (3/5624)、不可诊断的血管节段为0;回旋支图像质量为1分的节段占回旋支节段的98.73% (4152/4205)、2分的节段占1.02% (43/4205)、3分的节段占0.17% (7/4205)、不可诊断的血管节段为3段,中间支图像均显示良好。1003例患者中17例患者由于心率变异性较大,导致血管有运动伪影,但结果基本可供诊断,由此可知,影响图像质量的因素主要是心率变异性。
节段号 评分/分 合计 1 2 3 4 右冠状动脉 1 992 7 4 0 1003 2 987 10 6 0 1003 3 997 5 0 0 1002 4 992 0 0 0 992 左冠状动脉主干 5 1003 0 0 0 1003 6 1000 2 1 0 1003 7 995 6 2 0 1003 左冠状动脉前降支 8 1002 1 0 0 1003 9 979 0 0 0 979 10 633 0 0 0 633 左冠状动脉回旋支 11 990 11 1 0 1002 12 799 28 5 3 835 13 997 4 1 0 1002 14 391 0 0 0 391 15 975 0 0 0 975 16 531 0 0 0 531 17 415 0 0 0 415 18 20 0 0 0 20 注:表中,CCTA:冠状动脉CT成像。 表 1 1003例疑诊为冠心病患者CCTA冠状动脉图像质量评分表
Table 1. CCTA coronary image quality score scale for 1003 suspected patients with coronary heart disease
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70例行CAG检查的患者共显示出冠状动脉节段1014段,典型病例的CAG图像见图 2。基于节段水平分析,CCTA检查显示冠状动脉狭窄病变301段;CAG显示冠状动脉狭窄病变298段。基于节段分析、基于血管分析和基于患者分析,CCTA诊断冠状动脉狭窄的灵敏度、特异度、阳性预测值和阴性预测值的结果见表 2。CCTA与CAG在显示冠状动脉狭窄分级一致性检验上Kappa值为0.932,对Kappa值进行U检验,差异有统计学意义(U=2.4,P=0.008),这说明CCTA与CAG在显示冠状动脉狭窄分级上高度一致(图 3)。
图 2 疑似冠心病患者的曲面重组图像与心电门控图像
Figure 2. Curved planar reformation images and electrocardiogramgating images of patients with suspected coronary heart disease
图 3 冠状动脉狭窄患者的CCTA图像与CAG图像对比及心电门控图像
Figure 3. CCTA images and CAG images of patients with coronary artery stenosis were compared and the electrocardiogram-gating images were obtained
分析部位 结果 统计分析(%) 真阳性 假阳性 真阴性 假阴性 灵敏度 特异度 阳性预测值 阴性预测值 基于节段分析(n=1014) 289 12 706 9 97 98.3 96 98.7 基于血管分析(n=210) 159 7 40 4 97.5 85.1 95.8 90.9 基于患者分析(n=70) 70 0 0 0 100 100 100 100 表 2 第3代双源CT诊断冠状动脉狭窄准确性的结果
Table 2. Accuracy of Force CT in the diagnosis of coronary artery stenosis
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1003例患者CCTA的DLP为16.5~78.7 mGy×cm[ (45.0±11.5)mGy×cm],ED为0.43×2.04 mSv[ (1.17±0.29)mSv]。
第3代双源CT低剂量Turbo Flash成像图像质量与诊断效能的临床研究
Study of image quality and diagnostic accuracy of low-dose coronary angiography using third-generation dual-source CT with free breathing and heart rate
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摘要:
目的探讨第3代双源CT大螺距前瞻性心电门控扫描模式(Turbo Flash)冠状动脉CT成像(CCTA)评价冠状动脉狭窄的准确性、图像质量及有效辐射剂量。 方法前瞻性收集2016年4月至2017年4月接受第3代双源CCTA检查的患者1003例,其中有70例患者在CCTA检查后30 d内行冠状动脉造影(CAG)。对冠状动脉各节段图像质量进行评分,计算有效辐射剂量。以CAG结果为“金标准”,计算CCTA显示冠状动脉病变的灵敏度、特异度、阳性预测值和阴性预测值;CCTA与CAG评价冠状动脉狭窄分级的一致性采用Kappa值并进行U检验。 结果(1) 图像质量:右冠状动脉不可诊断血管节段为0,左冠状动脉主干及前降支不可诊断血管节段为0,左冠状动脉回旋支不可诊断血管节段为0.04% (3/835)。(2)准确性评价:基于节段水平分析,Force CT诊断冠状动脉狭窄的灵敏度为97.0% (289/298)、特异度为98.3% (706/718)、阳性预测值为96.0% (289/301)、阴性预测值为98.7% (706/715);基于血管分析,灵敏度为97.5% (159/163)、特异度为85.1% (40/47)、阳性预测值为95.8% (159/166)、阴性预测值为90.9% (40/44);基于患者分析,灵敏度、特异度、阳性预测值、阴性预测值均为100%。CCTA与CAG显示的冠状动脉狭窄部位高度一致(U=2.4,P=0.008)。(3)辐射剂量:有效辐射剂量为(1.17±0.29)mSv。 结论第3代双源CT Turbo Flash模式可以在自然呼吸、无心率干预下进行冠状动脉成像,扫描成功率高,图像质量佳,评价冠状动脉狭窄的准确性高,有效辐射剂量低。 -
关键词:
- 体层摄影术, X线计算机 /
- 冠状动脉疾病 /
- 辐射剂量 /
- 第3代双源CT
Abstract:ObjectiveTo prospectively investigate the diagnostic accuracy, image quality, and radiation doses of electrocardiogram (ECG)-triggered high-pitch acquisition (turbo flash) coronary computed tomography(CT) angiography(CCTA) using third-generation dual-source CT compared with coronary angiography(CAG) for the diagnosis of significant coronary stenoses. MethodsProspectively collected 1003 patients who received the third-generation dual-source CCTA examination from April 2016 to April 2017. Among them, 70 patients underwent coronary angiography(CAG) 30 days after CCTA examination to score the image quality of each segment of coronary artery and calculate the effective radiation dose. The sensitivity, specificity, positive predictive value and negative predictive value of CCTA for coronary artery lesions were calculated using CAG results as the gold standard. The consistency of CCTA and CAG in grading coronary artery stenosis was evaluated by Kappa value and U test. Results(1) Image quality:no non-diagnostic image quality was observed in the right coronary artery nor left anterior descending artery. The rate of coronary segments with non-diagnostic image quality reached 0.04% in the left circumflex artery. (2) Diagnostic accuracy:the sensitivity, specificity, and positive and negative predictive values totaled 97.0%(289/298), 98.3%(706/718), 96.0%(289/301), 98.7%(706/715) for segment assessment and 97.5%(159/163), 85.1% (40/47), 95.8%(159/166), 90.9%(40/44) for vessel assessment, and all the values are 100% for patients assessment. CCTA was highly consistent with the site of coronary artery stenosis shown by CAG(U=2.4, P < 0.05). ⑶ Radiation doses:the effective radiation dose was(1.17±0.29) mSv on average. ConclusionsCCTA using the prospectively ECG-triggered high-pitch mode (turbo flash) of the third-generation dual-source CT system is associated with high diagnostic accuracy for the assessment of coronary artery stenoses at low doses. -
表 1 1003例疑诊为冠心病患者CCTA冠状动脉图像质量评分表
Table 1. CCTA coronary image quality score scale for 1003 suspected patients with coronary heart disease
节段号 评分/分 合计 1 2 3 4 右冠状动脉 1 992 7 4 0 1003 2 987 10 6 0 1003 3 997 5 0 0 1002 4 992 0 0 0 992 左冠状动脉主干 5 1003 0 0 0 1003 6 1000 2 1 0 1003 7 995 6 2 0 1003 左冠状动脉前降支 8 1002 1 0 0 1003 9 979 0 0 0 979 10 633 0 0 0 633 左冠状动脉回旋支 11 990 11 1 0 1002 12 799 28 5 3 835 13 997 4 1 0 1002 14 391 0 0 0 391 15 975 0 0 0 975 16 531 0 0 0 531 17 415 0 0 0 415 18 20 0 0 0 20 注:表中,CCTA:冠状动脉CT成像。 表 2 第3代双源CT诊断冠状动脉狭窄准确性的结果
Table 2. Accuracy of Force CT in the diagnosis of coronary artery stenosis
分析部位 结果 统计分析(%) 真阳性 假阳性 真阴性 假阴性 灵敏度 特异度 阳性预测值 阴性预测值 基于节段分析(n=1014) 289 12 706 9 97 98.3 96 98.7 基于血管分析(n=210) 159 7 40 4 97.5 85.1 95.8 90.9 基于患者分析(n=70) 70 0 0 0 100 100 100 100 -
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