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检测存活心肌是否存在以及存活心肌的数量对于缺血性心脏病患者的临床治疗决策的制定具有重要的指导价值[1-2]。虽然多种无创性影像技术可用于评价心肌活力,但不同影像技术的原理导致了其对于心肌活力检测结果的差异[3]。其中核素心肌灌注/代谢显像(以下简称18F-FDG PET)与心脏磁共振成像(cardiac magnetic resonance,CMR)都是评价心肌活力重要的无创性影像技术。与心肌灌注显像相结合的18F-FDG PET心肌代谢显像通过对心肌葡萄糖代谢状况的检测来评价心肌活力;而CMR则利用延迟成像中钆对比剂在纤维瘢痕组织中的异常聚集,使瘢痕组织(梗死心肌)与正常心肌在T1加权像上呈现不同的信号,从而区分梗死心肌与存活心肌,2种影像技术各具优势。目前,PET/MRI已开始用于临床上对存活心肌的一体化检测,研究结果显示,18F-FDG PET与CMR相结合更有利于心肌活力的评价,可以充分发挥18F-FDG PET与CMR各自的优势[4-7]。然而,二者结合的前提是对二者差异的深入认识,以及产生差异的原因的合理解释。虽然以往已有18F-FDG PET与CMR评价心肌活力的价值的对比研究,但样本量相对较少,且对二者的差异分析仍不够全面[4]。本研究旨在进行更加深入且全面的研究,为18F-FDG PET与CMR在评价心肌活力方面更有效地结合提供依据。
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本研究共纳入285例缺血性心脏病合并心功能不全的患者,其中107例患者LVEF≤35%,178例患者LVEF>35%且<50%。209例患者病变血管数目为3支,50例患者为2支,26例患者为单支。285例缺血性心脏病合并心功能不全患者的基线资料见表1。
基本特征 数值 性别[例(%)] 男性 260(91.2) 女性 25(8.8) 年龄(岁, )$\bar x \pm s $ 57.8±10.0 BMI(kg/m2, )$\bar x \pm s $ 25.1±4.3 高血压[例(%)] 153(53.7) 高脂血症[例(%)] 217(76.1) 糖尿病[例(%)] 120(42.1) 吸烟[例(%)] 207(72.6) 脑梗死[例(%)] 43(15.1) COPD[例(%)] 8(2.8) 外周动脉粥样硬化[例(%)] 48(16.8) 既往心肌梗死[例(%)] 233(81.8) LVEF(%) 26.0±12.0 LVEDV(ml, )$\bar x \pm s $ 241.7±96.2 LVESV(ml, )$ \bar x \pm s $ 177.6±86.6 注:BMI为身体质量指数;COPD为慢性阻塞性肺疾病;LVEF为左室射血分数;LVEDV为左室舒张末期容积;LVESV为左室收缩末期容积 表 1 285例缺血性心脏病合并心功能不全患者的基线资料
Table 1. The baseline information of 285 patients with ischemic heart failure combined with cardiac dysfunction
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285例患者总共4845个心肌节段,共有3376个(69.7%,3376/4845)18F-FDG PET显示室壁运动异常的心肌节段被纳入分析。CMR显示其中1308个节段为无梗死、1371个节段为非透壁梗死、697个节段为透壁梗死。而18F-FDG PET则显示其中1263个节段灌注/代谢均正常(顿抑心肌)、606个节段为冬眠心肌、344个节段为非透壁梗死伴正常心肌、901个节段为非透壁梗死伴冬眠心肌、262个节段为透壁梗死心肌(图1、表2)。
图 1 缺血性心脏病患者的CMR与18F-FDG PET所示不同心肌活力的显像图
Figure 1. Myocardial viability on cardiac magnetic resonance (CMR) and 18F-fluorodeoxyglucose (FDG) PET in patients with ischemic heart failure
CMR 结果 18F-FDG PET 结果 合计 正常心肌 冬眠心肌 非透壁梗死伴正常心肌 非透壁梗死伴冬眠心肌 透壁梗死心肌 无梗死 879 237 46 146 0 1308 非透壁梗死 358 328 147 510 28 1371 透壁梗死 26 41 151 245 234 697 合计 1263 606 344 901 262 3376 注:FDG为氟脱氧葡萄糖;PET为正电子发射断层显像术;CMR为心脏磁共振成像 表 2 18F-FDG PET与CMR评价3376个室壁运动异常的心肌节段心肌活力的结果比较(个)
Table 2. Comparison of 18F-fluorodeoxyglucose (FDG) PET and cardiac magnetic resonance (CMR) in assessment of myocardial viability in 3376 segments with wall motion abnormality (n)
在个体水平,18F-FDG PET和CMR检测的梗死心肌总含量分别为17.6%±13.0%和19.2%±13.4%,二者之间存在显著的相关性(r=0.67,P<0.001,图2A)。Bland-Altman法分析结果显示:与CMR相比,18F-FDG PET对于梗死心肌总含量的检测存在一定程度的低估,CMR与18F-FDG PET评价梗死心肌总含量差值的95%CI为−12.7%~27.8%,平均差值为7.5%(图2B)。
图 2 285例缺血性心脏病患者CMR检测的梗死心肌总含量与18F-FDG PET检测的梗死心肌总含量的相关性(A)和一致性分析(B)
Figure 2. The correlation (A) and agreement (B) of the total content of infarcted myocardium measured through cardiac magnetic resonance (CMR) and 18F-fluorodeoxyglucose (FDG) PET in 285 patients with ischemic heart failure
在CMR显示为透壁梗死的697个运动异常节段中,18F-FDG PET显示绝大多数(90.4%,630/697)节段可见透壁或非透壁梗死,二者显示出较高的一致性。而在CMR显示为非透壁梗死的1371个运动异常节段中,却有多达686个(50.0%,686/1371)节段18F-FDG PET未显示梗死改变,其中358个节段为正常心肌,328个节段为冬眠心肌。
以CMR发现延迟强化作为评价心肌梗死(包括透壁和非透壁心肌梗死)的标准,在节段水平,18F-FDG PET检测梗死心肌的灵敏度为63.6%(1315/2068)、特异度为85.3%(1116/1308)。随着室壁运动障碍严重程度的加剧,18F-FDG PET检测梗死心肌的灵敏度逐步提高,其对室壁运动轻度减低、重度减低和无运动的心肌节段的检测灵敏度分别为46.3%(223/482)、60.7%(568/936)和80.6%(524/650),而特异度则逐步轻度降低,分别为89.8%(467/520)、84.2%(484/575)和77.5%(165/213)。
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在个体水平, CMR检测的每例患者梗死心肌总含量与18F-FDG PET检测的冬眠心肌总含量之间无显著的相关性(r=−0.09,P=0.12)。在节段水平,在CMR检测为非透壁梗死的1371个节段中,18F-FDG PET检测838个(61.1%)节段有冬眠心肌,其中328个(23.9%)节段完全为冬眠心肌,510个(37.2%)节段有部分为冬眠心肌。而在CMR检测为透壁梗死的697个节段中,18F-FDG PET检测286个(41.0%)节段有冬眠心肌,其中有41个(5.9%)节段完全为冬眠心肌,245个(35.2%)节段有部分为冬眠心肌。CMR检测为非透壁梗死的节段比透壁梗死的节段含有更多的冬眠心肌(61.1%对41.0%,χ2=66.207,P<0.001)。
而另一方面,在室壁运动异常而CMR检测为无梗死或非透壁梗死的2679个节段中,有1237个(46.2%)节段18F-FDG PET检测为灌注/代谢正常(顿抑心肌),1221个(45.6%)节段18F-FDG PET检测有冬眠心肌。
核素心肌灌注/代谢显像与心脏磁共振成像评价缺血性心脏病心肌活力的对比研究
Comparison of radionuclide myocardial perfusion/metabolic imaging with cardiac magnetic resonance for assessing myocardial viability in ischemic heart failure
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摘要:
目的 对比核素心肌灌注/代谢显像[以下简称18F-氟脱氧葡萄糖(FDG) PET]与心脏磁共振成像(CMR)在缺血性心脏病患者心肌活力评价中的价值。 方法 回顾性分析2016年3月至2019年12月于中国医学科学院阜外医院同期(一个月内)接受18F-FDG PET与CMR评价心肌活力的缺血性心脏病合并心功能不全的患者285例,其中男性260例、女性25例,年龄(57.8±10.0)岁。按照17节段法分析18F-FDG PET与CMR 2种方法鉴别各心肌节段存活心肌与梗死心肌结果的一致性和差异。采用Spearman相关系数和Kendall′s tau-b相关系数分析2种方法之间鉴别心肌活力类型的相关性。采用Bland-Altman法分析比较2种方法检测梗死心肌的一致性。 结果 285例患者总共4845个心肌节段,共有3376个(69.7%)18F-FDG PET显示室壁运动异常的心肌节段被纳入分析。18F-FDG PET与CMR检测的梗死心肌总含量分别为17.6%±13.0%和19.2%±13.4%,二者之间存在显著的相关性(r=0.67,P<0.001)。与CMR相比,18F-FDG PET对于梗死心肌总含量的检测存在一定程度的低估(梗死心肌总含量差值的95%CI为−12.7%~27.8%,平均差值为7.5%)。在CMR检测为透壁梗死的697个运动异常节段中,18F-FDG PET检测绝大多数(90.4%,630/697)节段可见透壁或非透壁梗死,二者显示出较高的一致性。而在CMR检测为非透壁梗死的1371个节段中,却有多达686个(50.0%)节段18F-FDG PET未检测到梗死改变。在个体水平,CMR检测的每例患者的梗死心肌总含量与18F-FDG PET检测的冬眠心肌总含量之间无显著的相关性(r=−0.09,P=0.12)。在节段水平,在CMR检测为非透壁梗死的1371个节段中,18F-FDG PET检测838个(61.1%)节段有冬眠心肌;而在CMR检测为透壁梗死的697个节段中,18F-FDG PET检测286个(41.0%)节段有冬眠心肌。CMR检测为非透壁梗死的节段比透壁梗死的节段含有更多的冬眠心肌(61.1% 对41.0%, χ2=66.207,P<0.001)。 结论 18F-FDG PET与CMR在评价缺血性心脏病患者心肌活力中各具优势。CMR在检测心肌梗死方面具有更高的检出率,而18F-FDG PET能够检出更多的存活心肌并鉴别冬眠心肌,18F-FDG PET与CMR 二者相结合可以提供更全面的心肌活力信息。 Abstract:Objective To compare the capability of radionuclide myocardial perfusion/metabolic imaging (hereinafter referred to as 18F-FDG PET) and cardiac magnetic resonance (CMR) in the assessment of myocardial viability among patients with ischemic heart failure. Methods A total of 285 consecutive patients with ischemic heart failure combined with cardiac dysfunction who underwent 18F-FDG PET and CMR imaging simultaneously (within a month) at Fuwai Hospital, Chinese Academy of Medical Sciences from March 2016 to December 2019 were included in the retrospective analysis. The patients comprised 260 males and 25 females, aged (57.8±10.0) years. The 17-segment method was used to compare the agreement and differences of 18F-FDG PET and CMR in the identification of viable myocardium and infarcted myocardium in each myocardial segment. Spearman correlation coefficient and Kendall′s tau-b correlation coefficient were used to analyze the correlation between the two methods in the identification of different myocardial viabilities. The Bland-Altman method was used to evaluate the diagnostic agreement between the two methods in assessing infarcted myocardium. Results Of the 285 patients with a total of 4845 myocardial segments, 3376 (69.7%) myocardial segments with wall motion abnormality on 18F-FDG PET were included in the analysis. The total content of infarcted myocardium measured through 18F-FDG PET and CMR was 17.6%±13.0% and 19.2%±13.4%, respectively, and a significant correlation existed between them (r=0.67, P<0.001). By contrast, 18F-FDG PET may underestimate the content of infarcted myocardium compared with CMR (The 95%CI of the total difference in infarcted myocardium content was −12.7%–27.8%, and the mean difference was 7.5%). Among the 697 segments with motion abnormality detected through CMR as transmural infarctions, most (90.4%, 630/697) showed transmural or non-transmural infarctions detected through 18F-FDG PET, showing a high agreement between the two methods. Among the 1371 segments detected as non-transmural infarctions through CMR, as many as 686 (50.0%) did not show infarct changes on 18F-FDG PET. At the individual level, no significant correlation (r=−0.09, P=0.12) exists between the total infarcted myocardium content detected through CMR and the total hibernating myocardium content detected through 18F-FDG PET in each patient. Among the 1371 segments detected as non-transmural infarctions through CMR, 838 (61.1%) had hibernating myocardium detected through 18F-FDG PET. Moreover, among the 697 segments detected as transmural infarctions through CMR, 286 (41.0%) had hibernating myocardium detected through 18F-FDG PET. Segments with non-transmural infarctions detected through CMR contained more hibernating myocardium than those with transmural infarctions (61.1% vs. 41.0%, χ2=66.207, P<0.001). Conclusions 18F-FDG PET and CMR have their strengths in assessing myocardial viability in patients with ischemic heart failure. CMR is superior to 18F-FDG PET in terms of identifying infarcted myocardium, whereas 18F-FDG PET is more sensitive in detecting viable myocardium with the ability to distinguish hibernating myocardium. Combining 18F-FDG PET and CMR will provide more comprehensive information on myocardial viability. -
表 1 285例缺血性心脏病合并心功能不全患者的基线资料
Table 1. The baseline information of 285 patients with ischemic heart failure combined with cardiac dysfunction
基本特征 数值 性别[例(%)] 男性 260(91.2) 女性 25(8.8) 年龄(岁, )$\bar x \pm s $ 57.8±10.0 BMI(kg/m2, )$\bar x \pm s $ 25.1±4.3 高血压[例(%)] 153(53.7) 高脂血症[例(%)] 217(76.1) 糖尿病[例(%)] 120(42.1) 吸烟[例(%)] 207(72.6) 脑梗死[例(%)] 43(15.1) COPD[例(%)] 8(2.8) 外周动脉粥样硬化[例(%)] 48(16.8) 既往心肌梗死[例(%)] 233(81.8) LVEF(%) 26.0±12.0 LVEDV(ml, )$\bar x \pm s $ 241.7±96.2 LVESV(ml, )$ \bar x \pm s $ 177.6±86.6 注:BMI为身体质量指数;COPD为慢性阻塞性肺疾病;LVEF为左室射血分数;LVEDV为左室舒张末期容积;LVESV为左室收缩末期容积 表 2 18F-FDG PET与CMR评价3376个室壁运动异常的心肌节段心肌活力的结果比较(个)
Table 2. Comparison of 18F-fluorodeoxyglucose (FDG) PET and cardiac magnetic resonance (CMR) in assessment of myocardial viability in 3376 segments with wall motion abnormality (n)
CMR 结果 18F-FDG PET 结果 合计 正常心肌 冬眠心肌 非透壁梗死伴正常心肌 非透壁梗死伴冬眠心肌 透壁梗死心肌 无梗死 879 237 46 146 0 1308 非透壁梗死 358 328 147 510 28 1371 透壁梗死 26 41 151 245 234 697 合计 1263 606 344 901 262 3376 注:FDG为氟脱氧葡萄糖;PET为正电子发射断层显像术;CMR为心脏磁共振成像 -
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