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近年来,尽管经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)有效降低了急性心肌梗死(acute myocardial infarction,AMI)患者的病死率,但AMI仍为目前冠状动脉粥样硬化性心脏病(简称冠心病)患者致死、致残的主要病因[1]。行PCI的目的在于挽救濒死心肌,改善AMI患者的预后。心肌挽救量(myocardial salvage,MS)对于PCI的疗效评估及预后判断具有重要价值[2]。由MS与初始心肌危险区面积(area at risk,AAR)的比值获得的心肌挽救指数(myocardial salvage index,MSI)是AMI患者行PCI是否获益的独立预测因子[3]。
门控SPECT心肌灌注显像(gated SPECT myocardial perfusion imaging,GSMPI)通过计算机软件自动处理可“一站式”获得血流灌注参数及多项功能参数[4]。在急诊PCI前注射显像剂99Tcm-MIBI行GSMPI检测AMI患者的初始心肌AAR的方法的临床价值已在早期的大样本研究中得到验证[5-6],通过与PCI后再次显像获得的心肌最终梗死面积(final infarction size,FIS)进行比较可获得MS及MSI。一项对765例AMI患者的大样本研究结果表明,经再灌注治疗后MSI<0.5的AMI患者,其6个月病死率明显高于MSI≥0.5者;MSI与AMI患者的6个月病死率呈独立相关,MSI能够预测AMI患者的6个月病死率[5]。该研究结果还显示,在用于测试AMI患者再灌注治疗疗效的临床试验中,MSI可作为病死率的替代指标,尤其是对于新治疗方案的有效性的判断,能够明显降低对样本量的要求,且可行性更佳。然而,临床实践中在急诊时行GSMPI通常很难实现,原因包括:核素显像剂难以及时供应、大多数单位不具备夜间急诊条件、核医学科距离急诊科或胸痛中心较远等,以上原因导致GSMPI在AMI患者急诊时的应用受到限制[3, 7-8]。
近年来有学者提出,利用AMI患者行PCI后早期心肌顿抑的原理,通过PCI后早期行1次静息状态下GSMPI即可间接获得AAR[9-12],从而实现对MS及MSI的定量评估,该方法的结果与2次显像法的一致性很好,且操作简便,同时降低了辐射剂量及检查费用,实用价值明显提高,对AMI患者的危险度分层、个体化治疗方案制定、疗效评价、预后判断具有重要价值。笔者拟对该新显像方案的机制、应用价值、优势及发展前景作一综述。
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