多層螺旋CT冠狀動(dòng)脈檢查

多排螺旋CT冠狀動(dòng)脈成像影響CT冠狀動(dòng)脈成像質(zhì)量的

主要因素

因素設(shè)備參數(shù)空間分辨力探測(cè)器層厚度時(shí)間分辨力球管選擇速度Z－軸時(shí)間分辨力探測(cè)器寬度后處理功能簡(jiǎn)便、實(shí)用的后處理軟件

冠狀動(dòng)脈管腔大于50%狹窄者，16排CT與64排CT的比較

SepSpePPVNPV16－MSCT95%69%79%92%64－MSCT97%90%93%96%HamonM,Radiology,2007,Dec,245(3):720-731.

16排CT在空間分辨力方面仍是限制準(zhǔn)確評(píng)價(jià)冠脈病變的因素

IriartX,Eur.Radiol,2007,(10)17:2581-2588KnollmannF,Int.J.CardiovascImaging,2007Set.12HamonM,Radiology,2007Dec,245(3):720-731.64-sliceCT

withz-Sharptechnology0.6x32x2=64Spartialresolution:0.4mmx0.4mmx0.4mmTemporalresolution:0.33s/r165msCourtesyofSiemensmedicalsolutionChina

=83msrotationtime0.33s4Temp.Resolution=DualSourceCTCourtesyofSiemensmedicalsolutionChina

TOSHIBAZ-軸時(shí)間分辨力：16cmcoverageperrotation空間分辨力：320x0.5mmdetectorelements時(shí)間分辨力：350msecrotationtime

(數(shù)據(jù)由東芝公司提供)oneaquilion256-iCTZ-軸時(shí)間分辨力：8cm納米探測(cè)器空間分辨力：0.625x128(256－Slices)時(shí)間分辨力：270msecrotationtime

（數(shù)據(jù)由Philips公司提供）VCT-XT:GEZ-軸時(shí)間分辨力：4cmcoverageperrotation空間分辨力：64x0.625mmdetectorelements時(shí)間分辨力：350msecrotationtime前瞻性ECG門控掃描：實(shí)時(shí)心電信號(hào)調(diào)節(jié)，降低輻射劑量呂濱，中華放射學(xué)雜志，2007，41（10），1011

心臟、冠狀動(dòng)脈CT檢查：

更高的時(shí)間分辨力

更高的空間分辨力

最小的輻射劑量

更寬的探測(cè)器（Z－軸時(shí)間分辨力）

簡(jiǎn)便易行的后處理軟件推薦選擇設(shè)備：使用64排以上CT設(shè)備空間分辨力為毫米級(jí)

0.4x0.4x0.4mmYZX

冠、矢狀位重建—Co.Sa.Reconstruction多層面重建--MPR最大密度投影重建--MIP最小密度投影重建--Mip容積編碼重建—VolumeRendering冠脈檢查注意要點(diǎn)五、心臟CT成像適應(yīng)癥簡(jiǎn)介美國(guó)多學(xué)科學(xué)會(huì)聯(lián)合推薦心臟（包括心胸部）CT成像適應(yīng)征：

ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR

JournalofAmericancollegeofCardiology2006,48:1475-14971－9分法CT心臟檢查分級(jí)

（7－9分）1，有癥狀者、中等以上冠心病風(fēng)險(xiǎn)、ECG不確切、不能進(jìn)行運(yùn)動(dòng)試驗(yàn)，無癥狀者不推薦CT檢查（篩查）2，急性胸痛者，中等以上冠心病風(fēng)險(xiǎn)、ECG無改變、酶學(xué)正常者3，各種檢查結(jié)果均不能明確診斷者4，冠狀動(dòng)脈、大血管、心腔和瓣膜等的形態(tài)學(xué)檢查5，腫瘤、血栓、心包病變、肺靜脈、冠狀動(dòng)脈＋內(nèi)乳動(dòng)脈、主動(dòng)脈夾層＋動(dòng)脈瘤、肺栓塞正常冠狀動(dòng)脈正常冠狀動(dòng)脈不同心率冠脈成像結(jié)果(支數(shù)%)血管成<6060-6970-7980-89>90像等級(jí)

414882.232278.521866.112070.63448.632815.68220.09829.74124.12535.7242.261.4144.284.711115.2100010.60正常冠狀動(dòng)脈左冠狀動(dòng)脈狹窄CTA與DSA對(duì)照CTA與DSA對(duì)照前降支狹窄明確診斷后介入治療CT檢測(cè)冠脈狹窄準(zhǔn)確性

MDCTvs.ANGIOGRAPHY作者例數(shù)旋轉(zhuǎn)時(shí)間/周敏感度特異度陰性期望值不能評(píng)價(jià)Leschka53370ms94%97%99%--Raff70330ms86%95%98%12%Leber59330ms73%97%99%--Mollet52330ms99%95%99%2%Ropers82330ms95%93%99%4%楊立等61330ms90%94%93%--

冠脈粥樣硬化斑塊鈣化（混合性）斑塊纖維斑塊軟斑塊（脂池）AgatstonScore90+20HU30+20HU管壁偏心性斑塊管壁偏心性斑塊管壁偏心性斑塊管壁偏心性斑塊管壁環(huán)周性斑塊粥樣硬化斑塊導(dǎo)致管腔狹窄冠脈血管造影冠脈支架治療TheprogressofcoronaryatherosclerosisPlaqueruptureresultingmyocardiuminfarctionCourtesyofDr.WeiLi-xin.PLAGeneralHospital,ChinaThevulnerableplaquewithoutlumenstenosisTheaidsofcoronaryCTimaging:detectthevulunerableplaquebeforeruptureCourtesyofDr.WeiLi-xin.PLAGeneralHospital,ChinaCT發(fā)現(xiàn)冠脈斑塊的敏感度

PLAQUEDETECTION：MDCTVS.IVUS83segmentsin22patientsSensitivityplaquepersegment:94%(all)16-sliceCT53%(non-calcified)Achenbachetal:Circulation2003----------------------------------------------------------------------------------------------58vesselsin37patientsSensitivityplaquedetection:85%(all)16-sliceCT82%(non-calcified)Laberetal.JACC2004

----------------------------------------------------------------------------------------------32vesselsin18patientsSensitivityplaquedetection:84%(all)64-sliceCTLeberetalJACC2005

Thecontroversyinidentificationofplaquetypeswith

MSCTSoftplaque:11+/-12HUFibrousplaque:76+/21HUCalcifiedplaque:516+/-198HU

Therewerestatisticallyhighlysignificantdifferencesinthedensitometriccharacteristicsamongtheplaquesandlumen

TheIVUS-basedcoronaryplaqueconfigurationcanbeaccuratelyidentifiedbyMSCT.

MotoyamaS.CirculationJ.2007Mar:71:363-366Softplaque1426HUIntermediateplaque9121HUcalcifiedplaque419194HUSchroederetal.JACC2001Thecontroversyinidentificationofplaquetypes:MSCTvs.IVUSCourtesyofDr.LarsK.HofmannThecontroversyinidentificationofplaquetypeswith

MSCT

TheoverlapofCTvalueontheplaquecomposition:16-sliceCTresultsvs.IVUS

meanCTvalueIVUS58+/-43HUHypo-echo.Plaque121+/-34HUHyper-echo.PlaqueSignificantdifferencesandsubstantialoverlapbetweentheplaquestypes

PohalK.atherosclerosis,2007,Jan,190:174-180.

LAD:soft-plaqueNosignificantstenosisPLAQUETRANSFORM

A54-y/omanwith“cardiopalmus”.LADirregular-surfaceplaquewithlowerdensityandlumenstenosis<50%

2005-11-09治療及生活習(xí)慣干預(yù)05-11：速降脂，40mg/日，30天20mg/日，90天飲食控制：不吃內(nèi)臟類食物，增加蔬菜類戒煙：遠(yuǎn)動(dòng):6km/H，30min/日

2006-08-01

2008-12-19Cor.Dissection血管迂曲、壁冠狀動(dòng)脈（肌橋）血管迂曲、壁冠狀動(dòng)脈（肌橋）心肌橋-壁冠狀動(dòng)脈冠狀動(dòng)脈部分節(jié)段被心肌纖維覆蓋，在心肌內(nèi)走行一段距離后又淺露于心肌表面，覆蓋在該段冠狀動(dòng)脈上的心肌束稱為心肌橋（MyocardialBridgeMB），位于心肌橋下的冠狀動(dòng)脈稱為壁冠狀動(dòng)脈（MuralCoronaryArteryMCA）。心肌橋=心肌橋-壁冠狀動(dòng)脈復(fù)合體（MB-MCA）楊立趙林芬李穎等。中華醫(yī)學(xué)雜志，2006，86：2858-2862心肌橋相關(guān)問題一般為良性先天發(fā)育異常可能的臨床意義：引起心肌退變與冠狀動(dòng)脈動(dòng)脈硬化、心律不齊相關(guān)導(dǎo)致急性心肌缺血、猝死等趙林芬楊立中國(guó)臨床醫(yī)學(xué)影像雜志2007，18：285-287。Normalpatternoftheleftanteriordescendingartery(LAD)asseenonaxialplane(A,B)andmultiplanarreformation(C,D).Theleftanteriordescendingartery(arrow)isembeddedthroughallofitslengthintheepicardialfat.*Interventricularseptum.CCTAcoronarycomputedtomographicangiography.

K0NEN，JACC,2007,49(5):587-693.CoronarymorphologyThenormalmorphologyofRCAThenormalLADIntramusculaLAD,superficialtype,asseenonaxialplane(A,B)andmultiplanarreformation(C,D).ThemidLAD(arrow)showsatypicaldeviationandstraiteningandisonlypartiallysurroundedbymyocardium.Ofnote,anatherosclerotic

plaqueintheproximalLAD,whereastheintramuscularsegmentisfreeofdisease.

Konen，JACC,2007,49(5):587-693.IntramuscularLAD,rightventriculartype(arrow).InthisvariantitisfrequentlydifficulttofollowtheLADonsequentialaxialimages(A,B)becauseitdisappearsbetweentherightventriculartrabeculae,whereasthemultiplanarreformationimageseasilyshowitsintraventricularcourse(C,D).Konen，JACC,2007,49(5):587-693.IntramuscularLAD,rightventriculartype(arrow).InthisvariantitisfrequentlydifficulttofollowtheLADonsequentialaxialimages(A,B)becauseitdisappearsbetweentherightventriculartrabeculae,whereasthemultiplanarreformationimageseasilyshowitsintraventricularcourse(C,D).Konen，JACC,2007,49(5):587-693.SUPERFICIALTYPEVENTRICULARTYPE

(深在型）MB-MCAONRCAAtherosclerosisonMCARightventriculartypeRightventriculartypeRightventriculartypeMCAondiastolicandsystolicphasediastolicphasesystolicphase

MCA:MuralCoronaryArteryMCAonDiastolicphaseMCAonsystolicphaseMB-MCAMB:MyocardialBridge,MCA:MuralCoronaryArteryMCAondiastolicandsystolicphase

DiastolicphaseSystolicphaseM，42y，AMI4years(at38yearsold)RCA:NOSIGNIFICANTSTENOSISLCX:NOSIGNIFICANTSTENOSISMB:MyocardialBridgeMCA:MuralCoronaryArteryLAD:MB-MCAF，67y，EFFORTANGINA，3MMyocardialinfarctionF，67y，EFFORTANGINA，3MM,53y,ChestMalaise3yearsMyocardialischemia女63歲，

冠心病17年，高血壓

2年擴(kuò)張性心肌病肥厚性心肌病瓣膜病變左房黏液瘤心臟腫瘤—心房腫瘤？“胸痛三聯(lián)”檢查--PE“胸痛三聯(lián)”檢查—主動(dòng)脈壁內(nèi)血腫CABG復(fù)查ANASTOMOSISSTENOSIS支架通暢冠脈支架評(píng)價(jià)M/58支架鄰近再發(fā)狹窄支架內(nèi)膜增生