多排螺旋CT在心外科的临床应用.ppt

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1、多排螺旋CT在心外科的临床应用 Still waters run deep.流静水深流静水深,人静心深人静心深 Where there is life,there is hope。有生命必有希望。有生命必有希望MDCT和和DSCT在中国的情况在中国的情况 1616排排排排MDCTMDCT共共共共550550台台台台,64,64排排排排MDCTMDCT共共共共350350台台台台,DSCT,DSCT装机装机装机装机3636台台台台 68%(63668%(636家医院家医院家医院家医院)开展冠状动脉开展冠状动脉开展冠状动脉开展冠状动脉CTACTA检查检查检查检查 53%(496 53%(496家医

2、院家医院家医院家医院)每月开展冠脉每月开展冠脉每月开展冠脉每月开展冠脉CTA 5CTA 52020例例例例 阜外医院阜外医院阜外医院阜外医院每天每天每天每天冠状动脉冠状动脉冠状动脉冠状动脉CTACTA平均平均平均平均4545例例例例Light-speed VCT,GELight-speed VCT,GE阜外医院的阜外医院的CT设备设备Dual Source CT,SiemensDual Source CT,SiemensSUBTITLESl Coronary Artery Diseasel Aortic Diseasesl Congenital Heart Diseasesl Coronary

3、 Artery Diseasel35.1%(97/279)男性和男性和18.8%(62/330)女性女性冠状动脉钙化阳性冠状动脉钙化阳性,p0.001lAgaston钙化积分钙化积分103.1374.9(男性组男性组)、48.0219.2(女性组女性组),p0.05 l男性组和女性组均随年龄增加而升高男性组和女性组均随年龄增加而升高,p0.001l150例小样本研究：北京地区比上海和广州发例小样本研究：北京地区比上海和广州发病率高且严重病率高且严重,p0.05l危险因素、颈动脉超声同时被评估危险因素、颈动脉超声同时被评估社区亚临床人群冠状动脉粥样硬化初社区亚临床人群冠状动脉粥样硬化初步研究结果

4、（阜外医院资料）步研究结果（阜外医院资料）冠状动脉斑块成像冠状动脉斑块成像F68%ACS 68%ACS 是由是由50%50%狭窄的病变导致狭窄的病变导致 (Circulation 1995;92:657)(Circulation 1995;92:657)F 51%51%不稳定病变呈现不稳定病变呈现“正性重构正性重构”，(Circulation 2000;101:604-10)(Circulation 2000;101:604-10)F MDCT MDCT 可以探测危险斑块，同时显示狭窄可以探测危险斑块，同时显示狭窄 动脉粥样硬化模型研究动脉粥样硬化模型研究 国家自然科学基金项目国家自然科学基金

5、项目国家自然科学基金项目国家自然科学基金项目新西兰白兔模型的造影图像新西兰白兔模型的造影图像MDCT探探测尚无管腔狭窄的危尚无管腔狭窄的危险斑斑块 l l纤维斑块纤维斑块男性，男性，男性，男性，4141岁岁岁岁,不稳定心绞痛不稳定心绞痛不稳定心绞痛不稳定心绞痛薄层纤维帽，较大脂核薄层纤维帽，较大脂核薄层纤维帽，较大脂核薄层纤维帽，较大脂核64-MDCT与与IVUS的对照研究的对照研究（阜外医院资料：（阜外医院资料：（阜外医院资料：（阜外医院资料：n n6666）16-MDCT：48例例(119节段节段),r=0.58,p0.00164-MDCT：18例例(25节段节段),r=0.87,p0.0

6、01 中华放射学杂志中华放射学杂志2007;41:1027-1031.钙化斑块非钙化斑块混合斑块敏感性(%)92%68%73%特异性(%)96%83%89%冠心病诊断冠心病诊断 MDCT与传统冠状动脉造影对照（阜外医院资料：（阜外医院资料：（阜外医院资料：（阜外医院资料：n=1056n=1056；97.3%97.3%冠状动脉节段可以分析冠状动脉节段可以分析冠状动脉节段可以分析冠状动脉节段可以分析）64-MDCT64-MDCT敏感性敏感性特异性特异性按节段诊断按节段诊断8888 (83%)(83%)9494 (93%)(93%)按患者诊断按患者诊断9696 (91%)(91%)7777 (86%

7、)(86%)Sun Z,Jiang W.Diagnostic value of multislice computed tomography angiography in coronary artery disease:A meta-analysis.European Journal of Radiology2006;60:279-286 急性冠脉综合征急性冠脉综合征Acute Coronary Syndrome男性男性,42岁,吸烟吸烟,高高LDL,急性不急性不稳定心定心绞痛痛发作后作后16小小时完全阻塞性病变，指导完全阻塞性病变，指导PCIu他汀他汀类药物治物治疗能否抑能否抑制斑制斑块进展

8、？展？u药物？物？PCI？哪个更好？哪个更好？斑块随访斑块随访34例例MDCT与与SPECT对照研究照研究结果果(阜外医院阜外医院资料料):敏感性敏感性=93.3%(14/15),特异性特异性=84.2%(16/19)，准确率，准确率=88.2%(30/34).早期探测急性心内膜下心肌梗塞早期探测急性心内膜下心肌梗塞平扫平扫平扫平扫 动脉期增强扫描动脉期增强扫描动脉期增强扫描动脉期增强扫描 5 5分钟延迟扫描分钟延迟扫描分钟延迟扫描分钟延迟扫描 前降支结扎后前降支结扎后3小时小时CT扫描扫描 “首过法首过法首过法首过法”MRA”MRA同位素同位素同位素同位素SPECTSPECTTTC染色冠状动

9、脉搭桥术后随访冠状动脉搭桥术后随访n 2006.3月月2008.10月，月，1436例例(男男1192/女女244，60.811.8岁岁).n 通畅率通畅率:LIMA=92%(877/953)，p0.001SVG=87.1%(1455/1670).n 通畅率通畅率:LAD=91.9%(557/606),LCx=87.2%(599/687)，RCA=84.4%(621/736)p0.52 MDCT诊断冠状断冠状动脉搭脉搭桥血管再狭窄血管再狭窄SENSPEPPVNPVGregory 70%92%89%77Sigurdsson 86%99%8199Gregory SA,et al.Am J Card

10、iol 2006;98:877-884.Sigurdsson G,et al.J Am Coll Cardiol 2006;48:772-778.u男性男性,75岁,高危高危险因素因素u无无OMI,CABG适适应症症心功能研究心功能研究 DSCT,UCG DSCT,UCG 和和和和 MRI MRI对照研究对照研究对照研究对照研究lDSCTlMRICourtesy of SD Image Institute,China辐射剂量管理辐射剂量管理uu实现前瞻性心电门控扫描实现前瞻性心电门控扫描实现前瞻性心电门控扫描实现前瞻性心电门控扫描uu辐射剂量从辐射剂量从辐射剂量从辐射剂量从 13.54.1(1

11、.2-28.1)mSv 13.54.1(1.2-28.1)mSv降低为降低为4.04.01.5(1.2-7.5)mSv1.5(1.2-7.5)mSv （阜外医院资料：（阜外医院资料：（阜外医院资料：（阜外医院资料：n n316316）SUBTITLESl Coronary Artery Diseasel Aortic Diseasesl Congenital Heart Diseasesl Aortic DiseasesMDCT诊断主动脉疾患诊断主动脉疾患u2278 例例(M/F=1740/538)49.512.3岁岁 u24小时急诊小时急诊u平均每天平均每天13例例u术前和术后均行术前和术后

12、均行CT检查检查 u替代血管造影替代血管造影 MIP/CPR 三维重建图像三维重建图像u 男性，男性，42岁u 腹主腹主动脉瘤脉瘤 u 支架隔离支架隔离术前后前后n Female,35 years.n Marfans syndrome n Stanford B aortic disection.n Davidaorta replacementSUBTITLESl Coronary Artery Diseasel Aortic Diseasesl Congenital Heart Diseasesl Congenital Heart DiseasesCongenital Heart Diseas

13、es on MDCTu774 patients(M/F=425/349,14.818.3 yearsu3 days to 79 years;223 pt.1 yearuSupplemental tool for cardiac echo and catheterizations.CT诊断先心病的优势和适应症诊断先心病的优势和适应症l观察肺动脉发育和体肺侧支血管情况观察肺动脉发育和体肺侧支血管情况 l观察主动脉弓发育和畸形观察主动脉弓发育和畸形 l肺静脉畸形引流的诊断肺静脉畸形引流的诊断 l28例手术证实：例手术证实：CT诊断敏感性诊断敏感性91.3（超声（超声85.7%）CT诊断特异性诊断特异

14、性100（超声（超声94.3%）主肺间隔缺损动脉导管未闭主肺间隔缺损动脉导管未闭右肺右肺动脉起自升主脉起自升主动脉脉动脉脉导管未管未闭l 男性，男性，16个月个月.l 主主动脉脉缩窄窄l 主动脉弓发育不良主动脉弓发育不良l 动脉导管未闭室间隔缺损动脉导管未闭室间隔缺损主动脉弓离断 女性，女性，1个月，主个月，主动脉弓离断（脉弓离断（B型）型）女性，女性，37岁，主，主动脉弓离断（脉弓离断（C型）型）肺静脉畸形引流肺静脉畸形引流F 右上肺静脉入左房右上肺静脉入左房F 右下肺静脉入下腔右下肺静脉入下腔 F 左上肺静脉入冠状静脉窦左上肺静脉入冠状静脉窦 F 左下肺静脉入左房左下肺静脉入左房1979年

15、诺贝尔生理和医学奖获得者年诺贝尔生理和医学奖获得者 “因为发明了计算机体层摄影术（因为发明了计算机体层摄影术（因为发明了计算机体层摄影术（因为发明了计算机体层摄影术（CTCT）Allan M.Cormack(1924-1998)Allan M.Cormack(1924-1998)Godfrey N.Hounsfield(1919-2004)Godfrey N.Hounsfield(1919-2004)下一个有前途的应用将会是冠状动脉成像下一个有前途的应用将会是冠状动脉成像下一个有前途的应用将会是冠状动脉成像下一个有前途的应用将会是冠状动脉成像 Hounsfield GN.Hounsfield

16、GN.计算机医学成像计算机医学成像.诺贝尔获奖感言诺贝尔获奖感言,1979,1979年年.12.8.12.8日日Clinical Applications of Multi-Clinical Applications of Multi-detector row Spiral CT detector row Spiral CT（MDCTMDCT）on Cardiovascualr Surgeryon Cardiovascualr SurgeryBin Lu,M.D.Bin Lu,M.D.Bin Lu,M.D.Bin Lu,M.D.Department of Radiology,Fu Wai Ca

17、rdiovascular Department of Radiology,Fu Wai Cardiovascular Department of Radiology,Fu Wai Cardiovascular Department of Radiology,Fu Wai Cardiovascular Institute,Peking Union Medical CollegeInstitute,Peking Union Medical CollegeInstitute,Peking Union Medical CollegeInstitute,Peking Union Medical Coll

18、ege11 Dec.200811 Dec.200811 Dec.200811 Dec.2008MDCT and DSCT in China 16-MDCT(550),64-MDCT(350),DSCT(36)16-MDCT(550),64-MDCT(350),DSCT(36)68%(636 hospitals)perform CCTA 68%(636 hospitals)perform CCTA 53%(496 hospitals)perform 5-20 cases of CCTA per month 53%(496 hospitals)perform 5-20 cases of CCTA

19、per month 45 cases of CCTA performed in FuWai 45 cases of CCTA performed in FuWai per dayper dayLight-speed VCT,GELight-speed VCT,GECT Scanners in Fu Wai HospitalDual Source CT,SiemensDual Source CT,SiemensSUBTITLESl Coronary Artery Diseasel Aortic Diseasesl Congenital Heart Diseasesl Coronary Arter

20、y Diseasel35.1%(97/279)male and 18.8%(62/330)female are CAC positive,p0.001lAgaston score:103.1374.9(male)and 48.0219.2(female),p0.05 lCAC score are rising with increasing of age,p Southern(ShangHai and GuangZhou),p0.05lRisk factors,carotid US were evaluated 1.1 Prevalence of Sub-clinical Coronary A

21、therosclerosis Prevalence of Sub-clinical Coronary Atherosclerosis on Chinese Populationon Chinese Population1.2 Coronary Artery Plaque ImagingF 68%ACS caused by lesions of 50%stenosis(Circulation 1995;92:657)F 51%unstable lesions are positive remodeling;(Circulation 2000;101:604-10)F MDCT visualize

22、s both vulnerable plaques and luminal narrowing Atherosclerotic Model on Rabbits Granted by the Natural Science Fundation of ChinaGranted by the Natural Science Fundation of ChinaTranscatherter Angiography on NewZealand White Rabbit ModelsDetection of plaque without stenosis l lFibrous plaqueMale,41

23、 years,Unstable anginaMale,41 years,Unstable anginaThin-fibrous cap and big fatty coreThin-fibrous cap and big fatty core64-MDCT vs IVUS(Fu Wai Data)48 cases on 16-MDCT,r=0.58,p0.00118 cases on 64-MDCT,r=0.87,p0.001 Chinese J Radiology 2007;41:1027-1031.CalcifiedNon-calcifiedMixturedSensitivity(%)92

24、%68%73%Specificity(%)96%83%89%1.3 Diagnosis of CAD Comparison of MDCT with Conventional Coronary Angiography（n=1056n=1056；97.3%of segments were evaluable97.3%of segments were evaluable）64-MDCT64-MDCTSensitivitySensitivitySpecificitySpecificitySegment-basedSegment-based8888 (83%)(83%)9494 (93%)(93%)P

25、atient-basedPatient-based9696 (91%)(91%)7777 (86%)(86%)Sun Z,Jiang W.Diagnostic value of multislice computed tomography angiography in coronary artery disease:A meta-analysis.European Journal of Radiology2006;60:279-286 1.4 Acute Coronary SyndromeMale,42 years,current smoking,High LDL,onset of unsta

26、ble angina in 16 hoursCoronary Total OcclusionuCan statins inhibit vulnerable/soft plaque progression?uWhich is better?Medication?PCI?1.5 Plaque F-UComparison study between MDCT and SPECT(34 Cases of FUWAI hospital):SEN=93.3%(14/15),SPE=84.2%(16/19)and ACCU=88.2%(30/34).1.6 Detection of Acute Myocar

27、dial InfarctionPlain ScansPlain Scans First-pass CTAFirst-pass CTA Late-enhancement of Late-enhancement of 5 mins5 mins 3 Hours later of LAD Ligation First-pass MRAFirst-pass MRASPECTSPECTTTC染色1.7 Follow-up of CABG (Data from Fu Wai Hospital)n Mar.2006 to Oct.2008,1436 patients(M/F=1192/244,60.811.8

28、 years).n Patency:LIMA=92%(877/953)SVG=87.1%(1455/1670)p0.001n Patency:LAD=91.9%(557/606),LCx=87.2%(599/687)RCA=84.4%(621/736)p0.52Evaluation of CABG Restenosis by MDCTSENSPEPPVNPVGregory 70%92%89%77Sigurdsson 86%99%8199Gregory SA,et al.Am J Cardiol 2006;98:877-884.Sigurdsson G,et al.J Am Coll Cardi

29、ol 2006;48:772-778.uMale,75 years,high risksuNon-MI,indication for CABG1.8 Heart Function Evaluations Comparison study among DSCT,UCG and MRIComparison study among DSCT,UCG and MRIlDSCTlMRICourtesy of SD Image Institute,China1.9 Exposion Dose ManagementuuProspective ECG Triggering is availableProspe

30、ctive ECG Triggering is availableuuDose is decreased:13.54.1(1.2-28.1)mSvDose is decreased:13.54.1(1.2-28.1)mSv to 4.04.01.5(1.2-7.5)mSv1.5(1.2-7.5)mSvSUBTITLESl Coronary Artery Diseasel Aortic Diseasesl Congenital Heart Diseasesl Aortic DiseasesAortic Diseases on MDCTu2278 patients(M/F=1740/538)49.

31、512.3 years u24-hour emergencyuAverage 13 cases per dayubefore and after operation uTo substitute of conventional Angiography MIP/CPR Reconstructed Imagesu Male,42 years.u Abdominal Aortic Aneurysm.u Before and after intraluminal stenting isolation.n Female,35 years.n Marfans syndrome n Stanford B a

32、ortic disection.n Davidaorta replacementSUBTITLESl Coronary Artery Diseasel Aortic Diseasesl Congenital Heart Diseasesl Congenital Heart DiseasesCongenital Heart Diseases on MDCTu774 patients(M/F=425/349,14.818.3 yearsu3 days to 79 years;223 pt.1 yearuSupplemental tool for cardiac echo and catheteri

33、zations.Advantages and Indications of CT for CHDlPulmonary artery developments and aorto-pulmonary collaterals.lAortic arch developments and malformations.lAbnormal drainage of pulmonary veins.lSurgery results of 28 cases:Sen.=91.3%(85.7%)Spe.=100%(94.3%)Aorto-pulmonary septal defectPDAR.PA originat

34、ed from A.AO+PDAl Male,16 months.l Aortic Coarctationl Dysplasia of Aortic Archl PDA+VSDAortic Interruption Female,1 month years old.Aortic Aortic InterruptionInterruption（Type B）Female,37 years old.Aortic Aortic InterruptionInterruption（Type C）Abnormally Pulmonary Vein ConnectionsF R.S.PV to LAF R.

35、I.PV to IVC F L.S.PV to C.S F L.I.PV to LAThe Nobel Prize in Physiology or Medicine 1979The Nobel Prize in Physiology or Medicine 1979for the development of computer assisted for the development of computer assisted tomographytomographyAllan M.Cormack(1924-1998)Allan M.Cormack(1924-1998)Godfrey N.Hounsfield(1919-2004)Godfrey N.Hounsfield(1919-2004)“A further promising field may be the detection of the coronary arteries”Hounsfield GN.Computed Medical Imaging.Nobel Lecture,8 Dec.1979