多層螺旋CT冠狀動(dòng)脈檢查課件

1、多排螺旋CT冠狀動(dòng)脈成像多排螺旋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 探測器寬度 后處理功能 簡便、實(shí)用的后處理 軟件 影響CT冠狀動(dòng)脈成像質(zhì)量的主要因素 冠狀動(dòng)脈管腔大于50%狹窄者， 16排CT與64排CT的比較 Sep Spe PPV NPV16MSCT 95% 69% 79% 92%64MSCT 97% 90% 93% 96%Hamon M, Radiology,2007,Dec,245(3):720-731. 冠狀動(dòng)脈管腔大于50%狹窄者， 16排CT在空間分辨力方面仍是限制準(zhǔn)確評(píng)價(jià)冠

2、脈病變的因素 Iriart X, Eur. Radiol,2007,(10)17:2581-2588 Knollmann F, Int.J.Cardiovasc Imaging,2007 Set. 12 Hamon M, Radiology, 2007 Dec, 245(3):720-731. 64-slice CT with z-Sharp technology0.6 x 32 x 2 = 64Spartial resolution:0.4mm x 0.4mm x 0.4mmTemporal resolution: 0.33s/r 165 msCourtesy of Siemens medi

3、cal solution China 64-slice CT with z-Sharp tech= 83 msrotation time 0.33s4Temp. Resolution =Dual Source CTCourtesy of Siemens medical solution China = 83 msrotation time 0.33sTempTOSHIBAZ-軸時(shí)間分辨力：16 cm coverage per rotation空間分辨力： 320 x 0.5 mm detector elements時(shí)間分辨力： 350 msec rotation time (數(shù)據(jù)由東芝公司提供

4、)one aquilionTOSHIBAone aquilion256-iCT Z-軸時(shí)間分辨力：8cm納米探測器空間分辨力： 0.625x128(256Slices)時(shí)間分辨力： 270 msec rotation time （數(shù)據(jù)由Philips公司提供）256-iCT Z-軸時(shí)間分辨力：8cm納米探測器VCT-XT: GEZ-軸時(shí)間分辨力：4 cm coverage per rotation空間分辨力： 64 x 0.625 mm detector elements時(shí)間分辨力： 350 msec rotation time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

5、學(xué)雜志，2007，41（10），1011 VCT-XT: GE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器（Z軸時(shí)間分辨力）簡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空間分辨力為毫米級(jí)0.4x0.4x0.4 mmYZ X 空間分辨力為毫米級(jí)0.4x0.4x0.4 mmYZ X 螺旋CT三維重建技術(shù)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Volume Rendering螺旋CT三維重建技術(shù)冠、

6、矢狀位重建Co. Sa. Reco多層螺旋CT技術(shù)進(jìn)展多層螺旋CT技術(shù)進(jìn)展冠脈檢查注意要點(diǎn)技術(shù)簡介和心理溝通呼吸訓(xùn)練心律和心率的干預(yù)硝酸甘油的使用冠脈檢查注意要點(diǎn)技術(shù)簡介和心理溝通五、心臟CT成像適應(yīng)癥簡介美國多學(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/SIRJournal of American college of Cardiology 2006,48:1475-1497五、心臟CT成像適應(yīng)癥簡介美國多學(xué)科學(xué)會(huì)聯(lián)合推薦心臟（包括心19分法CT心臟檢查分級(jí)（79分）1，有癥狀者、中等以上冠心病風(fēng)險(xiǎn)、ECG不 確切、

7、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19分法CT心臟檢查分級(jí)（79分）1，有癥狀者、中等以正常冠狀動(dòng)脈正常冠狀動(dòng)脈正常冠狀動(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 90像等級(jí) 4 148 82.2 322 78.5 218 66.1 120 70.6 34 48.6 3 28 15.6 82 20.0 98 29.7 41 24.1 25 35.7 2

8、 4 2.2 6 1.4 14 4.2 8 4.71 11 15.2 1 0 0 0 1 0.6 0不同心率冠脈成像結(jié)果(支數(shù) %)血管成 60 正常冠狀動(dòng)脈正常冠狀動(dòng)脈左冠狀動(dòng)脈狹窄左冠狀動(dòng)脈狹窄CTA 與DSA對(duì)照CTA 與DSA對(duì)照CTA與DSA對(duì)照CTA與DSA對(duì)照前降支狹窄前降支狹窄明確診斷后介入治療明確診斷后介入治療CT檢測冠脈狹窄準(zhǔn)確性MDCT vs. 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)Leschka 53 370 ms 94% 97% 99% - Raff 70 330 ms 86% 95% 98% 12%Leber 59 33

9、0 ms 73% 97% 99% -Mollet 52 330 ms 99% 95% 99% 2%Ropers 82 330 ms 95% 93% 99% 4%楊立等 61 330 ms 90% 94% 93% - CT檢測冠脈狹窄準(zhǔn)確性MDCT vs. ANGIOGRAP冠脈粥樣硬化斑塊鈣化（混合性）斑塊 纖維斑塊 軟斑塊（脂池） Agatston Score 90 + 20HU 30 + 20HU冠脈粥樣硬化斑塊鈣化（混合性）斑塊 纖維斑塊 軟斑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)周性斑塊管壁環(huán)周性斑塊多層螺

10、旋CT冠狀動(dòng)脈檢查課件粥樣硬化斑塊導(dǎo)致管腔狹窄粥樣硬化斑塊導(dǎo)致管腔狹窄冠脈血管造影冠脈血管造影冠脈支架治療冠脈支架治療The progress of coronary atherosclerosisThe progress of coronary atherPlaque rupture resulting myocardium infarctionCourtesy of Dr. Wei Li-xin. PLA General Hospital, ChinaPlaque rupture resulting myocaThe vulnerable plaque without lumen sten

11、osisThe aids of coronary CT imaging:detect the vulunerable plaque before ruptureCourtesy of Dr. Wei Li-xin. PLA General Hospital, ChinaThe vulnerable plaque The aidsCT發(fā)現(xiàn)冠脈斑塊的敏感度PLAQUE DETECTION：MDCT VS. IVUS83 segments in 22 patients Sensitivity plaque per segment: 94%(all)16-slice CT 53%(non-calcif

12、ied)Achenbach et al: Circulation 2003 -58 vessels in 37 patients Sensitivity plaque detection: 85%(all)16-slice CT 82%(non-calcified)Laber et al. JACC 2004 -32 vessels in 18 patients Sensitivity plaque detection: 84%(all)64-slice CT Leber et al JACC 2005 CT發(fā)現(xiàn)冠脈斑塊的敏感度PLAQUE DETECTION：The controversy

13、in identification of plaque types with MSCT Soft plaque:11+/-12HU Fibrous plaque:76+/21HU Calcified plaque:516+/-198HU There were statistically highly significant differences in the densitometric characteristics among the plaques and lumen The IVUS-based coronary plaque configuration can be accurate

14、ly identified by MSCT. Motoyama S. Circulation J. 2007 Mar: 71:363-366The controversy in identificatSoft plaque 14 26 HUIntermediate plaque 91 21 HUcalcified plaque 419 194 HUSchroeder et al. JACC 2001The controversy in identification of plaque types:MSCT vs. IVUSCourtesy of Dr. Lars K. HofmannSoft

15、plaque 14 26 HUIntermedThe controversy in identification of plaque types with MSCT The overlap of CT value on the plaque composition: 16-slice CT results vs. IVUS mean CT value IVUS 58+/-43HU Hypo-echo. Plaque 121+/-34HU Hyper-echo. PlaqueSignificant differences and substantial overlap between the p

16、laques types Pohal K. atherosclerosis, 2007,Jan,190:174-180. The controversy in identificatLAD:soft-plaqueLAD:soft-plaqueNo significant stenosisNo significant stenosisPLAQUE TRANSFORM A 54-y/o man with “cardiopalmus”. LAD irregular-surface plaque with lower density and lumen stenosis 50% 2005-11-09P

17、LAQUE TRANSFORM A 54-y/o man 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): 6 km/H，30min /日治療及生活習(xí)慣干預(yù)05-11： 2006-08-01 2006-08-01 2008-12-19 2008-12-19多層螺旋CT冠狀動(dòng)脈檢查課件Cor. DissectionCor. 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）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

18、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（Myocardial Bridge MB），位于心肌橋下的冠狀動(dòng)脈稱為壁冠狀動(dòng)脈（Mural Coronary Artery MCA ）。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-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)走心肌橋相關(guān)問題一般為良性先天發(fā)育異?？赡艿呐R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 中國臨床醫(yī)學(xué)影像雜志 2007，18：285-287。心肌橋相關(guān)問題一般為良

19、性先天發(fā)育異常趙林芬 楊立 中國臨Normal pattern of the left anterior descending artery (LAD) as seen on axial plane (A, B) and multiplanar reformation (C, D). The left anterior descending artery (arrow) is embedded through all of its length in the epicardial fat. *Interventricular septum. CCTA coronary computed tom

20、ographic angiography.K0NEN，JACC, 2007,49(5): 587-693.Normal pattern of the left antCoronary morphologyThe normal morphology of RCACoronary morphologyThe normal The normal LADThe normal LADIntramuscula LAD, superficial type, as seen on axial plane (A, B) and multiplanar reformation (C, D). The mid LA

21、D (arrow) shows a typical deviation and straitening and is only partially surrounded by myocardium. Of note, an atheroscleroticplaque in the proximal LAD, whereas the intramuscular segment is free of disease. Konen，JACC, 2007,49(5): 587-693.Intramuscula LAD, superficial Intramuscular LAD, right vent

22、ricular type (arrow). In this variant it is frequently difficult to follow the LAD on sequential axial images (A, B) because it disappears between the right ventricular trabeculae, whereas the multiplanar reformationimages easily show its intraventricular course (C, D). Konen，JACC, 2007,49(5): 587-6

23、93.Intramuscular LAD, right ventrIntramuscular LAD, right ventricular type (arrow). In this variant it is frequentlydifficult to follow the LAD on sequential axial images (A, B) because it disappearsbetween the right ventricular trabeculae, whereas the multiplanar reformationimages easily show its i

24、ntraventricular course (C, D). Konen，JACC, 2007,49(5): 587-693.Intramuscular LAD, right ventrSUPERFICIAL TYPESUPERFICIAL TYPEVENTRICULAR TYPE(深在型）VENTRICULAR TYPE(深在型）MB-MCA ON RCAMB-MCA ON RCAAtherosclerosis on MCAAtherosclerosis on MCARight ventricular type Right ventricular type Right ventricular

25、 typeRight ventricular typeRight ventricular typeRight ventricular typeMCA on diastolic and systolic phase diastolic phase systolic phase MCA: Mural Coronary ArteryMCA on diastolic and systolic MCA on Diastolic phase MCA on systolic phaseMCA on Diastolic phase MB-MCAMB: Myocardial Bridge, MCA: Mural

26、 Coronary ArteryMB-MCAMB: Myocardial Bridge, MCA on diastolic and systolic phase Diastolic phase Systolic phase MCA on diastolic and systolic 多層螺旋CT冠狀動(dòng)脈檢查課件M，42y，AMI 4 years (at 38 years old)M，42y，AMI 4 years (at 38 yearsRCA: NO SIGNIFICANT STENOSISRCA: LCX: NO SIGNIFICANT STENOSIS LCX:MB: Myocardia

27、l BridgeMCA: Mural Coronary Artery LAD: MB-MCAMB: Myocardial Bridge LAD: MF，67y，EFFORT ANGINA，3MMyocardial infarction F，67y，EFFORT ANGINA，3MF，67y，EFFORT ANGINA，3MF，67y，EFFORT ANGINA，3M M, 53 y, Chest Malaise 3 years M, 53 y,Myocardial ischemiaMyocardial ischemia多層螺旋CT冠狀動(dòng)脈檢查課件女63歲，冠心病17年，高血壓2年女63歲，冠心

28、病17年，高血壓2年多層螺旋CT冠狀動(dòng)脈檢查課件擴(kuò)張性心肌病擴(kuò)張性心肌病肥厚性心肌病術(shù)前 術(shù)后肥厚性心肌病術(shù)前 多層螺旋CT冠狀動(dòng)脈檢查課件瓣膜病變瓣膜病變左房黏液瘤左房黏液瘤心臟腫瘤心房腫瘤心臟腫瘤心房腫瘤？“胸痛三聯(lián)”檢查-PE“胸痛三聯(lián)”檢查-PE“胸痛三聯(lián)”檢查主動(dòng)脈壁內(nèi)血腫“胸痛三聯(lián)”檢查主動(dòng)脈壁內(nèi)血腫多層螺旋CT冠狀動(dòng)脈檢查課件CABG復(fù)查CABG復(fù)查多層螺旋CT冠狀動(dòng)脈檢查課件ANASTOMOSIS STENOSISANASTOMOSIS STENOSIS支架通暢支架通暢冠脈支架評(píng)價(jià)冠脈支架評(píng)價(jià)M/58M/58支架鄰近再發(fā)狹窄支架鄰近再發(fā)狹窄支架內(nèi)膜增生支架內(nèi)膜增生In-Sten

29、t Restenosis74 cases 16 MDCT(n=27), 64 MDCT(N=43)Demonstration ISR: Accuracy 93% (10/70) Sen 100% PPV 67% Spe 91% NPV 100%MDCTIVUS stent diameter and area : R=0.78, R=0.73Van Mieghem CA, et al, Circulation, 2006,114(7):616-619In-Stent RestenosisVan Mieghem37個(gè)冠脈內(nèi)支架CTA與DSA評(píng)價(jià)再狹窄 劉新，楊立 等， 中華放射學(xué)雜志，2006，4

30、0（8）：808 sen spe ppv npv肉眼觀察法（） 18 69 20 67 CT值測量法（） 27 81 38 7237個(gè)冠脈內(nèi)支架CTA與DSA評(píng)價(jià)再狹窄 劉新，楊立 冠狀動(dòng)脈起源和分布變異LAD、LCX單獨(dú)在左冠竇開口：LCX異位起源RCA、D1RCA、LAD共干LADRCA回旋支缺如冠狀動(dòng)脈間交通RCA起源主動(dòng)脈冠狀動(dòng)脈起源和分布變異LAD、LCX單獨(dú)在左冠竇開口：LAD、LCX共同起源左冠竇 LAD、LCX共同起源左冠竇 多層螺旋CT冠狀動(dòng)脈檢查課件LCX起自D1并纖細(xì)LCX起自D1并纖細(xì)左、右冠脈共干左、右冠脈共干冠脈畸形并左右交通冠脈畸形并左右交通左冠經(jīng)交通支與右冠相連左冠經(jīng)交通支與右冠相