多层螺旋CT冠状动脉检查

多排螺旋CT冠状动脉成像,影响CT冠状动脉成像质量的主要因素,因 素 设备参数 空间分辨力 探测器层厚度 时间分辨力 球管选择速度 Z轴时间分辨力 探测器宽度 后处理功能 简便、实用的后处理 软件,冠状动脉管腔大于50%狭窄者， 16排CT与64排CT的比较 Sep Spe PPV NPV16MSCT 95% 69% 79% 92%64MSCT 97% 90% 93% 96%Hamon M, Radiology,2007,Dec,245(3):720-731.,16排CT在空间分辨力方面仍是限制准确评价冠脉病变的因素 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 technology,0.6 x 32 x 2 = 64,Spartial resolution:0.4mm x 0.4mm x 0.4mmTemporal resolution: 0.33s/r 165 ms,Courtesy of Siemens medical solution China,Dual Source CT,Courtesy of Siemens medical solution China,TOSHIBA,Z-轴时间分辨力：16 cm coverage per rotation空间分辨力： 320 x 0.5 mm detector elements时间分辨力： 350 msec rotation time (数据由东芝公司提供),one aquilion,256-iCT,Z-轴时间分辨力：8cm纳米探测器空间分辨力： 0.625x128(256Slices)时间分辨力： 270 msec rotation time （数据由Philips公司提供）,VCT-XT: GEZ-轴时间分辨力：4 cm coverage per rotation空间分辨力： 64 x 0.625 mm detector elements时间分辨力： 350 msec rotation time前瞻性ECG门控扫描：实时心电信号调节，降低辐射剂量吕滨，中华放射学杂志，2007，41（10），1011,心脏、冠状动脉CT检查：更高的时间分辨力更高的空间分辨力最小的辐射剂量更宽的探测器（Z轴时间分辨力）简便易行的后处理软件,推荐选择设备：使用64排以上CT设备,空间分辨力为毫米级0.4x0.4x0.4 mm,Y,Z,X,螺旋CT三维重建技术,冠、矢状位重建Co. Sa. Reconstruction多层面重建- MPR最大密度投影重建-MIP最小密度投影重建-Mip容积编码重建Volume Rendering,多层螺旋CT技术进展,冠脉检查注意要点,技术简介和心理沟通呼吸训练心律和心率的干预硝酸甘油的使用,五、心脏CT成像适应症简介,美国多学科学会联合推荐心脏（包括心胸部）CT成像适应征：ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIRJournal of American college of Cardiology 2006,48:1475-1497,19分法CT心脏检查分级（79分）,1，有症状者、中等以上冠心病风险、ECG不 确切、不能进行运动试验，无症状者不推 荐CT检查（筛查）2，急性胸痛者，中等以上冠心病风险、ECG无改 变、酶学正常者3，各种检查结果均不能明确诊断者4，冠状动脉、大血管、心腔和瓣膜等的形态学检查5，肿瘤、血栓、心包病变、肺静脉、冠状动脉内 乳动脉、主动脉夹层动脉瘤、肺栓塞,正常冠状动脉,正常冠状动脉,不同心率冠脉成像结果(支数 %),血管成 90像等级 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 4 2.2 6 1.4 14 4.2 8 4.71 11 15.2 1 0 0 0 1 0.6 0,正常冠状动脉,左冠状动脉狭窄,CTA 与DSA对照,CTA与DSA对照,前降支狭窄,明确诊断后介入治疗,CT检测冠脉狭窄准确性MDCT vs. ANGIOGRAPHY,作者 例数 旋转时间/周 敏感度 特异度 阴性期望值 不能评价Leschka 53 370 ms 94% 97% 99% - Raff 70 330 ms 86% 95% 98% 12%Leber 59 330 ms 73% 97% 99% -Mollet 52 330 ms 99% 95% 99% 2%Ropers 82 330 ms 95% 93% 99% 4%杨立等 61 330 ms 90% 94% 93% -,冠脉粥样硬化斑块,钙化（混合性）斑块 纤维斑块 软斑块（脂池） Agatston Score 90 + 20HU 30 + 20HU,管壁偏心性斑块,管壁偏心性斑块,管壁偏心性斑块,管壁偏心性斑块,管壁环周性斑块,粥样硬化斑块导致管腔狭窄,冠脉血管造影,冠脉支架治疗,The progress of coronary atherosclerosis,Plaque rupture resulting myocardium infarction,Courtesy of Dr. Wei Li-xin. PLA General Hospital, China,The vulnerable plaque without lumen stenosis,The aids of coronary CT imaging:detect the vulunerable plaque before rupture,Courtesy of Dr. Wei Li-xin. PLA General Hospital, China,CT发现冠脉斑块的敏感度PLAQUE DETECTION：MDCT VS. IVUS,83 segments in 22 patients Sensitivity plaque per segment: 94%(all)16-slice CT 53%(non-calcified)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,The controversy 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 accurately identified by MSCT. Motoyama S. Circulation J. 2007 Mar: 71:363-366,Soft plaque 14 26 HU,Intermediate plaque 91 21 HU,calcified plaque 419 194 HU,Schroeder et al. JACC 2001,The controversy in identification of plaque types:MSCT vs. IVUS,Courtesy of Dr. Lars K. Hofmann,The 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 plaques types Pohal K. atherosclerosis, 2007,Jan,190:174-180.,LAD:soft-plaque,No significant stenosis,PLAQUE TRANSFORM,A 54-y/o man with “cardiopalmus”. LAD irregular-surface plaque with lower density and lumen stenosis 50%,2005-11-09,治疗及生活习惯干预,05-11：速降脂，40mg/日，30天 20mg/日，90天饮食控制：不吃内脏类食物，增加蔬菜类戒烟：远动: 6 km/H，30min /日,2006-08-01,2008-12-19,Cor. Dissection,血管迂曲、壁冠状动脉（肌桥）,血管迂曲、壁冠状动脉（肌桥）,心肌桥-壁冠状动脉,冠状动脉部分节段被心肌纤维覆盖，在心肌内走行一段距离后又浅露于心肌表面，覆盖在该段冠状动脉上的心肌束称为心肌桥（Myocardial Bridge MB），位于心肌桥下的冠状动脉称为壁冠状动脉（Mural Coronary Artery MCA ）。心肌桥=心肌桥-壁冠状动脉复合体（MB-MCA）,杨立 赵林芬 李颖等。中华医学杂志， 2006，86：2858-2862,心肌桥相关问题,一般为良性先天发育异常可能的临床意义： 引起心肌退变 与冠状动脉动脉硬化、心律不齐相关 导致急性心肌缺血、猝死等,赵林芬 杨立 中国临床医学影像杂志 2007，18：285-287。,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 tomographic angiography.,K0NEN，JACC, 2007,49(5): 587-693.,Coronary morphology,The normal morphology of RCA,The normal LAD,Intramuscula LAD, superficial type, as seen on axial plane (A, B) and multiplanar reformation (C, D). The mid LAD (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.,Intramuscular LAD, right ventricular 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): 587-693.,Intramuscular 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 intraventricular course (C, D).,Konen，JACC, 2007,49(5): 587-693.,SUPERFICIAL TYPE,VENTRICULAR TYPE(深在型）,MB-MCA ON RCA,Atherosclerosis on MCA,Right ventricular type,Right ventricular type,Right ventricular type,MCA on diastolic and systolic phase,diastolic phase systolic phase,MCA: Mural Coronary Artery,MCA on Diastolic phase MCA on systolic phase,MB-MCA,MB: Myocardial Bridge, MCA: Mural Coronary Artery,MCA on diastolic and systolic phase,Diastolic phase Systolic phase,M，42y，AMI 4 years (at 38 years old),RCA: NO SIGNIFICANT STENOSIS,LCX: NO SIGNIFICANT STENOSIS,MB: Myocardial BridgeMCA: Mural Coronary Artery,LAD: MB-MCA,F，67y，EFFORT ANGINA，3MMyocardial infarction,F，67y，EFFORT ANGINA，3M,M, 53 y, Chest Malaise 3 years,Myocardial ischemia,女63岁，冠心病17年，高血压2年,扩张性心肌病,肥厚性心肌病,术前 术后,瓣膜病变,左房黏液瘤,心脏肿瘤心房肿瘤,？,“胸痛三联”检查-PE,“胸痛三联”检查主动脉壁内血肿,CABG复查,ANASTOMOSIS STENOSIS,支架通畅,冠脉支架评价,M/58,支架邻近再发狭窄,支架内膜增生,In-Stent Restenosis,74 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=0.73,Van Mieghem CA, et al, Circulation, 2006,114(7):616-619,37个冠脉内支架CTA与DSA评价再狭窄,刘新，杨立 等， 中华放射学杂志，2006，40（8）：808,sen spe ppv npv肉眼观察法（） 18 69 20 67 CT值测量法（） 27 81 38 72,冠状动脉起源和分布变异,LAD、LCX单独在左冠窦开口：LCX异位起源RCA、D1RCA、LAD共干LADRCA回旋支缺如冠状动脉间交通RCA起源主动脉,LAD、LCX共同起源左冠窦,LCX起自D1并纤细,左、右冠脉共干,冠脉畸形并左右交通,左冠经交通支与右冠相连,LCX 起源RCA,LCX 起源RCA,心脏CT和其他检查