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左室声学造影的临床应用

2015-01-30 南方医科大学附属南方医院 吴爵非 刘俭 查道刚 刘伊丽 中国医学论坛报

左室声学造影临床应用
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医学影像技术是20世纪医学研究取得重大成就的领域之一，其发展的核心内容是应用各种造影剂对比显像。超声造影是临床应用最广泛、也是唯一非常规应用造影剂的影像技术。本文将介绍在心血管疾病临床治疗中左室声学造影(LVO)的应用。 在LVO中，受试者经周围静脉注射超声造影剂(包裹1μm~10μm惰性气体的脂质或白蛋白微泡)。微泡通过肺血管床后进入左室，使左室影像对比增强，清晰界定左室壁内膜，以辅助观察

医学影像技术是20世纪医学研究取得重大成就的领域之一，其发展的核心内容是应用各种造影剂对比显像。超声造影是临床应用最广泛、也是唯一非常规应用造影剂的影像技术。本文将介绍在心血管疾病临床治疗中左室声学造影(LVO)的应用。

在LVO中，受试者经周围静脉注射超声造影剂(包裹1μm~10μm惰性气体的脂质或白蛋白微泡)。微泡通过肺血管床后进入左室，使左室影像对比增强，清晰界定左室壁内膜，以辅助观察室壁运动和室壁结构改变。

LVO在负荷超声试验中的应用

国际指南明确指出，可疑稳定性冠心病(SCAD)患者，如验前概率[PTP，根据年龄、性别和胸痛类型预测患冠心病(CAD)的可能性]为15%~65%，就应进行心脏负荷试验，评估冠脉血流储备和检出缺血心肌，进而确定后续诊疗方案。

心电图(ECG)运动负荷(平板或踏车运动)试验仍是最基本的心脏负荷试验。但ECG运动负荷试验对存在左束支传导阻滞(LBBB)、起搏心律和预激综合征(WPW)等的患者缺乏诊断价值。同时，ECG运动负荷试验的假阳性结果常见于有左室肥厚、电解质紊乱、室内传导异常、心房颤动和应用洋地黄的患者。此外，ECG运动负荷试验在女性患者中的敏感性和特异性较低。

因此，在ECG运动负荷试验的基础上，国际广泛开展了无创性负荷影像试验，从负荷后的室壁运动和心肌血流灌注变化来检出可逆性心肌缺血。其中负荷超声和负荷核素[单光子发射计算机断层显像(SPECT)]是最常用的手段。与其他影像试验相比，运动负荷超声的室壁运动分析对SCAD诊断的敏感性、特异性较高。

各个标准二维(2D)左室超声切面均与冠状动脉各个主支分布密切相关，这是应用负荷超声试验的基础。发现负荷后某个左室室壁节段增厚异常(供-求不匹配)，可推测相应冠脉的狭窄程度。因此，超声图像的清晰度直接影响结果评估的质量。2013年欧洲心脏病学会(ESC)SCAD指南明确提出，当静息超声显示有2个以上连续左室节段不清楚时就应常规应用超声造影剂。

2014年，我们对100余例患者进行了联合平板运动负荷超声和ECG检查，均安全、高质量地完成，与大家分享几例。

图1 为1例男性患者，65岁，临床表现为非典型心绞痛。PTP评估有59%的可能患CAD。运动达峰值后无明显胸痛，但超声心动图显示左室心尖和前壁运动减弱，提示为左前降支(LAD)病变。冠脉造影证实为LAD近段接近闭塞性狭窄。


图2冠脉造影提示LAD病变及置入冠脉支架前后FFR测量结果。A：LAD狭窄处术前FFR测值为0.72；B：LAD狭窄处支架置入术后FFR为0.85。


图2 为1例男性患者，1个月前因急性下壁ST段抬高型心肌梗死，在某医院行右冠状动脉(RCA)支架重建，同时发现LAD病变，嘱择期处理。平板负荷超声试验检出左室前壁心肌缺血。冠脉造影显示LAD中重度狭窄。LAD灌注心肌区域的血流储备分数(FFR)为0.72(FFR小于0.75~0.80是进行血流重建的指征)。置入支架后，FFR恢复至0.88。

LVO用于特殊心肌病的诊断

图3为1例男性患者，52岁，反复心力衰竭史5年。2013年经某医院心脏超声检查显示双房增大，左室射血分数(LVEF)为31%，诊断为限制型心肌病。同年该院心脏磁共振成像(MRI)显示全心增大、室间隔及左室壁广泛延迟强化(LGE)，诊断为扩张型心肌病。2014年6月28日经我院心内科经胸超声检查显示双房大、右室大、重度三尖瓣关闭不全、肺动脉压38mmHg、LVEF为43%。因超声图像欠清晰，遂进行LVO，结果显示为典型左室心肌致密化不全。



图4为1例60岁男性患者，因眼睑及下肢浮肿1月余来我院检查。ECG显示有轻度ST-T改变。因经胸超声图像不够清晰而行超声LVO，意外发现右室心尖闭塞，考虑为限制型心肌病。结合多年血嗜酸性粒细胞增高史，推断为少见的嗜酸性粒细胞增多性心内膜心肌病(Loffler’s心肌病)。遂行心脏MRI检查，显示为右室心尖内膜增厚、心肌纤维化、心包增厚、右室变小、右房增大。测周围静脉压为17cm水柱。右心心内膜活检显示，嗜酸性粒细胞局部沉积;骨髓活检显示，各阶段嗜酸性粒细胞增多。经泼尼松口服治疗，嗜酸性粒细胞值恢复正常。最后诊断为特发性嗜酸性粒细胞增多性心内膜心肌炎、右室限制型心肌病、轻度大循环淤血。

无创负荷试验室应为心内科的主要组成单元之一，用于筛查CAD、冠脉重建后心肌功能评估和非心脏手术前CAD评估。心电图运动负荷试验是最基本的无创手段，运动/药物影像负荷试验是必要的补充手段(尤其针对女性患者)。负荷SPECT是最常用的评估心肌灌注方法，负荷超声是最常用的评估室壁运动方法，同步左室声学造影能提高室壁运动分析的质量和可信度，且对特殊心肌病有特异性诊断价值。


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    2015-12-17 日月

    #声学造影#

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=1981503, encodeId=fbd6198150375, content=<a href='/topic/show?id=018242368da' target=_blank style='color:#2F92EE;'>#声学造影#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42368, encryptionId=018242368da, topicName=声学造影)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4a4d285, createdName=日月, createdTime=Thu Dec 17 01:05:00 CST 2015, time=2015-12-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1835587, encodeId=9da2183558eb1, content=<a href='/topic/show?id=cfdc22e893f' target=_blank style='color:#2F92EE;'>#临床应用#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22789, encryptionId=cfdc22e893f, topicName=临床应用)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=fc8528, createdName=clmlylxy, createdTime=Thu Jul 02 21:05:00 CST 2015, time=2015-07-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=16631, encodeId=edda166311c, content=非常好的文章，学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f2fb1607679, createdName=orthoW, createdTime=Sat Feb 21 10:36:00 CST 2015, time=2015-02-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=16220, encodeId=b57b16220bf, content=已阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=da6b7222, createdName=chinayinhan, createdTime=Tue Feb 17 00:57:00 CST 2015, time=2015-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=15482, encodeId=7ec915482cd, content=明白, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200609/ef6a57dbe7f1489dad7446b7c5217858/d5e4fe65996c4446a029b0f5d056abb1.jpg, createdBy=6b011518214, createdName=午夜星河, createdTime=Sun Feb 15 13:56:00 CST 2015, time=2015-02-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1493980, encodeId=91a7149398060, content=<a href='/topic/show?id=3e34949e333' target=_blank style='color:#2F92EE;'>#造影#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94973, encryptionId=3e34949e333, topicName=造影)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=908d9134595, createdName=sodoo, createdTime=Sun Feb 01 01:05:00 CST 2015, time=2015-02-01, status=1, ipAttribution=)]
    2015-07-02 clmlylxy

    #临床应用#

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1981503, encodeId=fbd6198150375, content=<a href='/topic/show?id=018242368da' target=_blank style='color:#2F92EE;'>#声学造影#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42368, encryptionId=018242368da, topicName=声学造影)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4a4d285, createdName=日月, createdTime=Thu Dec 17 01:05:00 CST 2015, time=2015-12-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1835587, encodeId=9da2183558eb1, content=<a href='/topic/show?id=cfdc22e893f' target=_blank style='color:#2F92EE;'>#临床应用#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22789, encryptionId=cfdc22e893f, topicName=临床应用)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=fc8528, createdName=clmlylxy, createdTime=Thu Jul 02 21:05:00 CST 2015, time=2015-07-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=16631, encodeId=edda166311c, content=非常好的文章，学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f2fb1607679, createdName=orthoW, createdTime=Sat Feb 21 10:36:00 CST 2015, time=2015-02-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=16220, encodeId=b57b16220bf, content=已阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=da6b7222, createdName=chinayinhan, createdTime=Tue Feb 17 00:57:00 CST 2015, time=2015-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=15482, encodeId=7ec915482cd, content=明白, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200609/ef6a57dbe7f1489dad7446b7c5217858/d5e4fe65996c4446a029b0f5d056abb1.jpg, createdBy=6b011518214, createdName=午夜星河, createdTime=Sun Feb 15 13:56:00 CST 2015, time=2015-02-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1493980, encodeId=91a7149398060, content=<a href='/topic/show?id=3e34949e333' target=_blank style='color:#2F92EE;'>#造影#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94973, encryptionId=3e34949e333, topicName=造影)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=908d9134595, createdName=sodoo, createdTime=Sun Feb 01 01:05:00 CST 2015, time=2015-02-01, status=1, ipAttribution=)]
    2015-02-21 orthoW

    非常好的文章，学习

    0

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    2015-02-17 chinayinhan

    已阅

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1981503, encodeId=fbd6198150375, content=<a href='/topic/show?id=018242368da' target=_blank style='color:#2F92EE;'>#声学造影#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42368, encryptionId=018242368da, topicName=声学造影)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4a4d285, createdName=日月, createdTime=Thu Dec 17 01:05:00 CST 2015, time=2015-12-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1835587, encodeId=9da2183558eb1, content=<a href='/topic/show?id=cfdc22e893f' target=_blank style='color:#2F92EE;'>#临床应用#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22789, encryptionId=cfdc22e893f, topicName=临床应用)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=fc8528, createdName=clmlylxy, createdTime=Thu Jul 02 21:05:00 CST 2015, time=2015-07-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=16631, encodeId=edda166311c, content=非常好的文章，学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f2fb1607679, createdName=orthoW, createdTime=Sat Feb 21 10:36:00 CST 2015, time=2015-02-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=16220, encodeId=b57b16220bf, content=已阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=da6b7222, createdName=chinayinhan, createdTime=Tue Feb 17 00:57:00 CST 2015, time=2015-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=15482, encodeId=7ec915482cd, content=明白, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200609/ef6a57dbe7f1489dad7446b7c5217858/d5e4fe65996c4446a029b0f5d056abb1.jpg, createdBy=6b011518214, createdName=午夜星河, createdTime=Sun Feb 15 13:56:00 CST 2015, time=2015-02-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1493980, encodeId=91a7149398060, content=<a href='/topic/show?id=3e34949e333' target=_blank style='color:#2F92EE;'>#造影#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94973, encryptionId=3e34949e333, topicName=造影)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=908d9134595, createdName=sodoo, createdTime=Sun Feb 01 01:05:00 CST 2015, time=2015-02-01, status=1, ipAttribution=)]
    2015-02-15 午夜星河

    明白

    0

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    2015-02-01 sodoo

    #造影#

    0