64层螺旋CT血管造影对复杂先天性心脏病诊断应用临床研究
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摘要
目的：研究64层螺旋CT对复杂先天性心脏病的扫描方法、图像的后处理方法及诊断程序,并与Echo及金标准(手术结果或DSA结果)相比较,探讨64层螺旋CT血管造影在复杂先天性心脏病诊断及手术治疗中的临床应用价值。方法：回顾性分析26例(其中男12例,女14例,平均年龄17.13±16.24岁,中位年龄14岁,最大55岁,最小54天)34种畸形的复杂先天性心脏病患者MSCTA资料,并与金标准(手术结果或DSA结果)及Echo结果比较研究。所有原始图像采用AW4.3工作站进行后处理。结果采用SPSS 13统计软件分析。对心内结构和心外结构异常的诊断,均分别统计Echo组和MSCTA组的灵敏度和假阴性率,并就两组间的灵敏度进行卡方检验,两组间诊断符合性进行一致性检验。对心内外全部结构异常的诊断,分别统计Echo、MSCTA、MSCTA+Echo组的灵敏度和假阴性率,并就三组间的灵敏度进行卡方检验,以及三组间两两诊断符合性的一致性检验。P<0.05差异有统计学意义。结果：26例患者,共有心内外结构异常34种,其中心内结构异常8种,包括室间隔缺损(n=16),房间隔缺损(n=6),肺动脉瓣闭锁(n=1),卵圆孔未闭(n=1),单心房(n=1),房室瓣返流(n=5),肺动脉瓣狭窄(n=1),主动脉瓣重度返流(n=3)；心外结构异常26种,包括右室双出口(n=2),肺动脉狭窄(n=9),肺动脉异常增宽(n=10),主动脉骑跨(n=6),主动脉离断(n=1),主动脉弓发育不良(n=2),主动脉缩窄(n=1),永存动脉干(n=2),动脉导管未闭(n=7),冠脉解剖异常(n=3),双上腔静脉(n=3),左锁骨下静脉异常引流(n=1),右位主动脉弓(n=5),主动脉扩张(n=5),肺动脉骑跨(n=1),肺动脉双重血供(n=1),右肺门双重血供(n=1),右心增大(n=16),完全性肺静脉异位引流(n=2),左心增大(n=10),主动脉右冠窦瘤样扩张(n=1),肺动脉起源异常(n=1),完全性大动脉转位(n=4),升主动脉根部内膜撕脱(n=1),矫正型大动脉转位(n=1),心大静脉引流异常(n=1)。结合手术结果或DSA结果,共发现心内、外血管结构异常131处,其中心内结构异常34处,心外大血管异常97处。MSCTA、Echo诊断心内畸形灵敏度分别为67.65%(23／34)、97.06%(33／34)(X2=10.12,P=0.001<0.05),假阴性率分别为32.35%(11／34)、2.94%(1／34)；MSCTA、Echo诊断心外畸形灵敏度分别为93.81%(91／97)、67.01%(65／97)(X2=22.12,P<0.000<0.05),假阴性率分别为6.19%(6／97)、32.99%(32／97)；MSCTA组、Echo组、MSCTA+Echo组诊断CCHD的灵敏度分别为87.02%(114／131)、74.81%(98／131)、94.66%(124／131)(X2=21.18,P<0.0001<0.05),假阴性率分别为12.98%(17／131)、25.19%(33／131)、5.34%(7／131)。结论：MSCTA能够用于评价复杂先天性心脏病的形态学改变,特别表现在能够准确评价心外大血管解剖形态、排列关系、冠状动脉的解剖变异及心外侧支循环空间位置关系。MSCTA与Echo联合,有助于提高复杂先天性心脏病的诊断灵敏度。三维重建图像能在术前准确提供心脏大血管的起源与解剖形态、异常侧支循环的分布情况和一些常见并发症,有助于术前手术方案的制定和完善,以及对术后患者进行追踪及疗效评价。
Objective:The aim of study was to approach scan type、images'post processing mode and diagnostic program of 64-slice spiral computer tomography in the detection of complex congenital heart disease
(CCHD), approaching the value of multi-slice spiral computer tomography angiography (MSCTA) in the detection of deformities in patienmts with complex congenital heart disease (CCHD). and to compare the consequence with gold standard (operation treat or digital subtraction angiography (DSA) consequence)、MSCTA and echocardiography(Echo),
Method:MSCTA and echocardiography were performed in 26 patients (males 12, females 14, mean age 17.125 years old, meta-age 14 years old, oldest 55 years old, youngest 54 days)with known complex congenital heart disease, to compare the consequence with gold standard (operation or DSA) and echocardiography. All MSCTA raw images were reconstructed with multiple planar reconstruction (MPR),maximum intensity projection (MIP), surface shaded display(SSD) and volume rendering (VR). Statistics of consequence were done by SPSS 13. Every patient were dedvided into two groups(the group of Echo and the group of MSCTA) on the diagnosis of intracardiac or extracardiac malformation, a evaluation of diagnostic test(sensitivity and omission diagnose rate),and sensitivity'chi square test, consistency check were done between the two group, P<0.05 were statistical significance. Every patient were dedvided into three groups(the group of Echo、the group of MSCTA and the group of MSCTA+Echo) on the diagnosis of CCHD, a evaluation of diagnostic test(sensitivity and omission diagnose rate),and sensitivity'chi square test, consistency check were done within the three group, P<0.05 were statistical significance. Result:There were 34 kinds of cardiovascular malformations,8 kinds of intracardiac malformation, including Ventricualr Septal Defect (VSD;n=16), Atrial Septal Defect (ASD;n=6), Pulmonic Valve Atresia (PVA; n=1),Acleistocardia (n=1),Single Atrium (n=1),Atrio-rentriculor Valve Backstreaming (n =5), Pulmonic Valvular Stenosis (PVS; n=1), Backstreaming of Aortic Valve (n=3).26 kinds of extracardiac malformation, including Outlet Right Ventricle (n=2), Pulmonary Artery Stenosis (PAS; n=9), Widen of Pulmonary Artery(n=10), Aortic Overriding (n=6), Interruption of Aortic Arch (n=1), Underdevelopment of Aortic Arch (n=2), Coarctation of Aorta (COA; n=1), Persistent Truncus Arteriosus (PTA; n=2), Patent Ductus Arteriosus (PDA;n=7), Abnormal Anatomy of Coronary Artery (n=3), Double Superior Vena Cava (n=3), Anomalous of Left Subclavian vein Connection (n=1), Right Sided Aortic Arch (n=5), Aortectasia(n=5), Pulmonary Artery Straddle(n=1), Souble Blood Supply of Pulmonary Artery (n=1), Double Blood Supply of Hilum of Right Lung (n=1), Increment of Cor Dextrum (n=16), Total Anomalous of Pulmonary Venous Connection (TAPVD; n=2), Increment of Cor Sinistrum (n=10), Broaden of Right Coronary Sinus (n=1), Anomalous Origin of Pulmonary Artery(n=1), Complete Transposition of Great Arteries (n=4), Endomembrane Avulsion of Aorta Ascendens (n=1), Corrected Transposition of Great Arteries (n=1), Anomalous of Coronary Vein Connection (n=1). The total of 131 anomalies was diagnosed, including 34 intracardiac and 97 extracardiac malformation. The diagnosis sensitivity on intracardiac malformation of MSCTA、Echo were 67.65%(23/34)、97.06 %(33/34)((X2=10.12, P=0.001<0.05), with their omission diagnose rate were 32.35%(11/34)、2.94%(1/34). The diagnosis sensitivity on extracardiac malformation of MSCTA、Echo were 93.81%(91/97)、67.01%(65/97)(X2=22.12, P<0.000<0.05), with their omission diagnose rate were 6.19%(6/97)、32.99%(32/97). The diagnosis sensitivity on CCHD of MSCTA、Echo、MSCTA+Echo were 87.02%(114/131)、74.81%(98/131)、94.66%(124/131)(X2=21.18, P<0.0001<0.05), with their omission diagnose rate were 12.98%(17/131)、25.19% (33/131)、5.34%(7/131). Conclusion:Morphological alteration of complex congenital heart disease could be estimated by MSCTA. It could exactly appraise of great vessels' anatomic form、disposed relation、dissection anomalism of coronary artery、dimensional position relation of collateral circulation exceptionally MSCTA and Echo may become an altenrative method in the detection of complex congenital heart disease. The combination of both is helpful to provide a final diagnosis and also to improve the treatment management of that. Some common complication and preoperative information,such as origin and anatomic form of great vessels、distribution of abnormal collateral circulation, could be exactly displayed with three-dimensional reconstruction image, it make for preoperative operation plan and tracing、curative evaluation of postoperative patients.
Objective:The aim of study was to approach scan type、images'post processing mode and diagnostic program of 64-slice spiral computer tomography in the detection of complex congenital heart disease
(CCHD), approaching the value of multi-slice spiral computer tomography angiography (MSCTA) in the detection of deformities in patienmts with complex congenital heart disease (CCHD). and to compare the consequence with gold standard (operation treat or digital subtraction angiography (DSA) consequence)、MSCTA and echocardiography(Echo),
Method:MSCTA and echocardiography were performed in 26 patients (males 12, females 14, mean age 17.125 years old, meta-age 14 years old, oldest 55 years old, youngest 54 days)with known complex congenital heart disease, to compare the consequence with gold standard (operation or DSA) and echocardiography. All MSCTA raw images were reconstructed with multiple planar reconstruction (MPR),maximum intensity projection (MIP), surface shaded display(SSD) and volume rendering (VR). Statistics of consequence were done by SPSS 13. Every patient were dedvided into two groups(the group of Echo and the group of MSCTA) on the diagnosis of intracardiac or extracardiac malformation, a evaluation of diagnostic test(sensitivity and omission diagnose rate),and sensitivity'chi square test, consistency check were done between the two group, P<0.05 were statistical significance. Every patient were dedvided into three groups(the group of Echo、the group of MSCTA and the group of MSCTA+Echo) on the diagnosis of CCHD, a evaluation of diagnostic test(sensitivity and omission diagnose rate),and sensitivity'chi square test, consistency check were done within the three group, P<0.05 were statistical significance. Result:There were 34 kinds of cardiovascular malformations,8 kinds of intracardiac malformation, including Ventricualr Septal Defect (VSD;n=16), Atrial Septal Defect (ASD;n=6), Pulmonic Valve Atresia (PVA; n=1),Acleistocardia (n=1),Single Atrium (n=1),Atrio-rentriculor Valve Backstreaming (n =5), Pulmonic Valvular Stenosis (PVS; n=1), Backstreaming of Aortic Valve (n=3).26 kinds of extracardiac malformation, including Outlet Right Ventricle (n=2), Pulmonary Artery Stenosis (PAS; n=9), Widen of Pulmonary Artery(n=10), Aortic Overriding (n=6), Interruption of Aortic Arch (n=1), Underdevelopment of Aortic Arch (n=2), Coarctation of Aorta (COA; n=1), Persistent Truncus Arteriosus (PTA; n=2), Patent Ductus Arteriosus (PDA;n=7), Abnormal Anatomy of Coronary Artery (n=3), Double Superior Vena Cava (n=3), Anomalous of Left Subclavian vein Connection (n=1), Right Sided Aortic Arch (n=5), Aortectasia(n=5), Pulmonary Artery Straddle(n=1), Souble Blood Supply of Pulmonary Artery (n=1), Double Blood Supply of Hilum of Right Lung (n=1), Increment of Cor Dextrum (n=16), Total Anomalous of Pulmonary Venous Connection (TAPVD; n=2), Increment of Cor Sinistrum (n=10), Broaden of Right Coronary Sinus (n=1), Anomalous Origin of Pulmonary Artery(n=1), Complete Transposition of Great Arteries (n=4), Endomembrane Avulsion of Aorta Ascendens (n=1), Corrected Transposition of Great Arteries (n=1), Anomalous of Coronary Vein Connection (n=1). The total of 131 anomalies was diagnosed, including 34 intracardiac and 97 extracardiac malformation. The diagnosis sensitivity on intracardiac malformation of MSCTA、Echo were 67.65%(23/34)、97.06 %(33/34)((X2=10.12, P=0.001<0.05), with their omission diagnose rate were 32.35%(11/34)、2.94%(1/34). The diagnosis sensitivity on extracardiac malformation of MSCTA、Echo were 93.81%(91/97)、67.01%(65/97)(X2=22.12, P<0.000<0.05), with their omission diagnose rate were 6.19%(6/97)、32.99%(32/97). The diagnosis sensitivity on CCHD of MSCTA、Echo、MSCTA+Echo were 87.02%(114/131)、74.81%(98/131)、94.66%(124/131)(X2=21.18, P<0.0001<0.05), with their omission diagnose rate were 12.98%(17/131)、25.19% (33/131)、5.34%(7/131). Conclusion:Morphological alteration of complex congenital heart disease could be estimated by MSCTA. It could exactly appraise of great vessels' anatomic form、disposed relation、dissection anomalism of coronary artery、dimensional position relation of collateral circulation exceptionally MSCTA and Echo may become an altenrative method in the detection of complex congenital heart disease. The combination of both is helpful to provide a final diagnosis and also to improve the treatment management of that. Some common complication and preoperative information,such as origin and anatomic form of great vessels、distribution of abnormal collateral circulation, could be exactly displayed with three-dimensional reconstruction image, it make for preoperative operation plan and tracing、curative evaluation of postoperative patients.
引文
1. Samyn MM. A review of the complementary information available with cardiac magnetic resonance imaging and multi-slice computed tomography (CT) during the study of congenital heart disease[J]. Inter J Cardiovas Image,2004,20 (6):569-578.
2.陶中良,张玉玲,孙向东,等.常见先天性心脏病的诊断与手术治疗[J].河南外科学杂志,2003,9(5)：4-5.
3.周爱卿.心导管术-先天性心脏病诊断与治疗[M].济南：山东科学技术出版社,1997：160.
4. Francois CJ, Tuite D,Deshpande V, et al. Pulmonary Vein Imaging with Unenhanced Three-dimensional Balanced Steadv-State Free Precession MR Angiography:Initial Clinical Evaluation.Radiology[J].2009,250(3): 932-939.
5. Pena E, Nguyen ET, Merchant N, et al. ALCAPA Syndrome:Not Just a Pediatric Disease, RadioGraphics[J].2009,29(2):553-565.
6.孙立军,江海寿,李军,等.复杂先天性心脏病数字造影和超声诊断的对比研究[J].中华放射学杂志,1999,33(11)：729-733.
7. Funabashi N, Asano M, Sekine T, et al.. Direction, location, and size of shunt flow in congenital heart disease evaluated by ECG-gated multi-slice computed tomography. International Journal of Cardiology [J].2006; 112(3): 399-404.
8.江一峰,叶剑定,吴健等.64层螺旋CT在复杂先天性心脏病诊断中的应用.中华医学会第十五次全国放射学学术会议.2008年10月,重庆,860-861.
9.王俊,徐莹,肖香佐.EBCT、MRI、MSCT对先天性心脏病诊断价值的比较.江西医学院学报[J]2005,45(6)：162-164.
10.黄美萍,梁长虹,曾辉,等.多层螺旋CT在小儿复杂先天性心脏病诊断中的应用[J].中华放射学杂志,2004,38(7)：726-731.
11. Shuman WP; Branch KR; May JM. et al. Prospective versus Retrospective ECG Gating for 64-Detector CT of the Coronary Arteries:Comparison of Image Quality and Patient Radiation Dose,Radiology [J].2008,248(2): 431-437.
12. Morin RL, Gerber TC, McCollough CH. Radiation dose in computed tomography of the heart. Circulation[J].2003,107(6):917-922.
13. Hunold P, Vogt FM, Schmermund A, et al. Radiation exposure during cardiac CT:effective doses at multi-detector row CT and electron-beam CT. Radiology[J].2003;226(1):145-152.
14. Hall EJ. Lessons We Have Learned from Our Children:Cancer Risks from Diadnostic Radiology. Pediatr Radiol[J].2002,3299(10):700-706.
15.高建华,孙宪昶,李剑颖,等.不同前置滤线器对64层螺旋CT管状动脉成像质量及放射剂量影响的对照研究.中华放射学杂志[J].2007,41(8)：858-861.
16. Goo HW, Park IS, Ko JK, et al. CT of congenital heart disease:normal anatomy and typical pathologic conditions. RadioGraphics [J].2003;23 (SpecIssue):S147-S165.
17.王荣品.多层螺旋CT在复杂型先天性心脏病中的应用[J].临床放射学杂志,2007,26(5)：516-518.
18. Maintz D, Seifarth H, Raupach R, et al.64-slice multidetector coronary CT angiography:in vitro evaluation of 68 different stents[J]. Eur Radiol, 2006,16 (4):818-826.
19. Raman SV, Cook SC, McCarthy B, et al.Usefulness of multi-detector row conputed tomography to quantify right ventricular size and functiong in adults with either letralogy of Fallot or transposition of the great arteries[J].J Am Cardio,2005,95 (5):683-686.
20. Boxt LM.Magnetic resonance and conputed tomographic evaluation of congenital heart disease[J].Magn Reson Imaging,2004,19(6):827-847.
21. Uergens KU, Fischbach R. Left ventricular function studied with MDCT[J].Eur Radiol,2006,16 (2):342-357.
22. Alkadhi H, Wildermuth S, Bettex DA, et al. Mitral regurgitation: quantification with 16-detector row CT—initial experience[J]. Radiology, 2006,238 (2):454-463.
23. Schuijf JD, Bax JJ, Salm LP, et al. Noninvasive coronary imaging and assessment of left ventricular function using 16-slice computed tomography[J].Am J Cardiol,2005,95 (5):571-574.
24. Juergens KU, Grude M, Maintz D, et al. Multidetector row CT of left ventricular function with dedicated analysis software versus MR imaging: initial experience[J]. Radiology,2004,230 (2):403-410.
1. Samyn MM.A review of the complementary information available with cardiac magnetic resonance imaging and multi-slice computed tomography (CT) during the study of congenital heart disease[J]. Inter J Cardiovas Image,2004,20 (6):569-578.
2.陶中良,张玉玲,孙向东,等.常见先天性心脏病的诊断与手术治疗[J].河南外科学杂志,2003,9(5)：4-5.
3.周爱卿.心导管术-先天性心脏病诊断与治疗[M].济南：山东科学技术出版社,1997：160.
4.王荣品.多层螺旋CT在复杂型先天性心脏病中的应用[J].临床放射学杂志,2007,26(5)：516-518.
5.柳宏波.多层螺旋CT在先天性心脏病诊断中的应用进展.中国实用儿科杂志[J],2006,21(9)：709—711.
6. Funabashi N, Asano M,Sekine T, et al.. Direction, location, and size of shunt flow in congenital heart disease evaluated by ECG-gated multislice computed tomography. International Journal of Cardiology[J].2006;112(3): 399-404.
7.江一峰叶剑定,吴健等.64层螺旋CT在复杂先天性心脏病诊断中的应用.中华医学会第十五次全国放射学学术会议.2008年10月,重庆,860-861.
8.李向民,李箐,孟俊非,等.先天性大血管转位的EBCT诊断.影像诊断与 介入放射学[J],2000,9(4)：198-200.
9.王俊,徐莹,肖香佐.EBCT、MRI、MSCT对先天性心脏病诊断价值的比较.江西医学院学报[J]2005,45(6)：162-164.
10.黄美萍,梁长虹,曾辉,等.多层螺旋CT在小儿复杂先天性心脏病诊断中的应用[J].中华放射学杂志,2004,38(7)：726-731.
11.王荣品,先正元,杨明放,等.多层螺旋CT对复杂型先天性心脏病的诊断价值[J].临床放射学杂志2007,26(4)：341-346.
12.周阳泱,韩萍,冯敢生,等.多层螺旋CT血管造影在小儿复杂先天性心脏病中的临床应用价值[J].中华小儿外科杂志,2005,26(11)：579-582.
13.孙立军,江海寿,李军,等.复杂先天性心脏病数字造影和超声诊断的对比研究[J].中华放射学杂志,1999,33(11)：729-733.
14. Maintz D, Seifarth H, Raupach R, et al.64-slice multidetector coronary CT angiography:in vitro evaluation of 68 different stents[J]. Eur Radiol, 2006,16 (4):818-826.
15. Hall EJ. Lessons We Have Learned from Our Children:Cancer Risks from Diadnostic Radiology. Pediatr Radiol[J].2002,3299(10):700-706.
16. Shuman WP; Branch KR; May JM. et al. Prospective versus Retrospective ECG Gating for 64-Detector CT of the Coronary Arteries:Comparison of Image Quality and Patient Radiation Dose,Radiology [J].2008,248(2): 431-437.
17. Morin RL, Gerber TC, McCollough CH. Radiation dose in computed tomography of the heart. Circulation[J].2003,107(6):917-922.
18. Hunold P, Vogt FM, Schmermund A, et al. Radiation exposure during cardiac CT:effective doses at multidetector row CT and electron-beam CT. Radiology[J].2003;226(1):145-152.
19.高建华,孙宪昶,李剑颖,等.不同前置滤线器对64层螺旋CT管状动脉成像质量及放射剂量影响的对照研究.中华放射学杂志[J].2007,41(8)：858-861.
20. Goo HW, Park IS, Ko JK, et al. CT of congenital heart disease:normal anatomy and typical pathologic conditions. RadioGraphics [J].2003;23(Spec Issue):S147-S165.
21. Francois CJ, Tuite D,Deshpande V, et al. Pulmonary Vein Imaging with Unenhanced Three-dimensional Balanced Steady-State Free Precession MR Angiography:Initial Clinical Evaluation.Radiology[J].2009,250(3): 932-939.
22. Pena E,Nguyen ET,Merchant N, et al. ALCAPA Syndrome:Not Just a Pediatric Disease, RadioGraphics[J].2009,29(2):553-565.
23. Raman SV, Cook SC, McCarthy B, et al.Usefulness of multi-detector row conputed tomography to quantify right ventricular size and functiong in adults with either letralogy of Fallot or transposition of the great arteries[J].J Am Cardio,2005,95 (5):683-686.
24. Boxt LM.Magnetic resonance and conputed tomographic evaluation of congenital heart disease[J].Magn Reson Imaging,2004,19 (6):827-847.
25. Juergens KU, Fischbach R. Left ventricular function studied with MDCT[J].Eur Radiol,2006,16 (2):342-357.
26. Alkadhi H, Wildermuth S, Bettex DA,et al. Mitral regurgitation: quantification with 16-detector row CT—initial experience[J]. Radiology, 2006,238 (2):454-463.
27. Schuijf JD, Bax JJ, Salm LP, et al. Noninvasive coronary imaging and assessment of left ventricular function using 16-slice computed tomography[J].Am J Cardiol,2005,95 (5):571-574.
28. Juergens KU, Grude M, Maintz D, et al. Multidetector row CT of left ventricular function with dedicated analysis software versus MR imaging: initial experience[J]. Radiology,2004,230 (2):403-410.
29. Namdar M, Hany TF, Koepfli P, et al. Integrated PET/CT for the assessment of coronary artery disease:a feasibility study[J]. J Nucl Med, 2005,46 (6):930-935.
2.陶中良,张玉玲,孙向东,等.常见先天性心脏病的诊断与手术治疗[J].河南外科学杂志,2003,9(5)：4-5.
3.周爱卿.心导管术-先天性心脏病诊断与治疗[M].济南：山东科学技术出版社,1997：160.
4. Francois CJ, Tuite D,Deshpande V, et al. Pulmonary Vein Imaging with Unenhanced Three-dimensional Balanced Steadv-State Free Precession MR Angiography:Initial Clinical Evaluation.Radiology[J].2009,250(3): 932-939.
5. Pena E, Nguyen ET, Merchant N, et al. ALCAPA Syndrome:Not Just a Pediatric Disease, RadioGraphics[J].2009,29(2):553-565.
6.孙立军,江海寿,李军,等.复杂先天性心脏病数字造影和超声诊断的对比研究[J].中华放射学杂志,1999,33(11)：729-733.
7. Funabashi N, Asano M, Sekine T, et al.. Direction, location, and size of shunt flow in congenital heart disease evaluated by ECG-gated multi-slice computed tomography. International Journal of Cardiology [J].2006; 112(3): 399-404.
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