双源CT前瞻性心电门控扫描在小儿肺动脉发育异常中的临床应用价值
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摘要
肺动脉畸形是胚胎时期原始动脉弓发育异常所致,各种先心病畸形中,单发或是伴发的肺动脉畸形比较多见,其中复杂先天性心脏病中合并肺动脉发育异常的比率更高,准确评价肺动脉发育情况对决定手术时机、术后康复及合并其他呼吸系统疾病的治疗均有重要临床意义,甚至直接决定着能否手术及手术的方式。经胸壁超声心动图(transthoracic echocardiography, TTE)在显示心内畸形及瓣膜病变有较大优势,是临床上最常用的无创检查方法,但超声波受到肺内气体及骨骼等的影响,使超声检查及肺动脉测量准确性受到限制,并很大程度上依赖于诊断人员的个人技术,难以获取准确的测量值,更不能对心外肺动脉畸形进行有效诊断。X线心血管造影(cardioangiography, CAG)是一种有创检查,操作复杂且受体位限制,尤其对小儿患者,此检查常需要在全麻下完成,操作复杂且危险性大。电子束CT具有较高的时间分辨率,但因检查成本较高未能普及。MRI检查时间较长且噪声较大,在新生儿及婴幼儿中难以获得较好效果。临床需要一种无创情况下能对肺动脉的测量更为直观、准确、可信的无创检查方法,从而有利于手术适应症的把握。多层螺旋CT (multi-slice spiral CT, MSCT)具有扫描速度快、扫描范围大、时间和空间分辨率高、无创快捷等优势,在心血管疾病的诊断中前景广阔,但关键问题在于如何有效的降低辐射剂量。
双源CT (dual-source CT, DSCT)具有两套呈90度角的X-ray球管和探测器系统,其单扇区成像时间分辨率达到了83ms,成像速度更快,尽可能地减少了呼吸运动造成的伪影,满足了高心率条件下对图像质量的提升,其多平面重组(MPR)、最大密度投影(MIP)及容积再现(VR)等多种图像重组技术可立体地呈现心内外大血管结构,已初步应用于先心病的检查中。目前在双源CT心血管造影检查中回顾性心电门控模式应用较普遍,但是其低螺距及重叠螺旋扫描产生了较高的辐射剂量,尽管应用了降低射线剂量的方法,包括因人而宜的个体化CT检查参数设置,低管电压和管电流调整能将先心病CT检查有效辐射剂量降至3.6mSv,但是其射线辐射仍是回顾性心电门控检查的固有限制。前瞻性心电门控横断面扫描可显著降低辐射剂量,已成功应用于成人冠状动脉检查,并有部分将其用于小儿先心病检查的文献报道。
目的本研究应用双源CT前瞻性心电门控扫描对临床怀疑肺动脉发育异常的患儿进行心胸联合血管成像,探讨前瞻性心电门控低剂量扫描技术在小儿肺动脉发育异常中的临床应用价值。
方法经TTE拟诊为先天性心脏病合并肺动脉畸形及临床怀疑肺动脉发育异常的患儿43例(平均年龄：18月,范围：2月-13岁；男性23例,女性20例；平均体重13kg)。通过采用实时的心电图适应性剂量调控技术(ECG-Pulsing).降低管电压和管电流来实现对患儿的低剂量扫描。管电压、管电流采用个体化方案：体重被用来作为调整管电压和管电流的标准执行：<5kg的患儿、管电压80kV,管电流40～59mAs；5-10kg的患儿,管电压80 kV,管电流60～79mAs；>10kg的患儿,管电压80 kV,管电流80～120mAs。采用前瞻性心电门控技术,采集中心期相为40%R-R间期,其他扫描参数：准直2×32×0.6mm,重建层厚0.75mm,机架旋转一圈时间0.33S。对扫描参数、辐射剂量进行详细记录和统计。所得原始图像全部传入后处理工作站Leonardo,进行多平面重组(MPR)、最大密度投影(MIP)以及容积再现(VR)等多种图像重组,由2名在心血管影像诊断领域有5年经验的放射科医师独立阅片,对图像质量进行评价,针对不一致的评价经共同阅片讨论,达成一致意见,并把诊断结果与手术和／或CAG的结果进行对照分析。43例患儿全部同时行TTE检查,13例经CAG检查,37例患者经手术证实。计算DSCT和TTE两种检查方法对肺动脉发育畸形的诊断准确率,利用四格表资料的x2检验比较二者差异是否具有统计学意义。
结果43例患儿术前DSCT心血管造影准确诊断肺动脉发育异常48处。
肺动脉扩张13处：肺动脉主干扩张合并左右肺动脉同时扩张9处；肺动脉主干扩张合并左肺动脉扩张,右肺动脉无扩张或狭窄2处；肺动脉主干扩张合并右肺动脉扩张,左肺动脉无扩张或狭窄2处。
肺动脉狭窄13处：肺动脉瓣狭窄4处,同时合并瓣狭窄后肺动脉干扩张；右室流出道漏斗部狭窄2处；肺动脉分支狭窄7处。肺动脉分支狭窄包含：肺动脉主干合并左右肺动脉同时狭窄4处；肺动脉主干合并左肺动脉狭窄,右肺动脉无扩张或狭窄1处；肺动脉主干合并右肺动脉狭窄,左肺动脉无扩张或狭窄2处。
肺动脉闭锁6处：肺动脉闭锁,左右肺动脉汇合4处,其中2处经肺动脉主干分出左右肺动脉,2处未显示肺动脉主干；肺动脉闭锁,左右肺动脉无汇合2处,由侧枝单独供血。
肺动脉缺如6处：健侧肺动脉跨纵隔供血(马蹄肺)2处,肺动脉主干分出的两支肺动脉进入一侧肺野,其中一支肺动脉跨越纵隔进入对侧供应肺血；体循环供血,由PDA或大侧枝供应肺血2处；一侧肺动脉完全或部分缺如,无血供,同侧肺未发育或发育不良2处
肺动脉起源异常或异常交通9处：主肺动脉间隔缺损2处；永存动脉干1处；一侧肺动脉起源异常5处,含左肺动脉主干起于右肺动脉2处,左下肺动脉起于右肺动脉1处,右肺动脉起于升主动脉2处；肺动脉与冠脉异常交通1处。
肺动脉分支发育变异1处：左肺动脉主干较短,左肺动脉分叉较早。
漏诊1处,为左、右肺动脉分叉处远端分支广泛狭窄。
43例均经手术和/或CAG证实,DSCT对肺动脉发育异常总的诊断准确率为98.0%,TTE对肺动脉发育异常的诊断准确率为73.5%,二者的准确率差异有统计学意义(x2=31.24,P<0.05)。43例术前DSCT血管造影均获得满意图像,平均主观图像质量分数是4.2±0.8。对所有病例前瞻性心电门控下的扫描参数及辐射剂量进行记录,所得平均有效辐射剂量为0.38±0.08mSv。
结论DSCT前瞻性心电门控心胸联合血管成像对小儿脉动脉发育异常具重要的临床应用价值,诊断准确率明显高于TTE。DSCT前瞻性心电门控是一种有效减低辐射剂量的扫描方式,是小儿肺动脉发育异常术前诊断首选的检查方法之一。
BACKGROUND:
Pulmonary artery dysplasia which results from anomalies of original embryonic arcade is not a rare disease. In all sorts of congenital heart disease deformity, solitary or accompanied pulmonary artery malformations occur more frequently, and the ratio of complex congenital heart disease accompanied with pulmonary artety dysplasia is higher. Evaluating the pulmonary artery development conditions accurately enables to determine the operation time, and is helpful for postoperative rehabilitation and treatment of other complicated respiratory disease, even has an effect on the decision of surgery and the way of surgery. Transthoracic echocardiography (TTE) remains a primary imaging examination in patients with suspected CHD, and is superior in displaying intracardiac deformity and valve lesions, sometimes eliminating the need for cardiac catheterization. However, because of a small field of view,and interference of air and bone, it is difficult to demonstrate extracardiac vascular structures in their entirety. Ultrasound examination and pulmonary artery measurement which mostly depends on the individual experience is restricted. It is difficult to acquire accurate measurement values and more effective diagnosis of the pulmonary artery branches outside heart chamber.Cardioangiography(CAG) is an invasive modality which yields important hemodynamic data and defines anatomy clearly in vessels which are accessible to catheterization. However, CAG often gives only indirect information regarding venous connections and arterial anatomy distal to high-grade stenosis or atresia. It also produces high doses of ionizing radiation and is limited by the inherent risk of iodinated contrast material. Electron beam CT has high time resolution, but it failed to be widely used because the check cost is high. MRI takes a longer time and generates much noise in the examination, and it fails to obtain good imaging. A non-invasive method which can be more intuitive, accurate and credible for pulmonary arterial measurement in clinic setting is required. What's more, it will help to maste the surgical indications. With the advantages of higher scanning speed, larger scanning range, higher temporal resolution and spatial resolution and the noninvasive examination, MDCT (multi-slice, MSCT) has a wide perspective.However, how to reduce effective radiation dose is still a problem.
The dual-source CT (DSCT) scanner is characterized by two x-ray tubes and two corresponding detectors mounted onto the rotating gantry with an angular offset of 90°. Its single sector imaging temporal resolution reached 83ms, so it reduced the artifact caused by breathing movement and obtained high quality image in the condition of high rate.Multiplanar reconstruction (MPR), maximum indensity projection (MIP) and volume rendering (VR) three-dimensionally represent intra and extra cardiac vascular structures. Such reconstruction methods have been initially used in congenital heart disease. Currently Retrospectively ECG-gated DSCT angiocardiography has been widely used, however, the use of a low pitch and overlapping spiral CT acquisition results in the relatively high radiation dose as a retrospective ECG-gated examination. Although the combined use of dose-saving methods including a body-size-adaptive CT protocol, low tube voltage and tube current modulation can reduce the CT dose to 3.6 mSv for the patients with CHD, high radiation is still the major inherent limitation for retrospective ECG-gated CT. Prospective ECG-triggering technique transverse scan is able to significantly reduce radiation dose, and has been successfully applied in adult coronary artery examnation, as well as the pediatric congenital heart disease examination which has been reported.
OBJECTIVE:
To explore the clinical value of low-dose prospective ECG-triggering dual-source CT angiography in the evaluation of the pediatric dysplastic pulmonary arteries.
METHODS:
Forty-three patients with suspected dysplastic pulmonary arteries underwent both prospectiveECG-gated DSCT angiography and Transthoracic echocardiography(TTE). All children (average age:18 months;male 23 cases, female 20 cases; the average weight 13kg). Real-time electrocardiogram (ECG- Pulsing adaptive dose control techniques) was performed. The tube voltage and tube current were reduced to achieve low effective radiation dosage. Body weight-based adjustments of tube voltage and tube current were performed:< 5kg of children,80kV and 40～59mAs; 5-10kg of children,80 kV and 60～79mAs;> 10kg of children,80 kV and 80～120mAs. Using the electric switch control technology, prospective heart date are collected between 40% R-R period.Other scanning parameters:alignment 2×32×0.6 mm, reconstruction thick layer of 0.75 mm, frame whirl time 0.33s. The details and statistics of the radiation dose and scanning parameters were recorded. All images were transferred to an external workstation Leonardo. Multiplanar reconstruction (MPR), maximum density projection (MIP) and volume rendering (VR) were performed to demonstrate cardiac abnormalities. Two radiologists with 5 years experience in the field of cardiovascular imaging diagnosis assessed the overall image quality respectively, discussed of the inconsistency and reached the consensus. The imaging diagnosis was compared with surgery and/or CAG results. Forty-three cases all underwent DSCT and TTE, thirteen patients underwent cardioangiography (CAG) simultaneously. Surgical confirmation was available in thirty-seven patients. Surgical and CAG findings were used as the reference standard and compared to the DSCT results. Descriptive statistics was used to compare efficacy.
RESULTS:
There were 48 deformities in the final accurate diagnoses of pulmonary artery dysplasia in the 43 patients with preoperative DSCT cardiovascular angiography, with pulmonary artery dilated(n=13), pulmonary stenosis(n=13), pulmonary atresia (n=6), pulmonary part absence (n=6), pulmonary anomalous origin or abnormal traffic(n=9), pulmonary arterial branch development variation (n=l). The main pulmonary artery branch after the forking distal widely stricture was missing. The diagnostic accuracy for DSCT is 98.0%, for TTE is 73.5%.There are statistical difference between them (χ2= 31.24, P<0.05). Preoperative DSCT angiography and image reconstruction of all 43 cases are satisfactory. Average score of subjective image quality is 4.2±0.8.The average effective scan dosage is about 0.38±0.08 mSv.
CONCLUSION:
The DSCT prospectively ECG-gated transverse vascular imaging has important clinical application value in the evaluation of the pediatric pulmonary artery dysplasia, with an obviously higher diagnostic accuracy than TTE.The DSCT prospectively ECG-gated transverse is an effective way to reduce radiation dosage and is the preferred recommendation for pediatric pulmonary artery dysplasia for preoperative diagnosis.
双源CT (dual-source CT, DSCT)具有两套呈90度角的X-ray球管和探测器系统,其单扇区成像时间分辨率达到了83ms,成像速度更快,尽可能地减少了呼吸运动造成的伪影,满足了高心率条件下对图像质量的提升,其多平面重组(MPR)、最大密度投影(MIP)及容积再现(VR)等多种图像重组技术可立体地呈现心内外大血管结构,已初步应用于先心病的检查中。目前在双源CT心血管造影检查中回顾性心电门控模式应用较普遍,但是其低螺距及重叠螺旋扫描产生了较高的辐射剂量,尽管应用了降低射线剂量的方法,包括因人而宜的个体化CT检查参数设置,低管电压和管电流调整能将先心病CT检查有效辐射剂量降至3.6mSv,但是其射线辐射仍是回顾性心电门控检查的固有限制。前瞻性心电门控横断面扫描可显著降低辐射剂量,已成功应用于成人冠状动脉检查,并有部分将其用于小儿先心病检查的文献报道。
目的本研究应用双源CT前瞻性心电门控扫描对临床怀疑肺动脉发育异常的患儿进行心胸联合血管成像,探讨前瞻性心电门控低剂量扫描技术在小儿肺动脉发育异常中的临床应用价值。
方法经TTE拟诊为先天性心脏病合并肺动脉畸形及临床怀疑肺动脉发育异常的患儿43例(平均年龄：18月,范围：2月-13岁；男性23例,女性20例；平均体重13kg)。通过采用实时的心电图适应性剂量调控技术(ECG-Pulsing).降低管电压和管电流来实现对患儿的低剂量扫描。管电压、管电流采用个体化方案：体重被用来作为调整管电压和管电流的标准执行：<5kg的患儿、管电压80kV,管电流40～59mAs；5-10kg的患儿,管电压80 kV,管电流60～79mAs；>10kg的患儿,管电压80 kV,管电流80～120mAs。采用前瞻性心电门控技术,采集中心期相为40%R-R间期,其他扫描参数：准直2×32×0.6mm,重建层厚0.75mm,机架旋转一圈时间0.33S。对扫描参数、辐射剂量进行详细记录和统计。所得原始图像全部传入后处理工作站Leonardo,进行多平面重组(MPR)、最大密度投影(MIP)以及容积再现(VR)等多种图像重组,由2名在心血管影像诊断领域有5年经验的放射科医师独立阅片,对图像质量进行评价,针对不一致的评价经共同阅片讨论,达成一致意见,并把诊断结果与手术和／或CAG的结果进行对照分析。43例患儿全部同时行TTE检查,13例经CAG检查,37例患者经手术证实。计算DSCT和TTE两种检查方法对肺动脉发育畸形的诊断准确率,利用四格表资料的x2检验比较二者差异是否具有统计学意义。
结果43例患儿术前DSCT心血管造影准确诊断肺动脉发育异常48处。
肺动脉扩张13处：肺动脉主干扩张合并左右肺动脉同时扩张9处；肺动脉主干扩张合并左肺动脉扩张,右肺动脉无扩张或狭窄2处；肺动脉主干扩张合并右肺动脉扩张,左肺动脉无扩张或狭窄2处。
肺动脉狭窄13处：肺动脉瓣狭窄4处,同时合并瓣狭窄后肺动脉干扩张；右室流出道漏斗部狭窄2处；肺动脉分支狭窄7处。肺动脉分支狭窄包含：肺动脉主干合并左右肺动脉同时狭窄4处；肺动脉主干合并左肺动脉狭窄,右肺动脉无扩张或狭窄1处；肺动脉主干合并右肺动脉狭窄,左肺动脉无扩张或狭窄2处。
肺动脉闭锁6处：肺动脉闭锁,左右肺动脉汇合4处,其中2处经肺动脉主干分出左右肺动脉,2处未显示肺动脉主干；肺动脉闭锁,左右肺动脉无汇合2处,由侧枝单独供血。
肺动脉缺如6处：健侧肺动脉跨纵隔供血(马蹄肺)2处,肺动脉主干分出的两支肺动脉进入一侧肺野,其中一支肺动脉跨越纵隔进入对侧供应肺血；体循环供血,由PDA或大侧枝供应肺血2处；一侧肺动脉完全或部分缺如,无血供,同侧肺未发育或发育不良2处
肺动脉起源异常或异常交通9处：主肺动脉间隔缺损2处；永存动脉干1处；一侧肺动脉起源异常5处,含左肺动脉主干起于右肺动脉2处,左下肺动脉起于右肺动脉1处,右肺动脉起于升主动脉2处；肺动脉与冠脉异常交通1处。
肺动脉分支发育变异1处：左肺动脉主干较短,左肺动脉分叉较早。
漏诊1处,为左、右肺动脉分叉处远端分支广泛狭窄。
43例均经手术和/或CAG证实,DSCT对肺动脉发育异常总的诊断准确率为98.0%,TTE对肺动脉发育异常的诊断准确率为73.5%,二者的准确率差异有统计学意义(x2=31.24,P<0.05)。43例术前DSCT血管造影均获得满意图像,平均主观图像质量分数是4.2±0.8。对所有病例前瞻性心电门控下的扫描参数及辐射剂量进行记录,所得平均有效辐射剂量为0.38±0.08mSv。
结论DSCT前瞻性心电门控心胸联合血管成像对小儿脉动脉发育异常具重要的临床应用价值,诊断准确率明显高于TTE。DSCT前瞻性心电门控是一种有效减低辐射剂量的扫描方式,是小儿肺动脉发育异常术前诊断首选的检查方法之一。
BACKGROUND:
Pulmonary artery dysplasia which results from anomalies of original embryonic arcade is not a rare disease. In all sorts of congenital heart disease deformity, solitary or accompanied pulmonary artery malformations occur more frequently, and the ratio of complex congenital heart disease accompanied with pulmonary artety dysplasia is higher. Evaluating the pulmonary artery development conditions accurately enables to determine the operation time, and is helpful for postoperative rehabilitation and treatment of other complicated respiratory disease, even has an effect on the decision of surgery and the way of surgery. Transthoracic echocardiography (TTE) remains a primary imaging examination in patients with suspected CHD, and is superior in displaying intracardiac deformity and valve lesions, sometimes eliminating the need for cardiac catheterization. However, because of a small field of view,and interference of air and bone, it is difficult to demonstrate extracardiac vascular structures in their entirety. Ultrasound examination and pulmonary artery measurement which mostly depends on the individual experience is restricted. It is difficult to acquire accurate measurement values and more effective diagnosis of the pulmonary artery branches outside heart chamber.Cardioangiography(CAG) is an invasive modality which yields important hemodynamic data and defines anatomy clearly in vessels which are accessible to catheterization. However, CAG often gives only indirect information regarding venous connections and arterial anatomy distal to high-grade stenosis or atresia. It also produces high doses of ionizing radiation and is limited by the inherent risk of iodinated contrast material. Electron beam CT has high time resolution, but it failed to be widely used because the check cost is high. MRI takes a longer time and generates much noise in the examination, and it fails to obtain good imaging. A non-invasive method which can be more intuitive, accurate and credible for pulmonary arterial measurement in clinic setting is required. What's more, it will help to maste the surgical indications. With the advantages of higher scanning speed, larger scanning range, higher temporal resolution and spatial resolution and the noninvasive examination, MDCT (multi-slice, MSCT) has a wide perspective.However, how to reduce effective radiation dose is still a problem.
The dual-source CT (DSCT) scanner is characterized by two x-ray tubes and two corresponding detectors mounted onto the rotating gantry with an angular offset of 90°. Its single sector imaging temporal resolution reached 83ms, so it reduced the artifact caused by breathing movement and obtained high quality image in the condition of high rate.Multiplanar reconstruction (MPR), maximum indensity projection (MIP) and volume rendering (VR) three-dimensionally represent intra and extra cardiac vascular structures. Such reconstruction methods have been initially used in congenital heart disease. Currently Retrospectively ECG-gated DSCT angiocardiography has been widely used, however, the use of a low pitch and overlapping spiral CT acquisition results in the relatively high radiation dose as a retrospective ECG-gated examination. Although the combined use of dose-saving methods including a body-size-adaptive CT protocol, low tube voltage and tube current modulation can reduce the CT dose to 3.6 mSv for the patients with CHD, high radiation is still the major inherent limitation for retrospective ECG-gated CT. Prospective ECG-triggering technique transverse scan is able to significantly reduce radiation dose, and has been successfully applied in adult coronary artery examnation, as well as the pediatric congenital heart disease examination which has been reported.
OBJECTIVE:
To explore the clinical value of low-dose prospective ECG-triggering dual-source CT angiography in the evaluation of the pediatric dysplastic pulmonary arteries.
METHODS:
Forty-three patients with suspected dysplastic pulmonary arteries underwent both prospectiveECG-gated DSCT angiography and Transthoracic echocardiography(TTE). All children (average age:18 months;male 23 cases, female 20 cases; the average weight 13kg). Real-time electrocardiogram (ECG- Pulsing adaptive dose control techniques) was performed. The tube voltage and tube current were reduced to achieve low effective radiation dosage. Body weight-based adjustments of tube voltage and tube current were performed:< 5kg of children,80kV and 40～59mAs; 5-10kg of children,80 kV and 60～79mAs;> 10kg of children,80 kV and 80～120mAs. Using the electric switch control technology, prospective heart date are collected between 40% R-R period.Other scanning parameters:alignment 2×32×0.6 mm, reconstruction thick layer of 0.75 mm, frame whirl time 0.33s. The details and statistics of the radiation dose and scanning parameters were recorded. All images were transferred to an external workstation Leonardo. Multiplanar reconstruction (MPR), maximum density projection (MIP) and volume rendering (VR) were performed to demonstrate cardiac abnormalities. Two radiologists with 5 years experience in the field of cardiovascular imaging diagnosis assessed the overall image quality respectively, discussed of the inconsistency and reached the consensus. The imaging diagnosis was compared with surgery and/or CAG results. Forty-three cases all underwent DSCT and TTE, thirteen patients underwent cardioangiography (CAG) simultaneously. Surgical confirmation was available in thirty-seven patients. Surgical and CAG findings were used as the reference standard and compared to the DSCT results. Descriptive statistics was used to compare efficacy.
RESULTS:
There were 48 deformities in the final accurate diagnoses of pulmonary artery dysplasia in the 43 patients with preoperative DSCT cardiovascular angiography, with pulmonary artery dilated(n=13), pulmonary stenosis(n=13), pulmonary atresia (n=6), pulmonary part absence (n=6), pulmonary anomalous origin or abnormal traffic(n=9), pulmonary arterial branch development variation (n=l). The main pulmonary artery branch after the forking distal widely stricture was missing. The diagnostic accuracy for DSCT is 98.0%, for TTE is 73.5%.There are statistical difference between them (χ2= 31.24, P<0.05). Preoperative DSCT angiography and image reconstruction of all 43 cases are satisfactory. Average score of subjective image quality is 4.2±0.8.The average effective scan dosage is about 0.38±0.08 mSv.
CONCLUSION:
The DSCT prospectively ECG-gated transverse vascular imaging has important clinical application value in the evaluation of the pediatric pulmonary artery dysplasia, with an obviously higher diagnostic accuracy than TTE.The DSCT prospectively ECG-gated transverse is an effective way to reduce radiation dosage and is the preferred recommendation for pediatric pulmonary artery dysplasia for preoperative diagnosis.
引文
1. Kawano T, Ishii M, Takagi J,et al. Three-dimensional helical computed tomographic angiography in neonates and infants with complex congenital heart disease[J].Am Heart J,2000 Apr; Vol.139 (4), pp.654-60.
2. Kim TH, Kim YM, Suh CH,et al.Helical CT angiography and three dimensional reconstruction of total anomalous pulmonary venous connections in neonates and infants[J].Am Radio J,2000,175:1381.
3. Reimann AJ, Rinck D, Birinci-Aydogan A, et al.Dual-source computed tomography: advances of improved temporal resolution in coronary plaque imaging.Invest Radiol,2007,42:196-203.
4. Johnson TR, Nikolaou K, Wintersperger BJ,et al. Dual-source CT cardiac imaging: initial experience. Eur Radiol,2006,16(7):1409-15.
5. Leschka S, Scheffel H, Desbiolles L,et al. Image quality and reconstruction intervals of dual-source CT coronary angiography:recommendations for ECG-pulsing windowing. Invest Radiol.2007,42(8):543-9.
6. Scheffel H,Alkadhi H,Plass A, et al. Accuracy of dual-source CT coronary angiography: First experience in a high pre-test probability population without heart rate control. Eur Radiol,2006,16(12):2739-47.
7. Paul JF;Abada HT. Strategies for reduction of radiation dose in cardiac multislice CT[J]. Eur Radiol 2007 17 (8):2028-37.
8. Mahnken AH, Bruder H, Suess C, et al.Dual-source computed tomography for assessing cardiac function: a phantom study [J]. Invest Radiol.2007 Jul,42(7):491-8.
9. Khatri S, Varma SK, Khatri P, et al.Sixty-four-slice multidetector-row computed tomographic angiography for evaluating congenital heart disease.Pediatr Cardiol, 2008,29:755-762.
10. Kalra MK, Maher MM, Toth TL,et al. Techniques and applications of automatic tube current modulation for CT. Radiology,2008,233:649-657.
11. Goo HW, Seo DM, Yun TJ,et al.Coronary artery anomalies and clinically important anatomy in patients with congenital heart disease:multislice CT findings.Pediatr Radiol,2009,39:265-273.
12. Hsieh J,Londt J,Vass M,et al.Step-and-shoot data acquisition and reconstruction for cardiac x-ray computed tomography.Med Phys,2006,33:4236-4248.
13. D'Agotion A.G, Rami-Jardin M, Khalil C,et al.Low dose ECG-gated 64-slices helical CT angiograph of the chest :revaluation image quality of 105 patients.Eur Radiol 2006 16(8):2137-2146.
14. Paul J.-F, Abada H.T.Strategies for reduction of radiation dose in cardiac Multislice CT. Eur Radiol,2007,17(8):2028-2037.
15. Hohl C, Muhlenbrich G, Wildberger J.E, et al.Estimation of radiation exposure in Low dose Multislice CT tomography of the heart andcomparison with a calculation program. Eur Radiol,2007,16:1841-1846.
16. Hatenell GG.Developments in echocardiography[J].Radiol Clin North Am,1934,32: 461-475.
17. Haramati LB, Glickstein JS, Issenberg HJ,et al.MR imaging and CT of vascular anomalies and connections in patients with congenital heart disease:significance in surgical planning. Radiographics,2002,22:337-349.
18.陶子瑜,黄国英,林其珊,等.彩色多普勒超色心动图诊断先天性心脏的准确性及其对外科手术指导价值的研究[J].Chin J Based Pediatr,2007,12(5):338-346.
19. Casdidy SC,Schmidt KG,Van Hare GH,et al.Complication of pediatric cardiae catheterization A-3 year study [J]. Am Cardiol,1992,19:1285.
20. TonkinI L.Imaging of pediatric congenital heart disease [J].J Thorac Imaging,2000, 15(4):274-279.
21. Lee JJ,Kang D.Feasibility of electron beam tomography in diagnosis of congenital heart disease:comparison with echocardiography[J].Eur J Radiol,2001,38(3): 185-190.
22. Beier UH, Jelnin V, Jain S et al.Cardiac computed tomography compared to transthoracic echocardiography in the management of congenital heart disease[J]. Catheter Cardiovasc Interv] 2006 Sep; Vol.68 (3), pp.441-9.
23. Crean.A Cardiovascular MR and CT in congenital heart disease [J]. Heart 2007,93 (12):1637-47.
24. Boxt LM.Magnetic resonance and computed tomographic evaluation of congenital heart disease [J]. J Magn Reson Imaging,2004,19 (6):827-47.
25.李坤成,主编.中华影像医学心血管系统卷.北京.人民卫生出版社,2007,236-266
26. Bacher K, Bogaert E, Lapere R,et al. Patientspecific dose and radiation risk estimation in pediatric cardiac catheterization. Circulation,2005,111:83-89.
27. Mollet NR, Cademartiri F, van Miefhem CA, et al.High resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography[J]. Circulatoin,2005,112:2318.
28. Eric J.Lessons we have learned from our children:cancer risks from diagnostic radiology.Pediatr Radiol,2002,32:700.
29. Earls JP, Berman EL, Urban BA, et al. Prospectively gated transverse coronary CT angiography versus retrospectively gated helical technique: improved image quality and reduced radiation dose. Radiology,2008,246:742-753.
30.段艳华,王锡明,程召平,等.前瞻性心电门控双源CT冠状动脉成像在高心率患者中应用的可行性研究.中华放射学杂志,2009,43：716.
31. Leschka S,Wildermuth S, Boehm T et al (2006) Noninvasive coronary angiography with 64-section CT: effect of average heart rate and heart rate variability on image quality. Radiology 241:378-38.
32. Zhaoping Cheng,Ximing Wang,Yanhua Duan et al.Low-dose prospective ECG-triggering dual-source CT angiography in infants and children with complex congenital heart disease:first experience. European Radiology,2010,20:2503-2511.
33. Hausleiter J, Meyer T, Hermann F,et al. Estimated radiation dose associated with cardiac CT angiography.JAMA,2009,301:500-507.
34.汪曾炜,刘维永,张宝仁,主编.心脏外科学.北京：人民军医出版社,2003,916.
35.戴汝平,高建华.先天性心脏病多排螺旋CT成像与诊断.北京.科学出版社,2009,11.
36.周阳泱,韩萍,冯敢生.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中华小儿外科杂志,2005,26：579.
37.郝晶,李坤成.心脏的多层螺旋CT检查.中国医学影像技术,2002,18：601.
38.司彪,柳橙,乔彬,等.双源CT和超声心动图评价婴幼儿先天性心脏病肺动脉的对照研究.临床放射学杂志,2009,28：1430-1433.
39.肖婷婷,陈树宝,张玉奇.法乐四联症肺血管发育评估方法的探讨[J].心肺血管病杂志,2002,21：26-28.
40. Kawahira Y Kishimoto H, Kawata H, et al. New indicator for the Fontan operation:diameters of the pulmonary veins in patients with univentricularheart[J]. J Card Surg,1999,14:259-265.
41. Senzaki H, Kato H, Akagi M, et al. Relationship between the pulmonary artery index and physiological properties of the pulmonary vascularbed[J].Jpn Circ J,1996,60:334-340.
42. Agnoletti G Boudjemline Y Bonnet D, et al. Surgical reconstruction of occluded pulmonary arteries in patients with congenital heart disease:effects on pulmonary artery growth[J]. Circulation,2004,109:2314-2318.
43. Cho JM, Puga FJ, Damielson GK, et al. Early and long—term results of the surgical treatment of tetralogy of Fallot with pulmonary atresia, with or without maj or aortopulmonary collateral[J]. J Thoracic Cardio Surg,2002,124:70-81.
44. Diller GP,Gatzoulis MA. Pulmonary vascular disease in adults with congenital heartdisease[J]. Circulmion,2007,115:1039-1050.
45.丁以群,黄美萍,张镜芳.多排螺旋CT在PA/VSD/MAPCAs诊治中的价值[J].中华胸心血管外科杂志,2007,23：25-28.
46. Das M,Mahnken AH, Muhlenbruch G et al. Individually adapted examination protocols for reduction of radiation exposure for 16-MDCT chest examinations[J]. AR2005,184:1437-1443.
2. Kim TH, Kim YM, Suh CH,et al.Helical CT angiography and three dimensional reconstruction of total anomalous pulmonary venous connections in neonates and infants[J].Am Radio J,2000,175:1381.
3. Reimann AJ, Rinck D, Birinci-Aydogan A, et al.Dual-source computed tomography: advances of improved temporal resolution in coronary plaque imaging.Invest Radiol,2007,42:196-203.
4. Johnson TR, Nikolaou K, Wintersperger BJ,et al. Dual-source CT cardiac imaging: initial experience. Eur Radiol,2006,16(7):1409-15.
5. Leschka S, Scheffel H, Desbiolles L,et al. Image quality and reconstruction intervals of dual-source CT coronary angiography:recommendations for ECG-pulsing windowing. Invest Radiol.2007,42(8):543-9.
6. Scheffel H,Alkadhi H,Plass A, et al. Accuracy of dual-source CT coronary angiography: First experience in a high pre-test probability population without heart rate control. Eur Radiol,2006,16(12):2739-47.
7. Paul JF;Abada HT. Strategies for reduction of radiation dose in cardiac multislice CT[J]. Eur Radiol 2007 17 (8):2028-37.
8. Mahnken AH, Bruder H, Suess C, et al.Dual-source computed tomography for assessing cardiac function: a phantom study [J]. Invest Radiol.2007 Jul,42(7):491-8.
9. Khatri S, Varma SK, Khatri P, et al.Sixty-four-slice multidetector-row computed tomographic angiography for evaluating congenital heart disease.Pediatr Cardiol, 2008,29:755-762.
10. Kalra MK, Maher MM, Toth TL,et al. Techniques and applications of automatic tube current modulation for CT. Radiology,2008,233:649-657.
11. Goo HW, Seo DM, Yun TJ,et al.Coronary artery anomalies and clinically important anatomy in patients with congenital heart disease:multislice CT findings.Pediatr Radiol,2009,39:265-273.
12. Hsieh J,Londt J,Vass M,et al.Step-and-shoot data acquisition and reconstruction for cardiac x-ray computed tomography.Med Phys,2006,33:4236-4248.
13. D'Agotion A.G, Rami-Jardin M, Khalil C,et al.Low dose ECG-gated 64-slices helical CT angiograph of the chest :revaluation image quality of 105 patients.Eur Radiol 2006 16(8):2137-2146.
14. Paul J.-F, Abada H.T.Strategies for reduction of radiation dose in cardiac Multislice CT. Eur Radiol,2007,17(8):2028-2037.
15. Hohl C, Muhlenbrich G, Wildberger J.E, et al.Estimation of radiation exposure in Low dose Multislice CT tomography of the heart andcomparison with a calculation program. Eur Radiol,2007,16:1841-1846.
16. Hatenell GG.Developments in echocardiography[J].Radiol Clin North Am,1934,32: 461-475.
17. Haramati LB, Glickstein JS, Issenberg HJ,et al.MR imaging and CT of vascular anomalies and connections in patients with congenital heart disease:significance in surgical planning. Radiographics,2002,22:337-349.
18.陶子瑜,黄国英,林其珊,等.彩色多普勒超色心动图诊断先天性心脏的准确性及其对外科手术指导价值的研究[J].Chin J Based Pediatr,2007,12(5):338-346.
19. Casdidy SC,Schmidt KG,Van Hare GH,et al.Complication of pediatric cardiae catheterization A-3 year study [J]. Am Cardiol,1992,19:1285.
20. TonkinI L.Imaging of pediatric congenital heart disease [J].J Thorac Imaging,2000, 15(4):274-279.
21. Lee JJ,Kang D.Feasibility of electron beam tomography in diagnosis of congenital heart disease:comparison with echocardiography[J].Eur J Radiol,2001,38(3): 185-190.
22. Beier UH, Jelnin V, Jain S et al.Cardiac computed tomography compared to transthoracic echocardiography in the management of congenital heart disease[J]. Catheter Cardiovasc Interv] 2006 Sep; Vol.68 (3), pp.441-9.
23. Crean.A Cardiovascular MR and CT in congenital heart disease [J]. Heart 2007,93 (12):1637-47.
24. Boxt LM.Magnetic resonance and computed tomographic evaluation of congenital heart disease [J]. J Magn Reson Imaging,2004,19 (6):827-47.
25.李坤成,主编.中华影像医学心血管系统卷.北京.人民卫生出版社,2007,236-266
26. Bacher K, Bogaert E, Lapere R,et al. Patientspecific dose and radiation risk estimation in pediatric cardiac catheterization. Circulation,2005,111:83-89.
27. Mollet NR, Cademartiri F, van Miefhem CA, et al.High resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography[J]. Circulatoin,2005,112:2318.
28. Eric J.Lessons we have learned from our children:cancer risks from diagnostic radiology.Pediatr Radiol,2002,32:700.
29. Earls JP, Berman EL, Urban BA, et al. Prospectively gated transverse coronary CT angiography versus retrospectively gated helical technique: improved image quality and reduced radiation dose. Radiology,2008,246:742-753.
30.段艳华,王锡明,程召平,等.前瞻性心电门控双源CT冠状动脉成像在高心率患者中应用的可行性研究.中华放射学杂志,2009,43：716.
31. Leschka S,Wildermuth S, Boehm T et al (2006) Noninvasive coronary angiography with 64-section CT: effect of average heart rate and heart rate variability on image quality. Radiology 241:378-38.
32. Zhaoping Cheng,Ximing Wang,Yanhua Duan et al.Low-dose prospective ECG-triggering dual-source CT angiography in infants and children with complex congenital heart disease:first experience. European Radiology,2010,20:2503-2511.
33. Hausleiter J, Meyer T, Hermann F,et al. Estimated radiation dose associated with cardiac CT angiography.JAMA,2009,301:500-507.
34.汪曾炜,刘维永,张宝仁,主编.心脏外科学.北京：人民军医出版社,2003,916.
35.戴汝平,高建华.先天性心脏病多排螺旋CT成像与诊断.北京.科学出版社,2009,11.
36.周阳泱,韩萍,冯敢生.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中华小儿外科杂志,2005,26：579.
37.郝晶,李坤成.心脏的多层螺旋CT检查.中国医学影像技术,2002,18：601.
38.司彪,柳橙,乔彬,等.双源CT和超声心动图评价婴幼儿先天性心脏病肺动脉的对照研究.临床放射学杂志,2009,28：1430-1433.
39.肖婷婷,陈树宝,张玉奇.法乐四联症肺血管发育评估方法的探讨[J].心肺血管病杂志,2002,21：26-28.
40. Kawahira Y Kishimoto H, Kawata H, et al. New indicator for the Fontan operation:diameters of the pulmonary veins in patients with univentricularheart[J]. J Card Surg,1999,14:259-265.
41. Senzaki H, Kato H, Akagi M, et al. Relationship between the pulmonary artery index and physiological properties of the pulmonary vascularbed[J].Jpn Circ J,1996,60:334-340.
42. Agnoletti G Boudjemline Y Bonnet D, et al. Surgical reconstruction of occluded pulmonary arteries in patients with congenital heart disease:effects on pulmonary artery growth[J]. Circulation,2004,109:2314-2318.
43. Cho JM, Puga FJ, Damielson GK, et al. Early and long—term results of the surgical treatment of tetralogy of Fallot with pulmonary atresia, with or without maj or aortopulmonary collateral[J]. J Thoracic Cardio Surg,2002,124:70-81.
44. Diller GP,Gatzoulis MA. Pulmonary vascular disease in adults with congenital heartdisease[J]. Circulmion,2007,115:1039-1050.
45.丁以群,黄美萍,张镜芳.多排螺旋CT在PA/VSD/MAPCAs诊治中的价值[J].中华胸心血管外科杂志,2007,23：25-28.
46. Das M,Mahnken AH, Muhlenbruch G et al. Individually adapted examination protocols for reduction of radiation exposure for 16-MDCT chest examinations[J]. AR2005,184:1437-1443.