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1、存活心肌的评价和临床意义温存活心肌的评价和临床意义温州医学院附属第一医院张怀勤州医学院附属第一医院张怀勤CP1173554-2心肌因素心肌因素正常心肌正常心肌疤痕心肌疤痕心肌冬眠心肌冬眠心肌缺血缺血/顿抑心肌顿抑心肌凋亡心肌凋亡心肌肥大心肌肥大心肌全身因素和其他全身因素和其他RASS交感神经交感神经血管扩张血管扩张利钠肽利钠肽细胞因子细胞因子糖尿病糖尿病代谢综合症代谢综合症睡眠呼吸暂停综合症睡眠呼吸暂停综合症肾脏疾病肾脏疾病环境因素环境因素年龄年龄非心肌的心血管因素非心肌的心血管因素冠状动脉病变范围冠状动脉病变范围内皮功能内皮功能心律失常心律失常二尖瓣功能二尖瓣功能心室收缩同步性心室收缩同步性
2、舒张功能舒张功能缺血性心脏病缺血性心脏病心力衰竭心力衰竭ChareonthaitaweePetal,JAmCollCardiol2005;46:567-74.ChareonthaitaweePetal,JAmCollCardiol2005;46:567-74.正电子发射型计算机断层显像正电子发射型计算机断层显像(PET)(PET)l通过代谢显像（心肌的葡萄糖代谢和脂肪酸代谢）结合通过代谢显像（心肌的葡萄糖代谢和脂肪酸代谢）结合灌注显像评价心肌的代谢血流灌注是否相匹配来识灌注显像评价心肌的代谢血流灌注是否相匹配来识别存活心肌别存活心肌. .l 灌注显像灌注显像 (N-13 ammonia or
3、rubidium-82)(N-13 ammonia or rubidium-82) l 代谢显像代谢显像 ( F-18 ( F-18 fluorodeoxyglucosefluorodeoxyglucose = FDG) = FDG) l 是识别存活心肌的金标准是识别存活心肌的金标准OHHOHOHO18FMyocyteFDGUptake正常心肌细胞正常心肌细胞 缺血心肌细胞缺血心肌细胞Glucose6-phosphataseHexokinaseGlucose6-phosphataseG6PD-GlucoseGlycolyticPathwayD-GlucoseXFFAGlucose6-phosp
4、hataseHexokinaseGlucose6-phosphataseFDG-6-PG6PGlycolyticPathwayD-GlucoseXFDGFDGD-GlucoseFDG-6-PFDGFDGFDGFDGFDGFDGFDGFDGFDGFDGFDGFDGFDGFDGFFAFFAFFAFFAFFAFFAFFAFFAFFAFFAFFAFFAFFAFFAPET:灌注灌注-代谢不匹配代谢不匹配 perfusion metabolism Hibernationwith permission from Taegtmeyer and Dilsizian左室前壁心肌血供中断左室前壁心肌血供中断, ,前
5、壁心梗前壁心梗; ;下排下排: :前壁梗死前壁梗死的心肌糖代谢旺盛的心肌糖代谢旺盛, ,提示心肌存活。提示心肌存活。201铊（铊（TL）单光子断层显像）单光子断层显像l常规运动常规运动-再分布心肌显像再分布心肌显像l运动运动-再分布再分布-再注射心肌显像再注射心肌显像l静态静态-再分布心肌显像再分布心肌显像201201铊（铊（TLTL）单光子断层显像）单光子断层显像l运动-再分布-再注射心肌显像 延迟再分布显像 再注射显像 l运动-再分布-再注射心肌显像 对于CRV术后室壁收缩功能 改善的阳性预测值为69%，阴性预测值为89%。l静态-再分布心肌显像常规运动-再分布心肌显像：201铊（TL）单
6、光子断层（201TL- SPECT）心肌显像 细胞膜完整识别 RVRVLVLVRARALALALVLVLALA存活心肌存活心肌MRI延迟高强化延迟高强化CourtesyofDr.ThomasGerberCourtesyofDr.ThomasGerbertime正常心肌正常心肌缺血心肌缺血心肌首次通过首次通过延迟强化延迟强化Gadinjection梗死心肌梗死心肌CourtesyofDr.ThomasGerberCourtesyofDr.ThomasGerberMRI延迟高强化延迟高强化机制机制GdGdNaNaNaNaNaNaNaGdGdGdGdGdGdGdNaGdGdGdGdGdGdNaNaN
7、aNaNaKKKKKKKKKKNaNaNaNaintactcellmembrane(viablemyocardium)rupturedcellmembrane(acuteinfarction)collagenmatrix(chronicinfarction)NaNaNaNaNaNaGdNaGdGdGdGdGdMRI延迟高强化机制延迟高强化机制CourtesyofDr.RayKimPETvsceCMRDiagnosticAccuracySensitivitySpecificityn=29patientsMeanLVEF=3210%AdaptedfromKhletal.EurHeartJ2006;
8、27:846-53.PETvsceMRIViableMyocardiumAdaptedfromKhletal.EurHeartJ2006;27:846-53.Pre-revascPre-revascLVEF25%LVEF25%Post-revascPost-revascLVEF45%LVEF45%64排排CT对比剂延迟强化对比剂延迟强化BaksetalAJR:188,2007BaksetalAJR:188,2007n=6pigsn=6pigs64-sliceCTFollowingPrimaryPCIHabisetal.JACC2007;49:1178-85.n=36patientsn=36pa
9、tients存活心肌检测存活心肌检测64-SliceCTHabisetal.JACC2007;49:1178-85.nSensitivitySpecificityAccuracyPPVNPVPatients3692%100%94%100%85%All segments57698%94%97%99%79%64排排CT延迟强化延迟强化低剂量多巴酚丁胺心超低剂量多巴酚丁胺心超Habisetal:JACC2007;49:1178.Habisetal:JACC2007;49:1178.n=36n=36三、存活心肌检测的临床意义三、存活心肌检测的临床意义72岁女性岁女性糖尿病糖尿病心功能心功能NYHAcl
10、assIIILVEF26%左室中度扩大左室中度扩大多支病变多支病变肾功能损害肾功能损害有有TIA史史72year-oldWomanHeartFailure药物药物?负荷核素显像负荷核素显像?存活心肌检查存活心肌检查?冠状动脉造影冠状动脉造影?植入性装置植入性装置?下一步处理？下一步处理？72岁女性岁女性SPECTSestamibiSASAStressStressRestRestApexApexMidMidBaseBaseStressStressRestRestHLAHLAVLAVLAGatedSPECTLVEF=27%GatedSPECTLVEF=27%72岁女性岁女性ViabilityPET
11、SASANHNH3 3FDGFDGApexApexMidMidBaseBaseNHNH3 3 FDGFDGHLAHLAVLAVLABeforeCABGLVEF=BeforeCABGLVEF=26%26%AfterCABGLVEF=AfterCABGLVEF=45%45%72岁女性岁女性Improvement(%)CP1116396-4DiCarliMetal,Circulation1995;92:3436-44.Extentmismatch(%LV)r=0.87,SEE=10.8P0.001PET存活心肌存活心肌心力衰竭症状改善心力衰竭症状改善18%MultivesselCADMeanLVEF
12、=286%CP1173554-5RevascularizationRevascularizationMedicaltherapyMedicaltherapy-79.6%-79.6%P0.0001P0.000122=147=147 22=1.43=1.43 DeathDeathraterate(%/yr)(%/yr)23.0%23.0%P=0.23P=0.23AllmanetalJACC2002AllmanetalJACC2002核素核素核素核素/ /心超心超心超心超 和预后和预后和预后和预后 Meta-AnalysisMeta-Analysisofof24Studies3,088Patient
13、s24Studies3,088PatientsCP1275728-8PARR-2PARR-2PETPETPETPET指导治疗和标准治疗指导治疗和标准治疗指导治疗和标准治疗指导治疗和标准治疗Event-Event-freefreesurvivalsurvivalDaysDaysPETarmPETarmStandardarmStandardarm430patients430patientsp=0.046p=0.046BeanlandsRetal.JACC2007;13:2007.BeanlandsRetal.JACC2007;13:2007.CP1314974-1BeanlandsRetal:JA
14、CC50:2002,2007BeanlandsRetal:JACC50:2002,2007DaysDaysADHEREarmADHEREarmStandardarmStandardarmPARR-2PET指导治疗和标准治疗指导治疗和标准治疗Event-Event-freefreesurvivalsurvivalp=0.019p=0.019CRTResponseSPECTPredictsLVEFResponsetoCRT2727 2727n=50n=50MeanLVEF=20%MeanLVEF=20%P=0.00004P=0.00004%PtswithPositive%PtswithPositi
15、veEchoResponseEchoResponseAdelsteinEetal.AHJ2007;153:110AdelsteinEetal.AHJ2007;153:110CP1315140-5TotalscarscoreTotalscarscoreYpenburgetal:EHJ28:33,2007Ypenburgetal:EHJ28:33,2007AbsolutechangeAbsolutechangeinLVEF(%)inLVEF(%)n=51ptsn=51ptsmeanLVEF=22%meanLVEF=22%r=0.63,P0.001r=0.63,P0.001-100102030010
16、203040SPECTScarandCRTResponseSPECTScarandCRTResponseCP1322903-2ChangeChangeinEFinEF(%)(%)Totalscar(%)Totalscar(%)r=0.480r=0.480P=0.02P=0.02White.JACC2006;48:1953White.JACC2006;48:1953MRIandCRTResponse存活心肌对预后的影响存活心肌对预后的影响Adapted, with permission, from Allman et al. 心功能不全存活心肌检查流程心功能不全存活心肌检查流程结束语结束语谢谢大家聆听！谢谢大家聆听！52
