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1、存活心肌的评价和临床意义存活心肌的评价和临床意义存活心肌的评价和临床意义存活心肌的评价和临床意义 温州医学院附属第一医院温州医学院附属第一医院温州医学院附属第一医院温州医学院附属第一医院 张怀勤张怀勤张怀勤张怀勤CP1173554-2心肌要素心肌要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要素和其他全身要素和其他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要素环境要素年龄年龄非心肌的心血管要素非心肌的心血管要素
2、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Chareonthaitawee P et al, J Am Coll Cardiol 2005;46:567-74.Chareonthaitawee P et al, J Am Coll Cardiol 2005;46:567-74.一、存活心肌的概念一、存活心肌的概念1.顿抑心肌顿抑心肌stunned myocardium 2.冬眠心肌冬眠心肌hibernating myocardium)3.伤残心肌或坏死心肌伤残心肌或坏死
3、心肌 maimed myocarduium Stunning顿顿抑心肌抑心肌CP1275728-1功能不全的心肌功能不全的心肌Hibernation冬眠心肌冬眠心肌 存活心肌的特性存活心肌的特性 收缩收缩 灌注灌注 代谢代谢正常心肌正常心肌 N N N 顿抑心肌顿抑心肌 - N N - 冬眠心肌冬眠心肌 疤痕心肌疤痕心肌 Schelbert et al, J Nucl Med 35 (Suppl), 1994.二、存活心肌的识别二、存活心肌的识别 心电图评价心电图评价 AMI时深的倒置时深的倒置T波波 早期胜利再灌注时早期胜利再灌注时T波倒置波倒置 体表心电图一过性体表心电图一过性QS波波 心
4、绞痛发作时的缺血性改动心绞痛发作时的缺血性改动存活心肌的识别存活心肌的识别 二维超声心动图二维超声心动图2DE 药物负荷药物负荷2DE 多巴酚丁胺多巴酚丁胺 硝酸酯硝酸酯 潘生丁潘生丁 腺苷腺苷 心肌声学造影心肌声学造影 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经过代谢显像心肌的葡萄糖代谢和脂肪酸代谢结合经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能否相匹配来识灌注显像评价心肌的代谢血流灌注能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 rubidium-82) (N-13 ammo
5、nia or rubidium-82) l l 代谢显像代谢显像 ( F-18 fluorodeoxyglucose = FDG) ( F-18 fluorodeoxyglucose = FDG) l l 是识别存活心肌的金规范是识别存活心肌的金规范lOHHOHOHO18FMyocyte FDG Uptake正常心肌正常心肌细细胞胞 缺血心缺血心肌肌细细胞胞Glucose 6-phosphataseHexokinaseGlucose 6-phosphataseG6P D-GlucoseGlycolytic Pathway D-GlucoseXFFAGlucose 6-phosphataseHe
6、xokinaseGlucose 6-phosphataseFDG-6-PG6PGlycolytic Pathway D-GlucoseXFDGFDG D-GlucoseFDG-6-PFDGFDGFDGFDGFDGFDGFDGFDGFDGFDGFDGFDGFDGFDGFFAFFAFFAFFAFFAFFAFFAFFAFFAFFAFFAFFAFFAFFAPET : 灌注灌注-代谢不匹配代谢不匹配 perfusion perfusion metabolism metabolism Hibernation Hibernation with permission from Taegtmeyer and D
7、ilsizian左室前壁心肌血供中断左室前壁心肌血供中断, ,前壁心梗前壁心梗; ;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常规运动常规运动-再分布心肌显像再分布心肌显像 运动运动-再分布再分布-再注射心肌显像再注射心肌显像 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运动运动- -再分布再分布- -再注射心肌显像再注射心肌显像l 延迟再分布显像延迟再分布显像 l 再注射显像再注射显像 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
8、 对于对于CRVCRV术后室壁收术后室壁收缩功能缩功能l 改善的阳性预测值为改善的阳性预测值为69%69%,阴性预测值为,阴性预测值为89%89%。l静态静态- -再分布心肌显像再分布心肌显像 常规运动-再分布心肌显像:201铊TL单光子断层201TL- SPECT心肌显像 细胞膜完好识别 RVRVLVLVRARALALALVLVLALA存活心肌存活心肌 MRI 延迟高强化延迟高强化Courtesy of Dr. Thomas GerberCourtesy of Dr. Thomas Gerbertime正常心肌正常心肌缺血心肌缺血心肌初次经过初次经过延迟强化延迟强化Gadinjection梗
9、死心肌梗死心肌Courtesy of Dr. Thomas GerberCourtesy of Dr. Thomas GerberMRI 延迟高强化延迟高强化机制机制GdGdNaNaNaNaNaNaNaGdGdGdGdGdGdGdNaGdGdGdGdGdGdNaNaNaNaNaKKKKKKKKKKNaNaNaNaintact cell membrane(viable myocardium)ruptured cell membrane(acute infarction)collagen matrix(chronic infarction)NaNaNaNaNaNaGdNaGdGdGdGdGdMRI
10、 延迟高强化机制延迟高强化机制Courtesy of Dr. Ray KimPET vs ceCMRDiagnostic AccuracySensitivitySpecificityn = 29 patientsMean LVEF = 3210% Adapted from Khl et al. Eur Heart J 2006;27:846-53.PET vs ceMRIViable MyocardiumAdapted from Khl et al. Eur Heart J 2006;27:846-53.Pre-revascPre-revascLVEF 25%LVEF 25%Post-reva
11、scPost-revascLVEF 45%LVEF 45%64排排CT 对比剂延迟强化对比剂延迟强化Baks et al AJR:188, 2007Baks et al AJR:188, 2007n=6 pigsn=6 pigs64-slice CT Following Primary PCIHabis et al. JACC 2007;49:1178-85.n=36 patientsn=36 patients存活心肌检测存活心肌检测64-Slice CTHabis et al. JACC 2007;49:1178-85.nSensitivitySpecificityAccuracyPPVNP
12、VPatients3692%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Habis et al: JACC 2007;49:1178.Habis et al: JACC 2007;49:1178.Habis et al: JACC 2007;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 NYHA class IIILVEF 26%左室中度扩展左室中度扩展多支病变多支病变肾功能损害肾功能损害有有TI
13、A史史72 year-old WomanHeart Failure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?植入性安装植入性安装?下一步下一步处置?置? 72 岁女性岁女性SPECT SestamibiSASAStressStress Rest RestApexApexMidMidBaseBaseStressStress Rest RestHLAHLAVLAVLAGated SPECT LVEF = 27%Gated SPECT LVEF = 27%72 岁女性岁女性Viability PETSASA NH3 NH3 FDG FDGApexApex
14、MidMidBaseBase NH3 NH3 FDG FDGHLAHLAVLAVLABefore CABG LVEF = 26%Before CABG LVEF = 26%After CABG LVEF = 45%After CABG LVEF = 45%72 岁女性岁女性Improvement(%)CP1116396-4Di Carli M et al, Circulation 1995;92:3436-44.Extent mismatch (%LV)r=0.87,SEE=10.8P0.001PET 存活心肌存活心肌心力衰竭病症改善心力衰竭病症改善 18%Multivessel CADMea
15、n LVEF = 286%CP1173554-5RevascularizationRevascularizationRevascularizationMedical therapyMedical therapyMedical therapy-79.6%-79.6%-79.6%P0.0001P0.0001P0.00012 22=147=147=147 2 22=1.43=1.43=1.43 Death Death Death rate rate rate (%/yr)(%/yr)(%/yr)23.0%23.0%23.0%P=0.23P=0.23P=0.23Allman et al JACC 20
16、02Allman et al JACC 2002核素核素核素核素/ /心超心超心超心超 和和和和预预后后后后 Meta-Analysis of 24 Studies 3,088 Meta-Analysis of 24 Studies 3,088 PatientsPatientsCP1275728-8PARR-2PARR-2PETPET指点治指点治指点治指点治疗疗疗疗和和和和规规规规范治范治范治范治疗疗疗疗Event-Event-Event-freefreefreesurvivalsurvivalsurvivalDaysDaysDaysPET armPET armPET armStandard
17、armStandard armStandard arm430 patients430 patientsp = 0.046p = 0.046Beanlands R et al. JACC 2007;13:2007.Beanlands R et al. JACC 2007;13:2007.CP1314974-1Beanlands R et al: JACC 50:2002, 2007Beanlands R et al: JACC 50:2002, 2007Beanlands R et al: JACC 50:2002, 2007DaysDaysDaysADHERE armADHERE armADH
18、ERE armStandard armStandard armStandard armPARR-2PET指点治疗和规范治疗指点治疗和规范治疗Event-Event-Event-freefreefreesurvivalsurvivalsurvivalp = 0.019p = 0.019CRT ResponseSPECT Predicts LVEF Response to CRT27272727n=50n=50Mean LVEF=20%Mean LVEF=20%P=0.00004P=0.00004%Pts with Positive %Pts with Positive Echo Response
19、Echo ResponseAdelstein E et al. AHJ 2007;153:110Adelstein E et al. AHJ 2007;153:110Adelstein E et al. AHJ 2007;153:110CP1315140-5Total scar scoreTotal scar scoreYpenburg et al: EHJ 28:33, 2007Ypenburg et al: EHJ 28:33, 2007Absolute changeAbsolute changein LVEF (%)in LVEF (%)n=51 ptsn=51 ptsmean LVEF
20、=22%mean LVEF=22%r=0.63, P0.001r=0.63, P0.001-100102030010203040SPECT Scar and CRT ResponseSPECT Scar and CRT ResponseCP1322903-2ChangeChangeChangein EFin EFin EF(%)(%)(%)Total scar (%)Total scar (%)Total scar (%)r=0.480r=0.480r=0.480P=0.02P=0.02P=0.02White. JACC 2006;48:1953White. JACC 2006;48:1953White. JACC 2006;48:1953MRI and CRT Response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