双源CT低剂量冠状动脉成像及心肌桥的影像学研究
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摘要
目的：通过对比分析双源CT冠状动脉成像（CT coronary angiography,CTA）前瞻性心电门控扫描与回顾性心电门控扫描的图像质量和辐射剂量，为低剂量、个性化CT冠状动脉成像扫描方案的制定提供参考依据。
材料与方法：将90例行双源CT冠状动脉检查的患者依据扫描方式不同分为两组：前瞻扫描组40例，要求患者心率平稳且≤70bpm，图像采集时间窗为62-78%R-R间期，管电压120KV,应用自动管电流调制技术（automatic tube current modulation，ATCM），参考管电流为400mAs；回顾扫描组50例，采用ATCM技术、ECG管电流自动调制技术及螺距-心率自动匹配技术，管电压120KV，参考管电流为400mAs。由两位经验丰富的放射医生对所有冠脉节段（直径≥1mm）进行图像质量评分，意见不一致时协商确定。评分标准采用4分法（1分：优秀；2分：轻度伪影或/和错层；3分：中度伪影或/和错层；4分：严重伪影或/和错层），1-3分能用于图像诊断，4分不能用于诊断。对两组满足诊断要求（≤3分）的冠脉节段及评价为优（1分）的冠脉节段进行非参数秩和检验。计算所有患者CTA检查的辐射剂量，两组间比较采用配对t检验。
结果：（1）前瞻扫描组40例患者共评价冠脉554段，满足诊断（≤3分）及评价为优（1分）的冠脉节段比例分别为99.27%和96.93%。回顾扫描组50例患者共评价冠脉645段，满足诊断（≤3分）及评价为优（1分）的冠脉节段比例分别为98.76%和88.99%。对两组间满足诊断的冠脉节段比例进行比较，有统计学差异（P=0.024）；评价为优的冠脉节段比例前瞻扫描组明显高于回顾扫描组，统计学差异明显（P＜0.001）。（2）前瞻扫描组和回顾扫描组的有效辐射剂量分别为4.46mSv和6.61mSv，两组间比较差异具有统计学意义（P＜0.001）。
结论：回顾性心电门控扫描应用各种降低辐射剂量的措施后，可明显降低辐射剂量；对于高心率及心律不齐患者有优势。前瞻性心电门控扫描是减少辐射剂量的有效方式，但较低且平稳的心率是其获得优质图像的保证。临床工作中应根据患者不同情况选择合适的扫描方式及参数，在保证图像质量的前提下，尽可能达到低剂量扫描。
第一节不完全心肌桥及完全性心肌桥的CT影像特征分析
目的：探讨心肌桥的分型及不同类型心肌桥-壁冠状动脉的CT影像特征。
材料和方法：收集50例行双源CT冠状动脉成像，诊断有心肌桥患者的影像学资料，所有患者采用回顾性心电门控扫描，重建显示冠脉的最佳收缩期及舒张期图像，重建层厚/层间距为0.75mm/0.5mm。根据冠状动脉被心肌包绕程度分为两组：不完全心肌桥组（冠状动脉被心肌部分包绕，至少在1/2以上）和完全性心肌桥组（冠状动脉完全被心肌包绕）。测量50例患者心肌桥的最佳舒张期及收缩期壁冠状动脉最窄处、桥前段及桥后段正常血管的管径，计算壁冠状动脉的狭窄率，其差异的比较采用两配对t检验。评价心肌桥患者桥前段冠脉伴发的粥样硬化改变，两组心肌桥间差异的比较采用卡方检验。
结果：50例患者中，冠脉CTA显示58处心肌桥，平均长度为2.02cm，其中不完全心肌桥23处，完全性心肌桥35处。58处心肌桥中前降支中段32处（60%），前降支远段17处（29.3%），前降支近段1处，第一对角支3处，第一钝缘支4处，右冠后降支1处。不完全心肌桥组舒张期及收缩期壁冠状动脉管径及狭窄率分别为1.93mm、1.71mm、4.7%和20.4%，完全性心肌桥组舒张期及收缩期壁冠状动脉管径及狭窄率分别为2.21mm、1.63mm、8.1%和33.7%。两组心肌桥舒张期及收缩期壁冠状动脉管径差值的差异具有统计学意义（P=0.008）；两组心肌桥收缩期壁冠状动脉狭窄率的比较，差异具有统计学意义（P=0.014）。8处不完全心肌桥及15处完全性心肌桥的桥前段冠脉伴发粥样硬化病变，其差异无统计学意义（P=0.339）。
结论：完全性心肌桥对壁冠状动脉的压迫程度较不完全心肌桥严重，且持续时间更长。冠脉CTA成像能够无创地显示心肌桥的长度和厚度，评价壁冠状动脉舒张期和收缩期的形态学变化及伴发的粥样硬化改变，为临床治疗计划提供客观的依据。
第二节CT冠状动脉成像诊断心肌桥的价值，与CAG对照
目的：对比分析冠脉CTA和CAG检查患者的影像学资料，探讨冠脉CTA对心肌桥诊断的临床应用价值。
材料和方法：收集83例同时行双源CT冠状动脉成像（冠脉CTA）及CAG检查患者的影像学资料。图像分析采用双盲法，即由两位放射科诊断医生及两位介入科医生分别在不知道冠脉CTA及CAG诊断结果的前提下进行，两种检查手段对心肌桥的诊断分别由两组医生协商做出，计算CTA及CAG对心肌桥的检出率并采用卡方检验进行比较。
结果：（1）83例患者中冠脉CTA显示41例共48处心肌桥，检出率为49.4%（41/83），28处为完全心肌桥，20处为不完全心肌桥。48处心肌桥中29处位于前降支中段，11处位于前降支远段，2处位于右冠后降支，1处位于第一锐缘支，3处位于第一钝缘支，1处位于中间支，1处位于第一对角支。41例患者中7例为2处心肌桥。（2）CAG显示19例共19处冠脉“挤牛奶”效应，即19例（19处）心肌桥，检出率为22.9%（19/83）。19处心肌桥中16处位于前降支中段，2处位于前降支远段，1处位于右冠后降支。与CTA对照，CAG显示的19处心肌桥与其位置一致，其中15处为完全性心肌桥，4处为不完全心肌。冠脉CTA对心肌桥的检出率高于CAG，差异具有统计学意义（P＜0.001）。
结论：双源CT冠状动脉成像能多方位、直观显示冠状动脉与心肌的解剖关系，对心肌桥的显示优于CAG，且具有无创性检查的优点；但CAG在显示壁冠状动脉血流动力学方面优于CTA。
第三节单纯性心肌桥患者心肌首过灌注成像的初步研究
目的以正常心肌首过灌注为对照，初步评估单纯性前降支心肌桥患者相应供血区的冠脉CTA心肌首过灌注情况，为临床综合评价心肌桥及临床诊治策略的制定提供参考依据。
材料和方法收集42例以胸痛就诊、冠脉CTA诊断为单纯前降支心肌桥的患者资料；病例组内根据心肌桥类型分为完全性心肌桥组及不完全心肌桥组；根据收缩期壁冠状动脉受压程度分为收缩期狭窄≥50%组及收缩期狭窄＜50%组。20例冠脉CTA显示冠脉无异常的体检者作为正常对照组。所有患者均采用回顾性扫描，全剂量曝光时间窗30-75%R-R间期，重建最佳舒张期（65%-75%RR）及收缩期（30%-40%RR）图像，重建层厚/间距为0.75mm/0.5mm。采用美国泰瑞工作站的心功能分析软件获得舒张期及收缩期时左室心肌17节段平均CT值。计算前降支供血区（1、2、7、8、13、14及17段）的平均CT值作为首过心肌灌注值。测量主动脉CT值，计算心肌平均CT值与主动脉平均CT值的比值为心肌首过灌注校正值（corrected MP, c-MP）。将主动脉平均CT值与心肌平均CT值进行相关性分析。心肌桥组和正常组的心肌平均CT值及c-MP行两独立样本t检验。完全性心肌桥组及不完全心肌桥组、狭窄≥50%组及狭窄＜50%组和正常组间的心肌平均CT值及c-MP采用多组间比较。
结果(1)正常组主动脉平均CT值为367.1HU，心肌桥组主动脉平均CT值为398HU，均与心肌平均CT值呈明显正相关（r=0.768-0.854，P＜0.001）。
(2)舒张期心肌桥组和正常组前降支供血区的平均CT值为94.0HU及96.0HU（P=0.216）、舒张期心肌桥组和正常组前降支供血区的c-MP为0.236及0.263（P＜0.001）；收缩期心肌桥组和正常组的前降支供血区平均CT值为89.3HU及94.6HU（P＜0.001）、收缩期心肌桥组和正常组的前降支供血区c-MP为0.225及0.259（P＜0.001）。
(3)完全性心肌桥组舒张期及收缩期的前降支供血区平均CT值为90.9HU及86.5HU，低于不完全心肌桥组（100.8HU及95.7HU），差异均有统计学意义（P＜0.05）。完全性心肌桥组的舒张期及收缩期c-MP为0.235及0.224，不完全心肌桥组为0.240及0.228，均明显低于正常组，差异均具有统计学意义（P＜0.05）。
(4)狭窄≥50%组舒张期及收缩期的前降支供血区平均CT值为91.7HU及87.2HU，低于狭窄＜50%组（96.9HU及92.1HU），差异均有统计学意义（P＜0.05）。狭窄≥50%组的舒张期及收缩期c-MP为0.234及0.223，狭窄＜50%组为0.239及0.227，均明显低于正常组，差异均具有统计学意义（P＜0.05）。
结论测量心肌桥患者冠脉CTA检查时舒张期及收缩期首过灌注心肌CT值，能一定程度反应相应冠脉供血区的心肌血流灌注情况。以胸痛就诊单纯前降支心肌桥患者前降支供血区心肌平均CT值低于正常组，以收缩期更明显，特别是完全性心肌桥并收缩期狭窄≥50%的患者，应引起临床关注。
Objective: To analyze the differences of radiation dose and image quality of prospectiveversus retrospective ECG gated coronary angiography with dual source CT, in order toprovide individualized scanning procedure for the clinical application of low dose coronaryangiograph.
Materials and Methods:90patients who were referred for coronary CT angiography withdual source CT scanner were enrolled and divided into two groups: prospective group (PG)included40cases, tube voltage was120KV, and reference tube current was400mAs withapplication of automatic tube current modulation (ATCM) scanning technique; Theretrospective group (RG) included50cases, tube voltage was120KV, reference tubecurrent was400mAs with application of ATCM technique, and ECG automatic tube currentmodulation and pitch-rate matching technology were also used. Two radiologistindependently assessed image quality in segments (diameter>1mm)) by using a four-pointscale; and the assessable image quality was defined as scored1,2and3. Radiation dose ofCTA exam was calculated.
Results:(1) Of the40cases in PG,554segments of coronary artery were showed, thepercentage of assessable coronary segments (≤3points) was99.27%and scored as excellent(1point) was segments was96.93%.645segments of coronary artery were revealed in RG(50cases),98.76%could fulfill the requirement of diagnosis and88.99%were excellent.The total segments with assessable image quality was significant difference (p=0.024)between these two groups, and the segments scored1in PG group were more than RGgroup (P＜0.001).(2) the mean radiation dose of PG group and RG group was4.46mSvand6.61mSv, and it was statistically significant difference (P＜0.001).
Conclusions: With various procedures of radiation dose reduction, low radiation dosecould also be achieved with RG without heart rate control. PG is the most effectiveapproach for the reduction of radiation dose, yet low and stable heart rate wereindispensible for high image quality. In clinical work, the appropriate scan mode andparameters should be selected based on patients’ conditions to ensure image quality andlow-dose scan.
Chapter Ⅰ The CT imaging characteristics of incomplete and completemyocardial bridges-mural coronary artery
Objective: To study the types of the myocardial bridge (MB) and the CT imagingcharacteristics of MB and mural coronary artery (MCA).
Materials and Methods: Fifty patients with dual source coronary CT angiography(DSCTA) evidenced with MB were included. The MB was divided into into two groups:incomplete MB group (partial encasement) and complete MB group (full encasement). Thediameter of MCA, proximal segment and distal segment in best systole phase and diastolephase, the MCA stenosis rate, the presence of atheromatous change proximal to the MBwere evaluated.
Results: A total of58MBs were detected, the average length was2.02cm,23wereincomplete MBs and35were complete MBs. Thirty-two (55.2%) MBs were in the middlesegment of left anterior descending artery (LAD);17(29.3%) MBs were in the distalsegment of LAD;1MB was in the proximal segment of LAD;3MBs in the first diagonal
branch;4MBs in the first obtuse marginal branch,1MB in posterior descending artery of
right coronary artery. The diameter and stenosis rate of MCA of both incomplete MB andcomplete MB in diastole and systole phase was1.93mm,1.71mm,4.7%,20.4%and2.21mm,1.63mm,8.1%and33.7%. It was statistically significant difference of diameterchange and stenosis rate between these two groups (P=0.008, P=0.014). Atherosclerosislesion was evidenced in8incomplete MB（34.78%） and15complete MB（42.86%）at theproximal segment of MB, and there were no significant difference between two groups(P=0.339).
Conclusions: Complete MB induced the narrowing of MCA more serious than incompleteMB, and last longer. DSCTA can vividly display the incomplete and complete myocardialMB, accurately evaluate the shape change of MB-MCA in diastole and systole phase anddetect the atherosclerosis lesion in the proximal segment of MB.
Chapter Ⅱ Diagnosis of myocardial bridges: a comparison betweencomputed tomography and invasive coronary angiography
Objective: To assess the evaluation of dual-source CT coronary angiography (CTA) indiagnosing myocardial bridges, and compared with invasive coronary angiography (CAG).
Materials and Methods: Analysis of83cases simultaneously underwent CTA and CAGexam. CTA and CAG images were analyzed by two cardiovascular and interventionalradiologists who did not know the results of CTA and CAG. Calculate the detection rate ofmyocardial bridges diagnosed in CTA and CAG and compared the difference using χ2test.
Results:⑴CTA detected41cases and a total of48myocardial bridges, the rate was49.4%(41/83).20were incomplete MB and28were complete MB.29located in themiddle left anterior descending artery,11in the distal left anterior descending artery, two in the posterior descending artery of right coronary, one in the first acute margial branch,three in the first obtuse marginal branch, one in the intermidiate branch, one in the firstdiagonal branch; and7cases with double myocardial bridge.⑵CAG revealed19patientsand a total of19myocardial bridges which were the same as detected in CTA examination,the detection rate was22.9%(19/83), and16located in the middle left anterior descendingartery,2located in the distal left anterior descending artery, one in the posterior descendingartery of right coronary artery. Compared the difference of detection rate between CTA andCAG, there were significant difference (P <0.001).
Conclusions: CT coronary angiography can display the anatomy relationship betweencoronary artery and myocardium directly and non-invasive, which were better than CAG,but CAG was helpful at the evaluation of hemodynamic change.
Chapter Ⅲ First-pass myocardial perfusion of the patients with isolatedmyocardial Bridge
Objective: To investigate the first-pass myocardium perfusion (MP) of the patients withisolated MB on dual source CT coronary angiography (CTA) compared with normalcontrol cases.
Materials and Methods:42cases with isolated MB of LAD on CTA were enrolled as thecase group (MB group), and all cases with the symptom of chest pain. According with MBtype and degree of systolic narrowing, there were subgroups (complete myocardial bridgegroup and incomplete myocardial bridge group, stenosis≥50%group and systolic stenosis<50%).20patients with normal coronary arteries on CTA were enrolled as the controlgroup. All patients were scanned with retrospective ECG-gated technique and reconstructedthe optimal systolic (30%-40%RR) and diastolic (65%-75%RR) images, slice thickness 0.75mm, increment0.5mm, reconstruction kernel B26f. The systolic and diastolic imageswere sent into the Terry workstation, and measured the segmental myocardial perfusion inHounsfield units (HU) with semiautomated method for17segments American HeartAssociation. The region of myocardium supplied by the left anterior descending artery wassegment1,2,7,8,13,14and17, calculated the average CT value as the MP. Measured theattenuation of the aorta artery (AA) at the root, and then calculated the corrected MP(c-MP).
Results:(1) The CT value of AA in control group was367.1HU, and398HU in MB group,which was positively correlated with the myocardium average CT value (r=0.768-0.854，P＜0.001).
(2) The myocardium CT value and c-MP of MB group and control group at diastolic phasewere94.0HU and96.0HU (p=0.216),0.236and0.263(P <0.001), respectively; themyocardium CT value and c-MP of MB group and control group at systolic phase were89.3HU and94.6HU (P<0.001),0.225and0.259(P<0.001), respectively.
(3) The myocardium CT value of complete MB group at diastolic and systolic phase were90.9HU and86.5HU, of incomplete MB group were100.8HU and95.7HU (P＜0.05)。Thec-MP of complete myocardial bridge group in diastole and systole were0.235and0.224,the incomplete myocardial bridge group was0.240and0.228, and there were no significantdifference (P＞0.05), but both were much smaller than the control group (P＜0.05).
(4) The myocardium CT value of stenosis≥50%group at diastolic and systolic phase were91.7HU and87.2HU, of stenosis <50%group were96.9HU and92.1HU (P＜0.05)。Thec-MP of stenosis≥50%group in diastole and systole were0.234and0.223, the stenosis<50%group were0.239and0.227, and there were no significant difference (P＞0.05), butboth were much smaller than the control group (P＜0.05).
Conclusions: By measuring the diastolic and systolic myocardium CT value of the patientswith isolated MB can be evaluate the blood supply to a certain extent. The average CT ofmyocardium was lower than the control group in the patient with isolated myocardial bridge of LAD with the symptom of chest pain, more obvious in MB group and systolicstenosis≥50%group.
材料与方法：将90例行双源CT冠状动脉检查的患者依据扫描方式不同分为两组：前瞻扫描组40例，要求患者心率平稳且≤70bpm，图像采集时间窗为62-78%R-R间期，管电压120KV,应用自动管电流调制技术（automatic tube current modulation，ATCM），参考管电流为400mAs；回顾扫描组50例，采用ATCM技术、ECG管电流自动调制技术及螺距-心率自动匹配技术，管电压120KV，参考管电流为400mAs。由两位经验丰富的放射医生对所有冠脉节段（直径≥1mm）进行图像质量评分，意见不一致时协商确定。评分标准采用4分法（1分：优秀；2分：轻度伪影或/和错层；3分：中度伪影或/和错层；4分：严重伪影或/和错层），1-3分能用于图像诊断，4分不能用于诊断。对两组满足诊断要求（≤3分）的冠脉节段及评价为优（1分）的冠脉节段进行非参数秩和检验。计算所有患者CTA检查的辐射剂量，两组间比较采用配对t检验。
结果：（1）前瞻扫描组40例患者共评价冠脉554段，满足诊断（≤3分）及评价为优（1分）的冠脉节段比例分别为99.27%和96.93%。回顾扫描组50例患者共评价冠脉645段，满足诊断（≤3分）及评价为优（1分）的冠脉节段比例分别为98.76%和88.99%。对两组间满足诊断的冠脉节段比例进行比较，有统计学差异（P=0.024）；评价为优的冠脉节段比例前瞻扫描组明显高于回顾扫描组，统计学差异明显（P＜0.001）。（2）前瞻扫描组和回顾扫描组的有效辐射剂量分别为4.46mSv和6.61mSv，两组间比较差异具有统计学意义（P＜0.001）。
结论：回顾性心电门控扫描应用各种降低辐射剂量的措施后，可明显降低辐射剂量；对于高心率及心律不齐患者有优势。前瞻性心电门控扫描是减少辐射剂量的有效方式，但较低且平稳的心率是其获得优质图像的保证。临床工作中应根据患者不同情况选择合适的扫描方式及参数，在保证图像质量的前提下，尽可能达到低剂量扫描。
第一节不完全心肌桥及完全性心肌桥的CT影像特征分析
目的：探讨心肌桥的分型及不同类型心肌桥-壁冠状动脉的CT影像特征。
材料和方法：收集50例行双源CT冠状动脉成像，诊断有心肌桥患者的影像学资料，所有患者采用回顾性心电门控扫描，重建显示冠脉的最佳收缩期及舒张期图像，重建层厚/层间距为0.75mm/0.5mm。根据冠状动脉被心肌包绕程度分为两组：不完全心肌桥组（冠状动脉被心肌部分包绕，至少在1/2以上）和完全性心肌桥组（冠状动脉完全被心肌包绕）。测量50例患者心肌桥的最佳舒张期及收缩期壁冠状动脉最窄处、桥前段及桥后段正常血管的管径，计算壁冠状动脉的狭窄率，其差异的比较采用两配对t检验。评价心肌桥患者桥前段冠脉伴发的粥样硬化改变，两组心肌桥间差异的比较采用卡方检验。
结果：50例患者中，冠脉CTA显示58处心肌桥，平均长度为2.02cm，其中不完全心肌桥23处，完全性心肌桥35处。58处心肌桥中前降支中段32处（60%），前降支远段17处（29.3%），前降支近段1处，第一对角支3处，第一钝缘支4处，右冠后降支1处。不完全心肌桥组舒张期及收缩期壁冠状动脉管径及狭窄率分别为1.93mm、1.71mm、4.7%和20.4%，完全性心肌桥组舒张期及收缩期壁冠状动脉管径及狭窄率分别为2.21mm、1.63mm、8.1%和33.7%。两组心肌桥舒张期及收缩期壁冠状动脉管径差值的差异具有统计学意义（P=0.008）；两组心肌桥收缩期壁冠状动脉狭窄率的比较，差异具有统计学意义（P=0.014）。8处不完全心肌桥及15处完全性心肌桥的桥前段冠脉伴发粥样硬化病变，其差异无统计学意义（P=0.339）。
结论：完全性心肌桥对壁冠状动脉的压迫程度较不完全心肌桥严重，且持续时间更长。冠脉CTA成像能够无创地显示心肌桥的长度和厚度，评价壁冠状动脉舒张期和收缩期的形态学变化及伴发的粥样硬化改变，为临床治疗计划提供客观的依据。
第二节CT冠状动脉成像诊断心肌桥的价值，与CAG对照
目的：对比分析冠脉CTA和CAG检查患者的影像学资料，探讨冠脉CTA对心肌桥诊断的临床应用价值。
材料和方法：收集83例同时行双源CT冠状动脉成像（冠脉CTA）及CAG检查患者的影像学资料。图像分析采用双盲法，即由两位放射科诊断医生及两位介入科医生分别在不知道冠脉CTA及CAG诊断结果的前提下进行，两种检查手段对心肌桥的诊断分别由两组医生协商做出，计算CTA及CAG对心肌桥的检出率并采用卡方检验进行比较。
结果：（1）83例患者中冠脉CTA显示41例共48处心肌桥，检出率为49.4%（41/83），28处为完全心肌桥，20处为不完全心肌桥。48处心肌桥中29处位于前降支中段，11处位于前降支远段，2处位于右冠后降支，1处位于第一锐缘支，3处位于第一钝缘支，1处位于中间支，1处位于第一对角支。41例患者中7例为2处心肌桥。（2）CAG显示19例共19处冠脉“挤牛奶”效应，即19例（19处）心肌桥，检出率为22.9%（19/83）。19处心肌桥中16处位于前降支中段，2处位于前降支远段，1处位于右冠后降支。与CTA对照，CAG显示的19处心肌桥与其位置一致，其中15处为完全性心肌桥，4处为不完全心肌。冠脉CTA对心肌桥的检出率高于CAG，差异具有统计学意义（P＜0.001）。
结论：双源CT冠状动脉成像能多方位、直观显示冠状动脉与心肌的解剖关系，对心肌桥的显示优于CAG，且具有无创性检查的优点；但CAG在显示壁冠状动脉血流动力学方面优于CTA。
第三节单纯性心肌桥患者心肌首过灌注成像的初步研究
目的以正常心肌首过灌注为对照，初步评估单纯性前降支心肌桥患者相应供血区的冠脉CTA心肌首过灌注情况，为临床综合评价心肌桥及临床诊治策略的制定提供参考依据。
材料和方法收集42例以胸痛就诊、冠脉CTA诊断为单纯前降支心肌桥的患者资料；病例组内根据心肌桥类型分为完全性心肌桥组及不完全心肌桥组；根据收缩期壁冠状动脉受压程度分为收缩期狭窄≥50%组及收缩期狭窄＜50%组。20例冠脉CTA显示冠脉无异常的体检者作为正常对照组。所有患者均采用回顾性扫描，全剂量曝光时间窗30-75%R-R间期，重建最佳舒张期（65%-75%RR）及收缩期（30%-40%RR）图像，重建层厚/间距为0.75mm/0.5mm。采用美国泰瑞工作站的心功能分析软件获得舒张期及收缩期时左室心肌17节段平均CT值。计算前降支供血区（1、2、7、8、13、14及17段）的平均CT值作为首过心肌灌注值。测量主动脉CT值，计算心肌平均CT值与主动脉平均CT值的比值为心肌首过灌注校正值（corrected MP, c-MP）。将主动脉平均CT值与心肌平均CT值进行相关性分析。心肌桥组和正常组的心肌平均CT值及c-MP行两独立样本t检验。完全性心肌桥组及不完全心肌桥组、狭窄≥50%组及狭窄＜50%组和正常组间的心肌平均CT值及c-MP采用多组间比较。
结果(1)正常组主动脉平均CT值为367.1HU，心肌桥组主动脉平均CT值为398HU，均与心肌平均CT值呈明显正相关（r=0.768-0.854，P＜0.001）。
(2)舒张期心肌桥组和正常组前降支供血区的平均CT值为94.0HU及96.0HU（P=0.216）、舒张期心肌桥组和正常组前降支供血区的c-MP为0.236及0.263（P＜0.001）；收缩期心肌桥组和正常组的前降支供血区平均CT值为89.3HU及94.6HU（P＜0.001）、收缩期心肌桥组和正常组的前降支供血区c-MP为0.225及0.259（P＜0.001）。
(3)完全性心肌桥组舒张期及收缩期的前降支供血区平均CT值为90.9HU及86.5HU，低于不完全心肌桥组（100.8HU及95.7HU），差异均有统计学意义（P＜0.05）。完全性心肌桥组的舒张期及收缩期c-MP为0.235及0.224，不完全心肌桥组为0.240及0.228，均明显低于正常组，差异均具有统计学意义（P＜0.05）。
(4)狭窄≥50%组舒张期及收缩期的前降支供血区平均CT值为91.7HU及87.2HU，低于狭窄＜50%组（96.9HU及92.1HU），差异均有统计学意义（P＜0.05）。狭窄≥50%组的舒张期及收缩期c-MP为0.234及0.223，狭窄＜50%组为0.239及0.227，均明显低于正常组，差异均具有统计学意义（P＜0.05）。
结论测量心肌桥患者冠脉CTA检查时舒张期及收缩期首过灌注心肌CT值，能一定程度反应相应冠脉供血区的心肌血流灌注情况。以胸痛就诊单纯前降支心肌桥患者前降支供血区心肌平均CT值低于正常组，以收缩期更明显，特别是完全性心肌桥并收缩期狭窄≥50%的患者，应引起临床关注。
Objective: To analyze the differences of radiation dose and image quality of prospectiveversus retrospective ECG gated coronary angiography with dual source CT, in order toprovide individualized scanning procedure for the clinical application of low dose coronaryangiograph.
Materials and Methods:90patients who were referred for coronary CT angiography withdual source CT scanner were enrolled and divided into two groups: prospective group (PG)included40cases, tube voltage was120KV, and reference tube current was400mAs withapplication of automatic tube current modulation (ATCM) scanning technique; Theretrospective group (RG) included50cases, tube voltage was120KV, reference tubecurrent was400mAs with application of ATCM technique, and ECG automatic tube currentmodulation and pitch-rate matching technology were also used. Two radiologistindependently assessed image quality in segments (diameter>1mm)) by using a four-pointscale; and the assessable image quality was defined as scored1,2and3. Radiation dose ofCTA exam was calculated.
Results:(1) Of the40cases in PG,554segments of coronary artery were showed, thepercentage of assessable coronary segments (≤3points) was99.27%and scored as excellent(1point) was segments was96.93%.645segments of coronary artery were revealed in RG(50cases),98.76%could fulfill the requirement of diagnosis and88.99%were excellent.The total segments with assessable image quality was significant difference (p=0.024)between these two groups, and the segments scored1in PG group were more than RGgroup (P＜0.001).(2) the mean radiation dose of PG group and RG group was4.46mSvand6.61mSv, and it was statistically significant difference (P＜0.001).
Conclusions: With various procedures of radiation dose reduction, low radiation dosecould also be achieved with RG without heart rate control. PG is the most effectiveapproach for the reduction of radiation dose, yet low and stable heart rate wereindispensible for high image quality. In clinical work, the appropriate scan mode andparameters should be selected based on patients’ conditions to ensure image quality andlow-dose scan.
Chapter Ⅰ The CT imaging characteristics of incomplete and completemyocardial bridges-mural coronary artery
Objective: To study the types of the myocardial bridge (MB) and the CT imagingcharacteristics of MB and mural coronary artery (MCA).
Materials and Methods: Fifty patients with dual source coronary CT angiography(DSCTA) evidenced with MB were included. The MB was divided into into two groups:incomplete MB group (partial encasement) and complete MB group (full encasement). Thediameter of MCA, proximal segment and distal segment in best systole phase and diastolephase, the MCA stenosis rate, the presence of atheromatous change proximal to the MBwere evaluated.
Results: A total of58MBs were detected, the average length was2.02cm,23wereincomplete MBs and35were complete MBs. Thirty-two (55.2%) MBs were in the middlesegment of left anterior descending artery (LAD);17(29.3%) MBs were in the distalsegment of LAD;1MB was in the proximal segment of LAD;3MBs in the first diagonal
branch;4MBs in the first obtuse marginal branch,1MB in posterior descending artery of
right coronary artery. The diameter and stenosis rate of MCA of both incomplete MB andcomplete MB in diastole and systole phase was1.93mm,1.71mm,4.7%,20.4%and2.21mm,1.63mm,8.1%and33.7%. It was statistically significant difference of diameterchange and stenosis rate between these two groups (P=0.008, P=0.014). Atherosclerosislesion was evidenced in8incomplete MB（34.78%） and15complete MB（42.86%）at theproximal segment of MB, and there were no significant difference between two groups(P=0.339).
Conclusions: Complete MB induced the narrowing of MCA more serious than incompleteMB, and last longer. DSCTA can vividly display the incomplete and complete myocardialMB, accurately evaluate the shape change of MB-MCA in diastole and systole phase anddetect the atherosclerosis lesion in the proximal segment of MB.
Chapter Ⅱ Diagnosis of myocardial bridges: a comparison betweencomputed tomography and invasive coronary angiography
Objective: To assess the evaluation of dual-source CT coronary angiography (CTA) indiagnosing myocardial bridges, and compared with invasive coronary angiography (CAG).
Materials and Methods: Analysis of83cases simultaneously underwent CTA and CAGexam. CTA and CAG images were analyzed by two cardiovascular and interventionalradiologists who did not know the results of CTA and CAG. Calculate the detection rate ofmyocardial bridges diagnosed in CTA and CAG and compared the difference using χ2test.
Results:⑴CTA detected41cases and a total of48myocardial bridges, the rate was49.4%(41/83).20were incomplete MB and28were complete MB.29located in themiddle left anterior descending artery,11in the distal left anterior descending artery, two in the posterior descending artery of right coronary, one in the first acute margial branch,three in the first obtuse marginal branch, one in the intermidiate branch, one in the firstdiagonal branch; and7cases with double myocardial bridge.⑵CAG revealed19patientsand a total of19myocardial bridges which were the same as detected in CTA examination,the detection rate was22.9%(19/83), and16located in the middle left anterior descendingartery,2located in the distal left anterior descending artery, one in the posterior descendingartery of right coronary artery. Compared the difference of detection rate between CTA andCAG, there were significant difference (P <0.001).
Conclusions: CT coronary angiography can display the anatomy relationship betweencoronary artery and myocardium directly and non-invasive, which were better than CAG,but CAG was helpful at the evaluation of hemodynamic change.
Chapter Ⅲ First-pass myocardial perfusion of the patients with isolatedmyocardial Bridge
Objective: To investigate the first-pass myocardium perfusion (MP) of the patients withisolated MB on dual source CT coronary angiography (CTA) compared with normalcontrol cases.
Materials and Methods:42cases with isolated MB of LAD on CTA were enrolled as thecase group (MB group), and all cases with the symptom of chest pain. According with MBtype and degree of systolic narrowing, there were subgroups (complete myocardial bridgegroup and incomplete myocardial bridge group, stenosis≥50%group and systolic stenosis<50%).20patients with normal coronary arteries on CTA were enrolled as the controlgroup. All patients were scanned with retrospective ECG-gated technique and reconstructedthe optimal systolic (30%-40%RR) and diastolic (65%-75%RR) images, slice thickness 0.75mm, increment0.5mm, reconstruction kernel B26f. The systolic and diastolic imageswere sent into the Terry workstation, and measured the segmental myocardial perfusion inHounsfield units (HU) with semiautomated method for17segments American HeartAssociation. The region of myocardium supplied by the left anterior descending artery wassegment1,2,7,8,13,14and17, calculated the average CT value as the MP. Measured theattenuation of the aorta artery (AA) at the root, and then calculated the corrected MP(c-MP).
Results:(1) The CT value of AA in control group was367.1HU, and398HU in MB group,which was positively correlated with the myocardium average CT value (r=0.768-0.854，P＜0.001).
(2) The myocardium CT value and c-MP of MB group and control group at diastolic phasewere94.0HU and96.0HU (p=0.216),0.236and0.263(P <0.001), respectively; themyocardium CT value and c-MP of MB group and control group at systolic phase were89.3HU and94.6HU (P<0.001),0.225and0.259(P<0.001), respectively.
(3) The myocardium CT value of complete MB group at diastolic and systolic phase were90.9HU and86.5HU, of incomplete MB group were100.8HU and95.7HU (P＜0.05)。Thec-MP of complete myocardial bridge group in diastole and systole were0.235and0.224,the incomplete myocardial bridge group was0.240and0.228, and there were no significantdifference (P＞0.05), but both were much smaller than the control group (P＜0.05).
(4) The myocardium CT value of stenosis≥50%group at diastolic and systolic phase were91.7HU and87.2HU, of stenosis <50%group were96.9HU and92.1HU (P＜0.05)。Thec-MP of stenosis≥50%group in diastole and systole were0.234and0.223, the stenosis<50%group were0.239and0.227, and there were no significant difference (P＞0.05), butboth were much smaller than the control group (P＜0.05).
Conclusions: By measuring the diastolic and systolic myocardium CT value of the patientswith isolated MB can be evaluate the blood supply to a certain extent. The average CT ofmyocardium was lower than the control group in the patient with isolated myocardial bridge of LAD with the symptom of chest pain, more obvious in MB group and systolicstenosis≥50%group.
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