本文選題：雙側(cè)雙向Glenn分流術(shù)　切入點(diǎn)：雙源CT　出處：《山東大學(xué)》2015年博士論文

【摘要】：第一部分雙源CT低劑量前瞻性心電門控步進(jìn)式掃描在搏動(dòng)性雙側(cè)雙向Glenn術(shù)后患兒中的臨床應(yīng)用目的：探討雙源CT低劑量前瞻性心電門控步進(jìn)式掃描(簡(jiǎn)稱低劑量步進(jìn)式掃描)技術(shù)作為一種無(wú)創(chuàng)的形態(tài)學(xué)方面的評(píng)價(jià)方法在搏動(dòng)性雙側(cè)雙向Glenn術(shù)后患兒中的應(yīng)用價(jià)值。方法：前瞻性收集20例搏動(dòng)性雙側(cè)雙向Glenn術(shù)后患兒(平均年齡為4.2±1.6歲,范圍2-6歲；男15例,女5例；平均體重15.4±3.7 kg,范圍10-21 kg),于低劑量步進(jìn)式掃描后1周內(nèi)行傳統(tǒng)心血管造影檢查(conventional cardiac angiography, CCA)。步進(jìn)式掃描參數(shù)設(shè)置：探測(cè)器準(zhǔn)直為2×32×0.6mm,球管旋轉(zhuǎn)時(shí)間為0.33s/r,采集時(shí)間窗預(yù)設(shè)為40%R-R間期,管電壓為80kV,管電流根據(jù)患兒體重調(diào)節(jié)：體重不超過(guò)6kg,每kg增加lOmAs,體重超過(guò)6kg,超出部分在60mAs基礎(chǔ)上每kg增加5mAs,管電流最大140 mAs。由兩名具備五年以上心血管影像診斷經(jīng)驗(yàn)的醫(yī)師采用5分法對(duì)圖像質(zhì)量進(jìn)行主觀評(píng)價(jià),運(yùn)用Kappa檢驗(yàn)評(píng)價(jià)兩名醫(yī)師對(duì)圖像質(zhì)量主觀評(píng)價(jià)的一致性。測(cè)量患兒雙側(cè)上腔靜脈及肺動(dòng)脈的CT值及噪聲。術(shù)后患兒的形態(tài)學(xué)評(píng)價(jià)包括,雙側(cè)上腔靜脈和肺動(dòng)脈的形態(tài)測(cè)量,上腔靜脈和肺動(dòng)脈的吻合位置關(guān)系,是否出現(xiàn)血栓形成、體肺側(cè)支循環(huán)及肺動(dòng)靜脈畸形等,以CCA結(jié)果作為金標(biāo)準(zhǔn),運(yùn)用Bland-Altman檢驗(yàn)和線性回歸分析評(píng)價(jià)CT血管造影(CT angiography,CTA)和CCA的符合程度并計(jì)算Pearson's相關(guān)系數(shù)。計(jì)算低劑量步進(jìn)式掃描和CCA的有效輻射劑量(effective dose, ED)。結(jié)果：左側(cè)上腔靜脈、右側(cè)上腔靜脈、左側(cè)肺動(dòng)脈、右側(cè)肺動(dòng)脈的強(qiáng)化CT值分別為351.1±52.3HU、353.8±60.4HU、345.7±57.OHU、356.5±67.6HU,噪聲分別為26.4±4.1HU、24.5±5.4HU、25.2±3.7HU、24.5±4.4HU。所有圖像均滿足診斷要求,其中5分5例,4分11例,3分4例,圖像質(zhì)量主觀評(píng)分平均為4.05±0.69,兩名醫(yī)師的一致性好(k=0.76,P0.05)。低劑量步進(jìn)式掃描可以全面直觀地顯示雙側(cè)上腔靜脈和肺動(dòng)脈,發(fā)現(xiàn)14支上腔靜脈管腔擴(kuò)張,16處肺動(dòng)脈局限性狹窄。61.5%(24/39)的上腔靜脈吻合于肺動(dòng)脈上方,38.5%(15/39)的上腔靜脈吻合于肺動(dòng)脈前方。1例患兒發(fā)現(xiàn)血栓形成。13例患兒發(fā)現(xiàn)33支體-肺循環(huán)側(cè)支血管,其中發(fā)現(xiàn)2支側(cè)支血管者6例,3支側(cè)支血管者7例；33支側(cè)支血管中起自主動(dòng)脈弓2支、降主動(dòng)脈15支、肋間動(dòng)脈8支、左鎖骨下動(dòng)脈2支、左胸廓內(nèi)動(dòng)脈2支、左椎動(dòng)脈1支、右胸廓內(nèi)動(dòng)脈3支。20例患兒沒(méi)有發(fā)現(xiàn)肺動(dòng)靜脈畸形。CTA在形態(tài)測(cè)量方面與CCA的一致性好(R10.8,P0.001)。Bland-Altman檢驗(yàn)表明CTA測(cè)量值在一定程度上偏大(平均偏倚值0)。低劑量步進(jìn)式掃描平均ED為0.50±0.17 mSv(0.27-0.89 mSv)；CCA平均ED為4.85±1.34 mSv(3.07-6.72 mSv)。結(jié)論：雙源CT低劑量前瞻性心電門控步進(jìn)式掃描可以準(zhǔn)確地對(duì)保留前向血流的雙側(cè)雙向Glenn術(shù)后患兒進(jìn)行形態(tài)學(xué)方面的評(píng)價(jià),簡(jiǎn)便無(wú)創(chuàng)且輻射劑量低。第二部分128層雙源CT低劑量前瞻性心電門控大螺距掃描結(jié)合迭代重建在雙側(cè)雙向Glenn術(shù)后患兒中的臨床應(yīng)用目的：探討128層雙源CT低劑量前瞻性心電門控大螺距掃描(簡(jiǎn)稱低劑量大螺距掃描)結(jié)合迭代重建技術(shù)在雙側(cè)雙向Glenn術(shù)后患兒中的臨床應(yīng)用價(jià)值,并將管電壓70kV組與80kV組的圖像質(zhì)量及輻射劑量進(jìn)行比較,以探索70kV應(yīng)用于雙側(cè)雙向Glenn術(shù)后患兒的可行性。方法：前瞻性收集雙側(cè)雙向Glenn術(shù)后患兒40例,隨機(jī)分為A、B兩組,A組患兒20例(平均年齡為5.4±3.0歲,范圍1-10歲；男8例,女12例；平均體重19.2±6.9 kg,范圍10-31 kg)行80kV低劑量大螺距掃描,B組患兒20例(平均年齡為5.3±2.7歲,范圍1-10歲；男9例,女11例；平均體重18.8±5.6 kg,范圍9-30 kg)行70kV低劑量大螺距掃描。所有患兒于低劑量大螺距掃描后1周內(nèi)行傳統(tǒng)心血管造影檢查(conventional cardiac angiography, CCA)。大螺距掃描參數(shù)設(shè)置：探測(cè)器準(zhǔn)直為2×64×0.6mm,球管旋轉(zhuǎn)時(shí)間為0.28s/r,螺距為3.4,數(shù)據(jù)采集起始時(shí)相預(yù)設(shè)為10%R-R間期；A組管電壓為80kV,管電流根據(jù)患兒體重調(diào)節(jié)：不超過(guò)6kg,管電流為10mAs/kg,6kg以上,管電流在60mAs的基礎(chǔ)上增加5mAs/kg; B組管電壓為70kV,管電流在A組的計(jì)算方法所得管電流基礎(chǔ)上增加20mAs。記錄兩組的掃描長(zhǎng)度和掃描時(shí)間。運(yùn)用基于原始數(shù)據(jù)的迭代重建技術(shù)獲得薄層圖像,重建強(qiáng)度為3,卷積核為I26f。將薄層圖像傳輸至工作站進(jìn)行圖像后處理。由兩名具備五年以上心血管影像診斷經(jīng)驗(yàn)的醫(yī)師采用5分法對(duì)圖像質(zhì)量進(jìn)行主觀評(píng)價(jià)。分別測(cè)量?jī)山M圖像的升主動(dòng)脈根部、胸背部肌肉、雙側(cè)上腔靜脈及肺動(dòng)脈的CT值和噪聲,計(jì)算升主動(dòng)脈根部的信噪比(signal-to-noise ratio, SNR)和對(duì)比噪聲比(contrast-to-noise ratio,CNR)。計(jì)算有效輻射劑量(effective dose, ED)。采用Student's t檢驗(yàn)比較兩組患兒的一般資料、圖像CT值、噪聲、SNR、CNR及ED,采用Mann-Whitney U檢驗(yàn)比較兩組圖像質(zhì)量主觀評(píng)分,采用Kappa檢驗(yàn)比較兩名醫(yī)師對(duì)圖像質(zhì)量主觀評(píng)分的一致性。觀察患兒術(shù)后雙側(cè)上腔靜脈有無(wú)擴(kuò)張、肺動(dòng)脈有無(wú)狹窄、體-肺循環(huán)側(cè)支血管數(shù)目、有無(wú)血栓形成及肺動(dòng)靜脈畸形情況,并以CCA結(jié)果作為標(biāo)準(zhǔn),評(píng)價(jià)兩組圖像的診斷準(zhǔn)確性。結(jié)果：所有雙側(cè)雙向G1enn術(shù)后患兒均成功完成低劑量大螺距掃描。兩組患兒的年齡(t=0.054,P0.05)、體重(t=0.176,P0.05)、心率(t=0.461,P0.05)、掃描長(zhǎng)度(t=0.393,P0.05)及掃描時(shí)間(t=0.250,P0.05)差別無(wú)統(tǒng)計(jì)學(xué)意義。A、B兩組患兒CT圖像的升主動(dòng)脈CT值分別為323.1±55.3HU、361.7±61.6HU(t=2.086,P0.05),差異有統(tǒng)計(jì)學(xué)意義,B組高于A組；升主動(dòng)脈的噪聲、SNR、CNR(t=1.586、0.884、1.028,P0.05),差別均無(wú)統(tǒng)計(jì)學(xué)意義。兩組圖像的左上腔靜脈、右上腔靜脈、左肺動(dòng)脈及右肺動(dòng)脈的CT值(t=2.288、2.476、2.495、2.216,P0.05)差異有統(tǒng)計(jì)學(xué)意義,B組高于A組；左上腔靜脈、右上腔靜脈、左肺動(dòng)脈及右肺動(dòng)脈的噪聲(t=1.535、1.610、1.366、1.159,P0.05)差別無(wú)統(tǒng)計(jì)學(xué)意義。兩組所有患兒圖像均滿足診斷要求,A組5分8例,4分10例,3分2例,B組5分6例,4分11例,3分3例；兩名醫(yī)師的一致性好(k=0.74、0.75,P0.05)。A、B組圖像質(zhì)量主觀評(píng)價(jià)平均得分分別為4.30±0.66、4.15±0.67(u=176.00,P0.05),主觀評(píng)分差別無(wú)統(tǒng)計(jì)學(xué)意義。所有患兒的圖像均未出現(xiàn)運(yùn)動(dòng)偽影。CT發(fā)現(xiàn)發(fā)現(xiàn)上腔靜脈擴(kuò)張17處(A組9處,B組8處),肺動(dòng)脈狹窄10處(A組5處,B組5處)；體-肺循環(huán)側(cè)支血管49支(A組23支,B組26支),所有患兒均未發(fā)現(xiàn)血栓形成及動(dòng)靜脈畸形形成。以CCA結(jié)果作為標(biāo)準(zhǔn),兩組診斷準(zhǔn)確率均為100%。A、B兩組的ED平均分別為0.32±0.12 mSv.0.25±0.08mSv(t=2.128,P0.05),差異有統(tǒng)計(jì)學(xué)意義,B組小于A組。結(jié)論：128層雙源CT低劑量前瞻性心電門控大螺距掃描結(jié)合迭代重建技術(shù)在雙側(cè)雙向Glenn術(shù)后患兒中可以低輻射劑量獲取滿足診斷的圖像,并且將管電壓由80kV降至70kV后圖像強(qiáng)化程度提高的同時(shí)圖像質(zhì)量無(wú)明顯下降,70kV可以用于雙側(cè)雙向Glenn術(shù)后患兒形態(tài)學(xué)方面的評(píng)價(jià)。
[Abstract]:Objective : To investigate the clinical application of double - source CT low - dose forward - looking heart - gated progressive scan in pediatric patients with dual - sided and double - sided , double - source CT . Methods : To investigate the application value of double - source CT low - dose forward - looking heart - gated progressive scanning technique as a noninvasive morphological aspect in children with dual - sided and double - sided , double - source CT . Methods : Twenty cases of bilateral bilateral bilateral bidirectional cardiac surgery were prospectively collected ( mean age : 4.2 鹵 1.6 years , range 2 - 6 years ) .
There were 15 males and 5 females .
Mean body weight was 15.4 鹵 3.7 kg ( range 10 - 21 kg ) , and conventional cardiac angiography ( CCA ) was performed within 1 week after low - dose progressive scan . The results were as follows : collimation of the detector is 2 脳 32 脳 0.6mm , the rotation time of the ball tube is 0.33s / r , the acquisition time window is preset to 40 % R - R interval , the tube voltage is 80kV , the tube current is more than 6 kg per kg and the tube current is up to 140 mAs . Results : The enhanced CT values of left superior vena cava , right superior vena cava , left pulmonary artery and right pulmonary artery were 351.1 鹵 52.3HU , 353.8 鹵 60.4 HU , 345.7 鹵 57.OHU , 356.5 鹵 67.6 HU , respectively , and the noise was 26 . 4 鹵 4 . 1 HU , 24.5 鹵 5.4 HU , 25 . 2 鹵 3 . 7HU , 24.5 鹵 4.4 HU respectively . Low - dose progressive scan showed that the superior vena cava and pulmonary artery in bilateral superior vena cava were fully and intuitively displayed , 14 superior vena cava lumen were dilated , 16 pulmonary artery stenosis was found at 16 . The superior vena cava at 38.5 % ( 24 / 39 ) was anastomosed to the pulmonary artery , 38.5 % ( 15 / 39 ) of superior vena cava was anastomosed to the pulmonary artery .
Among the 33 collateral vessels , 2 branches from the aortic arch , 15 branches of descending aorta , 8 branches of intercostals , 2 branches of the lower left clavian artery , 2 branches of the left thoracic artery , 1 left vertebral artery and 3 branches of the right thoracic artery . The Bland - Altman test showed that the CTA measurements were somewhat larger ( mean bias value 0 ) . The mean ED of the low - dose progressive scan was 0.50 鹵 0.17 ( 0.27 - 0.89 ) .
The average ED of CCA is 4.85 鹵 1.34 ( 3.07 - 6.72 ) . Objective : To investigate the clinical application value of double - source CT low - dose prospective ECG gated large - pitch scanning combined with iterative reconstruction in the pediatric patients with bilateral two - sided and two - sided and two - sided and two - sided patients after bilateral two - way , double - source CT . Methods : Forty - four children with double - source CT were randomly divided into two groups : group A , group B , and group A : 20 cases ( mean age 5.4 鹵 3.0 years , range 1 - 10 years ) .
8 males and 12 females ;
The average body weight was 19.2 鹵 6.9 kg ( range 10 - 31 kg ) , 80 kV low - dose long - pitch scan , 20 children in group B ( mean age 5.3 鹵 2.7 years , range 1 - 10 years ) ;
There were 9 males and 11 females .
The average body weight was 18 . 8 鹵 5.6 kg ( range 9 - 30 kg ) at 70 kV low - dose long - pitch scan . All children underwent conventional cardiac angiography ( CCA ) within 1 week after low - dose large - pitch scanning . Parameter setting of large pitch scanning : the collimation of the detector is 2 脳 64 脳 0.6mm , the rotation time of the bulb is 0.28 s / r , the pitch is 3.4 , and the phase preset at the start of data acquisition is 10 % R - R interval ;
A group A tube voltage is 80kV , the tube current is adjusted according to the weight of the child : no more than 6kg , the tube current is 10mAs / kg , 6kg or more , the tube current is increased by 5mAs / kg on the basis of 60mAs , the tube current is increased by 20mAs on the basis of 60mAs . Effective dose ( ED ) was calculated . Results : The CT values of ascending aorta were 323.1 鹵 55.3HU , 361.7 鹵 61.6HU ( t = 2.086 , P0.05 ) .
The noise , SNR , CNR ( t = 1.586 , 0.884 , 1.028 , P0.05 ) of ascending aorta were not statistically significant . The difference of left superior vena cava , right superior vena cava , left pulmonary artery and right pulmonary artery was significant ( t = 2.288 , 2.476 , 2.495 , 2.216 , P0.05 ) .
There was no significant difference between the left superior vena cava , the right superior vena cava , the left pulmonary artery and the right pulmonary artery ( t = 1.535 , 1.610 , 1.366 , 1.159 , P0.05 ) .
The average scores of subjective evaluation of image quality in group A and B were 4.30 鹵 0.66 , 4.15 鹵 0.67 ( u = 176.00 , P0.05 ) .
There were 49 branches ( 23 branches in group A and 26 branches in group B ) on the side branch of the body - pulmonary circulation . All the children had no thrombosis and arteriovenous malformations . The diagnostic accuracy of the two groups was 0 . 32 鹵 0.12 , 0 . 25 鹵 0 . 08 ( t = 2.128 , P < 0 . 05 ) .

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R726.5;R816.92

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