【正文】 天津醫(yī)科大學(xué)碩士研究生學(xué)位論文中英文縮寫表心肌造影超聲心動(dòng)圖 myocardial contrast echocardiography（MCE）超聲心動(dòng)圖負(fù)荷試驗(yàn) stressech echocardiography（SE)負(fù)荷心肌造影超聲心動(dòng)圖 myocardial contrast stress echocardiography（MCSE)全功能聲學(xué)密度定量技術(shù) global acoustic densitometry (GAD)超聲心動(dòng)圖 ultrasonic cardiography（UCG）冠狀動(dòng)脈造影 coronary artery angiography (CAG）多巴酚丁胺負(fù)荷試驗(yàn) dobutamine stress trial (DST)小劑量多巴酚丁胺負(fù)荷超聲心動(dòng)圖 lowdose dobutamine stress echocardiography (LDDSE)峰值密度 peak density (PI)達(dá)到峰值密度的時(shí)間 time to peak density (TP)心肌血流量 myocardial blood flow (MBF)感興趣區(qū) regin of interest(ROI)背向散射積分 integrated backscatter (IBS)心肌梗死 myocardial infarction （MI）經(jīng)皮冠狀動(dòng)脈介入治療 percutaneous coronary intervention (PCI)冠狀動(dòng)脈旁路移植術(shù) coronary artery bypass grafting (CABG) 存活心肌 viability myocardium （VM)頓抑心肌 standstill myocardium （SM)冬眠心肌 hibernation myocardium（HM)傷殘心肌 wounded myocardium (WM)摘要目的: 心肌造影超聲心動(dòng)圖(myocardial contrast echocardiography MCE)已成為檢測(cè)心肌微循環(huán)完整性和心肌血流灌注的一種較為肯定和獨(dú)特的方法，負(fù)荷心肌造影超聲心動(dòng)圖(myocardial contrast stress echocardiography, MCSE)可以同時(shí)檢查心肌收縮功能儲(chǔ)備，二者結(jié)合可廣泛應(yīng)用于無創(chuàng)性估測(cè)心肌灌注、心肌存活性及心功能狀況。本研究應(yīng)用實(shí)時(shí)聲學(xué)造影、心肌負(fù)荷造影以及全功能聲學(xué)密度定量技術(shù)(global acoustic densitometry,GAD)，比較正常對(duì)照、X 綜合征、心肌梗死患者應(yīng)用多巴酚丁胺負(fù)荷試驗(yàn)(dobutamine stress trial, DST)前、后的變化情況，旨在評(píng)價(jià)心肌造影負(fù)荷超聲心動(dòng)圖檢測(cè)心肌血流量(myocardial blood flow,MBF)的臨床應(yīng)用價(jià)值。方法: 入選經(jīng)病史、體格檢查、心電圖、心肌酶及超聲心動(dòng)圖（ultrasonic cardiography ，UCG）檢查結(jié)果和冠狀動(dòng)脈造影（coronary artery angiography ,CAG）結(jié)果的明確診斷住院患者35例，分為心肌梗死組8 例，CAG示雙支至多支狹窄閉塞不等。非冠心病組27例，非冠心病組又按下列條件分為對(duì)照組19 例、 X 綜合征組8 例,均行經(jīng)靜脈MCE，其中對(duì)照組7例、X 綜合征組8例、心肌梗死組8例行經(jīng)靜脈DST后再重復(fù)心肌聲學(xué)造影。啟動(dòng)GAD 軟件,檢測(cè)峰值密度(peak density PI) ,閃爍顯像后即刻至達(dá)到峰值密度的時(shí)間(time to peak density TP) ,該節(jié)段的MBF[MBF=（PI/TP）PI]。結(jié)果: 非冠心病組與心肌梗死組比較性別、年齡和吸煙史、高血壓史和糖尿病史患者比例差異無統(tǒng)計(jì)學(xué)意義。各組MCE前后心率、血壓比較差異無統(tǒng)計(jì)學(xué)意義（P），多巴酚丁胺20181。g／(kgmin)劑量DST后心率、血壓值較DST前增大（P）；多巴酚丁胺30181。g／(kgmin)劑量后心率、血壓較DST前增大（P）。 正常對(duì)照組心肌聲學(xué)顯影的PI與X綜合征組相比較差異沒有統(tǒng)計(jì)學(xué)意義(P), X綜合征組TP較正常對(duì)照組長(zhǎng)（P），X綜合征組MBF較正常對(duì)照組低（P）。正常對(duì)照組與心肌梗死組比較，心肌造影后對(duì)照組心肌充盈良好，心肌梗死組可見局限性充盈缺損。定量檢測(cè)PI、MBF，心肌梗死組PI、MBF較對(duì)照組減低（P、P）,心肌梗死組TP較對(duì)照組明顯延長(zhǎng)（P）。 X綜合征組與心肌梗死組比較，心肌造影示心肌梗死組PI較X綜合征組有降低趨勢(shì)，但差異沒有統(tǒng)計(jì)學(xué)意義（P)，心肌梗死組TP較X綜合征組延長(zhǎng)（P），心肌梗死組MBF較X綜合征組減少（P）。 正常對(duì)照組負(fù)荷前、后心肌造影示，應(yīng)用多巴酚丁胺后PI較負(fù)荷前有增加趨勢(shì)，負(fù)荷后TP較負(fù)荷前有縮小趨勢(shì)，但差異無統(tǒng)計(jì)學(xué)意義(P)，負(fù)荷后MBF較負(fù)荷前明顯增加(P)。 X綜合征患者組負(fù)荷前、后心肌造影顯示，經(jīng)靜脈DST后PI雖較負(fù)荷前增高，差異無統(tǒng)計(jì)學(xué)意義（P)，負(fù)荷后TP較負(fù)荷前縮短、MBF較負(fù)荷前有所增加，但差異均無統(tǒng)計(jì)學(xué)意義（P)。 心肌梗死組多巴酚丁胺10～20181。g／(kgmin)劑量負(fù)荷前、后心肌造影示負(fù)荷后TP較負(fù)荷前縮短（P），負(fù)荷后MBF較負(fù)荷前增大（P），PI無明顯變化，差異無統(tǒng)計(jì)學(xué)意義（P）。 梗死區(qū)負(fù)荷前、后心肌造影結(jié)果示梗死區(qū)多巴酚丁胺負(fù)荷后TP較負(fù)荷前縮短（P）；MBF較負(fù)荷前增大（P）。缺血區(qū)負(fù)荷前、后心肌造影結(jié)果示缺血區(qū)多巴酚丁胺負(fù)荷后TP較負(fù)荷前縮短（P），MBF較負(fù)荷前增大（P）。 DST后，X綜合征患者組PI、 MBF較心肌梗死組增大，（P），TP無明顯變化（P）。結(jié)論: 1 MCE已成為檢測(cè)心肌微循環(huán)完整性和心肌血流灌注的一種較為肯定和獨(dú)特的方法，MCSE可以檢查心肌收縮功能儲(chǔ)備，二者結(jié)合可廣泛應(yīng)用于無創(chuàng)性估測(cè)心肌灌注、心肌存活性及心功能狀況。應(yīng)用SonoVue聲學(xué)造影劑，無毒、無副作用，是有效、安全的。2 X 綜合征患者M(jìn)CE的TP長(zhǎng)于正常對(duì)照組，MBF明顯低于正常對(duì)照組可利用這些指標(biāo)對(duì)心肌的微循環(huán)灌注情況進(jìn)行定量評(píng)價(jià)。由于X 綜合征患者合并微血管內(nèi)皮功能異常,心肌血流速度緩慢,造成MBF的降低。X 綜合征患者行多巴酚丁胺負(fù)荷后PI、MBF較負(fù)荷前有增加傾向，考慮與冠脈儲(chǔ)備功能下降，不能根據(jù)機(jī)體的需要有效地增加心肌的灌注有關(guān)。提示X 綜合征的發(fā)生機(jī)制可能為冠脈血流儲(chǔ)備異常,與冠脈的微循環(huán)病變明顯相關(guān)。實(shí)時(shí)MCE、MCSE及GAD能夠定量分析MBF,可無創(chuàng)性的評(píng)估X 綜合征患者心肌血流灌注情況,冠脈血流儲(chǔ)備，對(duì)深入了解其微循環(huán)灌注異常的特點(diǎn)有較高的臨床應(yīng)用價(jià)值。其中X 綜合征患者M(jìn)CSE未見文獻(xiàn)報(bào)道。3 心肌梗死組PI、MBF顯著小于正常對(duì)照組，TP較正常對(duì)照組顯著延長(zhǎng)。表明心肌梗死患者冠脈儲(chǔ)備低下或者無冠脈儲(chǔ)備。對(duì)照組心肌造影顯像,左心室各節(jié)段充盈良好，心肌梗死患者心尖兩腔觀心肌造影顯像,梗死對(duì)應(yīng)室壁充盈缺失， GAD曲線低平,充盈缺失。心肌梗死組多巴酚丁胺負(fù)荷后，與負(fù)荷前比較，TP縮短、MBF增大，負(fù)荷前充盈缺失處可見造影劑稀疏充盈表現(xiàn)，表明有存活心肌。梗死區(qū)心肌多巴酚丁胺負(fù)荷后心肌造影顯示較負(fù)荷前TP縮短、MBF增加，表明梗死區(qū)存在殘存心肌，考慮與側(cè)枝循環(huán)有關(guān)。非梗死區(qū)多巴酚丁胺負(fù)荷后心肌造影顯示TP較負(fù)荷前縮短、MBF增加，表明非梗死區(qū)存在冬眠、頓抑心肌。MCE結(jié)合小劑量多巴酚丁胺負(fù)荷造影可評(píng)價(jià)心肌梗死患者存活心肌，是一種廉價(jià)、可廣泛應(yīng)用代替其他方法的無創(chuàng)性估測(cè)存活心肌的方法。早期、準(zhǔn)確的評(píng)價(jià)存活心肌對(duì)挽救缺血心肌的溶栓治療、 PCI以及CABG的療效和預(yù)后有著至關(guān)重要的指導(dǎo)和判斷意義。關(guān)鍵詞：心肌造影 負(fù)荷超聲心動(dòng)圖 多巴酚丁胺負(fù)荷試驗(yàn) X 綜合征 心肌梗死 心肌血流量 AbstractObjective MCE has been a positive and special method in detecting myocardial microcirculation and myocardial blood may check myocardial contraction restore. To extensive noninvasive evaluate myocardial flow、myocardial viability and myocardial study with realtime myocardial contrast echocardiography and myocardial contrast stress echocardiography and global acoustic densitometry were to pare control、syndrome X、myocardial infarction with lowdose dobutamine assiment clinic value with myocardial blood flow. Methods Thirtyfive patients were to history, examination,Electrocardiograph,myocardial enzyme , ultrasonic cardiography and coronary artery angiography. These patients were divided into myocardial infarction(8 cases,double or multiply branch stenosis or occluded with CAG), noheart disease［27 cases,according to next condition, were divided into control(19 cases), syndrome X(8 cases)］.All were injected (7 cases), syndrome X(8 cases),MI(8 cases) were injected LDDSE and PI、TP、MBF[MBF=（PI/TP）PI] with GAD. Results Sex、ages、cigrate、hyptention and diabetes were no deference in MI and noheart rate、blood stress were no deference in before and after MCE(P）.Heart rate、blood stress were larger in after dobutamine 20181。g／(kgmin) and 30181。g／(kgmin) than in before DST (P, P）. PI was no deference in syndrome X and control(P）.TP was longer in syndrome X than in control (P）.MBF was lower in syndrome X than in control (P）.Compare with control and MI,after MCE, myocardium was fulled better in control and shorted of in 、MBF were significantly lower in MI than in control(P, P）.TP was significantly longer in MI than in control(P）.PI was no deference in syndrome X and in MI(P）.TP was significantly longer in MI than in syndrome X(P）.MBF was lower in MI than in syndrome X(P）.In control,PI was no deference in after DST and in before,MBF was significantly larger in after DST than in before(P）.In syndrome X, PI、TP、MBF were no degerence in after DST and in before(P）.In MI,TP was shorter in after dobutamine 10～20181。g／(kgmin) than in before(P）,MBF was significantly longer(P）, PI was no deference(P）. In infarct regin,TP was shorter in after DST than in before (P）,MBF was larger(P）.In ischemic regin,TP was shorter in after DST