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徐迎佳老师:关注CT放射剂量 实现CT和MRI从诊断到治疗的转变

发布于:2009-07-24 11:26    

医心:徐老师,您好!非常高兴您能接受我们医心的采访,您是CIT2009 factoid工作组成员,今年您负责的部分是CT和核磁共振(MRI)。今天我们想就这两方面的问题对您进行一次简短采访。心血管影像研讨会是从2008年新增的一个版块,今年无论是在课程设计还是应用领域都相对扩宽,请您为我们介绍CT和MRI这两项技术在心脏病学领域主要应用在哪些方面?

        徐迎佳:应该说CT和MRI这几年刚应用于心血管领域,特别MRI是更新的概念。概括来讲,CT主要用于观察冠脉血管的解剖以及评价心肌功能;MRI除上述功能外,还应用于存活心肌的检测和复杂先心病的诊断。因MRI受各方面限制,有关这方面的研究刚刚起步,尤其是在心脏功能的研究方面,很多中心还没有大规模地应用于临床,但CT特别是冠脉CT目前在全国比较大的中心都已经应用地非常好了,不论是64排CT,上海有一些医院有128排CT,可以说对冠脉CT来说这项技术目前已经非常成熟了,在很多的中心可作为一个很好的筛查工具,从某种程度来说,它取代了一个传统的冠脉造影。但现阶段无论是CT还是MRI,其用于功能方面的研究在各个中心开展情况虽然不一样,但总的来说,开展得还不是非常广泛。特别是对心梗之后存活心肌的评估来说,CT和MRI虽然有非常好的应用前景,但是目前的整个应用情况无论是从我们中心也好,从国内其他大的中心来说,也并不是特别的普及,可能许多医生都没有很接受这样一个概念,但国外在这方面的研究也都在这方面的研究深入起来,而且,越来越多的资料也提示CT和MRI在心脏功能尤其是梗死后存活心肌的评估方面的应用以后可能会成为一个亮点。

        医心:您刚才也提到了在CT在某些方面可以取代传统的冠脉造影,我们经常看到的资料也是介入心脏病学家和影像学家进行的是CT和冠脉造影之间的对比,但是MRI这方面我们看到的资料相对是比较少的,我们想能不能就CT、MRI、冠脉造影这三者之间的优劣势做一个详细的对比?

        徐迎佳:CT因为属无创影像技术,在临床应用中有其特别的优势,大多数患者和介入医生比较容易接受,但是一个非常大的问题就是它放射剂量并不少,在这次 Factoid PPT制作过程中,我发现国外专家开始越来越重视这一方面,现阶段我们更多地集中在CT诊断符合率和准确率上,国外可能比我们提前一步,他们觉得CT假如单单作为一个筛选的手段,有很大的局限性,因为他的放射性剂量比较大,我们平常不去讲放射剂量,我们注射进去的造影剂和我们做一个冠脉造影的造影剂没有差异,或者有些你会发现更多,我们要做更多更精确的话,我们要推75ml造影剂,而一个普通的冠脉造影熟练的医生不到50ml就解决了。

       所以从一个放射剂量和造影剂的应用剂量来说呢,我们现在还没有提升到一个高度,在国外已经有越来越多的研究开始关注这方面,而且他们还用了比较减少放射剂量的研究,取得了很好的结果,就是说把放射剂量减少75%甚至更多,但是影像没有任何影响的效果,这是非常令人振奋的。

       我想其实国内中心在开展CT方面应该没有什么问题,但是以后应多从患者角度出发,应该想办法,不但要做好,而且患者的安全性这方面也应提起大家的重视。MRI这方面因为它没有辐射,所以应该是潜在来说有一个非常好的发展趋势,但是MRI机器比较贵,不是每个中心都有,并且一般MRI获取影像的时间比较长,所以需要患者很好的配合,另外一方面磁共振在很多中心无论是置入起搏器还是支架的患者,都应该作为一个磁共振相对的禁忌症,这样的话就去掉了一大部分心血管的病人,而CT在一些支架术后再狭窄的评估方面其实它的影像分析方面取得了很好的进步。

       在这次Factoid里面我也加了一些关于术后再狭窄的CT评估,就是说在支架术后的一些评估上面他们的影像也非常有优势,但MRI在这一方面包括我们置入搏器和支架术后的可能这方面的研究还少一点,所以一个是价钱比较贵,它本身来说扫描的时间偏长,另外一当面如何解决像我们置入起搏器的病人和支架术后病人的一个随访问题,可能以后还需要一些时间解决。当然有些中心这些不是绝对的禁忌症,大多数中心可能MRI隶属于放射科的,它这些他们是不做的。他认为你放了这些东西,MRI本来就是一个相对的禁忌症,所以这方面可能还是需要进一步探讨。

        医心:除了您刚才提的类似于关于放射量的也算是一种病发证,还有一个CT再评价,支架再狭窄方面,在您的factoid PPT中还涉及到哪些问题?

        徐迎佳:基本上把近些年CT、磁共振一些新的发展特别是一些临床的、大规模临床的一些数据一些CT影像的一些阴性预测率,阳性预测率,把这些大型的临床试验的结果都涵盖进去。Factoid 最后,我主要介绍了CT、磁共振应用于治疗方面的一些新的进展,因为我们主要关注的之前我们谈到的也都是在诊断方面,传统的心血管影像我们也都集中在它的诊断方面,而不是治疗。

        只是一个诊断的手段,目前来说,其实以后的一个发展趋势,CT也好,磁共振也好,它慢慢的会走入一个治疗的领域。怎么讲呢,就是说CT它都可以在我们治疗当中在我们PCI治疗中起到一定的作用,扮演一定的角色。在最后,我们介绍的就是CT磁共振怎么在导管室的匹配当中,他是在导管室实时我们做的时候,它作为一个很好的一个影像的辅助工具,特别是在复杂的PCI,当然是一些简单的病变,我们不需要这样很复杂要结合到CT要结合到MRI,但是对一些很复杂的病变,我们不单单需要IVUS这样影像的一个技术,然后还需要一个我们MRI和CT的辅助,特别是在一些CTO病变,慢性闭塞性病变,我们找不到一个前向的径路的情况下,CT也好,MRI也好,起到一个很好的辅助和补充的一个作用,而且可以大大地缩短我们手术的时间,提高手术成功率,所以这方面来说,国外已经做的很多,其实CT和MRI信号同步传输到导管室可以给术者提供更多,更有用的影像信息,但我们的实验室还没有达到,可能在国内的也就是阜外这样大的实验室也还没有达到。

        但总体来说,这是一个趋势,特别在国外一些大的中心,他们已经开始这方面的研究了,我想以后随着介入的复杂性越来越高了,介入技术越来越成熟,他们越来越挑战那些高难度的病例,以后他们需要这些CT也好,磁共振也好,辅助他们达到攀登一个更高的介入的高度,所以我在factoid PPT最后一部分主要是其应用前景。希望到2010年的factoid当中我们可能有中国的一些中心在这方面的研究,或者其他数据有更多内容。

       医心:我们也非常期待您的这份非常漂亮幻灯。



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