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目的:评估左心室室壁瘤部位存活心肌和室性心律失常对室壁瘤患者预后的影响。方法:研究纳入160例左心室室壁瘤患者。所有患者均行~(99)Tc~m-甲氧基异丁基异腈(MIBI)心肌灌注显像和门控~(18)F-氟代脱氧葡萄糖(FDG)心肌代射显像。定量门控心肌断层软件获得患者左心室功能参数,包括舒张末期容积(EDV)、收缩末期容积(ESV)、左心室射血分数(LVEF)。对心肌灌注和代谢显像图像半定量分析,获得心肌灌注和代谢的异常分,以及灌注-代谢不匹配分(MMS)。室壁瘤部位MMS≥2.0,定义为室壁瘤部位有存活心肌。160例患者根据室壁瘤部位心肌存活情况分为无心肌存活组(n=97)和有心肌存活组(n=63),两组患者进一步根据是否合并室性心律失常分为4个亚组:无心肌存活且无室性心律失常为组1(n=68)、无心肌存活且有室性心律失常为组2(n=29)、有心肌存活且无室性心律失常患者为组3(n=50)、有心肌存活且有室性心律失常患者为组4(n=13)。平均随访(50±7)个月,心原性死亡为随访终点。Kaplan-Meier方法获得生存曲线,并用Log-rank法比较率的差异。结果:160例患者的平均LVEF为(34±11)%。共19例(11.9%)患者发生心原性死亡。组1患者的长期生存率达94.1%,但是与组2(89.7%)、组3(86.0%)的生存率相比,差异无统计学意义(P>0.05)。组4的生存率(61.5%)明显低于其他3组(P=0.004)。多因素Cox回归分析显示:女性[风险比(HR)=5.101,95%可信区间(CI):1.853~14.044,P=0.002]、门控正电子发射计算机断层扫描(GPET)-ESV(HR=1.009,95%CI:1.002~1.015,P=0.013)、室壁瘤部位MMS与室性心律失常交互作用(HR=1.368,95%CI:1.113~1.681,P=0.003)是心原性死亡的独立危险因素,而手术治疗(HR=0.199,95%CI:0.054~0.742,P=0.016)则降低心原性死亡风险。结论:室壁瘤患者如果室壁瘤部位有存活心肌合并室性心律失常为高危患者,需要对这类患者早期采取积极治疗措施(手术+纠正室性心律失常治疗),以改善其长期预后。
PURPOSE: To evaluate the effect of viable myocardium and ventricular arrhythmias in patients with ventricular aneurysm on the prognosis of patients with left ventricular aneurysm. Methods: The study enrolled 160 patients with left ventricular aneurysm. All patients underwent ~ (99) Tc ~ m-methoxyisobutylisonitrile (MIBI) myocardial perfusion imaging and gated ~ (18) F-fluorodeoxyglucose (FDG) Left ventricular function parameters, including end-diastolic volume (EDV), end-systolic volume (ESV), and left ventricular ejection fraction (LVEF), were obtained using quantitative gated myocardial tomography software. Semi-quantitative analysis of myocardial perfusion and metabolic imaging images, abnormal myocardial perfusion and metabolism scores, and perfusion-metabolic mismatch scores (MMS) were obtained. Ventricular aneurysm site MMS ≥ 2.0, defined as ventricular aneurysm site with viable myocardium. One hundred and sixty-six patients were divided into non-cardiac survival group (n = 97) and myocardial survival group (n = 63) according to the survival of myocardial aneurysm. The two groups were further divided into 4 subgroups according to whether they had ventricular arrhythmia or not : Group 2 without nocturnal arrhythmias (n = 68) without myocardial viability and without ventricular arrhythmias in group 2 (n = 29), group 3 with myocardial viability and no ventricular arrhythmias (n = 50), patients with myocardial viability and ventricular arrhythmias were Group 4 (n = 13). The average follow-up (50 ± 7) months, cardiac death was the end of follow-up. Kaplan-Meier method to obtain survival curves, and Log-rank method to compare the rate of difference. Results: The average LVEF in 160 patients was (34 ± 11)%. A total of 19 patients (11.9%) had cardiac death. The long-term survival rate of group 1 was 94.1%, but there was no significant difference between group 2 (89.7%) and group 3 (86.0%) (P> 0.05). Group 4 survival rate (61.5%) was significantly lower than the other three groups (P = 0.004). Multivariate Cox regression analysis showed that women had a significantly higher rate of risk (HR = 5.101, 95% CI: 1.853-14.044, P = 0.002), gated positron emission computed tomography (GPET) = 1.009, 95% CI: 1.002 ~ 1.015, P = 0.013). The interaction between ventricular aneurysm MMS and ventricular arrhythmia (HR = 1.368,95% CI: 1.113-1.681, P = 0.003) (HR = 0.199, 95% CI: 0.054-0.742, P = 0.016) decreased the risk of cardiac death. CONCLUSIONS: If patients with aneurysm have surviving myocardium with ventricular arrhythmias who are at high risk, aggressive management of these patients (surgery + correction of ventricular arrhythmia) is needed to improve their long-term prognosis.