Application value of low tube voltage, low concentration iodine contrast agent combined with adaptive statistical iterative reconstruction-V technique in left atrium and pulmonary vein CT imaging before radiofrequency catheter ablation for atrial fibrillation
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摘要:
目的 探讨低管电压、低浓度碘对比剂联合多模型迭代重建（ASIR-V）在心房颤动患者经导管射频消融术前左心房（LA）和肺静脉（PV）CT成像中的运用价值。 方法 回顾性分析2019年1月~2021年6月在遂宁市中心医院确诊经导管射频消融的所有心房颤动患者，并按管电压分为实验组（A组）和对照组（B组），143例/组。A组使用低管电压100 kVp，对比剂碘海醇300 mgI/mL，ASIR-V 10%~100%间隔10%重建；B组使用常规管电压120 kVp，对比剂碘帕醇370 mgI/mL，ASIR-V 50%重建。LA和PV图像质量客观评价采用信噪比和对比噪声比进行比较，主观评分采用双盲法以5分法评价。对患者一般临床资料、辐射剂量、碘摄入量、LA和PV解剖变异显示率及相关测量指标及图像质量进行评价。 结果 A、B两组比较，LA和PV的CT值、解剖变异显示率以及相关测量指标差异均无统计学意义（P > 0.05）。A组有效辐射剂量和碘摄入量分别较B组减少约37.4%、29.9%（P < 0.05）。随ASIR-V重建比例的增加，A组的SD值逐渐降低，而信噪比及对比噪声比逐渐升高（P < 0.05）；A组重建图像中，70%和80% ASIR-V的主观评分最高（P < 0.05）。 结论 低管电压（100 kVp）、低浓度碘对比剂（300 mgI/mL）联合70%或80% ASIR-V扫描方案可用于心房颤动患者经导管射频消融术前对LA和PV解剖及相关指标的评价，在保证图像质量的前提下，可显著降低电离辐射并减少碘剂摄入量。 Abstract:Objective To investigate the application value of low tube voltage, low concentration iodine contrast agent combined with adaptive statistical iterative reconstruction-V (ASIR-V) in CT imaging of left atrium (LA) and pulmonary vein (PV) in patients with atrial fibrillation before radiofrequency catheter ablation. Methods All atrial fibrillation patients diagnosed with radiofrequency catheter ablation in our Hospital from January 2019 to June 2021 were retrospectively analyzed. The patients were divided into experimental group (group A) and control group (group B) according to tube voltage, with 143 cases in each group. Group A used low tube voltage 100 kVp, contrast agent iohexol 300 mgI/mL, ASIR-V 10%-100% interval 10% reconstruction. Group B used conventional tube voltage 120 kVp, contrast agent iopamidol 370 mgI/mL, ASIR-V 50% reconstruction.The objective evaluation of LA and PV image quality was performed by comparing the signal-to-noise ratio and contrast-to-noise ratio, and the subjective score was evaluated by a double-blind method on a 5-point scale. The general clinical data, radiation dose, iodine intake, display rate of LA and PV anatomical variation, related measurement indexes and image quality were evaluated. Results There was no significant difference in CT value, anatomical variation display rate and related measurement indexes of LA and PV between groups A and B (P > 0.05). Compared with group B, the effective radiation dose and iodine intake of group A were decreased (P < 0.05). With the increase of ASIR-V reconstruction ratio, the SD value of group A gradually decreased, while the signal-to-noise ratio and contrast-to-noise ratio gradually increased (P < 0.05). In the reconstructed images of group A, the subjective scores of 70% and 80% ASIR-V were the highest (P < 0.05). Conclusion Low tube voltage (100 kVp), low concentration iodine contrast agent (300 mgI/mL) combined with 70% or 80% ASIR-V scanning scheme can be used to evaluate LA and PV anatomy and related indicators before radiofrequency catheter ablation in atrial fibrillation patients. Significant reductions in ionizing radiation and iodine intake can be achieved without sacrificing image quality. -
图 1 LA和PV图像质量主观评分的比较
A~B：患者女性，68岁，因心绞痛、呼吸困难、全身乏力入院，行100 kV、300 mgI/mL、ASIR-V 70%重建的LA和PV CT血管成像，A：轴位图像示左心房增大，左心耳充盈非常好，图像质量5分; B：VR图像示各级肺静脉解剖清晰显示，图像质量5分。C~D：患者男性，76岁，因心悸、头昏、胸闷入院，行120 kVp、370 mgI/mL、ASIR-V50%重建的LA和PV CT血管成像，C：轴位图像示左心房增大，左心耳内可见少许充盈缺损（红色箭头处），图像质量5分; D：VR图像示各级肺静脉解剖结构显示较清晰，图像质量4分.
Figure 1. Comparison of subjective ratings of LA and PV image quality.
图 2 典型病例
患者32岁，女性，因心前区隐痛入院接受治疗，彩超提示左心房占位肿物，行100 kV、300 mgI/mL、ASIR-V 80%重建的LA和PV CT血管成像：横轴位（A）、冠状位（B）、矢状位（C）示左心房内低密度团块，大小约3.5 cm×3 cm×2 cm，考虑粘液瘤可能，图像质量主观评分均为5分; D：术后病理活检证实为粘液瘤，HE染色，×40（低倍放大）.
Figure 2. Typical case.
表 1 两组患者的临床基本资料、辐射剂量和碘摄入量的比较
Table 1. Comparison of basic clinical data, radiation dose and iodine intake between two groups of patients (n=143)
临床资料 A组 B组 χ2/t/Z P 性別(男/女） 78/65 83/60 0.355 0.634 年龄（岁, Mean±SD) 64.3±10.5 60.9±9.9 1.018 0.315 身高（cm, Mean±SD) 159.53±7.38 160.40±7.94 -0.433 0.667 体质量(kg, Mean±SD 60.4±10.6 61.8±9.1 0.504 0.617 BMI(kg/m2, Mean±SD) 22.65±3.14 21.76±3.04 0.915 0.366 高血压(%) 35.7 39.9 0.536 0.542 心血管疾病(%) 56.6 61.5 0.709 0.471 CTDIvol(mGy) 8.36(6.43, 10.88)* 16.32(10.89, 21.01)* -3.976 < 0.001 DLP(mGy·cm) 142.17(118.29, 176.11)* 238.42(187.41, 262.09)* -4.910 < 0.001 ED(mSv) 1.99(1.66, 2.47)* 3.33(2.62, 3.67)* -4.910 < 0.001 碘摄人量（g, Mean±SD) 18.55±1.47 26.46±1.35 19.99 < 0.001 *以中位数（上下四分位数）表示; CTDIvol：CT容积剂量指数; DLP：剂量长度乘积; ED：有效剂量; A组：实验组，管电压100 kVp，碘海醇300 mg I/mL; B组：对照组，管电压120 kVp，碘帕醇370 mg I/mL. 
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表 2 不同重建算法下左心房和肺静脉CT值的比较
Table 2. Comparison of CT values of left atrium and pulmonary vein under different reconstruction algorithms (Hu)
重建算法 CT值 左心房 左上肺静脉 左下肺静脉 右上肺静脉 右下肺静脉 120kV
ASIR-V 50%413.60(379.55, 447.15) 413.45(380.25, 452.65) 409.45(380.00, 438.80) 404.65(376.00, 450.83) 410.95(370.60, 435.80) 100kV
ASIR-V 10%354.90(342.53, 429.38) 370.90(344.48, 429.85) 349.75(330.13, 386.48) 365.80(348.28, 419.23) 351.15(333.63, 404.63) 100kV
ASIR-V 20%354.75(342.20, 429.43) 370.90(344.40, 429.80) 349.75(330.18, 386.53) 365.65(348.30, 419.33) 351.05(333.60, 404.78) 100kV
ASIR-V 30%354.45(342.30, 429.40) 370.85(344.30, 429.80) 349.70(330.15, 386.68) 365.55(348.30, 419.43) 351.00(333.60, 404.88) 100kV
ASIR-V 40%354.30(342.43, 429.48) 370.80(344.30, 429.73) 349.65(329.95, 386.85) 365.40(348.33, 419.60) 350.90(333.53, 405.00) 100kV
ASIR-V 50%354.20(342.40, 429.43) 370.80(344.20, 429.75) 349.60(330.05, 386.95) 365.25(348.40, 419.70) 350.90(333.53, 405.10) 100kV
ASIR-V 60%354.10(342.53, 429.48) 370.75(344.13, 429.60) 349.60(330.03, 387.03) 365.15(348.38, 419.88) 350.80(333.53, 405.15) 100kV
ASIR-V 70%353.95(342.35, 429.50) 370.75(344.03, 429.60) 349.55(329.98, 387.18) 365.00(348.40, 419.95) 350.70(333.40, 405.25) 100kV
ASIR-V 80%353.80(342.73, 429.58) 370.75(343.93, 429.53) 349.55(329.95, 387.20) 362.60(348.48, 420.15) 350.60(352.25, 405.38) 100kV
ASIR-V 90%353.60(343.05, 429.48) 370.70(343.88, 429.55) 349.50(329.93, 387.43) 364.75(348.50, 420.15) 350.60(333.15, 405.48) 100kV
ASIR-V 100%353.60(343.05, 429.60) 370.70(343.68, 429.55) 349.50(329.78, 387.58) 364.65(348.50, 420.33) 350.60(333.23, 405.58) H 11.502 6.580 13.399 5.220 9.484 P 0.402 0.832 0.268 0.920 0.577 数据以中位数（上下四分位数）表示.
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表 3 不同重建法下左心房和肺静脉SD值的比较
Table 3. Comparison of SD values of left atrium and pulmonary veins under different reconstruction algorithms
重建算法 SD值 左心房 左上肺静脉 左下肺静脉 右上肺静脉 右下肺静脉 120kV
ASIR-V 50%39.74(36.78, 46.18) 36.24(31.39, 43.94) 38.94(33.61, 44.27) 38.2(32.43, 45.44) 36.55(30.89, 44.45) 100kV
ASIR-V 10%45.26(41.12, 48.26) 38.84(35.42, 43.04) 40.65(36.57, 44.47) 41.6(35.83, 46.06) 40.96(38.20, 44.73) 100kV
ASIR-V 20%42.80(39.43, 45.69) 37.23(33.27, 40.24) 38.65(34.81, 42.70) 39.15(33.99, 44.09) 38.80(35.86, 42.31) 100kV
ASIR-V 30%40.28(37.45, 43.56) 35.8(31.35, 38.07) 36.90(32.78, 41.07) 37.00(32.36, 42.37) 36.47(33.73, 40.12) 100kV
ASIR-V 40%37.65(35.03, 41.11) 33.19(29.30, 35.79) 34.79(30.64, 39.09) 35.24(30.44, 40.53) 34.36(31.70, 37.88) 100kV
ASIR-V 50%35.40(32.93, 39.22) 31.9(27.63, 34.27) 32.7(28.90, 37.52) 33.65(28.73, 38.89) 32.55(29.97, 35.39) 100kV
ASIR-V 60%33.34(30.55, 36.06) 29.45(25.79, 32.93) 30.69(27.32, 35.80) 31.55(27.12, 37.09) 30.54(28.12, 32.28) 100kV
ASIR-V 70%31.60(28.51, 33.89) 27.54(24.37, 31.11) 28.95(25.70, 34.21) 29.54(25.57, 35.55) 28.90(26.35, 30.75) 100kV
ASIR-V 80%29.25(26.32, 32.05) 25.40(22.65, 29.27) 27.10(23.83, 32.51) 27.49(23.85, 33.77) 26.40(23.56, 28.87) 100kV
ASIR-V 90%27.30(24.39, 29.80) 23.55(21.02, 27.75) 25.50(21.65, 31.21) 25.80(22.18, 32.45) 25.20(22.60, 27.41) 100kV
ASIR-V 100%24.95(22.22, 27.92) 21.60(19.22, 26.25) 23.85(20.05, 29.93) 23.95(20.48, 31.03) 23.20(20.67, 25.65) H 181.947 128.036 150.841 100.395 145.075 P < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 数据以中位数（上下四分位数）表示.
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表 4 不同重建算法下左心房和肺静脉SNR的比较
Table 4. Comparison of SNR of left atrium and pulmonary vein under different reconstruction algorithms
重建算法 SNR 左心房 左上肺静脉 左下肺静脉 右上肺静脉 右下肺静脉 120kV
ASIR-V 50%10.36(8.96, 11.36) 11.74(10.17, 12.60) 10.69(9.36, 11.94) 10.84(9.33, 11.98) 10.68(8.84, 12.66) 100kV
ASIR-V 10%8.59(7.65, 9.19) 10.2(8.45, 12.15) 9.10(8.06, 10.15) 9.66(7.93, 11.00) 8.94(8.28, 10.02) 100kV
ASIR-V 20%9.06(8.17, 9.74) 10.74(9.01, 12.79) 9.62(8.63, 10.64) 10.10(8.42, 11.61) 9.40(8.83, 10.43) 100kV
ASIR-V 30%9.52(8.63, 10.43) 11.26(9.47, 13.25) 10.1(9.07, 11.11) 10.54(8.87, 12.20) 10.12(9.38, 10.93) 100kV
ASIR-V 40%10.09(9.22, 11.12) 12.05(10.20, 13.79) 10.74(9.48, 11.69) 11.04(9.43, 12.97) 10.67(10.05, 11.65) 100kV
ASIR-V 50%10.40(9.67, 11.33) 12.52(10.91, 14.31) 11.33(9.86, 12.26) 11.56(9.98, 13.76) 11.17(10.75, 12.37) 100kV
ASIR-V 60%11.39(10.60, 12.78) 13.20(11.74, 15.00) 11.88(10.11, 12.86) 12.07(10.63, 14.76) 11.97(11.44, 13.32) 100kV
ASIR-V 70%12.20(11.29, 13.75) 13.93(12.57, 15.79) 13.06(11.11, 13.48) 12.65(11.29, 15.81) 12.82(11.98, 14.41) 100kV
ASIR-V 80%13.15(12.12, 14.36) 14.94(13.55, 17.02) 13.75(12.06, 14.50) 13.39(11.93, 17.06) 13.90(12.48, 15.79) 100kV
ASIR-V 90%14.10(12.80, 15.34) 16.00(14.11, 18.30) 14.56(12.97, 15.98) 14.04(12.48, 18.32) 15.08(13.22, 16.73) 100kV
ASIR-V 100%15.23(13.62, 16.14) 17.36(15.13, 20.07) 15.60(14.01, 17.30) 14.79(13.06, 19.79) 16.47(14.15, 17.88) H 166.675 120.026 134.934 86.752 139.948 P < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 数据以中位数（上下四分位数）表示.
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表 5 不同重建算下法左心房和肺静脉CNR的比较
Table 5. Comparison of CNR of left atrium and pulmonary vein under different reconstruction algorithms
重建算法 CNR 左心房 左上肺静脉 左下肺静脉 右上肺静脉 右下肺静脉 120kV
ASIR-V 50%10.79(9.32, 12.07) 11.22(9.38, 12.96) 10.57(9.47, 12.46) 10.84(9.78, 12.49) 10.7(9.33, 12.12) 100kV
ASIR-V 10%8.54(6.51, 12.83) 8.1(7.34, 12.43) 9.24(7.66, 12.40) 9.40(7.49, 12.27) 8.65(6.81, 11.22) 100kV
ASIR-V 20%9.23(6.83, 13.58) 8.67(7.34, 12.43) 9.82(8.38, 13.14) 10.04(7.95, 12.96) 9.30(7.30, 11.93) 100kV
ASIR-V 30%9.96(7.41, 14.36) 9.3(7.78, 13.18) 10.52(8.92, 13.97) 10.67(8.44, 13.68) 9.9(7.78, 12.69) 100kV
ASIR-V 40%10.75(7.98, 15.44) 10.26(8.33, 14.05) 11.36(9.55, 14.87) 11.55(9.02, 14.77) 10.63(8.42, 13.55) 100kV
ASIR-V 50%11.52(8.40, 16.67) 10.82(8.87, 15.05) 12.20(10.13, 15.70) 12.44(9.63, 15.92) 11.39(9.05, 14.49) 100kV
ASIR-V 60%12.45(8.71, 18.21) 11.85(9.52, 16.23) 12.99(10.83, 16.72) 13.55(10.43, 16.90) 14.49(9.85, 15.86) 100kV
ASIR-V 70%13.4(9.45, 19.63) 12.88(10.12, 17.51) 13.73(11.54, 17.40) 14.24(11.14, 18.30) 13.66(10.55, 17.39) 100kV
ASIR-V 80%14.72(10.06, 21.34) 14.23(10.80, 19.03) 14.46(12.36, 18.66) 15.1(12.08, 20.27) 15.14(11.19, 19.29) 100kV
ASIR-V 90%15.97(10.74, 23.63) 15.55(11.46, 20.90) 15.16(13.10, 20.00) 16.23(12.95, 22.42) 16.7(11.77, 21.77) 100kV
ASIR-V 100%17.66(11.55, 26.12) 17.02(12.23, 22.99) 16.52(14.97, 22.17) 17.60(13.84, 24.22) 18.38(12.44, 24.74) H 61.864 74.611 81.959 65.618 71.755 P < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 数据以中位数（上下四分位数）表示.
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表 6 不同重建算法下左心房及肺静脉图像质量主观评分的比较
Table 6. Comparison of subjective scores of left atrium and pulmonary vein image quality under different reconstruction algorithms (score, Mean±SD)
重建算法 医师1 医师2 Kappa P 120kV ASIR-V 50% 4.45±0.77 4.50±0.75 0.764 < 0.001 100kV ASIR-V 10% 2.95±0.69 2.95±0.60 0.822 < 0.001 100kV ASIR-V 20% 3.05±0.60 3.00±0.65 0.907 < 0.001 100kV ASIR-V 30% 3.30±0.57 3.35±0.59 0.905 < 0.001 100kV ASIR-V 40% 3.65±0.49 3.70±0.47 0.886 < 0.001 100kV ASIR-V 50% 4.15±0.67 4.20±0.70 0.916 < 0.001 100kV ASIR-V 60% 4.50±0.51 4.55±0.51 0.900 < 0.001 100kV ASIR-V 70% 4.80±0.41 4.85±0.37 0.828 < 0.001 100kV ASIR-V 80% 4.85±0.37 4.90±0.31 0.773 < 0.001 100kV ASIR-V 90% 4.70±0.57 4.75±0.44 0.871 < 0.001 100kV ASIR-V 100% 4.65±0.59 4.60±0.68 0.890 < 0.001 Z 152.131 156.636 - - P < 0.001 < 0.001 - -
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表 7 常规四支肺静脉相对于冠状位和轴位的夹角
Table 7. The included angle of the conventional four pulmonary veins relative to the coronal and axial views (°, Mean±SD)
项目 A组 B组 P 左上肺静脉(冠状位） 39±14 41±16 0.7664 左下肺静脉(冠状位） 9±7 11±6 0.1844 右上肺静脉(冠状位） 25±9 27±10 0.4156 右下肺静脉(冠状位） 11±5 12±6 0.3732 左上肺静脉(轴位） 17±9 14±10 0.2828 左下肺静脉(轴位） 28±16 30±17 0.6593 右上肺静脉(轴位） 22±16 21±13 0.9330 右下肺静脉(轴位） 27±17 31±17 0.4728
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