Method for predicting myocardial viability

FIELD: medicine, cardiology.

SUBSTANCE: the present innovation deals with positron emission tomography (PET) to perform it with 18F-fluorooxyglucose (18F-FDG), moreover, at detecting myocardial viability in patients with disorders in carbohydrate exchange one should pre-introduce perorally trimetasidine thrice daily at the dosage of 20 mg for 8-12 d, 1 d before the onset of PET-trial it is necessary to exclude caffeine-containing products out of patient's diet and medicinal preparations and at 18F-FDG in myocardium being 50% and more against its maximal accumulation it is possible to diagnose viable myocardium, if below 50% - nonviable myocardium.

EFFECT: higher efficiency and accuracy of diagnostics.

8 dwg, 2 ex

 

The invention relates to medicine, more specifically to cardiology, and may find application in the diagnosis and treatment of coronary heart disease (CHD), including in patients with diabetes or impaired carbohydrate tolerance after myocardial infarction.

The study of myocardial viability is extremely important to define the tactics of treatment and prognosis of surgical treatment of CHD patients with severe systolic dysfunction of the left ventricle, acute circulatory failure.

In patients with ischemic heart disease, myocardial infarction, violation of segmental contractility can be reversible when the cardiomyocytes retain their viability, and irreversible, when these violations due to fibrous or robovie changes.

It is known that patients with viable myocardium in the conservative treatment have a more adverse prognosis compared to patients with impaired contractility caused only robovie changes.

In this regard, the identification of myocardial viability is an important criterion for definition of tactics of treatment of patients with regional impaired contractility of the left ventricle. In particular, the viability of the myocardium along with information on the status of the coronary vessels and the fraction vibraimage be crucial in determining the indications for surgical treatment of ischemic heart disease, because timely surgical revascularization of viable disfunktsioniruyuschikh plots restore contractility, reduces the likelihood of heart failure and improves the prognosis. Identification of viable myocardium is most relevant to patients with the expressed violations of systolic function with ejection fraction of 35% or less, as in this case, the risk of surgical intervention is justified by the potential improvements in both regional and global contractility of the left ventricle.

It should be noted that a special group consists of patients with carbohydrate metabolism disorders (diabetes mellitus and impaired carbohydrate tolerance)because the risk of developing intra - and postoperative complications is much higher than in patients with normal carbohydrate metabolism. In this regard, the definition of tactics of this group of patients requires the highest accuracy assessment of myocardial viability for establishing the need for and possibilities of surgical treatment.

Viable myocardium is characterized by several factors: the integrity of cell membranes, retained metabolic activity and inotropic reserve. These characteristics form the basis of the various modern methods used to identify jiznesposobnost the myocardium.

The most approved method of detecting myocardial viability is myocardial perfusion studies with201Tl-chloride. However, despite the good sensitivity of this method, when performing scintigraphy with201Tl-chloride has a relatively high percentage of false-positive results, thereby reducing its specificity [J.J. Bax, Cornel J. H., Visser F.V., et al. Prediction of recovery of regional ventricular dysfunction following revasculariztion; Comparison of FIS-fluorodeoxyglucose SPECT, thallium-201 stress-reinjection SPECT and dobutomine echocardiography. // J. Am. Coil Cardiol. 1996; 28, p 558-564]. Additionally, the long half-life isotope201Tl (73.1 hours) creates a high radiation load on the patient.

One of the most common and available methods for detection of myocardial viability is stress echocardiography with dobutamine is a synthetic inotropic beta adrainostimulatoram [Dyadyk A.I., Bagriy SUPERVISION, Swan IA, Vatutin N.T., Taradin GG, Shchukin E.V. Stress echocardiography. Message 1 // Cardiology. - 1996. - So 36. No. 1. - P.57-60, I. Afridi minimalistic, Kleiman N.S., Raizer, A.E. et al. Dobutamine echocardiography in myocardial hibernation. Optimal dose and accuracy in predicting recovery of ventricular function after coronary angioplasty // Circulation. - 1995. - Vol.91. - P.663-670].

Method stress echocardiography with dobutamine, as noted by the authors, is essential in identifying areas of viable myocardium. These data are important not only from the point the view of the knowledge about the pathophysiology of the myocardium, but predicting hemodynamic success of such interventions as transluminal balloon angioplasty of coronary artery or coronary bypass surgery, as well as for proper treatment tactics.

Dobutamine in small doses (5-10 mcg/kg / min) can temporarily restore or improve airway Hypo - or kinetycznych areas of the myocardium with inotropic reserve. Stress tests with low doses of dobutamine, as a rule, do not induce myocardial ischemia and therefore can be used even in patients with severe angina and heart failure.

The sign of the vitality disfunktsioniruyuschikh segments of the myocardium is improved contractility and infusion of high doses of dobutamine, when, after a temporary improvement of contractility again there are areas of regional dysfunction (the so-called two-phase response). It is believed that a more reliable marker of myocardial viability is its ability to insufficiency, which is determined only by the introduction of high doses of dobutamine. Meanwhile, the introduction of high doses of it in severe left ventricular dysfunction contraindicated and research is necessary to limit the introduction of small doses of the drug. With the utmost care stress echocardiography with dobutamine should be performed for patients with zheludochno the diversified rhythm disorders, since the introduction of even small doses of the drug can cause in this category of patients izaurralde complications: hemodynamically significant ventricular tachycardia or ventricular fibrillation.

Quite effective in the diagnosis of myocardial viability is the combined study of perfusion and glucose metabolism in the myocardium. Marshall et al. for the first time proposed a method for identifying viable myocardium by defining security metabolism18F-FDG in disfunktsioniruyuschikh segments with reduced perfusion [Marshall RS, Tilisch J.H., M.E. Phelps et al. Identification and differentiation of resting myocardial ischemia and infarction in man with positron emission tomography, 18 F-labeled fluorodeoxyglucose, and N-13-ammonia. //Circulation. - 1983. No. 67. - P.766-778]. Studies have shown a high predictive value for the simultaneous assessment of perfusion and glucose metabolism in the myocardium in patients with ischemic heart disease. However, the combined isotopic study of perfusion and myocardial metabolism is always associated with higher financial cost of research and increasing the radiation load on the patient.

Due to the rather serious shortcomings in the above-mentioned methods for the assessment of myocardial viability in recent years in the world practice more widespread positron emission tomography (PET). Today it is considered by many the author is in, the most accurate method for detection of metabolic activity in the myocardium.

As you know, in terms of insufficient intake of oxygen increases the utilization of glucose as a metabolic substrate of cardiomyocytes due to its large oxygen efficiency and strengthen the processes of anaerobic glycolysis. PET studies in patients with coronary artery disease suggests that the accumulation of18F-Tordesillas (18F-FDG) is a synthetic analogue of native glucose disfunktsioniruyuschikh myocardial areas with reduced coronary blood flow evidence of their viability, which was then confirmed by numerous works. However, PET with18F-FDG has a number of disadvantages associated with the uneven accumulation of radiotracer in normal myocardium. Great influence on the capture of18F-FDG in the myocardium have free fatty acids, which are the main metabolic substrate cardiomyocytes under conditions of adequate oxygen supply. Therefore, the areas of hypometabolism of glucose may be due not only to non-viable myocardium, but may be due to substrate priority fatty acids.

Methodologically, there are two methods of studying metabolism18F-FDG: fasting and on the background of artificial euglycemic hyperinsulinemia, which is achieved by infusion of glucose is insulin infusion within 2 hours before the examination. Normal PET study with18F-FDG fasting detects low accumulation in the myocardium, as in conditions of sufficient oxygen supply the main source of energy for cardiomycytes are fatty acids. This method proved to be highly sensitive in the detection of dysfunctional areas of viable myocardium lesions of small size, identified as zones with high seizure of glucose on the background of reduced accumulation of radiotracer in the healthy regions, and areas of necrosis.

However, studies on an empty stomach is insufficiently informative. Under conditions of adequate oxygen supply to the heart muscle when the PET study with18F-FDG performed on an empty stomach, the myocardium is determined on a background level, which makes it difficult visualization. The ratio of accumulation myocardium/blood from healthy patients after a 12 hour famine is 1.5, whereas in conditions of artificial hyperglycemia it reaches 3. In addition, when performing research on an empty stomach is observed heterogeneity accumulation18F-FDG, which makes the correct interpretation of PET studies. Some authors have noted the failure prediction of recovery of contractility in the areas of regional dysfunction of the left ventricle, if you look at the safe metabolism in small plots mi the kard, find out when you study18F-FDG on an empty stomach, so as to restore contractile function after revascularization require safety not less than 70% of the affected area, while this method does not allow her to pinpoint.

For these reasons, the most widely used study18F-FDG after prior oral or intravenous glucose with the aim of increasing substrate concentration in the blood and shift metabolism in myocytes in the direction of glycolysis. The most proven method is the introduction of a glucose-insulin infusion (hyperinsulinemic-euglycemic clamping), infusion which increases the accumulation of18F-FDG in the myocardium by improving the processes of glycolysis and glycogen synthesis, as well as, to a greater extent, due to inhibition of lipolytic processes and reduce the level of fatty acids in the blood. However, the method of introduction of a glucose-insulin infusion is very time consuming, because it requires constant monitoring of the glucose level in the blood plasma of a patient in order to avoid hypoglycemic events, which is especially dangerous for patients with diabetes. In addition, the duration of infusion is more than 2 hours requires special equipment in the Department: two perfusion for dosed intravenous injections, blood glucose meter, test strips.

This technique allows the floor is a raised image of the myocardium good quality mainly in patients with normal carbohydrate metabolism, in patients with carbohydrate metabolism even when all these conditions a good image of the myocardium able to get far from all patients.

Alternative methods of introducing glucose-insulin infusion is oral administration of the drug "Acipimox" (a derivative of nicotinic acid), which reduces the concentration of free fatty acids in plasma and thereby improves the utilization of glucose by the cardiomyocytes. However, in Russia and some other countries the product is not registered, and its use in the preparation before the PET study impossible. Intravenous injection of nicotinic acid or oral administration of the drug "Nikoshpan subjectively poorly tolerated by patients with severe skin hyperemic response.

It should again be noted that methodological difficulties in the implementation and interpretation of PET studies of the myocardium with18F-FDG is most frequently observed in the group of patients with impaired carbohydrate metabolism: diabetes mellitus and impaired carbohydrate tolerance. As you know, the native transport of glucose and its synthetic analogue of18F-FDG in cardiomyocytes is insulin-dependent receptor-Transporter (GLUT IV). The absolute insufficiency of insulin in patients with diabetes mellitus type 1 and reduce the density of insulin the receptors, as well as reducing their sensitivity to insulin in diabetes mellitus type 2 and in violation of tolerance to carbohydrates reduce the seizure of18F-FDG cardiomyocytes, resulting in poor visualization of the left ventricle and makes it impossible for reliable interpretation of PET images. At the same time, the detection of myocardial viability in patients with diabetes mellitus and impaired carbohydrate tolerance is the most important because timely revascularization of viable disfunktsioniruyuschikh of the myocardium in these patients leads to increased life expectancy, reduced risk of acute coronary complications and heart failure. However, the risk of intraoperative and postoperative complications in patients with diabetes, as already noted, much higher than in the group of patients with normal carbohydrate metabolism. Therefore, accurate assessment of the viability disfunktsioniruyuschikh attack allows accurate determination of the indications for surgical treatment of ischemic heart disease in patients with diabetes mellitus.

In this regard, in recent years much attention is paid to the diagnostic capabilities of PET with labeled fatty acids or11C-acetate for the diagnosis of myocardial viability. Groppler with co-authors [R.J. Gropler, Geltman E.M, Sampathkumaran, K. et al. /Comparison of carbon-11-acetate with fluorine-18-deoxyglucose for delineating viable myocardium by positron emission tomography. // J. Am. Coll. Cardiol - 1993 - No. 22 - P.1587-1597] found that the prognostic accuracy in the detection of myocardial viability in some patients in the study with11With-acetate is higher than with18F-FDG, as in 15% of cases, the areas of the myocardium showed hypermetabolism of glucose, proved to be unviable due to the fact that anaerobic metabolism was not able long to maintain their viability. Because recycling11C-acetate does not depend on the level of consumption by the myocardium of metabolic substrates and accurately reflects the level of oxidative metabolism, its use is probably optimal for the assessment of myocardial viability. However, the half-life of the isotope11With a small (20 minutes), so its use is possible only in large PET centers with medical tsikloferona and the radiochemical laboratory. Laboratory of radioisotope methods that have positron tomography and single-photon imagers with high-energy collimators for registration photon energy of 511 Kev (the energy produced by annihilation of a positron and an electron in the reaction of an emitted positron) and blocks match, in everyday practice, the use of radiopharmaceuticals labeled on Itron-emitting isotope 18F, because the half-life of this radionuclide is 2 hours, which allows the transport of labeled18F RN of radiochemical laboratories. So18F-FDG still retains its position as the "gold standard" of myocardial viability.

Closest to the present invention is a method for the diagnosis of myocardial viability by PET with18F-Tordesillas (18F-FDG), described in the article [M. Schmidta, Votha E., Schneiderb C.A., et al. F-18-FDG uptake is a reliable predictory of functional recovery of akinetic but viable infarct dementia regions as defined by magnetic resonance imaging before and after revascularization // Magnetic Resonance Imaging. - 2004. - V. 22. - P.229-236]. This study investigated the information content of the PET with18F-FDG in the diagnosis of viable myocardium in patients with impaired regional contractility of the left ventricle due to post-infarction cardiosclerosis. The research was carried out on positron emission tomography "ECAT EXACT 921" Siemens CTI.

1 hour before intravenous18F-FDG patients received oral 50 g of glucose.18F-FDG was administered intravenous bolus at a dose of 370 MBq. 30 minutes after injection18F-FDG was performed emission scan duration 30 minutes, which was preceded by transmission study for the correction of scatter radiation that reduces the quantities of the artifacts. The resulting scan sinogram been reconstructed transaxial slices using the method of "filtering Back projection with a Hanning filter of 0.4. To obtain images of the left ventricular short and two long axes transaxial slices were reorientation. Evaluation of the scans was performed using the semi-quantitative analysis, for which we used the method polar mapping. At the first stage of construction of the polar map on tomographic slices made on the short axis of the heart, automatically detected region with the maximum accumulation of the radiopharmaceutical (RN), then automatically build functional images stiralnih charts myocardium from top to basal. The result is a picture of the left ventricle (polar map), which is integrally was visualized relative capture RN in each Department of the myocardium, expressed in percent. As a reference segment for which the calculation was made of the capture of the radiopharmaceutical in the myocardium, was chosen as the site of the left ventricle with a maximum accumulation of18F-FDG, a normal airway and belonging to the basin of the coronary artery with the degree of stenosis of 75%. Based on the level of capture of RN as a percentage of its accumulated the Yu in the reference segment of the left ventricle, disfunctioncause segments were divided into 2 groups: viable (accumulation RN ≥50% of the maximum accumulation in the reference segment) and nonviable (accumulation RN <50% of the maximum accumulation in the reference segment).

The authors demonstrated the high information content of PET with18F-FDG in the differential diagnosis of viable and nonviable disfunktsioniruyuschikh infarction in patients with postinfarction cardiosclerosis, which was confirmed by the improvement of systolic left ventricular function after surgical revascularization. In connection with the impossibility of obtaining reliable data in patients with diabetes mellitus and impaired carbohydrate tolerance in terms of research, the authors of such patients in the study were not included.

Thus, this method and other known methods of determining the state of the myocardium in the postinfarction period by the PET, has a significant limitation, because it makes it impossible for reliable interpretation of PET images in patients with diabetes mellitus and impaired carbohydrate tolerance, which significantly reduces its value.

The technical result of the present invention is to improve the accuracy of PET diagnosis of myocardial viability due to the possibility of its use is obtaining reliable results in patients with impaired carbohydrate metabolism.

This result is achieved by the fact that before the implementation of PET in patients with impaired carbohydrate metabolism within 8-12 days daily 3 times a day administered orally Trimetazidine in a dose of 20 mg per day until the PET studies excluded from the diet caffeine-containing foods and drugs at the time of capture18F-FDG in the myocardium 50% or more of the value of its maximum accumulation diagnose viable myocardium, less than 50% is unsustainable.

Doing for several years diagnosis IB method with PET18F-FDG, including the detection of myocardial viability, often received false-positive results when low capture18F-FDG was detected in viable myocardium. So, in the study of myocardial metabolism in patients with postinfarction cardiosclerosis lower-rear localization on tomoscintigraphy on the short axis of the left ventricle was determined two areas of pronounced reduction of glucose metabolism, one of which was located in the post-infarction region (basal segments of the lower and posterior walls of the left ventricle) (figure 1, arrow), and the second in the middle segments of the anterior wall of the left ventricle and interventricular septum (figure 1, arrow-dashed line) and localization did not correspond to the pool of the infarct-related coronary artery. Subsequent implementation of the PET perfusion radiopharmaceuticals 13N-ammonia in the basal segments of the lower and posterior walls of the left ventricle was determined by the marked reduction of myocardial perfusion (consistent defect in perfusion and metabolism), which confirmed the non-viability of the myocardium in this area (figure 2, arrow), but in the middle segments of the anterior wall of the left ventricle and interventricular septum disorders of perfusion were not identified, which is not typical for non-viable myocardium in this area (figure 2, arrow-dashed line). It should be noted that one aspect of this research was to study the influence of different kinds of conservative anti-ischemic therapy on perfusion and myocardial metabolism. It was noted that patients who took anti-ischemic drug Trimetazidine"when executing PAT was observed uniform distribution of the radiopharmaceutical in the areas of viable myocardium and the lack of grip in the areas of postinfarction cardiosclerosis, so it was much easier they have a differential diagnosis of viable and nonviable myocardium. It was also noted that patients who do not consume caffeinated products (coffee, tea, chocolate), also improved the quality of visualization of the myocardium of the left ventricle.

This prompted the above patient to repeat a PET study of myocardial metabolism after a 10-day pickup is and they drug Trimetazidine", the purpose of which was agreed with the attending cardiologist. Re-PET study was performed in 11 days. A series of tomograms of the left ventricle in the study of glucose metabolism was visualized only one plot pronounced reduction of glucose metabolism, located in the basal segments of the lower and posterior walls of the left ventricle (figure 3, arrow), consistent with nonviable myocardium and is consistent with the data of figure 2, arrow. In the remaining segments of the left ventricle was observed uniform distribution18F-FDG, and capture RN was more than 50% of the maximum accumulation, which allowed to consider the myocardium of these segments as a viable and to clarify the diagnosis.

On the basis of the diagnosis the patient was performed surgical revascularization in the middle segments of the anterior wall of the left ventricle and interventricular septum, resulting in the stabilization of his condition.

In connection with the foregoing decided to try to conduct a similar study in a patient with impaired carbohydrate metabolism, namely to perform a PET before and in patients receiving Trimetazidine.

The patient So in the analysis of electrocardiograms (ECG) in the dynamics in leads characterizing the anterior wall of the left ventricle were detected changes characteristic of focal lesions m & e is Arda, it was therefore suspected myocardial infarction, myocardial infarction unknown old. Biochemical analysis of blood found increased concentrations of glucose in the blood plasma to 6.5 mmol/L. According to the results of glucose tolerance test, the patient was diagnosed with impaired carbohydrate tolerance. Given the patient's age (77 years), the presence of cardiac complaints plan, risk factors for CAD (family history, hypertension, age, gender, impairment of carbohydrate tolerance), electrocardiographic indications of myocardial infarction, the patient was made a comprehensive study of the cardiovascular system. Standard echocardiographic examination of the heart revealed a decline in global contractility of the left ventricle, diffuse hypokinesia of all departments of the myocardium with preferential involvement of the anterior wall and interventricular septum. Non-invasive multi-layer spiral computed tomography showed a total coronary artery atherosclerosis. To estimate the amount of viable myocardium, the patient was recommended PET with18F-FDG.

PET study of myocardial metabolism with18F-FDG was performed 02.11.2004, positron tomograph "High Resolution+" after 0.5 hours after administration 372 MBq RN. 1 hour to research the Finance, the patient was asked to take carbohydrate food. Injection of insulin before the study was carried out, taking into account the normal value of glucose concentration in blood plasma (6.2 mmol/l). In the method PET scan was to study the thorax (10 minute drive and 20 minute issue). Reconstruction of the original data was carried out in on-line mode using the Zoom 2.5 and filter Back projection". The series of the left ventricle in the study of glucose metabolism noted marked diffuse-uneven distribution of radiopharmaceuticals. There was a high residual background of radiotracer in the left ventricular cavity, which is very complicated the interpretation of the results (figure 4).

After that, the patient was assigned to the drug Trimetazidine in a dosage of 20 mg 3 times daily, 8 days PET study of the myocardium with18F-FDG repeated. The day before the examination the patient was advised to refrain from consumption of caffeinated products. In re PET study on a series of tomograms of the left ventricle in the study of glucose metabolism observed uniform distribution of the radiopharmaceutical in the middle segment of the anterior wall of the left ventricle was determined by the small area of the lower grip RN, area occupied 1/3 of the segment, capturing RN in this area accounted for 49% of the maximum accumulation, which allowed to consider it as a viable (figure 5). P and subsequent implementation of PET perfusion radiopharmaceuticals 13N-ammonia was determined by a consistent defect in perfusion and metabolism in the middle segment of the anterior wall of the left ventricle, which confirmed the presence of viable myocardium in this area. On the basis of the diagnosis the patient was recommended conservative treatment.

Obtaining such a convincing positive results after taking sick Trimetazidine allowed in future work successfully use this simple technique to perform PET imaging in patients with ischemic heart disease, regional and global systolic dysfunction of the left ventricle and carbohydrate metabolism.

The method consists in the following.

For 8-12 days prior to the PET study, the patient is prescribed an oral drug Trimetazidine in a dose of 20 mg 3 times a day. The day before the examination the patient is advised to refrain from consumption of caffeinated products. The day of the examination permitted easy carbohydrate Breakfast. It is not recommended the abolition of oral antidiabetic drugs or insulin on the day of the study. 1 hour before injection18F-FDG patient is assigned a carbohydrate intake of food, if the concentration of glucose in blood plasma does not exceed the value of 9 mmol/L. When exceeding this figure, the patient is additionally subcutaneous injection regular insulin at a dose of 46 standard units. According to the international recommendations of PET scanning with18F-FDG is 30 minutes after intravenous injection of the radiopharmaceutical in the dose rate of 180 MBq/m2· surface area (m2). PET scan is performed in a horizontal position on the back. Scans a single anatomic area (chest). Traditionally for the correction of scattering radiation, reducing the number of artifacts, methods of PET myocardial provides for performing transmission using68Ge/68Ga sources, which precedes the emission scan. The duration of study is determined by international standards, with a transmission scan is 10 minutes, and is followed by the emission scan duration 20 minutes. Reconstruction of the original data is in on-line mode using the Zoom 2.5 and filter Back projection". Visual assessment of the uniformity of distribution of the radiopharmaceutical in the myocardium is carried out in sections, built on a vertical, horizontal, and the short axis of the left ventricle, slice thickness - 1.5 cm semi-Quantitative evaluation is performed on a standardized 9-segment or 16-segment model of the left ventricle (depending on software positron tomograph for postprocessing of obrabotka.otlichno) using the technique of polar mapping, running software automatically. The uniform distribution of the radiopharmaceutical in various segments of the myocardium is estimated as a percentage of the value of the maximum accumulation, and if the capture18F-FDG myocardium is more than 50 percent of the value of its maximum accumulation, diagnosed viable myocardium, less than 50% is unsustainable.

The essence of the method is illustrated by the following examples.

Example 1. Patient R., born in 1943 surveyed in the Department PAT cnerry. Diagnosis: hypertension 2 tbsp., risk 4. Ischemic heart disease, myocardial infarction, transmural myocardial infarction of anterior localization. Diabetes mellitus type 2, insulin dependent.

From the anamnesis: In December 2003 had a massive transmural myocardial infarction of anterior localization without previous angina. Postinfarction period was uneventful. In January 2004 he was discharged from the cardiology hospital where he received treatment for myocardial infarction, for outpatient care. Echocardiographic study performed on an outpatient basis, were identified violations the regional contractility of the left ventricle at the apex, anterior-septal area of the left ventricle. The patient was consulted by the surgeon to decide on the appropriate the spine surgical treatment of ischemic heart disease due to diabetes mellitus type 2. Given the presence of regional impaired contractility of the left ventricle, the patient was recommended to perform a PET with18F-FDG to assess the amount of viable myocardium.

Because of comorbidity, the patient was discovered diabetes mellitus type 2, she was assigned to the drug Trimetazidine in the dosage of 20 mg 3 times a day and 12 days was made PET study of myocardial metabolism with18F-FDG positron tomograph "High Resolution+" after 0.5 hours after administration 302 MBq RN. In the morning the day of the examination to the patient were performed insulin injections "Protoman" - 2 standard units and insulin "Actrapid" - 4 standard units, which the patient received daily by the attending physician endocrinologist. 1 hour before the examination the patient was asked to take a 50 g glucose. The glucose concentration in blood plasma was 6.3 mmol/l In the technique of PET scan was to study the thorax (10-minute transmission and a 30-minute issue). The resulting scan sinogram reconstructed transaxial slices using filtering methods "Back projection" filter Harming 0.4 and Zoom of 2.5. The series of the left ventricle in the study of glucose metabolism was visualized plot pronounced reduction of glucose metabolism (capture RN accounted for 31% of the maximum is its accumulation in the apical and middle segments of the anterior wall of the left ventricle and interventricular septum, that corresponded to the area akinesia of the myocardium by echocardiography (6, arrow). The myocardium in this area was regarded as impractical. Given the absence of clinical manifestations of coronary artery disease, and the presence of viable myocardium in the pool of the infarct-related coronary artery the patient in the surgical treatment was denied due to lack of evidence.

Subsequent executions of PET perfusion radiopharmaceuticals13N-ammonia in the apical and middle segments of the anterior wall of the left ventricle was determined by the marked reduction of myocardial perfusion (consistent defect in perfusion and metabolism), which coincided with the data of the PET with18F - FDG about failing myocardium in this area (Fig.7, arrow).

She was on conservative treatment. Dynamic observation of the patient within 7 months of ill health she was not observed, there was no recurrence of angina and acute manifestation of coronary complications.

Example 2. Patient B., born in 1946 surveyed in the Department PAT cnerry. Diagnosis: hypertension 3 tbsp., risk 4. Coronary heart disease, angina III functional class, postinfarction cardiosclerosis, necessarily myocardial infarction in 1999, coronary artery bypass surgery in 1999, impaired carbohydrate tolerance.

From the anamnesis: In February 1999, the pen is carried necessarily myocardial infarction anterior-lateral localization without previous angina. In the postinfarction period marks the emergence of pain, the respective strokes voltage IV functional class. Given the ineffectiveness of therapy antiischemic drugs, in October 1999 was performed surgical revascularization attack. Over the next 4 years, the health of the patient was satisfactory, it was noted good exercise tolerance, pain not had anticipated. In April-may 2004 the patient reiterates the appearance of ischemic pain syndrome that caused her to seek medical help from a cardiologist in the hospital at the place of residence, which sent her on a consultation with a surgeon to perform coronary angiography-sonographie. Coronaro-sonography revealed a non-functioning right shunt coronary artery shunts the anterior interventricular, diagonal and circumflex branches of the left coronary artery was functioning well. Echocardiographic study performed on an outpatient basis, was revealed hypokinesia posterior part of the interventricular septum, which belongs to the basin of the right coronary artery. The patient was encouraged implementation of PET18F-FDG to identify viable myocardium in the pool right coronary artery, so that the subsequent decide on tselesoobraznost is repeated surgical treatment.

The patient was prescribed medication "Trimetazidine in the dosage of 20 mg 3 times a day and 12 days 19.10.2004, were completed PET study of myocardial metabolism with18F-FDG in pet imaging "High Resolution+" after 0.5 hours after administration 379 MBq RN. 1 hour before the examination the patient was asked to take a 50 g glucose. The concentration of glucose in blood plasma before the study was 5.2 mmol/l In the technique of PET scan was to study the thorax (10-minute transmission and a 30-minute issue). The resulting scan sinogram reconstructed in transaxial slices using filtering methods "Back projection" filter Harming 0.4 and Zoom of 2.5. The series of the left ventricle in the study of glucose metabolism plot pronounced reduction of glucose metabolism (less than 50% of the maximum accumulation in intact myocardium) was not determined. Based on the results of PET infarction in all departments of the left ventricle, including disfunktsioniruyuschikh myocardium was assessed to be viable (Fig). The presence of viable myocardium in the pool right coronary artery was the indication for re-operative treatment, which was completed in December 2004. Currently, the condition of the patient is satisfactory, the pain disappeared, has improved perenosimost physical activity. In June 2005, it is planned to re-echocardiography.

To date, the proposed method, a survey of 11 patients with ischemic heart disease, regional and global systolic dysfunction of the left ventricle and carbohydrate metabolism. Of these, 2 patients were diagnosed with diabetes mellitus type 2, 1 patient - 1 diabetes type 2 patients is impaired carbohydrate tolerance.

The proposed method is compared with the known has a number of significant advantages.

1. Provides a reliable diagnosis of myocardial viability in all patients with CHD, including patients with diabetes mellitus and impaired carbohydrate tolerance, which allows you to choose the adequate tactics of their treatment.

2. Easily perform PET studies in patients with impaired carbohydrate metabolism, eliminating the need to introduce them to the glucose-insulin infusion and continuous monitoring of glucose levels in blood plasma to avoid the potential occurrence in them of hypoglycemic condition that can occur when using these modes, the implementation of PET.

3. Reduces radiation exposure to the patient and the medical staff, eliminating the need to perform additional PET studies with perfusion radiopharmaceuticals to confirm jiznesposobnost the myocardium.

4. Does not increase the pharmacological patient load, because the use of anti-ischemic drug Trimetazidine" shows patients X and well they are tolerated.

The method developed in the PET Department of cnrri and was clinically tested in 11 patients with a positive result.

A method for the diagnosis of myocardial viability by positron emission tomography (PET) with18F-Tordesillas (18F-FDG), characterized in that in the determination of myocardial viability in patients with impaired carbohydrate metabolism they previously within 8-12 days daily 3 times a day administered orally Trimetazidine in a dose of 20 mg per day until the PET studies excluded from the diet caffeine-containing foods and drugs at the time of capture18F-FDG in the myocardium 50% or more of the value of its maximum accumulation diagnose viable myocardium, less than 50% is unsustainable.



 

Same patents:

FIELD: medicine.

SUBSTANCE: method involves carrying out multi-spiral computer-aided tomographic examination of mammary gland with slice width being equal to 1mm and tomography step of 1 mm without patient position being changed before and after introducing contrasting substance. The received data are are used for building multi-plane and three-dimensional reconstructions. Neoplasm malignance degree is evaluated from degree of contrasting substance accumulation in arterial, venous and delayed phase. Detected nodular formation density being found to grow 2-2.5 times as high in venous contrasting phase and/or grouped micro-calcinates being detected, mammary gland carcinoma case is to be diagnosed.

EFFECT: high accuracy of diagnosis.

FIELD: medical engineering.

SUBSTANCE: method involves forming X-ray radiation flow, letting pass it through filter transparent mainly for high power radiation spectrum portion of X-ray tube. The filter is mounted in front of volume under study. The X-ray radiation flow is directed to transducers for recording X-ray radiation quanta. Data are read from the transducers and image is built by applying computer software. An additional X-ray radiation flow is let pass through the filter transparent mainly for low power radiation spectrum portion of X-ray tube and mounted in front of volume under study. Another embodiment of the invention is characterized with scanning X-ray radiation flow being produced. High power radiation spectrum portion is directed to a transducers row for recording X-ray radiation quanta. X-ray radiation flow is additionally let pass through the filter transparent mainly for low power radiation spectrum portion of X-ray tube and mounted in front of volume under study. The X-ray radiation flow is directed to an additional transducers row for recording X-ray radiation quanta set in parallel to the available row.

EFFECT: high quality of diagnosis.

FIELD: medicine, radio diagnostics.

SUBSTANCE: one should intravenously inject osteotropic technetium99-labelled radiopharmpreparation followed by planar static scintigraphy, emission computer tomography and computerized informational processing due to building a three-dimensional model. Then comes comparative quantitative evaluation for accumulation of radiopharmpreparation in transplant's projection and in the part of intact bony tissue being transplant-symmetrical one to detect a corresponding coefficient of accumulation the value of which being ≥4.0 indicates restored efficient perfusion and intensive metabolic process in fragment's bony tissue.

EFFECT: higher accuracy and efficiency of diagnostics.

2 ex

FIELD: medicine, stereotaxic neurosurgery.

SUBSTANCE: the present innovation deals with treating cerebral glial neoplasms located in deep departments and functionally valuable cerebral areas. One should perform MRT and PET to determine the area for maximal tumor proliferation and carry out stereotaxic cryodestruction in this area and 2-3 mm beyond its limits. The method provides deterioration in tumor growth or its stoppage that enables to efficiently apply combined treatment and gives the chance for conducting therapy of tumors which traditionally are considered to be inoperable.

EFFECT: higher efficiency of therapy.

1 dwg, 1 ex

FIELD: medicine.

SUBSTANCE: method involves applying spiral computer tomography followed by multi-planar three-dimensional reconstruction on pre- intra- and postoperative periods.

EFFECT: enhanced effectiveness in planning, virtual modeling of operation volume and controlling treatment course.

3 cl

FIELD: medicine, oncology.

SUBSTANCE: the present innovation deals with prediction due to double scanning by technique of positron emission tomography (PET) with 18F-fluorodesoxyglucose and detecting the value of its accumulation in a focus, moreover, after the first scanning one should apply urinary catheter for a patient, and the second scanning should be fulfilled not earlier than 4 h after introduction of 18F-fluorodesoxyglucose and at increased standardized accumulation value of 18F-fluorodesoxyglucose in observed foci after the second scanning being by 10% higher against the results obtained after the first scanning one should diagnose malignant neoplasm.

EFFECT: higher accuracy of diagnostics.

6 dwg, 4 ex

FIELD: medicine, cardiology.

SUBSTANCE: one should carry out multiplayer spiral computer tomography followed by reconstruction and analysis of pictures obtained during diastolic phase of cardiac cycle at trigger's shift for 5%, and at heart rate being above 70 beats/min - preliminary introduction of beta-blocking agents, moreover, to perform analysis one should apply pictures obtained in interval of 45-65% against the duration of cardiac cycle at delaying the trigger for 50% against the duration of cardiac cycle at heart rate being below 60 beats/min, at heart rate being 60-65 beats/min - for 55%, at heart rate being equal to 65-70 beats/min - for 60-65% and at heart rate being above 70 beats/min - for 45%, and at detecting narrowing and/or occlusion in the lumen of coronary arteries one should diagnose stenosis. Moreover, at heart rate being equal to 65-70 beats/min, one should delay the trigger for the trunk of left-handed coronary and left-handed anterior descending arteries for 65% against the duration of cardiac cycle, and for left-handed rounding and dextral coronary arteries - for 60%.

EFFECT: higher efficiency of diagnostics.

1 cl, 2 ex, 1 tbl

The invention relates to medicine, namely to vascular neurosurgery

The invention relates to medicine, namely to neurosurgery

The invention relates to medicine, namely to neurosurgery

FIELD: medicine, cardiology.

SUBSTANCE: one should carry out multiplayer spiral computer tomography followed by reconstruction and analysis of pictures obtained during diastolic phase of cardiac cycle at trigger's shift for 5%, and at heart rate being above 70 beats/min - preliminary introduction of beta-blocking agents, moreover, to perform analysis one should apply pictures obtained in interval of 45-65% against the duration of cardiac cycle at delaying the trigger for 50% against the duration of cardiac cycle at heart rate being below 60 beats/min, at heart rate being 60-65 beats/min - for 55%, at heart rate being equal to 65-70 beats/min - for 60-65% and at heart rate being above 70 beats/min - for 45%, and at detecting narrowing and/or occlusion in the lumen of coronary arteries one should diagnose stenosis. Moreover, at heart rate being equal to 65-70 beats/min, one should delay the trigger for the trunk of left-handed coronary and left-handed anterior descending arteries for 65% against the duration of cardiac cycle, and for left-handed rounding and dextral coronary arteries - for 60%.

EFFECT: higher efficiency of diagnostics.

1 cl, 2 ex, 1 tbl

FIELD: medicine, oncology.

SUBSTANCE: the present innovation deals with prediction due to double scanning by technique of positron emission tomography (PET) with 18F-fluorodesoxyglucose and detecting the value of its accumulation in a focus, moreover, after the first scanning one should apply urinary catheter for a patient, and the second scanning should be fulfilled not earlier than 4 h after introduction of 18F-fluorodesoxyglucose and at increased standardized accumulation value of 18F-fluorodesoxyglucose in observed foci after the second scanning being by 10% higher against the results obtained after the first scanning one should diagnose malignant neoplasm.

EFFECT: higher accuracy of diagnostics.

6 dwg, 4 ex

FIELD: medicine.

SUBSTANCE: method involves applying spiral computer tomography followed by multi-planar three-dimensional reconstruction on pre- intra- and postoperative periods.

EFFECT: enhanced effectiveness in planning, virtual modeling of operation volume and controlling treatment course.

3 cl

FIELD: medicine, stereotaxic neurosurgery.

SUBSTANCE: the present innovation deals with treating cerebral glial neoplasms located in deep departments and functionally valuable cerebral areas. One should perform MRT and PET to determine the area for maximal tumor proliferation and carry out stereotaxic cryodestruction in this area and 2-3 mm beyond its limits. The method provides deterioration in tumor growth or its stoppage that enables to efficiently apply combined treatment and gives the chance for conducting therapy of tumors which traditionally are considered to be inoperable.

EFFECT: higher efficiency of therapy.

1 dwg, 1 ex

FIELD: medicine, radio diagnostics.

SUBSTANCE: one should intravenously inject osteotropic technetium99-labelled radiopharmpreparation followed by planar static scintigraphy, emission computer tomography and computerized informational processing due to building a three-dimensional model. Then comes comparative quantitative evaluation for accumulation of radiopharmpreparation in transplant's projection and in the part of intact bony tissue being transplant-symmetrical one to detect a corresponding coefficient of accumulation the value of which being ≥4.0 indicates restored efficient perfusion and intensive metabolic process in fragment's bony tissue.

EFFECT: higher accuracy and efficiency of diagnostics.

2 ex

FIELD: medical engineering.

SUBSTANCE: method involves forming X-ray radiation flow, letting pass it through filter transparent mainly for high power radiation spectrum portion of X-ray tube. The filter is mounted in front of volume under study. The X-ray radiation flow is directed to transducers for recording X-ray radiation quanta. Data are read from the transducers and image is built by applying computer software. An additional X-ray radiation flow is let pass through the filter transparent mainly for low power radiation spectrum portion of X-ray tube and mounted in front of volume under study. Another embodiment of the invention is characterized with scanning X-ray radiation flow being produced. High power radiation spectrum portion is directed to a transducers row for recording X-ray radiation quanta. X-ray radiation flow is additionally let pass through the filter transparent mainly for low power radiation spectrum portion of X-ray tube and mounted in front of volume under study. The X-ray radiation flow is directed to an additional transducers row for recording X-ray radiation quanta set in parallel to the available row.

EFFECT: high quality of diagnosis.

FIELD: medicine.

SUBSTANCE: method involves carrying out multi-spiral computer-aided tomographic examination of mammary gland with slice width being equal to 1mm and tomography step of 1 mm without patient position being changed before and after introducing contrasting substance. The received data are are used for building multi-plane and three-dimensional reconstructions. Neoplasm malignance degree is evaluated from degree of contrasting substance accumulation in arterial, venous and delayed phase. Detected nodular formation density being found to grow 2-2.5 times as high in venous contrasting phase and/or grouped micro-calcinates being detected, mammary gland carcinoma case is to be diagnosed.

EFFECT: high accuracy of diagnosis.

FIELD: medicine, cardiology.

SUBSTANCE: the present innovation deals with positron emission tomography (PET) to perform it with 18F-fluorooxyglucose (18F-FDG), moreover, at detecting myocardial viability in patients with disorders in carbohydrate exchange one should pre-introduce perorally trimetasidine thrice daily at the dosage of 20 mg for 8-12 d, 1 d before the onset of PET-trial it is necessary to exclude caffeine-containing products out of patient's diet and medicinal preparations and at 18F-FDG in myocardium being 50% and more against its maximal accumulation it is possible to diagnose viable myocardium, if below 50% - nonviable myocardium.

EFFECT: higher efficiency and accuracy of diagnostics.

8 dwg, 2 ex

FIELD: biology; medicine.

SUBSTANCE: device can be used for diagnosing state of internal organs. Device has narrow discontinuous radiation beam former with sweep, radiation detector, synchronization unit, drive, master oscillator, counter, analog-to-digital converter, processor and monitor. Radiation detector is made in form of M identical layers disposed one after another in the direction of radiation propagation. Any layer is made in form of N isolated parallel linear arrays; each of each consists of K pin-diodes connected in parallel, back-biased and disposed in one line along line of sweep of the beam. All M linear arrays being disposed layer by layer and having similar order numbers are connected to each other and to information inputs of analog-to-digital converter. Count input of counter is connected with output of master oscillator. Control input of the counter is connected with output of sweep radiation beam former. Output of pulse counter is connected with the second information input of processor. Clock output of counter is connected with control inputs of analog-to-digital converter. Radiation detector is used which detector has high efficiency of X-ray radiation energy conversion to electric signal. Design of the detector proposed allows using counter which provide simple determination of spatial location of read-out image element (pixel) and its correspondence to definite area (zone) of object to be diagnosed.

EFFECT: reduced dosage load; increased speed of operation when reading information out.

3 dwg

FIELD: medicine.

SUBSTANCE: method involves measuring main pulmonary artery diameter. Chest diameter is additionally measured at the level the examination is carried out. Vasculothoracic index VTI1 is calculated as ratio of transverse chest diameter at the level of the main pulmonary artery to main pulmonary artery diameter. VTI2 is also calculated as ratio of transverse chest diameter at the level of pulmonary artery bifurcation to main pulmonary artery diameter at given level. Mean VTI is calculated as (VTI1+ VTI2)/2. Mean VTI value being equal to 6.9-9.4, moderate pulmonary hypertension severity is considered to be the case. The value being less than 6.8, apparent pulmonary hypertension is considered to be the case.

EFFECT: high accuracy of diagnosis.

2 dwg

Up!