^99Tc^m-聚合白蛋白显像在肝肺综合征及肝移植中的应用

^99Tc^m-MAA imaging evaluation in the diagnosis of hepatopulmonary syndrome and its application in liver transplantation

目的探讨动态肺灌注显像对低氧血症肝肺综合征（HPS）的诊断价值及其在肝移植患者中的应用价值。方法对肝硬化拟行肝移植的23例患者行^99Tc^m-聚合白蛋白（MAA）心血管显像，随即进行动态肺灌注显像，观察动态心血管显像和全身放射性分布情况，按公式“（全身计数-双肺计数）／全身计数”，计算肺分流率。按最后诊断分成3组：Ⅰ组为慢性肝病合并HPS患者12例，Ⅱ组为慢性肝病合并原发肺疾病导致低氧血症患者3例，Ⅲ组为无低氧血症患者8例，比较3组肺分流率。比较不同Child—Pugh肝功能分级患者肺分流率。比较短期内（住院期间）死亡组和肝移植后病情稳定出院组肺分流率。采用SPSS13．0软件对数据进行独立样本t检验。结果所有患者未见心内分流。Ⅰ组患者肺外不同程度显影，Ⅱ组和Ⅲ组（1例除外）未见肺外组织显影，仅见双肺显影。Ⅰ组、Ⅱ组和Ⅲ组分流率分别为（21．27±7．47）％、（8．22±0．94）％和（10．24±3．54）％，Ⅰ组分流率明显高于Ⅱ组和Ⅲ组（t=-2．94，P〈0．05和t=-3．88，P〈0．05），Ⅱ组和Ⅲ组分流率差异无统计学意义（t=0．94，P〉0．05）。Child—PtIgh肝功能A级和B级患者肺分流率分别为（12．7±6．0）％和（17．7±8．7）％，差异无统计学意义（t=-1．38，P〉0．05）。入院后死亡组肺分流率为（24．76±6．78）％，明显高于肝移植后病情稳定出院组[（11．78±5．07）％，t=5．10，P〈0．05]。结论Child—Pugh肝功能A级和B级不影响肺分流率。肺动态灌注显像可作为肝移植患者低氧血症HPS的无创伤性和定量诊断手段，分流率高者围手术期短期预后差。

Objective There is controversy regarding the effects of liver transplantation on hepatopuhnonary syndrome （HPS）. It is important to have an accurate diagnosis of peri-liver-transplantation HPS. The aim of the study was to evaluate the diagnosis of HPS in patients with hypoxemia by dynamic pulmonary perfusion imaging and evaluate the effects of liver transplantation on HPS. Methods Twenty-three patients with liver cirrhosis in the department of liver transplantation were enrolled. Dynamic pulmonary perfusion imaging including radionuclide cardioangiography and whole body scan were performed after injection of 185 MBq ^99Tc^m-macroaggregated albumin （MAA）. Shunt rate was calculated according to the formula （whole body count -lung count）/whole body count. Patients were divided into three groups according to final diagnosis： group Ⅰ , 12 patients with HPS; group Ⅱ , 5 patients with hypoxemia caused by primary lung diseases; group Ⅲ, 8 patients without hypoxemia. Shunt rates of patients with different Child-Pugh grades were compared. Shunt rates of the death group and the survival group in short term （ during hospital stay） were compared. SPSS 13.0 was used for data analysis and independent t-test was used to compare results among groups. Results No right and left ventricular shunting was observed in all patients. Extra-pulmonary accumulation of ^99Tc^m-MAA was observed in group Ⅰ , no extra-pulmonary accumulation of ^99Tc^m-MAA was observed in group Ⅱand Ⅲ（except 1 patient）. Shunt rates of group Ⅰ , Ⅱand Ⅲwere （21.27 ±7.47）%, （ 8.22 ±0.94） % and （ 10.24 ±3.54） % , respectively, Shunt rate of group I was larger than that of group ]I and m statistically （t = - 2.94, P 〈 0.05 and t = - 3. 88, P 〈 0.05）. No significant difference was found between group Ⅱand Ⅲ（ t = 0.94, P 〉 0.05）. The shunt rates of patients with Child-Pugh grade A and B were （ 12.7 ±6.0） % and （ 17.7 ±8.7 ） % , respectively, with no statistically significant difference （t = - 1.38, P 〉 0.05）. During hospital stay, shunt rate of the death group was statistically larger than that of the survival group [ （24.76± 6.78） % vs （ 11.78 ±5.07 ） % , t = 5. 10, P 〈 0.05 ]. Conclusions Child-Pugh grades A and B do not show shunt rate differences. Dynamic pulmonary perfusion imaging is a noninvasive qualitative and quantitative means in the diagnosis of HPS in liver cirrhosis patients with hypoxemia before and after liver transplantation. Patients with higher shunt rates have a poorer prognosis in perioperative period.