左心室超声造影评估左心室心尖部血栓、收缩功能及抗凝治疗的价值

doi:10.3877/cma.j.issn.1672-6448.2017.06.009

目的

评价左心室超声造影（LVO)在明确心肌梗死患者是否存在左心室附壁血栓、准确测量左心室射血分数（LVEF）以及监测抗凝治疗效果的临床应用价值。

方法

回顾性分析2015年8月至2016年10月中日友好医院收治的因常规超声心动图怀疑附壁血栓而行LVO的26例心肌梗死患者。6例患者抗凝治疗后3~11个月行LVO复查。采用配对资料的McNemar检验比较常规超声心动图与LVO明确诊断存在及排除血栓比例差异；采用Bland-Altman分析不同年资超声医师间常规超声心动图、LVO测量LVEF的一致性。

结果

常规超声心动图明确诊断心尖部附壁血栓形成6例，排除血栓4例，可疑或不能确定16例。LVO明确诊断心尖部附壁血栓形成10例，排除血栓15例，不能确定1例。LVO明确诊断存在或排除心尖部血栓形成的比例高于常规超声心动图[96.2%（25/26） vs 38.5%（10/26）]，且差异有统计学意义（χ²=13.067，P<0.001）。Bland-Altman分析图显示，高年资与低年资超声医师LVO测量LVEF的差值均数为1.5%，95%可信区间为（-9.6%，6.5%）；高年资与低年资超声医师常规超声心动图测量LVEF的差值均数为3.5%，95%可信区间为（-23.9%，16.9%）。不同年资超声医师间LVO测量LVEF的一致性LVO优于常规超声心动图。6例患者抗凝治疗后复查LVO，1例血栓消失，4例血栓明显缩小，1例无明显变化。

结论

对怀疑有心尖部附壁血栓形成的心肌梗死患者，LVO能够明显增强诊断信心，更详尽描述血栓大小形态，增加测量LVEF的一致性，在对患者进行风险评估、抗凝策略制定以及连续监测治疗效果方面有潜在应用价值。

关键词: 超声检查, 造影剂, 左心室, 血栓形成, 治疗结果

Objective

To demonstrate the clinical value of left ventricular opacification (LVO) , compared to conventional echocardiography, on interpretation of apical thrombus, measuring left ventricular ejection fraction (LVEF), and monitoring the effects of anticoagulation.

Methods

This retrospective study included twenty-six myocardial infarction patients with suspected apical thrombus on routine echocardiography in China-Japan friendship hospital between August 2015 and October 2016. All patients underwent LVO using microbubble contrast agent (SonoVue). Six patients had repeated LVO examination 3-11 months after anticoagulant therapy. The diagnostic performance of routine echocardiography and LVO were compared using McNemar test. The interobserver agreement in measuring LVEF by conventional echocardiograph and LVO were analyzed using Bland-Altman analysis.

Results

Apical thrombus were diagnosed in 6 patients, excluded in 4 patients and inconclusive in 16 patients by routine echocardiography, while diagnosed in 10 patients, excluded in 15 patients and inconclusive in 1 patients by LVO. The inconclusive results were significantly improved when using LVO [96.2%(25/26) vs 38.5%(10/26)] (χ²=13.067, P<0.001). Bland-Altman chart showed the mean difference of LVEF by LVO between senior and junior doctors was 1.5%[95% CI(-9.6%, 6.5%)], while the mean difference was 3.5% [95%CI(-23.9%, 16.9%)] when using routine echocardiography. The interobserver agreement in measuring LVEF was better for LVO. Six patients were followed up 3-11 months after anticoagulation. Of them, 1 thrombus disappeared, 4 diminished and 1 had no significant change.

Conclusion

LVO has the potential value of improving the diagnosis of apical thrombus, assessment of LVEF, and monitoring of anticoagulation in myocardial infarction patients.

Key words: Ultrasonography, Contrast media, Left ventricular, Thrombosis, Treatment outcomes

表1 LVO前后患者血压及心率比较（±s）

时间	例数	收缩压（mmHg）	舒张压（mmHg）	心率（次/min）
LVO前	26	122.82±10.23	75.36±15.32	68.36±18.22
LVO后	26	124.09±7.01	74.55±12.14	69.55±15.64
t值	?	-0.629	0.431	-0.895
P值	?	0.543	0.675	0.392

表1 LVO前后患者血压及心率比较（±s）

时间	例数	收缩压（mmHg）	舒张压（mmHg）	心率（次/min）
LVO前	26	122.82±10.23	75.36±15.32	68.36±18.22
LVO后	26	124.09±7.01	74.55±12.14	69.55±15.64
t值	?	-0.629	0.431	-0.895
P值	?	0.543	0.675	0.392

图1 左心室心尖部超声造影动态图。示左心室内呈高回声充填，无明显声衰减和涡流现象，心内膜勾画清晰

图3 高年资与低年资超声医师左心室超声造影测量左心室射血分数的Bland-Altman分析图

图8，9 患者华法林抗凝治疗前后左心室超声造影图。图8为治疗前，心尖部可见附壁血栓，基底宽度为12 mm，长径为18 mm；图8为治疗4个月后，血栓形态及大小较治疗前变化不大（基底宽度为12 mm，长径为17 mm）

[1]	Mulvagh SL, Rakowski H, Vannan MA, et al. American Society of Echocardiography consensus statement on the clinical applications of ultrasonic contrast agents in echocardiography [J]. J Am Soc Echocardiogr, 2008, 21(11):1179-1201.
[2]	Porter TR, Abdelmoneim S, Belcik JT, et al. Guidelines for the cardiac sonographer in the performance of contrast echocardiography: A focused update from the American Society of Echocardiography [J]. J Am Soc Echocardiogr, 2014, 27(8):797-810.
[3]	Senior R, Becher H, Monaghan M, et al. Contrast echocardiography: evidence-based recommendations by European Association of Echocardiography [J]. Eur J Echocardiogr, 2009, 10(2):194-212.
[4]	中华医学会超声医学分会超声心动图学组. 中国心血管超声造影增强检查专家共识 [J/CD]. 中华医学超声杂志：电子版, 2015, 12(9):667-680.
[5]	Wada H, Yasu T, Sakakura K, et al. Contrast echocardiography for the diagnosis of left ventricular thrombus in anterior myocardial infarction [J]. Heart Vessels, 2014, 29(3):308-312.
[6]	Abdelmoneim SS, Pellikka PA, Mulvagh SL. Contrast echocardiography for assessment of left ventricular thrombi [J]. J Ultrasound Med, 2014, 33(8):1337-1344.
[7]	谢晋国，查道刚，宾建平, 等. 经静脉左心室声学造影对左心室附壁血栓的诊断价值 [J]. 临床内科杂志, 2005, 22(3):175-176.
[8]	Olszewski R, Timperley J, Szmigielski C, et al. The clinical applications of contrast echocardiography [J]. Eur J Echocardiogr, 2007, 8(3):S13-S23.
[9]	Kirkpatrick JN, Wong T, Bednarz JE, et al. Differential diagnosis of cardiac masses using contrast echocardiographic perfusion imaging [J]. J Am Coll Cardiol, 2004, 43(8):1412-1419.
[10]	Plana JC, Mikati IA, Dokainish H, et al. A randomized cross-over study for evaluation of the effect of image optimization with contrast on the diagnostic accuracy of dobutamine echocardiography in coronary artery disease: the OPTIMIZE Trial [J]. JACC Cardiovasc Imaging, 2008, 1(2):145-152.
[11]	朱烨，陈明. 心腔内超声造影对左心室心肌致密化不全肌小梁的定量分析 [J]. 中国医学影像学杂志, 2014, 22(6):405-408.
[12]	王飞，赖玉琼，曹进进. 左心室腔声学造影改善急性心肌梗死患者内膜分辨的应用价值 [J]. 岭南心血管病杂志, 2015, 21(4):501-506.
[13]	吕清，郑智超，王新房,等. 全氟显左心声学造影的临床应用 [J]. 临床心血管病杂志, 2005, 21(11):674-676.
[14]	Bernier M, Abdelmoneim SS, Stuart Moir W, et al. CUTE-CV: A Prospective study of enhanced left atrial appendage visualization with microbubble contrast agent use during transesophageal echocardiography guided cardioversion [J]. Echocardiography, 2013, 30(9):1091-1097.
[15]	Jung PH, Mueller M, Schuhmann C, et al. Contrast enhanced transesophageal echocardiography in patients with atrial fibrillation referred to electrical cardioversion improves atrial thrombus detection and may reduce associated thromboembolic events [J]. Cardiovasc Ultrasound, 2013, 11(1):1.

[1]	张婉微, 秦芸芸, 蔡绮哲, 林明明, 田润雨, 金姗, 吕秀章. 心肌收缩早期延长对非ST段抬高型急性冠脉综合征患者冠状动脉严重狭窄的预测价值[J]. 中华医学超声杂志（电子版）, 2023, 20(10): 1016-1022.
[2]	任书堂, 刘晓程, 张亚东, 孙佳英, 陈萍, 周建华, 龙进, 黄云洲. 左心室辅助装置支持下单纯收缩期主动脉瓣反流的超声心动图特征[J]. 中华医学超声杂志（电子版）, 2023, 20(10): 1023-1028.
[3]	何金梅, 尹立雪, 谭静, 张文军, 王锐, 任梅, 廖明娇. 超声心肌做功技术对2型糖尿病患者潜在左心室心肌收缩功能损伤的评价[J]. 中华医学超声杂志（电子版）, 2023, 20(10): 1029-1035.
[4]	魏淑婕, 惠品晶, 丁亚芳, 张白, 颜燕红, 周鹏, 黄亚波. 单侧颈内动脉闭塞患者行颞浅动脉-大脑中动脉搭桥术的脑血流动力学评估[J]. 中华医学超声杂志（电子版）, 2023, 20(10): 1046-1055.
[5]	张璇, 马宇童, 苗玉倩, 张云, 吴士文, 党晓楚, 陈颖颖, 钟兆明, 王雪娟, 胡淼, 孙岩峰, 马秀珠, 吕发勤, 寇海燕. 超声对Duchenne肌营养不良儿童膈肌功能的评价[J]. 中华医学超声杂志（电子版）, 2023, 20(10): 1068-1073.
[6]	朱连华, 费翔, 韩鹏, 姜波, 李楠, 罗渝昆. 高帧频超声造影在胆囊息肉样病变中的鉴别诊断价值[J]. 中华医学超声杂志（电子版）, 2023, 20(09): 904-910.
[7]	张梅芳, 谭莹, 朱巧珍, 温昕, 袁鹰, 秦越, 郭洪波, 侯伶秀, 黄文兰, 彭桂艳, 李胜利. 早孕期胎儿头臀长正中矢状切面超声图像的人工智能质控研究[J]. 中华医学超声杂志（电子版）, 2023, 20(09): 945-950.
[8]	陈舜, 薛恩生, 叶琴. PDCA在持续改进超声危急值管理制度中的价值[J]. 中华医学超声杂志（电子版）, 2023, 20(09): 974-978.
[9]	周钰菡, 肖欢, 唐毅, 杨春江, 周娟, 朱丽容, 徐娟, 牟芳婷. 超声对儿童髋关节暂时性滑膜炎的诊断价值[J]. 中华医学超声杂志（电子版）, 2023, 20(08): 795-800.
[10]	刘欢颜, 华扬, 贾凌云, 赵新宇, 刘蓓蓓. 颈内动脉闭塞病变管腔结构和血流动力学特征分析[J]. 中华医学超声杂志（电子版）, 2023, 20(08): 809-815.
[11]	郏亚平, 曾书娥. 含鳞状细胞癌成分的乳腺化生性癌的超声与病理特征分析[J]. 中华医学超声杂志（电子版）, 2023, 20(08): 844-848.
[12]	张丽丽, 陈莉, 余美琴, 聂小艳, 王婧玲, 刘婷. PDCA循环法在超声浅表器官亚专科建设中的应用[J]. 中华医学超声杂志（电子版）, 2023, 20(07): 717-721.
[13]	黄应雄, 叶子, 蒋鹏, 詹红, 姚陈, 崔冀. 急性肠系膜静脉血栓形成致透壁性肠坏死的临床危险因素分析[J]. 中华普通外科学文献(电子版), 2023, 17(06): 413-421.
[14]	张海涛, 康婵娟, 翟静洁. 胰管支架置入治疗急性胆源性胰腺炎效果观察[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 654-657.
[15]	朱翔宇, 王建美, 张辉, 叶红英. 无创左心室压力-应变循环技术在左心室功能参数与肝硬化的相关性分析[J]. 中华消化病与影像杂志(电子版), 2023, 13(06): 494-498.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

The value of left ventricular opacification in patients with myocardial infarction on improving diagnosis confidence of apical thrombus and monitoring the effects of anticoagulation

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

The value of left ventricular opacification in patients with myocardial infarction on improving diagnosis confidence of apical thrombus and monitoring the effects of anticoagulation