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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2018, Vol. 15 ›› Issue (03) : 191 -197. doi: 10.3877/cma.j.issn.1672-6448.2018.03.006

所属专题： 文献；

心血管超声影像学

经食管实时三维超声心动图评估心房颤动患者左心耳结构及其与血栓形成的相关性
张恒1, 温赐祥1,†(), 朱文燕1, 高晓梅1   
  1. 1. 519000　广东省珠海市人民医院超声影像科
  • 收稿日期:2017-08-15 出版日期:2018-03-01
  • 通信作者: 温赐祥

Assessment of left atrial appendage structure and thrombosis in patients with atrial fibrillation by real-time three-dimensional transesophageal echocardiography

Heng Zhang1, Cixiang Wen1,†(), Wenyan Zhu1, Xiaomei Gao1   

  1. 1. Department of Ultrasound, Zhuhai People′s Hospital, Zhuhai 519000, China
  • Received:2017-08-15 Published:2018-03-01
  • Corresponding author: Cixiang Wen
  • About author:
    Corresponding author: Wen Cixiang, Email:
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引用本文：

张恒, 温赐祥, 朱文燕, 高晓梅. 经食管实时三维超声心动图评估心房颤动患者左心耳结构及其与血栓形成的相关性[J]. 中华医学超声杂志（电子版）, 2018, 15(03): 191-197.

Heng Zhang, Cixiang Wen, Wenyan Zhu, Xiaomei Gao. Assessment of left atrial appendage structure and thrombosis in patients with atrial fibrillation by real-time three-dimensional transesophageal echocardiography[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2018, 15(03): 191-197.

目的

应用经食管实时三维超声心动图（RT-3D TEE）评估心房颤动患者左心耳（LAA）形态及排空分数，同时分析LAA血栓形成的独立危险因素。

方法

选择2015年1月至2017年1月在广东省珠海市人民医院行RT-3D TEE检查的90例患者。其中53例心房颤动患者（AF组），37例非心房颤动患者（NAF组）。53例AF组患者中，11例患者LAA内血栓（血栓组），13例患者LAA自发显影（自发显影组），29例患者LAA未见异常（未见异常组）。采用RT-3D TEE测量并计算所有患者LAA分叶数、排空分数、开口宽度指数（LAA-WI）、长度指数（LAA-LI）、开口面积指数（LAA-OI）、最大容积指数（LAA-VImax）、最小容积指数（LAA-VImin）、射血分数（LAA-EF）、排空血流速度（LAA-v）、左心房最大容积指数（LA-VImax）。采用方差分析比较血栓组、自发显影组、未见异常组及NAF组患者LAA分叶数，进一步组间两两比较采用LSD-t检验；采用t检验分别比较AF组和NAF组患者二维面积法、三维面积法和三维容积法测量的LAA排空分数；采用t检验比较血栓组或自发显影组与未见异常组患者年龄、LAA-WI、LAA-LI、LAA-OI、LAA-VImax、LAA-VImin、LAA-EF、LAA-v、LA-VImax及LAA分叶数差异；采用Logistic回归分析分析LAA血栓形成的独立危险因素。

结果

血栓组、自发显影组、未见异常组、NAF组患者LAA平均分叶数分别为（3.57±0.77）、（3.28±0.99）、（2.57±0.68）、（2.76±1.13）叶。血栓组患者LAA平均分叶数较自发显影组、未见异常组、NAF组患者增多，且与NAF组比较差异有统计学意义（t=2.294，P<0.05）；而其余任意两组间差异均无统计学意义。AF组患者二维面积法、三维面积法和三维容积法测量的LAA排空分数均低于NAF组患者，且差异均有统计学意义（t=8.671、7.082、10.432，P均<0.05）。血栓组或自发显影组患者LAA-WI、LAA-OI、LAA-VImax、LAA-VImin、LA-VImax及LAA分叶数均大于未见异常组患者[（18.27±2.14）mm/m2 vs （12.76±1.93）mm/m2，（3.45±0.46）cm2/m2 vs （2.64±0.37） cm2/m2，（6.63±0.73）ml/m2 vs （4.72±0.48）ml/m2，（4.22±0.53）ml/m2 vs （2.51±0.22）ml/m2，（4.57±0.32）ml/m2 vs （4.21±0.28）ml/m2，（3.62±0.11）叶vs （2.57±0.08）叶]，LAA-EF、LAA-v均小于未见异常组患者[（34.12±2.31）% vs （48.09±2.74）%，（29.11±1.08）cm/s vs （48.18±2.11）cm/s]，且差异均有统计学意义（t=9.849、7.107、11.000、14.787、4.367、40.471、19.814、42.417，P均<0.001）；而年龄、LAA-LI差异均无统计学意义。Logistic回归分析结果表明，LAA排空分数是LAA血栓或自发显影形成的独立危险因素（OR=2.323，95%CI：1.471-2.821）。

结论

RT-3D TEE评估LAA复杂结构可行且准确性更高。LAA分叶数增多、排空功能减低与LAA血栓形成相关，且LAA排空分数降低是LAA血栓形成的独立危险因素。

关键词: 超声心动描记术，经食管, 超声心动描记术，三维, 心房颤动, 心耳, 血栓形成, 危险因素
Objective

To examine the morphology and emptying score of the left atrial appendage (LAA) by real-time three-dimensional echocardiography (RT-3D TEE) in patients with atrial fibrillation (AF), and to identify the independent risk factors for left atrial thrombosis.

Methods

In total, 90 patients who underwent RT-3D TEE examination in Zhuhai People′s Hospital from January 2015 to January 2017 were enrolled, including 53 with AF (AF group) and 37 without AP (NAF group). Of the 53 cases of AF, 11 had LAA thrombus (thrombus group), 13 had spontaneous development (spontaneous development group), and 29 had no abnormal LAA (non-abnormal group). RT-3D TEE was used to measure and calculate the LAA lobe number, emptying fraction, width index (LAA-WI), length index (LAA-LI), open area index (LAA-OI), maximum volume index (LAA-VImax), minimum volume index (LAA-VImin), ejection fraction (LAA-EF), velocity (LAA-v), and maximum volume index (LA-VImax). Analysis of variance was used to compare LAA lobe number among the thrombus group, spontaneous development group, non-abnormal group, and NAF group, and LSD-t test was adopted for further comparisons between any two groups. The t-test was used to compare the emptying fractions measured by the two-dimensional area method, three-dimensional area method, and three-dimensional volume method between the AF group and NAF group, as well as age, LAA-WI, LAA-LI, LAA-OI, LAA-VImax, LAA-VImin, LAA-EF, LAA-v, LA-VImax, and lobe number between the thrombus group or spontaneous development group and non-abnormal group. Logistic regression analysis was used to analyze the independent risk factors for left atrial thrombosis.

Results

The average number of LAA lobes in the thrombus group, spontaneous development group, non-abnormal group, and NAF group were (3.57±0.77), (3.28±0.99), (2.57±0.68), and (2.76±1.13), respectively. The average number of LAA lobes was higher in the thrombus group than in the spontaneous development group, non-abnormal group, and NAF group, and the difference between the thrombus group and NAF group was statistically significant (t=2.294, P<0.05). The emptying fractions measured by the two-dimensional area method, three-dimensional area method, and three-dimensional volume method were significantly lower in the AF group than in the NAF group (t=8.671, 7.082, 10.432, all P<0.05). LAA-WI, LAA-OI, LAA-VImax, LAA-VImin, LA-VImax, and lobe number in the thrombus group or the spontaneous development group were all significantly greater than those in the non-abnormal group [(18.27±2.14) mm/m2 vs (12.76±1.93) mm/m2, (3.45±0.46) cm2/m2 vs (2.64±0.37) cm2/m2, (6.63±0.73) ml/m2 vs (4.72±0.48) ml/m2, (4.22±0.53) ml/m2 vs (2.51±0.22) ml/m2, (4.57±0.32) ml/m2 vs (4.21±0.28) ml/m2, (3.62±0.11) vs (2.57±0.08)], while LAA-EF and LAA-v were significantly smaller than those in the non-abnormal group [(34.12±2.31)% vs (48.09±2.74)%, (29.11±1.08) cm/s vs (48.18±2.11) cm/s] (t=9.849, 7.107, 11.000, 14.787, 4.367, 40.471, 19.814, 42.417, all P<0.001), although there was no significant difference in age or LAA-LI. Logistic regression analysis showed that LAA emptying fraction was an independent risk factor for thrombosis or spontaneous development (OR=2.323, 95% CI: 1.471-2.821).

Conclusions

Using RT-3DTEE to evaluate the complex structure of LAA is feasible and accurate. Increased lobe number and decreased emptying fraction are associated with thrombosis. Decreased emptying fraction is an independent risk factor for thrombosis.

Key words: Echocardiography, transesophageal, Echocardiography, three-dimensional, Atrial fibrillation, Atrial appendage, Thrombosis, Risk factors
图2 经食管二维超声心动图显示食道中段主动脉瓣短轴切面，测量左心耳排空流速为35.3 cm/s
图5 三维容积法测量左心耳排空分数
图6，7 经食管实时三维超声心动图显示三维重建左心耳及其分叶数。图6示左心耳三叶；图7示左心耳四叶；箭头示分叶
表1 AF组与NAF组患者LAA排空分数比较（%，±s）
组别 例数 EFA-2D EFA-3D EFV-3D
AF组 53 0.34±0.11 0.33±0.13 0.35±0.08
NAF组 37 0.53±0.09 0.51±0.10 0.52±0.07
t值 ? 8.671 7.082 10.432
P值 ? <0.001 <0.001 <0.001
表2 血栓组或自发显影组与未见异常组患者各参数比较（±s）
组别 例数 年龄（岁） LAA-WI（mm/m2） LAA-LI（mm/m2） LAA-OI（cm2/m2） LAA-VImax（ml/m2）
血栓组及自发显影组 24 56.11±8.71 18.27±2.14 21.41±3.13 3.45±0.46 6.63±0.73
未见异常组 29 56.92±9.03 12.76±1.93 20.08±3.24 2.64±0.37 4.72±0.48
t值 ? 0.330 9.849 1.510 7.107 11.000
P值 ? 0.743 <0.001 0.137 <0.001 <0.001
组别 例数 LAA-VImin（ml/m2） LAA-EF（%） LAA-v（cm/s） LA-VImax（ml/m2） LAA分叶数（叶）
血栓组或自发显影组 24 4.22±0.53 34.12±2.31 29.11±1.08 4.57±0.32 3.62±0.11
未见异常组 29 2.51±0.22 48.09±2.74 48.18±2.11 4.21±0.28 2.57±0.08
t值 ? 14.787 19.814 42.417 4.367 40.471
P值 ? <0.001 <0.001 <0.001 <0.001 <0.001
表3 LAA血栓形成独立危险因素Logistic回归分析结果
变量 B s Wald χ2 P OR 95%CI for OR
LAA-WI 0.212 0.15 1.998 0.278 1.236 0.921-1.659
LAA-OI 0.302 0.19 2.523 0.263 1.353 0.932-1.963
LAA-VImax 0.241 0.23 1.127 0.316 1.275 0.815-1.985
LAA-VImin 0.201 0.193 1.085 0.313 1.2222 0.837-1.786
LAA-EF 1.672 0.912 3.361 0.022 2.323 1.471-2.821
LAA-v 0.911 0.712 1.48 0.249 1.102 0.880-1.564
LA-VImax 0.431 0.511 0.711 0.327 1.534 1.034-1.816
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