切换至 "中华医学电子期刊资源库"

中华医学超声杂志(电子版) ›› 2019, Vol. 16 ›› Issue (09) : 641 -646. doi: 10.3877/cma.j.issn.1672-6448.2019.09.001

所属专题: 文献

心血管超声影像学

经食管超声心动图在左心耳封堵术中的应用价值研究
吴春霞1, 王静1,(), 谌勉1, 余正春1   
  1. 1. 430022,武汉亚洲心脏病医院超声中心 华中科技大学附属协和医院超声影像科
  • 收稿日期:2018-06-24 出版日期:2019-09-01
  • 通信作者: 王静
  • 基金资助:
    武汉市卫生健康委员会基金(WX19Q13)

Application value of transesophageal echocardiography in left atrial appendage occlusion

Chunxia Wu1, Jing Wang1,(), Mian Chen1, Zhengchun Yu1   

  1. 1. Department of Ultrasonography, Wuhan Union Hospital, Wuhan Asia Heart Hospital, Wuhan 430022, China
  • Received:2018-06-24 Published:2019-09-01
  • Corresponding author: Jing Wang
  • About author:
    Corresponding author: Wang Jing, Email:
引用本文:

吴春霞, 王静, 谌勉, 余正春. 经食管超声心动图在左心耳封堵术中的应用价值研究[J/OL]. 中华医学超声杂志(电子版), 2019, 16(09): 641-646.

Chunxia Wu, Jing Wang, Mian Chen, Zhengchun Yu. Application value of transesophageal echocardiography in left atrial appendage occlusion[J/OL]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2019, 16(09): 641-646.

目的

探讨经食管超声心动图(TEE)在经皮左心耳封堵术前筛选、术中监测及术后随访中的应用价值。

方法

选取2016年1月至2016年12月武汉亚洲心脏病医院共54例心房颤动患者应用Watchman封堵器行经皮左心耳封堵术,依据封堵术后是否出现残余分流分为残余分流组与无残余分流组。术前所有患者均行经胸超声心动图(TTE)和TEE检查,排除瓣膜器质性病变及左心耳血栓者。术前TEE测量入选患者的左心耳最大开口径及最大深度;术中TEE引导房间隔穿刺、联合X线血管造影选择封堵器型号,引导封堵传输系统的定位及指导封堵器释放,并评估术中安全性;术后即刻及45 d进行随访超声检查。残余分流组与无残余分流组的最大压缩比及最小压缩比均值比较采用t检验;TEE所测左心耳最大开口径与术中X线造影及最终所选封堵器大小的相关性分析采用Pearson法。

结果

54例行左心耳封堵术的患者,均封堵成功,压缩比均在8%~20%之间,残余分流组与无残余分流组组间最大压缩比及最小压缩比均值比较[(17.70±2.28)% vs(17.10±2.42)%,(12.40±2.82)% vs(12.60±2.68)%],差异均无统计学意义(P均>0.05);87%(47/54)的患者左心耳开口径与深度最大值在TEE 135°上获得;TEE 135°上所测LAA开口径与TEE 4个角度上所测最大开口径,TEE测量LAA最大开口径与造影测量LAA开口径,TEE 135°所测LAA开口径与所选封堵器型号,相关性均较好(r=0.919、0.622、0.602,P均<0.001),相关方程分别为:Y=1.01X+1.11、Y=0.68X+6.56、Y=0.80X+1.24;所有随访患者均未出现脑血管或其他血管栓塞事件,术中出现少量心包腔积液3例,术后7 d复查均未见心包腔积液,2例术后45 d复查封堵器表面出现血栓。

结论

TEE在左心耳封堵术前对患者的筛选、术中引导房间隔穿刺、封堵器型号的选择、指导释放过程及即刻评估封堵效果、术后随访中有重要的应用价值,TEE 135°扫查较其他角度检测出残余分流更敏感。

Objective

To evaluate the value of transesophageal echocardiography in the preoperative screening, intraoperative monitoring, and postoperative follow-up in patients undergoing percutaneous left atrial appendage (LAA) occlusion.

Methods

Fifty-four patients with atrial fibrillation were treated by percutaneous closure of the LAA with the Watchman occluder in Wuhan Asia Heart Hospital from January 2016 to December 2016. According to whether there was residual shunt after closure, the patients were divided into a residual shunt group and a non-residual shunt group. Before the operation, all patients were examined by transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), and patients with valvular pathological changes or left atrial appendage thrombus were excluded. The maximum opening and depth of the LAA were measured by TEE before operation. During the operation, TEE guided atrial septum puncture combined with X-ray angiography were used to select the occluder model, guide the location of the blocking transmission system and the release of the occluder, and evaluate the safety of the operation. The follow-up ultrasound examination was performed immediately and 45 days after the operation. The t-test was used to compare the maximum and minimum compression ratios between the two groups. The correlation between the maximum opening diameter of the LAA measured by TEE and the size of the selected occluder was analyzed by the Pearson method.

Results

Fifty-four patients who underwent left atrial appendage occlusion were successfully occluded, and the compression ratio was between 8% and 20%. The comparison of the maximum and minimum compression ratios differed significantly between the residual shunt group and the non-residual shunt group [(17.70±2.28)% vs (17.10±2.42)%, (12.40±2.82)% vs (12.60±2.68)%, all P>0.05]. In 87% (47/54) of the patients, the maximum opening and depth of left atrial appendage were obtained by TEE at 135°. There was a significant positive correlation between the maximum LAA opening diameter measured by TEE at four angles and the LAA opening diameter measured by TEE at 135°, between the maximum LAA opening diameter measured by TEE and the LAA opening diameter measured by X-ray angiography, as well as between the LAA opening diameter measured by TEE at 135° and the selected occluder model (r=0.919, 0.622, 0.602, all P<0.001), and the correlation equations were: Y=1.01X+ 1.11, Y=0.68X+ 6.56, and Y=0.80X+ 1.24, respectively. There were no cerebrovascular or other vascular embolization events in all patients undergoing follow-up. A small amount of pericardial effusion was found in three cases with cerebrovascular or other vascular embolism. No pericardial effusion was found at 7 d after operation, and thrombus appeared on the surface of the occluder in two cases at 45 d after the operation.

Conclusions

TEE is of great value for the screening of patients before LAA closure, the selection of percutaneous puncture and occluder model, the guidance of the release process, the immediate assessment of the blocking effect, and the postoperative follow-up. TEE performed at 135° is more sensitive for residual shunt detection than that performed at other angles.

图1 心房颤动患者经食管超声心动图检查左心耳图像。图a~d分别显示经食管超声心动图 0°、45°、90°及135°测量左心耳的开口径及深度
图2 TEE 135°所测左心耳开口径与TEE所测最大开口径相关图像
图3 TEE所测左心耳最大开口径与X线造影测量左心耳开口径相关图像
图4 TEE 135°所测左心耳开口径与所选封堵器型号相关图像
图5 经食管超声心动图观察封堵术后是否出现残余分流。图a显示封堵后出现残余分流;图b显示封堵后未见残余分流
[1]
De Backer O, Arnous S, Ihlemann N, et al. Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an updat [J]. Open Heart, 2014, 1(1): e000020.
[2]
Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation [J]. Ann Thorac Surg, 1996, 61(2): 755-759.
[3]
Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design : a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society [J]. Heart Rhythm, 2012, 9(4): 632-696. e21.
[4]
European Heart Rhythm Association, European Association for Cardio-thoracic Surgery, Camm AJ, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology(ESC) [J]. Eur Heart J, 2010, 31(19): 2369-2429.
[5]
邢小飞,刘楠楠,周微微, 等. 经食管超声心动图与增强CT在心房颤动患者拟行射频消融术前左心耳血栓检测中的研究 [J]. 中国超声医学杂志, 2017, 33(8): 694-697.
[6]
Sievert H, Lesh MD, Trepels T, et al. Percutaneous left atrial appendage transcatheter occlusion to prevent stroke in hight-risk patients with atrial fibrillation:early clinical experience [J]. Circulation, 2002, 105(16): 1887-1889.
[7]
樊友启,杨倩,蒋峻, 等. 经导管左心耳封堵术预防房颤血栓栓塞 [J]. 中华急诊医学杂志, 2014, 23(7): 735-739.
[8]
Schwartzman D, Katz WE, Smith AJ, et al. Malpositioning of a left atrial appendage occlusion device? A case with implications for percutaneous transcatheter left atrial appendage occlusion device therapy [J]. Heart Rhythm, 2007, 4(5): 648-650
[9]
Holmes DR, Reddy VY, Turi ZG, et al. Percutaneous closure of the left atrial appendage versus warfin therapy for prevention of stroke in patients with atrialfibrillation: a randomized non-inferiority trial [J]. Lacet, 2009, 374(9689): 534-542.
[10]
Chun KR, Bordignon S, Urban V, et al. Left atrial appendage closure followed by 6 weeks of antithrombotic therapy: a prospective single-center experience [J]. Heart Rhythm, 2013, 10(12): 1792-1799.
[11]
Viles-Gonzalez JF, Kar S, Douglas P, et a1. The clinical impact of incomplete left atrial appendage closure with the Watchman Device in patients with atrial fibrillation:a PROTECT AF (Pereutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients Witll Atrial Fibrillation)substudy [J]. J Am Coil Cardiol, 2012, 59(10): 923-929.
[12]
Meincke F, Schmidt-Salzmann M, Kreidel F, et al. New technical and anticoagulation aspects for left atrial appendage closure using the WATCHMAN? device in patients not taking warfarin [J]. EuroIntervention, 2013, 9(4): 463-468.
[13]
Bai R, Horton RP, DI Biase L, et al. Intraprocedural and long-term incomplete occlusion of the left atrial appendage following placement of the WATCHMAN device: a single center experience [J]. J Cardiovasc Electrophysiol, 2012, 23(5): 455-461.
[14]
Konoyza TF, Kahlert P, Plicht B, et a1. Risk factors for thrombus formation on the Amplatzer Cardiac Plug after left atrail appendage occlusion [J]. JACC Cardiovasc Interv, 2013, 6(6): 606-613.
[1] 曹雨欣, 毛卓君, 梁嘉赫, 伊江浦, 张泽凯, 马文帅, 陈云涛, 李晓倩, 张宇新, 曹铁生, 袁丽君. 3D打印心脏模型在模拟左心耳封堵术临床教学中的应用价值[J/OL]. 中华医学超声杂志(电子版), 2024, 21(06): 602-607.
[2] 孔莹, 惠品晶, 丁亚芳, 周炳元. 基于对比增强经颅多普勒的多模式超声评估卵圆孔未闭相关右向左分流的临床意义[J/OL]. 中华医学超声杂志(电子版), 2024, 21(04): 345-351.
[3] 张胜男, 苗雅敬, 周虹, 韩高洁, 王静, 仝巧立, 张旭倩, 尹洪宁. 左心耳三维经食管超声测量与Watchman左心耳封堵器大小的相关性研究[J/OL]. 中华医学超声杂志(电子版), 2024, 21(02): 107-113.
[4] 刘丹妮, 敖梦, 冉海涛, 李世玉, 秦芳. 三维超声心动图及二维斑点追踪成像对持续性心房颤动复律后双心房逆向重构的评估[J/OL]. 中华医学超声杂志(电子版), 2023, 20(08): 827-835.
[5] 张煜彭, 李浩南, 付焱, 冯继伟, 刘凯, 张文凯. 术后房颤对老年髋部骨折患者预后影响的研究进展[J/OL]. 中华老年骨科与康复电子杂志, 2024, 10(01): 51-56.
[6] 黄淑萍, 龚蓓, 申铁梅, 杨丹莉, 陈秀梅, 李国琪, 李星, 麦爱欢, 钟冰, 广东省护士协会心血管疾病护理分会, 南方心血管护理联盟. 心房颤动患者介入手术围术期护理专家共识[J/OL]. 中华介入放射学电子杂志, 2024, 12(01): 1-9.
[7] 田佳丽, 陈晓波. 卵圆孔未闭隧道特点对介入封堵术的影响因素分析[J/OL]. 中华介入放射学电子杂志, 2023, 11(04): 346-351.
[8] 付明鹏, 牛国栋, 岑志富, 乔宇, 郭金锐, 郭雨龙, 谢阳, 刘晨, 袁华苑, 刘可, 何姗姗. 三维标测系统指导下国产花瓣状脉冲电场消融系统应用一例[J/OL]. 中华心脏与心律电子杂志, 2024, 12(03): 180-184.
[9] 储慧民, 杜先锋. 心腔内超声心动图指导左心耳封堵的规范化标准流程[J/OL]. 中华心脏与心律电子杂志, 2024, 12(01): 1-5.
[10] 储慧民. 心腔内超声心动图指导下的左心耳封堵术标准流程解析[J/OL]. 中华心脏与心律电子杂志, 2024, 12(01): 58-58.
[11] 王慧俐, 张沛刚, 李军, 薛立新, 刘向阳, 冯小梅, 刘江, 李芳, 王海雄. 经心腔内超声心动图指导下左心耳封堵与无导线起搏器植入术一例[J/OL]. 中华心脏与心律电子杂志, 2023, 11(04): 238-241.
[12] 文明, 张丽, 谢芳, 艾克拜尔·艾力, 克力木·阿不都热依木. 构建胃食管反流病患者发生心房颤动的临床预测模型[J/OL]. 中华胃食管反流病电子杂志, 2024, 11(03): 130-136.
[13] 古丽尼格尔·吾布力, 印纹源, 冯艳, 买买提·依斯热依力, 克力木·阿不都热依木, 夏木西娅·哈德尔. 探讨胃食管反流病与心房颤动、酸反流及食管运动特征的相关性[J/OL]. 中华胃食管反流病电子杂志, 2024, 11(01): 31-36.
[14] 郑屹, 刘莹, 张煜坤, 李广平, 陈康寅, 刘彤. 既往及新发心房颤动对急性心肌梗死患者远期卒中风险的影响[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 406-417.
[15] 李芳, 戴西望, 王凯, 郭廷昊, 涂江龙. 非瓣膜性心房颤动相关性卒中的治疗研究进展[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(04): 393-397.
阅读次数
全文


摘要