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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） ›› 2024, Vol. 21 ›› Issue (02) : 107 -113. doi: 10.3877/cma.j.issn.1672-6448.2024.02.001

心血管超声影像学

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
张胜男1, 苗雅敬1, 周虹1, 韩高洁1, 王静1, 仝巧立1, 张旭倩1, 尹洪宁1,†()   
  1. 1. 050000　石家庄，河北医科大学第二医院心脏超声科
  • 收稿日期:2023-09-01 出版日期:2024-02-01
  • 通信作者: 尹洪宁

Correlation between three-dimensional transesophageal ultrasound measurement of left atrial appendage and size of Watchman left atrial appendage closure device

Shengnan Zhang1, Yajing Miao1, Hong Zhou1, Gaojie Han1, Jing Wang1, Qiaoli Tong1, Xuqian Zhang1, Hongning Yin1,†()   

  1. 1. Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
  • Received:2023-09-01 Published:2024-02-01
  • Corresponding author: Hongning Yin
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引用本文：

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]. 中华医学超声杂志（电子版）, 2024, 21(02): 107-113.

Shengnan Zhang, Yajing Miao, Hong Zhou, Gaojie Han, Jing Wang, Qiaoli Tong, Xuqian Zhang, Hongning Yin. Correlation between three-dimensional transesophageal ultrasound measurement of left atrial appendage and size of Watchman left atrial appendage closure device[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2024, 21(02): 107-113.

目的

探讨三维经食管超声心动图（3D-TEE）测量心房颤动患者的左心耳口内径参数与Watchman左心耳封堵器大小之间的相关性。

方法

选取2020年6月至2022年6月于河北医科大学第二医院心血管内科拟行Watchman左心耳封堵术的75例非瓣膜性心房颤动患者，并在术前48 h内完成TEE检查，测量二维TEE 0°、45°、90°及135°左心耳口内径，三维TEE左心耳开口最大值与最小值、左心耳周长导出直径（PDD）、左心耳面积导出直径（ADD），与术中植入的左心耳封堵器型号、封堵后封堵器平均直径进行Spearman相关及线性回归分析。

结果

75例患者成功植入Watchman左心耳封堵器，并完成术后3、6个月TEE随访。在术前TEE检查中，左心耳排空速度减低（速度<40 cm/s）组的左心耳开口内径大于左心耳排空速度正常（速度≥40 cm/s）组（P均<0.001）。在二维TEE各切面测量中，135°切面测量的左心耳开口最大[（19.73±3.62）mm]，而三维TEE测量的左心耳开口最大值[（22.52±3.88）mm]大于二维TEE左心耳参数。在术中及术后TEE随访中，出现并发症17例（17/75，22.60%）。经分析，左心耳内径二维TEE 0°、45°、90°、135°测值，三维TEE最大值与最小值和三维TEE-ADD、三维TEE-PDD与释放后封堵器平均直径呈正相关，其中三维TEE-PDD与释放后封堵器平均直径相关程度最高（rs =0.614、0.660、0.660、0.704、0.770、0.624、0.812、0.825，P均<0.001）。左心耳内径二维TEE 0°、45°、90°、135°测值，三维TEE最大值与最小值和三维TEE-ADD、三维TEE-PDD与封堵器型号呈正相关，其中三维TEE-PDD与封堵器型号相关程度最高（rs =0.596、0.683、0.606、0.725、0.788、0.670、0.823、0.836，P均<0.001）。三维TEE-PDD作为自变量，封堵器平均直径作为因变量，得到线性回归方程：封堵器平均直径=0.663PDD+6.337。

结论

术前TEE测量左心耳口内径对于Watchman左心耳封堵器型号选择具有非常重要的指导价值，尤其是三维TEE-PDD与封堵器型号相关性最好，可能更有助于指导术前Watchman左心耳封堵器型号选择。

关键词: 心房颤动, 三维经食管超声心动图, 左心耳封堵
Objective

To explore the correlation between the left atrial appendage orifice diameter parameters measured by three-dimensional transesophageal echocardiography (3D-TEE) and the size of the Watchman left atrial appendage occluder in patients with atrial fibrillation.

Methods

Seventy-five patients with non-valvular atrial fibrillation who were scheduled to undergo Watchman left atrial appendage occlusion at the Department of Cardiovascular Medicine of the Second Hospital of Hebei Medical University from June 2020 to June 2022 were selected, and TEE examinations were completed within 48 hours before the operation. The inner diameter of the left atrial appendage at 0°, 45°, 90°, and 135° sections was measured by two-dimensional (2D) TEE. The maximum and minimum values of the left atrial appendage opening, the left atrial appendage perimeter derived diameter (PDD), and the left atrial appendage area derived diameter (ADD) were measured by 3D-TEE. Spearman correlation and linear regression analyses were performed between the above parameters and the model of left atrial appendage occluder implanted during the operation and the average diameter of the occluder after occluding.

Results

All the patients were successfully implanted with a Watchman left atrial appendage occlusion device and completed TEE follow-up at 3 and 6 months after surgery. In the preoperative TEE examination, the inner diameter of the left atrial appendage opening in the group with reduced left atrial appendage emptying velocity (<40 cm/s) was larger than that of the group with normal left atrial appendage emptying velocity (≥40 cm/s). In the measurement of each section of 2D-TEE, the opening of left atrial appendage measured at 135° section was the largest, while the maximum opening of left atrial appendage measured by 3D-TEE was greater than that of 2D-TEE. During intraoperative and postoperative TEE follow-up, 17 cases (17/75, 22.60%) had complications. Spearman correlation analysis showed that the inner diameter of the left atrial appendage measured by 2D-TEE at 0°, 45°, 90°, and 135° sections as well as the maximum and minimum values of of the left atrial appendage opening, ADD, and PDD measured by 3D-TEE were positively correlated with the average diameter of the device after release, among which PDD had the highest correlation with the average diameter of the device after release (rs=0.614, 0.660, 0.660, 0.704, 0.770, 0.624, 0.812, and 0.825, respectively, P<0.001). The inner diameter of the left atrial appendage measured by 2D-TEE at 0°, 45°, 90°, and 135° sections as well as the maximum and minimum values of of the left atrial appendage opening, ADD, and PDD measured by 3D-TEE were positively correlated with the size of device (rs=0.596, 0.683, 0.606, 0.725, 0.788, 0.670, 0.823, and 0.836, respectively, P<0.001). When using PDD as the independent variable and the average diameter of the device after release the dependent variable, the following linear regression equation was obtained: the average diameter of the device after release = 0.663PDD+6.337.

Conclusion

Preoperative TEE measurement of the inner diameter of the left atrial appendage opening has very important guiding value in the selection of the size of the Watchman left atrial appendage closure device. Especially, PDD obtained by three-dimensional TEE has the best correlation with the device size, and may be more helpful to guide the size selection of Watchman left atrial appendage closure device before the procedure.

Key words: Atrial fibrillation, Three-dimensional transesophageal echocardiography, Left atrial appendage occlusion
图1 二维经食管超声心动图从0°、45°、90°和135°四个不同角度测量左心耳口内径 注：LCX为左冠状动脉回旋支；LAA为左心耳
图2 Q-LAB 3DQ软件对经食管超声心动图三维左心耳图像进行后处理分析，测量最大径、最小径、左心耳口面积和周长
图3 经食管超声心动图示左心耳封堵术后并发症。图a为X-plane显示左心耳封堵器血栓；图b示左心耳封堵器残余分流；图c示左心耳封堵术后少量心包积液
表1 75例Watchman左心耳封堵术患者的术前超声心动图参数（）
超声参数 全部患者（n=75） 左心耳排空速度≥40 cm/s（n=34） 左心耳排空速度<40 cm/s（n=41） P值
左心耳排空速度（cm/s） 43.92±24.34 65.00±21.04 26.44±6.37 -
左心房前后径（mm） 40.39±5.56 37.71±4.43 42.61±5.46 <0.001
左心室舒张末期内径（mm） 48.08±5.09 46.38±4.23 49.49±5.35 <0.001
E/e' 14.51±5.34 13.62±4.20 15.24±6.09 0.19
三尖瓣流速压差（mmHg） 29.55±7.81 27.88±5.90 30.82±8.87 0.16
LVEF（%） 60.51±8.99 62.15±7.81 59.16±9.75 0.15
LAA0°内径（mm）* 19.56±3.23 18.42±3.09 20.45±3.11 <0.001
LAA45°内径（mm） 18.65±2.92 17.38±2.51 19.71±2.84 <0.001
LAA90°内径（mm） 18.49±3.08 16.88±2.43 19.83±2.94 <0.001
LAA135°内径（mm） 19.73±3.62 17.91±2.96 21.24±3.46 <0.001
LAA3D最大内径（mm） 22.52±3.88 20.79±3.60 23.95±3.54 <0.001
LAA3D 最小内径（mm） 18.60±3.12 17.18±2.41 19.78±3.19 <0.001
LAA3D-ADD（mm） 24.77±3.93 22.88±3.21 26.34±3.81 <0.001
LAA3D-PDD（mm） 24.91±2.54 23.38±2.76 26.84±4.23 <0.001
表2 封堵器尺寸与左心耳各种测量内径的Spearman相关性分析（n=75）
相关性分析结果 封堵器尺寸与ADD 封堵器尺寸与PDD 封堵器尺寸与三维最大内径 封堵器尺寸与三维最小内径 封堵器尺寸与二维各角度测量内径
0° 45° 90° 135°
rs值 0.812 0.825 0.788 0.670 0.596 0.683 0.606 0.725
P值 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
表3 封堵器平均直径与左心耳各种测量内径的Spearman相关性分析（n=75）
相关性分析结果 封堵器平均直径与ADD 封堵器平均直径与PDD 封堵器平均直径与三维最大内径 封堵器平均直径与三维最小内径 封堵器平均直径与二维各角度测量内径
0° 45° 90° 135°
rs值 0.823 0.836 0.770 0.670 0.614 0.660 0.597 0.704
P值 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
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