经食道超声对不同形状左心耳封堵即时效果的若干指标分析

发布时间：2018-03-28 08:35

  本文选题：经食道超声心动图　切入点：左心耳封堵术　出处：《南方医科大学》2017年硕士论文

【摘要】：背景:左心耳封堵术(left atrial appendage closure,LAAC)是近年来国内外针对非瓣膜性房颤患者预防脑卒中的研究热点。左心耳(left atrial appendage,LAA)形态结构复杂,且存在明显的个体差异,临床上将左心耳分为菜花型、鸡翅型、风向标型、仙人掌型四种类型,不同形态左心耳因解剖差异,需要不同的植入策略。经食道超声心动图(transesophageal echocardiography,TEE)不仅用于术前筛查,术中指导,对LAAC手术即时效果评价的更具有重要价值。目前,关于不同形状左心耳行LAAC即时效果差异性的研究较少,本文的目的在于通过TEE对LAAC即时效果相关指标的评价,分析不同形状左心耳封堵术即时效果相关指标的差异,进一步探讨该相关指标对LAAC的临床意义。方法:纳入2013年1月至2016年12月我院和外院行Watchman左心耳封堵术47例,术前对左心耳进行TEE评估,记录左心耳形状、分叶数、不同角度切面(0°、45°、90°、135°)的开口最大直径及深度,术中在TEE指导下,结合TEE测得左心耳开口最大直径及透视下开口最大直径,选择合适大小的封堵器,完成手术,记录即时效果相关指标(露肩值、封堵器压缩比、封堵器周边残余分流宽度、封堵器大小)。分析不同形态左心耳封堵即时效果相关指标是否存在差异;对比不同形状左心耳TEE测值和透视下测值对封堵器直径选择的参考价值。结果:1例因左心耳开口直径太大,选择Watchman最大直径封堵器未能完全封堵,另1例患者植入封堵器过程中出现心包积液未能成完成手术,其余45例(95.7%)患者均成功置入Watchman封堵器(男29例,女16例,平均年龄66.82±9.21岁),其中菜花型21例(46.7%),鸡翅型7例(15.6%),风向标型2例(4.4%),仙人掌型15例(33.3%);30例患者左心耳为多叶(66.7%),10例为双叶(22.2%),4例为单叶(8.9%),1例分叶数未能明确。1、不同形状左心耳行LAAC即时效果相关指标的差异露肩情况:14例(31.1%)患者出现封堵器露肩,露肩值均小于该例封堵器深度的1/3。其中菜花型出现5例露肩(35.7%)、鸡翅型0例、风向标型1例(7.1%)、仙人掌型8例(57.1%)。露肩值分别为菜花型(2±3.60)mm、鸡翅型(0)mm,风向标型(5±7.07)mm、仙人掌型(3.23±3.11)mm;不同形状左心耳的露肩情况及露肩值存在统计学意义,P值分别为(P=0.029)和(P=0.021),仙人掌型左心耳较鸡翅型、菜花型更易出现封堵器露肩,且仙人掌型左心耳露肩值较鸡翅型大。残余分流情况:12例(26.7%)出现残余分流,1例分流术宽度为5mm,1例为8mm,其余均≤3mm;菜花型出现5例(45.5%),风向标2例(18.2%),鸡翅型0例,仙人掌型4(36.4%),因为个别案例例数较少,P值无法计算。封堵器压缩比情况:最小压缩比(18.24±6.52)%,最大压缩比(25.76±6.07)%,不同形状LAA压缩比分别为:菜花型(21.55±7.32)%,鸡翅型(19.28±3.03)%,仙人掌型(21.37±7.97)%,P=0.784,不同形状左心耳行LAAC的封堵器压缩比无统计学差异(P0.05)。封堵器大小:菜花型(28.71±3.09)mm,鸡翅型(26.57±2.07)mm,风向标型(31.50±2.12)mm,仙人掌型(28.4±2.97)mm,P=0.176。不同形状左心耳行LAAC的封堵器大小无统计学相关。2、其他1)封堵器大小选择参考:TEE对左心耳四个角度测量的直径(P=0.391)及深度(P=0.896)无统计学差异;仙人掌型左心耳90度切面测值(r=0.659,P=0.008)对比透视下测值(r=0.361,P=0.38),对选择封堵器大小的参考意义更大;鸡翅型(r=l,P=0.000)和菜花型(r=0.779,P=0.008)左心耳透视下测值较TEE更有参考意义。2)LAA分叶数与封堵器露肩(r=0.069,P=0.672),残余分流(r=0.551,P=0.1),封堵器压缩比(r=0.283,P=0.1),封堵器大小(r=0.099,P=0.528)均无统计学意义相关。3)残余分流与封堵器压缩比无统计学相关(r=0.115,P=0.512)。结论:1、不同形状左心耳封堵的露肩情况存在差异,而封堵器压缩比、残余分流无统计学差异,仙人掌型较鸡翅型、菜花型LAA更易出现露肩,仙人掌型LAA露肩值较鸡翅型LAA更大。2、鸡翅型和菜花型LAA透视下测值较TEE测值参考价值更大,仙人掌型LAA在TEE90度切面测值较透视下测值参考价值更大。3、左心耳分叶数与封堵术即时效果相关指标无统计学相关,封堵器压缩比与残余分流无统计学相关。
[Abstract]:Background: left atrial appendage occlusion (left atrial appendage closure, LAAC) is a hot research at home and abroad for patients with non valvular atrial fibrillation and stroke prevention in recent years. The left atrial appendage (left atrial appendage, LAA) structure is complex, and there are obvious individual differences, clinically divided into left heart ear cauliflower, chicken wings vane type, type, type of cactus four types, different forms of left atrial appendage because of anatomical differences need to implant different strategies. Transesophageal echocardiography (transesophageal, echocardiography, TEE) is not only used for preoperative screening, intraoperative guidance, evaluation of the LAAC operation instant effect has more important value. At present, the research on the difference the shape of left atrial appendage LAAC immediate effect of less, the purpose of this paper is to evaluate the effect of TEE on LAAC by instant related indicators, analysis of the relevant indicators of the different shape of left atrial appendage occlusion and instant effects. The difference, to further explore the clinical significance of the related indexes of LAAC. Methods: from January 2013 to December 2016 in our hospital and underwent left atrial Watchman occlusion of left atrial appendage in 47 cases, TEE preoperative assessment, left atrial appendage shape records, leaf number, different section angle (0 degrees, 45 degrees, 90 degrees. 135 degrees) opening of the maximum diameter and depth, under the guidance of TEE during the operation, combined with the TEE measured the maximum diameter of the left atrial appendage opening under fluoroscopy and opening diameter, select the appropriate size of the occluder, complete the operation, record relevant indicators of immediate effect (Strapless value, occluder compression ratio, occluder around the residual shunt width, the size of occluder). Analysis of whether there are differences between the related indexes of different forms of left atrial appendage occlusion immediate effect; comparison of different shapes of left atrial appendage TEE value under fluoroscopy to measuring value of occluder diameter selection of reference value. Results: 1 cases with left atrial diameter is too large, 閫夋嫨Watchman鏈，

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