改良右心声学造影与传统右心声学造影对照研究

目的比较改良右心声学造影与传统右心声学造影检测心内或心外右向左分流（RLS）的安全性、稳定性和有效性。 方法（1）显微镜下检测：2种右心声学造影方法[改良法：8 ml生理盐水（AS）＋1 ml静脉血＋1 ml空气；传统法：9 mlAS＋1ml空气]分别震荡10、20次后（AS10组、AS20组、ASb10组、ASb20组）显微镜下观察产生微泡大小、数目、红细胞形态；（2）临床实验：选取2014年4至12月四川省人民医院门诊及住院患者中临床怀疑有RLS者（隐源性脑卒中、短暂性脑缺血发作、先兆性偏头痛、仰卧呼吸-直立位低氧血症患者）32例。所有患者均采用2种右心声学造影方法分别震荡10、20次进行造影（AS10组、AS20组、ASb10组、ASb20组）。记录患者右心显影时间，观察RLS情况并进行半定量分析；监测患者造影前后血氧饱和度、血清间接胆红素浓度及尿胆原浓度。采用单因素方差分析比较各组产生微泡数目、大小及患者右心显影时间差异，进一步组间两两比较采用LSD-t检验；采用χ²比较各组患者RSL检出率差异，进一步组间两两比较采用χ²分割检验；采用秩和检验比较各组患者RLS半定量分析结果，进一步组间两两比较采用Nemenyi检验；采用配对t检验患者造影前后血氧饱和度、血清间接胆红素浓度及尿胆原浓度差异。 结果显微镜下观察，震荡次数越多，红细胞膜破坏越明显。ASb20组产生微泡数目最多，约为AS10组的4倍，且差异有统计学意义（t=14.180，P<0.01）；而各组产生微泡大小差异无统计学意义。32例患者中，改良右心声学造影法观测到RLS者22例（22/32，68.8%），传统右心声学造影法观测到RLS者18例（18/32，56.3%）。任意两组患者间RLS半定量分析结果差异均有统计学意义（ASb20组与AS10组、AS20组、ASb10组比较：χ²=13.567、11.646、9.001；Asb10组与AS10组、AS20组比较：χ²=9.125、2.589；AS20组与AS10组比较：χ²=8.127；P均<0.01）。所有患者造影前后血氧饱和度、血清间接胆红素浓度及尿胆原浓度差异均无统计学意义。 结论改良右心声学造影法是一种安全、稳定、高性价比的检查RSL的方法；改良右心声学造影法RLS的半定量评估及其与临床事件的关系尚需进一步研究。

A comparative study on modified right heart contrast echocardiography and traditional right heart contrast echocardiography

ObjectiveTo compare the safety, stability and effectiveness of modified right heart contrast echocardiography and traditional right heart contrast echocardiography in detection of intra- or extra-cardiac right to left shunt (RLS). Methods(1) Microscopic analysis: After agitating 10 times or 20 times (AS10, AS20, ASb10, ASb20), two right heart contrast agent (modified: 8 ml saline+ 1 ml blood+ 1 ml air; traditional: 9 ml saline+ 1 ml air) underwent the microscopic examination to compare the bubble size, bubble number and red blood cell morphology; (2) Clinical experiment: Thirty-two inpatients or outpatients suspected of RLS (cryptogenic stroke, transient ischemic attack, migraine with aura or platypnea-orthodeoxia syndrome) in Sichuan Provincial Hospital were selected. All patients underwent two right heart contrast echocardiography in which contrast agents had been agitated for 10 and 20 times (AS10, AS20, ASb10, ASb20). Monitor the right heart developing time, RLS and the oxygen saturation change were monitored and the RLS were semi-quantitatively analyzed. The indirect bilirubin and urobilinogen change after the contrast echocardiography were compared. ResultsMicroscopic analysis showed that red blood cell membrane damaged more seriously as the agitated times increased. ASb20 generated more bubbles and the number of bubbles was about 4 times of that of AS10 generated (t=14.180, P<0.01); but the bubble size difference was not significant. With the modified method, RLS were detected in 22 patients (68.8%, 22/32). With the traditional method, RLS were detected in 18 patients (56.3%, 18/32). The results of semi-quantitative analysis of RLS was significant different between any two groups (ASb20 vs. AS10, AS20, ASb10: χ²=13.567, 11.646 and 9.001, respectively; ASb10 vs. AS10, AS20: χ²=9.125 and 2.589; AS20 vs. AS10: χ²= 8.127; all P<0.01). The change of oxygen saturation, the indirect bilirubin and urobilinogen were not significant after the contrast echocardiography. ConclusionsModified right heart contrast echocardiography is a safe, stable and cost-effective method to detect RLS. The semi-quantitative analysis of RLS with modified right heart contrast echocardiography and their relationship with clinical accident needs further research.