经食管超声心动图在左心耳封堵术中的应用价值研究

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。

Application value of transesophageal echocardiography in left atrial appendage occlusion

ObjectiveTo 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. MethodsFifty-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. ResultsFifty-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. ConclusionsTEE 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.