经食道超声心动图结合声学造影对卵圆孔未闭的评估价值
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南京医科大学第一附属医院心脏科

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国家自然基金面上项目(编号:82270362):PLEKHG2Q1192X截短突变激活FHL1/Rac1信号致肥厚型心 肌病的机制研究


Value of saline contrast transesophageal echocardiography in the evaluation of patent foramen ovale
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Nanjing Medical University,the Heart department of the First Affiliated Hospital,Jiangsu Nanjing

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    摘要:

    目的:对比研究经胸超声心动图(transthoracic echocardiography,TTE)及经食道超声心动图(transesophageal echocardiography, TEE)结合声学造影对卵圆孔未闭(patent foramen ovale,PFO)右向左分流的评估价值,提出最佳诊断策略。 方法:回顾性纳入2020年2月至2022年2月南京医科大学第一附属医院心血管内科收治的186例隐源性卒中(cryptogenic stroke,CS)、短暂性脑缺血发作(transient ischemic attack,TIA)、偏头痛的患者,并经食道超声心动图或心导管检查证实为PFO的患者进行研究。分别进行经胸超声心动图下声学造影(contrast transthoracic echocardiography,cTTE)及经食道超声心动图下声学造影(contrast transesophageal echocardiography, cTEE)。另外在cTEE下配合患者自主Valsalva动作增加一次检查者握拳放置患者腹部按压放松的操作,分别观察3个心动周期内左房左室内微气泡出现的数量,评估房间隔水平右向左分流程度。 结果:静息时cTTE检测到右向左分流(right-to-left shunt,RLS)的有 135例,cTEE检测到RLS的有 140例。 Valsalva动作下,cTTE检测到RLS的有 186例,cTEE检测到RLS的有 186例,提示Valsalva动作时无论cTTE还是cTEE方法的PFO-RLS检查率均有显著提升。在检出右向左分流的PFO患者,cTTE中I级27 例;II级31例;III级128 例;cTEE中I级 80 例;II级 56 例;III级 50 例,其中 110例患者RLS程度cTTE高于cTEE,其中46例cTTE时III级,cTEE时II级;43例cTTE时III级,cTEE时I级;21例cTTE时II级,cTEE时I级。59例患者在cTTE和cTEE间发生相同程度的RLS, 仅17例患者cTTE下RLS的程度低于cTEE。cTEE下进行Valsalva动作时,同时配合检查者握拳放置腹部按压放松时,RLS I级 35例,II级 46例,III 级105例,有76例患者RLS等级提升,其中有 21例患者从I级提升到II级, 24例患者从I级提升到III级,31例患者从II级提升到III级,中-大量分流患者的比例显著提升。 结论:对卵圆孔未闭患者的右向左分流程度(PFO-RLS),cTTE静息状态下及Valsalva动作下检出率与cTEE无明显差异,但检出分流程度高于cTEE;但cTEE时,患者在自主Valsalva动作下,配合检查者握拳放置患者腹部按压放松,可以显著提升PFO患者右向左分流程度。同时结合经食道超声心动图对PFO解剖结构形态诊断结果诊断,对PFO治疗及封堵术前评估有较大价值。

    Abstract:

    Objective Comparative study of value of saline contrast transthoracic echocardiography and transesophageal echocardiography in right-to-left shunt of patent foramen ovale (PFO), and evaluation of the optimal diagnostic strategy. Methods A retrospective study was conducted on 186 patients admitted the cardiovascular department of the First Affiliated Hospital of Nanjing Medical University from February 2020 to February 2022 with cryptogenic stroke (CS), transient ischemic attack (TIA) and migraine who were confirmed to have a patent foramen ovale (PFO) through transesophageal echocardiography or cardiac catheterization. Both transthoracic echocardiography (cTTE) and transesophageal echocardiography (cTEE) were performed. In addition, during cTEE, the operator clenched their fist and placed it on the patient's abdomen, applying pressure and then releasing it, while the patient performed a Valsalva maneuver. The number of microbubbles appearing in the left atrium and left ventricle within three cardiac cycles was observed to assess the degree of right-to-left shunting at the level of the interatrial septum. Results During rest, cTTE detected 135 cases of right to left shunting (RLS), while cTEE detected 140 cases of RLS. During the Valsalva maneuver, cTTE detected 186 cases of RLS, and cTEE also detected 186 cases of RLS, indicating a significant increase in the detection rate of PFO-RLS during the Valsalva maneuver compared to the rest state, regardless of the cTTE or cTEE method. Among the patients with detected right to left shunting PFO, cTTE classified 27 cases as grade I, 31 cases as grade II, and 128 cases as grade III. On the other hand, cTEE classified 80 cases as grade I, 56 cases as grade II, and 50 cases as grade III. Among these cases, 110 patients had a higher RLS degree in cTTE compared to cTEE, with 46 cases being grade III in cTTE and grade II in cTEE, 43 cases being grade III in cTTE and grade I in cTEE, and 21 cases being grade II in cTTE and grade I in cTEE. 59 patients had the same degree of RLS detected in both cTTE and cTEE. Only 17 cases had a lower degree of RLS shunting in cTTE compared to cTEE. During the Valsalva maneuver with cTEE, while the operator clenched their fist and applied pressure on the patient's abdomen and then released it, 35 cases were classified as grade I, 46 cases as grade II, and 105 cases as grade III. 76 patients had an increase in RLS grade, including 21 patients who upgraded from grade I to grade II, 24 patients who upgraded from grade I to grade III, and 31 patients who upgraded from grade II to grade III. The proportion of patients with moderate to large shunting significantly increased.Conclusion The detection rates of right-to-left shunt degree in patients with patent foramen ovale (PFO-RLS) using contrast transthoracic echocardiography (cTTE) at rest and during Valsalva maneuver showed no significant difference compared to contrast transesophageal echocardiography (cTEE), but the detection of shunt degree was higher with cTEE. However, during cTEE, when patients performed the Valsalva maneuver and the operator applied abdominal pressure by making a fist and relaxing, the right-to-left shunt degree in PFO patients could be significantly increased. Combined with transesophageal echocardiography, it has great value in diagnosing the anatomical structure and morphology of PFO and assessing PFO treatment and closure procedures.

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  • 收稿日期:2023-05-23
  • 最后修改日期:2023-08-23
  • 录用日期:2023-10-25
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