本文選題：經(jīng)食道超聲心動圖　切入點：左心耳封堵術(shù)　出處：《南方醫(yī)科大學》2017年碩士論文

【摘要】：背景:左心耳封堵術(shù)(left atrial appendage closure,LAAC)是近年來國內(nèi)外針對非瓣膜性房顫患者預防腦卒中的研究熱點。左心耳(left atrial appendage,LAA)形態(tài)結(jié)構(gòu)復雜,且存在明顯的個體差異,臨床上將左心耳分為菜花型、雞翅型、風向標型、仙人掌型四種類型,不同形態(tài)左心耳因解剖差異,需要不同的植入策略。經(jīng)食道超聲心動圖(transesophageal echocardiography,TEE)不僅用于術(shù)前篩查,術(shù)中指導,對LAAC手術(shù)即時效果評價的更具有重要價值。目前,關(guān)于不同形狀左心耳行LAAC即時效果差異性的研究較少,本文的目的在于通過TEE對LAAC即時效果相關(guān)指標的評價,分析不同形狀左心耳封堵術(shù)即時效果相關(guān)指標的差異,進一步探討該相關(guān)指標對LAAC的臨床意義。方法:納入2013年1月至2016年12月我院和外院行Watchman左心耳封堵術(shù)47例,術(shù)前對左心耳進行TEE評估,記錄左心耳形狀、分葉數(shù)、不同角度切面(0°、45°、90°、135°)的開口最大直徑及深度,術(shù)中在TEE指導下,結(jié)合TEE測得左心耳開口最大直徑及透視下開口最大直徑,選擇合適大小的封堵器,完成手術(shù),記錄即時效果相關(guān)指標(露肩值、封堵器壓縮比、封堵器周邊殘余分流寬度、封堵器大小)。分析不同形態(tài)左心耳封堵即時效果相關(guān)指標是否存在差異;對比不同形狀左心耳TEE測值和透視下測值對封堵器直徑選擇的參考價值。結(jié)果:1例因左心耳開口直徑太大,選擇Watchman最大直徑封堵器未能完全封堵,另1例患者植入封堵器過程中出現(xiàn)心包積液未能成完成手術(shù),其余45例(95.7%)患者均成功置入Watchman封堵器(男29例,女16例,平均年齡66.82±9.21歲),其中菜花型21例(46.7%),雞翅型7例(15.6%),風向標型2例(4.4%),仙人掌型15例(33.3%);30例患者左心耳為多葉(66.7%),10例為雙葉(22.2%),4例為單葉(8.9%),1例分葉數(shù)未能明確。1、不同形狀左心耳行LAAC即時效果相關(guān)指標的差異露肩情況:14例(31.1%)患者出現(xiàn)封堵器露肩,露肩值均小于該例封堵器深度的1/3。其中菜花型出現(xiàn)5例露肩(35.7%)、雞翅型0例、風向標型1例(7.1%)、仙人掌型8例(57.1%)。露肩值分別為菜花型(2±3.60)mm、雞翅型(0)mm,風向標型(5±7.07)mm、仙人掌型(3.23±3.11)mm;不同形狀左心耳的露肩情況及露肩值存在統(tǒng)計學意義,P值分別為(P=0.029)和(P=0.021),仙人掌型左心耳較雞翅型、菜花型更易出現(xiàn)封堵器露肩,且仙人掌型左心耳露肩值較雞翅型大。殘余分流情況:12例(26.7%)出現(xiàn)殘余分流,1例分流術(shù)寬度為5mm,1例為8mm,其余均≤3mm;菜花型出現(xiàn)5例(45.5%),風向標2例(18.2%),雞翅型0例,仙人掌型4(36.4%),因為個別案例例數(shù)較少,P值無法計算。封堵器壓縮比情況:最小壓縮比(18.24±6.52)%,最大壓縮比(25.76±6.07)%,不同形狀LAA壓縮比分別為:菜花型(21.55±7.32)%,雞翅型(19.28±3.03)%,仙人掌型(21.37±7.97)%,P=0.784,不同形狀左心耳行LAAC的封堵器壓縮比無統(tǒng)計學差異(P0.05)。封堵器大小:菜花型(28.71±3.09)mm,雞翅型(26.57±2.07)mm,風向標型(31.50±2.12)mm,仙人掌型(28.4±2.97)mm,P=0.176。不同形狀左心耳行LAAC的封堵器大小無統(tǒng)計學相關(guān)。2、其他1)封堵器大小選擇參考:TEE對左心耳四個角度測量的直徑(P=0.391)及深度(P=0.896)無統(tǒng)計學差異;仙人掌型左心耳90度切面測值(r=0.659,P=0.008)對比透視下測值(r=0.361,P=0.38),對選擇封堵器大小的參考意義更大;雞翅型(r=l,P=0.000)和菜花型(r=0.779,P=0.008)左心耳透視下測值較TEE更有參考意義。2)LAA分葉數(shù)與封堵器露肩(r=0.069,P=0.672),殘余分流(r=0.551,P=0.1),封堵器壓縮比(r=0.283,P=0.1),封堵器大小(r=0.099,P=0.528)均無統(tǒng)計學意義相關(guān)。3)殘余分流與封堵器壓縮比無統(tǒng)計學相關(guān)(r=0.115,P=0.512)。結(jié)論:1、不同形狀左心耳封堵的露肩情況存在差異,而封堵器壓縮比、殘余分流無統(tǒng)計學差異,仙人掌型較雞翅型、菜花型LAA更易出現(xiàn)露肩,仙人掌型LAA露肩值較雞翅型LAA更大。2、雞翅型和菜花型LAA透視下測值較TEE測值參考價值更大,仙人掌型LAA在TEE90度切面測值較透視下測值參考價值更大。3、左心耳分葉數(shù)與封堵術(shù)即時效果相關(guān)指標無統(tǒng)計學相關(guān),封堵器壓縮比與殘余分流無統(tǒng)計學相關(guān)。
[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，

本文編號：1675562