实时三维经食管超声心动图在非瓣膜病心房颤动患者经导管左心耳ACP封堵术中的临床应用

Clinical implication of real-time three-dimensional transesophageal echoeardiography in percutaneous transcatheter left atrial appendage closure with Amplatzer Cardiac Plug （ACP） device for non-valvular atrial fibrillation patients

目的评价实时三维经食管超声心动图（RT-3DTEE）在非瓣膜病心房颤动患者经导管左心耳ACP封堵术中的应用价值。方法应用二维经食管超声心动图（2DTEE）及RT-3DTEE测量入选患者左心耳口部及颈部直径，观察左心耳口部及颈部形态、小叶分布，并在2D-TEE及RT-3DTEE全程引导下行经导管左心耳ACP封堵术。结果15例患者全部手术成功。术中2D-TEE测量左心耳开口最大径为（20．5±2．9）mm，位于135°；颈部直径分别为45°（17．1±2．8）mm，90°（18．0±4．0）mm，135°（22．1±4．7）mm。RT-3DTEE观察：左心耳形态：单叶2例，多叶13例，其中双叶短颈2例；菜花型6例，风向标型2例，鸡翅型3例．仙人掌型2例，复合型2例。左心耳近端形态：靴型3例，宽口型2例，窄口型6例，直筒型2例，双叶短颈型2例。所有患者术后封堵器边缘均无明显残余漏。结论在经导管左心耳ACP封堵术中，RT-3DTEE在术前病例筛选及指导封堵器型号选择、术中全程实时引导、术后疗效评估等方面均具有重要的应用价值。

Objective To evaluate the application value of real-time three-dimensional echocardiography （RT-3D TEE） in nonvalvular atrial fibrillation patients after transcatheter left atrial appendage closure （LAAC） with the Amplatzer Cardiac Plug （ACP）. Methods The two-dimensional transesophageal echocardiography （2D TEE） and RT-3D TEE were performed in selected patients to measure the diameter of left atrial appendage ostium and landing zone, to observe left atrial appendage morphology and lobular distribution. These were also performed to guide the whole process of transcatheter LAAC with ACP, which included the atrial septal puncture, sheathing canal cruise, occluder device implantation,and verifying the stability of occluder device and releasing the device. It involved observing ACP occluder morphology, location, stability, surrounding residual shunt, whether influencing the mitral valve and left superior pulmonary vein flow, and pericardial effusion. Results A total of 15 patients （100%） successfully underwent LAAC with the ACP. The maximum diameter of left atrial appendage ostium by 2D TEE measurement during operation was （20.5± 2.9）mm, located at 135°. The diameter of left atrial appendage landing zone was （17.1 ± 2.8） ram, located at 45° （18.0 ± 4.0） mm, located at 90°; （22.1 ± 4.7）mm, located at 135°, respectively. The left atrial appendage morphology：2 had one leaf and 13had two leaves or more, including 2 cases of bifoliate short neck shape. In 15 patients, 6 cases of cauliflower type, 2 cases of wind sock type,3 cases of chicken wing type, 2 cases of cactus type and 2 cases of complex type. The proximal left atrial appendage morphology：3 cases of boot type, 2 cases of wide mouth type, 6 cases of narrow mouth type, 2 cases of straight tube type, and 2 cases of bifoliate short neck type. There was no obvious residual shunt in all the patients at immediately post-operation. Conclusions In the transcatheter LAAC with the ACP, RT-3D TEE has important application value in the preoperative selection of patients, the choice of appropriate occluder, guidance of full-process monitoring during operation, the postoperative effect evaluation and so on.