经胸超声心动图结合右心声学造影在判断卵圆孔未闭右向左分流中的临床价值

Clinical values of transthoracic echocardiography combined with right heart contrast echocardiography in the right-to-left shunt of patent foramen ovale

目的探讨经胸超声心动图(transthoracic echocardiography,TTE)结合右心声学造影在判断卵圆孔未闭(patent foramen ovale,PFO)右向左分流中的临床应用价值。方法收集2013年1月至2016年12月在我院心血管内科和神经内科接诊的不明原因脑卒中和偏头痛患者373例(其中脑卒中患者121例,偏头痛252例),为进一步诊断有无PFO,均接受TTE和右心声学造影检查,其中103例进行了经食道超声心动图(transesophageal echocardiography,TEE)检查。结果 (1)在静息状态下,373例患者TTE结果显示22例合并有PFO;在TTE未检出PFO的351例患者中,103例患者同时接受了TEE检查,结果显示49例患者合并PFO。(2)右心声学造影检查结果显示:186例患者在Valsalva状态和剧烈咳嗽时存在不同程度的右向右向左分流检出率为49.87%。其中轻度右向左分流(Ⅰ级)69例;中度分流(Ⅱ级)70例;重度分流(Ⅲ级)47例。(3)TTE检测出22例PFO和TEE检测出49例PFO患者,右心声学造影均显示中度以上右向左分流。(4)59例TTE结合右心声学造影证实为中度以上右向左分流且MRI证实有脑梗塞灶的患者,均在TTE引导下成功进行了PFO介入封堵术,术后1个月复查经右心声学造影显示,55例在Valsalva和剧烈咳嗽状态下右向左分流消失,4例仍有少量右向左分流。结论 TTE结合右心声学造影不仅能清晰显示PFO右向左分流的存在,并可判断右向左分流程度,为PFO的临床治疗提供直接依据;同时还能作为PFO封堵术后临床随访的重要工具。

Objective To explore the clinical values of transthoracic echocardiography （TTE） combined with right heart contrast echocardiography in the diagnosis of patent foramen ovale （PFO） and to assess the efficacy of transcatheter closure in PFO. Methods Three hundred and seventy-three patients, including 121 cases with unexplained stroke and 252 cases with migraine, who admitted in the cardiological and neurological departments of our hospital from January 2013 to December 2016, and needed to further diagnose in the presence or absence of PFO, were recruited in this study. All patients underwent TTE and right heart contrast echocardiography, and 103 of them underwent transesophageal echocardiography （TEE） voluntarily. Results ① In the resting state, TTE in 373 patients showed 22 cases with PFO. Next, 103 cases of 351 patients with no PFO detected by TTE received TEE, and the results showed 49 patients with PFO. ② All patients also underwent right heart contrast echocardiography when examined with TTE. The results showed that 186 of 373 cases （49.87%） had varying degrees of right-to-left shunt under the condition of Valsalva maneuver or severe cough [69 cases with mild right-to-left shunt （gradeⅠ）, 70 cases with moderate shunt（grade Ⅱ） and 47 cases with severe shunt（grade Ⅲ）]. ③ And the examination also showed moderate or severe right-to-left shunts in both 22 cases with PFO confirmed by TTE and 49 cases with PFO confirmed by TEE. ④ Finally, 59 patients, having moderate or severe right-to-left shunts confirmed by TTE combined with right heart contrast echocardiography and focal cerebral infarction by MRI, underwent TTE-guided percutaneous transcatheter closure. Right heart contrast echocardiography after 1-month closure operation showed that 55 cases had no right-to-left shunts and 4 cases had mild shunts （grade Ⅰ） under the condition of Valsalva maneuver or severe cough. Conclusion The combination of TTE and right heart contrast echocardiography could not only show the extent of right-to-left shunt in PFO clearly and provide direct basis for PFO clinical treatment, but also be an effective follow-up method after PFO transcatheter closure. It has been an important tool in PFO diagnosis and follow-up examination after transcatheter closure.