平面CT及三维重建术前指导选择Watchman左心耳封堵器的对比研究

Clinical value of plane computed tomography and three-dimensional segmented CT reconstruction for the guidance of left atrial appendage closure：a comparative study of Watchman device selection

目的 比较平面计算机断层扫描（CT）和CT三维重建（CT-3D）左心耳（LAA）锚定区测值差异,并评估两者在Watchman左心耳封堵术中的应用价值.方法 宁波市第一医院2014年10月至2016年7月77例非瓣膜性心房颤动（房颤）患者左心耳封堵术前行左心耳CT血管成像（CTA）检查及经食管超声心动图检查（TEE）,采用平面CT（CT-P）于水平、冠状、矢状面测量左心耳锚定区内径和深度,并利用CT三维重建后测量左心耳锚定区最大径和深度,比较CT-P与CT-3D锚定区最大径及深度测值间差异及相关性.对封堵成功的患者,比较CT-P、CT-3D与X线左心耳造影（LAA-A）锚定区最大径及封堵器大小之间的相关性.结果77例患者均顺利完成左心耳CTA检查,封堵成功73例（73/77）,失败4例（4/77）.CT-P水平、冠状、矢状面锚定区内径分别为（21.1±4.8） mm、（20.7±4.4） mm、（18.4±4.5） mm,CT-P锚定区最大径为（22.5±4.3） mm、深度为（28.3±7.9） mm;CT-3D锚定区最大径为（25.6±4.7） mm,深度为（32.5±7.5） mm.术中LAA-A锚定区内径为（22.4±3.9） mm,成功植入封堵器的大小为（27.6±3.2） mm.Pearson相关分析：CT-P 与CT-3D锚定区最大径间相关性（r=0.748）优于两者深度间相关性（r=0.564）,CT-P锚定区最大径与术中LAA-A测值及封堵器大小的相关系数分别为0.476、0.492（P=0.000）,CT-3D锚定区最大径与术中LAA-A测值及封堵器大小的相关系数分别为0.600、0.632（P=0.000）.术中LAA-A测值与最终选择的封堵器型号之间相关性最好（r=0.750, P=0.000）.CT-3D锚定区最大径测值大于CT-P最大径及LAA-A测值（P〈0.01）.结论 CT三维重建锚定区内径测值大于平面CT最大径及X线左心耳造影内径测值,且CT三维重建左心耳锚定区最大径与X线造影测值及封堵器型号的相关性优于平面CT测值,对Watchman封堵器型号的选择更具有指导意义.

Objective To explore the clinical value of plane computed tomography（CT-P） and three-dimensional segmented CT reconstruction（CT-3D） before the left atrial appendage closure（LAAC） procedure by comparing the measurement of LAA and the size of Watchman device. Methods Seventy-seven atrial fibril-lation patients before LAAC procedure were taken a LAA CTA examination,and the data of the LAA ostium inner diameter and depth of horizontal,coronal and digital plane by CT-P were acquired,and the maximal and the minimal dimensions of LAA landing zone on CT-3D views were measured. The measurements by CT-P and CT-3D were compared and the difference and correlation were evaluated. Then the maximum diameters of CT-P and CT-3D were compared with LAA angiography （LAA-A） diameter and the sized Watchman device. Results Seventy-three（73/77） atrial fibrillation patients achieved successful LAA occlusion with Watchman device and 4（4/77） cases failed. LAA landing zone inner diameters of horizontal,coronal and sagittal plane by CT-P were （21.1±4.8） mm,（20.7±4.4） mm and （18.4±4.5） mm respectively. The maximal LAA landing zone dimension of CT-P was （22.5±4.3） mm. The depth was （28.3±7.9） mm. The maximal dimension of CT-3D was （25.6±4.7） mm and the maximal depth was （32.5±7.5） mm. LAA landing zone diameter of LAA-A and the size of closure were （22.4 ± 3.9） mm and （27.6 ± 3.2） mm. Pearson correlation analysis showed that the correlation of LAA landing zone diameters between CT-P and CT-3D （r=0.748） were better than that of depth （r=0.564）. Correlation between the LAA landing zone maximum diameters by CT-P to LAA-A and the sized device were 0.476 and 0.492 （P=0.000）. Correlation between the LAA landing zone maximum diameter by CT-P to LAA-Aand the size of device were 0.600 and 0.632 （P=0.000）. Correlation between LAA-A and the size of device was most relative（r=0.750,P=0.000）. The maximal dimension of CT-3D was bigger than the measurements of CT-P maximum and LAA-A （P〈0.01）. Conclusions LAA landing zone maximal dimension of CT-3D was bigger than the measurements of CT-P maximum and LAA-A. Compared to CT-P,CT-3D had better correlation to the measurements of LAA-A and the size of device. Therefore,the guidance of CT-3D maybe be more accurate before LAAC for proper selection of watchman device.