双源CT在左心耳封堵术前评估及指导选择Watchman^(TM)封堵器型号的应用

Application of Dual Source CT in Preoperative Evaluation of Left Atrial Appendage Occlusion and Size Selection of Watchman^(TM) Occluder

目的比较双源CT(DSCT)、经食管超声心动图检查(TEE)和左心耳造影在左心耳封堵术(LAAO)中的评估结果,研究DSCT指导LAAO的应用价值。方法回顾性分析接受LAAO的78例心房颤动患者,比较术前DSCT及TEE对左心耳(LAA)血栓的检出率,分析术前DSCT、术中TEE及LAA造影三者评估LAA最大开口和长度,预测Watchman^(TM)封堵器型号的准确率以及它们之间的相关性。结果当DSCT增加60 s延迟显像时,与TEE的血栓检出率差异无统计学意义(P>0.05),DSCT诊断血栓的敏感性为100%,特异性为98.6%,阳性预测率为80%,阴性预测率为100%,与TEE诊断血栓一致性的Kappa值为0.88(P<0.01);DSCT、TEE与LAA造影测量LAA最大开口的差异无统计学意义(P>0.05),其测量最大开口分别为(23.07±4.21)mm、(22.87±3.70)mm和(22.52±3.76)mm,并且DSCT与TEE和LAA造影测量结果之间都有显著的相关性及一致性[rTEE=0.812,P<0.01,组内相关系数(ICC)=0.89(0.83~0.93);rLAA造影=0.802,P<0.01,ICC=0.88(0.82~0.93)];三种方法所预测的封堵器大小分别为DSCT:(26.92±3.94)mm、TEE:(26.88±3.73)mm和LAA造影:(26.96±3.73)mm,与实际植入大小(27.81±3.69)mm均具有显著的相关性及一致性[rDSCT=0.886,P<0.01,ICC=0.94(0.90~0.96);rTEE=0.849,P<0.01,ICC=0.92(0.87~0.95);rLAA造影=0.924,P<0.01,ICC=0.96(0.94~0.98)];在心耳最大长度测量方面[DSCT:(27.22±4.72)mm、TEE:(25.76±4.58)mm和LAA造影:(24.12±3.88)mm],三种方法的结果具有统计学差异(P<0.05),DSCT对LAA长度测量结果大于TEE与LAA造影。结论在LAAO治疗中,DSCT可在术前检出患者的LAA血栓,评估患者的手术适应证,同时准确测量心耳开口大小及长度,为预选封堵器型号提供重要的参考价值。

Objective To compare detection results of dual source computed tomography(DSCT),trans-esophageal echocardiography(TEE)and left atrial appendage angiography and investigate application value of DSCT in guiding left atrial appendage occlusion(LAAO).Methods A retrospective analysis was performed on 78 patients with atrial fibrillation who planned to undergo LAAO.LAA thrombosis detection rates from DSCT and TEE were compared before the operation.Accuracies of LAA maximal orifice diameter,length,size prediction of Watchman^(TM) occluder detected by preoperative DSCT,intraoperative TEE and LAA angiography and their correlations were assessed.Results When image delay of DSCT was increased by 60 s,there was no significant difference in thrombus detection of DSCT and TEE(P>0.05).The sensitivity,specificity,positive predictive value and negative predictive value of LAA thrombus diagnosed by DSCT were 100.0%,98.6%,80.0%and 100.0%respectively,and the Kappa value representative of diagnostic consistency with TEE was 0.88(P<0.01).The difference of LAA maximal orifice diameter measured by DSCT,TEE and LAA angiography was insignificant(P>0.05),with parallel maximal orifice diameter of(23.07±4.21)mm,(22.87±3.70)mm and(22.52±3.76)mm respectively.Results of DSCT were highly correlated and consistent with TEE and LAA angiography[rTEE=0.812,P<0.01,ICC=0.89(0.83~0.93);rLAA angiography=0.802,P<0.01,ICC=0.88(0.82~0.93)].The predicted sizes of WatchmanTM occluders were(26.92±3.94)mm for DSCT,(26.88±3.73)mm for TEE and(26.96±3.73)mm for LAA angiography respectively,which were markedly correlated and consistent with actual implant size of(27.81±3.69)mm[rDSCT=0.886,P<0.01,ICC=0.94(0.90~0.96);rTEE=0.849,P<0.01,ICC=0.92(0.87~0.95);rLAA angiography=0.924,P<0.01,ICC=0.96(0.94~0.98)].There exist statistical difference in LAA maximal lengths detected by three imaging modalities[(27.22±4.72)mm for DSCT,(25.76±4.58)mm for TEE and(24.12±3.88)mm for LAA angiography,P<0.05],of which LAA length detected by DSCT was larger than TEE and LAA angiography.Conclusion DSCT may help to detect LAA thrombus and assess indications before operation in LAAO treatment,as well as provide vital reference on size selection of WatchmanTM occluder by precisely measuring the size and length of auricular orifice.