实时三维经食道超声心动图联合右心造影评估成人卵圆孔未闭的临床应用价值

Clinical application value of contrast-enhanced real-time three-dimensional transesophageal echocardiography in evaluating patent foramen ovale of adult patients

目的:探讨实时三维经食道超声心动图联合右心造影评估成人卵圆孔未闭(PFO)的临床应用价值。方法:回顾性分析2018年11月至2020年8月就诊于武汉大学中南医院神经内科诊断为隐源性卒中(CS)住院患者112例(CS组),纳入同期入院排除CS患者100例(非CS组),所有患者均行经胸右心声学造影(c-TTE)、经食道二维超声心动图(TEE)及实时经食道三维超声心动图(RT-3DTEE),同时对患者行右心声学造影检查。对比TEE、RT-3DTEE测量PFO直径及隧道长度的差异性,比较c-TTE、经食道超声心动图联合右心造影(c-TEE)、三维经食道超声心动图联合右心造影(c-RT-3DTEE)对右向左分流(RLS)的半定量分级,应用c-RT-3DTEE技术评估PFO直径、隧道长度及RLS分级与CS的相关性。结果:(1)CS组与非CS组在一般临床资料方面没有统计学差异。(2)c-TTE、TEE联合右心造影、RT-3DTEE联合右心造影对PFO检出率及超声特征比较:c-TTE阳性率58.5%(124/212),c-TEE和c-RT-3DTEE分别为56.6%(120/212)及70%(142/212),c-RT-3DTEE对RLS的检出率高于c-TEE(P=0.028);c-RT-3DTEE对RLS分流1级及2级分流量判定高于c-TTE及c-TEE(P=0.001);RT-3DTEE测量PFO直径显著大于TEE[(2.3±1.0)mm vs(1.9±0.8)mm,P<0.001]。(3)RT-3DTEE联合右心造影评估PFO超声形态特征与CS的相关性:CS组PFO的发生率明显高于非CS组(76.8%vs 56.0%,P=0.001),且CS组PFO直径大于非CS组[2.6(2.2,3.2)mm vs 1.8(1.5,2.0)mm,P<0.001]。RLS分流级别与CS呈正相关,相关系数r=0.540(P<0.001)。RLS分流等级与PFO直径具有强相关性(相关系数为0.749,P<0.001)。结论:RT-3DTEE联合右心造影可以准确、客观地诊断PFO及评估PFO的形态特征,具有重要的临床应用价值,可为隐源性卒中患者的“个体化”诊疗提供可靠依据。

Objective:To investigate the clinical application value of contrast-enhanced real-time three-dimensional transesophageal echocardiography(c-RT-3DTEE)in evaluating patent foramen ovale(PFO)of adult patients.Methods:A retrospective analysis was performed on 112 hospitalized patients diagnosed as cryptogenic stroke(CS)and 100 hospitalized patients without CS at the Department of Neurology,Zhongnan Hospital of Wuhan University,from November 2018 to August 2020.All patients underwent contrast transthoracic echocardiography(c-TTE),contrast transesophageal echocardiography(c-TEE)and c-RT-3DTEE.The difference of the PFO diameter and tunnel length measured by transesophageal echocardiography(TEE)and RT-3DTEE were compared,the comparison of semi-quantitative classification of right-to-left shunt(RLS)by c-TTE,c-TTE and c-RT-3DTEE were analyzed;the association between PFO diameter,tunnel length and RLS by c-RT-3DTEE and CS were evaluated.Results:(1)No statistical difference was found in general clinical characteristics between patients with and without CS.(2)The positive rate of c-TTE,c-TEE and c-RT-3DTEE in the diagnosis of RLS were 58.5%(124/212),56.6%(120/212),and 70%(142/212),respectively,the difference between c-RT-3DTEE and c-TEE was statistically significant(P=0.028);The semi-quantitative grade of RLS(level 1 and level 2)by c-RT-3DTEE was significantly higher than that by c-TTE and c-TEE(P=0.001).PFO diameter by RT-3DTEE was greater as compared with that by TEE,(2.3±1.0)mm vs(1.9±0.8)mm,P<0.001.(3)Compared with that respectively in patients without CS,the incidence of PFO was higher(76.8%vs 56.0%,P=0.001),and the diameter of PFO was larger in patients with CS,2.6(2.2,3.2)mm vs 1.8(1.5,2.0)mm,P<0.001.The grade of RLS shunt by c-RT-3DTEE were positively correlated with CS and PFO diameter,and the correlation coefficient were 0.540 and 0.749(both P<0.001),respectively.Conclusion:c-RT-3DTEE can accurately and objectively assess PFO,and provide a reliable basis for individualized diagnosis and treatment of patients with cryptogenic stroke.