心脏计算机断层扫描与经食管超声心动图诊断左心耳封堵术后残余漏的对比研究

A comparative study of cardiac computerized tomography and transesophageal echocardiography in diagnosing device residual leak after left atrial appendage occlusion

目的比较心脏计算机断层扫描(CCT)与经食管超声心动图(TEE)在诊断左心耳封堵术(LAAC)后6个月器械残余漏中的作用。方法连续纳入2019年4月至12月在上海市东方医院(同济大学附属东方医院)心脏内科成功实施LAAC并同时完成术后6个月CCT及TEE随访的非瓣膜性心房颤动(房颤)患者,分析对比封堵器残余漏情况,并观察器械表面相关血栓及主要临床不良事件的发生率。结果54例房颤患者成功实施LAAC术(Watchman封堵器47例,Leftear封堵器7例)且同时完成术后6个月的CCT及TEE随访,平均年龄(70.3±8.3)岁,CHA_(2)DS_(2)-VASC评分(4.50±1.63)分,HAS-BLED评分(2.72±0.99)分,其中持续性房颤患者31例(57.4%)。LAAC后残余漏分为封堵器周围残余分流和封堵器内皮化不完全所致跨封堵器膜漏。CCT在周围残余分流检出率上高于TEE(38.9%比27.8%,P=0.221),在内皮化不完全所致跨封堵器膜漏的检出率上显著高于TEE(63.0%比22.2%,P<0.01)。Watchman和Leftear封堵器的内皮化不完全发生率差异有统计学意义(57.4%比100.0%,P=0.038)。3例患者发现器械表面相关血栓形成,所有患者均无卒中、短暂性脑缺血发作、系统性栓塞、大出血、心脏压塞、死亡等主要临床不良事件发生。结论与TEE相比,CCT能更加精准地发现和诊断LAAC术后封堵器残余漏,尤其对封堵器内皮化不完全的检出率更高。早期诊断封堵器残余漏并调整抗凝策略对于预防器械表面相关血栓形成具有重要的临床意义。

Objective To compare the role of cardiac computerized tomography(CCT)and transesophageal echocardiography(TEE)in detecting device residual leak at 6 months following left atrial appendage closure(LAAC).Methods Non-valvular atrial fibrillation(NVAF)patients who underwent successful LAAC from April to December 2019 in our hospital and completed CCT and TEE examinations at 6 months follow-up were enrolled.Device residual leak,device related thrombus(DRT)and major adverse events were analyzed.Results At 6 months follow-up,54 patients were enrolled(47 Watchman^(TM) and 7 Leftear^(TM))with a mean age of(70.3±8.3)years,CHA_(2)DS_(2)-VASc score of(4.50±1.63)and HAS-BLED score of(2.72±0.99).Thirty-one(57.4%)patients had persistent NVAF.Peri-device leak(PDL)was detected in 15 patients(27.8%)by TEE and 21 patients(38.9%)by CCT(P=0.221).Rate of incomplete device endothelialization(IDE)detected by CCT was significantly higher than TEE(63.0%vs.22.2%,P<0.01).There was a statistically significant difference in the incidence of IDE between Watchman and Leftear occluders(57.4%vs.100.0%,P=0.038).DRT was found in three patients,however,no major adverse events including stroke,transient ischemic attack(TIA),systemic embolism,major bleeding,pericardial tamponade,and death occurred.Conclusions Compared with TEE,CCT can more accurately detect device residual leak after LAAC,especially for IDE.Early diagnosis of device residual leak and adjustment of anticoagulation strategy have important clinical significance for preventing DRT formation.