经胸右心声学造影预估肝硬化伴食管胃底静脉曲张内镜下治疗效果的初步研究

Prediction of efficacy of endoscopic therapy of liver cirrhosis with esophagogastric varices by contrast transthoracic echocardiography

目的探讨经胸超声心动图(TTE)和经胸右心声学造影(C-TTE)对肝硬化伴食管胃底静脉曲张内镜下治疗效果是否有预测价值。方法前瞻性选取2020年5月至2021年3月在四川省人民医院行首次食管胃底静脉曲张内镜下治疗并完成完整随访的26例肝硬化失代偿期患者。根据内镜下序贯治疗次数将患者分为2组:治疗次数≥3次或转介入、外科手术治疗的为内镜下治疗效果不佳组(14例);治疗次数<3次的为内镜下治疗效果良好组(12例)。比较分析2组患者的一般资料、术前生化指标、食管胃底静脉曲张及治疗情况,以及术前TTE和C-TTE参数。结果治疗效果良好组与治疗效果不佳组术前生化指标、TTE参数比较,差异均无统计学意义(P均>0.05)。2组患者食管静脉曲张范围比较,差异存在统计学意义(P<0.05),2组均以中下段食管静脉曲张占比最多,治疗效果不佳组该比例更高(85.71%vs 41.67%)。术前C-TTE显示治疗效果不佳组有78.57%存在右向左分流(RLS)(心内水平2例,心外水平8例,心内合并心外1例),中量及以上占比达50.00%;而治疗效果良好组仅33.33%存在RLS(心内水平1例,心外水平3例),中量及以上占比约16.67%。治疗效果不佳组RLS的发生率高于治疗效果良好组(χ^(2)=5.418,P=0.020),中量及以上分流量占比也高于治疗效果良好组。结论通过C-TTE明确是否伴发心内和(或)心外水平RLS,可能有助于预测肝硬化伴食管胃底静脉曲张内镜下治疗的效果,C-TTE对其治疗效果预估可能有一定指导价值。

Objective To evaluate the predictive value of transthoracic echocardiography(TTE)and contrast transthoracic echocardiography(C-TTE)for the efficacy of endoscopic treatment of liver cirrhosis with esophagogastric varices.Methods Twenty-six patients with decompensated liver cirrhosis who underwent treatment of esophagogastric varices for the first time at Sichuan Provincial People's Hospital from May 2020 to March 2021 were selected.They were grouped into either a poor therapeutic effect group or a good therapeutic effect group according to the number of endoscopic treatments that they received:treatment times≥3 or conversion to interventional and surgical treatment(poor therapeutic effect group),and treatment times<3(good therapeutic effect group).Preoperative TTE and C-TTE parameters,endoscopic therapy,and biochemical indexes of the two groups were analyzed retrospectively and statistically.Results There was no significant difference in TTE parameters or biochemical indexes between the two groups(P>0.05).There was a significant difference in the range of esophageal varices between the two groups(P<0.05).The middle and lower esophageal varices accounted for the most in both groups,and the ratio of middle and lower esophageal varices was greater in the poor therapeutic effect group(85.71%vs 41.67%).Preoperative C-TTE showed that 78.57%of the patients in the poor therapeutic effect group had right to left shunt(RLS)(2 cases with intracardiac level,8 with extracardiac level,and 1 with intracardiac combined with extracardiac level),and 50.00%had moderate or above RLS.In the good therapeutic effect group,only 33.33%of the patients had RLS(1 case with intracardiac level and 3 with extracardiac level),and about 16.67%had moderate or above RLS.The probability of RLS and were significantly higher than those in the good therapeutic effect group(χ^(2)=5.418,P<0.05).Conclusion C-TTE can be used to determine whether patients with liver cirrhosis with esophagogastric varices are accompanied by intracardiac or/and extracardiac RLS,which may be helpful to predict the effect of endoscopic treatment of liver cirrhosis with esophagogastric varices.C-TTE may have certain guiding value in predicting the treatment effect.