改良Valsalva动作与小腿肌紧张动作在经胸右心声学造影诊断卵圆孔未闭中的应用价值

Comparison of the application value of mVM and calf muscle tension motion in the diagnosis of patent foramen ovale by cTTE

目的比较改良Valsalva动作(mVM)与小腿肌紧张动作在经胸右心声学造影(cTTE)诊断卵圆孔未闭(PFO)中的应用价值。方法选取2022年6月至2023年6月南京医科大学附属南京医院收治的87例疑似PFO患者作为研究对象。所有患者均接受经食管超声心动图(TEE)联合cTTE检查,判断右向左分流(RLS)来源,根据左心内是否出现微气泡及微气泡初始出现时间分为PFO组(存在异常血流)和正常组,比较分析两组的临床资料。所有患者分别在安静状态、mVM和小腿肌紧张动作下进行cTTE,比较分析这三种辅助状态下cTTE的PFO检出率、RLS微气泡初始出现的心动周期、RLS分流量检出程度。结果以TEE联合cTTE检查结果作为诊断的金标准,将87例患者分为PFO组68例(包括23例少量RLS、7例中量RLS、38例大量RLS)和正常组19例。两组临床资料比较显示,PFO组年龄小于正常组,出现头痛症状的比例高于正常组,差异均有统计学意义(P<0.05)。与安静状态相比,mVM和小腿肌紧张动作下的PFO检出率更高、RLS微气泡初始出现的心动周期更早,差异均有统计学意义(P<0.05),而mVM与小腿肌紧张动作下的PFO检出率、RLS微气泡初始出现的心动周期比较差异均无统计学意义(P>0.05)。安静状态、mVM、小腿肌紧张动作下少量RLS的检出率比较差异有统计学意义(P<0.05),而中量和大量RLS的检出率比较差异无统计学意义(P>0.05)。一致性检验结果显示,安静状态、mVM、小腿肌紧张动作下的PFO检出的特异度比较差异无统计学意义(P>0.05),但mVM、小腿肌紧张动作下的PFO检出的敏感度和Kappa值均显著高于安静状态(P<0.05),且以mVM的Kappa值最大,PFO检出结果与实际结果一致性最强。结论mVM与小腿肌紧张动作是cTTE诊断PFO的有效辅助方式,尤其是mVM在辅助cTTE诊断中的临床实际意义最强。小腿肌紧张动作是一种简单有效的辅助动作,当患者不能进行有效的mVM时,可采用小腿肌紧张动作进行替代。

Objective To compare the application value of modifi ed Valsalva maneuver(mVM)and calf muscle tension motion in the diagnosis of patent foramen ovale(PFO)by contrast transthoracic echocardiography(cTTE).Method 87 suspected PFO patients admitted to Nanjing First Hospital Affi liated to Nanjing Medical University from June 2022 to June 2023 were selected as the study objects.All patients underwent transesophageal echocardiography(TEE)combined with cTTE examination to determine the source of right-to-left shunt(RLS),and were divided into PFO group(presence of abnormal blood fl ow)and normal group according to whether microbubbles appeared in the left heart and the initial time of microbubbles,and the clinical data of the two groups were compared and analyzed.All patients underwent cTTE under quiet state,mVM and calf muscle tension respectively.The detection rate of PFO,the initial cardiac cycle of RLS microbubbles and the detection degree of RLS shunt volume in cTTE under these three auxiliary states were compared and analyzed.Result Using TEE combined with cTTE examination as the gold standard,68 cases of 87 suspected PFO patients were examined in PFO group,including 23 cases of small RLS,7 cases of medium RLS,38 cases of large RLS,and 19 cases of normal group.The comparison of clinical data between the two groups showed that the age of PFO group was smaller than that of normal group,and the proportion of headache symptoms was higher than that of normal group,with statistical signifi cance(P<0.05).Compared with the quiet state,the positive detection rate of PFO in mVM and calf muscle tension movement was higher,and the initial cardiac cycle of RLS microbubbles was earlier,with statistical signifi cance(P<0.05).There was no signifi cant difference in the positive rate of PFO and the initial cardiac cycle of RLS microbubbles between mVM and calf muscle tension(P>0.05).There was signifi cant difference in the detection rate of a small amount of RLS under quiet state,mVM and calf muscle tension(P<0.05),but there was no signifi cant difference in the detection rate of a large amount of RLS between medium and large amounts of RLS(P>0.05).Consistency test results showed that there was no statistical signifi cance in the specifi city of PFO detected under quiet state,mVM and calf muscle tension movements(P>0.05),but the sensitivity and Kappa value of PFO detected under mVM and calf muscle tension movements were signifi cantly higher than those under quiet state(P<0.05),and the Kappa value of mVM was the largest.The PFO results are most consistent with the actual results.Conclusion mVM and calf muscle tension are effective auxiliary ways for cTTE to diagnose PFO,especially mVM has the strongest clinical signifi cance in assisting cTTE diagnosis.Calf muscle tension is a simple and effective auxiliary action for the diagnosis of PFO.For mVM patients who cannot perform effectively,calf muscle tension can replace mVM to a certain extent.