基于对比增强经颅多普勒的多模式超声评估卵圆孔未闭相关右向左分流的临床意义

Clinical significance of contrast-enhanced transcranial Doppler based multimodal ultrasound in assessing right-to-left shunt associated with patent foramen ovale

目的研究对比增强经颅多普勒(c-TCD)与经食管超声心动图声学造影(c-TEE)评估卵圆孔未闭(PFO)相关右向左分流(RLS)的临床意义。方法回顾性连续纳入2020年1月至2022年6月在苏州大学附属第一医院因头晕、晕厥、偏头痛、缺血性卒中或短暂性脑缺血发作(TIA)等临床表现就诊,临床可疑RLS的患者243例,所有患者均完成c-TCD、TEE和c-TEE检查。分析c-TCD、c-TEE对PFO-RLS的检出结果。采用McNemar-Bowker检验比较c-TCD和c-TEE对PFO-RLS的半定量分级;并分析c-TCD评估下PFO-RLS分流类型、分流等级及与PFO直径和隧道长度的关系。结果纳入的243例患者中,偏头痛及头晕、晕厥等占71.2%(173/243),缺血性卒中或TIA占28.8%(70/243)。以TEE结合c-TEE结果为参考标准,确诊232例PFO-RLS。c-TCD、c-TEE对PFO-RLS的检出率均为99.1%(230/232)。c-TCD检查:静息状态、传统Valsalva动作、定量Valsalva动作时,大量分流的检出率分别为20.7%(48/232)、41.4%(96/232)、67.7%(157/232),两两比较差异均有统计学意义(P均<0.001)。c-TEE检查:静息状态、腹部加压下,小量分流的检出率分别为18.1%(42/232)、32.8%(76/232),中量分流的检出率分别为0.9%(2/232)、25.0%(58/232),大量分流的检出率分别为3.0%(7/232)、41.4%(96/232)。c-TCD与c-TEE评估的PFO-RLS分流等级差异有统计学意义(Boweker检验值为51.524,P<0.001)。小量分流,c-TEE检出率高于c-TCD(χ^(2)=5.222,P=0.022);中量分流,c-TEE检出率高于c-TCD(χ^(2)=20.885,P<0.001);大量分流,c-TCD检出率高于c-TEE(χ^(2)=53.923,P<0.001)。34.9%(81/232)的患者分流等级c-TCD高于c-TEE;55.6%(129/232)的患者c-TCD和c-TEE评估的分流等级相同;9.5%(22/232)的患者分流等级c-TCD低于c-TEE。c-TCD评估下固有型RLS的PFO直径大于潜在型RLS的PFO直径(P<0.05),隧道长度差异无统计学意义(P>0.05)。PFO-RLS分流等级与PFO直径呈正相关(r=0.307,P<0.05),与隧道长度无相关性(P>0.05)。结论c-TCD是评估RLS的有效血流动力学依据,充分的Valsalva动作下c-TDC可为PFO-RLS提供可靠的半定量诊断结果,c-TEE可明确RLS的来源,两者共同联合可为个体化诊断提供科学依据。

Objective To investigate the clinical significance of contrast-enhanced transcranial Doppler(c-TCD)and contrast-transesophageal echocardiography(c-TEE)in the assessment of right-to-left shunt(RLS)associated with patent foramen ovale(PFO).Methods A total of 243 patients who presented with symptoms such as dizziness,syncope,migraine,palpitations,transient ischemic attack(TIA),or ischemic stroke and were clinically suspected of having a RLS were retrospectively enrolled from January 2020 to June 2022 at the Department of Neurology or Cardiology of the first Affiliated Hospital of Soochow University.Each patient was subject to c-TCD,transesophageal echocardiography(TEE),and c-TEE.The detection results of PFO-RLS by c-TCD and c-TEE were analyzed.The McNemar-Bowker test was used to compare the semi-quantitative grading of c-TCD and c-TEE for PFO-RLS,and the relationship of PFO-RLS shunt types and grades with PFO diameter and tunnel length under c-TCD evaluation was analyzed.Results Among the 243 enrolled patients,migraines,dizziness,and syncope accounted for 71.2%(173/243),while ischemic stroke or TIA accounted for 28.8%(70/243).Using TEE combined with c-TEE results as the reference standard,232 cases of PFO-RLS were diagnosed.The detection rates of c-TCD and c-TEE for PFO-RLS were both 99.1%(230/232).For c-TCD examination,the detection rates for large shunts were 20.7%(48/232)at rest,41.4%(96/232)during traditional Valsalva maneuver,and 67.7%(157/232)during quantitative Valsalva maneuver.There were statistically significant differences between each pair of detection rates(P<0.001).However,there were no statistically significant differences in the detection rates for small and moderate shunts(P>0.05).For c-TEE examination,the detection rates for small shunts were 18.1%(42/232)at rest and 32.8%(76/232)under abdominal pressure.The detection rates for moderate shunts were 0.9%(2/232)at rest and 25.0%(58/232)under abdominal pressure.The detection rates for large shunts were 3.0%(7/232)at rest and 41.4%(96/232)under abdominal pressure.There was a statistically significant difference in the shunt grades of PFO-RLS evaluated by c-TCD and c-TEE(Boweker test value=51.524,P<0.001).For small shunts,the detection rate of c-TEE was higher than that of c-TCD(χ^(2)=5.222,P=0.022);for moderate shunts,the detection rate of c-TEE was higher than that of c-TCD(χ^(2)=20.885,P<0.001);for large shunts,the detection rate of c-TCD was higher than that of c-TEE(χ^(2)=53.923,P<0.001).Among the patients,34.9%(81/232)had a higher shunt grade assessed by c-TCD than by c-TEE;55.6%(129/232)had the same shunt grade assessed by both c-TCD and c-TEE;9.5%(22/232)had a lower shunt grade assessed by c-TCD compared to c-TEE.The PFO diameter of the inherent type RLS was greater than that of the potential type RLS(P<0.05),while there was no significant difference in tunnel length(P>0.05)as assessed by c-TCD.Correlation analysis showed a positive correlation between the shunt grade of PFO-RLS and PFO diameter(r=0.307,P<0.05),but there was no correlation with tunnel length(P>0.05).Conclusion c-TCD provides an effective hemodynamic basis for evaluating PFO-RLS,and its sufficient Valsalva maneuver can provide reliable semi-quantitative diagnosis results for PFO-RLS.c-TEE can identify the source of RLS.The combination of these diagnostic techniques provides a scientific basis for individualized diagnosis of RLS.