超声心动图在三尖瓣下移畸形中的临床应用价值

Clinical application of echocardiography in Ebstein's anomaly

目的总结三尖瓣下移畸形矫治术前、术后超声图像特点及诊断要点,探讨超声心动图对此畸形术前诊断及术后随访的应用价值。方法回顾性分析、对比2018年1月至2023年7月在首都医科大学附属北京安贞医院确诊的68例三尖瓣下移畸形患者矫治术前、术后6个月的临床特征和超声心动图资料,总结概括合并畸形及手术方式,对比三尖瓣反流情况,测量三尖瓣瓣环直径、固有右心房面积、功能右心室面积、房化右心室面积、右心室前后径、左心室舒张末期内径、肺动脉内径、三尖瓣环收缩期位移、左心室偏心指数、右心室面积变化率,采用t检验对比术前与术后6个月腔室大小、瓣膜情况及心脏功能,采用χ^(2)检验对比术前超声和术中瓣膜下移、发育不良和缺如情况。结果68例患者术中所见均证实术前超声诊断及分级和分型。与术前比较,术后6个月右心室前后径[(19.03±2.73)mm vs(29.99±3.80)mm]、固有右心房面积[(14.67±3.76)cm^(2)vs(22.39±5.25)cm^(2)]、房化右心室面积[(13.08±3.19)cm^(2)vs(17.10±3.95)cm^(2)]、三尖瓣瓣环直径[(25.92±5.38)mm vs(33.64±6.21)mm]、左心室偏心指数[(0.93±0.08)%vs(1.45±0.07)%]均减小,差异具有统计学意义(t=55.982、32.530、29.612、36.870、1.420,P均<0.001);术后功能右心室面积[(18.59±2.99)cm^(2)vs(14.70±3.05)cm^(2)]、左心室舒张末期内径[(38.06±4.178)mm vs(29.75±3.73)mm]较术前增加,差异具有统计学意义(t=-32.055、-34.607,P均<0.001)。无论采用哪种手术方式,术后三尖瓣反流程度均较术前明显减轻。术后三尖瓣环收缩期位移与术前无明显改变(P>0.05)。术前超声心动图检查仅提示1例前叶后下部分下移,但术中发现前叶部分下移患者多达6例,前叶下移情况与术中所见差异有统计学意义(χ^(2)=5.731,P=0.018),而其余瓣叶下移、发育不良、缺如情况与术中所见差异无统计学意义(P>0.05)。结论超声心动图对三尖瓣瓣叶发育情况的评价可为制定治疗策略提供重要依据,首选作为三尖瓣下移畸形术前诊断、评价瓣叶解剖结构、术后随访的检查方式,具有重要临床价值。

Objective To summarize the ultrasonic characteristics and diagnostic points of Ebstein's anomaly before and after surgery,and to discuss the application value of echocardiography in preoperative diagnosis and postoperative follow-up of this malformation.Methods The clinical characteristics and echocardiographic data of 68 patients with Ebstein's anomaly before and 6 months after surgery at Beijing Anzhen Hospital from January 2018 to July 2023 were retrospectively analyzed and compared.The combined malformations and surgical methods were summarized,tricuspid regurgitation was compared between before and after surgery,and tricuspid valve annular diameter,right atrium area,functional right ventricular area,atrialized portion of the right ventricle area,right ventricular anterior-posterior diameter,left ventricular end-diastolic diameter,pulmonary artery diameter,tricuspid annular plane systolic execution,left ventricular eccentricity index,and right ventricle fractional area change were measured.The t-test was used to compare chamber size,valve condition,and cardiac function between before and after surgery.Theχ^(2) test was used to compare preoperative and intraoperative valve displacement,dysplasia,and absence conditions.Results Postoperative right ventricular anteroposterior diameter[(19.03±2.73)mm vs(29.99±3.80)mm],right atrial area[(14.67±3.76)cm^(2)vs(22.39±5.25)cm^(2)],atrialized portion of the right ventricle[(13.08±3.19)cm^(2)vs(17.10±3.95)cm^(2)],tricuspid annular diameter[(25.92±5.38)mm vs(33.64±6.21)mm],and left ventricular eccentricity index[(0.93±0.08)%vs(1.45±0.07)%]were significantly lower than the preoperative values(t=55.982,32.530,29.612,36.870,and 1.420,respectively,P<0.001 for all).The functional right ventricular area[(18.59±2.99)cm^(2)vs(14.70±3.05)cm^(2)]and left ventricular end-diastolic diameter[(38.06±4.178)mm vs(29.75±3.73)mm]were significantly increased after operation(t=-32.055 and-34.607,respectively,P<0.001 for both).The degree of tricuspid regurgitation was significantly reduced after operation.Tricuspid annular plane systolic excution had no significant change after operation(P>0.05).Displacement of the posterior part of the anterior valve was the only diagnosed anomaly(one patient)before operation,but six patients were found to have anterior valve displacement during the operation.There was a statistically significant difference in the detected anterior valve displacement between before and during operation(χ^(2)=5.731,P=0.018),while there were no significant differences in displacement,dysplasia,or absence of the other valves(P>0.05).Conclusion Echocardiography can provide an important basis for the details of the tricuspid valve.It is the first choice for the preoperative diagnosis of Ebstein's anomaly,the evaluation of the anatomical structure of the valve,and the postoperative follow-up of patients.