CT成像在静脉窦型房间隔缺损诊断中的价值

The value of CT imaging in the diagnosis of sinus venosus atrial septal defect

目的比较冠状动脉CT血管成像及先天性心脏病CT检查和经胸超声心动图(TTE)诊断静脉窦型房间隔缺损(SVASD)的价值,总结SVASD的CT影像特征并探讨其指导外科术式选择的意义。方法回顾性分析2017年1月至2021年12月经手术确诊为SVASD的患者443例,所有患者术前行冠状动脉CT血管成像或先天性心脏病CT检查、TTE,以手术结果为金标准,采用配对卡方检验比较CT和TTE诊断SVASD类型和肺静脉引流准确度的差异;比较上腔静脉窦型与下腔静脉窦型房间隔缺损(ASD)肺静脉引流的差异。总结SVASD的影像特征,并分析其对应的外科术式。结果CT和TTE诊断SVASD类型的准确度分布为63.21%、57.56%,差异无统计学意义(P=0.065);443例SVASD中159例(35.89%)合并PAPVC,284例(64.11%)无PAPVC,CT和TTE诊断肺静脉引流的准确度分别为98.42%、73.81%,差异有统计学意义(P<0.001)。上腔静脉窦型ASD共有145例,其中101例(69.66%)合并PAPVC;下腔静脉窦型ASD共有298例,其中58例(19.46%)合并PAPVC,两者差异有统计学意义(χ^(2)=106.79,P<0.001),上腔静脉窦型合并PAPVC者更多。SVASD的CT影像特征可分为4种。第1种,单纯SVASD,不合并PAPVC,共284例(64.11%),外科手术需直接缝合或使用自体心包片、涤纶片修补缺损即可。第2种,合并PAPVC的SVASD,包括部分肺静脉引流至上腔静脉低位的上腔静脉窦型、合并PAPVC的下腔静脉窦型,共151例(34.09%),在修补缺损的同时需要把异位引流的肺静脉隔入左心房。第3种为上腔静脉窦型,部分肺静脉引流至上腔静脉高位,共7例(1.58%),无法将其直接隔入左心房,需要行Warden手术。第4种很少见(1例,0.22%),肺静脉异位引流至冠状静脉窦,需要切开冠状静脉窦顶,使其与左心房交通,重建窦顶将冠状静脉血流引流回右心房,并修补缺损。结论CT和TTE均可以判断SVASD的类型,CT比TTE诊断PAPVC准确度更高,SVASD术前CT影像特征可以为外科手术提供有价值的信息,指导手术方式的选择。

Objective To compare the value of coronary CT angiography,congenital heart disease CT,and transthoracic echocardiography(TTE)in the diagnosis of sinus venosus atrial septal defect(SVASD),to summarize the CT image features of SVASD,and to explore its significance in guiding the selection of surgical procedures.Methods A total of 443 patients of SVASD diagnosed by surgical procedures from January 2017 to December 2021 were retrospectively analyzed.All patients underwent coronary CT angiography or congenital heart disease CT examination and TTE before surgery.Using surgical results as the gold standard,McNemar test was used to analyze the differences between CT and TTE in distinguishing SVASD and pulmonary venous drainage.The difference of pulmonary venosus drainage was analyzed between superior sinus venosus atrial septal defect(ASD)and inferior sinus venosus ASD.The image features of SVASD were summarized and the corresponding surgical procedures were analyzed.Results No significant difference was found between CT and TTE for the diagnostic accuracy of the SVASD(63.21%,57.56%,P=0.065).There were 159 patients(35.89%)with PAPVC and 284 patients(64.11%)without PAPVC in the 443 SVASD patients.The diagnostic accuracy of CT and TTE in diagnosing pulmonary venous drainage was statistically significantly different(98.42%,73.81%,P<0.001).Among 145 patients with superior sinus venosus ASD,101(69.66%)were associated with PAPVC;in contrast,among 298 patients with inferior sinus venosus ASD,58(19.46%)had PAPVC.The difference between the two groups was statistically significant(χ^(2)=106.79,P<0.001),indicating a higher prevalence of PAPVC in patients with superior sinus venosus ASD.The CT imaging features of SVASD can be categorized into four types.The first type was SVASD alone without PAPVC,comprising 284 patients(64.11%).Surgical intervention for this type typically involved direct suturing or closure using a patch.The second type was SVASD with concomitant PAPVC,encompassing 151 patients(34.09%).This type included superior sinus venosus ASD with anomalous pulmonary venous low connection and inferior sinus venosus ASD with PAPVC.During the repair of the defect,it was necessary to redirect the anomalous pulmonary veins into the left atrium.The third type was superior sinus venosus ASD in 7 patients(1.58%).The position of pulmonary vein draining into superior vena cava was too high to be directly corrected to the left atrium,requiring Warden′s technique.The fourth type was rare(1 patient,0.22%).The anomalous pulmonary vein drained into the coronary sinus.The surgery included incision of the roof of the coronary sinus to redirect pulmonary vein flow to the left atrium,reconstruction of the roof of the sinus to drain coronary vein back to the right atrium,and repair of the ASD.Conclusions Both CT and TTE can diagnose the type of SVASD,and CT is more accurate than TTE in the diagnosis of PAPVC.CT image features of SVASD can provide valuable information for surgical procedures and guide the selection of surgical procedures.