Value of Transesophageal Three-dimensional Echocardiography in Diagnosis of Perivalvular Leakage after Aortic Valve Replacement
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摘要:
目的 探讨经食管三维超声（RT-3D-TEE）对主动脉瓣置换术后瓣周漏评估的临床意义。 方法 选取北华大学附属医院2015年1月至2018年12月收治的主动脉瓣置换术后疑似瓣周漏患者70例，均接受二维经胸超声心动图（2D-TTE）检查和RT-3D-TEE检查，比较2D-TTE与RT-3D-TEE检查对主动脉瓣置换术后瓣周漏的诊断、破口位置和范围及瓣周其他情况评估的差异。90例患者均再次接受手术治疗。 结果 70例患者中，经术中观察确诊瓣周漏45例，非瓣周漏25例。2D-TTE诊断正确52例（诊断为瓣周漏36例，含6例疑似诊断），误诊9例，漏诊9例，RT-3D-TEE诊断正确70例（诊断为瓣周漏45例，含3例疑似诊断），RT-3D-TEE的诊断准确率（100.0%）高于2D-TTE（74.29%），差异有统计学意义（P < 0.05）。2D-TTE诊断的36例瓣周漏中，破口位于左冠瓣区5例，右冠瓣区8例，多个破口或破口面积超过单个瓣叶区域11例，其余12例分区不明确，在RT-3D-TEE诊断的45例瓣周漏中，破口位于左冠瓣区9例，右冠瓣区15例，多个破口或破口面积超过单个瓣叶区域18例，其余3例分区不明确，经手术证实，RT-3D-TEE诊断的漏口位置与范围与术中观察基本一致。术中发现，9例患者合并瓣环部分脱位，6例合并瓣周脓肿，3例合并二尖瓣机械瓣卡瓣，RT-3D-TEE全部诊断正确，2D-TTE正确诊断合并瓣环部分脱位6例，合并瓣周脓肿3例，漏诊合并二尖瓣机械瓣卡瓣3例。2种检查方法在测量瓣周漏破口的长度和宽度方面，差异无统计学意义（P > 0.05）。RT-3D-TEE对合并有瓣环脱位、瓣周脓肿、二尖瓣卡瓣的诊断准确度高于2D-TTE。 结论 RT-3D-TEE因其观察位置的特殊性表现出对人工瓣膜整体观图像上的优势，是对2D-TTE诊断主动脉瓣置换术后瓣周漏的良好补充。 -
关键词:
- 人工主动脉瓣置换术 /
- 瓣周漏 /
- 经食管三维超声心动图
Abstract:Objective To explore the clinical value of transesophageal three-dimensional echocardiography （RT-3D-TEE） in the diagnosis of perivalvular leakage after aortic valve replacement. Methods 70 patients with suspectde perivalvular leak after aortic valve replacement in our hospital from January 2015 to December 2018 were selected.All patients underwent 2-D transthoracic echocardiography （2D-TTE） and RT-3D-TEE was compared. The accuracy of the two methods in the diagnosis of perivalvular leakage after aortic valve replacement, and the location, range and other conditions of perivalvular leakage were compared. All 70 patients underwent surgery again. Results After surgical treatment, 45 cases of perivalvular leakage and 25 cases of non-perivalvular leakage were confirmed.2D-TTE was diagnosed correctly in 52 cases, misdiagnosed in 9 case and missed in 9 cases. RT-3D-TEE was diagnosed correctly in 70 cases. The diagnostic accuracy of RT-3D-TEE （100.0%） was higher than that of 2D-TTE （80.0%）, and the difference was statistically significant （P < 0.05）. Among the 36 cases of perivalvular leakage diagnosed by 2D-TTE, 5 were located in the left coronary valve region, 8 were located in the right coronary valve region, 11 had multiple or larger than a single lobe region, and the remaining 12 cases could not be clearly identified. Among the 45 cases of perivalvular leakage diagnosed by RT-3D-TEE, 9 cases were located in the left coronary valve region, 15 cases were located in the right coronary valve region, 18 cases had multiple or larger than a single lobe region, and the remaining 3 cases could not be clearly identified. The location and scope of leakage in the diagnosis of RT-3D-TEE were basically consistent with the intraoperative observation.RT-3D-TEE diagnosed 9 patients with partial flap ring dislocation, 6 patients with perivalvular abscess, and 3 patients with mechanical mitral valve sticking, which was consistent with the intraoperative observation. 2D-TTE diagnosed 6 patients with partial flap ring dislocation, 3 patients with perivalvular abscess and 3 patients with mechanical mitral valve sticking were misdiagnosed.There was no significant difference in the length and width of perivalvular leakage between the two methods （P > 0.05）. The diagnostic accuracy of RT-3D-TEE was higher than that of 2D-TTE in the diagnosis of ring dislocation, perivalvular abscess and mechanical mitral valve valves. Conclusion RT-3D-TEE is a good complement to 2D-TTE in the diagnosis of perivalvular leakage after aortic valve replacement because of its superiority in the overall image of prosthetic valve because of its special observation position. -
图 1 2D-TTE示主动脉瓣位人工瓣瓣环右前方新月形瓣周裂隙
Figure 1. 2D-TTE shows a crescent-shaped perivalvular fissure right front of the artificial valvular ring in aortic position
图 2 RT-3D-TEE示主动脉瓣位人工瓣瓣环前方大量瓣周漏
Figure 2. RT-3D-TEE shows a large amount of perivalvular leakage in front of the artificial valvular ring at aortic position
表 1 患者一般资料
Table 1. General information of patients
项目 临床特征 n 构成比（%） 原发疾病 风湿性心脏病 45 64.29 先天性心脏病 8 11.43 瓣膜退行性变 7 10 感染性心内膜炎 10 14.28 人工主动脉瓣类型 机械瓣 52 74.29 生物瓣 18 25.71 首次换瓣至本次
入院时间间隔<1 a 21 30 1～5 a 15 21.43 >5 a 34 48.57 本次就诊症状 呼吸困难 44 62.86 活动后心悸 65 92.86 心绞痛 38 54.29 发热 15 21.43 贫血 10 14.29 手术方式 瓣周漏修补术 57 81.43 二次换瓣术 13 18.57 
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表 2 2D-TTE与RT-3D-TEE测量瓣周漏破口大小比较[（
$\bar x \pm s $ ），mm]Table 2. Comparison of perivalvular leak size measured by 2D-TTE and RT-3D-TEE [（
$\bar x \pm s $ ），mm]检查方法 例数（破口数） 破口长度 破口宽度 2D-TTE 24（37） 5.8 ± 0.9 4.7 ± 0.6 RT-3D-TEE 24（37） 5.6 ± 0.7 4.5 ± 0.7 t 1.067 0.152 P 0.290 0.191
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