左心耳解剖形态、功能与非瓣膜性心房颤动患者脑卒中发生风险的相关性研究

doi:10.16150/j.1671-2870.2020.02.010

摘要/Abstract

摘要：

目的：探究左心耳解剖形态、功能等因素与心房颤动（房颤）患者发生脑卒中之间的关系。方法：回顾性分析223例非瓣膜性房颤患者,根据其既往有无心源性脑卒中分为脑卒中组（70例）和非脑卒中组（153例）。按规范采集经胸及经食管超声心动图图像,并收集详细的临床资料。结果：脑卒中组与非脑卒中组患者在年龄、高血压及糖尿病占比、肾小球滤过率、左房内径及有无右心房增大方面差异有统计学意义;检查提示左心耳的形态、左心耳各角度开口内径、左心耳深度、左心耳深度/开口内径比值、左心耳内自发显影及左心耳内血流速度等指标在组间的差异亦有统计学意义（P<0.05）。左心耳形态为仙人掌型、菜花型的房颤患者脑卒中的发生率显著高于鸡翅型和风向标型的患者。多因素逻辑回归分析结果显示,左心耳开口内径之和、心耳内血流速度增加是脑卒中发生的保护性因素,而左心耳深度之和增加是脑卒中发生的危险因素。左心耳开口内径之和、心耳内血流速度及左心耳深度之和分别为≤71 mm、≤41 cm/s及≥103 mm时,对应预测脑卒中的灵敏度及特异度分别为91%、83%、79%及46%、74%、89%。结论：左心耳形态呈仙人掌型或菜花型及开口内径之和、深度之和以及心耳内血流速度等指标与心源性脑卒中发生相关。左心耳解剖形态及功能等可能具有一定的预测房颤患者发生脑卒中风险的价值,可以作为CHA₂DS₂VASc评分的重要补充。

关键词: 经食管超声心动图, 左心耳解剖形态, 心房颤动, 脑卒中

Abstract:

Objective: To explore anatomic structure and function of left atrial appendage (LAA) in the risk assessment of cardiogenic stroke in patients with atrial fibrillation (AF). Methods: A total of 223 patients with non-valvular atrial fibrillation (NVAF), including 70 with and 153 without episodes of cardiogenic stroke, were enrolled in the study. The transthoracic and transesophageal echocardiography were retrieved and analyzed along with clinical data. Results: Between subjects with and without episodes of stroke, there were significant differences in demographic and laboratory parameters, including age, prevalence of hypertension or diabetes, glomerular filtration rate, atrial size of both sides, opening inner diameter of each angle of LAA, depth of the LAA, ratio of the depth/opening inner diameter, spontaneous echo contrast (SEC) in LAA and the blood flow (P<0.05). Patients with cactus- or cauliflower-shaped LAA had a higher incidence of stoke than those with wing- or wind vane-shaped LAA. Multivariable logistic regression analysis showed that higher sum of opening inner diameters and higher blood flow velocity in LAA were protective factors against stroke, and the higher sum of depths in LAA was an independent risk factor for stroke. When the cutoff values for the sum of opening inner diameters, the blood flow velocity and the sum of depths in LAA were set as≤71 mm, ≤41 cm/s and≥103 mm, the sensitivity and specificity of each parameter for stroke predication were 91% and 83%, 79% and 46%, 74% and 89% respectively. Conclusion: The incidenceof cardiogenic stroke is associated with anatomic features of LAA, such as cactus- or auliflower-shaped LAA, the sum of opening inner diameters and depths of LAA, and blood flow velocity in LAA. Evaluation of anatomy and function of LAA might facilitate stroke prediction as a supplement of CHA₂DS₂VASc score in patients with AF.

Key words: Transesophageal echocardiography, Left atrial appendage anatomy, Atrial fibrillation, Stroke

中图分类号:

R541.7

王晨琛, 杨文波, 华玮, 陈晔芬, 苏秀秀, 龚俊世, 方跃华. 左心耳解剖形态、功能与非瓣膜性心房颤动患者脑卒中发生风险的相关性研究[J]. 诊断学理论与实践, 2020, 19(02): 151-156.

WANG Chenchen, YANG Wenbo, HUA Wei, CHEN Yefen, SU Xiuxiu, GONG Junshi, FANG Yuehua. The morphology and function of left atrial appendage in the risk assessment of stroke in patients with non-valvular atrial fibrillation[J]. Journal of Diagnostics Concepts & Practice, 2020, 19(02): 151-156.

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参考文献 14

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指标	非脑卒中组（n=153）	脑卒中组（n=70）	t或χ²值	P值
性别（男）	61.4%	62.9%	0.4	0.880
年龄（岁）	61.5±9.3	66.3±7.0	-4.2	<0.001
BMI（kg/m²）	24.8±3.0	25.1±3.0	-0.7	0.520
高血压病	71（46.4）	52（74.3）	15.1	<0.001
糖尿病	20（13.1）	23（32.9）	12.1	<0.001
肾小球滤过率[mL/（min·1.73 m²）]	88.1±12.7	72.3±13.4	8.2	<0.001
CHA₂DS₂VASc评分	1.5±1.1	3.1±1.3	-9.2	<0.001
收缩压（mmHg）	130.6±20.2	133.6±20.3	-1.0	0.310
舒张压（mmHg）	77.1±12.5	77.3±14.2	-0.7	0.950
持续性房颤	55（35.9)	51（72.9）	26.2	<0.001
LVEF(%)	64.2±7.2	65.1±7.6	-0.8	0.410
左心房内径(mm)	41.0±4.0	43.7±3.9	-3.9	<0.001
右心房增大	31（20.3）	24（34.3）	5.1	0.030
二尖瓣反流（3~4分）	4（2.6）	1（1.4）	/	/
三尖瓣最大反流速度（m/s）	2.4±0.2	2.5±0.3	-1.5	0.130
抗凝药治疗^*	123（80.4）	60（85.7）	0.9	0.336
抗血小板治疗^*	15（9.8）	19（27.1）	11.2	0.001

左心耳分型	非脑卒中	脑卒中	总计
鸡翅型	102（75.6）	33（24.4）	135
仙人掌型	19（51.4）	18（48.6）	37
风向标型	21（87.5）	3（12.5）	24
菜花型	11（40.7）	16（59.3）	27
总计	153	70	223

指标	左心耳解剖结构	非脑卒中组（n=153）	脑卒中组（n=70）	t值	P值
开口内径（mm）	0°	20.2±3.0	18.2±4.7	3.2	0.020
	45°	19.5±2.4	17.1±4.0	4.7	<0.001
	90°	19.9±2.7	17.6±4.4	4.1	<0.001
	135°	21.4±3.0	18.8±4.8	4.3	<0.001
开口内径之和（mm）	-	81.0±9.1	71.7±16.5	4.5	<0.001
深度（mm）	0°	23.0±4.2	28.8±5.2	-9.0	<0.001
	45°	22.0±3.5	28.3±4.3	-11.5	<0.001
	90°	21.6±3.7	27.8±4.0	-11.3	<0.001
	135°	19.3±3.3	26.0±4.2	-11.8	<0.001
深度之和（mm）	-	85.9±12.2	111.0±14.9	-13.2	<0.001
深度/开口内径比值	0°	1.1±0.2	1.7±0.6	-8.0	<0.001
	45°	1.1±0.2	1.8±0.5	-9.9	<0.001
	90°	1.1±0.2	1.7±0.6	-8.4	<0.001
	135°	0.9±0.2	1.5±0.5	-9.5	<0.001
深度之和/开口之和比值	-	1.1±0.1	1.6±0.5	-9.8	<0.001
分叶数（个）	-	1.2±0.4	2.0±0.8	-8.0	<0.001

指标	曲线下面积	标准误	P值	95%置信区间
指标	曲线下面积	标准误	P值	下限	上限
左心耳开口内径（mm）
0°	0.630	0.045	0.002	0.542	0.719
45°	0.685	0.044	<0.001	0.600	0.771
90°	0.653	0.044	<0.001	0.567	0.739
135°	0.673	0.044	<0.001	0.587	0.760
各角度之和	0.672	0.044	<0.001	0.586	0.758
左心耳深度（mm）
0°	0.819	0.029	<0.001	0.762	0.876
45°	0.871	0.026	<0.001	0.820	0.922
90°	0.872	0.025	<0.001	0.823	0.920
135°	0.899	0.023	<0.001	0.855	0.944
各角度之和	0.905	0.021	<0.001	0.864	0.946
左心耳深度/开口内径比值
0°	0.831	0.033	<0.001	0.767	0.896
45°	0.892	0.027	<0.001	0.840	0.944
90°	0.854	0.030	<0.001	0.796	0.912
135°	0.871	0.031	<0.001	0.810	0.933
各角度之和	0.883	0.030	<0.001	0.825	0.941
左心耳血流速度（cm/s）	0.843	0.029	<0.001	0.787	0.900
年龄（岁）	0.644	0.038	0.001	0.570	0.718
左房内径（mm）	0.648	0.038	<0.001	0.573	0.722
CHA₂DS₂VASc评分（分）	0.813	0.030	<0.001	0.754	0.873
肾小球滤过率[mL/（min·1.73 m²）]	0.813	0.030	<0.001	0.754	0.873

指标	OR值（95%置信区间）	P值
开口内径之和（mm）	0.901（0.831,0.977）	0.012
深度之和（mm）	1.192（1.092,1.301）	<0.001
心耳内血流速度(cm/s)	0.922（0.871,0.975）	0.005