徐婧,陈传智,邢俊,王琦,王亮,张奇

• 1:上海市东方医院(同济大学附属东方医院)心脏内科

摘要(Abstract)：

目的 比较心脏计算机断层扫描（CCT）与经食管超声心动图（TEE）在诊断左心耳封堵术（LAAC）后6个月器械残余漏中的作用。方法 连续纳入2019年4月至12月在上海市东方医院（同济大学附属东方医院）心脏内科成功实施LAAC并同时完成术后6个月CCT及TEE随访的非瓣膜性心房颤动（房颤）患者，分析对比封堵器残余漏情况，并观察器械表面相关血栓及主要临床不良事件的发生率。结果 54例房颤患者成功实施LAAC术（Watchman封堵器47例，Leftear封堵器7例）且同时完成术后6个月的CCT及TEE随访，平均年龄（70.3±8.3）岁，CHA_2DS_2-VASC评分（4.50±1.63）分，HAS-BLED评分（2.72±0.99）分，其中持续性房颤患者31例（57.4%）。LAAC后残余漏分为封堵器周围残余分流和封堵器内皮化不完全所致跨封堵器膜漏。CCT在周围残余分流检出率上高于TEE(38.9%比27.8%,P=0.221)，在内皮化不完全所致跨封堵器膜漏的检出率上显著高于TEE(63.0%比22.2%,P<0.01)。Watchman和Leftear封堵器的内皮化不完全发生率差异有统计学意义（57.4%比100.0%,P=0.038）。3例患者发现器械表面相关血栓形成，所有患者均无卒中、短暂性脑缺血发作、系统性栓塞、大出血、心脏压塞、死亡等主要临床不良事件发生。结论 与TEE相比，CCT能更加精准地发现和诊断LAAC术后封堵器残余漏，尤其对封堵器内皮化不完全的检出率更高。早期诊断封堵器残余漏并调整抗凝策略对于预防器械表面相关血栓形成具有重要的临床意义。

关键词(KeyWords)： 心房颤动;左心耳封堵术;残余漏;经食管超声心动图;心脏计算机断层扫描

Abstract:

Keywords:

基金项目(Foundation): 上海市浦东新区学科带头人计划项目（PWRD2018-06）

作者(Author): 徐婧,陈传智,邢俊,王琦,王亮,张奇

参考文献(References)：

• [1] Schnabel RB, Yin X, Gona P, et al. 50 year trends in atrial fi brillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study:a cohort study[J]. Lancet,2015, 386(9989):154-162.
• [2] Cresti A, García-Fernández MA, Sievert H, et al. Prevalence of extra-appendage thrombosis in non-valvular atrial fibrillation and atrial flutter in patients undergoing cardioversion:a large transoesophageal echo study[J]. EuroIntervention, 2019, 15(3):e225-e230.
• [3] Lip GY, Hammerstingl C, Marin F, et al. Left atrial thrombus resolution in atrial fibrillation or flutter:results of a prospective study with rivaroxaban(X-TRA)and a retrospective observational registry providing baseline data(CLOT-AF)[J].Am Heart J, 2016, 178:126-134.
• [4] Belgaid DR, Khan Z, Zaidi M, et al. Prospective randomized evaluation of the watchman left atrial appendage closure device in patients with atrial fi brillation versus long-term warfarin therapy:The PREVAIL trial[J]. Int J Cardiol, 2016, 219:177-179.
• [5] Osmancik P, Tousek P, Herman D, et al. Interventional left atrial appendage closure vs novel anticoagulation agents in patients with atrial fibrillation indicated for long-term anticoagulation(PRAGUE-17 study)[J]. Am Heart J,2017, 183:108-114.
• [6] Reddy VY, Sievert H, Halperin J, et al. Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation:a randomized clinical trial[J]. JAMA, 2014, 312(19):1988-1998.
• [7] Bai Y, Xue X, Duenninger E, et al. Real-world survival data of device-related thrombus following left atrial appendage closure:4-year experience from a single center[J]. Heart Vessels, 2019, 34(8):1360-1369.
• [8] Pracon R, Bangalore S, Dzielinska Z, et al. Device thrombosis after percutaneous left atrial appendage occlusion is related to patient and procedural characteristics but not to duration of postimplantation dual antiplatelet therapy[J]. Circ Cardiovasc Interv, 2018, 11(3):e005997.
• [9] Qamar SR, Jalal S, Nicolaou S, et al. Comparison of cardiac computed tomography angiography and transoesophageal echocardiography for device surveillance after left atrial appendage closure[J]. EuroIntervention, 2019, 15(8):663-670.
• [10] Banga S, Osman M, Sengupta PP, et al. CT assessment of the left atrial appendage post-transcatheter occlusion-A systematic review and meta analysis[J]. J Cardiovasc Comput Tomogr,2021, 15(4):348-355.
• [11] Saw J, Fahmy P, DeJong P, et al. Cardiac CT angiography for device surveillance after endovascular left atrial appendage closure[J]. Eur Heart J Cardiovasc Imaging, 2015, 16(11):1198-1206.
• [12] Fastner C, Hoffmann L, Aboukoura M, et al. Real-world experience comparing two common left atrial appendage closure devices[J]. BMC Cardiovasc Disord,2018, 18(1):171.
• [13] Ajmal M, Hutchinson MD, Lee K, et al. Outcomes in patients implanted with a Watchman device in relation to choice of anticoagulation and indication for implant[J]. J Interv Card Electrophysiol, 2022,64(1):1-8.
• [14] Chen M, Wang ZQ, Wang QS, et al. One-stop strategy for treatment of atrial fi brillation:feasibility and safety of combining catheter ablation and left atrial appendage closure in a single procedure[J]. Chin Med J(Engl), 2020, 133(12):1422-1428.
• [15] Tzikas A, Holmes DR Jr, Gafoor S, et al. Percutaneous left atrial appendage occlusion:the Munich consensus document on definitions, endpoints, and data collection requirements for clinical studies[J]. Europace, 2017, 19(1):4-15.
• [16] Wunderlich NC, Beigel R, Swaans MJ, et al. Percutaneous interventions for left atrial appendage exclusion:options,assessment, and imaging using 2D and 3D echocardiography[J].JACC Cardiovasc Imaging, 2015, 8(4):472-488.
• [17]王逸轩.超声心动图在非瓣膜性心房颤动患者经皮左心耳封堵术中的应用进展[J].临床超声医学杂志，2020, 22(3):212-215.
• [18] Dudzinski DM, Schwartzenberg S, Upadhyay GA,et al. Role of transesophageal echocardiography in left atrial appendage device closure[J]. Interv Cardiol Clin, 2014, 3(2):255-280.
• [19] Angelillis M, Gargiulo G, Moschovitis A, et al. Computed tomography detection and quantification of left atrial appendage residual patency as collateral finding after percutaneous closure[J]. Int J Cardiol, 2018, 260:42-46.
• [20]李世英，柳景华.欧美出血学术研究会（BARC）关于出血的统一定义[J].中国介入心脏病学杂志，2012, 20(4):231-234.
• [21] Sivasambu B, Arbab-Zadeh A, Hays A, et al. Delayed endothelialization of watchman device identifi ed with cardiac CT[J].J Cardiovasc Electrophysiol, 2019, 30(8):1319-1324.
• [22] Galea R, Gr?ni C. Device neo-endothelialization after left atrial appendage closure:the role of cardiac computed tomography angiography[J]. Int J Cardiovasc Imaging, 2021,37(7):2299-2301.
• [23] Lindner S, Behnes M, Wenke A, et al. Incomplete n e o-endothelialization of left atrial appendage closure devices is frequent after 6 months:a pilot imaging study[J]. Int J Cardiovasc Imaging, 2021,37(7):2291-2298.
• [24] Schwartz RS, Holmes DR, Van Tassel RA, et al. Left atrial appendage obliteration:mechanisms of healing and intracardiac integration[J]. JACC Cardiovasc Interv, 2010, 3(8):870-877.
• [25] Tang X, Zhang Z, Wang F, et al. Percutaneous left atrial appendage closure with lACBES?occluder-a preclinical feasibility study[J]. Circ J, 2017, 82(1):87-92.
• [26] Bass JL. Transcatheter occlusion of the left atrial appendage--experimental testing of a new Amplatzer device[J]. Catheter Cardiovasc Interv, 2010, 76(2):181-185.
• [27] Lam YY, Yan BP, Doshi SK, et al. Preclinical evaluation of a new left atrial appendage occluder(Lifetech LAmbre?device)in a canine model[J]. Int J Cardiol, 2013, 168(4):3996-4001.
• [28] Granier M, Laugaudin G, Massin F, et al. Occurrence of incomplete endothelialization causing residual permeability after left atrial appendage closure[J]. J Invasive Cardiol,2018, 30(7):245-250.
• [29] Massarenti L, Yilmaz A. Incomplete endothelialization o f left atrial appendage occlusion device 10 months after implantation[J]. J Cardiovasc Electrophysiol, 2012, 23(12):1384-1385.
• [30] Prosperi-Porta G, Schnell G, Colbert J, et al. Multiple thromboembolic events from a left atrial appendage occlusion device[J]. Can J Cardiol, 2018, 34(3):342.e313-342.e315.
• [31] Kim YJ, Park SJ, Shin SY, et al. Removed 5-yearold amulet device:triplet of peridevice leakage, poor endothelialization, and device-related thrombus[J]. JACC Cardiovasc Interv,2021,14(21):2405-2406.