经导管主动脉瓣置换术后瓣膜血栓的经胸超声心动图评估The value of transthoracic echocardiography in diagnosis of valve thrombus after transcatheter aortic valve replacement
王建德,任心爽,王婧金,梁玉,逄坤静,王浩,牛冠男,王墨杨,吴永健,吕滨
摘要(Abstract)：
目的 评估经胸超声心动图（TTE）在经导管主动脉瓣置换术（TAVR）术后人工瓣膜血栓中的诊断价值。方法 收集2015年6月至2019年6月于中国医学科学院阜外医院成功实施TAVR的80例患者术前、术后及随访期TTE数据和CT数据进行回顾分析。与CT诊断TAVR瓣膜血栓进行对比，分析TTE在形态学及血流动力学方面评估TAVR瓣膜血栓的价值。结果 随访的80例患者中，CT诊断TAVR瓣膜血栓36例（45.00%）。患者随访时峰值流速（Vmax）、峰值跨瓣压差（PPG）、平均跨瓣压差（MPG）及有效瓣口面积（AVA）与出院前比较，差异均无统计学意义（均P>0.05）。血栓组与正常组Vmax、PPG、MPG、ΔVmax、ΔPPG、ΔMPG及ΔVmax%、ΔPPG%、ΔMPG%比较，差异均无统计学意义（均P>0.05），但是AVA[(1.47±0.29)cm2比（1.71±0.45)cm2，P=0.006]、ΔAVA[（-0.15±0.35)cm2比（0.07±0.44)cm2，P=0.018]及ΔAVA%[（-7.10±18.73）%比（8.61±31.12)%,P=0.007]的差异均有统计学意义。CT血栓负荷低分组18例（50.0%），中间组14例（38.9%），高分组4例（11.1%）。CT血栓负荷高分组与低分组、中间组PPG[(39.15±17.49)mmHg比（17.73±7.21)mmHg比（26.04±12.93)mmHg,P=0.003]、ΔVmax%[(25.01±33.18）%比（-6.52±17.47）%比（3.35±24.30)%,P=0.040]、ΔAVA%[（-30.54±17.10）%比（-4.97±14.87）%比（-3.32±19.95)%,P=0.020]的差异均有统计学意义，而低分组与中间组比较，差异均无统计学意义（均P>0.05）。AVA绝对变化值曲线下面积0.615(P=0.078），以ΔAVA>0.28 cm2预测TAVR瓣膜血栓的特异度为75.0%，敏感度为25.0%。ΔAVA%的曲线下面积为0.638(P=0.035），以ΔAVA%>15.4%预测TAVR瓣膜血栓的特异度为77.3%，敏感度为27.8%。所有患者TTE检查均未发现TAVR瓣叶增厚及血栓附着，仅CT血栓负荷高分组2例患者TTE显示瓣架内血流加速、Vmax及MPG明显增高而提示血栓可能。结论 TAVR术后瓣膜血栓的血流动力学改变以静默为主，AVA的变化可以为血栓形成评估提供参考，但可靠性较差。
关键词(KeyWords)： 血栓;经胸超声心动图;经导管主动脉瓣置换术
基金项目(Foundation):
作者(Author): 王建德,任心爽,王婧金,梁玉,逄坤静,王浩,牛冠男,王墨杨,吴永健,吕滨
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