袁明远,李炜,郇强,宁忠平,赵志宏

• 1:上海健康医学院附属周浦医院放射科
• 2:上海健康医学院附属周浦医院心血管内科
• 3:杭州师范大学附属医院心血管内科

摘要(Abstract)：

目的 分析心房颤动（房颤）患者左心耳发育不良的临床及影像学特点，探讨其预防左心房血栓抗凝方案。方法 回顾性研究2018年7月至2023年10月上海健康医学院附属周浦医院经左心房电子计算机断层扫描造影成像（CTV）和（或）经食管超声心动图（TEE）检查发现左心耳发育不良的房颤患者5例，分析其临床特征、影像学资料、抗凝治疗方案。结果 5例房颤患者，1例完成左心房CTV及TEE检查，1例完成胸部CT平扫及TEE检查，3例完成左心房CTV检查。5例患者均依靠左心房CTV延迟期及肺静脉期多平面重建和（或）TEE结果诊断左心耳发育不良，TEE可见细小的左心耳间隙或不能见到左心耳口。左心耳发育不良均表现为左心耳小，左心耳壁肥厚，无左心耳腔或左心耳腔细小，左心房CTV对比剂难以进入。5例患者均合并心脑血管动脉粥样硬化，1例行冷冻消融术，既有抗血小板方案也有抗凝方案或二者兼有。结论 左心房CTV延迟期及肺静脉期多平面重建可明确诊断特殊类型的发育不良的左心耳，TEE对诊断有一定辅助作用。伴左心耳发育不良的房颤患者抗凝方案有待进一步认识。

关键词(KeyWords)： 左心耳发育不良;心房颤动;电子计算机断层扫描造影成像;经食管超声心动图;抗凝治疗

Abstract:

Keywords:

基金项目(Foundation): 上海市浦东新区高峰学科建设基金项目（PWYgf2021-04）;; 上海市浦东新区新兴交叉学科建设项目（PWXx2020-06）;; 杭州市重点学科心血管内科学建设基金项目（HZ202014）

作者(Author): 袁明远,李炜,郇强,宁忠平,赵志宏

参考文献(References)：

• [1]Schotten U,Verheule S,Kirchhof P,et al.Pathophysiological mechanisms of atrial fibrillation:a translational appraisal[J].Physiol Rev,2011,91(1):265-325.DOI:10.1152/physrev.00031.2009.
• [2]Patti G,Pengo V,Marcucci R,et al.The left atrial appendage:from embryology to prevention of thromboembolism[J].Eur Heart J,2017,38(12):877-887.DOI:10.1093/eurheartj/ehw159.
• [3]张波,申爱强.先天性左心耳缺如一例[J].中华心血管病杂志,2017,45(7):623-624.DOI:10.3760/cma.j.issn.0253-3758.2017.07.014.
• [4]Hasegawa H,Ito T,Hourai R,et al.Hypoplastic left atrial appendage:a case report and literature review[J].Am J Case Rep,2021,22:e933260.DOI:10.12659/AJCR.933260.
• [5]黄从新,张澍,黄德嘉,等,心房颤动:目前的认识和治疗建议(2018)[J].中华心律失常学杂志,2018,22(4):279-342.DOI:10.3760/cma.j.issn.1007-6638.2018.04.002.
• [6]Tan NY,Yasin OZ,Sugrue A,et al.Anatomy and physiologic roles of the left atrial appendage:implications for endocardial and epicardial device closure[J].Interv Cardiol Clin,2018,7(2):185-199.DOI:10.1016/j.iccl.2017.12.001.
• [7]Tabata T,Oki T,Yamada H,et al.Role of left atrial appendage in left atrial reservoir function as evaluated by left atrial appendage clamping during cardiac surgery[J].Am J Cardiol,1998,81(3):327-332.DOI:10.1016/s0002-9149(97)00903-x.
• [8]Di Biase L,Santangeli P,Anselmino M,et al.Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation?Results from a multicenter study[J].J Am Coll Cardiol,2012,60(6):531-538.DOI:10.1016/j.jacc.2012.04.032.
• [9]Ciuk S,Janas P,Klimek-Piotrowska W.Clinical anatomy of human heart atria and interatrial septum-anatomical basis for interventional cardiologists and electrocardiologists.Part 2:left atrium[J].Kardiol Pol,2018,76(3):510-519.DOI:10.5603/KP.a2018.0001.
• [10]Hensey M,O'Neill L,Mahon C,et al.A review of the anatomical and histological attributes of the left atrial appendage with descriptive pathological examination of morphology and histology[J].J Atr Fibrillation,2018:10(6):1650.DOI:10.4022/jafib.1650.
• [11]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.中国左心耳封堵预防心房颤动卒中专家共识(2019)[J].中华心血管病杂志,2019,47(12):937-955.DOI:10.3760/cma.j.issn.025 3?3758.2019.12.002.
• [12]Barbero U,Ho SY.Anatomy of the atria:a road map to the left atrial appendage[J].Herzschrittmacherther Elektrophysiol,2017,28(4):347-354.DOI:10.1007/s00399-017-0535-x.
• [13]Naksuk N,Padmanabhan D,Yogeswaran V,et al.Left atrial appendage:embryolo gy,anatomy,physiolo gy,arrhythmia and therapeutic intervention[J].JACC Clin Electrophysiol,2016,2(4):403-412.DOI:10.1016/j.jacep.2016.06.006.
• [14]Guo LJ,Ding MY,Sun DD,et al.Congenital absence of left atrial appendage combined with type A Wolff-ParkinsonWhite syndrome diagnosed by multimodal imaging[J].J Clin Ultrasound,2022,50(1):28-30.DOI:10.1002/jcu.23096.
• [15]De Ponti R,Lumia D,Zoli L,et al.Agenesia of the left atrial appendage:possible but very rare[J].J Cardiovasc Med(Hagerstown),2016,17 Suppl 2:e116-e117.DOI:10.2459/ICM.0000000000000173.
• [16]Song IG,Kim SH,Oh YS,et al.Underdevelopment of left atrial appendage[J].Korean Circ J,2017,47(1):141-143.DOI:10.4070/kcj.2016.0181.
• [17]Cresti A,Stricagnoli M,Baratta P,et al.Multimodality imaging and clinical significance of severe left atrial appendage hypoplasia[J].Eur Heart J Cardiovasc Imaging,2020,21(8):936.DOI:10.1093/ehjci/jeaa053.
• [18]Vaideeswar P and Karande S.Congenital absence of the left atrial appendage[J].J Postgrad Med,2020,66(2):108-109.DOI:10.4103/jpgm.JPGM_671_19.
• [19]Cresti A,Solari M,Gismondi AL,et al.Incidence and clinical relevance of left atrial appendage membranes:a new congenital heart disease?[J].Eur Heart J Cardiovasc Imaging,2022,23(5):673-679.DOI:10.1093/ehjci/jeab076.
• [20]Karan A,Omar M,Missov E,et al.A self-flushing left atrial appendage:a case of a fenestrated left atrial appendage membrane[J].Eur Heart J Case Rep,2023,7(8):ytad356.DOI:10.10 9 3/ehj cr/ytad356.
• [21]Sakatani Y,Ito T,Hasegawa H,et al.Left atrial appendage ostial stenosis:a case report and literature review[J].Am J Case Rep,2021,22:e930510.DOI:10,12659/AJCR.930510.
• [22]Tinggaard AB,Korsholm K,Jensen JM,et al.Spontaneously occluded left atrial appendage in a patient with atrial fibrillation and stroke:a case report[J],Eur Heart J Case Rep,2020,4(2):1-4.DOI:10.1093/ehjcr/ytaa027.
• [23]崔贝贝,曹爱芳,李明凤.先天性左心耳缺如伴左肺静脉共干变异一例[J].解剖学杂志,2021,44(3):277.DOI:10.3969/j.issn.1001-1633.2021.03.028.
• [24]Rosso R,Vexler D,Viskin S,et al.Congenital absence of left atrial appendage[J].J Cardiovasc Electrophysiol,2014,25(7):795.DOI:10.1111/jce.12383.
• [25]Pourafkari L,Sadeghpour A,Baghbani-Oskouei A,et al.Absent left atrial appendage:case report and review of the literature[J].Cardiovasc Pathol,2020,45:107178.DOI:10.1016/j.carpath.2019.107178.
• [26]Pashun RA,Gannon MP,Tomassetti C,et al.Congenital absence of the left atrial appendage[J].J Cardiovasc Comput Tomogr,2020,14(6):e115-e117.DOI:10.1016/j.jcct2019.07.009.
• [27]Katsumata Y,Kashimura S,Nishiyama T,et al.The absence of a left atrial appendage in a patient with paroxysmal atrial fibrillation with a persistent left superior vena cava[J].Eur Heart J Cardiovasc Imaging,2017,18(3):374.DOI:10.1093/ehjci/jew227.
• [28]Zalewska L,Geca G,Stanek P.The left atrial appendage congenital aneurysm in a two-year-old child:a case report[J].Cardiol Young,2022,32(7):1154-1157.DOI:10.1017/S1047951121004522.
• [29]Sawieki KT,Mehta CK,Silverberg RA.Five-chambered heart:palpitations and syncope due to a left atrial appendage aneurysm[J].Circ Cardiovasc Imaging,2021,14(12):1147-1150.DOI:10.1161/CIRCIMAGING.121.013469.
• [30]Kissami I,El Ouazzani G,El Bekkaoui M,et al.Giant aneurysm of the left atrial appendage:a case report of a rare cause of dyspnea in a 55-year old woman[J].Ann Med Surg(Lond),2021,71:102905.DOI:10.1016/j.amsu.2021.102905.
• [31]成彦,邹颖,李歆,等.左心耳缺如患者射频消融手术后的抗凝治疗[J].医药导报,2021,40(8):1128-1130.DOI:10.3870/j.issn.1004-0781.2021.08.027.