李佳琪,鲁静朝,靳雅琼,王梦肖,张洁,王科科,刘凡

• 1:河北医科大学第二医院心内科

摘要(Abstract)：

目的 比较使用心脏CT血管造影（CCTA）和经食管超声心动图（TEE）术前评估左心耳封堵术（LAAC）的差异。方法 计算机检索PubMed、EMBASE、the Cochrane Library、中国知网、万方和中国生物医学文献数据库（CBM）中比较使用CCTA与TEE对LAAC进行术前评估的相关研究，检索时限均为建库至2023年7月18日。使用RevMan 5.4及Stata 15.1软件进行Meta分析。结果 共纳入21篇文献，2 137例患者。与TEE相比，术前使用CCTA测量的左心耳（LAA）最大直径更大（MD 2.27 mm,95%CI1.70～2.83,P<0.001）、预测封堵器尺寸的准确性更高（RR1.67,95%CI1.39～2.01,P<0.001）。基于是否行三维重建和封堵器的类型对以上结局指标进行亚组分析，得出了相似的结果。术前行两种成像方式，手术成功率比较（RR 1.03,95%CI 0.98～1.08,P=0.230）差异无统计学意义。此外，术前行基于CCTA的三维重建，术中更换封堵器数量更少（MD–0.29枚，95%CI–0.53～–0.04,P=0.020），对比剂用量更少（MD–4.48 ml,95%CI–7.40～–1.56,P=0.003），手术时间更短（MD–14.98min,95%CI–17.79～–12.17,P<0.001），术后残余漏发生率更低（RR 0.59,95%CI 0.36～0.99,P=0.040）。结论 与TEE相比，LAAC术前行CCTA，提高了预测封堵器尺寸的准确性。术前行基于CCTA的三维重建，减少了术中更换封堵器的数量和对比剂用量，缩短了手术时间，提高了手术效率，还与较低的术后残余漏的发生率相关。因此，CCTA在LAAC术前评估上更具优势。

关键词(KeyWords)： 心脏CT血管造影;经食管超声心动图;左心耳封堵术;心房颤动

Abstract:

Keywords:

基金项目(Foundation): 河北省科技计划项目（15277770D）

作者(Author): 李佳琪,鲁静朝,靳雅琼,王梦肖,张洁,王科科,刘凡

参考文献(References)：

• [1]Kakkar AK,Mueller I,Bassand JP,et al.Risk profiles and antithrombotic treatment of patients newly diagnosed with atrial fibrillation at risk of stroke:perspectives from the international,observational,prospective GARFIELD registry[J].PLoS One,2013,8(5):e63479.DOI:10.1371/journal.pone.0063479.
• [2]丁树生,宁彬.左心耳封堵术后装置不完全内皮化的危险因素及临床影响[J].中国介入心脏病学杂志,2023,31(9):673-678.DOI:10.3969/j.issn.1004-8812.2023.09.006.
• [3]Kirchhof P,Benussi S,Kotecha D,et al.2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS[J].Eur Heart J,2016,37(38):2893-2962.DOI:10.1093/eurheartj/ehw210.
• [4]January CT,Wann LS,Calkins H,et al.2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation:a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons[J].Circulation,2019,140(2):e125-e151.DOI:10.1161/CIR.0000000000000665.
• [5]Xu B,Betancor J,Sato K,et al.Computed tomography measurement of the left atrial appendage for optimal sizing of the Watchman device[J].J Cardiovasc Comput Tomogr,2018,12(1):50-55.DOI:10.1016/j.jcct.2017.11.012.
• [6]Kavinsky CJ,Kusumoto FM,Bavry AA,et al.SCAI/ACC/HRS Institutional and Operator Requirements for Left Atrial Appendage Occlusion[J].J Am Coll Cardiol,2016,67(19):2295-2305.DOI:10.1016/j.jacc.2015.12.001.
• [7]Zhang K,Zhou J,Zhang T,et al.Comparison of multiple imaging modalities for measuring orifice diameter and selecting occluder size in patients undergoing left atrial appendage closure[J].Clin Cardiol,2022,45(8):864-872.DOI:10.1002/clc.23869.
• [8]Wang M,Li W,Ruan Z,et al.A randomized trial of preoperative planning of left atrial appendage occlusion using cardiac computed tomography angiography[J].Surg Innov,2023,30(3):303-313.DOI:10.1177/15533506231156687.
• [9]Ruan ZB,Wang F,Chen GC,et al.A comparative study of three imaging modalities for size selection of a Watchman left atrial appendage closure device[J].Yonsei Med J,2022,63(4):325-332.DOI:10.3349/ymj.2022.63.4.325.
• [10]Kim WD,Cho I,Kim YD,et al.Improving left atrial appendage occlusion device size determination by three-dimensional printingbased preprocedural simulation[J].Front Cardiovasc Med,2022,9:830062.DOI:10.3389/fcvm.2022.830062.
• [11]Freixa X,Cepas-Guillen P,Korsholm K,et al.Usefulness of a novel sizing chart for left atrial appendage occlusion with the Amplatzer Amulet[J].Catheter Cardiovasc Interv,2022,100(5):801-809.DOI:10.1002/ccd.30406.
• [12]So CY,Kang G,Villablanca PA,et al.Additive value of preprocedural computed tomography planning versus standalone transesophageal echocardiogram guidance to left atrial appendage occlusion:comparison of real-world practice[J].J Am Heart Assoc,2021,10(17):e020615.DOI:10.1161/JAHA.120.020615.
• [13]Osmancik P,Herman D,Linkova H,et al.A comparison of cardiac computed tomography,transesophageal and intracardiac echocardiography,and fluoroscopy for planning left atrial appendage closure[J].J Atr Fibrillation,2021,13(6):20200449.DOI:10.4022/jafib.20200449.
• [14]Italiano G,Maltagliati A,Mantegazza V,et al.Multimodality approach for endovascular left atrial appendage closure:headto-head comparison among 2D and 3D echocardiography,angiography,and computer tomography[J].Diagnostics(Basel),2020,10(12):1103.DOI:10.3390/diagnostics 10121103.
• [15]Hachulla AL,Noble S,Guglielmi G,et al.3D-printed heart modelto guide LAA closure:useful in clinical practice?[J].Eur Radiol,2019,29(1):251-258.DOI:10.1007/s00330-018-5569-x.
• [16]Obasare E,Mainigi SK,Morris DL,et al.CT based 3D printing is superior to transesophageal echocardiography for preprocedure planning in left atrial appendage device closure[J].Int J Cardiovasc Imaging,2018,34(5):821-831.DOI:10.1007/s10554-017-1289-6.
• [17]Eng MH,Wang DD,Greenbaum AB,et al.Prospective,randomized comparison of 3-dimensional computed tomography guidance versus TEE data for left atrial appendage occlusion(PRO3DLAAO)[J].Catheter Cardiovasc Interv,2018,92(2):401-407.DOI:10.1002/ccd.27514.
• [18]Ciobotaru V,Combes N,Martin CA,et al.Left atrial appendage occlusion simulation based on three-dimensional printing:new insights into outcome and technique[J].EuroIntervention,2018,14(2):176-184.DOI:10.4244/EIJ-D-17-00970.
• [19]Rajwani A,Nelson AJ,Shirazi MG,et al.CT sizing for left atrial appendage closure is associated with favourable outcomes for procedural safety[J].Eur Heart J Cardiovasc Imaging,2017,18(12):1361-1368.DOI:10.1093/ehjci/jew212.
• [20]Li H,Qingyao,Bingshen,et al.Application of 3D printing technology to left atrial appendage occlusion[J].Int J Cardiol,2017,231:258-263.DOI:10.1016/j.ijcard.2017.01.031.
• [21]Hell MM,Achenbach S,Yoo IS,et al.3D printing for sizing left atrial appendage closure device:head-to-head comparison with computed tomography and transoesophageal echocardiography[J].EuroIntervention,2017,13(10):1234-1241.DOI:10.4244/EIJ-D-17-00359.
• [22]Chow DH,Bieliauskas G,Sawaya FJ,et al.A comparative study of different imaging modalities for successful percutaneous left atrial appendage closure[J].Open Heart,2017,4(2):e000627.DOI:10.1136/openhrt-2017-000627.
• [23]Saw J,Fahmy P,Spencer R,et al.Comparing measurements of CT angiography,TEE,and fluoroscopy of the left atrial appendage for percutaneous closure[J].J Cardiovasc Electrophysiol,2016,27(4):414-422.DOI:10.1111/jce.12909.
• [24]何莹,高律萍,曹成瑛,等.CCTA三维形态学术前评估在左心耳封堵导管消融一站式治疗中的应用[J].影像科学与光化学,2022,40(6):1364-1369.DOI:10.7517/issn.1674-0475.220804.
• [25]刘阁,陈韬,穆洋,等.三种影像学测量技术对左心耳封堵器尺寸选择的指导价值[J].协和医学杂志,2020,11(1):21-26.DOI:10.3969/j.issn.1674-9081.20190196.
• [26]张涛,陈立斌,储慧民,等.经食管超声心动图及CT左心耳造影在左心耳Watchman封堵术前的应用价值[J].中华超声影像学杂志,2017,26(11):964-969.DOI:10.3760/cma.j.issn.1004-4477.2017.11.011.
• [27]黄从新,张澍,黄德嘉,等.左心耳干预预防心房颤动患者血栓栓塞事件:目前的认识和建议-2019[J].中国心脏起搏与心电生理杂志,2019,33(5):385-401.DOI:10.13333/j.cnki.cjcpe.2019.05.001.
• [28]Budge LP,Shaffer KM,Moorman JR,et al.Analysis of in vivo left atrial appendage morphology in patients with atrial fibrillation:a direct comparison of transesophageal echocardiography,planar cardiac CT,and segmented threedimensional cardiac CT[J],J Interv Card Electrophysiol,2008,23(2):87-93.DOI:10.1007/s10840-008-9281-7.
• [29]Reddy VY,Gibson DN,Kar S,et al.Post-approval U.S.experience with left atrial appendage closure for stroke prevention in atrial fibrillation[J].J Am Coll Cardiol,2017,69(3):253-261.DOI:10.1016/j.j acc.2016.10.010.
• [30]徐婧,陈传智,邢俊,等.心脏计算机断层扫描与经食管超声心动图诊断左心耳封堵术后残余漏的对比研究[J].中国介入心脏病学杂志,2022,30(6):409-415.DOI:10.3969/j.issn.1004-8812.2022.06.003.
• [31]郭琼,赵晴雯,顾先林,等.经心腔内与经食管超声心动图引导下左心耳封堵术的系统评价与Meta分析[J],中国胸心血管外科临床杂志,2022,29(11):1492-1502.DOI:10.7507/1007-4848.202208045.
• [32]KongD,Jiang Y,ZhangX,et al.Reference value of perimeter-derived diameter assessed by three-dimensional transesophageal echocardiography in left atrial appendage occluder size selection[J].Echocardiography,2020,37(11):1828-1837.DOI:10.1111/echo.14705.