Risk factors of out-of hospital pericardial effusion after left atrial appendage closure
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摘要: 目的 探讨左心耳和毗邻结构的距离以及术后心律与左心耳封堵(left atrial appendage closure，LAAC)术后院外心包积液(out-of-hospital pericardial effusion，OHPE)的关系。方法 回顾性纳入2015年5月—2019年5月于南方医科大学南方医院行LAAC的52例患者，其中发生OHPE 12例纳入OHPE组，余40例纳入对照组。利用心血管造影计算机断层扫描(cardiac computed tomography angiography，cCTA)评估左心耳与毗邻结构，包括肺动脉(pulmonary artery，PA)、左上肺静脉(left superior pulmonary vein，LSPV)、左冠状动脉回旋支(left circumflex coronary artery，LCX)的距离。采用多因素logistic回归分析LAAC术后发生OHPE的危险因素，并利用受试者工作特征曲线(receiver operating characteristic curve，ROC)分析危险因素对OHPE的诊断价值。结果 与对照组比较，OHPE组左心耳与PA、LSPV的距离明显减小[PA：(3.6±1.5) mm vs (2.5±1.3) mm，P=0.006；LSPV：(3.2±1.4) mm vs (2.6±1.9) mm，P=0.025]；两组左心耳与LCX的距离差异无统计学意义(P=0.157)。多因素回归分析显示，左心耳与PA的距离是LAAC术后发生OHPE的独立保护因素(OR=0.466，95%CI：0.234~0.927，P=0.030)。左心耳与PA的距离预测OHPE的ROC曲线下面积为0.765(95%CI：0.626~0.871，P < 0.01)，最佳预测值为2 mm，特异度为90.0%，灵敏度为58.3%。此外，转复窦性心律的患者更易发生OHPE(OR=7.071，95%CI：1.124~44.506，P=0.037)。结论 左心耳与PA的距离可作为LAAC术后OHPE的预测指标，转复窦性心律的患者更容易发生OHPE。Abstract: Objective To explore the relationship between the distance from the left atrial appendage to neighboring structures, postoperative heart rhythm, and out-of-hospital pericardial effusion(OHPE) after left atrial appendage closure(LAAC).Methods Fifty-two patients who underwent LAAC at Southern Hospital of Southern Medical University from May 2015 to May 2019 were retrospectively included, 12 cases with OHPE were included in the OHPE group, and the other 40 cases were included in the control group. Cardiac computed tomography angiography(cCTA) was used to measure the distance from the left atrial appendage to neighboring structures, including the pulmonary artery(PA), left superior pulmonary vein(LSPV), and left circumflex coronary artery(LCX). Logistic regression analysis was used to identify risk factors of OHPE after LAAC, and the receiver operating characteristic curve(ROC) was used to analyze the diagnostic value of risk factors for OHPE.Results Compared with the control group, the distance from the left atrial appendage to PA and LSPV in the OHPE group was significantly shorter(PA: [3.6±1.5]mm vs[2.5±1.3]mm, P=0.006; LSPV: [3.2±1.4]mm vs[2.6±1.9]mm, P=0.025); There was no statistically significant difference in the distance from the left atrial appendage to LCX between the two groups(P=0.157). Logistic regression analysis showed that the distance from the left atrial appendage to PA was an independent protective factor for OHPE(OR=0.466, 95%CI: 0.234-0.927, P=0.030). ROC analysis revealed that the area under the ROC curve of OHPE predicted by the distance from the left atrial appendage to PA was 0.765(95%CI: 0.626-0.871, P < 0.01), the cut-off value was 2 mm, the specificity was 90.0%, and the sensitivity was 58.3%. Otherwise, patients who converted to sinus rhythm were more likely to develop OHPE(OR=7.071, 95%CI: 1.124-44.506, P=0.037).Conclusion The distance from the left atrial appendage to PA can be used as a predictor of OHPE after LAAC. Patients who converted to sinus rhythm are more likely to develop OHPE.
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图 1 左心耳与PA的距离预测OHPE的ROC曲线
Figure 1. The ROC curve of OHPE predicted by the distance from left atrial appendage to PA
表 1 研究对象的临床基线资料
Table 1. Clinical baseline data
例(%), X±S 项目 整体(52例) 对照组(40例) OHPE组(12例) P 年龄/岁 66.7±8.3 66.4±8.2 67.6±9.3 0.671 男性 33(63.5) 23(57.5) 10(83.3) 0.198 BMI/(kg/m2) 24.9±4.3 24.8±4.1 25.0±5.1 0.872 高血压 36(69.2) 26(65.0) 10(83.3) 0.395 糖尿病 8(15.4) 4(10.0) 4(33.3) 0.131 CHA2DS2-VASc评分 4.4±1.8 4.3±1.7 4.8±2.1 0.412 HAS-BLED评分 2.0±1.1 2.0±1.0 1.9±1.2 0.991 左心室射血分数/% 59.5±8.0 60.4±7.1 56.6±10.4 0.154 左心房内径/mm 44.7±6.7 44.4±6.2 45.6±8.5 0.312 NYHA分级 1.000 Ⅰ 10(19.2) 8(20.0) 2(16.7) Ⅱ 39(75.0) 30(75.0) 9(75.0) Ⅲ 3(5.8) 2(5.0) 1(8.3) 房颤类型 0.811 阵发性 18(34.6) 13(32.5) 5(41.7) 持续性 34(65.4) 27(67.5) 7(58.3) 封堵器类型 0.565 盖子式 16(30.8) 11(27.5) 5(41.7) 塞子式 36(69.2) 29(72.5) 7(58.3) 封堵器尺寸/mm 28.8±3.7 29.0±3.5 28.3±4.3 0.566 左心耳类型 0.212 仙人掌型 11(21.2) 10(25.0) 1(8.3) 鸡翅型 16(30.8) 14(35.0) 2(16.7) 风向标型 10(19.2) 7(17.5) 3(25.0) 菜花型 15(28.8) 9(22.5) 6(50.0) cCTA测量值/mm 左心耳开口长轴 28.9±3.8 29.4±3.5 27.2±4.5 0.089 左心耳开口短轴 22.2±4.8 22.6±4.5 20.6±5.5 0.193 术式 0.321 一站式手术 40(76.9) 29(72.5) 11(91.7) 仅左心耳封堵 12(23.1) 11(27.5) 1(8.3) 
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表 2 对照组与OHPE组左心耳毗邻结构的距离
Table 2. The distance from the left atrial appendage to adjacent structures
mm, X±S 组别 左心耳与PA距离 左心耳与LSPV距离 左心耳与LCX距离 对照组(40例) 3.6±1.5 3.2±1.4 2.9±1.5 OHPE组(12例) 2.5±1.3 2.6±1.9 3.4±1.2 P 0.006 0.025 0.157
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表 3 OHPE危险因素的logistic回归分析
Table 3. Risk factors of OHPE analyzed by logistic analysis
项目 单因素 多因素 OR 95%CI P OR 95%CI P 糖尿病 4.500 0.924~21.925 0.063 4.639 0.779~27.619 0.092 左心耳与PA距离 0.463 0.236~0.907 0.025 0.466 0.234~0.927 0.030
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