Clinical value of transesophageal echocardiography combined with right heart acoustic contrast in the diagnosis of pulmonary arteriovenous shunt
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摘要: 目的 探讨经食管超声心动图结合右心声学造影(c-TEE)检测肺内动-静脉分流(P-RLS)的临床价值。方法 对1 893例因不同病因接受经食管超声心动图检查的患者行食管下右心声学造影检查，以评估P-RLS的情况。结果 1 893例患者中，共1 524例患者存在P-RLS(80.5%)，其中1级分流812例，2级分流413例，3级分流299例。342例患者行肺动脉CTA检查，71例患者同时行肺动脉CTA和肺动脉造影检查，共检出肺内动静脉瘘14例(0.9%)。另外，1 125例(73.8%)患者存在卵圆孔未闭右向左分流(PFO-RLS)，826例(54.2%)患者同时存在PFO-RLS和P-RLS，698例(45.8%)患者存在单纯P-RLS。根据有无P-RLS分组，P-RLS患者与无P-RLS患者在性别、年龄、身高、体重、基础疾病、吸烟史、饮酒史上无明显统计学差异。根据是否存在右向左分流(RLS)相关的神经系统并发症(NC)分组，RLS-NC组与对照组间PFO-RLS和总P-RLS的检出率无明显差异，RLS-NC组3级P-RLS的发生率高于对照组(P=0.033)，1级P-RLS的发生率低于对照组(P=0.021)。P-RLS 3级与NC(偏头痛、不明原因脑卒中、晕厥)有显著相关性(OR=3.794；95%CI 1.054~13.653；P=0.041)。结论 c-TEE可以检测是PFO的分流还是P-RLS，P-RLS的发生率很高，P-RLS 3级与NC相关。Abstract: Objective To explore the clinical value of transesophageal echocardiography combined with right heart acoustic contrast(c-TEE) in detecting pulmonary arteriovenous shunt(P-RLS).Methods A total of 1893 patients who underwent transesophageal echocardiography for different etiologies were evaluated for P-RLS by performing inferior right esophageal echocardiography.Results Among 1893 patients, a total of 1524 patients had P-RLS(80.5%), including 812 cases of grade 1 in P-RLS, 413 cases of grade 2, and 299 cases of grade 3. The 342 patients underwent pulmonary artery CTA examination, and 71 patients underwent both pulmonary artery CTA and pulmonary angiography examination. A total of 14 cases(0.9%) of pulmonary arteriovenous fistula were detected. In addition, 1125 patients had right to left shunt of patent foramen ovale(PFO-RLS), accounting for 73.8%. The 826 patients had both PFO-RLS and P-RLS(54.2%), and 698 patients had simple P-RLS(45.8%). There were no significant statistical differences in gender, age, height, weight, underlying diseases, smoking history, and alcohol consumption history between P-RLS patients and without P-RLS patients. According to the presence of neurological complications(NC) related to right to left shunt(RLS), there was no significant difference in the detection rates of PFO-RLS and total P-RLS between the RLS-NC group and the control group. The incidence of grade 3 in P-RLS in the RLS-NC group was higher than that in the control group(P=0.033), and the incidence of grade 1 P-RLS was lower than that in the control group(P=0.021). There is a significant correlation between P-RLS grade 3 and NC(migraine, unexplained stroke, syncope)(OR=3.794; 95%CI1.054-13.653; P=0.041).Conclusion c-TEE can detect whether it is diversion of PFO or P-RLS. The incidence of P-RLS is high, and P-RLS grade 3 is associated with NC.
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表 1 P-RLS和无P-RLS患者基本特征
Table 1. General data
例(%), X±S 项目 P-RLS (1 524例) 无P-RLS (369例) P 男 528(34.6) 199(53.8) 0.070 年龄/岁 45.5±15.7 51.6±14.8 0.100 身高/cm 164.8±7.7 166.2±7.9 0.341 体重/kg 58.8±10.0 61.4±9.1 0.138 高血压 470(30.8) 114(30.8) 0.994 糖尿病 57(3.7) 14(3.8) >0.999 吸烟 142(9.3) 57(15.4) 0.474 饮酒 99(6.5) 43(11.5) 0.410 肝病 43(2.8) 14(3.8) >0.999 慢性阻塞性肺病 0 14(3.8) 0.195 慢性肾脏疾病 0 0 恶性肿瘤 0 0 
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表 2 基本特征与P-RLS的相关性
Table 2. Correlation between basic characteristics and P-RLS
变量 P-RLS OR(95%CI) P 年龄 0.974(0.945~1.003) 0.076 性别 0.453(0.190~1.079) 0.074 身高 0.978(0.924~1.034) 0.429 体重 0.974(0.933~1.017) 0.239 高血压 1.003(0.397~2.539) 0.994 糖尿病 0.971(0.104~9.096) 0.979 吸烟 0.567(0.163~1.976) 0.373 饮酒 0.537(0.129~2.235) 0.392 肝病 0.721(0.072~7.228) 0.781
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表 3 RLS-NC组和对照组基本特征、PFO-RLS、P-RLS情况比较
Table 3. Basic data, PFO-RLS, and P-RLS between RLS-NC and Control Group
例(%), X±S 项目 RLS-NC组(1 225例) 对照组(189例) P 男 479(39.1) 70(37.0) 0.772 年龄/岁 43.4±15.0 53.4±15.6 ＜0.050 身高/cm 165.7±7.3 163.9±8.5 0.171 体重/kg 58.8±9.5 60.2±10.7 0.486 高血压 366(29.9) 66(34.8) 0.563 糖尿病 14(1.1) 16(8.7) 0.048 吸烟 126(10.3) 21(10.9) 0.925 饮酒 56(4.6) 25(13.0) 0.094 PFO-RLS 761(62.1) 107(56.5) 0.534 肺内分流 986(80.5) 152(80.4) 0.997 1级 436(35.6) 107(56.5) 0.021 2级 302(24.1) 33(17.4) 0.997 3级 254(20.7) 12(6.5) 0.033
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