The value of left atrial appendage orifice diameter in predicting peridevice leak after the implantation of WATCHMAN occluder
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摘要:
目的 经皮左心耳封堵术是非瓣膜性心房颤动(房颤)患者脑卒中的有效预防措施，封堵器周边残余分流(PDL)是手术是否成功的重要评价指标，本文探讨左心耳口部直径预测WATCHMAN封堵器植入后残余分流的价值。 方法 回顾性纳入2015年1月—2020年12月在宁波大学附属第一医院心律失常诊疗中心住院接受经皮WATCHMAN左心耳封堵器植入且术后完成经食管超声心动图随访的293例非瓣膜性房颤患者，并根据经食管超声心动图所示的PDL大小将研究对象分为2组：PDL＜3 mm组(253例)和PDL≥3 mm组(40例)。比较2组患者左心耳口部直径大小，采用多因素logistic回归分析左心耳口部直径是否为PDL≥3 mm的独立危险因素，采用ROC曲线评估左心耳口部直径大小对于判断是否存在PDL≥3 mm的价值。 结果 PDL≥3 mm组患者的左心耳口部直径最大值高于PDL＜3 mm组患者[(24.4±3.3)mm vs. (22.3±3.7)mm, P=0.001]。多因素logistic回归分析结果显示左心耳口部直径最大值是PDL≥3 mm的独立影响因素(OR=1.192，95% CI：1.060~1.340，P=0.003)。ROC曲线的AUC为0.675(95% CI：0.590~0.761，P＜0.001)；当左心耳口部直径最大值≥23 mm时，患者可能存在PDL≥3 mm(灵敏度为72.5%，特异度为56.1%)。 结论 在接受WATCHMAN封堵器植入的非瓣膜性房颤患者中，左心耳口部直径大对预测严重PDL有一定的参考价值。 -
关键词:
- 心房颤动 /
- 左心耳封堵术 /
- WATCHMAN封堵器 /
- 左心耳口部直径 /
- 残余分流
Abstract:Objective Percutaneous left atrial appendage (LAA) closure has been proved to be effective in preventing ischemic stroke for patients with nonvalvular atrial fibrillation (AF). Peridevice leak (PDL) is an important parameter to determine the successful implantation of the occluder. This study aimed to investigate the value of LAA orifice diameter in predicting PDL after the implantation of WATCHMAN occluder. Methods A total of 293 patients with AF who underwent LAA closure with WATCHMAN occluder and finished transesophageal echocardiography (TEE) follow-up in the Arrhythmia Center of First Affiliated Hospital of Ningbo University between January 2015 and December 2020 were included. The study population was divided into two groups due to the PDL detected by TEE: PDL < 3 mm group (n=253) and PDL≥3 mm group (n=40). LAA orifice diameter was compared between groups. The relationship between LAA orifice diameter and PDL≥3 mm was analyzed by multivariable logistic regression. The accuracy of LAA orifice diameter for predicting PDL≥3 mm was evaluated by ROC curve. Results LAA maximal orifice diameter in the PDL≥3 mm group was larger than that in the PDL < 3 mm group [(24.4±3.3) mm vs. (22.3±3.7) mm, P=0.001]. Multivariable logistic regression showed that LAA maximal orifice diameter was associated with PDL≥3 mm (OR=1.192, 95% CI: 1.060-1.340, P=0.003). In the ROC analysis, area under the curve was 0.675 (95% CI: 0.590-0.761, P < 0.001). The cut-off value of LAA maximal orifice diameter for predicting PDL≥3 mm was 23 mm, yielding a sensitivity of 72.5% and a specificity of 56.1%. Conclusion LAA orifice diameter has a reference value for predicting significant PDL after the implantation of WATCHMAN occluder in patients with nonvalvular AF. -
图 1 左心耳口部直径预测WATCHMAN封堵器植入后PDL的ROC曲线
Figure 1. ROC curve of left atrial appendage orifice diameter in predicting PDL after WATCHMAN device implantation
表 1 2组非瓣膜性房颤患者基线资料比较
Table 1. Comparison of baseline data between two groups of patients with non-valvular atrial fibrillation
项目 PDL≥3 mm组(n=40) PDL＜3 mm组(n=253) 统计量 P值 年龄(x±s，岁) 69.3±8.9 68.9±8.7 0.271a 0.787 性别(男/女，例) 28/12 169/84 0.161b 0.689 阵发性心房颤动[例(%)] 4(10.0) 60(23.7) 3.806b 0.051 充血性心力衰竭[例(%)] 6(15.0) 26(10.3) 0.792b 0.373 高血压[例(%)] 26(65.0) 168(66.4) 0.030b 0.862 糖尿病[例(%)] 8(20.0) 44(17.4) 0.161b 0.688 短暂性脑缺血发作或脑卒中史[例(%)] 33(82.5) 172(68.0) 3.463b 0.063 血管疾病[例(%)] 27(67.5) 170(67.2) 0.001b 0.969 出血病史[例(%)] 7(17.5) 55(21.7) 0.372b 0.542 CHA2DS2-VASc评分(x±s，分) 4.6±1.2 4.4±1.5 0.897a 0.373 HAS-BLED评分(x±s，分) 3.0±1.1 3.0±1.0 0.085a 0.932 左心房内径(x±s，mm) 45.0±5.7 44.5±7.0 0.433a 0.665 左心室舒张末期内经(x±s，mm) 48.7±6.1 48.5±5.1 0.223a 0.823 左心室射血分数(x±s，%) 60.2±8.4 62.2±7.2 1.158a 0.115 左心耳口部直径最大值(x±s，mm) 24.4±3.3 22.3±3.7 3.410a 0.001 左心耳深度最大值(x±s，mm) 31.7±8.6 27.5±10.4 2.133a 0.034 注：a为t值，b为χ2值。 
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表 2 变量赋值情况
Table 2. Variable assignment situation
变量 赋值方法 性别 男性=1，女性=2 年龄 以实际值赋值 房颤类型 阵发性房颤=1，持续性房颤=2 CHA2DS2-VASc评分 以实际值赋值 HAS-BLED评分 以实际值赋值 左心房内径 以实际值赋值 左心室射血分数 以实际值赋值 左心耳口部直径最大值 以实际值赋值 左心耳深度最大值 以实际值赋值
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表 3 WATCHMAN封堵器植入后PDL≥3 mm影响因素的logistic回归分析
Table 3. Logistic regression analysis to factors associated with PDL (≥3 mm) after WATCHMAN device implantation
变量 B SE Waldχ2 P值 OR值 95% CI 性别(女性) 0.076 0.476 0.026 0.873 1.079 0.424~2.744 年龄 -0.011 0.028 0.142 0.706 0.990 0.937~1.045 持续性房颤 0.462 0.612 0.571 0.450 1.588 0.479~5.268 CHA2DS2-VASc评分 0.165 0.188 0.766 0.382 1.179 0.815~1.706 HAS-BLED评分 -0.046 0.220 0.043 0.836 0.955 0.621~1.470 左心房内径 -0.025 0.033 0.561 0.454 0.976 0.914~1.041 左心室射血分数 -0.041 0.024 2.993 0.084 0.959 0.915~1.006 左心耳口部直径最大值 0.175 0.060 8.594 0.003 1.192 1.060~1.340 左心耳深度最大值 0.029 0.024 1.449 0.229 1.030 0.982~1.080
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