【摘要】 目的：对比研究经胸超声心动图（transthoracic echocardiography,TTE）及经食道超声心动图（transesophageal echocardiography,TEE）结合声学造影对卵圆孔未闭（patent foramen ovale,PFO）右向左分流（right-to-left shunt,RLS）的评估价值，提出最佳诊断策略。方法：回顾性纳入2020年2月—2022年2月南京医科大学第一附属医院心血管内科收治的186例隐源性卒中（cryptogenic stroke,CS）、短暂性脑缺血发作（transient ischemic attack,TIA）、偏头痛的患者，并经TEE或心导管检查证实为PFO的患者，分别进行经胸超声心动图下声学造影（contrast transthoracic echocardiography,c TTE）及经食道超声心动图下声学造影（contrast transesophageal echocardiography,cTEE）。另外在cTEE下配合患者自主Valsalva动作增加1次检查者握拳放置患者腹部按压放松的操作，分别观察3个心动周期内左房左室内微气泡出现的数量，评估房间隔水平的RLS分流程度。结果：静息时cTTE检测到RLS 136例，cTEE检测到RLS 140例。Valsalva动作下，c TTE检测到RLS 186例，c TEE检测到RLS 186例，提示Valsalva动作时无论cTTE还是cTEE,PFO-RLS检出率均有显著提升。检出RLS的PFO患者，c TTE检测到Ⅰ级27例，Ⅱ级31例，Ⅲ级128例；c TEE检测到Ⅰ级80例，Ⅱ级56例，Ⅲ级50例。110例患者cTTE检出的RLS分流程度高于c TEE，其中46例c TTE时Ⅲ级，cTEE时Ⅱ级；43例cTTE时Ⅲ级，cTEE时Ⅰ级；21例cTTE时Ⅱ级，cTEE时Ⅰ级。c TEE下进行Valsalva动作时，同时配合检查者握拳放置腹部按压放松时，检测到RLSⅠ级35例，Ⅱ级46例，Ⅲ级105例，76例患者RLS分流程度提升，其中21例患者从Ⅰ级提升到Ⅱ级，24例患者从Ⅰ级提升到Ⅲ级，31例患者从Ⅱ级提升到Ⅲ级，中-大量分流的比例显著增加。结论：cTTE检出的RLS分流程度高于cTEE。cTEE检查时，患者配合检查者按压，Valsalva动作下检出的RLS分流程度增加。c TTE结合TEE对PFO解剖结构的判断、对PFO治疗及封堵术前评估有较大价值。更多还原

【Abstract】 Objective:This study aims to compare transthoracic echocardiography(TTE)and transesophageal echocardiography(TEE)combined with contrast echocardiography in the evaluation of right-to-left shunt(RLS)of patent foramen ovale(PFO),and propose the optimal diagnostic strategy. Methods:A retrospective study was conducted on 186 patients admitted the cardiovascular department of the First Affiliated Hospital of Nanjing Medical University from February 2020 to February 2022 with cryptogenic stroke(CS),transient ischemic attack(TIA)and migraine who were confirmed to have a patent foramen ovale(PFO)through TEE or cardiac catheterization. Both contrast transthoracic echocardiography(cTTE)and contrast transesophageal echocardiography(cTEE)were performed. In addition,during cTEE,the operator clenched their fist and placed it on the patient’s abdomen,applying pressure and then releasing it,while the patient performed a Valsalva maneuver. The number of microbubbles appearing in the left atrium and left ventricle within three cardiac cycles was observed to assess the degree of RLS at the level of the interatrial septum. Results:During rest,cTTE detected 136 cases of RLS,while cTEE detected 140 cases of RLS. During the Valsalva maneuver,c TTE detected 186cases of RLS,and cTEE also detected 186 cases of RLS,indicating a significant increase in the detection rate of PFO-RLS during the Valsalva maneuver compared to the rest state,regardless of the cTTE or c TEE method. Among the PFO patients with RLS detected,cTTE classified 27 cases as grade Ⅰ,31 cases as grade Ⅱ,and 128 cases as grade Ⅲ. On the other hand,c TEE classified 80 cases as grade I,56 cases as grade Ⅱ,and 50 cases as grade Ⅲ. Among these cases,110 patients had a higher RLS degree in cTTE compared to cTEE,with 46 cases being grade Ⅲ in cTTE and grade Ⅱ in cTEE,43 cases being grade Ⅲ in cTTE and grade Ⅰ in c TEE,and 21cases being grade Ⅱ in cTTE and grade Ⅰ in c TEE. During the Valsalva maneuver with cTEE,while the operator clenched their fist and applied pressure on the patient’s abdomen and then released it,35 cases were classified as grade Ⅰ,46 cases as grade Ⅱ,and105 cases as grade Ⅲ. There were 76 patients with an increase in RLS degree,including 21 patients who upgraded from grade Ⅰ to grade Ⅱ,24 patients who upgraded from grade Ⅰ to grade Ⅲ,and 31 patients who upgraded from grade Ⅱ to grade Ⅲ. The proportion of patients with moderate to large shunting significantly increased. Conclusion:The RLS level detected by c TTE is higher than that of cTEE. During the cTEE examination,when the patient cooperates with the examiner to press,the degree of RLS detected under Valsalva’s action increases. The combination of cTTE and TEE in diagnosing the anatomical structure and morphology of PFO is of great value for the treatment and preoperative evaluation of PFO occlusion.更多还原