多平面经食管超声心动图在鉴别左心耳内血栓与梳状肌的作用
作者：杨宗奇 沈卫峰 张绍昌 施仲伟 胡厚达 陶巨蔚
单位：杨宗奇 沈卫峰 施仲伟 胡厚达 上海市，上海第二医科大学附属瑞金医院 心内科 200025；张绍昌 陶巨蔚 上海胸科医院
关键词：超声心动描记术,经食管 左心耳梳状肌 血栓形成
中国循环杂志990115 摘要 目的:了解多平面经食管超声心动图(TEE)在鉴别左心耳内血栓与梳状肌的作用。方法:采用多平面TEE观察54例风湿性心脏病二尖瓣狭窄患者左心耳结构。结果:54例患者中,30例在0～90°扫描切面左心耳尖部或侧壁出现直径0.30～0.78 cm大小回声,类似血栓形成,但当扫描切面转至110～135°时,左心耳底部可见2～4个平行排列、清晰的点状或条索状回声,为梳状肌,其中12例为手术证实;24例在0～90°C以及110～135°时左心耳和(或)左心房体部可见直径1.0～3.4 cm大小边缘清楚、致密的回声光团,为血栓形成,其中18例为手术证实。结论:多平面TEE能清晰观察左心耳内发达的梳状肌,并能与血栓作出可靠的鉴别诊断。
, http://www.100md.com
Usefulness of Multiplane Transesophageal Echocardiography in Differentiating Left Atrial Appendage Thrombus From Pectinate Muscles
Yang Zongqi,Shen Weifeng,Zhang Shaochang,et al.
Department of Cardiology,Ruijin Hospital,Shanghai Second Medical University,Shanghai(200025)
Abstract Objective:To understand the usefulness of multiplane transesophageal echocardiography(TEE) in differentiating left atrial appendage(LAA) thrombus from pectinate muscles.Methods:Fifty-four patients with rheumatic mitral stenosis were performed multiplane TEE to observe the structre of LAA.Results:In 30 among the 54 patients,with 0 degree to 90 degree imaging planes,mass(0.30～0.78 cm in diameter)present in the lateral wall or apex of LAA that may mimic thromi.By rotating transducer to 110 degree to 135 degree imaging planes,2～4 distinct pectinate muscles were identified,and no thrombus was seen,which were confirmed in operation in 12 patients.In another 24 patients,thrombi(1.0～3.4 cm in diameter)in the LAA and/or left atrial body were detected both at 0 degree to 90 degree imaging planes and 110 degree to 135 degree imaging planes,these were in agreement with findings during operation in 18 patients.Conclusion:Multiplane TEE could provide a unique view for us to clearly visulize the pectinate muscles and thus to differentiate it from thrombus.
, 百拇医药
Key words Echocardiography,Transesophageal;Left atrial appendage pectinate muscles;Thrombosis
本研究采用多平面经食管超声心动图(TEE)检查风湿性心脏病二尖瓣狭窄患者左心房、左心耳,了解多平面TEE在鉴别左心耳血栓与梳状肌的作用。
1 对象与方法
研究对象:1996年4月至1998年3月的54例行TEE检查的风湿性心脏病二尖瓣狭窄患者,其中男15例,女39例,年龄30～75(平均43.1±10.0)岁。窦性心律12例,心房颤动42例。14例患者行二尖瓣球囊扩张术,30例患者于体外循环下行直视瓣膜替换术。
超声心动图检查:采用HP-2500型和HP-2000型超声心动图仪。TEE检查采用5.0 MHZ多平面64晶片相控阵探头,按常规方法进行;以直径(cm)表示左心房、左心耳内团块状回声大小,非圆形团块状回声的直径为两个垂直方向的直径相加除以2。
, http://www.100md.com
2 结果
54例患者中,30例在0～90°扫描切面左心耳尖部或侧壁出现直径0.30～0.78 cm大小回声,类似血栓形成,但当扫描切面转至110～135°时,左心耳底部可见2～4个平行排列、清晰的点状或条索状回声(梳状回声),为梳状肌,其中12例手术,术中可见左心耳内梳状肌;24例在0～90°以及110～135°时左心耳和(或)左心房可见1.0～3.4 cm大小边缘清楚、致密的回声光团,为血栓形成(左心房体部血栓8例,左心耳血栓13例,二者同时并存3例),其中18例手术,术中可见左心房或左心耳血栓形成(附图)。
附图 左心耳梳状肌在经食管超声心动图各扫描切面的表现。在0°和45°扫描切面左心耳侧壁出现点状或块状回声,类似血栓(附图a、b),但当扫描切面转至125°时,左心耳底部可见4个平行排列、清晰的条索状回声(附图c),为梳状肌
, 百拇医药
在出现左心耳和(或)左心房血栓的24例患者中,16例左心耳梳状肌未能显示,另8例于110～135°扫描切面左心耳均可见清晰的梳状回声。
3 讨论
TEE常用于检测左心房腔和左心耳内的血栓形成。当患者疑有外周血管栓塞,决定是否需要抗凝治疗,对心房颤动施行复律治疗,对二尖瓣狭窄准备做二尖瓣球囊扩张术或外科闭式二尖瓣交界分离术,术前了解左心房和左心耳内有无血栓等,采用TEE检查颇为重要[1～4]。
左心耳为狭长的管状结构,壁厚,其边缘有数个深陷切迹,其腔面肌小梁交织成网(即梳状肌)。左心耳与左心房交界口较窄,尾端呈钩状,当血流缓慢时,左心耳内易于血栓形成[5]。Veinot等[6]对500例正常左心耳解剖结构研究表明,左心耳具有多个分叶(80%有2个以上分叶),这些分叶位于不同的平面,97%的左心耳梳状肌≥0.01 cm。如果没有认识到左心耳这些解剖结构变化,进行超声心动图检查时:①仅从某一切面观察,可能把正常的分叶当作血栓或者遗漏在另一叶出现的血栓;②分隔左肺上静脉与左心耳的膜状或嵴状组织可被误认为血栓或团块状回声[7,8];③梳状肌可能被误认为血栓[8]。
, http://www.100md.com
本研究于110～135°扫描切面为2～4个点状或条索状回声的梳状肌,在0～90°扫描切面表现为左心耳内直径0.30～0.78 cm大小回声,TEE检查时,结合多个扫描切面特别是在110～135°扫描切面能将左心耳内血栓与梳状肌鉴别开来。虽然单平面TEE和双平面TEE可通过转动管体,结合探头侧曲和前后弯曲增加视野,但延长检查时间给患者带来不适,而多平面探头可于0～180°范围内选择无数个扫描切面观察心脏结构,为鉴别左心耳内血栓与梳状肌提供最佳的观测视野。
故多平面TEE能清晰观察左心耳内发达的梳状肌,并能与血栓作出可靠的鉴别诊断。
作者简介：杨宗奇 男 36岁 主治医师 博士
参考文献
1 Achenberg W,Schluter M,Kremer P,et al.Transesophageal two-dimentional echocardiography form the detection of left atrial appendage thrombus.J Am Coll Cardiol,1986,7:163—166.
, http://www.100md.com
2 Pearson AC,Labovitz AJ,Tatieni S,et al.Superiority of transesophayeal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology.J Am Coll Cardiol,1991,17:66—72.
3 Manning WJ,Silverman DI,Gordon TSPF,et al.Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi.N Eng J Med,1993,328:750—755.
, http://www.100md.com
4 Orsinelli DA,Pearson AC.Usefulness of transesophageal echocardiography to screen for left atrial thrombus before elective cardioversion for atrial fibrillation.Am J Cardiol,1993,1337—1339.
5 Sharma S,Devine W,Anderson RH,et al.The determination of atrial arrangement by examination of appendage morphology in 1 842 heart specimens.Br Heart J,1988,60:227—231.
6 Veinot JP,Harrity PJ,Getil F,et al.Anatomy of the normal left atrial appendage:A quantitative study of age related changes in 500 autopsy hearts:implications for echcardiographic examination.Circulation,1997,96:3112—3115.
, http://www.100md.com
7 Blandchard DG,Dittrich HC,Mitchell M,et al.Diagnostic pitfalls in transesophageal echocardiography.J Am Soc Echocardiogr,1992,5:525—540.
8 Seward JB,Khandheria BK,Oh JK,et al.Critical appraisal of transesophageal echocardiography:limitations,pitfalls,and complications.J Am Soc Echocardiogr,1992,5:288—395.
(收稿:1998-05-30 修回:1998-11-11), 百拇医药
单位：杨宗奇 沈卫峰 施仲伟 胡厚达 上海市，上海第二医科大学附属瑞金医院 心内科 200025；张绍昌 陶巨蔚 上海胸科医院
关键词：超声心动描记术,经食管 左心耳梳状肌 血栓形成
中国循环杂志990115 摘要 目的:了解多平面经食管超声心动图(TEE)在鉴别左心耳内血栓与梳状肌的作用。方法:采用多平面TEE观察54例风湿性心脏病二尖瓣狭窄患者左心耳结构。结果:54例患者中,30例在0～90°扫描切面左心耳尖部或侧壁出现直径0.30～0.78 cm大小回声,类似血栓形成,但当扫描切面转至110～135°时,左心耳底部可见2～4个平行排列、清晰的点状或条索状回声,为梳状肌,其中12例为手术证实;24例在0～90°C以及110～135°时左心耳和(或)左心房体部可见直径1.0～3.4 cm大小边缘清楚、致密的回声光团,为血栓形成,其中18例为手术证实。结论:多平面TEE能清晰观察左心耳内发达的梳状肌,并能与血栓作出可靠的鉴别诊断。
, http://www.100md.com
Usefulness of Multiplane Transesophageal Echocardiography in Differentiating Left Atrial Appendage Thrombus From Pectinate Muscles
Yang Zongqi,Shen Weifeng,Zhang Shaochang,et al.
Department of Cardiology,Ruijin Hospital,Shanghai Second Medical University,Shanghai(200025)
Abstract Objective:To understand the usefulness of multiplane transesophageal echocardiography(TEE) in differentiating left atrial appendage(LAA) thrombus from pectinate muscles.Methods:Fifty-four patients with rheumatic mitral stenosis were performed multiplane TEE to observe the structre of LAA.Results:In 30 among the 54 patients,with 0 degree to 90 degree imaging planes,mass(0.30～0.78 cm in diameter)present in the lateral wall or apex of LAA that may mimic thromi.By rotating transducer to 110 degree to 135 degree imaging planes,2～4 distinct pectinate muscles were identified,and no thrombus was seen,which were confirmed in operation in 12 patients.In another 24 patients,thrombi(1.0～3.4 cm in diameter)in the LAA and/or left atrial body were detected both at 0 degree to 90 degree imaging planes and 110 degree to 135 degree imaging planes,these were in agreement with findings during operation in 18 patients.Conclusion:Multiplane TEE could provide a unique view for us to clearly visulize the pectinate muscles and thus to differentiate it from thrombus.
, 百拇医药
Key words Echocardiography,Transesophageal;Left atrial appendage pectinate muscles;Thrombosis
本研究采用多平面经食管超声心动图(TEE)检查风湿性心脏病二尖瓣狭窄患者左心房、左心耳,了解多平面TEE在鉴别左心耳血栓与梳状肌的作用。
1 对象与方法
研究对象:1996年4月至1998年3月的54例行TEE检查的风湿性心脏病二尖瓣狭窄患者,其中男15例,女39例,年龄30～75(平均43.1±10.0)岁。窦性心律12例,心房颤动42例。14例患者行二尖瓣球囊扩张术,30例患者于体外循环下行直视瓣膜替换术。
超声心动图检查:采用HP-2500型和HP-2000型超声心动图仪。TEE检查采用5.0 MHZ多平面64晶片相控阵探头,按常规方法进行;以直径(cm)表示左心房、左心耳内团块状回声大小,非圆形团块状回声的直径为两个垂直方向的直径相加除以2。
, http://www.100md.com
2 结果
54例患者中,30例在0～90°扫描切面左心耳尖部或侧壁出现直径0.30～0.78 cm大小回声,类似血栓形成,但当扫描切面转至110～135°时,左心耳底部可见2～4个平行排列、清晰的点状或条索状回声(梳状回声),为梳状肌,其中12例手术,术中可见左心耳内梳状肌;24例在0～90°以及110～135°时左心耳和(或)左心房可见1.0～3.4 cm大小边缘清楚、致密的回声光团,为血栓形成(左心房体部血栓8例,左心耳血栓13例,二者同时并存3例),其中18例手术,术中可见左心房或左心耳血栓形成(附图)。
附图 左心耳梳状肌在经食管超声心动图各扫描切面的表现。在0°和45°扫描切面左心耳侧壁出现点状或块状回声,类似血栓(附图a、b),但当扫描切面转至125°时,左心耳底部可见4个平行排列、清晰的条索状回声(附图c),为梳状肌
, 百拇医药
在出现左心耳和(或)左心房血栓的24例患者中,16例左心耳梳状肌未能显示,另8例于110～135°扫描切面左心耳均可见清晰的梳状回声。
3 讨论
TEE常用于检测左心房腔和左心耳内的血栓形成。当患者疑有外周血管栓塞,决定是否需要抗凝治疗,对心房颤动施行复律治疗,对二尖瓣狭窄准备做二尖瓣球囊扩张术或外科闭式二尖瓣交界分离术,术前了解左心房和左心耳内有无血栓等,采用TEE检查颇为重要[1～4]。
左心耳为狭长的管状结构,壁厚,其边缘有数个深陷切迹,其腔面肌小梁交织成网(即梳状肌)。左心耳与左心房交界口较窄,尾端呈钩状,当血流缓慢时,左心耳内易于血栓形成[5]。Veinot等[6]对500例正常左心耳解剖结构研究表明,左心耳具有多个分叶(80%有2个以上分叶),这些分叶位于不同的平面,97%的左心耳梳状肌≥0.01 cm。如果没有认识到左心耳这些解剖结构变化,进行超声心动图检查时:①仅从某一切面观察,可能把正常的分叶当作血栓或者遗漏在另一叶出现的血栓;②分隔左肺上静脉与左心耳的膜状或嵴状组织可被误认为血栓或团块状回声[7,8];③梳状肌可能被误认为血栓[8]。
, http://www.100md.com
本研究于110～135°扫描切面为2～4个点状或条索状回声的梳状肌,在0～90°扫描切面表现为左心耳内直径0.30～0.78 cm大小回声,TEE检查时,结合多个扫描切面特别是在110～135°扫描切面能将左心耳内血栓与梳状肌鉴别开来。虽然单平面TEE和双平面TEE可通过转动管体,结合探头侧曲和前后弯曲增加视野,但延长检查时间给患者带来不适,而多平面探头可于0～180°范围内选择无数个扫描切面观察心脏结构,为鉴别左心耳内血栓与梳状肌提供最佳的观测视野。
故多平面TEE能清晰观察左心耳内发达的梳状肌,并能与血栓作出可靠的鉴别诊断。
作者简介：杨宗奇 男 36岁 主治医师 博士
参考文献
1 Achenberg W,Schluter M,Kremer P,et al.Transesophageal two-dimentional echocardiography form the detection of left atrial appendage thrombus.J Am Coll Cardiol,1986,7:163—166.
, http://www.100md.com
2 Pearson AC,Labovitz AJ,Tatieni S,et al.Superiority of transesophayeal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology.J Am Coll Cardiol,1991,17:66—72.
3 Manning WJ,Silverman DI,Gordon TSPF,et al.Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi.N Eng J Med,1993,328:750—755.
, http://www.100md.com
4 Orsinelli DA,Pearson AC.Usefulness of transesophageal echocardiography to screen for left atrial thrombus before elective cardioversion for atrial fibrillation.Am J Cardiol,1993,1337—1339.
5 Sharma S,Devine W,Anderson RH,et al.The determination of atrial arrangement by examination of appendage morphology in 1 842 heart specimens.Br Heart J,1988,60:227—231.
6 Veinot JP,Harrity PJ,Getil F,et al.Anatomy of the normal left atrial appendage:A quantitative study of age related changes in 500 autopsy hearts:implications for echcardiographic examination.Circulation,1997,96:3112—3115.
, http://www.100md.com
7 Blandchard DG,Dittrich HC,Mitchell M,et al.Diagnostic pitfalls in transesophageal echocardiography.J Am Soc Echocardiogr,1992,5:525—540.
8 Seward JB,Khandheria BK,Oh JK,et al.Critical appraisal of transesophageal echocardiography:limitations,pitfalls,and complications.J Am Soc Echocardiogr,1992,5:288—395.
(收稿:1998-05-30 修回:1998-11-11), 百拇医药