| Objective: To compare detection results between transesophageal echocardiography(TEE)and CT during the perioperative period of left atrial appendage occlusion(LAAO).Furthermore,to investigate application value of 3DTEE-iCrop and CT-volume rendering technique(CT-VRT)in LAAO.Methods: A retrospective analysis was performed on 43 patients with nonvalvular atrial fibrillation admitted to Taizhou People’s Hospital from June 2020 to February 2021.All patients underwent CT before LAAO,TEE was re-examined for patients diagnosed with LAA thrombosis by CT.TEE and Left atrial appendage angiography(LAA-A)were performed on patients without thrombosis to guide operation during LAAO.1.The detection of LAA thrombus,the evaluation of LAA shape and the evaluation of LAA size measurement by TEE and CT: Preoperative CT was performed.For LAA with poor filling in the first phase,delayed scanning was added to 60 s to determine whether it was completely filled.Patients without filling in both phases underwent preoperative TEE review.Intraoperative TEE was performed for patients without thrombosis.LAA image was obtained from four angles of 0°,45°,90° and 135° in two-dimensional mode,left atrial appendage thrombi were judged again,and the longest diameter and the shortest diameter of LAA orifice were measured.TEE 3D full-volume mode to obtain LAAimage,through the iCrop software to display the LAA spindle morphology and the number of lobes,measured the longest diameter and the shortest diameter of LAAorifice;CT was used to cut out LAA3 D images by VRT,and the spindle morphology and number of lobes of LAAwere judged from multiple angles,and the longest diameter and the shortest diameter of LAAorifice were measured.2.3DTEE-iCrop,CT-VRT and LAA-Aevaluated LAAmaximal orifice long diameter and depth of LAA,and predicted occluder size: The maximum long diameter and depth of LAA orifice were obtained by intraoperative 3DTEE-iCrop and preoperative CT-VRT,and the maximum long diameter and depth of the LAAorifice were measured by LAA-Aafter injecting contrast agent into LAA through pigtail catheter during operation.The maximum orifice long diameter of each measurement method added 3-5mm was used to predict the size of WATCHMAN.Result: When image delay of CT was increased by 60 s,there was no significant difference between CT and TEE in thrombus detection(P>0.05).Using the results of TEE as the standard,the sensitivity,specificity,positive predictive value and negative predictive value of LAA thrombus diagnosed by CT were 100%,97.4%,80% and 100% respectively,and the Kappa value representative of diagnostic consistency with TEE was 0.88(P<0.05).Finally,39 patients underwent LAAO,LAAspindle morphology and lobulation number were evaluated by CT-VRT,results showed that there were 13(33.3%)cases of chicken wing shape,26(66.7%)of non-chicken wing shape,11(28.2%)of single lobed,and 28(71.8%)of multi-lobed.The3DTEE-iCrop showed that there were 13(33.3%)cases of chicken wing shape,26(66.7%)of non-chicken wing shape,12(30.8%)of single lobed,and 27(69.2%)of multi-lobed.And there was no significant difference between 3DTEE iCrop and CT-VRT(P>0.05).Using the results of CT-VRT as the standard,the accuracy of 3DTEE-iCrop for spindle shape was 94.9%,and the Kappa value representative of diagnostic consistency was 0.88(P<0.05),the accuracy for lobulation number was 97.4%,and the Kappa value representative of diagnostic consistency was 0.94(P<0.05).Evaluation results of 2DTEE,3DTEE-iCrop,and CT-VRT: The LAAmaximal orifice long diameter measured by 2DTEE,3DTEE-iCrop and CT-VRT were 22.73±3.08 mm,24.17±3.04 mm and 24.36±3.06 mm respectively,in which there exist statistical difference(P<0.05),of which LAA maximal orifice long diameter detected by 3DTEE-iCrop and CT-VRT were larger than 2DTEE.Multiple comparisons showed that there was no significant difference between 3DTEE iCrop and CT-VRT(P>0.05).Results of 3DTEE-iCrop was highly correlated and consistent with CT-VRT [(r=0.947,P<0.05,ICC = 0.95(0.90～ 0.97)].The LAA orifice short diameters were 19.36±2.85 mm for 2DTEE,19.27±2.63 mm for 3DTEE-iCrop,and 20.50±3.06 mm for CT-VRT respectively,and there was no significant difference in LAA orifice short diameters measured by three imaging modalities(P<0.05),and there was significant correlation and consistency among the three results [2DTEE and 3DTEE-iCrop: r=0.738,P<0.05;2DTEE and CT-VRT: r=0.611,P<0.05;3DTEE-iCrop and CT-VRT: r=0.835,P<0.05;ICC=0.72(0.58～0.83),P<0.05].Evaluation results of 3DTEE-iCrop,CT-VRT and LAA-A: The difference of LAA maximal orifice long diameter measured by 3DTEE-iCrop,CT-VRT and LAA-A(22.52±3.76mm)was insignificant(P>0.05),and there was significant correlation and consistency among the three results [3DTEE-iCrop 与 CT-VRT: r=0.947,P<0.05;3DTEE-iCrop 与 LAA-A:r=0.899,P<0.05;CT-VRT 与 LAA-A: r=0.921,P<0.05;ICC= 0.92(0.87～ 0.96)].There exist statistical difference in LAA depth detected by three imaging modalities(3DTEE-iCrop: 26.68±3.55 mm,CT-VRT: 27.75±4.07 mm,LAA-A: 24.46±4.15 mm,P<0.05),of which LAA depth detected by 3DTEE-iCrop and CT-VRT were larger than and LAA-A.Multiple comparisons show that there was no significant difference between 3DTEE-iCrop and CT-VRT for LAA depth(P>0.05),and there was highly correlated and consistent [r=0.609,P<0.05,ICC=0.60(0.36～0.77)].The results of predicted sizes for 3DTEE-iCrop,CT-VRT and LAA-A: The predicted sizes of WATCHMAN occluders were 28.38±3.36 mm for 3DTEE-iCrop,28.77±3.56 mm for CT-VRT and 27.77±3.35 mm for LAA-A respectively,there were no significant difference among three methods(P>0.05),which were markedly correlated and consistent with actual implant size of 28.46 ±3.57 mm [ 3DTEE-iCrop: r =0.893,P<0.05,ICC=0.89(0.80～0.94);CT-VRT: r=0.892,P<0.05,ICC=0.89(0.80～0.94);LAA-A: r=0.894,P<0.05,ICC=0.89(0.80～0.94)].Conclusion: Both 3DTEE-iCrop and CT-VRT can accurately evaluate the left atrial appendage in left atrial appendage occlusion:1.Transesophageal echocardiography can accurately diagnose the left atrial appendage thrombus.3DTE-iCrop can evaluate the shape of the left atrial appendage stereoscopically,provide real-time LAA orifice length and depth at different positions,and predict the size of occluders.It can display atrial septum in real time,guide transseptal puncture during operation,prevent new thrombosis,reduce the risk of embolism,and it has no radiation injury.2.Increasing the filling time of contrast medium appropriately can improve the accuracy of CT diagnosis in left atrial appendage thrombus.CT-VRT can visually evaluate the anatomy of left atrial appendage and accurately measure the LAA orifice length and depth.Non-invasive method has better compliance in the preoperative examination,but attention should be paid to radiation injury.3.3DTEE-iCrop and CT-VRT can accurately predict the size of occluder,and provide more available depth for WATCHMAN placement than LAA-A.Personalized imaging methods can be selected for different patients.The combination of high compliance of CT before operation and real-time accuracy of TEE during operation can provide more guarantee for LAAO. |
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