Application Of Transesophageal Echocardiography In Left Atrial Appendages Occlusion Combined With Catheter Ablation In Patients With Non-valvular Atrial Fibrillation

Part Ⅰ Application of transesophageal echocardiography in the study of factors of left cardiogenic thrombus in patients with non-valvular atrial fibrillationObjective Purpose To analyze and predict the risk factors of spontaneous development,mud-like changes or thrombus in left atrium or left atrial appendages in patients with non-valvular atrial fibrillation.Methods There were 109 patients with non-valvular atrial fibrillation.Those with either spontaneous development,mud-like changes or thrombus of left atrium or left atrial appendages were in the thrombus group(39 cases),and the rest were non-thrombus group(70 cases).Compared the basic clinical data of patients between the two groups,the parameters obtained by transthoracic echocardiography,transesophageal echocardiography and real-time three-dimensional transesophageal echocardiography were analyzed,and the risk factors of left cardiogenic thrombus with non-valvular atrial fibrillation were evaluated.Results In the thrombus group,Pe AF and BNP,LAD,E,and left atrial appendages lobulation number is more than another group,LAA-V decreased,and the differences between the two groups were statistically significant(P<0.05).There were no statistically significant differences in CHA2DS2-VASc score,age,gender,smoking history,history of vascular thrombus,history of hypertension and history of cerebral infarction between the two groups(P>0.05).Multivariate Logistic regression analysis showed that the decrease of LAA-V is the independent risk factor for thrombus in the left atrium or left atrial appendages in patients with non-valvular atrial fibrillation(P<0.05,OR=1.079,95%[CI]:1.033-1.127),and ROC curve showed that LAA-V had good discrimination ability for left atrium/left atrial appendages thrombus(AUC 0.782,95%[CI]:0.692-0.872,P<0.001).LAA-V≤43.50cm/s,its sensitivity and specificity on predicting thrombus were 87.20% and 62.90% respectively.Conclusions The increase of Pe AF,LAD,E,and BNP and more left atrial appendages lobulation can increase the risk of left atrium or left atrial thrombus in patients with non-valvular atrial fibrillation.In particular,the decrease of LAA-V can predict the thrombus of left atrium/left atrial appendages or the state before thrombus.And transesophageal echocardiography can provide more evidence for the clinical prevention and diagnosis and treatment of thrombus in patients with non-valvular atrial fibrillation.Part Ⅱ Application of transesophageal echocardiography in the combined treatment of non-valvular atrial fibrillation and the influencing factors of complicationsObjective Purpose To study the application of transesophageal echocardiography in the combined treatment of left atrial appendages occlusion and catheter ablation in patients with non-valvular atrial fibrillation,and to evaluate the complications and influencing factors after combined treatment.Methods There were 90 patients with non-valvular atrial fibrillation,of which 2 failed in occlusion,and the remaining 88 underwent left atrial appendages occlusion after prior catheter radio frequency catheter ablation,and the type was WATCHMAN occlusion device.All patients were monitored and guided to release the occlusion device by X-ray angiography,transesophageal echocardiography and real-time three-dimensional transesophageal echocardiography.Transesophageal echocardiography was used to evaluate the occlusion effect at 1 and 6 months after surgery,and to study the types of postoperative complications and the influencing factors for the change of complications,so as to further standardize the operation of combined therapy.Results The success rate of intraoperative occlusion was 97.78%.During the postoperative follow-up,the release of occlusion device was stable without shedding,and1 case was slightly displaced.No ischemic or hemorrhagic stroke,death,or major bleeding occurred after surgery.Intraoperative occlusion device compression ratio is 12%to 36%.The correlation between the maximum diameter of LAA(28.76±3.43)mm measured by X-ray imaging and the occlusion device type was higher than that(20.87±2.71)mm measured by transesophageal echocardiography(r=0.892 、 0.628,P<0.001).The 45° compression ratio of the shoulder exposure group immediately after surgery was smaller,and the 45° depth,135° depth and average LAA depth were more shallow,and the difference was statistically significant(P<0.05).There was no significant difference in type and lobulation number of left atrial appendages(P>0.05).There were statistically significant differences in left atrial appendages typing and lobulation between the group with immediate postoperative residual leakage and the group without residual leakage(P<0.05).The difference of the four angles` depth,average diameter and average depth of residual leakage group were statistically significant(P<0.05).More cases of shoulder exposure and residual leakage disappeared than new cases.The LAA diameter measured by X-ray angiography,the average diameter,45° diameter and 135° diameter measured by transesophageal echocardiography were larger in the group with new shoulder exposure compared with the group without new shoulder exposure,and the differences were statistically significant(P<0.05).The 135° diameter of the new residual leakage group was larger,and the difference was statistically significant(P<0.05).There were no statistically significant differences in left atrial appendages typing and lobulation number(P<0.05).Persistent residual leakage group had more left atrial appendages lobulation number(P<0.05).and larger compression ratio,larger diameter and depth of left atrial appendages were prone to persistent residual leakage(P<0.05).Persistent residual leakage combined and coexisted with shoulder exposure(P<0.05).There are 3cases of occlusion device related thrombus(3.40%),of which 66.67% combined with shoulder exposure and residual leakage,and none of them resulted in serious clinical consequences.Pericardial effusion occurred in 3 cases,of which 2 cases disappeared after follow-up observation,and 1 case improved after pericardial puncture and drainage after secondary cardiac tamponade.There were 17 patients with left to right atrial septal shunt1 month after operation,and all of them disappeared 6 months later.Conclusion 1.Transesophageal echocardiography plays a guiding role in radiofrequency catheter ablation combined with left atrial appendages occlusion.Increasing the compression ratio of occlusion device(12% to 36%)does not affect the safety and effectiveness of the treatment;2.The shallow depth of left atrial appendages and the small compression of occlusion device can lead to shoulder exposure.Cauliflower typing and cactus typing of left atrial appendages were related to the occurrence of residual leakage;3.Left atrial appendages with more lobes or deeper left atrial appendages can lead to residual leakage and persistence of residual leakage;4.The new occurrence of shoulder exposure and residual leakage is related to the larger diameter and deeper depth of left atrial appendages.