冠状静脉窦频率特点与持续性心房颤动导管消融术预后关系的临床研究

发布时间：2017-12-31 22:13

本文关键词：冠状静脉窦频率特点与持续性心房颤动导管消融术预后关系的临床研究　出处：《大连医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：背景:冠状静脉窦(冠状窦)位于心脏的左后部冠状沟内,其结构有利于不稳定微小折返环形成,从而与心房颤动(房颤)的触发有重要联系。房颤的导管消融过程中,针对此关键结构的干预可终止房颤。本研究的目的在于探究冠状窦频率是否与房颤的触发和维持及房颤导管消融术预后相关。方法:本回顾性研究共入组122例持续性房颤患者,所有患者均为症状性、药物难治性房颤,且首次接受房颤射频消融术治疗。患者在行射频消融术前,首先通过环状标测导管获得心房内多部位心内电图。持续性房颤患者的消融术式均采用统一的类似递进式消融术式。术后3个月内设为空白期。消融术后的3、6、9和12个月门诊行相关检查,评估导管消融治疗效果,1年后每6个月来门诊随诊1次。在随访期间,要接受包括问卷、24小时动态心电图,12导体表心电图等相关检查,用于评估患者是否有症状或复发。复发的患者的手术策略与第一次相同。手术成功的标准为在随访期间无心房颤动或其他持续性房性心律失常发生。结果:122例患者中12例(9.8%)在行肺静脉隔离后,心律由房颤转为窦性心律;其余110例继续行递进式消融,其中22例(18%)患者,在逐步消融过程中房颤终止。其中1例患者在行左房顶部消融时房颤终止,3例在行右上肺静脉前庭部位碎裂电位消融时房颤终止,1例在行左心耳基底部碎裂电位消融时房颤终止,2例在消融房间隔碎裂电位时房颤终止,15例患者在行冠状窦心内膜面消融时房颤终止。除外PVI终止的12例患者,余110例患者,依据消融过程中终止与否分为终止组与未终止组。终止组(22例患者)与未终止组(88例患者)相比较,终止的22例患者其冠状窦近端频率相对较快(10.2 ± 2.1 Hz和8.3 ± 1.8 Hz,P0.001),且终止的22例持续性房颤患者的冠状窦远端频率与近端频率比值相对较小(56.6±10.11%和70.7±9.8%,P0.001)。应用受试者工作特征曲线分析得出:冠状窦远端与近端频率比值67%预测房颤终止的阳性率为53%(敏感度为86%,特异度为67%,阴性预测值为95%)。终止组冠状窦远端与近端频率比值cut off值67%预测房颤终止的曲线下面积为0.842(95%可信区间为0.749-0.936;P0.001)。第1次术后复发48例患者,其中43例患者接受再次手术,6例患者接受三次手术。第一次术后,冠状窦远端频率与近端频率的比值67%的患者与比值≥67%的患者两组的成功率分别为69%和48%(p=0.032)。在经历平均1.4±0.6次手术和平均46±18个月的随访后,冠状窦远端频率与近端频率的比值67%的患者与比值≥67%的患者两组的成功率分别为90%和74%(p=0.042)。通过Logistic回归分析得出冠状窦远端与近端频率的比值是持续性房颤患者导管消融术预后的独立预测因子(OR 值 1.131,95%可信区间 1.053-1.214;p=0.001)。随访 46±18月后,研究显示冠状窦远端与近端频率的比值67%的患者其单次房颤消融术的预后及多次导管消融的长期预后均优于比值≥67%的患者。结论:1.冠状窦近端快速的电活动可能对持续性房颤的维持起重要作用。2.冠状窦远端与近端频率比值可能是消融术中房颤终止及患者远期预后的独立预测因素。3.冠状窦远端与近端频率比值67%的持续性房颤患者能从冠状窦心内膜消融中获益更多,可能这部分患者更适合接受冠状窦心内膜消融。
[Abstract]:Background: the coronary sinus (CS) located in the heart of the rear left coronary sulcus, its structure is conducive to unstable micro reentrant formation, and atrial fibrillation (AF) is an important trigger. Catheter ablation of atrial fibrillation in the process of the key structure of the intervention may terminate atrial fibrillation. This study the purpose is to explore whether the frequency of coronary sinus and atrial fibrillation trigger atrial fibrillation ablation and maintain and prognosis. Methods: a retrospective study in a cohort of 122 patients with persistent atrial fibrillation patients, all patients were symptomatic, drug refractory atrial fibrillation, and the first time to accept atrial fibrillation radiofrequency ablation therapy. The patients in the radiofrequency ablation, first through the circular mapping catheter for multi site atrial endocardial electrogram ablation in patients with atrial fibrillation. The last are used like the progressive ablation of unity. Within 3 months after surgery for blank ablation after 3, 6,9 and 12 months for outpatient examination, evaluation of catheter ablation treatment, 1 years after every 6 months to outpatient follow-up 1 times. During the follow-up period, to accept the questionnaires, 24 hour dynamic electrocardiogram, 12 lead ECGs and related inspection, to assess whether patients have symptoms or recurrent patients. Surgical strategy for the first time. And the recurrence of the same standard for successful surgery during the follow-up period without atrial fibrillation or persistent atrial arrhythmia. Results: 122 patients in 12 cases (9.8%) in pulmonary vein isolation after cardiac by atrial fibrillation to sinus rhythm; the remaining 110 cases underwent progressive type of ablation, including 22 cases (18%) patients in the ablation process gradually terminate atrial fibrillation. Among them, 1 cases of left atrial ablation of atrial fibrillation in patients with top termination, termination of 3 patients of right upper pulmonary vein antrum CFAEs ablation of atrial fibrillation, 1 cases of left atrial appendage at the base of potential Ablation of atrial fibrillation termination, termination of 2 cases of atrial septal ablation in CFAEs when AF terminated in 15 patients of coronary sinus endocardial surface ablation of atrial fibrillation. Except 12 cases of PVI termination patients, 110 cases, on the basis of the ablation process termination and divided into end group and non group. The final termination check group (22 patients) and non termination group (88 patients) compared to 22 cases of patients with coronary sinus proximal end frequency is relatively fast (10.2 + 2.1 + 1.8 Hz and 8.3 Hz, P0.001), distal coronary sinus frequency and termination of 22 cases of persistent atrial fibrillation in patients with proximal frequency the ratio of the smaller (56.6 + 10.11% and 70.7 + 9.8%, P0.001). The receiver operating characteristic curve analysis: application of distal coronary sinus and proximal frequency ratio of the 67% predicted positive rate of AF termination was 53% (sensitivity was 86%, specificity was 67%, the negative predictive value was 95%). Termination group the proximal and distal coronary sinus frequency ratio The value of cut off value of 67% AF termination forecast area under the curve was 0.842 (95% Ci, 0.749-0.936; P0.001). Postoperative recurrence in first patients with 48 cases, of which 43 patients underwent reoperation, 6 patients underwent surgery three times. After the first operation, two groups of patients and the success ratio was larger than 67% the proximal and distal coronary sinus frequency frequency ratio of 67% patients was respectively 69% and 48% (p=0.032). After an average of 1.4 + 0.6 and 46 + times operation average 18 months follow-up, the success of the two groups of patients with coronary ratio was larger than 67% Dou Yuanduan frequency and the proximal frequency ratio of 67%. Patients were 90% and 74% (p=0.042). Through Logistic regression analysis showed that the ratio of coronary Dou Yuanduan and proximal frequency are independent predictors of persistent atrial fibrillation ablation catheter patients prognosis (OR = 1.131,95% CI 1.053-1.214; p=0.001). Follow up of 46 + 18 months after study The long-term prognosis in coronary sinus distal and proximal frequency ratio of 67% patients with single atrial fibrillation ablation and the prognosis of multiple catheter ablation were better than the ratio was larger than 67% of the patients. Conclusion: the electrical activity of 1. coronary sinus proximal fast of persistent atrial fibrillation plays an important role in the maintenance of.2. and proximal coronary Dou Yuanduan frequency the ratio may be independent predictors of.3. in patients with distal coronary sinus catheter ablation of atrial fibrillation termination and long-term prognosis of patients with proximal frequency ratio of 67% persistent atrial fibrillation can benefit more from the coronary sinus endocardial ablation, may be more suitable for this part of the patients undergoing coronary sinus endocardial ablation.

【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.75

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