环肺静脉电隔离术的不同消融终点对房颤患者预后的影响

发布时间：2018-04-22 15:51

本文选题：房颤 + 双向阻滞　；参考：《山东大学》2014年硕士论文

【摘要】：研究背景阵发性房颤(atrial fibrillation, AF)由肺静脉(pulmonary veins, PVs)自发放电诱发,导致节段性消融电隔离术的出现及肺静脉的连续环形病灶消融治疗,PVs与左心房(left atrium, LA)连接处的消融隔离能够治愈AF。然而,随着射频消融(radio frequency catheter ablation, RFCA)手术时间的延长,X射线暴露时间越长,多种并发症例如心包填塞、气胸、假性股静脉瘤等出现风险越大。同时术后易并发伴心悸症状的心律失常,这也是目前未解决的难题。 PVs与LA双向阻滞能够降低肺静脉电位电活动传导,传入性传导阻滞的实现相对容易,表现为肺静脉电位(pulmonary vein potentials, PVPs)消失或者窦性或房颤心律下出现逸搏。对于传出性传导阻滞,心房起搏心律是否夺获相应的肺静脉是关键,即使肺静脉被夺获,其电位与心房激动顺序无关,也属于成功的传出阻滞。同侧环形肺静脉隔离术后有不同的消融终点。具体来说,最理想的终点是四条肺静脉电位完全消失；此外,任一PVP仍存在但传导延迟时间大于30ms可视为相对成功。只要任一PVP延迟时间小于30ms,均视为隔离失败。研究目的探讨环双侧PVs射频消融术的不同消融终点是否影响AF患者的术后复发情况。方法研究对象2008年6月至2012年8月,在山东大学齐鲁医院就诊,查体、心电图及动态心电图确诊患有AF,口服抗心律失常药物效果不佳,入院拟行RFCA治疗的137例患者,包括113例阵发性AF及24例持续性AF患者。向患者及家属讲明手术必要性及风险性,并签署知情同意书。分组根据患者术后复发与否,将113例阵发性AF患者分为复发组及未复发组；根据RFCA后的不同消融终点,除外肺静脉电位延迟时间小于30m.s的消融失败患者,将92例阵发性AF患者分为肺静脉电位消失组及肺静脉电位延迟组。射频消融治疗患者术前均排除手术禁忌症,局部麻醉下行环肺静脉电隔离术,经左锁骨下静脉放置电极导管于冠状静脉窦(coronary sinus, CS),2次穿刺房间隔,应用三维电解剖标测系统(CARTO, Biosense-Webster. Diamond Bar, CA, USA)行LA重建。将十电极双极导管(Lasso, Biosense-Webster)置于LA口,且距离PV开口约5mm处进行逐点消融(30-35W、43℃、17-20ml/min流速)。术后治疗及随访患者于术后三个月内常规给予口服抗凝药物治疗,根据术后心律变化口服胺碘酮1-3个月(需排除禁忌症)。每组患者分别接受随访2年,随访中出现心悸症状,行心电图或动态心电图检查,并记录术后房颤复发的首次时间,尤其是空白期(术后3个月)后,终点事件为具有心电图或动态心电图证据的AF。统计分析应用SPSS16.0软件,计量数据以x±s表示。利用Shapiro-Wilk (W检验)进行正态性检验,各组连续变量统计应用t检验；应用Kaplan-Meier生存分析及Log-rank方法对各组患者复发情况进行分析,检验水准均为0.05。结果基线资料137例房颤患者(年龄54.80±12.70岁)中,35例(25.55%)患者合并器质性心脏病包括28例(20.44%)合并冠状动脉粥样硬化性心脏病,1例(0.73%)合并先天性心脏病,3例(2.19%)合并瓣膜性心脏病,3例(2.19%)合并病态窦房结综合症。高血压病、糖尿病、高脂血症等高代谢性疾病分别存在于57(41.61%)、19(13.87%)、53(38.69%)例患者。其中9例(6.57%)房颤患者同时合并阵发性室上性心动过速,于手术中同时行射频消融术给予治疗。术中并发症术中较常见的严重并发症包括心房穿孔致心包填塞、肺静脉狭窄、气胸、卒中等,其中2例患者发生心包填塞,1例患者出现气胸,均因此终止手术。阵发性AF患者的复发与未复发组比较113例阵发性房颤患者中52例复发,其发作频率、持续时间及症状各有差异。对手术时间、心脏超声检查指标(左心房直径、左心室舒张末期容积、左室射血分数)、合并器质性心脏病、代谢性疾病等数据进行t检验,复发组与未复发组之间没有明显统计学差异(P0.05)。对阵发性AF患者术后复发情况的生存分析92例阵发性AF患者分为肺静脉电位消失组和肺静脉电位延迟组,肺静脉电位组共36例患者；肺静脉电位延迟组为任一肺静脉电位时间延迟大于30ms,共56例患者,两组均接受连续2年的随访,根据患者本人对自觉症状的描述或心电图诊断依据如实记录术后首次复发时间。应用Kaplan-Meier生存分析及Log-Rank检验,表明两组患者在术后两年内的复发率没有明显统计学差异(P=0.159)。术后3个月、6个月及12个月内的复发率均无统计学差异(P=0.812,0.640,0.186)。结论与肺静脉电位完全消失相比较,双向阻滞对阵发性房颤患者的复发情况及生活质量没有显著影响。
[Abstract]:Research background
Atrial fibrillation (AF) is induced by spontaneous discharge of the pulmonary vein (pulmonary veins, PVs), which leads to the emergence of segmental ablation and the continuous ring ablation of the pulmonary veins. The ablation isolation of PVs and the left atrium (left atrium, LA) junction can cure AF., however, with radiofrequency ablation (radio) Ter ablation, RFCA) the longer the operation time, the longer the exposure time of X ray, the more complications such as pericardial tamponade, pneumothorax, pseudovenous aneurysm, and so on, the greater the risk. At the same time, it is easy to be accompanied by palpitation symptoms of arrhythmia, which is an unsolved problem at present.
The bidirectional block of PVs and LA can reduce the electrical activity conduction of the pulmonary vein, and the realization of the afferent conduction block is relatively easy, which shows the disappearance of the pulmonary venous potential (pulmonary vein potentials, PVPs) or the escape of the sinus or atrial fibrillation. Even if the pulmonary vein was captured, its potential was not related to the order of atrial agitation, it was also a successful efferent block. There were different ablation endpoints after the ipsilateral circumferential pulmonary vein isolation. Specifically, the ideal end point was the complete disappearance of four pulmonary venous potentials; in addition, any PVP still existed but the delay time of conduction was greater than 30ms could be seen as relatively successful. As long as any PVP delay time is less than 30ms, it is regarded as an isolation failure.
research objective
Objective to investigate whether different ablation endpoints of circular bilateral PVs radiofrequency ablation affect postoperative recurrence in patients with AF.
Method
Subjects from June 2008 to August 2012 were diagnosed with AF in Qilu Hospital, Shandong University, examination body, electrocardiogram and dynamic electrocardiogram (ECG), oral antiarrhythmic drugs in 137 patients, including 113 paroxysmal AF and 24 patients with persistent AF. The necessity and risk of operation were explained to the patients and their families. And sign the informed consent.
113 paroxysmal AF patients were divided into recurrent and non recurrent groups according to the postoperative recurrence of the patients. According to the different ablation end points after RFCA, 92 cases of paroxysmal AF patients were divided into pulmonary venous potential disappearance group and pulmonary venous potential delay group, except for the failure patients with the delayed pulmonary venous potential delay less than 30m.s.
Patients with radiofrequency ablation were excluded from surgical contraindications before operation, under local anaesthesia, circumferential pulmonary vein isolation, left subclavian vein catheter in coronary sinus (coronary sinus, CS), 2 punctures of atrial septum, CARTO, Biosense-Webster. Diamond Bar, CA, USA) for LA reconstruction. Ten electricity would be used. Polar bipolar catheter (Lasso, Biosense-Webster) was placed at the LA port and ablation was performed at about 5mm from the opening of PV (30-35W, 43 C, 17-20ml/min flow rate).
Postoperative treatment and follow-up patients were given oral anticoagulant therapy within three months after operation. Oral amiodarone was taken for 1-3 months (excluding contraindications) according to postoperative arrhythmia. The patients in each group were followed up for 2 years. The palpitation symptoms occurred during the follow-up. The ECG or electrocardiographic examination were performed, and the first time of recurrence of atrial fibrillation after operation was recorded. Especially after the blank period (3 months after operation), the endpoint was AF. with electrocardiogram or dynamic electrocardiogram.
SPSS16.0 software was used in the statistical analysis. The measurement data was expressed in X + s. The normal test was carried out by Shapiro-Wilk (W test). The statistics of each group of continuous variables were applied to t test. The recurrence of each group was analyzed with Kaplan-Meier survival analysis and Log-rank method, and the test water was all 0.05.
Result
Baseline data of 137 patients with atrial fibrillation (age 54.80 + 12.70 years), 35 (25.55%) patients with organic heart disease including 28 (20.44%) with coronary atherosclerotic heart disease, 1 (0.73%) with congenital heart disease, 3 (2.19%) with valvular heart disease, 3 (2.19%) with sick sinus syndrome, hypertension, diabetes, Hyperlipidemia, such as hyperlipidemia, existed in 57 (41.61%), 19 (13.87%), and 53 (38.69%) patients, of which 9 (6.57%) patients with atrial fibrillation combined with paroxysmal supraventricular tachycardia and were treated with radiofrequency ablation at the same time.
The common serious complications during intraoperative complications included pericardial tamponade, pulmonary venous stenosis, pneumothorax, and moderate stroke, including pericardial tamponade in 2 patients and pneumothorax in 1 patients. All of them terminated the operation.
The recurrence rate of 113 paroxysmal atrial fibrillation patients in paroxysmal AF patients was compared with that of 52 patients with paroxysmal atrial fibrillation. Their frequency, duration and symptoms were different. The operation time, echocardiographic indexes (left atrium diameter, left ventricular end diastolic volume, left ventricular ejection fraction), combined organic heart disease, metabolic disease and other data were carried out. T test showed no significant difference between relapse group and non recurrence group (P0.05).
Survival analysis of recurrent AF patients after operation: 92 paroxysmal AF patients were divided into pulmonary vein potential disappearing group and pulmonary venous potential delay group, pulmonary vein potential group were 36 patients, pulmonary venous potential delay group was any pulmonary vein potential delay greater than 30ms, a total of 56 patients, two groups were followed up for 2 years, according to the patient Using Kaplan-Meier survival analysis and Log-Rank test, the recurrence rates of the two groups were not significantly different (P=0.159). There was no significant difference in the recurrence rate of 3 months, 6 months and 12 months after operation (P=0 .812,0.640,0.186).
conclusion
Compared with the complete disappearance of pulmonary venous potential, bidirectional block has no significant effect on recurrence and quality of life in patients with paroxysmal atrial fibrillation.

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R541.75

【参考文献】