两种射频消融术式对心房颤动患者左心房容积和功能的影响

发布时间：2018-05-27 14:38

本文选题：心房颤动 + 射频消融　；参考：《苏州大学》2016年博士论文

【摘要】：目的:心房颤动(房颤)是临床常见的心律失常,是脑卒中和心力衰竭强烈而独立的危险因子。房颤的治疗是当今心脏病学面临的巨大挑战,单纯频率控制不能降低脑卒中危险性、不能改善房室同步;以华法林为主的抗凝治疗,虽然可以降低脑卒中和死亡率,但是存在出血风险,而且必须长期密切监测凝血酶原时间国际标准化比值,患者依从性低。节律控制优于频率控制,可以降低总死亡率、短暂脑缺血发作、脑梗死、系统性栓塞、大出血、心力衰竭等终点事件的发生率。传统的节律控制方法包括抗心律失常药物、直流电复律、迷宫手术等,但这些方法因疗效和安全性问题而在临床上应用受限。因而导管介入射频消融成为目前治疗房颤的热点。受操作难易程度及成功率、可复制性等因素的影响,国内目前术式主要以环肺静脉射频消融(Circumferential pulmonary vein ablation,CPVA)为基础术式,结合碎裂电位(Complex Fractionated Atrial Electro-gram,CFAEs)消融。房颤消融术后心房基质的重构将影响左心房功能,消融点过多可能损伤左心房功能、增加术后发生房性心动过速(房速)的概率、增加发生并发症的概率。本研究通过评估环肺静脉射频消融术(CPVA)和环肺静脉射频消融+碎裂电位消融术(CPVA+CFAEs)两种术式对房颤患者左心房容积和功能的影响,进而深入了解心房容积和功能与房颤复发、新发房速、左心房功能的关系,丰富射频消融治疗房颤的临床资料,促进对房颤机制的深入了解,促进对房颤射频消融术式的改进,为房颤消融术式的评价及消融策略的选择提供临床数据。方法:选取符合房颤消融适应症、接受房颤射频消融治疗的患者作为研究对象,采用CPVA术式或CPVA+CFAEs术式对患者进行消融治疗。利用随机数表,采用随机单盲方式将患者入组选择术式。术前、术后记录空腹血糖、甘油三脂、总胆固醇、高密度脂蛋白、低密度脂蛋白、尿酸、肾素、血管紧张素-Ⅰ、血管紧张素-Ⅱ、C-反应蛋白、血沉、12导联心电图P波时限、左心房容积、二尖瓣运动曲线上舒张晚期速度峰值(Va)等指标。使用SPSS19.0统计分析软件对上述数据进行统计学分析处理,观察CPVA和CPVA+CFAEs两种术式前后上述指标的变化以及两组之间的差异,以及房颤复发率和新发房速的比例,以此评价不同术式对房颤患者左心房容积和功能的影响。结果:最终入组76例患者,均成功施行手术,未出现气胸、心包压塞、血栓栓塞、肺静脉狭窄、心房食道瘘等手术相关并发症。3个月后的随访数据,两组组内术后与术前比较无显著性差异,两组组间比较亦无显著性差异。6个月后的随访数据比较,CPVA组左心房容积等指标在消融前后的变化无统计学差异,但Va值术后高于术前,差异具有统计学意义(p=0.004);CPVA+CFAEs组左心房容积、Va值等指标在消融前后的差异均无统计学意义。术后6个月,Va值CPVA组高于CPVA+CAFEs组,差异具有统计学意义(p=0.036)。其余观察指标在组间对比及自身前后对比等均无显著性差异。术后随访6-24月(平均15±5.5月),共有12例房颤复发(CPVA组6例,CPVA+CFAEs组6例),术后新发房速9例(CPVA组4例,CPVA+CFAEs组5例)。两组间房颤复发率、新发房速比例无统计学差异。术后两组患者均未出现长期持续性房颤。结论:在房颤得到根治的同时,尽量少地消融左心房基质,可使左心房收缩功能得到改善。相反,如果过多地消融左心房基质,虽然房颤的维持基质被干预得更多,但是左心房收缩功能未必得到进一步的改善,且未观察到房颤复发率的减少。对于房颤的射频消融治疗,在追求减少复发率的同时,应尽量减少左心房消融面积。也就是说,应努力通过最少的消融面积,来达到根治房颤的效果。
[Abstract]:Objective: atrial fibrillation (atrial fibrillation) is a common clinical arrhythmia. It is a strong and independent risk factor for stroke and heart failure. The treatment of atrial fibrillation is a great challenge for cardiology today. Simple frequency control can not reduce the risk of stroke and can not improve atrioventricular synchronization. Warfarin based anticoagulant therapy can be reduced, although it can be reduced. Low stroke and mortality, but there is a risk of bleeding, and it is necessary to monitor the international normalized ratio of prothrombin time for a long time. Patient compliance is low. Rhythmic control is superior to frequency control. It can reduce the incidence of endpoints such as total mortality, transient ischemic attack, cerebral infarction, systemic thrombus, massive hemorrhage, heart failure and other endpoints. Rhythmic control methods include antiarrhythmic drugs, direct current cardioversion, maze operation and so on, but these methods are limited clinically for efficacy and safety. Therefore, catheter interventional radiofrequency ablation has become a hot spot in the treatment of atrial fibrillation. Circumferential pulmonary vein ablation (CPVA) was used as the basic operation, combined with the fragmentation potential (Complex Fractionated Atrial Electro-gram, CFAEs). The remodeling of atrial matrix after atrial fibrillation ablation will affect the function of the left atrium. Excessive ablation points may damage the function of the left atrium and increase the postoperative atrial properties. The probability of tachycardia (atrial tachycardia) increases the probability of complications. In this study, the effects of two kinds of surgical procedures on the left atrial volume and function of patients with atrial fibrillation (CPVA+CFAEs) and circumferential pulmonary vein radiofrequency ablation (CPVA) and radiofrequency ablation + clastic potential ablation were evaluated to further understand the atrial volume and function and the recurrence of atrial fibrillation. The relationship between the atrial tachycardia and the left atrium function, enriching the clinical data of radiofrequency ablation in the treatment of atrial fibrillation, promoting the understanding of the mechanism of atrial fibrillation, promoting the improvement of atrial fibrillation radiofrequency ablation, and providing clinical data for the evaluation of atrial fibrillation ablation and the choice of ablation strategies. Patients treated as subjects were treated with CPVA or CPVA+CFAEs. Random number tables were used to select patients in a random single blind method. Preoperative, postoperative recording of fasting blood glucose, glycerin three fat, total cholesterol, high density lipoprotein, low density lipoprotein, uric acid, renin, angiotensin I, blood Angiotensin II, C- reactive protein, erythrocyte sedimentation, P wave time limit of 12 lead electrocardiogram, left atrium volume, peak diastolic velocity peak (Va) on the mitral valve motion curve and other indexes. The above data were statistically analyzed by SPSS19.0 statistical analysis software, and the changes of the above indexes before and after the two kinds of CPVA and CPVA+ CFAEs were observed and two groups were observed. The difference in the rate of recurrence of atrial fibrillation and the rate of new atrial tachycardia were used to evaluate the effect of different surgical procedures on the volume and function of left atrium in patients with atrial fibrillation. Results: 76 patients were performed successfully, without pneumothorax, pericardial tamponade, thromboembolism, pulmonary vein narrowing, atrial esophagus fistula, and other surgical complications.3 months later. There was no significant difference between the two groups after the two groups, and there was no significant difference between the two groups. There was no significant difference in the left atrium volume of the CPVA group before and after the ablation, but the Va value was higher than that before the operation (p=0.004), and the left atrium volume in CPVA+CFAEs group was higher than that in the group CPVA+CFAEs. There was no statistical significance in the difference before and after ablation. 6 months after the operation, the Va value CPVA group was higher than the CPVA+CAFEs group, and the difference was statistically significant (p=0.036). The rest of the observation indexes had no significant difference between the groups and their own before and after. The postoperative follow-up was 6-24 months (average 15 + 5.5 months), and there were 12 cases of atrial fibrillation in 6 cases (6 cases). 6 cases in group CPVA+CFAEs, 9 cases of new atrial tachycardia after operation (group CPVA 4 cases, and group CPVA+CFAEs 5). There was no significant difference in the rate of recurrence of atrial fibrillation between the two groups. The two groups had no long-term persistent atrial fibrillation. Conclusion: the left atrial matrix was ablated as much as possible while the atrial fibrillation was radical. The left atrial systolic function could be improved. On the contrary, if the left atrial matrix is ablated too much, although the maintenance matrix of the atrial fibrillation is more interfered, the left atrial contraction function may not be further improved, and the recurrence rate of atrial fibrillation is not observed. That is to say, efforts should be made to cure the effect of atrial fibrillation by minimal ablation area.
【学位授予单位】：苏州大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R541.75

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