探讨心房颤动经不同消融方法后炎症因子变化及其与术后复发的关系

发布时间：2018-07-08 17:47

本文选题：阵发心房颤动 + 导管射频消融术　；参考：《天津医科大学》2017年硕士论文

【摘要】：目的观察冷冻球囊消融术(CBA)及导管射频消融术(RF)两种不同的消融方式在治疗阵发心房颤动(阵发房颤)术后多种炎症因子及心肌损伤标志物的变化;探讨相关炎症因子、心肌损伤标志物水平及其他危险因素与阵发房颤(Pa AF)消融术后复发的关系。方法连续选取在2015年10月到2016年6月期间因非瓣膜性阵发房颤(包括合并阵发心房扑动)入住天津市胸科医院,拟行房颤消融术的患者111例。所有患者均采集其基本信息,包括年龄、性别、既往病史、合并症(高血压、糖尿病以及高脂血症等)、服药情况等。病人入选后自愿选择手术方式(包括导管射频消融术和冷冻球囊消融术),并依据其选择分为冷冻球囊消融组(CB组)和导管射频消融组(RF组),其中行冷冻球囊消融术49例,行导管射频消融术62例。两组患者分别于术前及术后24小时抽取空腹肘静脉血,检测肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)、肌钙蛋白(Tn T)、谷草转氨酶(GOT)、超敏C反应蛋白(hs CRP)、白细胞(WBC)、中性粒细胞与淋巴细胞比值(NLR)、单核细胞(M)及红细胞分布宽度(RDW)等化验指标,采用酶联免疫吸附法(ELISA)分别测定术前、术后白介素-6(IL-6)。采取独立样本t检验及配对样本t检验分析两组患者术前术后上述指标的变化情况;采取Logistic回归分析法分析行两种术式后房颤复发(包括早期复发及晚期复发)的危险因素。将所有入选病例录入Excel软件建立随访数据库。病例随访采用定期随访及事件随时随访的方式。患者在术后1周、1个月、3个月、6个月及9个月时进行定期随访,随访内容包括症状描述、常规12导联心电图、24小时动态心电图。病人出现症状时嘱其随时就诊并行心电图等检查。房颤消融成功定义为在消融术3个月后常规心电图或者24小时动态心电图中无超过30秒的房颤、房扑或者房速。结果1、患者基本临床资料、术中情况及预后比较在入选的111例(63%为男性)患者中,49例患者入选为冷冻球囊消融术组(CB组),62例患者入选为导管射频消融术组(RF组)。两组患者的性别、年龄、发病时间及左房内径差异均无统计学意义(P0.05)。CB组4例患者行消融导管补点隔离,5例患者同时合并心房扑动,行三尖瓣环峡部(CTI)线性消融;RF组术中即刻肺静脉隔离率为100%,其中16例患者同时合并心房扑动,行三尖瓣环峡部(CTI)线性消融。CB组手术持续时间短于RF组,差异具有统计学意义(P0.05)。术后除CB组发生1例膈神经麻痹外,两组患者均未发生相关并发症,包括心包填塞、心房食道瘘、肺静脉狭窄、血栓栓塞等。经过(10.5±2.8)月的随访,CB组早期复发率为33.33%,晚期复发率为24.14%;RF组早期复发率为32.91%,晚期复发率为27.27%。CB组1例患者于术后6月行二次导管射频消融手术,术中发现右上肺静脉(RSPV)及右下肺静脉(RIPV)电位恢复,补点消融后,经过3个月随访未出现复发情况;RF组3例患者于术后6月行二次导管射频消融手术,其中2例患者术中证实为右上肺静脉(RSPV)电位恢复,1例患者为右上肺静脉(RSPV)、左上肺静脉(LSPV)及左下肺静脉(LIPV)电位恢复,经过(5.6±2.3)月的随访,未出现复发情况。2、CB组与RF组间炎症因子及心肌损伤标志物基线水平及术后水平的比较两组患者基线水平的hs CRP、WBC、NLR、M、CK、CK-MB、Tn T、GOT及RDW均无统计学差异(P0.05)。两组患者除RDW和IL-6术后有所下降外,hs CRP、WBC、NLR、M、CK、CK-MB、Tn T及GOT均有所升高,且均有统计学意义(P0.05)。并且CB组术后心肌损伤标志物Tn T、CK、CK-MB及GOT的升高明显高于RF组,具有统计学差异(P0.05)。3、CB组与RF组间炎症因子、心肌损伤标志物水平及其他危险因素与复发的关系通过单因素分析我们发现RF组除左心房内径(LAD)及性别(女性患者更高,P0.05)与早期复发有一定相关性外,基线水平的IL-6值、术后IL-6值、术后WBC值、术后M值也与早期复发具有一定相关性,具有统计学差异(P0.05),而RDW是晚期复发的独立危险因素,具有统计学差异(P0.05);Logistic回归分析显示基线水平的IL-6值及术后IL-6值是早期复发的独立危险因素,具有统计学差异(P0.05),并且通过分析我们发现基线水平的IL-6越高早期复发率越高。对于CB组我们发现性别是房颤早期复发(ERAF)的独立危险因素(女性患者更高,P0.05);且房颤的早期复发(ERAF)是晚期复发(LRAF)的独立危险因素(P0.05),没有发现其他相关炎症因子、心肌损伤标志物及其他危险因素与CB组复发的相关性。结论1、冷冻球囊消融术同导管射频消融一样,具有较高的安全性和有效性;2、冷冻球囊消融术组患者的术后心肌酶升高程度高于导管射频消融术组;3、炎症因子与导管射频消融术后房颤早期复发的发生具有一定相关性,未发现其与冷冻球囊消融术后早期复发的相关性;4、RDW与导管射频消融术后房颤的晚期复发具有相关性,未发现其与冷冻球囊消融术后晚期复发的相关性。5.冷冻球囊消融术中房颤早期复发(ERAF)是晚期复发(LRAF)的独立危险因素。
[Abstract]:Objective To observe the changes of various inflammatory factors and markers of myocardial injury after two different methods of cryosurgery ablation (CBA) and catheter radiofrequency ablation (RF) in the treatment of atrial fibrillation (atrial fibrillation), and to explore the related inflammatory factors, the level of myocardial damage markers and other risk factors and the postoperative Pa AF ablation. Methods 111 patients who were admitted to Tianjin Thoracic Hospital for non valvular atrial fibrillation (including combined atrial flutter) were selected from October 2015 to June 2016. All patients collected the basic information, including age, sex, past medical history, complication (hypertension, diabetes and diabetes). The patients were selected voluntarily (including catheter radiofrequency ablation and cryo balloon ablation) after admission, and were divided into cryo balloon ablation group (group CB) and catheter radiofrequency ablation group (group RF), including 49 cases of frozen balloon ablation and 62 cases of catheter radiofrequency ablation. The two groups were treated respectively. 24 hours before and 24 hours after the operation, the empty abdominal elbow vein blood was extracted, and the test indexes, such as creatine kinase (CK), creatine kinase isoenzyme (CK-MB), troponin (GOT), hypersensitive C reactive protein (HS CRP), leukocyte (WBC), neutrophils and lymphocyte ratio (NLR), mononuclear cell (M) and red cell distribution width (RDW), were used in enzyme linked immunosorbent assay. The preoperative and postoperative interleukins -6 (IL-6) were measured by immunoadsorption (ELISA). The changes of the above indexes were analyzed by independent sample t test and paired sample t test, and the risk factors for the recurrence of two kinds of postoperative atrial fibrillation (including early recurrence and late recurrence) were analyzed by Logistic regression analysis. Patients were followed up by Excel software to establish a follow-up database. Cases were followed up and followed up at any time. Patients were followed up at 1 weeks, 1 months, 3 months, 6 months, and 9 months after the operation. The follow-up contents included the description of the symptoms, the routine 12 lead electrocardiogram, and the 24 hour dynamic electrocardiogram. The success of atrial fibrillation ablation was defined as atrial fibrillation, atrial flutter, or atrial tachycardia without more than 30 seconds in routine electrocardiogram or 24 hour ambulatory electrocardiogram after 3 months of ablation. Results 1, the patient's basic clinical data, intraoperative conditions, and prognosis were compared in 111 cases (63% men), and 49 patients were selected as frozen balls. CB group (group RF), 62 patients were selected as catheter radiofrequency ablation group (group RF). The sex, age, onset time and left atrial diameter were not statistically significant (P0.05) in group.CB, 4 patients were separated by catheter patch, 5 patients combined with atrial flutter, and three apical isthmus (CTI) linear ablation; group RF was in the operation. The isolation rate of pulmonary vein was 100%, of which 16 patients combined with atrial flutter, and three apical annular isthmus (CTI) linear ablation.CB group had shorter operative duration than group RF, the difference was statistically significant (P0.05). The two groups had no related complications, including pericardial tamponade, atrial oesophagus fistula, except for 1 cases of phrenic paralysis in group CB. After (10.5 + 2.8) months follow-up, the early recurrence rate of the CB group was 33.33%, the late recurrence rate was 24.14%, the early recurrence rate in the RF group was 32.91%, and the late recurrence rate was 1 patients in group 27.27%.CB after two catheter radiofrequency ablation operations in June, and the right upper pulmonary vein (RSPV) and the right lower pulmonary vein (RIPV) potential were found during the operation. After 3 months of follow-up, no recurrence was found after 3 months of follow-up. 3 patients in group RF underwent two times of radiofrequency catheter ablation in June, of which 2 patients proved to be the right upper pulmonary vein (RSPV) potential recovery, 1 patients with right upper pulmonary vein (RSPV), the left superior pulmonary vein (LSPV) and the lower left pulmonary vein (LIPV) potential recovery, and (5.6 + 2.3). Compared with the baseline levels of the inflammatory factors and myocardial damage markers between group CB and RF, the baseline level of the two groups of HS CRP, WBC, NLR, M, CK, CK-MB, Tn T were not statistically different. And GOT all increased, and had statistical significance (P0.05). And the elevation of Tn T, CK, CK-MB and GOT in group CB was significantly higher than that in group RF, with statistical difference (P0.05).3, the relationship between the CB group and the inflammatory factors, the level of myocardial damage markers and the relationship between other risk factors and recurrence was found through single factor analysis. There was a certain correlation between the left atrium diameter (LAD) and the sex (higher female patients, P0.05) and the early recurrence. The IL-6 value of the baseline level, the postoperative IL-6 value, the postoperative WBC value and the postoperative M value were also correlated with the early recurrence (P0.05), and RDW was an independent risk factor for the late recurrence, with statistical difference (P0.05). Logistic regression analysis showed that the IL-6 value of baseline level and postoperative IL-6 were independent risk factors for early recurrence, with statistical difference (P0.05), and by analysis we found that the higher the baseline level of IL-6, the higher the early recurrence rate. We found that sex was an independent risk factor for the early recurrence of atrial fibrillation (ERAF) in the CB group (female patients). The early recurrence (ERAF) of atrial fibrillation (P0.05) was an independent risk factor (P0.05) for late recurrence (LRAF). No other related inflammatory factors, myocardial damage markers and other risk factors were associated with the recurrence of CB. Conclusion 1, frozen balloon ablation is as safe and effective as radiofrequency catheter ablation, and 2, cold The degree of myocardial enzyme elevation in the frozen balloon ablation group was higher than that of the catheter radiofrequency ablation group. 3, there was a correlation between the inflammatory factors and the early recurrence of atrial fibrillation after catheter radiofrequency ablation, and the correlation was not found in the early recurrence after the cryopreservation; 4, the late recurrence of atrial fibrillation after RDW and catheter radiofrequency ablation was developed. There is no correlation between the early recurrence of cryopreservation after cryopreservation and.5. cryopreservation (ERAF) is an independent risk factor for late recurrence (LRAF).
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.75

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