冷冻球囊导管肺静脉电隔离术的特点分析
发布时间:2018-07-24 15:30
【摘要】:本研究分为两个部分,分别探讨在冷冻球囊导管肺静脉电隔离术中实时肺静脉电位记录对持续肺静脉电隔离的预测价值和复发患者二次导管消融手术中肺静脉-左房电传导恢复的特点。这两部分共同为提高手术疗效和安全性以及优化手术流程、缩短手术时间提供了重要的参考。资料来自于在阜外医院心律失常中心接受单一术者进行的冷冻球囊导管消融术的心房颤动(简称房颤)患者。第一部分分析冷冻球囊导管在肺静脉电隔离术中的实时肺静脉电位记录的价值,共入选患者70例。第二部分探讨冷冻球囊导管房颤消融术后复发患者的二次手术特点,共入选9例接受二次导管消融的患者。第一部分:冷冻球囊导管心房颤动消融术中实时肺静脉电位记录的价值目的:探讨冷冻球囊导管肺静脉电隔离术中实时记录肺静脉电位的方法,可行性及应用价值。资料与方法:连续入选自2013年11月至2015年1月就诊于阜外医院的共计70例症状性房颤患者,其中阵发性房颤57例,持续性房颤13例。所有患者均利用冷冻球囊导管对各支肺静脉进行电隔离,并在各支肺静脉的冷冻消融过程中利用与球囊导管整合的环状标测电极对肺静脉电位进行实时记录。首次成功电隔离后即等待3分钟,观察左房-肺静脉的早期传导恢复,若未出现传导恢复(持续隔离组),则在原位巩固消融一次;若出现传导恢复(传导恢复组),则调整球囊位置后再次尝试电隔离。手术终点为各支肺静脉的完全电隔离。术后进行常规随访。结果:以上70例患者共计肺静脉282支,平均每例患者消融14±4.3次,274支(97.2%)达到了成功电隔离。平均手术时间为115.2±24.8分钟,透视时间为29.6±8.9分钟。其中232支(84.7%)肺静脉成功记录到实时电位。术中观察期内持续隔离组的首次电隔离时间为46.61±1.97秒,显著短于传导恢复组(97.30±7.57秒,P0.0001)。持续隔离组的首次电隔离时的球囊温度(-46.35±0.55℃)也显著低于传导恢复组(-40.16±1.26℃,P0.0001),而两组间球囊最低温度未见统计学差异(持续隔离组:-33.95±0.69℃,传导恢复组:-36.42±2.0℃,P=0.1428)。电隔离时间短于60秒预测持续肺静脉电隔离的敏感性为0.76,特异性为0.82(AUC=0.835:P0.0001)。除1例持续性膈神经麻痹和1例术后自限性轻微咯血外,未出现其它并发症。结论:冷冻球囊导管可以安全有效地对肺静脉进行电隔离。冷冻消融过程中通过有效记录肺静脉电位而得到的电隔离时间这一指标可以有效预测肺静脉的持续电隔离,而球囊温度则无法直接反映电隔离效果。因此电隔离时间这一指标可对优化手术操作,减少手术时间起到一定的指导作用。第二部分:冷冻球囊导管消融心房颤动术后复发患者的二次手术特点目的:总结冷冻球囊导管消融术后复发的房颤患者的二次手术特点,并指导对冷冻球囊消融术的优化。资料与方法:连续入选自2013年12月至2016年3月就诊于本中心行冷冻球囊消融术的房颤患者中于随访中复发并行二次手术的患者9例。所有患者利用三维标测系统指导的冷盐水灌注射频消融导管进行肺静脉的再隔离,并对其它可诱发的心动过速进行消融。将同侧肺静脉口部分为六个节段以便于左房-肺静脉恢复传导部位的分析。结果:以上9名患者均为男性,平均年龄48.1±11.5岁,持续性房颤3例,阵发性房颤6例。首次术中平均冷冻12.6±1.8次,平均手术时间为106.1±16.9分钟,平均透视时间为24.7±4.8分钟。9名患者共计存在肺静脉37支,其中左侧共干肺静脉1支,左上肺静脉8支,左下肺静脉8支,右上肺静脉9支,右下肺静脉9支,右中肺静脉2支。所有患者均使用28mm直径冷冻球囊导管进行消融。首次术中所有肺静脉均成功电隔离。以上患者于首次手术后平均4.5±2.5个月后接受二次手术。二次手术提示总计17支(45.9%)肺静脉恢复了左房-肺静脉传导,其中左侧共干肺静脉1支(100%),左上肺静脉2支(25%),左下肺静脉6支(75%),右上肺静脉3支(33.3%),右下肺静脉5支(55.5%)。9位患者中,无肺静脉恢复传导者1位(11.1%),有1支肺静脉传导恢复者2位(22.2%),2支肺静脉传导恢复者3位(33.3%),3支肺静脉传导恢复者3位(33.3%)。总计存在漏点19处,对于下肺静脉漏点数量显著多于上肺静脉,且集中于上下肺静脉结合部及下肺静脉的底部。以上肺静脉均于二次手术中成功补点隔离。此外二次手术中成功消融隔离上腔静脉一例,典型房扑一例,二尖瓣环折返性房速一例以及房室结折返性心动过速例。中位随访时间为5(1-19)个月,随访期间有1例患者再次复发心房颤动,服用抗心律失常药物后控制良好。其余8例患者于随访期间均为窦性心律。结论:冷冻球囊导管消融术后复发患者在二次手术中左房-肺静脉传导恢复的比例较小,且传导恢复部位存在一定的规律性,主要集中于双侧下肺静脉。补点消融重新隔离肺静脉并对同时存在的肺外触发灶,规则房性心动过速以及阵发性室上性心动过速进行消融治疗是安全、有效的。
[Abstract]:The present study was divided into two parts. The predictive value of real-time pulmonary venous potential recording on the continuous pulmonary vein isolation during the cryopreserved pulmonary venous isolation and the characteristics of the recovery of pulmonary vein and left atrial conduction during the two catheter ablation operation were discussed. The two parts were combined to improve the efficacy and safety of the operation. The first part analyses the value of the real-time pulmonary venous potential records of the cryopreserved balloon catheter in the pulmonary vein isolation. A total of 70 patients were selected. The second part discussed the two operation characteristics of the recurrent patients after cryopreservation catheter ablation. A total of 9 patients received two catheter ablation. The first part: the value of the real-time pulmonary venous potential recording during the cryo balloon catheter ablation of atrial fibrillation: the study of the pulmonary venous septum of the frozen balloon catheter The method, feasibility and application value of real-time recording of pulmonary venous potential in a total of 70 patients with symptomatic atrial fibrillation from November 2013 to January 2015, including 57 paroxysmal atrial fibrillation and 13 cases of persistent atrial fibrillation, were selected from November 2013 to January 2015. All patients were treated with frozen balloon catheter for each branch of pulmonary vein. Electrical isolation and real-time recording of pulmonary venous potential using a circular electrode integrated with balloon catheter in the process of freezing and ablation of the pulmonary veins. After first successful electrical isolation, it waits for 3 minutes to observe the early conduction recovery of the left atrial and pulmonary vein. If no conduction recovery (continuous isolation group) is not appeared, the ablation is in situ. If there was a conduction recovery (conduction recovery group), electrical isolation was tried again after adjusting the position of the balloon. The end of the operation was complete electrical isolation of the pulmonary veins. After the operation, the total pulmonary vein was followed up. Results: the total pulmonary vein was 282 in the 70 patients, the average of each patient was 14 + 4.3 times, and 274 (97.2%) reached the successful electrical isolation. Between 115.2 + 24.8 minutes and 29.6 + 8.9 minutes, 232 (84.7%) pulmonary veins were recorded successfully. The first electrical isolation time of the continuous isolation group during the observation period was 46.61 + 1.97 seconds, significantly shorter than the conduction recovery group (97.30 + 7.57, P0.0001). The balloon temperature of the first electrical isolation group was (-46.35 + 24.8). .55 C) was also significantly lower than that of conduction recovery group (-40.16 + 1.26 C, P0.0001), but the lowest temperature between the two groups was not statistically significant (-33.95 + 0.69 C, -36.42 2 C, P=0.1428). The sensitivity of electric isolation was 0.76 and 0.82 (AUC=0.835:P0.0). 001). Except for 1 cases of persistent phrenic paralysis and 1 cases of postoperative self limiting mild hemoptysis, there are no other complications. Conclusion: the frozen balloon catheter can be safely and effectively isolated from the pulmonary vein. The index of electrical isolation obtained by effective recording of the pulmonary venous potential in the process of cryosurgery can effectively predict the pulmonary vein. Continuous electrical isolation, and the balloon temperature can not directly reflect the effect of electrical isolation. Therefore, the index of electrical isolation can play a guiding role in optimizing operation and reducing operation time. The second part: two operation characteristics of cryopreservation catheter ablation for recurrent patients after atrial fibrillation: summary of frozen balloon catheter elimination The characteristics of the two operation of patients with recurrent atrial fibrillation and the optimization of cryo balloon ablation. Data and methods: 9 patients who had been followed up and two times of two surgery from December 2013 to March 2016 were followed up by cryo balloon ablation in the center. The radiofrequency catheter (RFD) guided by cold saline was used to reisolate the pulmonary vein and ablation of other induced tachycardia. Six segments of the ipsilateral pulmonary vein were used to facilitate the analysis of the left atrial and pulmonary vein recovery. Results: the above 9 patients were male, the average age was 48.1 + 11.5 years, and the persistent atrial fibrillation was 3. 6 cases of paroxysmal atrial fibrillation (paroxysmal atrial fibrillation). The average cryopreservation was 12.6 + 1.8 times in the first operation, the average operation time was 106.1 + 16.9 minutes. The average fluoroscopy time was 24.7 + 4.8 minutes. There were 37 pulmonary veins in.9 patients, including 1 left pulmonary veins, 8 left upper pulmonary veins, 8 branches of the lower left pulmonary vein, 9 branches of the right upper pulmonary vein, the right inferior pulmonary vein 9, and right middle lung. All patients were treated with a 28mm diameter cryo balloon catheter. All pulmonary veins were successfully isolated during the first operation. Two operations were performed on average 4.5 + 2.5 months after the first operation. Two operations suggested a total of 17 (45.9%) pulmonary veins recovered from the left atrial and pulmonary vein, of which the left common dry pulmonary vein was 1 (10). 0%) 2 (25%), 6 branches (75%) of left inferior pulmonary vein (75%), 3 (33.3%) of right upper pulmonary vein (33.3%) and 5 (55.5%).9 in right inferior pulmonary vein, 1 (11.1%) without pulmonary vein restorer, 1 branches of pulmonary vein conduction recovery. Point 19, the number of leaks in the lower pulmonary vein was significantly more than that of the upper pulmonary vein, and concentrated in the bottom of the upper and lower pulmonary veins and the bottom of the inferior pulmonary vein. All the pulmonary veins were successfully isolated in the two operation. In addition, a case of isolated superior vena cava, one case of typical atrial flutter, one case of mitral annulus reentrant atrial tachycardia and room in two operations. The median follow-up time of reentrant tachycardia was 5 (1-19) months. During the follow-up period, 1 patients had recurrent atrial fibrillation and had good control after taking antiarrhythmic drugs. The remaining 8 patients were sinus rhythm during the follow-up period. Conclusion: the recurrent patients after cryopballoon catheter ablation had left atrial and pulmonary veins in the two operation. The ratio of conduction recovery is small, and the conduction recovery part is regular, mainly concentrated in the bilateral inferior pulmonary vein. It is safe and effective to resend the pulmonary vein and the external pulmonary trigger, regular atrial tachycardia and paroxysmal supraventricular tachycardia at the same time.
【学位授予单位】:北京协和医学院
【学位级别】:博士
【学位授予年份】:2016
【分类号】:R541.75
[Abstract]:The present study was divided into two parts. The predictive value of real-time pulmonary venous potential recording on the continuous pulmonary vein isolation during the cryopreserved pulmonary venous isolation and the characteristics of the recovery of pulmonary vein and left atrial conduction during the two catheter ablation operation were discussed. The two parts were combined to improve the efficacy and safety of the operation. The first part analyses the value of the real-time pulmonary venous potential records of the cryopreserved balloon catheter in the pulmonary vein isolation. A total of 70 patients were selected. The second part discussed the two operation characteristics of the recurrent patients after cryopreservation catheter ablation. A total of 9 patients received two catheter ablation. The first part: the value of the real-time pulmonary venous potential recording during the cryo balloon catheter ablation of atrial fibrillation: the study of the pulmonary venous septum of the frozen balloon catheter The method, feasibility and application value of real-time recording of pulmonary venous potential in a total of 70 patients with symptomatic atrial fibrillation from November 2013 to January 2015, including 57 paroxysmal atrial fibrillation and 13 cases of persistent atrial fibrillation, were selected from November 2013 to January 2015. All patients were treated with frozen balloon catheter for each branch of pulmonary vein. Electrical isolation and real-time recording of pulmonary venous potential using a circular electrode integrated with balloon catheter in the process of freezing and ablation of the pulmonary veins. After first successful electrical isolation, it waits for 3 minutes to observe the early conduction recovery of the left atrial and pulmonary vein. If no conduction recovery (continuous isolation group) is not appeared, the ablation is in situ. If there was a conduction recovery (conduction recovery group), electrical isolation was tried again after adjusting the position of the balloon. The end of the operation was complete electrical isolation of the pulmonary veins. After the operation, the total pulmonary vein was followed up. Results: the total pulmonary vein was 282 in the 70 patients, the average of each patient was 14 + 4.3 times, and 274 (97.2%) reached the successful electrical isolation. Between 115.2 + 24.8 minutes and 29.6 + 8.9 minutes, 232 (84.7%) pulmonary veins were recorded successfully. The first electrical isolation time of the continuous isolation group during the observation period was 46.61 + 1.97 seconds, significantly shorter than the conduction recovery group (97.30 + 7.57, P0.0001). The balloon temperature of the first electrical isolation group was (-46.35 + 24.8). .55 C) was also significantly lower than that of conduction recovery group (-40.16 + 1.26 C, P0.0001), but the lowest temperature between the two groups was not statistically significant (-33.95 + 0.69 C, -36.42 2 C, P=0.1428). The sensitivity of electric isolation was 0.76 and 0.82 (AUC=0.835:P0.0). 001). Except for 1 cases of persistent phrenic paralysis and 1 cases of postoperative self limiting mild hemoptysis, there are no other complications. Conclusion: the frozen balloon catheter can be safely and effectively isolated from the pulmonary vein. The index of electrical isolation obtained by effective recording of the pulmonary venous potential in the process of cryosurgery can effectively predict the pulmonary vein. Continuous electrical isolation, and the balloon temperature can not directly reflect the effect of electrical isolation. Therefore, the index of electrical isolation can play a guiding role in optimizing operation and reducing operation time. The second part: two operation characteristics of cryopreservation catheter ablation for recurrent patients after atrial fibrillation: summary of frozen balloon catheter elimination The characteristics of the two operation of patients with recurrent atrial fibrillation and the optimization of cryo balloon ablation. Data and methods: 9 patients who had been followed up and two times of two surgery from December 2013 to March 2016 were followed up by cryo balloon ablation in the center. The radiofrequency catheter (RFD) guided by cold saline was used to reisolate the pulmonary vein and ablation of other induced tachycardia. Six segments of the ipsilateral pulmonary vein were used to facilitate the analysis of the left atrial and pulmonary vein recovery. Results: the above 9 patients were male, the average age was 48.1 + 11.5 years, and the persistent atrial fibrillation was 3. 6 cases of paroxysmal atrial fibrillation (paroxysmal atrial fibrillation). The average cryopreservation was 12.6 + 1.8 times in the first operation, the average operation time was 106.1 + 16.9 minutes. The average fluoroscopy time was 24.7 + 4.8 minutes. There were 37 pulmonary veins in.9 patients, including 1 left pulmonary veins, 8 left upper pulmonary veins, 8 branches of the lower left pulmonary vein, 9 branches of the right upper pulmonary vein, the right inferior pulmonary vein 9, and right middle lung. All patients were treated with a 28mm diameter cryo balloon catheter. All pulmonary veins were successfully isolated during the first operation. Two operations were performed on average 4.5 + 2.5 months after the first operation. Two operations suggested a total of 17 (45.9%) pulmonary veins recovered from the left atrial and pulmonary vein, of which the left common dry pulmonary vein was 1 (10). 0%) 2 (25%), 6 branches (75%) of left inferior pulmonary vein (75%), 3 (33.3%) of right upper pulmonary vein (33.3%) and 5 (55.5%).9 in right inferior pulmonary vein, 1 (11.1%) without pulmonary vein restorer, 1 branches of pulmonary vein conduction recovery. Point 19, the number of leaks in the lower pulmonary vein was significantly more than that of the upper pulmonary vein, and concentrated in the bottom of the upper and lower pulmonary veins and the bottom of the inferior pulmonary vein. All the pulmonary veins were successfully isolated in the two operation. In addition, a case of isolated superior vena cava, one case of typical atrial flutter, one case of mitral annulus reentrant atrial tachycardia and room in two operations. The median follow-up time of reentrant tachycardia was 5 (1-19) months. During the follow-up period, 1 patients had recurrent atrial fibrillation and had good control after taking antiarrhythmic drugs. The remaining 8 patients were sinus rhythm during the follow-up period. Conclusion: the recurrent patients after cryopballoon catheter ablation had left atrial and pulmonary veins in the two operation. The ratio of conduction recovery is small, and the conduction recovery part is regular, mainly concentrated in the bilateral inferior pulmonary vein. It is safe and effective to resend the pulmonary vein and the external pulmonary trigger, regular atrial tachycardia and paroxysmal supraventricular tachycardia at the same time.
【学位授予单位】:北京协和医学院
【学位级别】:博士
【学位授予年份】:2016
【分类号】:R541.75
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