心内膜下各种射频消融术式对房颤患者的网络Meta分析

发布时间：2018-11-08 14:06

【摘要】：[目的]心内膜下导管消融已经成为治疗阵发性房颤的一线方法,特别是对于抗心律失常药物效果较差的患者。然而导管消融对于持续性房颤患者的效果仍然不尽如人意。指南推荐对上述人群建议行肺静脉隔离联合心房基质消融,但是不同射频消融术式对于房颤患者的术后疗效、安全性仍不清楚。我们通过网络Meta分析对目前主流的射频消融术式的有效性及安全性进行比较和排序,为临床治疗决策的制定提供循证医学证据。[方法]此次网络Meta分析的数据均来自计算机检索Pubmed,EMBASE,和Cochrane数据库及国际会议记录,检索美国目前已批准的不同房颤射频消融术式与任一射频消融术式进行比较的随机对照研究。从中提取试验设计、纳入及排除标准、样本特征和临床结果的相关信息。主要结局为术后1年窦律维持率。次要结局是手术相关的并发症发生率。我们运用随机效应模型方法进行网络Meta分析,并得到相应的效应值。效应值采取比值比(Odds ratio,OR)和95%可信区间(95%Confidence interval,95%CI)的方式进行表示。同时对纳入的所有射频消融术式进行有效性及安全性的排序,并得到所有干预措施的“累计排序曲线下面积图”(surface under the cumulative ranking,SUCRA)及其相应 SUCRA 值。[结果]这篇网络Meta分析最终纳入34项随机对照研究,包含5930名房颤患者,随访时限在术后10个月至36个月之间。网络Meta分析结果显示:在房颤射频消融术后1年窦律维持率方面,所有射频消融术式与肺静脉隔离术相比均没有显示出明显的有效性。相反的是,与肺静脉隔离术式相比,单纯行局灶驱动加房颤转子消融(FIRM)[OR=0.10,95%CI(0.02,0.63)]和心房碎裂电位消融(CFAE)[OR=0.10,95%CI(0.04-0.27)]会明显降低房颤患者术后1年窦律维持率。另一方面,在手术相关并发症发生率方面,各房颤射频消融术式间均无明显差异。[结论](1)在房颤患者中,单纯行肺静脉隔离术的有效性及安全性均不劣于肺静脉隔离联合心房基质改良的复合术式。(2)基于网络Meta分析中SUCRA值排序,结合有效性及安全性两方面考虑,对持续性房颤患者行射频消融治疗时应优先选择行PVI+no-PV trigger术式,然而由于缺乏充足的直接比较数据,其结论的阐述仍应谨慎。(3)虽然单独行FIRM、CFAE术式的并发症发生率相对不高,但会使房颤患者术后的窦律维持率明显减低,术者应尽量避免对患者行该类术式。
[Abstract]:Objective: subendocardial catheter ablation has become a first-line method for the treatment of paroxysmal atrial fibrillation, especially in patients with poor antiarrhythmic drugs. However, catheter ablation is still unsatisfactory in patients with persistent atrial fibrillation. The guidelines recommend pulmonary vein isolation combined with atrial matrix ablation in these populations, but the safety of different radiofrequency ablation procedures for patients with atrial fibrillation remains unclear. We compare and rank the effectiveness and safety of the current mainstream radiofrequency ablation by network Meta analysis to provide evidence-based medical evidence for clinical decision making. [methods] the data of the Meta analysis of this network came from the computer retrieval of Pubmed,EMBASE, and Cochrane databases and the records of international conferences. To search for a randomized controlled study of radiofrequency ablation of atrial fibrillation currently approved in the United States and any radiofrequency ablation. Extract information about trial design, inclusion and exclusion criteria, sample characteristics and clinical results. The main outcome was the maintenance rate of sinus rhythm 1 year after operation. The secondary outcome is the incidence of surgical-related complications. We use the stochastic effect model method to analyze the network Meta, and get the corresponding effect value. The effect value was expressed by ratio (Odds ratio,OR) and 95% confidence interval (95%Confidence interval,95%CI). At the same time, the efficacy and safety of all the radiofrequency ablation methods were ranked, and the "area chart under the cumulative sorting curve" (surface under the cumulative ranking,SUCRA) and the corresponding SUCRA values of all intervention measures were obtained. [results] this network Meta analysis was included in 34 randomized controlled trials involving 5930 patients with atrial fibrillation. The duration of follow-up was between 10 and 36 months postoperatively. The results of network Meta analysis showed that all radiofrequency ablation methods were not effective compared with pulmonary vein isolation in sinus rhythm maintenance rate one year after radiofrequency ablation of atrial fibrillation. On the contrary, compared with the pulmonary vein isolation procedure, Ablation of (FIRM) (OR=0.10,95%CI _ (0.02) 0.63) and (CFAE) [OR=0.10,95%CI (0.04-0.27)] by focal drive plus atrial fibrillation trochanter ablation could significantly decrease postoperative atrial fibrillation patients. The maintenance rate of sinus rhythm was 1 year. On the other hand, there was no significant difference in the incidence of surgical complications among atrial fibrillation radiofrequency ablation. [conclusion] (1) in patients with atrial fibrillation, the efficacy and safety of pulmonary vein isolation alone is not inferior to that of the modified composite procedure of pulmonary vein isolation combined with atrial matrix. (2) based on network Meta analysis, the SUCRA value is ranked. Considering the efficacy and safety of radiofrequency catheter ablation (RFCA) in patients with persistent atrial fibrillation, PVI no-PV trigger procedure should be preferred. However, due to the lack of adequate direct comparison data, (3) although the incidence of complications of FIRM,CFAE alone is relatively low, the maintenance rate of sinus rhythm in patients with atrial fibrillation will be significantly reduced, and the surgeon should avoid this kind of operation as far as possible.
【学位授予单位】：昆明医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.75

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