难治性室性心律失常导管消融改良技术的初步探索性研究

发布时间：2019-01-12 12:36

【摘要】：本研究内容分为两个部分,分别探讨犬的改良剑突下经皮心包穿刺术的可行性和安全性以及经房间隔穿刺途径消融室壁瘤相关室性心动过速的有效性和安全性。这两部分研究分别从改良技术和优化消融策略两个方面来指导难治性室性心律失常的导管消融,为提高手术疗效和安全性,降低操作相关并发症的发生率等提供了新的思路。第一部分为动物实验,通过与常规的心包穿刺针(Tuohy斜面针)比较,评估改良的心包穿刺针在犬模型中行剑突下经皮心包穿刺术的可行性和安全性,实验分为改良的心包穿刺针组和Tuohy针组。第二部分为临床研究,资料来源于中国医学科学院阜外医院,共入选5例室壁瘤相关室速患者,经主动脉逆行法导管消融失败后,评估通过房间隔穿刺途径消融室速的有效性和安全性。第一部分:犬的改良剑突下经皮心包穿刺术的可行性和安全性研究目的:通过与常规的心包穿刺针(Tuohy斜面针)比较,探讨应用改良的心包穿刺针行剑突下经皮心包穿刺术的可行性和安全性。方法:成年杂交犬10只,随机分为改良的心包穿刺针组和Tuohy针组。由三位独立的研究者(分别达到高、中和初级电生理介入手术水平)进行剑突下经皮心包穿刺操作,且三位研究者既往均无使用改良心包穿刺针的经验。每位研究者分别尝试经前路和后路两种方法,每种方法分别进行两次尝试。通过导丝走形和心包腔造影来判断心包穿刺操作是否成功。操作完成后即刻处死,观察心脏及邻近组织脏器情况。分别记录进针深度和角度及操作相关并发症的发生情况。结果:改良的心包穿刺针组中,前路法进针角度平均为27.2±5.52°,而后路法进针角度明显大于前者,平均为68.0±7.26°(P0.01)。而进针深度两种方法并无显著性差异,前路法进针深度平均为69.3±11.87mm,后路法进针深度平均为74.3±10.89mm(P=0.094)。与改良的心包穿刺针组相比,Tuohy针组的并发症发生率相对较高,但并无统计学差异。Tuohy针组发生不经意穿刺到心肌组织的发生率为10%,改良穿刺针组为5%(P=0.491);Tuohy针组发生一例肺损伤;改良的心包穿刺针组发生一例局部冠状血管损伤,造成局限性的出血。结论:与常规的心包穿刺针Tuohy针相比,改良的心包穿刺针是一种安全、有效的进行剑突下经皮心包穿刺术的工具,其操作相关的并发症发生率相对更低。第二部分:经房间隔穿刺途径消融室壁瘤相关室性心动过速目的:本研究旨在评估经主动脉逆行法导管消融失败的室壁瘤相关室性心动过速患者,通过房间隔穿刺途径消融室速的有效性和安全性。方法:自2011年4月至2015年10月在中国医学科学院阜外医院入选室壁瘤相关室性心动过速患者共5例,常规经主动脉逆行法导管消融失败后,应用可控导管鞘经房间隔穿刺途径实施三维电解剖标测并进行导管消融治疗。收集患者基线资料。术后随访12月。有效性终点为导管消融成功,室速不能被诱发;安全性终点为术后无手术相关并发症。结果:5例患者中,4例为心尖部巨大室壁瘤,1例为左室间隔后基底部室壁瘤。2例患者外周动脉严重狭窄或闭塞,经主动脉逆行法失败。余3例患者经主动脉逆行法均未标测到理想靶点。应用可控导管鞘经房间隔穿刺途径行室速导管消融,均达到导管消融终点,无并发症发生。术后平均随访12(6-16)月,1例患者室速复发,再次穿刺房间隔后室速导管消融成功。结论:经房间隔穿刺途径进行左室心律失常导管消融是经主动脉逆行法的重要补充,应用可控导管鞘穿刺房间隔消融室壁瘤相关室性心动过速是安全有效的。
[Abstract]:This study is divided into two parts. The feasibility and safety of pericardiocentesis and the effectiveness and safety of transseptal puncture are discussed. This two part studies the catheter ablation of refractory ventricular arrhythmia from two aspects of improved technique and optimized ablation strategy, and provides a new way to improve the efficacy and safety of the operation and to reduce the incidence of operation-related complications. The first part was animal experiment, and the feasibility and safety of the modified pericardiocentesis was evaluated by comparing with the conventional pericardial puncture needle (Tuohy inclined needle). The experiment was divided into the modified pericardiocentesis needle group and the Tuohy needle group. The second part is a clinical study, which is derived from the Fuwai Hospital of the Chinese Academy of Medical Sciences. Part One: The feasibility and safety of pericardiocentesis under the modified sword process of canines: the feasibility and safety of pericardiocentesis with improved pericardiocentesis was discussed by comparing with the conventional pericardial puncture needle (Tuohy bevel needle). Methods: 10 adult hybrid dogs were randomly divided into modified pericardiocentesis needle and Tuohy needle. The pericardiocentesis was performed by three independent investigators (high, medium and primary electrophysiological interventions, respectively), and none of the three investigators had previously used the modified pericardiocentesis needle. Each investigator tried both anterior and posterior approaches, each of which was attempted twice, respectively. Whether the pericardiocentesis was successful was determined by wire guide and pericardiocentesis. The operation was completed immediately, and the organs of the heart and the adjacent tissues were observed. The depth and angle of the needle and the occurrence of the related complications were recorded separately. Results: In the modified pericardiocentesis needle group, the angle of the needle in the anterior approach was 27. 2 and 5.52 掳, and the angle of the needle in the posterior approach was significantly greater than that of the former, with an average of 68. 0 and 7.26 掳 (P0.01). There was no significant difference in the depth of the needle entering the needle. The average depth of the needle in the anterior approach was 69. 3/ 11. 87mm, and the depth of the needle in the posterior method was 74.3 and 10.89mm (P = 0.094). The incidence of complications in the Tuohy needle group was relatively high compared to the modified pericardial puncture group, but there was no statistical difference. The incidence rate of the tuohy needle group was 10%, the modified puncture needle group was 5% (P = 0.491), the Tuohy needle group had one lung injury, and the modified pericardiocentesis needle group had a partial coronary artery injury, which caused the limited bleeding. Conclusion: Compared with the conventional pericardial puncture needle Tuohy needle, the modified pericardiocentesis needle is a safe and effective tool for pericardiocentesis under the sword process, and the complication rate associated with its operation is relatively low. Part 2: Radiofrequency Catheter Ablation of Ventricular Tachycardia-related Ventricular Tachycardia: The purpose of this study is to assess the effectiveness and safety of ventricular tachycardia in patients with chamber-wall-aneurysm-associated ventricular tachycardia, which has failed by the procedure of transseptal puncture. Methods: From April 2011 to October 2015, a total of 5 patients with ventricular tachycardia were selected from Fuwai Hospital of the Chinese Academy of Medical Sciences, and after the failure of the conventional aortic retrograde catheter ablation, The three-dimensional electroanatomic mapping was performed by the transseptal puncture of the controlled catheter, and the catheter ablation was performed. Collect patient baseline data. The postoperative follow-up was 12 months. The efficacy endpoint was the success of the catheter ablation and the chamber speed could not be induced; the safety endpoint was the post-operative, non-surgical-related complication. Results: Of the 5 patients, 4 cases were the giant cell wall tumor of the apical part, and one case was the wall tumor of the basal bottom of the left ventricular septum. The ideal target point was not detected by the retrograde method of the aortic retrograde method in the remaining 3 patients. The catheter ablation of the catheter was performed by transseptal puncture with the controlled catheter, and the end of catheter ablation was achieved without complication. After the mean follow-up of 12 (6-16) months, 1 patient had a recurrence of room speed, and the ventricular tachycardia after transseptal re-puncture was successful. Conclusion: The ablation of the left ventricular arrhythmia catheter by transseptal puncture is an important supplement to the retrograde approach of the aorta.
【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】：2017
【分类号】：R541.7

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