长时程心电监测设备在心房颤动射频消融术后心律监测中的应用

发布时间：2019-05-30 10:25

【摘要】：研究背景心房颤动(atrial fibrillation, AF)是临床上最为常见的心律失常性疾病之一,且随着人口老龄化的加剧,其发病率正在逐年增加。缺血性脑卒中(ischemic stroke)是心房颤动的主要并发症之一,可显著降低心房颤动患者的生存质量并增加其死亡率。口服抗凝药物(e.g.华法林、达比加群)可显著降低心房颤动患者缺血性脑卒中的发生率,从而改善心房颤动患者的预后。射频消融手术(radiofrequency catheter ablation, RFCA)是目前临床上治疗心房颤动的主要手段之一,尤其是有明显临床症状且药物治疗无效的心房颤动患者。然而,心房颤动射频消融术后仍有30%-40%的患者会出现心房颤动的复发而需要药物治疗或再次行消融手术治疗。目前临床上常规应用24小时动态心电图(24h-Holter)来评估心房颤动患者射频消融术后的复发情况。但是由于24h-Holter监测时长相对较短,因而其对心房颤动复发的检出率相对较低。目前已有应用长时程监测设备筛查心律失常的相关报道,但尚无长时程监测设备对射频消融术后心房颤动复发监测最佳佩戴时长的报道。另外,有研究显示射频消融术后出现的早期心房颤动(early atrial fibrillation, EAF)或早期房性心动过速(early atrial tachycardia, EAT)可能是晚期心房颤动复发(late atrial fibrillation, LAF)的独立危险因素之一,但不同时间段内的早期房性心律失常与晚期房颤复发间的关系尚不明确。研究目的本研究通过应用长时程(7天)心电监测设备来评估：1)心房颤动射频消融术后7天内早期房性心律失常的发生率及心房颤动负荷；2)心房颤动射频消融术后7天内心房颤动相关临床症状(e.g.心悸、头晕)与房性心律失常的相关性；3)心房颤动射频消融术后7天内出现房性心律失常的危险因素；4)心房颤动射频消融术后长时程监测设备的最佳监测时长；5)不同长时程监测设备间其有效监测时间百分比是否存在差异。研究方法入组患者：于2016年03月01日至2016年05月31日因心房颤动为行射频消融手术治疗而于北京协和医院心内科住院的患者共20例。术前记录患者的性别、年龄、身体质量指数(body mass index, BMI)、心房颤动类型、患病时间、有无合并房扑、合并疾病、用药情况、肌酐、N末端脑钠肽原(NT-proBNP)、左房前后径(left atrial diameter, LAD)大小和左室射血分数(left ventricular ejection fraction, LVEF).射频消融术后即刻予长时程心电监测,7天后床旁随诊评估患者有无心房颤动相关临床症状,拆除设备,经公司配套软件导出数据,分析房性心律失常的发生率、发生时间及相应的心房颤动负荷。研究结果1.心房颤动射频消融术后7天内早期心房颤动的发生率为30%,早期房性心动过速的发生率为20%,早期房性心律失常的发生率总计为45%。2.在出现心房颤动相关临床症状的患者中,只有33.3%的患者被检测出早期心房颤动,11.1%的患者被检出早期房性心动过速；而在无心房颤动相关临床症状的患者中,有27.3%的患者被检测出早期心房颤动,另有18.2%的患者被检测出早期房性心动过速。3.左室射血分数降低是射频消融术后早期心房颤动的危险因素；性别、年龄、BMI、心房颤动类型、是否合并房扑、患病时间、合并疾病、左房前后径并不是消融术后7天内出现早期房性心律失常的危险因素。4.心房颤动射频消融术后7天内,共有9名患者检测出早期房性心律失常。其中射频消融术后24小时内有2名患者被检测出早期房性心律失常,射频消融术后3天内有7名患者被检测出早期房性心律失常,另有2名患者分别于射频消融术后第5天和第7天被检测出房性心律失常。Fisher确切概率法分析显示5天内和7天内其早期房性心律失常检出率无显著统计学差异(p＞0.05)。5.射频消融术后3天内监测出早期心房颤动的患者其房颤负荷大于20%,5天内检测出早期心房颤动的患者其房颤负荷均大于10%,；而在第7天被检测出早期心房颤动的患者的房颤负荷小于10%。6.北京欧桥公司的心卫士设备其有效监测时长占总监测时长的百分比为80.5±21.5%,而上海越光公司的贴心设备其有效时长占总监测时长的百分比为91.0±12.0%,两者的有效监测时长百分比无显著的统计学差异(p0.05)。研究结论1.心房颤动射频消融术后早期房性心律失常的发生率较高。2.心房颤动相关临床症状(e.g.心悸、头晕)并不能很好的提示射频消融术后有无早期心房颤动。3.左室射血分数降低是射频消融术后早期心房颤动的危险因素；而性别、年龄、BMI、患病时间、合并疾病、吸烟史和左房前后径并不是射频消融术后7天内出现早期房性心动过速的危险因素。4.相较于24h-Holter,长程监测设备可以显著提高早期房性心律失常的检出率；但超过一定时长后,延长监测时长并不能显著提高房性心律失常的检出率。5.房颤负荷越高的患者,其早期心房颤动出现的时间越早。6.不同长时程监测设备间其有效检测时长百分比可能无明显差异。
[Abstract]:Background Atrial fibrillation (AF) is one of the most common arrhythmia diseases in the world, and the incidence of atrial fibrillation is increasing year by year as the aging of the population is increasing. Ischemic stroke is one of the major complications of atrial fibrillation, which can significantly reduce the quality of life and increase the mortality of patients with atrial fibrillation. Oral anticoagulants (e. g., warfarin, dabigatran) can significantly reduce the incidence of ischemic stroke in patients with atrial fibrillation, thus improving the prognosis of patients with atrial fibrillation. Radiofrequency ablation (RFCA) is one of the main methods in the treatment of atrial fibrillation, especially in patients with atrial fibrillation which have obvious clinical symptoms and are not effective in the treatment of atrial fibrillation. However,30% to 40% of patients with atrial fibrillation after radiofrequency ablation will have a recurrence of atrial fibrillation, requiring a drug treatment or a re-operation of the ablation procedure. A 24-hour dynamic electrocardiogram (24-hour-Holter) was routinely applied to assess the recurrence of atrial fibrillation in patients with atrial fibrillation. However, since the duration of the 24 h-Holter monitoring is relatively short, the detection rate of the recurrence of atrial fibrillation is relatively low. A long time history monitoring device has been used to screen the related reports of arrhythmia, but no long time history monitoring equipment has been used to monitor the best wearing time of atrial fibrillation after radiofrequency ablation. In addition, early atrial fibrillation (EAF) or early atrial tachycardia (EAT), which occurs after radiofrequency ablation, may be one of the independent risk factors for late atrial fibrillation recurrence (LAF), However, the relationship between early atrial arrhythmia and the recurrence of late AF in different time periods is not clear. The purpose of this study was to evaluate the incidence of early atrial arrhythmia and the load of atrial fibrillation in 7 days after radiofrequency ablation of atrial fibrillation by applying a long-time (7-day) ECG monitoring device. 2) The related clinical symptoms of atrial fibrillation (e. g. palpitations, dizziness) and atrial arrhythmia within 7 days after radiofrequency ablation of atrial fibrillation;3) the risk factors of atrial arrhythmia within 7 days after radiofrequency ablation of atrial fibrillation; 4) The optimal monitoring time of the long time-course monitoring equipment after radiofrequency ablation of atrial fibrillation; and 5) whether the effective monitoring time percentage among the different long-time duration monitoring devices is different. The patients were enrolled in the study: a total of 20 patients were admitted to the Department of Cardiology of Peking Union and Hospital for the treatment of atrial fibrillation from 01/03/2016 to May 31,2016 for the treatment of atrial fibrillation. The patient's sex, age, body mass index (BMI), type of atrial fibrillation, time of illness, presence or absence of concomitant atrial flutter, combined disease, medication, muscle tone, N-terminal brain natriuretic peptide (NT-proBNP) and left atrial diameter were recorded before operation. LAD) and left ventricular ejection fraction (LVEF). The clinical symptoms and the time of atrial arrhythmia, the incidence of atrial arrhythmia, the time of occurrence and the corresponding atrial fibrillation load were analyzed by means of the software derived from the company's supporting software. Study Results 1. The incidence of early atrial fibrillation was 30%, the incidence of early atrial tachycardia was 20%, and the incidence of early atrial arrhythmia was 45%. Of the patients with related clinical symptoms of atrial fibrillation, only 33.3% of the patients were detected with early atrial fibrillation, 11.1% of the patients were detected early atrial tachycardia, and 27.3% of the patients who had no clinical symptoms associated with atrial fibrillation were detected with early atrial fibrillation, An additional 18.2% of patients were detected with early atrial tachycardia. The reduction of left ventricular ejection fraction is a risk factor for early atrial fibrillation after radiofrequency ablation; sex, age, BMI, type of atrial fibrillation, whether to merge atrial flutter, time of illness, and concomitant disease, The anterior and posterior diameter of the left atrium was not a risk factor for early atrial arrhythmias within 7 days after the ablation procedure. In 7 days after radiofrequency ablation of atrial fibrillation, a total of 9 patients detected early atrial arrhythmias. Two patients were detected early atrial arrhythmias within 24 hours of RF ablation,7 patients were detected early atrial arrhythmias within 3 days of RF ablation, and 2 patients were detected atrial arrhythmias on Days 5 and 7 after RF ablation, respectively. Fisher's exact probability method showed no significant difference in the detection rate of early atrial arrhythmias within 5 and 7 days (p> 0.05). The AF burden of patients with early atrial fibrillation was greater than 20% within 3 days of RF ablation, and the AF burden in patients with early atrial fibrillation was greater than 10% within 5 days, and the AF load of patients who had been tested for early atrial fibrillation on Day 7 was less than 10%. The effective monitoring duration of the heart guard equipment of the Beijing Ouqiao Company accounts for 80.5 to 21.5% of the total monitoring duration, while the effective length of the considerate equipment of the Shanghai Yueguang Company accounts for 91.0% to 12.0% of the total monitoring duration. There was no significant difference in the percentage of effective monitoring of the two groups (p0.05). Study Conclusion 1. The incidence of early atrial arrhythmia after radiofrequency ablation of atrial fibrillation was high. Atrial fibrillation-related clinical symptoms (e. g. palpitations, dizziness) did not provide a good indication of the presence of early atrial fibrillation after radiofrequency ablation. The decrease in left ventricular ejection fraction was a risk factor for early atrial fibrillation after radiofrequency ablation; while gender, age, BMI, time of illness, combined disease, smoking history, and anterior and posterior diameters of the left atrium were not the risk factors for early atrial tachycardia within 7 days after radiofrequency ablation. Compared with the 24-hour-Holter, the long-range monitoring device can significantly improve the detection rate of the early atrial arrhythmia, but after a certain period of time, the monitoring duration can be prolonged and the detection rate of the atrial arrhythmia can not be obviously improved. The higher the AF burden, the earlier the early atrial fibrillation. There may be no significant difference in the percentage of effective detection duration between different time-history monitoring devices.
【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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