持续性房颤患者射频消融术后左心房和左心室结构和功能的变化
发布时间：2019-07-02 13:54
【摘要】：背景：房颤是临床上最常见的心律失常之一,其患病率正逐年升高,常导致血栓栓塞、脑卒中等严重心脑血管事件。既往常用药物治疗房颤,但因其有效性和安全性逐渐受到挑战,射频消融术因效率较高,副作用较低而受到广泛青睐。研究显示,房颤可导致左心房和左心室增大及功能降低,而增大的左心房可进一步促进房颤维持,形成一个恶性循环。因此,患者房颤控制后左心房和左心室结构和功能是否能够恢复对房颤患者生活质量及预后均有影响。而射频消融术控制房颤后左心房和左心室结构与功能变化情况也逐渐受到关注。目的：通过测定持续性房颤患者行环肺静脉射频消融术前后左心房和左心室结构和功能相关指标(左心房前后径(LAD)、左心室舒张末内径(LVEDD)、左心室收缩末内径(LVESD)、左心室缩短分数(FS)、左心室射血分数(LVEF)以及血浆脑钠肽(BNP)或氨基末端脑钠肽前体(NT-proBNP)),对比手术成功组和失败组的前后变化,探讨导管射频消融治疗对房颤患者心脏结构和功能的影响。并对成功组与失败组术前相关指标(年龄、病程、LAD、NT-proBNP等)进行对比分析,探讨其对射频消融术预后的指导意义。方法：选择2013年1月到2015年11月间在北京协和医院心内科行射频消融术的57例符合条件的持续性房颤患者,查阅病历,获得其性别、年龄、房颤病程、体重指数(BMI)、术前的超声心动图测量的LAD、LVEDD、LVESD、FS、LVEF和血浆BNP、NT-proBNP。待其手术后至少6个月之后,打电话进行随访,询问症状,行动态心电图检查判断其手术成功或者失败,行超声心动图检查其术后相关指标及抽血查BNP、NT-proBNP。分别对比成功组和失败组手术前后的相关指标变化,以及成功组与失败组之间手术前的相关指标。结果：1、57例患者中,有32例接受并完成了随访。32例入组患者基本指标,年龄58.71±12.36岁(28例集中在40-70岁),术前LAD 42.56±4.41mm(最大不超过50mm),术前LVEF 64.81±8.83%(仅3例小于55%),术前NT-proBNP 826.71±624.29pg/ml。2、入组患者中24例无复发,归入成功组,8例出现复发,归入失败组,成功率75%。两组病人在年龄、BMI、血压、术前LAD、LVEF方面,P均0.05,都没有显著性差异；提示本研究入组病人的年龄、病程、术前LAD、LVEF、不能作为房颤术后复发预测因子。3、将32例患者术前指标与术后复发的相关性进行二元分析,结果显示,年龄、病程、BMI、术前LAD、LVEF、NT-proBNP与术后房颤复发OR值各不相同,但是P均0.05,未见显著差异,利用精确Fisher检验,对术前LAD正常者与增大者进行复发相关性分析,P0.05,未见显著性差异。也提示本研究入组病人的年龄、病程、术前LAD、LVEF、NT-proBNP不能作为房颤术后复发预测因子。4、成功组LAD(术前42.63±3.91mm vs 3术后9.21±3.11mm,P0.05),有显著性差异,提示消融成功后左心房发生可逆性重构；但是LVEDD、LVESD、FS、 LVEF的手术前后变化P值为0.535,0.507,0.914,0.448均0.05,无显著性差异,无明显变化。但术前LVEF降低的3例患者,在成功控制房颤后LVEF均上升。5、失败组手术前后LAD、LVEDD、LVESD、FS、LVEF变化的P值分别为0.266,0.101,0.238,0.489,0.422,均0.05,没有显著性差异。提示消融失败后房颤患者左心房和左心室结构与功能未进一步恶化。6、成功组与失败组术前NT-proBNP对比,(成功组1014.71±601.99pg/ml vs失败组450.71±516.27pg/ml, P=0.0480.05),有显著性差异,但成功组术前NT-proBNP明显高于失败组。7、成功组术后NT-proBNP降低,(术前1014.71±601.99pg/ml vs术后123.71 ±75.99pg/ml,P0.05),有显著性差异；失败组术后NT-proBNP升高,(术前450.71 ±516.27pg/ml vs术后987.86±738.81pg/ml, P=0.030.05),有显著性差异。结论：1、射频消融术是治疗房颤的有效方法,能有效维持窦律。2、射频消融术成功后,左心房可发生逆重构；但对于术前左心室结构和功能未见明显异常者,左心室结构和功能变化情况不明显。尚需进一步详细研究。3、对于研究中40-70岁之间的患者,本研究不支持年龄增大可作为房颤射频消融术后复发的预测因子,仍需进一步研究。4、对本研究入组的持续性房颤病人,病程长短不能作为射频消融术后复发的预测因子。5、术前左心房前后径(LAD)未超过50mm时,本研究不支持LAD可作为房颤患者射频消融术后复发的预测因子。6、术前左心室射血分数未降低(LVEF55%)时,本研究不支持LVEF可作为房颤患者射频消融术后复发的预测因子。7、房颤患者血清NT-proBNP升高,射频消融成功控制房颤后,心功能可恢复,NT-proBNP可显著降低。8、消融后NT-proBNP降低可作为消融成败的预测因素,而术前NT-proBNP基线水平不能作为消融成败的预测因素9、NT-proBNP对无症状的心功能异常患者比左心室射血分数(LVEF)更具检测优势。
[Abstract]:Background: Atrial fibrillation is one of the most common arrhythmias in the clinic. The prevalence of atrial fibrillation is increasing year by year, which often leads to serious cardiovascular and cerebrovascular events such as thromboembolic stroke and stroke. The prior commonly used drugs have been widely used for the treatment of atrial fibrillation, but due to the challenge of their effectiveness and safety, radiofrequency ablation is widely favored due to high efficiency and low side effects. The study shows that AF can lead to an increase in the left atrium and the left ventricle and a decrease in function, while the increased left atrium can further promote the maintenance of AF and form a vicious circle. Therefore, whether the left atrial and left ventricular structures and functions can be recovered after AF control has an impact on the quality of life and the prognosis of patients with atrial fibrillation. The changes of left atrium and left ventricular structure and function in the control of atrial fibrillation after radiofrequency ablation are also of concern. Objective: To determine the left atrial and left ventricular structure and function-related index (LAD), left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic internal diameter (LVESD) and left ventricular shortening fraction (FS) before and after radiofrequency ablation of pulmonary vein in patients with persistent AF. Left ventricular ejection fraction (LVEF) and plasma brain natriuretic peptide (BNP) or amino-terminal brain natriuretic peptide (NT-proBNP) were compared. The correlation between the success group and the failure group (age, course of course, LAD, NT-proBNP, etc.) was compared and analyzed, and its significance to the prognosis of radiofrequency ablation was discussed. Methods:57 eligible patients with persistent AF were selected from January 2013 to November 2015 in the cardiac internal medicine of Peking Union and Hospital, and the patient's medical records were reviewed to obtain their sex, age, course of atrial fibrillation, body mass index (BMI), LAD and LVEDD of pre-operative echocardiogram. LVESD, FS, LVEF, and plasma BNP, NT-proBNP. After at least 6 months after the operation, the patient was called for follow-up, the symptoms were inquired, the dynamic electrocardiogram of the line was determined to determine the success or failure of the operation, and the relevant index and blood draw of BNP and NT-proBNP were examined by echocardiography. The relevant index changes before and after operation of the successful group and the failure group were compared, and the related indexes before the operation between the successful group and the failure group were compared. Results: Of the 57 patients,32 patients received and completed the follow-up.32 patients had the basic index, the age was 58.71, the age was 12.36 years (28 cases were in the range of 40 to 70 years), the preoperative LAD 42.56 was 4.41 mm (not more than 50 mm), the preoperative LVEF 64.81 was 8.83% (only 3 cases was less than 55%), and the preoperative NT-proBNP 826.71 was 624.29 pg/ ml.2, Twenty-four of the enrolled patients had no recurrence, and they were included in the successful group. The 8 cases recurred, and they were included in the failure group and the success rate was 75%. There was no significant difference between the two groups in age, BMI, blood pressure, pre-operative LAD and LVEF. The relationship between preoperative and postoperative recurrence of 32 patients was analyzed. The results showed that, age, course, BMI, pre-operative LAD, LVEF, NT-proBNP were different from those of postoperative AF, but P was 0.05, no significant difference was found, and accurate Fisher's test was used. There was no significant difference in the correlation between the normal and the increase of the pre-operative LAD, P0.05. The age, course, pre-operative LAD, LVEF and NT-proBNP of the patients were also indicated to be not a predictor of the recurrence of AF.4. The successful group of LAD (42.63, 3.91 mm vs.3, 9.21, 3.11 mm, P 0.05) in the successful group showed a significant difference, indicating the reversible reconstruction of the left atrium after the successful ablation; however, the LVEDD, The post-operative changes of LVESD, FS and LVEF were 0.535, 0.507, 0.914, and 0.448, respectively. However, in 3 patients with LVEF decreased, LVEF was increased after successful control of AF. The P values of LAD, LVEDD, LVESD, FS and LVEF were 0.266, 0.101, 0.238, 0.489 and 0.422 in the failure group before and after operation, and there was no significant difference. The left atrium and left ventricular structure and function of the patients with atrial fibrillation after the ablation failure were not further deteriorated.6. The success group and the NT-proBNP in the failed group were compared with the NT-proBNP in the successful group (group 1014.71, 601.99 pg/ ml vs. the failure group 450.71, 516.27 pg/ ml, P = 0.0480.05), but the NT-proBNP was significantly higher in the successful group than in the failure group. The NT-proBNP in the successful group was decreased, (1014.71 to 601.99 pg/ ml and 123.71 to 75.99pg/ ml after operation, P0.05). There was a significant difference in the NT-proBNP after the failure group. The NT-proBNP in the failure group was increased, and the NT-proBNP in the failure group was increased (the pre-operation 450.71-516.27 pg/ ml vs. the post-operation 987.86-738.81 pg/ ml, P = 0.030.05), and there was a significant difference. Conclusion:1. Radiofrequency ablation is an effective method for the treatment of atrial fibrillation, which can be used to maintain the atrial fibrillation effectively. After the successful radiofrequency ablation, the left atrium may have an inverse reconstruction; however, the left ventricular structure and the function change are not obvious for the pre-operative left ventricular structure and function. a further detailed study is required.3. For patients in the study between 40 and 70 years of age, this study does not support an increase in age as a predictor of recurrence after radiofrequency ablation of AF, and a further study is required.4. Patients with persistent AF who are enrolled in this study, The duration of the course of course could not be a predictor of recurrence after radiofrequency ablation.5. The pre-operative left atrial diameter (LAD) was not more than 50 mm. The study did not support LAD as a predictor of recurrence after radiofrequency ablation in patients with atrial fibrillation.6. The preoperative left ventricular ejection fraction was not reduced (LVEF 55%). This study did not support LVEF as a predictor of recurrence after radiofrequency ablation in patients with atrial fibrillation.7. The increase of NT-proBNP in patients with atrial fibrillation and the success of radio-frequency ablation in the control of AF, the function of cardiac function can be recovered, and NT-proBNP can be significantly reduced.8. The decrease of NT-proBNP after ablation can be used as a predictor of the success or failure of the ablation. The pre-operative NT-proBNP baseline level could not be a predictor of success or failure of the ablation. NT-proBNP was more sensitive to asymptomatic cardiac dysfunction than the left ventricular ejection fraction (LVEF).
【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
本文编号：2508985
[Abstract]:Background: Atrial fibrillation is one of the most common arrhythmias in the clinic. The prevalence of atrial fibrillation is increasing year by year, which often leads to serious cardiovascular and cerebrovascular events such as thromboembolic stroke and stroke. The prior commonly used drugs have been widely used for the treatment of atrial fibrillation, but due to the challenge of their effectiveness and safety, radiofrequency ablation is widely favored due to high efficiency and low side effects. The study shows that AF can lead to an increase in the left atrium and the left ventricle and a decrease in function, while the increased left atrium can further promote the maintenance of AF and form a vicious circle. Therefore, whether the left atrial and left ventricular structures and functions can be recovered after AF control has an impact on the quality of life and the prognosis of patients with atrial fibrillation. The changes of left atrium and left ventricular structure and function in the control of atrial fibrillation after radiofrequency ablation are also of concern. Objective: To determine the left atrial and left ventricular structure and function-related index (LAD), left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic internal diameter (LVESD) and left ventricular shortening fraction (FS) before and after radiofrequency ablation of pulmonary vein in patients with persistent AF. Left ventricular ejection fraction (LVEF) and plasma brain natriuretic peptide (BNP) or amino-terminal brain natriuretic peptide (NT-proBNP) were compared. The correlation between the success group and the failure group (age, course of course, LAD, NT-proBNP, etc.) was compared and analyzed, and its significance to the prognosis of radiofrequency ablation was discussed. Methods:57 eligible patients with persistent AF were selected from January 2013 to November 2015 in the cardiac internal medicine of Peking Union and Hospital, and the patient's medical records were reviewed to obtain their sex, age, course of atrial fibrillation, body mass index (BMI), LAD and LVEDD of pre-operative echocardiogram. LVESD, FS, LVEF, and plasma BNP, NT-proBNP. After at least 6 months after the operation, the patient was called for follow-up, the symptoms were inquired, the dynamic electrocardiogram of the line was determined to determine the success or failure of the operation, and the relevant index and blood draw of BNP and NT-proBNP were examined by echocardiography. The relevant index changes before and after operation of the successful group and the failure group were compared, and the related indexes before the operation between the successful group and the failure group were compared. Results: Of the 57 patients,32 patients received and completed the follow-up.32 patients had the basic index, the age was 58.71, the age was 12.36 years (28 cases were in the range of 40 to 70 years), the preoperative LAD 42.56 was 4.41 mm (not more than 50 mm), the preoperative LVEF 64.81 was 8.83% (only 3 cases was less than 55%), and the preoperative NT-proBNP 826.71 was 624.29 pg/ ml.2, Twenty-four of the enrolled patients had no recurrence, and they were included in the successful group. The 8 cases recurred, and they were included in the failure group and the success rate was 75%. There was no significant difference between the two groups in age, BMI, blood pressure, pre-operative LAD and LVEF. The relationship between preoperative and postoperative recurrence of 32 patients was analyzed. The results showed that, age, course, BMI, pre-operative LAD, LVEF, NT-proBNP were different from those of postoperative AF, but P was 0.05, no significant difference was found, and accurate Fisher's test was used. There was no significant difference in the correlation between the normal and the increase of the pre-operative LAD, P0.05. The age, course, pre-operative LAD, LVEF and NT-proBNP of the patients were also indicated to be not a predictor of the recurrence of AF.4. The successful group of LAD (42.63, 3.91 mm vs.3, 9.21, 3.11 mm, P 0.05) in the successful group showed a significant difference, indicating the reversible reconstruction of the left atrium after the successful ablation; however, the LVEDD, The post-operative changes of LVESD, FS and LVEF were 0.535, 0.507, 0.914, and 0.448, respectively. However, in 3 patients with LVEF decreased, LVEF was increased after successful control of AF. The P values of LAD, LVEDD, LVESD, FS and LVEF were 0.266, 0.101, 0.238, 0.489 and 0.422 in the failure group before and after operation, and there was no significant difference. The left atrium and left ventricular structure and function of the patients with atrial fibrillation after the ablation failure were not further deteriorated.6. The success group and the NT-proBNP in the failed group were compared with the NT-proBNP in the successful group (group 1014.71, 601.99 pg/ ml vs. the failure group 450.71, 516.27 pg/ ml, P = 0.0480.05), but the NT-proBNP was significantly higher in the successful group than in the failure group. The NT-proBNP in the successful group was decreased, (1014.71 to 601.99 pg/ ml and 123.71 to 75.99pg/ ml after operation, P0.05). There was a significant difference in the NT-proBNP after the failure group. The NT-proBNP in the failure group was increased, and the NT-proBNP in the failure group was increased (the pre-operation 450.71-516.27 pg/ ml vs. the post-operation 987.86-738.81 pg/ ml, P = 0.030.05), and there was a significant difference. Conclusion:1. Radiofrequency ablation is an effective method for the treatment of atrial fibrillation, which can be used to maintain the atrial fibrillation effectively. After the successful radiofrequency ablation, the left atrium may have an inverse reconstruction; however, the left ventricular structure and the function change are not obvious for the pre-operative left ventricular structure and function. a further detailed study is required.3. For patients in the study between 40 and 70 years of age, this study does not support an increase in age as a predictor of recurrence after radiofrequency ablation of AF, and a further study is required.4. Patients with persistent AF who are enrolled in this study, The duration of the course of course could not be a predictor of recurrence after radiofrequency ablation.5. The pre-operative left atrial diameter (LAD) was not more than 50 mm. The study did not support LAD as a predictor of recurrence after radiofrequency ablation in patients with atrial fibrillation.6. The preoperative left ventricular ejection fraction was not reduced (LVEF 55%). This study did not support LVEF as a predictor of recurrence after radiofrequency ablation in patients with atrial fibrillation.7. The increase of NT-proBNP in patients with atrial fibrillation and the success of radio-frequency ablation in the control of AF, the function of cardiac function can be recovered, and NT-proBNP can be significantly reduced.8. The decrease of NT-proBNP after ablation can be used as a predictor of the success or failure of the ablation. The pre-operative NT-proBNP baseline level could not be a predictor of success or failure of the ablation. NT-proBNP was more sensitive to asymptomatic cardiac dysfunction than the left ventricular ejection fraction (LVEF).
【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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