發(fā)布時間：2018-04-22 15:51

  本文選題：房顫 + 雙向阻滯��； 參考：《山東大學(xué)》2014年碩士論文

【摘要】：研究背景 陣發(fā)性房顫(atrial fibrillation, AF)由肺靜脈(pulmonary veins, PVs)自發(fā)放電誘發(fā),導(dǎo)致節(jié)段性消融電隔離術(shù)的出現(xiàn)及肺靜脈的連續(xù)環(huán)形病灶消融治療,PVs與左心房(left atrium, LA)連接處的消融隔離能夠治愈AF。然而,隨著射頻消融(radio frequency catheter ablation, RFCA)手術(shù)時間的延長,X射線暴露時間越長,多種并發(fā)癥例如心包填塞、氣胸、假性股靜脈瘤等出現(xiàn)風(fēng)險(xiǎn)越大。同時術(shù)后易并發(fā)伴心悸癥狀的心律失常,這也是目前未解決的難題。 PVs與LA雙向阻滯能夠降低肺靜脈電位電活動傳導(dǎo),傳入性傳導(dǎo)阻滯的實(shí)現(xiàn)相對容易,表現(xiàn)為肺靜脈電位(pulmonary vein potentials, PVPs)消失或者竇性或房顫心律下出現(xiàn)逸搏。對于傳出性傳導(dǎo)阻滯,心房起搏心律是否奪獲相應(yīng)的肺靜脈是關(guān)鍵,即使肺靜脈被奪獲,其電位與心房激動順序無關(guān),也屬于成功的傳出阻滯。同側(cè)環(huán)形肺靜脈隔離術(shù)后有不同的消融終點(diǎn)。具體來說,最理想的終點(diǎn)是四條肺靜脈電位完全消失；此外,任一PVP仍存在但傳導(dǎo)延遲時間大于30ms可視為相對成功。只要任一PVP延遲時間小于30ms,均視為隔離失敗。 研究目的 探討環(huán)雙側(cè)PVs射頻消融術(shù)的不同消融終點(diǎn)是否影響AF患者的術(shù)后復(fù)發(fā)情況。 方法 研究對象2008年6月至2012年8月,在山東大學(xué)齊魯醫(yī)院就診,查體、心電圖及動態(tài)心電圖確診患有AF,口服抗心律失常藥物效果不佳,入院擬行RFCA治療的137例患者,包括113例陣發(fā)性AF及24例持續(xù)性AF患者。向患者及家屬講明手術(shù)必要性及風(fēng)險(xiǎn)性,并簽署知情同意書。 分組根據(jù)患者術(shù)后復(fù)發(fā)與否,將113例陣發(fā)性AF患者分為復(fù)發(fā)組及未復(fù)發(fā)組；根據(jù)RFCA后的不同消融終點(diǎn),除外肺靜脈電位延遲時間小于30m.s的消融失敗患者,將92例陣發(fā)性AF患者分為肺靜脈電位消失組及肺靜脈電位延遲組。 射頻消融治療患者術(shù)前均排除手術(shù)禁忌癥,局部麻醉下行環(huán)肺靜脈電隔離術(shù),經(jīng)左鎖骨下靜脈放置電極導(dǎo)管于冠狀靜脈竇(coronary sinus, CS),2次穿刺房間隔,應(yīng)用三維電解剖標(biāo)測系統(tǒng)(CARTO, Biosense-Webster. Diamond Bar, CA, USA)行LA重建。將十電極雙極導(dǎo)管(Lasso, Biosense-Webster)置于LA口,且距離PV開口約5mm處進(jìn)行逐點(diǎn)消融(30-35W、43℃、17-20ml/min流速)。 術(shù)后治療及隨訪患者于術(shù)后三個月內(nèi)常規(guī)給予口服抗凝藥物治療,根據(jù)術(shù)后心律變化口服胺碘酮1-3個月(需排除禁忌癥)。每組患者分別接受隨訪2年,隨訪中出現(xiàn)心悸癥狀,行心電圖或動態(tài)心電圖檢查,并記錄術(shù)后房顫復(fù)發(fā)的首次時間,尤其是空白期(術(shù)后3個月)后,終點(diǎn)事件為具有心電圖或動態(tài)心電圖證據(jù)的AF。 統(tǒng)計(jì)分析應(yīng)用SPSS16.0軟件,計(jì)量數(shù)據(jù)以x±s表示。利用Shapiro-Wilk (W檢驗(yàn))進(jìn)行正態(tài)性檢驗(yàn),各組連續(xù)變量統(tǒng)計(jì)應(yīng)用t檢驗(yàn)；應(yīng)用Kaplan-Meier生存分析及Log-rank方法對各組患者復(fù)發(fā)情況進(jìn)行分析,檢驗(yàn)水準(zhǔn)均為0.05。 結(jié)果 基線資料137例房顫患者(年齡54.80±12.70歲)中,35例(25.55%)患者合并器質(zhì)性心臟病包括28例(20.44%)合并冠狀動脈粥樣硬化性心臟病,1例(0.73%)合并先天性心臟病,3例(2.19%)合并瓣膜性心臟病,3例(2.19%)合并病態(tài)竇房結(jié)綜合癥。高血壓病、糖尿病、高脂血癥等高代謝性疾病分別存在于57(41.61%)、19(13.87%)、53(38.69%)例患者。其中9例(6.57%)房顫患者同時合并陣發(fā)性室上性心動過速,于手術(shù)中同時行射頻消融術(shù)給予治療。 術(shù)中并發(fā)癥術(shù)中較常見的嚴(yán)重并發(fā)癥包括心房穿孔致心包填塞、肺靜脈狹窄、氣胸、卒中等,其中2例患者發(fā)生心包填塞,1例患者出現(xiàn)氣胸,均因此終止手術(shù)。 陣發(fā)性AF患者的復(fù)發(fā)與未復(fù)發(fā)組比較113例陣發(fā)性房顫患者中52例復(fù)發(fā),其發(fā)作頻率、持續(xù)時間及癥狀各有差異。對手術(shù)時間、心臟超聲檢查指標(biāo)(左心房直徑、左心室舒張末期容積、左室射血分?jǐn)?shù))、合并器質(zhì)性心臟病、代謝性疾病等數(shù)據(jù)進(jìn)行t檢驗(yàn),復(fù)發(fā)組與未復(fù)發(fā)組之間沒有明顯統(tǒng)計(jì)學(xué)差異(P0.05)。 對陣發(fā)性AF患者術(shù)后復(fù)發(fā)情況的生存分析92例陣發(fā)性AF患者分為肺靜脈電位消失組和肺靜脈電位延遲組,肺靜脈電位組共36例患者；肺靜脈電位延遲組為任一肺靜脈電位時間延遲大于30ms,共56例患者,兩組均接受連續(xù)2年的隨訪,根據(jù)患者本人對自覺癥狀的描述或心電圖診斷依據(jù)如實(shí)記錄術(shù)后首次復(fù)發(fā)時間。應(yīng)用Kaplan-Meier生存分析及Log-Rank檢驗(yàn),表明兩組患者在術(shù)后兩年內(nèi)的復(fù)發(fā)率沒有明顯統(tǒng)計(jì)學(xué)差異(P=0.159)。術(shù)后3個月、6個月及12個月內(nèi)的復(fù)發(fā)率均無統(tǒng)計(jì)學(xué)差異(P=0.812,0.640,0.186)。 結(jié)論 與肺靜脈電位完全消失相比較,雙向阻滯對陣發(fā)性房顫患者的復(fù)發(fā)情況及生活質(zhì)量沒有顯著影響。
[Abstract]:Research background
Atrial fibrillation (AF) is induced by spontaneous discharge of the pulmonary vein (pulmonary veins, PVs), which leads to the emergence of segmental ablation and the continuous ring ablation of the pulmonary veins. The ablation isolation of PVs and the left atrium (left atrium, LA) junction can cure AF., however, with radiofrequency ablation (radio) Ter ablation, RFCA) the longer the operation time, the longer the exposure time of X ray, the more complications such as pericardial tamponade, pneumothorax, pseudovenous aneurysm, and so on, the greater the risk. At the same time, it is easy to be accompanied by palpitation symptoms of arrhythmia, which is an unsolved problem at present.
The bidirectional block of PVs and LA can reduce the electrical activity conduction of the pulmonary vein, and the realization of the afferent conduction block is relatively easy, which shows the disappearance of the pulmonary venous potential (pulmonary vein potentials, PVPs) or the escape of the sinus or atrial fibrillation. Even if the pulmonary vein was captured, its potential was not related to the order of atrial agitation, it was also a successful efferent block. There were different ablation endpoints after the ipsilateral circumferential pulmonary vein isolation. Specifically, the ideal end point was the complete disappearance of four pulmonary venous potentials; in addition, any PVP still existed but the delay time of conduction was greater than 30ms could be seen as relatively successful. As long as any PVP delay time is less than 30ms, it is regarded as an isolation failure.
research objective
Objective to investigate whether different ablation endpoints of circular bilateral PVs radiofrequency ablation affect postoperative recurrence in patients with AF.
Method
Subjects from June 2008 to August 2012 were diagnosed with AF in Qilu Hospital, Shandong University, examination body, electrocardiogram and dynamic electrocardiogram (ECG), oral antiarrhythmic drugs in 137 patients, including 113 paroxysmal AF and 24 patients with persistent AF. The necessity and risk of operation were explained to the patients and their families. And sign the informed consent.
113 paroxysmal AF patients were divided into recurrent and non recurrent groups according to the postoperative recurrence of the patients. According to the different ablation end points after RFCA, 92 cases of paroxysmal AF patients were divided into pulmonary venous potential disappearance group and pulmonary venous potential delay group, except for the failure patients with the delayed pulmonary venous potential delay less than 30m.s.
Patients with radiofrequency ablation were excluded from surgical contraindications before operation, under local anaesthesia, circumferential pulmonary vein isolation, left subclavian vein catheter in coronary sinus (coronary sinus, CS), 2 punctures of atrial septum, CARTO, Biosense-Webster. Diamond Bar, CA, USA) for LA reconstruction. Ten electricity would be used. Polar bipolar catheter (Lasso, Biosense-Webster) was placed at the LA port and ablation was performed at about 5mm from the opening of PV (30-35W, 43 C, 17-20ml/min flow rate).
Postoperative treatment and follow-up patients were given oral anticoagulant therapy within three months after operation. Oral amiodarone was taken for 1-3 months (excluding contraindications) according to postoperative arrhythmia. The patients in each group were followed up for 2 years. The palpitation symptoms occurred during the follow-up. The ECG or electrocardiographic examination were performed, and the first time of recurrence of atrial fibrillation after operation was recorded. Especially after the blank period (3 months after operation), the endpoint was AF. with electrocardiogram or dynamic electrocardiogram.
SPSS16.0 software was used in the statistical analysis. The measurement data was expressed in X + s. The normal test was carried out by Shapiro-Wilk (W test). The statistics of each group of continuous variables were applied to t test. The recurrence of each group was analyzed with Kaplan-Meier survival analysis and Log-rank method, and the test water was all 0.05.
Result
Baseline data of 137 patients with atrial fibrillation (age 54.80 + 12.70 years), 35 (25.55%) patients with organic heart disease including 28 (20.44%) with coronary atherosclerotic heart disease, 1 (0.73%) with congenital heart disease, 3 (2.19%) with valvular heart disease, 3 (2.19%) with sick sinus syndrome, hypertension, diabetes, Hyperlipidemia, such as hyperlipidemia, existed in 57 (41.61%), 19 (13.87%), and 53 (38.69%) patients, of which 9 (6.57%) patients with atrial fibrillation combined with paroxysmal supraventricular tachycardia and were treated with radiofrequency ablation at the same time.
The common serious complications during intraoperative complications included pericardial tamponade, pulmonary venous stenosis, pneumothorax, and moderate stroke, including pericardial tamponade in 2 patients and pneumothorax in 1 patients. All of them terminated the operation.
The recurrence rate of 113 paroxysmal atrial fibrillation patients in paroxysmal AF patients was compared with that of 52 patients with paroxysmal atrial fibrillation. Their frequency, duration and symptoms were different. The operation time, echocardiographic indexes (left atrium diameter, left ventricular end diastolic volume, left ventricular ejection fraction), combined organic heart disease, metabolic disease and other data were carried out. T test showed no significant difference between relapse group and non recurrence group (P0.05).
Survival analysis of recurrent AF patients after operation: 92 paroxysmal AF patients were divided into pulmonary vein potential disappearing group and pulmonary venous potential delay group, pulmonary vein potential group were 36 patients, pulmonary venous potential delay group was any pulmonary vein potential delay greater than 30ms, a total of 56 patients, two groups were followed up for 2 years, according to the patient Using Kaplan-Meier survival analysis and Log-Rank test, the recurrence rates of the two groups were not significantly different (P=0.159). There was no significant difference in the recurrence rate of 3 months, 6 months and 12 months after operation (P=0 .812,0.640,0.186).
conclusion
Compared with the complete disappearance of pulmonary venous potential, bidirectional block has no significant effect on recurrence and quality of life in patients with paroxysmal atrial fibrillation.

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R541.75

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相關(guān)期刊論文 前1條

1 劉少穩(wěn) ,楊延宗;射頻導(dǎo)管消融肺靜脈電隔離過程中殘存靜脈電位的鑒別診斷[J];中華心律失常學(xué)雜志;2005年03期

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本文編號：1787885