本文選題：自主神經(jīng)系統(tǒng) + 心房顫動��； 參考：《上海交通大學》2015年博士論文

【摘要】：本課題我們擬通過觀察皮膚神經(jīng)活性與星狀神經(jīng)節(jié)活性的關系、低強度迷走神經(jīng)刺激對心房顫動的影響以及環(huán)左房消融對心房顫動及心臟電生理的影響,來探討心房顫動與自主神經(jīng)系統(tǒng)的關系,同時進一步研究心房顫動診療的策略。本課題的研究內(nèi)容主要包括以下三個部分:(1)觀察胸部皮膚神經(jīng)活性與星狀神經(jīng)節(jié)活性關系,探討應用胸部皮膚神經(jīng)活性間接評估星狀神經(jīng)節(jié)活性的可行性及其與心率變化的關系。(2)觀察低強度迷走神經(jīng)刺激對心房顫動的影響,研究自主神經(jīng)干預治療房顫的新方法,探討心房顫動與自主神經(jīng)系統(tǒng)的關系及迷走神經(jīng)刺激抑制心房顫動的作用機制。(3)觀察環(huán)左房消融對心房顫動及心臟電生理的影響,評價心外膜環(huán)左房消融聯(lián)合肺靜脈消融治療心房顫動的有效性和安全性,進一步完善外科治療心房顫動的策略。研究結果表明:(1)胸部皮膚神經(jīng)活性可用于間接評估犬星狀神經(jīng)節(jié)活性,與心率變化存在很好的相關性,可用來預測心律失常的發(fā)生。(2)低強度迷走神經(jīng)刺激可以減慢房顫時的快速心室率,其作用機制可能是通過:(1)增加下腔靜脈-心房下部神經(jīng)節(jié)叢活性(inferior vena cava-inferior atrial ganglionated plexus nerve activity,IVC-IAGPNA),減慢房室結的傳導;(2)誘導星狀神經(jīng)節(jié)(stellate ganglion,SG)內(nèi)神經(jīng)節(jié)細胞凋亡,減弱SG的交感神經(jīng)活性。(3)心外膜環(huán)左房消融聯(lián)合肺靜脈消融可以安全、有效的隔離消融左房頂部及后壁。與單純肺靜脈消融相比,環(huán)左房消融聯(lián)合肺靜脈消融可以更有效的終止房顫的維持、抑制房顫的復發(fā),提高房顫的治療效果。第一部分胸部皮膚神經(jīng)活性與星狀神經(jīng)節(jié)活性的關系目的:星狀神經(jīng)節(jié)活性與心律失常的發(fā)生密切相關,被認為是心律失常發(fā)生的重要基礎。直接記錄星狀神經(jīng)節(jié)活性需要開胸手術,不僅操作復雜,而且創(chuàng)傷較大。相關研究,已證實上胸部的皮膚主要受來自星狀神經(jīng)節(jié)的交感神經(jīng)的支配。本研究擬通過觀察胸部皮膚神經(jīng)活性與星狀神經(jīng)節(jié)活性的關系,來探討應用胸部皮膚神經(jīng)活性間接評估星狀神經(jīng)節(jié)活性的可行性。方法:實驗用雜種犬9只,體重22~30Kg,5只用于急性實驗研究,4只用于慢性實驗研究。急性實驗:麻醉狀態(tài)下,將蜂毒明肽直接注射到犬的右側星狀神經(jīng)節(jié),同時記錄10分鐘犬右側星狀神經(jīng)節(jié)活性、胸部皮膚神經(jīng)活性及心電圖。慢性實驗:左側開胸,將神經(jīng)活性記錄儀植入犬體內(nèi)記錄左側星狀神經(jīng)節(jié)活性;待犬恢復2周后,在犬清醒狀態(tài)下,同時記錄30分鐘犬左側星狀神經(jīng)節(jié)活性、胸部皮膚神經(jīng)活性及心電圖。結果:急性實驗結果表明,胸部皮膚神經(jīng)活性與右側星狀神經(jīng)節(jié)活性呈明顯正相關(r=0.877,95%CI[0.732,1.000],P0.05);胸部皮膚神經(jīng)活性與心率也呈明顯的正相關(r=0.837,95%CI[0.752,0.923],P0.05)。慢性實驗結果表明,胸部皮膚神經(jīng)活性與左側星狀神經(jīng)節(jié)活性呈明顯正相關(r=0.746,95%CI[0.527,0.964],P0.05);胸部皮膚神經(jīng)活性與心率也呈明顯的正相關(r=0.706,95%CI[0.484,0.927],P0.05)。結論:胸部皮膚神經(jīng)活性可用于間接評估犬星狀神經(jīng)節(jié)活性,與心率變化存在很好的相關性,可用來預測心律失常的發(fā)生。第二部分低強度迷走神經(jīng)刺激抑制犬心房顫動的作用機制研究目的:目前,大量研究已證實低強度迷走神經(jīng)刺激(low-level vagal nerve stimulation,LL-VNS)可以有效抑制心房顫動的觸發(fā),但迷走神經(jīng)刺激(vagal nerve stimulation,VNS)對房顫維持的影響目前研究仍較少,而且迷走神經(jīng)刺激抑制心房顫動的具體作用機制仍不清楚。本實驗擬通過觀察迷走神經(jīng)刺激對犬心房顫動的影響,研究迷走神經(jīng)刺激抑制心房顫動的作用機制。方法:實驗用雜種犬6只,體重23~28Kg。全麻下,右側開胸,在右心耳上安裝植入型復律除顫器;安裝神經(jīng)活性記錄儀記錄下腔靜脈-心房下部神經(jīng)節(jié)叢活性(inferior vena cava-inferior atrial ganglionated plexus nerve activity,IVC-IAGPNA)、右側迷走神經(jīng)活性(right vagal nerve activity,RVNA)和左側迷走神經(jīng)活性(left vagal nerve activity,LVNA);在犬左側頸部迷走神經(jīng)上安裝迷走神經(jīng)刺激器。犬恢復2周后,打開復律除顫器進行右心耳快速起搏(600bpm),構建犬持續(xù)的心房顫動模型。模型構建成功后,打開迷走神經(jīng)刺激器,刺激模式為(14s ON,1.1min OFF或3min OFF)觀察迷走神經(jīng)刺激對犬心房顫動的影響,并對比觀察不同時間點犬左房右下GP及左、右迷走神經(jīng)活性的變化情況。病理研究,分別應用酪氨酸羥化酶染色和TUNEL檢測觀察星狀神經(jīng)節(jié)(stellate ganglion,SG)的病理變化情況,探究其可能的機制。結果:快速起搏2~6周(平均4.00±1.79周)后,6只犬均構建成持續(xù)的房顫模型。與房顫基線(142.04±7.93 bpm[95%CI,133.72 to 150.37])相比,犬的心室率在VNS 1.1min OFF(123.29±6.29 bpm[95%CI,116.69 to 129.89])(P=0.001)和VNS 3min OFF(120.01±4.93 bpm[95%CI,114.84 to 125.18])(P=0.001)時均有明顯減慢。IVC-IAGPNA在VNS 1.1min OFF(40.98±11.27m V-s[95%CI,29.16 to 52.80])(P=0.002)和VNS 3min OFF(39.78±10.14m V-s[95%CI,29.14 to 50.42])(P=0.001)時均較房顫基線(35.68±10.99 m V-s[95%CI,24.15 to 47.21])有明顯提高。酪氨酸羥化酶染色發(fā)現(xiàn),在成功取到雙側星狀神經(jīng)節(jié)的5只犬中,左側的星狀神經(jīng)節(jié)中均可見明顯的壞死區(qū),而右側未見明顯壞死區(qū)。左側壞死區(qū)的面積約占左側星狀神經(jīng)節(jié)面積的38.6±19.3%[95%CI,14.7%to 62.5%]。壞死區(qū)內(nèi)TH陰性神經(jīng)節(jié)細胞的百分比約為8.4±4.1%[95%CI,3.3%to 13.6%],較正常區(qū)內(nèi)TH陰性神經(jīng)節(jié)細胞的百分比(3.0±1.3%[95%CI,0%to 6.5%])明顯升高(P=0.04)。TUNEL檢測發(fā)現(xiàn),5只犬雙側星狀神經(jīng)節(jié)內(nèi)均可見到TUNEL陽性的神經(jīng)節(jié)細胞,左側星狀神經(jīng)節(jié)內(nèi)TUNEL陽性細胞的比例約為22.2±17.2%[95%CI,0.9%to 43.5%],右側星狀神經(jīng)節(jié)內(nèi)TUNEL陽性細胞的比例約為12.8±8.4%[95%CI,2.4%to 23.2%]。結論:迷走神經(jīng)刺激可以減慢房顫時的快速心室率,其作用機制可能是通過:(1)增加IVC-IAGPNA,減慢房室結的傳導;(2)誘導SG內(nèi)神經(jīng)節(jié)細胞凋亡,減弱SG的交感神經(jīng)活性。第三部分心外膜環(huán)左房消融聯(lián)合肺靜脈消融對心房顫動的影響目的:本研究的目的是評價心外膜環(huán)左房消融(circumferential left atrial ablation,CLAA)聯(lián)合肺靜脈隔離(pulmonary vein isolation,PVI)治療心房顫動(atrial fibrillation,AF)的有效性和安全性。方法:實驗用豬30只,隨機分為3組,每組各10只:房顫對照組(AF組)、肺靜脈消融組(PVI組)、環(huán)左房消融聯(lián)合肺靜脈消融組(CLAA+PVI組)。通過心房快速起搏構建持續(xù)的心房顫動模型。房顫構建成功后,AF組不做消融處理;PVI組應用雙極射頻消融鉗做肺靜脈隔離消融;CLAA+PVI組應用雙極射頻消融鉗先做肺靜脈隔離消融,再做環(huán)左房消融。消融后,應用電復律將所有房顫豬恢復竇性心律,再次檢測比較各組豬的房顫易感性及房顫維持時間的差異。結果:起搏6.27±0.69周后,所有豬均成功構建成穩(wěn)定的持續(xù)的房顫模型。PVI組和CLAA+PVI組的豬順利在心臟不停跳下實施心外膜消融術。2組中,單純肺靜脈消融使3只(3/20,15%)豬終止房顫,環(huán)左房消融聯(lián)合肺靜脈消融使5只(5/8,62.5%)豬終止房顫(P=0.022)。全部豬恢復竇性心律后,burst起搏可使AF組10只(10/10)豬全都誘發(fā)成持續(xù)的房顫;PVI組僅有3只(3/10,P=0.003)誘發(fā)成持續(xù)的房顫,CLAA+PVI組(0/10,P0.001)無持續(xù)的房顫誘發(fā)成功,均明顯低于AF組;而PVI組與CLAA+PVI組無明顯差異(P=0.211)。AF組誘導的房顫平均維持時間為1800s;PVI組的房顫平均維持時間為1217.90±444.10s[95%CI,900.21-1535.59],CLAA+PVI組的房顫平均維持時間為734.70±177.81s[95%CI,607.51-861.89],較AF組明顯縮短(P0.05);與PVI組相比,CLAA+PVI組的房顫平均維持時間也明顯縮短(P0.05)。結論:心外膜環(huán)左房消融聯(lián)合肺靜脈消融可以安全、有效的隔離消融左房頂部及后壁。與單純肺靜脈消融相比,環(huán)左房消融聯(lián)合肺靜脈消融可以更有效的終止房顫的維持、抑制房顫的復發(fā),提高房顫的治療效果。
[Abstract]:We intend to investigate the relationship between the activity of the cutaneous nerve and the stellate ganglion, the influence of the low intensity vagus nerve stimulation on atrial fibrillation and the effect of the left atrial ablation on atrial fibrillation and the electrophysiology of the heart, to explore the relationship between atrial fibrillation and the autonomic nervous system, and to further study the strategy of the diagnosis and treatment of atrial fibrillation. The main contents of this study include the following three parts: (1) observe the relationship between the activity of the thoracic skin nerve and the activity of the stellate ganglion, and discuss the feasibility of indirect evaluation of the activity of stellate ganglion with the activity of the skin of the chest and the relationship between the activity of the stellate ganglion and the change of heart rate. (2) observe the effect of the low intensity vagus nerve stimulation on the atrial fibrillation. A new method of autonomic nerve intervention in the treatment of atrial fibrillation. The relationship between atrial fibrillation and autonomic nervous system and the mechanism of vagus stimulation to inhibit atrial fibrillation. (3) observe the effect of left atrial ablation on atrial fibrillation and cardiac electrophysiology, and evaluate the effectiveness of left atrial ablation combined with pulmonary vein ablation in the treatment of atrial fibrillation. Safety, further improving the strategy of surgical treatment of atrial fibrillation. The results show: (1) the activity of the chest skin nerve can be used to indirectly evaluate the activity of the dog stellate ganglion, and there is a good correlation with the change of heart rate, which can be used to predict the occurrence of arrhythmia. (2) the low intensity vagus nerve stimulation can slow the rapid ventricular rate of atrial fibrillation. Its mechanism may be through: (1) increasing the activity of the inferior vena cava subatrium ganglion plexus (inferior vena cava-inferior atrial ganglionated plexus nerve activity, IVC-IAGPNA), slowing the conduction of atrioventricular node; (2) inducing the apoptosis of the ganglion cells in the stellate ganglion (stellate ganglion, SG) and reducing the sympathetic activity of the ganglion. (3) the heart. Epicardial left atrial ablation combined with pulmonary vein ablation can safely and effectively isolate the top and posterior wall of the left atrium. Compared with the only pulmonary vein ablation, the left atrial catheter ablation combined with the pulmonary vein ablation can effectively terminate the maintenance of atrial fibrillation, inhibit the recurrence of atrial fibrillation, and improve the treatment effect of atrial fibrillation. The activity of ganglionic ganglion Objective: the activity of stellate ganglion is closely related to the occurrence of arrhythmia, which is considered as an important basis for the occurrence of arrhythmia. Direct recording of stellate ganglion activity requires thoracotomy, not only complicated, but also traumatic. Related research has confirmed that the skin of the upper chest is mainly from the stellate ganglion. This study is to explore the feasibility of indirect evaluation of the activity of stellate ganglia by using the thoracic skin neuroactivity by observing the relationship between the neuroactivity of the chest skin and the activity of the stellate ganglion. Methods: 9 dogs in the experimental hybrid dogs, weight 22~30Kg, 5 were used in the acute experimental study, and 4 were used for chronic experimental study. In a sex experiment, the drug was injected into the right stellate ganglion of the dog by injecting MELITIN directly to the right stellate ganglion of the dog. At the same time, the right stellate ganglion activity, the nerve activity and electrocardiogram of the chest skin were recorded for 10 minutes. The chronic experiment: the left thoracotomy was carried out to record the activity of the left stellate ganglion in the dog. After 2 weeks of recovery, the dog was treated in dogs. At the same time, the left stellate ganglion activity of the dog, the nerve activity of the chest skin and the electrocardiogram were recorded for 30 minutes. Results: the results of acute experiment showed that the activity of the skin of the chest was positively correlated with the activity of the right stellate ganglion (r=0.877,95%CI[0.732,1.000], P0.05), and the neuroactivity of the chest skin and heart rate also showed a positive positive phase. R=0.837,95%CI[0.752,0.923] (P0.05). Chronic experimental results showed that there was a significant positive correlation between the activity of the chest skin and the activity of the left stellate ganglion (r=0.746,95%CI[0.527,0.964], P0.05); the neuroactivity of the chest skin was also positively correlated with the heart rate (r= 0.706,95%CI[0.484,0.927], P0.05). Conclusion: the neuroactivity of the chest skin is available. The activity of the stellate ganglion in dogs was evaluated indirectly, and there was a good correlation with heart rate changes. It could be used to predict the occurrence of arrhythmia. Second the mechanism of the inhibitory effect of low intensity vagus nerve stimulation on atrial fibrillation in dogs was studied. At present, a large number of studies have proved low-level vagal nerve stimulation, LL-V NS) can effectively inhibit the triggering of atrial fibrillation, but the effect of vagal nerve stimulation (VNS) on the maintenance of atrial fibrillation is still less, and the specific mechanism of the vagus stimulation inhibition of atrial fibrillation is still unclear. This experiment is to observe the effect of vagus nerve stimulation on atrial fibrillation in dogs and study the vagus The mechanism of the inhibition of atrial fibrillation by nerve stimulation. Methods: 6 dogs were tested in a hybrid dog, under 23~28Kg. general anesthesia, right open chest, and an implantable defibrillator on the right auricle, and a neuroactive recorder was installed to record the activity of inferior vena cava ganglion plexus (inferior vena cava-inferior atrial ganglionated plexus nerve AC) Tivity, IVC-IAGPNA), right vagus nerve activity (right vagal nerve activity, RVNA) and left vagus nerve activity (left vagal nerve activity, LVNA). The vagus nerve stimulator was installed on the vagus nerve in the left neck of the dog. After 2 weeks, the dog opened the cardioversion defibrillator to make the right auricle rapid pacing, and set up the continuous atrial fibrillation of the dog. After the model was built, the vagus stimulator was opened and the stimulation mode was observed (14s ON, 1.1min OFF or 3min OFF) to observe the effect of vagus nerve stimulation on the atrial fibrillation in dogs, and the changes in the activity of left and right vagus nerve in left atrium of dogs at different time points were compared. The pathological study was used to stain the tyrosine hydroxylase, respectively. The pathological changes of stellate ganglion (SG) were detected and observed by TUNEL. Results: after fast pacing 2~6 weeks (average 4 + 1.79 weeks), 6 dogs were constructed to build a continuous atrial fibrillation model. Compared with the baseline of atrial fibrillation (142.04 + 7.93 bpm[95%CI, 133.72 to 150.37]), the ventricular rate of dogs was VNS 1.1min OFF (123.29). When 6.29 bpm[95%CI, 116.69 to 129.89]) (P=0.001) and VNS 3min OFF (120.01 + 4.93 bpm[95%CI, 114.84 to 125.18]) (P=0.001), there was a significant decrease in the baseline of.IVC-IAGPNA. (35. The 68 + 10.99 m V-s[95%CI, 24.15 to 47.21]) was obviously improved. The necrotic area was found in the left stellate ganglion, while the left stellate ganglion had no obvious necrotic zone in the left stellate ganglion, and the area of the left necrotic area was about 38.6 + 19.3%[95%CI in the left stellate ganglion area. The percentage of TH negative ganglion cells in the necrotic area of 14.7%to 62.5%]. was about 8.4 + 4.1%[95%CI, 3.3%to 13.6%], and the percentage of TH negative ganglion cells in the normal area (3 + 1.3%[95%CI, 0%to 6.5%]) increased significantly (P=0.04).TUNEL detection found that 5 dogs could see the positive ganglion cells in the bilateral star shaped divine ganglion, left star The proportion of TUNEL positive cells in the ganglionic ganglion was about 22.2 + 17.2%[95%CI, 0.9%to 43.5%], and the proportion of TUNEL positive cells in the right stellate ganglion was about 12.8 + 8.4%[95%CI. 2.4%to 23.2%]. concluded that vagus nerve stimulation could slow the rapid ventricular rate of atrial fibrillation, and its mechanism may be through: (1) increasing IVC-IAGPNA and slowing atrioventricular node Conduction; (2) induce apoptosis in SG internal ganglion cells and weaken the sympathetic activity of SG. The purpose of the third part of the epicardial ring left atrial ablation combined with pulmonary vein ablation on atrial fibrillation: the purpose of this study was to evaluate circumferential left atrial ablation, CLAA) combined with pulmonary vein isolation (pulmonary vein isol). The efficacy and safety of ation, PVI) for the treatment of atrial fibrillation (atrial fibrillation, AF). Methods: 30 pigs were randomly divided into 3 groups, 10 rats in each group: atrial fibrillation control group (AF group), pulmonary vein ablation group (group PVI), left atrial ablation combined with pulmonary vein ablation group (group CLAA+PVI). Atrial fibrillation model was constructed by atrial rapid pacing. After the construction of the tremor was successful, the AF group did not do the ablation treatment; the PVI group applied the bipolar radiofrequency ablation forceps to the pulmonary vein isolation ablation; the CLAA+PVI group applied the bipolar radiofrequency ablation forceps to the pulmonary vein isolation ablation and the left atrium ablation. After ablation, all the atrial fibrillation pigs were restored to sinus rhythm and the susceptibility to atrial fibrillation in each group was compared again. Results: after 6.27 + 0.69 weeks of pacing, all pigs were successfully constructed into a stable persistent atrial fibrillation model.PVI and CLAA+PVI in group.2, and 3 (3/20,15%) pig terminated atrial fibrillation, 5 pigs were ablation combined with pulmonary vein ablation. (5/8,62.5%) the pig terminated atrial fibrillation (P=0.022). After all pigs were restored to sinus rhythm, burst pacing could induce 10 (10/10) pigs in the AF group to induce persistent atrial fibrillation; only 3 (3/10, P=0.003) induced persistent atrial fibrillation in group PVI, and the CLAA+PVI group (0/10, P0.001) was successfully induced by no persistent atrial fibrillation, all significantly lower than that in the AF group. The average maintenance time of atrial fibrillation induced by the difference (P=0.211) group.AF was 1800s, and the average maintenance time of atrial fibrillation in group PVI was 1217.90 + 444.10s[95%CI, 900.21-1535.59], and the average maintenance time of atrial fibrillation in group CLAA+PVI was 734.70 + 177.81s[95%CI, 607.51-861.89], and the AF group was significantly shorter (P0.05). Compared with the PVI group, the average maintenance time of atrial fibrillation was compared with the PVI group. Conclusion: the left atrial catheter ablation combined with pulmonary vein ablation can safely and effectively isolate the top and posterior wall of the left atrium. Compared with the pure pulmonary vein ablation, the left atrial catheter ablation combined with pulmonary vein ablation can more effectively terminate the maintenance of atrial fibrillation, inhibit the recurrence of atrial fibrillation and improve the therapeutic effect of atrial fibrillation.

【學位授予單位】：上海交通大學
【學位級別】：博士
【學位授予年份】：2015
【分類號】：R541.75

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