本文選題：心房顫動 + 射頻消融　； 參考：《蘇州大學》2016年博士論文

【摘要】：目的:心房顫動(房顫)是臨床常見的心律失常,是腦卒中和心力衰竭強烈而獨立的危險因子。房顫的治療是當今心臟病學面臨的巨大挑戰(zhàn),單純頻率控制不能降低腦卒中危險性、不能改善房室同步;以華法林為主的抗凝治療,雖然可以降低腦卒中和死亡率,但是存在出血風險,而且必須長期密切監(jiān)測凝血酶原時間國際標準化比值,患者依從性低。節(jié)律控制優(yōu)于頻率控制,可以降低總死亡率、短暫腦缺血發(fā)作、腦梗死、系統(tǒng)性栓塞、大出血、心力衰竭等終點事件的發(fā)生率。傳統(tǒng)的節(jié)律控制方法包括抗心律失常藥物、直流電復律、迷宮手術等,但這些方法因療效和安全性問題而在臨床上應用受限。因而導管介入射頻消融成為目前治療房顫的熱點。受操作難易程度及成功率、可復制性等因素的影響,國內目前術式主要以環(huán)肺靜脈射頻消融(Circumferential pulmonary vein ablation,CPVA)為基礎術式,結合碎裂電位(Complex Fractionated Atrial Electro-gram,CFAEs)消融。房顫消融術后心房基質的重構將影響左心房功能,消融點過多可能損傷左心房功能、增加術后發(fā)生房性心動過速(房速)的概率、增加發(fā)生并發(fā)癥的概率。本研究通過評估環(huán)肺靜脈射頻消融術(CPVA)和環(huán)肺靜脈射頻消融+碎裂電位消融術(CPVA+CFAEs)兩種術式對房顫患者左心房容積和功能的影響,進而深入了解心房容積和功能與房顫復發(fā)、新發(fā)房速、左心房功能的關系,豐富射頻消融治療房顫的臨床資料,促進對房顫機制的深入了解,促進對房顫射頻消融術式的改進,為房顫消融術式的評價及消融策略的選擇提供臨床數(shù)據。方法:選取符合房顫消融適應癥、接受房顫射頻消融治療的患者作為研究對象,采用CPVA術式或CPVA+CFAEs術式對患者進行消融治療。利用隨機數(shù)表,采用隨機單盲方式將患者入組選擇術式。術前、術后記錄空腹血糖、甘油三脂、總膽固醇、高密度脂蛋白、低密度脂蛋白、尿酸、腎素、血管緊張素-Ⅰ、血管緊張素-Ⅱ、C-反應蛋白、血沉、12導聯(lián)心電圖P波時限、左心房容積、二尖瓣運動曲線上舒張晚期速度峰值(Va)等指標。使用SPSS19.0統(tǒng)計分析軟件對上述數(shù)據進行統(tǒng)計學分析處理,觀察CPVA和CPVA+CFAEs兩種術式前后上述指標的變化以及兩組之間的差異,以及房顫復發(fā)率和新發(fā)房速的比例,以此評價不同術式對房顫患者左心房容積和功能的影響。結果:最終入組76例患者,均成功施行手術,未出現(xiàn)氣胸、心包壓塞、血栓栓塞、肺靜脈狹窄、心房食道瘺等手術相關并發(fā)癥。3個月后的隨訪數(shù)據,兩組組內術后與術前比較無顯著性差異,兩組組間比較亦無顯著性差異。6個月后的隨訪數(shù)據比較,CPVA組左心房容積等指標在消融前后的變化無統(tǒng)計學差異,但Va值術后高于術前,差異具有統(tǒng)計學意義(p=0.004);CPVA+CFAEs組左心房容積、Va值等指標在消融前后的差異均無統(tǒng)計學意義。術后6個月,Va值CPVA組高于CPVA+CAFEs組,差異具有統(tǒng)計學意義(p=0.036)。其余觀察指標在組間對比及自身前后對比等均無顯著性差異。術后隨訪6-24月(平均15±5.5月),共有12例房顫復發(fā)(CPVA組6例,CPVA+CFAEs組6例),術后新發(fā)房速9例(CPVA組4例,CPVA+CFAEs組5例)。兩組間房顫復發(fā)率、新發(fā)房速比例無統(tǒng)計學差異。術后兩組患者均未出現(xiàn)長期持續(xù)性房顫。結論:在房顫得到根治的同時,盡量少地消融左心房基質,可使左心房收縮功能得到改善。相反,如果過多地消融左心房基質,雖然房顫的維持基質被干預得更多,但是左心房收縮功能未必得到進一步的改善,且未觀察到房顫復發(fā)率的減少。對于房顫的射頻消融治療,在追求減少復發(fā)率的同時,應盡量減少左心房消融面積。也就是說,應努力通過最少的消融面積,來達到根治房顫的效果。
[Abstract]:Objective: atrial fibrillation (atrial fibrillation) is a common clinical arrhythmia. It is a strong and independent risk factor for stroke and heart failure. The treatment of atrial fibrillation is a great challenge for cardiology today. Simple frequency control can not reduce the risk of stroke and can not improve atrioventricular synchronization. Warfarin based anticoagulant therapy can be reduced, although it can be reduced. Low stroke and mortality, but there is a risk of bleeding, and it is necessary to monitor the international normalized ratio of prothrombin time for a long time. Patient compliance is low. Rhythmic control is superior to frequency control. It can reduce the incidence of endpoints such as total mortality, transient ischemic attack, cerebral infarction, systemic thrombus, massive hemorrhage, heart failure and other endpoints. Rhythmic control methods include antiarrhythmic drugs, direct current cardioversion, maze operation and so on, but these methods are limited clinically for efficacy and safety. Therefore, catheter interventional radiofrequency ablation has become a hot spot in the treatment of atrial fibrillation. Circumferential pulmonary vein ablation (CPVA) was used as the basic operation, combined with the fragmentation potential (Complex Fractionated Atrial Electro-gram, CFAEs). The remodeling of atrial matrix after atrial fibrillation ablation will affect the function of the left atrium. Excessive ablation points may damage the function of the left atrium and increase the postoperative atrial properties. The probability of tachycardia (atrial tachycardia) increases the probability of complications. In this study, the effects of two kinds of surgical procedures on the left atrial volume and function of patients with atrial fibrillation (CPVA+CFAEs) and circumferential pulmonary vein radiofrequency ablation (CPVA) and radiofrequency ablation + clastic potential ablation were evaluated to further understand the atrial volume and function and the recurrence of atrial fibrillation. The relationship between the atrial tachycardia and the left atrium function, enriching the clinical data of radiofrequency ablation in the treatment of atrial fibrillation, promoting the understanding of the mechanism of atrial fibrillation, promoting the improvement of atrial fibrillation radiofrequency ablation, and providing clinical data for the evaluation of atrial fibrillation ablation and the choice of ablation strategies. Patients treated as subjects were treated with CPVA or CPVA+CFAEs. Random number tables were used to select patients in a random single blind method. Preoperative, postoperative recording of fasting blood glucose, glycerin three fat, total cholesterol, high density lipoprotein, low density lipoprotein, uric acid, renin, angiotensin I, blood Angiotensin II, C- reactive protein, erythrocyte sedimentation, P wave time limit of 12 lead electrocardiogram, left atrium volume, peak diastolic velocity peak (Va) on the mitral valve motion curve and other indexes. The above data were statistically analyzed by SPSS19.0 statistical analysis software, and the changes of the above indexes before and after the two kinds of CPVA and CPVA+ CFAEs were observed and two groups were observed. The difference in the rate of recurrence of atrial fibrillation and the rate of new atrial tachycardia were used to evaluate the effect of different surgical procedures on the volume and function of left atrium in patients with atrial fibrillation. Results: 76 patients were performed successfully, without pneumothorax, pericardial tamponade, thromboembolism, pulmonary vein narrowing, atrial esophagus fistula, and other surgical complications.3 months later. There was no significant difference between the two groups after the two groups, and there was no significant difference between the two groups. There was no significant difference in the left atrium volume of the CPVA group before and after the ablation, but the Va value was higher than that before the operation (p=0.004), and the left atrium volume in CPVA+CFAEs group was higher than that in the group CPVA+CFAEs. There was no statistical significance in the difference before and after ablation. 6 months after the operation, the Va value CPVA group was higher than the CPVA+CAFEs group, and the difference was statistically significant (p=0.036). The rest of the observation indexes had no significant difference between the groups and their own before and after. The postoperative follow-up was 6-24 months (average 15 + 5.5 months), and there were 12 cases of atrial fibrillation in 6 cases (6 cases). 6 cases in group CPVA+CFAEs, 9 cases of new atrial tachycardia after operation (group CPVA 4 cases, and group CPVA+CFAEs 5). There was no significant difference in the rate of recurrence of atrial fibrillation between the two groups. The two groups had no long-term persistent atrial fibrillation. Conclusion: the left atrial matrix was ablated as much as possible while the atrial fibrillation was radical. The left atrial systolic function could be improved. On the contrary, if the left atrial matrix is ablated too much, although the maintenance matrix of the atrial fibrillation is more interfered, the left atrial contraction function may not be further improved, and the recurrence rate of atrial fibrillation is not observed. That is to say, efforts should be made to cure the effect of atrial fibrillation by minimal ablation area.
【學位授予單位】：蘇州大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R541.75

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