本文選題：心房顫動 + 射頻消融　； 參考：《昆明醫(yī)科大學(xué)》2017年碩士論文

【摘要】：[背景]心房顫動在臨床工作中是最常見的、危害較大的心律失常之一,且隨著我國人口老齡化的進展患病率及患病人數(shù)逐年攀升;現(xiàn)階段心房顫動主要的手術(shù)治療措施包括經(jīng)導(dǎo)管射頻消融及冷凍球囊消融;相比于冷凍球囊消融,經(jīng)導(dǎo)管射頻消融治療在臨床應(yīng)用更加廣泛,如何在提高導(dǎo)管消融有效性的同時,降低復(fù)發(fā)率,保證手術(shù)的安全性是心房顫動導(dǎo)管射頻消融治療的難點。壓力監(jiān)測消融導(dǎo)管是新型消融導(dǎo)管,因其具有術(shù)中實時監(jiān)測導(dǎo)管與心肌接觸力及其方向的優(yōu)勢,因此,相比于其他傳統(tǒng)類型消融導(dǎo)管(如TC導(dǎo)管),理論上可提高心房顫動射頻消融治療的安全性和有效性。將壓力監(jiān)測導(dǎo)管(ST導(dǎo)管)應(yīng)用于心房顫動射頻消融治療的相關(guān)研究已成為現(xiàn)階段的熱點。[目的]將壓力監(jiān)測導(dǎo)管(ST導(dǎo)管)與普通冷鹽水灌注導(dǎo)管(TC導(dǎo)管)在心房顫動導(dǎo)管消融治療中的安全性以及臨床療效等方面進行綜合的分析、比較,從而在心房顫動導(dǎo)管射頻消融手術(shù)中為患者更合理地選擇手術(shù)材料及制定更加合理的手術(shù)方案,以提高心房顫動導(dǎo)管射頻消融的近期及遠期成功率,減少術(shù)后復(fù)發(fā)的概率,并提高心房顫動導(dǎo)管消融的安全性,降低術(shù)中、術(shù)后并發(fā)癥發(fā)生率。[方法]隨機選取玉溪市人民醫(yī)院2014年01月至2016年5月間收治的陣發(fā)性房顫(Paroxysmal atrial fibrillation,PAF)以及左心房直徑(left atrial diameter,LAD)小于 40mm、病程小于 1 年的持續(xù)性房顫(persistent atrial fibrillation,PeAF)行壓力監(jiān)測導(dǎo)管射頻消融治療的患者共計34例,設(shè)為研究組。隨機抽取同期于玉溪市人民醫(yī)院接受普通冷鹽水灌注NaviStar導(dǎo)管消融治療的陣發(fā)性房顫患者以及病史LAD小于40mm、病程小于1年的持續(xù)性房顫患者34例,設(shè)為對照組。對照組與研究組男性各有28例、22例,共計50例,女性分別有6例、12例,共計18例,兩組共計68例患者。對照組平均年齡59. 50± 11. 58歲,研究組平均年齡58.62±10.67歲,本研究患者年齡在28～77歲范圍內(nèi),總體平均年齡58. 8± 11. 1歲;對照組及研究組分別有25例及24例PAF,合計51例,對照組及研究組分別有9例及8例PeAF,合計17例。對照組病例的平均射血分數(shù)62. 35±4.62%,研究組病例的平均射血分數(shù)61. 29±4. 68%;對照組病例持續(xù)性房顫患者的平均持續(xù)時間7. 50±1. 85月,研究組病例的持續(xù)性房顫患者的平均持續(xù)時間6. 22±1. 39月。對照組左房內(nèi)徑平均為31. 87±3. 76mm,研究組的平均為31. 52±4. 15mm。兩組間性別構(gòu)成、年齡、房顫病程、房顫類型構(gòu)成、左室射血分數(shù)、左心房內(nèi)徑等基線資料差異無明顯統(tǒng)計學(xué)意義(P0. 05)。入組病例均為陣發(fā)性房顫或者心房重構(gòu)不顯著且病史不長的持續(xù)性房顫,所以本研究消融策略為僅行雙側(cè)環(huán)肺靜脈前庭隔離(pulmonary vein isolation,PVI),如果肺靜脈隔離完成之后仍未轉(zhuǎn)復(fù)為竇性心律者,給予體外同步直流電復(fù)律(100J-200J)或靜脈注射伊布利特(lmg)轉(zhuǎn)律。極少數(shù)持續(xù)性房顫患者轉(zhuǎn)律治療后仍不能維持竇性心律,仍反復(fù)發(fā)作心房顫動、心房撲動的患者,則視情況加行左房頂部徑線、二尖瓣峽部徑線、左房前壁徑線、三尖瓣峽部徑線線性消融,以及必要的碎裂電位消融(complex fractionated atrial electrograms,CFAEs)。本研究觀察指標是比較兩組患者在手術(shù)時間、消融時間、X線曝光時間、X線曝光量、左房建模及肺靜脈定口時間、并發(fā)癥發(fā)生率的統(tǒng)計學(xué)差異,術(shù)后隨訪3、6、12月比較兩組患者術(shù)后竇性心律維持率,為房顫患者導(dǎo)管消融治療時在手術(shù)器械選擇及手術(shù)方案制定方面提供可靠參考。[結(jié)果]1.所有入選患者手術(shù)均成功進行,術(shù)中均轉(zhuǎn)為竇性心律,并能長時間維持。2.所有患者手術(shù)過程中未出現(xiàn)蒸汽爆破、急性心包填塞、腦梗死、肺栓塞、死亡等嚴重手術(shù)并發(fā)癥。3.術(shù)后無患者失訪,所有入組患者均完成術(shù)后3月、術(shù)后6月及術(shù)后12月的隨訪。4.相關(guān)觀察指標:研究組與對照組相比:4.1術(shù)后3月、6月隨訪,竇性心律維持率的差異兩組無統(tǒng)計學(xué)意義,分別為(94.1% vs.91.2%, P=0.642) (88. 23% vs.76. 5%, P=0.203)。術(shù)后 12 月隨訪:對照組有13例,研究組中有4例復(fù)發(fā),兩組竇性心律維持率情況差異有統(tǒng)計學(xué)意義(88. 23%vs.61. 7%, P0.05)。4.2手術(shù)時間研究組明顯短于對照組,兩組比較差異有統(tǒng)計學(xué)意義( 154. 85±28. 62minvs.165.88±22.17min,P0.05)。4. 3環(huán)肺靜脈消融時間研究組明顯短于對照組,兩組比較差異有統(tǒng)計學(xué)意義(89.71±20.41 minvs.101.62±16.82min,P0.05)。4.4左房建模及肺靜脈定口時間研究組明顯短于對照組,兩組比較差異有統(tǒng)計學(xué)意義(8.29±2. 22 min vs.10. 65±2. 58 min,P0.05)。4.5 X射線曝光時間研究組明顯少于對照組,且其差異有統(tǒng)計學(xué)意義(28. 35±5. 34min vs.39. 38±6.15min) 。4.6 X線曝光量研究組明顯低于對照組,兩組比較差異有統(tǒng)計學(xué)意義(417. 44±80. 45mGy vs.585.68±95.39mGy,P0. 05)。4. 7研究組發(fā)生3例并發(fā)癥,對照組中2例并發(fā)癥(8. 8% vs.5. 9%,P=0. 16)。[結(jié)論]本研究成果顯示,與TC導(dǎo)管相比,使用ST導(dǎo)管進行房顫導(dǎo)管消融手術(shù)能縮短整體手術(shù)時間、左房操作時間(左房建模及肺靜脈定口時間、消融時間)、X線曝光時間以及減少X線曝光量等;且具有更高的12月竇性心律維持率,遠期成功率需要進一步隨訪研究。綜上所述,壓力監(jiān)測導(dǎo)管在臨床應(yīng)用中具有較好的前景。
[Abstract]:[background] atrial fibrillation is one of the most common and harmful arrhythmias in clinical work, and the prevalence and number of diseases are increasing with the aging of the population in our country. The main surgical measures for atrial fibrillation include radiofrequency catheter ablation and cryo balloon ablation, compared with cryo balloon ablation and catheterization Radiofrequency ablation is more widely used in clinical practice. It is difficult to improve the effectiveness of catheter ablation, reduce the recurrence rate and ensure the safety of the operation. The pressure monitoring catheter is a new catheter. It has the advantages of monitoring the contact force of the catheter with the heart and its direction in real time. Therefore, compared with other conventional catheter ablation catheter (such as TC catheter), the safety and effectiveness of radiofrequency ablation for atrial fibrillation can be improved theoretically. The research on the application of pressure monitoring catheter (ST catheter) to radiofrequency ablation for atrial fibrillation has become a hot spot. [Objective] pressure monitoring catheter (ST catheter) and ordinary A comprehensive analysis of the safety and clinical efficacy of a cold saline infusion catheter (TC catheter) in the treatment of atrial fibrillation catheter ablation, and a comparison of them, so as to choose the surgical materials more rationally for the patients in the radiofrequency ablation of atrial fibrillation and to develop a more reasonable operation plan to improve the radiofrequency ablation of atrial fibrillation catheter. The short-term and long-term success rate, reducing the probability of postoperative recurrence, improving the safety of atrial fibrillation catheter ablation, and reducing the incidence of postoperative complications. [Methods] randomly selected Paroxysmal atrial fibrillation (PAF) and the diameter of left atrium (left at) in Yuxi People's Hospital from 01 months to May 2016 2014. Rial diameter, LAD) is less than 40mm, and 34 cases of persistent atrial fibrillation (persistent atrial fibrillation, PeAF) undergoing radiofrequency ablation therapy for persistent atrial fibrillation (PeAF) are set up in the study group. Patients with paroxysmal atrial fibrillation treated with common cold saline infusion of NaviStar catheter ablation at the Yuxi People's Hospital at the same time were randomly selected. As well as 34 cases of persistent atrial fibrillation patients with a history of LAD less than 40mm and a course less than 1 years, there were 28 cases in the control group and 22 cases in the study group, with a total of 50 cases, 6 women, 12 cases, 18 cases, and 68 patients in the two group. The average age of the control group was 59.50 + 11.58 years, the average age of the study group was 58.62 + 10.67 years. This study of the patients was studied in this study patient The average age was 28~77 years old, the average age was 58.8 + 11.1 years old. The control group and the study group had 25 cases and 24 PAF, 51 cases in the total. The control group and the study group were 9 cases and 8 cases PeAF respectively. The average ejection fraction of the control group was 62.35 + 4.62%. The average ejection fraction of the study group was 61.29 + 4.68%; the control group cases were in the control group. The average duration of the patients with persistent atrial fibrillation was 7.50 + 1.85 months. The average duration of the patients in the study group was 6.22 + 1.39 months. The average diameter of the left atrium in the control group was 31.87 + 3. 76mm, the average of the study group was 31.52 + 4. 15mm. two groups, the age, the course of atrial fibrillation, the type of atrial fibrillation, the left ventricular ejection fraction, There was no significant difference in baseline data from left atrium (P0. 05). All cases were paroxysmal atrial fibrillation or persistent atrial fibrillation with no significant atrial remodeling and not long history, so the ablation strategy was only bilateral pulmonary vestibule isolation (pulmonary vein isolation, PVI), if pulmonary vein isolation was completed. The patients who were converted to sinus rhythm were given an external synchronous direct current cardioversion (100J-200J) or intravenous injection of Britt (LMG). A few patients with persistent atrial fibrillation still could not maintain sinus rhythm and still have recurrent atrial fibrillation. Patients with atrial flutter were treated with the left atrium line, the mitral isthmus path, and the left atrium. Wall diameter, linear ablation of the three apical isthmus line, and the necessary complex fractionated atrial electrograms (CFAEs). This study was to compare the time of operation, ablation time, X-ray exposure time, X-ray exposure, left atrial model and pulmonary venous opening time, and the statistical difference in the incidence of complications in the two groups. The postoperative follow-up 3,6,12 months compared the two groups of patients with postoperative sinus rhythm maintenance, providing a reliable reference for the selection of surgical instruments and the formulation of surgical procedures in patients with atrial fibrillation. [results all the patients were successfully performed in all the patients in]1.. All the patients were converted to sinus rhythm during the operation, and all patients with.2. could be operated for a long time. No steam explosion, acute pericardial tamponade, cerebral infarction, pulmonary embolism, death, and other serious surgical complications such as.3. were not lost. All the patients were followed up in March, June and December after operation. The study group was compared with the control group: the difference of sinus rhythm maintenance rate in March, June and the difference of sinus rhythm maintenance rate after 4.1 operation The two groups were not statistically significant (94.1% vs.91.2%, P=0.642) (88.23% vs.76. 5%, P=0.203). After operation in December, there were 13 cases in the control group and 4 cases in the study group. The difference of the sinus rhythm maintenance rate in two groups was statistically significant (88. 23%vs.61. 7%, P0.05).4.2 operation time in the study group was significantly shorter than the control group, two groups were worse than the two groups. The difference was statistically significant (154.85 + 28. 62minvs.165.88 + 22.17min, P0.05).4. 3 ring pulmonary venous ablation time in the study group was significantly shorter than the control group. The two groups were statistically significant (89.71 + 20.41 minvs.101.62 + 16.82min, P0.05).4.4 left atrial modeling and pulmonary venous opening time in the study group were significantly shorter than those in the control group. The two groups were significantly different. Statistical significance (8.29 + 2.22 min vs.10. 65 + 2.58 min, P0.05).4.5 X ray exposure time study group was significantly less than the control group, and the difference was statistically significant (28.35 + 5. 34min vs.39. 38 + 6.15min).4.6 x exposure study group was significantly lower than the control group, two group compared with the difference was statistically significant (417.44 + 80. 45mGy vs.585.68 + 9. 5.39mGy, P0. 05) 3 cases of complications in the.4. 7 study group and 2 complications in the control group (8.8% vs.5. 9%, P=0. 16). [Conclusion] the results of this study showed that compared with TC catheter, the use of ST catheter to perform atrial fibrillation catheter ablation can shorten the overall operation time, left atrial operation time (left atrial modeling and pulmonary venous opening time, ablation time), X ray exposure Time and the reduction of X-ray exposure, and with a higher rate of sinus rhythm maintenance in December, the long-term success rate needs further follow-up study. To sum up, the pressure monitoring catheter has a good prospect in clinical application.
【學(xué)位授予單位】：昆明醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R541.75

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