本文選題：陣發(fā)心房顫動(dòng) + 導(dǎo)管射頻消融術(shù)��； 參考：《天津醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的觀察冷凍球囊消融術(shù)(CBA)及導(dǎo)管射頻消融術(shù)(RF)兩種不同的消融方式在治療陣發(fā)心房顫動(dòng)(陣發(fā)房顫)術(shù)后多種炎癥因子及心肌損傷標(biāo)志物的變化;探討相關(guān)炎癥因子、心肌損傷標(biāo)志物水平及其他危險(xiǎn)因素與陣發(fā)房顫(Pa AF)消融術(shù)后復(fù)發(fā)的關(guān)系。方法連續(xù)選取在2015年10月到2016年6月期間因非瓣膜性陣發(fā)房顫(包括合并陣發(fā)心房撲動(dòng))入住天津市胸科醫(yī)院,擬行房顫消融術(shù)的患者111例。所有患者均采集其基本信息,包括年齡、性別、既往病史、合并癥(高血壓、糖尿病以及高脂血癥等)、服藥情況等。病人入選后自愿選擇手術(shù)方式(包括導(dǎo)管射頻消融術(shù)和冷凍球囊消融術(shù)),并依據(jù)其選擇分為冷凍球囊消融組(CB組)和導(dǎo)管射頻消融組(RF組),其中行冷凍球囊消融術(shù)49例,行導(dǎo)管射頻消融術(shù)62例。兩組患者分別于術(shù)前及術(shù)后24小時(shí)抽取空腹肘靜脈血,檢測(cè)肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)、肌鈣蛋白(Tn T)、谷草轉(zhuǎn)氨酶(GOT)、超敏C反應(yīng)蛋白(hs CRP)、白細(xì)胞(WBC)、中性粒細(xì)胞與淋巴細(xì)胞比值(NLR)、單核細(xì)胞(M)及紅細(xì)胞分布寬度(RDW)等化驗(yàn)指標(biāo),采用酶聯(lián)免疫吸附法(ELISA)分別測(cè)定術(shù)前、術(shù)后白介素-6(IL-6)。采取獨(dú)立樣本t檢驗(yàn)及配對(duì)樣本t檢驗(yàn)分析兩組患者術(shù)前術(shù)后上述指標(biāo)的變化情況;采取Logistic回歸分析法分析行兩種術(shù)式后房顫復(fù)發(fā)(包括早期復(fù)發(fā)及晚期復(fù)發(fā))的危險(xiǎn)因素。將所有入選病例錄入Excel軟件建立隨訪數(shù)據(jù)庫(kù)。病例隨訪采用定期隨訪及事件隨時(shí)隨訪的方式�；颊咴谛g(shù)后1周、1個(gè)月、3個(gè)月、6個(gè)月及9個(gè)月時(shí)進(jìn)行定期隨訪,隨訪內(nèi)容包括癥狀描述、常規(guī)12導(dǎo)聯(lián)心電圖、24小時(shí)動(dòng)態(tài)心電圖。病人出現(xiàn)癥狀時(shí)囑其隨時(shí)就診并行心電圖等檢查。房顫消融成功定義為在消融術(shù)3個(gè)月后常規(guī)心電圖或者24小時(shí)動(dòng)態(tài)心電圖中無(wú)超過(guò)30秒的房顫、房撲或者房速。結(jié)果1、患者基本臨床資料、術(shù)中情況及預(yù)后比較在入選的111例(63%為男性)患者中,49例患者入選為冷凍球囊消融術(shù)組(CB組),62例患者入選為導(dǎo)管射頻消融術(shù)組(RF組)。兩組患者的性別、年齡、發(fā)病時(shí)間及左房?jī)?nèi)徑差異均無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。CB組4例患者行消融導(dǎo)管補(bǔ)點(diǎn)隔離,5例患者同時(shí)合并心房撲動(dòng),行三尖瓣環(huán)峽部(CTI)線性消融;RF組術(shù)中即刻肺靜脈隔離率為100%,其中16例患者同時(shí)合并心房撲動(dòng),行三尖瓣環(huán)峽部(CTI)線性消融。CB組手術(shù)持續(xù)時(shí)間短于RF組,差異具有統(tǒng)計(jì)學(xué)意義(P0.05)。術(shù)后除CB組發(fā)生1例膈神經(jīng)麻痹外,兩組患者均未發(fā)生相關(guān)并發(fā)癥,包括心包填塞、心房食道瘺、肺靜脈狹窄、血栓栓塞等。經(jīng)過(guò)(10.5±2.8)月的隨訪,CB組早期復(fù)發(fā)率為33.33%,晚期復(fù)發(fā)率為24.14%;RF組早期復(fù)發(fā)率為32.91%,晚期復(fù)發(fā)率為27.27%。CB組1例患者于術(shù)后6月行二次導(dǎo)管射頻消融手術(shù),術(shù)中發(fā)現(xiàn)右上肺靜脈(RSPV)及右下肺靜脈(RIPV)電位恢復(fù),補(bǔ)點(diǎn)消融后,經(jīng)過(guò)3個(gè)月隨訪未出現(xiàn)復(fù)發(fā)情況;RF組3例患者于術(shù)后6月行二次導(dǎo)管射頻消融手術(shù),其中2例患者術(shù)中證實(shí)為右上肺靜脈(RSPV)電位恢復(fù),1例患者為右上肺靜脈(RSPV)、左上肺靜脈(LSPV)及左下肺靜脈(LIPV)電位恢復(fù),經(jīng)過(guò)(5.6±2.3)月的隨訪,未出現(xiàn)復(fù)發(fā)情況。2、CB組與RF組間炎癥因子及心肌損傷標(biāo)志物基線水平及術(shù)后水平的比較兩組患者基線水平的hs CRP、WBC、NLR、M、CK、CK-MB、Tn T、GOT及RDW均無(wú)統(tǒng)計(jì)學(xué)差異(P0.05)。兩組患者除RDW和IL-6術(shù)后有所下降外,hs CRP、WBC、NLR、M、CK、CK-MB、Tn T及GOT均有所升高,且均有統(tǒng)計(jì)學(xué)意義(P0.05)。并且CB組術(shù)后心肌損傷標(biāo)志物Tn T、CK、CK-MB及GOT的升高明顯高于RF組,具有統(tǒng)計(jì)學(xué)差異(P0.05)。3、CB組與RF組間炎癥因子、心肌損傷標(biāo)志物水平及其他危險(xiǎn)因素與復(fù)發(fā)的關(guān)系通過(guò)單因素分析我們發(fā)現(xiàn)RF組除左心房?jī)?nèi)徑(LAD)及性別(女性患者更高,P0.05)與早期復(fù)發(fā)有一定相關(guān)性外,基線水平的IL-6值、術(shù)后IL-6值、術(shù)后WBC值、術(shù)后M值也與早期復(fù)發(fā)具有一定相關(guān)性,具有統(tǒng)計(jì)學(xué)差異(P0.05),而RDW是晚期復(fù)發(fā)的獨(dú)立危險(xiǎn)因素,具有統(tǒng)計(jì)學(xué)差異(P0.05);Logistic回歸分析顯示基線水平的IL-6值及術(shù)后IL-6值是早期復(fù)發(fā)的獨(dú)立危險(xiǎn)因素,具有統(tǒng)計(jì)學(xué)差異(P0.05),并且通過(guò)分析我們發(fā)現(xiàn)基線水平的IL-6越高早期復(fù)發(fā)率越高。對(duì)于CB組我們發(fā)現(xiàn)性別是房顫早期復(fù)發(fā)(ERAF)的獨(dú)立危險(xiǎn)因素(女性患者更高,P0.05);且房顫的早期復(fù)發(fā)(ERAF)是晚期復(fù)發(fā)(LRAF)的獨(dú)立危險(xiǎn)因素(P0.05),沒有發(fā)現(xiàn)其他相關(guān)炎癥因子、心肌損傷標(biāo)志物及其他危險(xiǎn)因素與CB組復(fù)發(fā)的相關(guān)性。結(jié)論1、冷凍球囊消融術(shù)同導(dǎo)管射頻消融一樣,具有較高的安全性和有效性;2、冷凍球囊消融術(shù)組患者的術(shù)后心肌酶升高程度高于導(dǎo)管射頻消融術(shù)組;3、炎癥因子與導(dǎo)管射頻消融術(shù)后房顫早期復(fù)發(fā)的發(fā)生具有一定相關(guān)性,未發(fā)現(xiàn)其與冷凍球囊消融術(shù)后早期復(fù)發(fā)的相關(guān)性;4、RDW與導(dǎo)管射頻消融術(shù)后房顫的晚期復(fù)發(fā)具有相關(guān)性,未發(fā)現(xiàn)其與冷凍球囊消融術(shù)后晚期復(fù)發(fā)的相關(guān)性。5.冷凍球囊消融術(shù)中房顫早期復(fù)發(fā)(ERAF)是晚期復(fù)發(fā)(LRAF)的獨(dú)立危險(xiǎn)因素。
[Abstract]:Objective To observe the changes of various inflammatory factors and markers of myocardial injury after two different methods of cryosurgery ablation (CBA) and catheter radiofrequency ablation (RF) in the treatment of atrial fibrillation (atrial fibrillation), and to explore the related inflammatory factors, the level of myocardial damage markers and other risk factors and the postoperative Pa AF ablation. Methods 111 patients who were admitted to Tianjin Thoracic Hospital for non valvular atrial fibrillation (including combined atrial flutter) were selected from October 2015 to June 2016. All patients collected the basic information, including age, sex, past medical history, complication (hypertension, diabetes and diabetes). The patients were selected voluntarily (including catheter radiofrequency ablation and cryo balloon ablation) after admission, and were divided into cryo balloon ablation group (group CB) and catheter radiofrequency ablation group (group RF), including 49 cases of frozen balloon ablation and 62 cases of catheter radiofrequency ablation. The two groups were treated respectively. 24 hours before and 24 hours after the operation, the empty abdominal elbow vein blood was extracted, and the test indexes, such as creatine kinase (CK), creatine kinase isoenzyme (CK-MB), troponin (GOT), hypersensitive C reactive protein (HS CRP), leukocyte (WBC), neutrophils and lymphocyte ratio (NLR), mononuclear cell (M) and red cell distribution width (RDW), were used in enzyme linked immunosorbent assay. The preoperative and postoperative interleukins -6 (IL-6) were measured by immunoadsorption (ELISA). The changes of the above indexes were analyzed by independent sample t test and paired sample t test, and the risk factors for the recurrence of two kinds of postoperative atrial fibrillation (including early recurrence and late recurrence) were analyzed by Logistic regression analysis. Patients were followed up by Excel software to establish a follow-up database. Cases were followed up and followed up at any time. Patients were followed up at 1 weeks, 1 months, 3 months, 6 months, and 9 months after the operation. The follow-up contents included the description of the symptoms, the routine 12 lead electrocardiogram, and the 24 hour dynamic electrocardiogram. The success of atrial fibrillation ablation was defined as atrial fibrillation, atrial flutter, or atrial tachycardia without more than 30 seconds in routine electrocardiogram or 24 hour ambulatory electrocardiogram after 3 months of ablation. Results 1, the patient's basic clinical data, intraoperative conditions, and prognosis were compared in 111 cases (63% men), and 49 patients were selected as frozen balls. CB group (group RF), 62 patients were selected as catheter radiofrequency ablation group (group RF). The sex, age, onset time and left atrial diameter were not statistically significant (P0.05) in group.CB, 4 patients were separated by catheter patch, 5 patients combined with atrial flutter, and three apical isthmus (CTI) linear ablation; group RF was in the operation. The isolation rate of pulmonary vein was 100%, of which 16 patients combined with atrial flutter, and three apical annular isthmus (CTI) linear ablation.CB group had shorter operative duration than group RF, the difference was statistically significant (P0.05). The two groups had no related complications, including pericardial tamponade, atrial oesophagus fistula, except for 1 cases of phrenic paralysis in group CB. After (10.5 + 2.8) months follow-up, the early recurrence rate of the CB group was 33.33%, the late recurrence rate was 24.14%, the early recurrence rate in the RF group was 32.91%, and the late recurrence rate was 1 patients in group 27.27%.CB after two catheter radiofrequency ablation operations in June, and the right upper pulmonary vein (RSPV) and the right lower pulmonary vein (RIPV) potential were found during the operation. After 3 months of follow-up, no recurrence was found after 3 months of follow-up. 3 patients in group RF underwent two times of radiofrequency catheter ablation in June, of which 2 patients proved to be the right upper pulmonary vein (RSPV) potential recovery, 1 patients with right upper pulmonary vein (RSPV), the left superior pulmonary vein (LSPV) and the lower left pulmonary vein (LIPV) potential recovery, and (5.6 + 2.3). Compared with the baseline levels of the inflammatory factors and myocardial damage markers between group CB and RF, the baseline level of the two groups of HS CRP, WBC, NLR, M, CK, CK-MB, Tn T were not statistically different. And GOT all increased, and had statistical significance (P0.05). And the elevation of Tn T, CK, CK-MB and GOT in group CB was significantly higher than that in group RF, with statistical difference (P0.05).3, the relationship between the CB group and the inflammatory factors, the level of myocardial damage markers and the relationship between other risk factors and recurrence was found through single factor analysis. There was a certain correlation between the left atrium diameter (LAD) and the sex (higher female patients, P0.05) and the early recurrence. The IL-6 value of the baseline level, the postoperative IL-6 value, the postoperative WBC value and the postoperative M value were also correlated with the early recurrence (P0.05), and RDW was an independent risk factor for the late recurrence, with statistical difference (P0.05). Logistic regression analysis showed that the IL-6 value of baseline level and postoperative IL-6 were independent risk factors for early recurrence, with statistical difference (P0.05), and by analysis we found that the higher the baseline level of IL-6, the higher the early recurrence rate. We found that sex was an independent risk factor for the early recurrence of atrial fibrillation (ERAF) in the CB group (female patients). The early recurrence (ERAF) of atrial fibrillation (P0.05) was an independent risk factor (P0.05) for late recurrence (LRAF). No other related inflammatory factors, myocardial damage markers and other risk factors were associated with the recurrence of CB. Conclusion 1, frozen balloon ablation is as safe and effective as radiofrequency catheter ablation, and 2, cold The degree of myocardial enzyme elevation in the frozen balloon ablation group was higher than that of the catheter radiofrequency ablation group. 3, there was a correlation between the inflammatory factors and the early recurrence of atrial fibrillation after catheter radiofrequency ablation, and the correlation was not found in the early recurrence after the cryopreservation; 4, the late recurrence of atrial fibrillation after RDW and catheter radiofrequency ablation was developed. There is no correlation between the early recurrence of cryopreservation after cryopreservation and.5. cryopreservation (ERAF) is an independent risk factor for late recurrence (LRAF).
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R541.75

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