冷凍球囊導(dǎo)管肺靜脈電隔離術(shù)的特點(diǎn)分析
發(fā)布時(shí)間：2018-07-24 15:30
【摘要】：本研究分為兩個(gè)部分,分別探討在冷凍球囊導(dǎo)管肺靜脈電隔離術(shù)中實(shí)時(shí)肺靜脈電位記錄對持續(xù)肺靜脈電隔離的預(yù)測價(jià)值和復(fù)發(fā)患者二次導(dǎo)管消融手術(shù)中肺靜脈-左房電傳導(dǎo)恢復(fù)的特點(diǎn)。這兩部分共同為提高手術(shù)療效和安全性以及優(yōu)化手術(shù)流程、縮短手術(shù)時(shí)間提供了重要的參考。資料來自于在阜外醫(yī)院心律失常中心接受單一術(shù)者進(jìn)行的冷凍球囊導(dǎo)管消融術(shù)的心房顫動(dòng)(簡稱房顫)患者。第一部分分析冷凍球囊導(dǎo)管在肺靜脈電隔離術(shù)中的實(shí)時(shí)肺靜脈電位記錄的價(jià)值,共入選患者70例。第二部分探討冷凍球囊導(dǎo)管房顫消融術(shù)后復(fù)發(fā)患者的二次手術(shù)特點(diǎn),共入選9例接受二次導(dǎo)管消融的患者。第一部分：冷凍球囊導(dǎo)管心房顫動(dòng)消融術(shù)中實(shí)時(shí)肺靜脈電位記錄的價(jià)值目的：探討冷凍球囊導(dǎo)管肺靜脈電隔離術(shù)中實(shí)時(shí)記錄肺靜脈電位的方法,可行性及應(yīng)用價(jià)值。資料與方法：連續(xù)入選自2013年11月至2015年1月就診于阜外醫(yī)院的共計(jì)70例癥狀性房顫患者,其中陣發(fā)性房顫57例,持續(xù)性房顫13例。所有患者均利用冷凍球囊導(dǎo)管對各支肺靜脈進(jìn)行電隔離,并在各支肺靜脈的冷凍消融過程中利用與球囊導(dǎo)管整合的環(huán)狀標(biāo)測電極對肺靜脈電位進(jìn)行實(shí)時(shí)記錄。首次成功電隔離后即等待3分鐘,觀察左房-肺靜脈的早期傳導(dǎo)恢復(fù),若未出現(xiàn)傳導(dǎo)恢復(fù)(持續(xù)隔離組),則在原位鞏固消融一次；若出現(xiàn)傳導(dǎo)恢復(fù)(傳導(dǎo)恢復(fù)組),則調(diào)整球囊位置后再次嘗試電隔離。手術(shù)終點(diǎn)為各支肺靜脈的完全電隔離。術(shù)后進(jìn)行常規(guī)隨訪。結(jié)果：以上70例患者共計(jì)肺靜脈282支,平均每例患者消融14±4.3次,274支(97.2%)達(dá)到了成功電隔離。平均手術(shù)時(shí)間為115.2±24.8分鐘,透視時(shí)間為29.6±8.9分鐘。其中232支(84.7%)肺靜脈成功記錄到實(shí)時(shí)電位。術(shù)中觀察期內(nèi)持續(xù)隔離組的首次電隔離時(shí)間為46.61±1.97秒,顯著短于傳導(dǎo)恢復(fù)組(97.30±7.57秒,P0.0001)。持續(xù)隔離組的首次電隔離時(shí)的球囊溫度(-46.35±0.55℃)也顯著低于傳導(dǎo)恢復(fù)組(-40.16±1.26℃,P0.0001),而兩組間球囊最低溫度未見統(tǒng)計(jì)學(xué)差異(持續(xù)隔離組：-33.95±0.69℃,傳導(dǎo)恢復(fù)組：-36.42±2.0℃,P=0.1428)。電隔離時(shí)間短于60秒預(yù)測持續(xù)肺靜脈電隔離的敏感性為0.76,特異性為0.82(AUC=0.835:P0.0001)。除1例持續(xù)性膈神經(jīng)麻痹和1例術(shù)后自限性輕微咯血外,未出現(xiàn)其它并發(fā)癥。結(jié)論：冷凍球囊導(dǎo)管可以安全有效地對肺靜脈進(jìn)行電隔離。冷凍消融過程中通過有效記錄肺靜脈電位而得到的電隔離時(shí)間這一指標(biāo)可以有效預(yù)測肺靜脈的持續(xù)電隔離,而球囊溫度則無法直接反映電隔離效果。因此電隔離時(shí)間這一指標(biāo)可對優(yōu)化手術(shù)操作,減少手術(shù)時(shí)間起到一定的指導(dǎo)作用。第二部分：冷凍球囊導(dǎo)管消融心房顫動(dòng)術(shù)后復(fù)發(fā)患者的二次手術(shù)特點(diǎn)目的：總結(jié)冷凍球囊導(dǎo)管消融術(shù)后復(fù)發(fā)的房顫患者的二次手術(shù)特點(diǎn),并指導(dǎo)對冷凍球囊消融術(shù)的優(yōu)化。資料與方法：連續(xù)入選自2013年12月至2016年3月就診于本中心行冷凍球囊消融術(shù)的房顫患者中于隨訪中復(fù)發(fā)并行二次手術(shù)的患者9例。所有患者利用三維標(biāo)測系統(tǒng)指導(dǎo)的冷鹽水灌注射頻消融導(dǎo)管進(jìn)行肺靜脈的再隔離,并對其它可誘發(fā)的心動(dòng)過速進(jìn)行消融。將同側(cè)肺靜脈口部分為六個(gè)節(jié)段以便于左房-肺靜脈恢復(fù)傳導(dǎo)部位的分析。結(jié)果：以上9名患者均為男性,平均年齡48.1±11.5歲,持續(xù)性房顫3例,陣發(fā)性房顫6例。首次術(shù)中平均冷凍12.6±1.8次,平均手術(shù)時(shí)間為106.1±16.9分鐘,平均透視時(shí)間為24.7±4.8分鐘。9名患者共計(jì)存在肺靜脈37支,其中左側(cè)共干肺靜脈1支,左上肺靜脈8支,左下肺靜脈8支,右上肺靜脈9支,右下肺靜脈9支,右中肺靜脈2支。所有患者均使用28mm直徑冷凍球囊導(dǎo)管進(jìn)行消融。首次術(shù)中所有肺靜脈均成功電隔離。以上患者于首次手術(shù)后平均4.5±2.5個(gè)月后接受二次手術(shù)。二次手術(shù)提示總計(jì)17支(45.9%)肺靜脈恢復(fù)了左房-肺靜脈傳導(dǎo),其中左側(cè)共干肺靜脈1支(100%),左上肺靜脈2支(25%),左下肺靜脈6支(75%),右上肺靜脈3支(33.3%),右下肺靜脈5支(55.5%)。9位患者中,無肺靜脈恢復(fù)傳導(dǎo)者1位(11.1%),有1支肺靜脈傳導(dǎo)恢復(fù)者2位(22.2%),2支肺靜脈傳導(dǎo)恢復(fù)者3位(33.3%),3支肺靜脈傳導(dǎo)恢復(fù)者3位(33.3%)�？傆�(jì)存在漏點(diǎn)19處,對于下肺靜脈漏點(diǎn)數(shù)量顯著多于上肺靜脈,且集中于上下肺靜脈結(jié)合部及下肺靜脈的底部。以上肺靜脈均于二次手術(shù)中成功補(bǔ)點(diǎn)隔離。此外二次手術(shù)中成功消融隔離上腔靜脈一例,典型房撲一例,二尖瓣環(huán)折返性房速一例以及房室結(jié)折返性心動(dòng)過速例。中位隨訪時(shí)間為5(1-19)個(gè)月,隨訪期間有1例患者再次復(fù)發(fā)心房顫動(dòng),服用抗心律失常藥物后控制良好。其余8例患者于隨訪期間均為竇性心律。結(jié)論：冷凍球囊導(dǎo)管消融術(shù)后復(fù)發(fā)患者在二次手術(shù)中左房-肺靜脈傳導(dǎo)恢復(fù)的比例較小,且傳導(dǎo)恢復(fù)部位存在一定的規(guī)律性,主要集中于雙側(cè)下肺靜脈。補(bǔ)點(diǎn)消融重新隔離肺靜脈并對同時(shí)存在的肺外觸發(fā)灶,規(guī)則房性心動(dòng)過速以及陣發(fā)性室上性心動(dòng)過速進(jìn)行消融治療是安全、有效的。
[Abstract]:The present study was divided into two parts. The predictive value of real-time pulmonary venous potential recording on the continuous pulmonary vein isolation during the cryopreserved pulmonary venous isolation and the characteristics of the recovery of pulmonary vein and left atrial conduction during the two catheter ablation operation were discussed. The two parts were combined to improve the efficacy and safety of the operation. The first part analyses the value of the real-time pulmonary venous potential records of the cryopreserved balloon catheter in the pulmonary vein isolation. A total of 70 patients were selected. The second part discussed the two operation characteristics of the recurrent patients after cryopreservation catheter ablation. A total of 9 patients received two catheter ablation. The first part: the value of the real-time pulmonary venous potential recording during the cryo balloon catheter ablation of atrial fibrillation: the study of the pulmonary venous septum of the frozen balloon catheter The method, feasibility and application value of real-time recording of pulmonary venous potential in a total of 70 patients with symptomatic atrial fibrillation from November 2013 to January 2015, including 57 paroxysmal atrial fibrillation and 13 cases of persistent atrial fibrillation, were selected from November 2013 to January 2015. All patients were treated with frozen balloon catheter for each branch of pulmonary vein. Electrical isolation and real-time recording of pulmonary venous potential using a circular electrode integrated with balloon catheter in the process of freezing and ablation of the pulmonary veins. After first successful electrical isolation, it waits for 3 minutes to observe the early conduction recovery of the left atrial and pulmonary vein. If no conduction recovery (continuous isolation group) is not appeared, the ablation is in situ. If there was a conduction recovery (conduction recovery group), electrical isolation was tried again after adjusting the position of the balloon. The end of the operation was complete electrical isolation of the pulmonary veins. After the operation, the total pulmonary vein was followed up. Results: the total pulmonary vein was 282 in the 70 patients, the average of each patient was 14 + 4.3 times, and 274 (97.2%) reached the successful electrical isolation. Between 115.2 + 24.8 minutes and 29.6 + 8.9 minutes, 232 (84.7%) pulmonary veins were recorded successfully. The first electrical isolation time of the continuous isolation group during the observation period was 46.61 + 1.97 seconds, significantly shorter than the conduction recovery group (97.30 + 7.57, P0.0001). The balloon temperature of the first electrical isolation group was (-46.35 + 24.8). .55 C) was also significantly lower than that of conduction recovery group (-40.16 + 1.26 C, P0.0001), but the lowest temperature between the two groups was not statistically significant (-33.95 + 0.69 C, -36.42 2 C, P=0.1428). The sensitivity of electric isolation was 0.76 and 0.82 (AUC=0.835:P0.0). 001). Except for 1 cases of persistent phrenic paralysis and 1 cases of postoperative self limiting mild hemoptysis, there are no other complications. Conclusion: the frozen balloon catheter can be safely and effectively isolated from the pulmonary vein. The index of electrical isolation obtained by effective recording of the pulmonary venous potential in the process of cryosurgery can effectively predict the pulmonary vein. Continuous electrical isolation, and the balloon temperature can not directly reflect the effect of electrical isolation. Therefore, the index of electrical isolation can play a guiding role in optimizing operation and reducing operation time. The second part: two operation characteristics of cryopreservation catheter ablation for recurrent patients after atrial fibrillation: summary of frozen balloon catheter elimination The characteristics of the two operation of patients with recurrent atrial fibrillation and the optimization of cryo balloon ablation. Data and methods: 9 patients who had been followed up and two times of two surgery from December 2013 to March 2016 were followed up by cryo balloon ablation in the center. The radiofrequency catheter (RFD) guided by cold saline was used to reisolate the pulmonary vein and ablation of other induced tachycardia. Six segments of the ipsilateral pulmonary vein were used to facilitate the analysis of the left atrial and pulmonary vein recovery. Results: the above 9 patients were male, the average age was 48.1 + 11.5 years, and the persistent atrial fibrillation was 3. 6 cases of paroxysmal atrial fibrillation (paroxysmal atrial fibrillation). The average cryopreservation was 12.6 + 1.8 times in the first operation, the average operation time was 106.1 + 16.9 minutes. The average fluoroscopy time was 24.7 + 4.8 minutes. There were 37 pulmonary veins in.9 patients, including 1 left pulmonary veins, 8 left upper pulmonary veins, 8 branches of the lower left pulmonary vein, 9 branches of the right upper pulmonary vein, the right inferior pulmonary vein 9, and right middle lung. All patients were treated with a 28mm diameter cryo balloon catheter. All pulmonary veins were successfully isolated during the first operation. Two operations were performed on average 4.5 + 2.5 months after the first operation. Two operations suggested a total of 17 (45.9%) pulmonary veins recovered from the left atrial and pulmonary vein, of which the left common dry pulmonary vein was 1 (10). 0%) 2 (25%), 6 branches (75%) of left inferior pulmonary vein (75%), 3 (33.3%) of right upper pulmonary vein (33.3%) and 5 (55.5%).9 in right inferior pulmonary vein, 1 (11.1%) without pulmonary vein restorer, 1 branches of pulmonary vein conduction recovery. Point 19, the number of leaks in the lower pulmonary vein was significantly more than that of the upper pulmonary vein, and concentrated in the bottom of the upper and lower pulmonary veins and the bottom of the inferior pulmonary vein. All the pulmonary veins were successfully isolated in the two operation. In addition, a case of isolated superior vena cava, one case of typical atrial flutter, one case of mitral annulus reentrant atrial tachycardia and room in two operations. The median follow-up time of reentrant tachycardia was 5 (1-19) months. During the follow-up period, 1 patients had recurrent atrial fibrillation and had good control after taking antiarrhythmic drugs. The remaining 8 patients were sinus rhythm during the follow-up period. Conclusion: the recurrent patients after cryopballoon catheter ablation had left atrial and pulmonary veins in the two operation. The ratio of conduction recovery is small, and the conduction recovery part is regular, mainly concentrated in the bilateral inferior pulmonary vein. It is safe and effective to resend the pulmonary vein and the external pulmonary trigger, regular atrial tachycardia and paroxysmal supraventricular tachycardia at the same time.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R541.75
[Abstract]:The present study was divided into two parts. The predictive value of real-time pulmonary venous potential recording on the continuous pulmonary vein isolation during the cryopreserved pulmonary venous isolation and the characteristics of the recovery of pulmonary vein and left atrial conduction during the two catheter ablation operation were discussed. The two parts were combined to improve the efficacy and safety of the operation. The first part analyses the value of the real-time pulmonary venous potential records of the cryopreserved balloon catheter in the pulmonary vein isolation. A total of 70 patients were selected. The second part discussed the two operation characteristics of the recurrent patients after cryopreservation catheter ablation. A total of 9 patients received two catheter ablation. The first part: the value of the real-time pulmonary venous potential recording during the cryo balloon catheter ablation of atrial fibrillation: the study of the pulmonary venous septum of the frozen balloon catheter The method, feasibility and application value of real-time recording of pulmonary venous potential in a total of 70 patients with symptomatic atrial fibrillation from November 2013 to January 2015, including 57 paroxysmal atrial fibrillation and 13 cases of persistent atrial fibrillation, were selected from November 2013 to January 2015. All patients were treated with frozen balloon catheter for each branch of pulmonary vein. Electrical isolation and real-time recording of pulmonary venous potential using a circular electrode integrated with balloon catheter in the process of freezing and ablation of the pulmonary veins. After first successful electrical isolation, it waits for 3 minutes to observe the early conduction recovery of the left atrial and pulmonary vein. If no conduction recovery (continuous isolation group) is not appeared, the ablation is in situ. If there was a conduction recovery (conduction recovery group), electrical isolation was tried again after adjusting the position of the balloon. The end of the operation was complete electrical isolation of the pulmonary veins. After the operation, the total pulmonary vein was followed up. Results: the total pulmonary vein was 282 in the 70 patients, the average of each patient was 14 + 4.3 times, and 274 (97.2%) reached the successful electrical isolation. Between 115.2 + 24.8 minutes and 29.6 + 8.9 minutes, 232 (84.7%) pulmonary veins were recorded successfully. The first electrical isolation time of the continuous isolation group during the observation period was 46.61 + 1.97 seconds, significantly shorter than the conduction recovery group (97.30 + 7.57, P0.0001). The balloon temperature of the first electrical isolation group was (-46.35 + 24.8). .55 C) was also significantly lower than that of conduction recovery group (-40.16 + 1.26 C, P0.0001), but the lowest temperature between the two groups was not statistically significant (-33.95 + 0.69 C, -36.42 2 C, P=0.1428). The sensitivity of electric isolation was 0.76 and 0.82 (AUC=0.835:P0.0). 001). Except for 1 cases of persistent phrenic paralysis and 1 cases of postoperative self limiting mild hemoptysis, there are no other complications. Conclusion: the frozen balloon catheter can be safely and effectively isolated from the pulmonary vein. The index of electrical isolation obtained by effective recording of the pulmonary venous potential in the process of cryosurgery can effectively predict the pulmonary vein. Continuous electrical isolation, and the balloon temperature can not directly reflect the effect of electrical isolation. Therefore, the index of electrical isolation can play a guiding role in optimizing operation and reducing operation time. The second part: two operation characteristics of cryopreservation catheter ablation for recurrent patients after atrial fibrillation: summary of frozen balloon catheter elimination The characteristics of the two operation of patients with recurrent atrial fibrillation and the optimization of cryo balloon ablation. Data and methods: 9 patients who had been followed up and two times of two surgery from December 2013 to March 2016 were followed up by cryo balloon ablation in the center. The radiofrequency catheter (RFD) guided by cold saline was used to reisolate the pulmonary vein and ablation of other induced tachycardia. Six segments of the ipsilateral pulmonary vein were used to facilitate the analysis of the left atrial and pulmonary vein recovery. Results: the above 9 patients were male, the average age was 48.1 + 11.5 years, and the persistent atrial fibrillation was 3. 6 cases of paroxysmal atrial fibrillation (paroxysmal atrial fibrillation). The average cryopreservation was 12.6 + 1.8 times in the first operation, the average operation time was 106.1 + 16.9 minutes. The average fluoroscopy time was 24.7 + 4.8 minutes. There were 37 pulmonary veins in.9 patients, including 1 left pulmonary veins, 8 left upper pulmonary veins, 8 branches of the lower left pulmonary vein, 9 branches of the right upper pulmonary vein, the right inferior pulmonary vein 9, and right middle lung. All patients were treated with a 28mm diameter cryo balloon catheter. All pulmonary veins were successfully isolated during the first operation. Two operations were performed on average 4.5 + 2.5 months after the first operation. Two operations suggested a total of 17 (45.9%) pulmonary veins recovered from the left atrial and pulmonary vein, of which the left common dry pulmonary vein was 1 (10). 0%) 2 (25%), 6 branches (75%) of left inferior pulmonary vein (75%), 3 (33.3%) of right upper pulmonary vein (33.3%) and 5 (55.5%).9 in right inferior pulmonary vein, 1 (11.1%) without pulmonary vein restorer, 1 branches of pulmonary vein conduction recovery. Point 19, the number of leaks in the lower pulmonary vein was significantly more than that of the upper pulmonary vein, and concentrated in the bottom of the upper and lower pulmonary veins and the bottom of the inferior pulmonary vein. All the pulmonary veins were successfully isolated in the two operation. In addition, a case of isolated superior vena cava, one case of typical atrial flutter, one case of mitral annulus reentrant atrial tachycardia and room in two operations. The median follow-up time of reentrant tachycardia was 5 (1-19) months. During the follow-up period, 1 patients had recurrent atrial fibrillation and had good control after taking antiarrhythmic drugs. The remaining 8 patients were sinus rhythm during the follow-up period. Conclusion: the recurrent patients after cryopballoon catheter ablation had left atrial and pulmonary veins in the two operation. The ratio of conduction recovery is small, and the conduction recovery part is regular, mainly concentrated in the bilateral inferior pulmonary vein. It is safe and effective to resend the pulmonary vein and the external pulmonary trigger, regular atrial tachycardia and paroxysmal supraventricular tachycardia at the same time.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R541.75
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