【摘要】：本研究內(nèi)容分為兩個部分,分別探討犬的改良劍突下經(jīng)皮心包穿刺術的可行性和安全性以及經(jīng)房間隔穿刺途徑消融室壁瘤相關室性心動過速的有效性和安全性。這兩部分研究分別從改良技術和優(yōu)化消融策略兩個方面來指導難治性室性心律失常的導管消融,為提高手術療效和安全性,降低操作相關并發(fā)癥的發(fā)生率等提供了新的思路。第一部分為動物實驗,通過與常規(guī)的心包穿刺針(Tuohy斜面針)比較,評估改良的心包穿刺針在犬模型中行劍突下經(jīng)皮心包穿刺術的可行性和安全性,實驗分為改良的心包穿刺針組和Tuohy針組。第二部分為臨床研究,資料來源于中國醫(yī)學科學院阜外醫(yī)院,共入選5例室壁瘤相關室速患者,經(jīng)主動脈逆行法導管消融失敗后,評估通過房間隔穿刺途徑消融室速的有效性和安全性。第一部分:犬的改良劍突下經(jīng)皮心包穿刺術的可行性和安全性研究目的:通過與常規(guī)的心包穿刺針(Tuohy斜面針)比較,探討應用改良的心包穿刺針行劍突下經(jīng)皮心包穿刺術的可行性和安全性。方法:成年雜交犬10只,隨機分為改良的心包穿刺針組和Tuohy針組。由三位獨立的研究者(分別達到高、中和初級電生理介入手術水平)進行劍突下經(jīng)皮心包穿刺操作,且三位研究者既往均無使用改良心包穿刺針的經(jīng)驗。每位研究者分別嘗試經(jīng)前路和后路兩種方法,每種方法分別進行兩次嘗試。通過導絲走形和心包腔造影來判斷心包穿刺操作是否成功。操作完成后即刻處死,觀察心臟及鄰近組織臟器情況。分別記錄進針深度和角度及操作相關并發(fā)癥的發(fā)生情況。結果:改良的心包穿刺針組中,前路法進針角度平均為27.2±5.52°,而后路法進針角度明顯大于前者,平均為68.0±7.26°(P0.01)。而進針深度兩種方法并無顯著性差異,前路法進針深度平均為69.3±11.87mm,后路法進針深度平均為74.3±10.89mm(P=0.094)。與改良的心包穿刺針組相比,Tuohy針組的并發(fā)癥發(fā)生率相對較高,但并無統(tǒng)計學差異。Tuohy針組發(fā)生不經(jīng)意穿刺到心肌組織的發(fā)生率為10%,改良穿刺針組為5%(P=0.491);Tuohy針組發(fā)生一例肺損傷;改良的心包穿刺針組發(fā)生一例局部冠狀血管損傷,造成局限性的出血。結論:與常規(guī)的心包穿刺針Tuohy針相比,改良的心包穿刺針是一種安全、有效的進行劍突下經(jīng)皮心包穿刺術的工具,其操作相關的并發(fā)癥發(fā)生率相對更低。第二部分:經(jīng)房間隔穿刺途徑消融室壁瘤相關室性心動過速目的:本研究旨在評估經(jīng)主動脈逆行法導管消融失敗的室壁瘤相關室性心動過速患者,通過房間隔穿刺途徑消融室速的有效性和安全性。方法:自2011年4月至2015年10月在中國醫(yī)學科學院阜外醫(yī)院入選室壁瘤相關室性心動過速患者共5例,常規(guī)經(jīng)主動脈逆行法導管消融失敗后,應用可控導管鞘經(jīng)房間隔穿刺途徑實施三維電解剖標測并進行導管消融治療。收集患者基線資料。術后隨訪12月。有效性終點為導管消融成功,室速不能被誘發(fā);安全性終點為術后無手術相關并發(fā)癥。結果:5例患者中,4例為心尖部巨大室壁瘤,1例為左室間隔后基底部室壁瘤。2例患者外周動脈嚴重狹窄或閉塞,經(jīng)主動脈逆行法失敗。余3例患者經(jīng)主動脈逆行法均未標測到理想靶點。應用可控導管鞘經(jīng)房間隔穿刺途徑行室速導管消融,均達到導管消融終點,無并發(fā)癥發(fā)生。術后平均隨訪12(6-16)月,1例患者室速復發(fā),再次穿刺房間隔后室速導管消融成功。結論:經(jīng)房間隔穿刺途徑進行左室心律失常導管消融是經(jīng)主動脈逆行法的重要補充,應用可控導管鞘穿刺房間隔消融室壁瘤相關室性心動過速是安全有效的。
[Abstract]:This study is divided into two parts. The feasibility and safety of pericardiocentesis and the effectiveness and safety of transseptal puncture are discussed. This two part studies the catheter ablation of refractory ventricular arrhythmia from two aspects of improved technique and optimized ablation strategy, and provides a new way to improve the efficacy and safety of the operation and to reduce the incidence of operation-related complications. The first part was animal experiment, and the feasibility and safety of the modified pericardiocentesis was evaluated by comparing with the conventional pericardial puncture needle (Tuohy inclined needle). The experiment was divided into the modified pericardiocentesis needle group and the Tuohy needle group. The second part is a clinical study, which is derived from the Fuwai Hospital of the Chinese Academy of Medical Sciences. Part One: The feasibility and safety of pericardiocentesis under the modified sword process of canines: the feasibility and safety of pericardiocentesis with improved pericardiocentesis was discussed by comparing with the conventional pericardial puncture needle (Tuohy bevel needle). Methods: 10 adult hybrid dogs were randomly divided into modified pericardiocentesis needle and Tuohy needle. The pericardiocentesis was performed by three independent investigators (high, medium and primary electrophysiological interventions, respectively), and none of the three investigators had previously used the modified pericardiocentesis needle. Each investigator tried both anterior and posterior approaches, each of which was attempted twice, respectively. Whether the pericardiocentesis was successful was determined by wire guide and pericardiocentesis. The operation was completed immediately, and the organs of the heart and the adjacent tissues were observed. The depth and angle of the needle and the occurrence of the related complications were recorded separately. Results: In the modified pericardiocentesis needle group, the angle of the needle in the anterior approach was 27. 2 and 5.52 擄, and the angle of the needle in the posterior approach was significantly greater than that of the former, with an average of 68. 0 and 7.26 擄 (P0.01). There was no significant difference in the depth of the needle entering the needle. The average depth of the needle in the anterior approach was 69. 3/ 11. 87mm, and the depth of the needle in the posterior method was 74.3 and 10.89mm (P = 0.094). The incidence of complications in the Tuohy needle group was relatively high compared to the modified pericardial puncture group, but there was no statistical difference. The incidence rate of the tuohy needle group was 10%, the modified puncture needle group was 5% (P = 0.491), the Tuohy needle group had one lung injury, and the modified pericardiocentesis needle group had a partial coronary artery injury, which caused the limited bleeding. Conclusion: Compared with the conventional pericardial puncture needle Tuohy needle, the modified pericardiocentesis needle is a safe and effective tool for pericardiocentesis under the sword process, and the complication rate associated with its operation is relatively low. Part 2: Radiofrequency Catheter Ablation of Ventricular Tachycardia-related Ventricular Tachycardia: The purpose of this study is to assess the effectiveness and safety of ventricular tachycardia in patients with chamber-wall-aneurysm-associated ventricular tachycardia, which has failed by the procedure of transseptal puncture. Methods: From April 2011 to October 2015, a total of 5 patients with ventricular tachycardia were selected from Fuwai Hospital of the Chinese Academy of Medical Sciences, and after the failure of the conventional aortic retrograde catheter ablation, The three-dimensional electroanatomic mapping was performed by the transseptal puncture of the controlled catheter, and the catheter ablation was performed. Collect patient baseline data. The postoperative follow-up was 12 months. The efficacy endpoint was the success of the catheter ablation and the chamber speed could not be induced; the safety endpoint was the post-operative, non-surgical-related complication. Results: Of the 5 patients, 4 cases were the giant cell wall tumor of the apical part, and one case was the wall tumor of the basal bottom of the left ventricular septum. The ideal target point was not detected by the retrograde method of the aortic retrograde method in the remaining 3 patients. The catheter ablation of the catheter was performed by transseptal puncture with the controlled catheter, and the end of catheter ablation was achieved without complication. After the mean follow-up of 12 (6-16) months, 1 patient had a recurrence of room speed, and the ventricular tachycardia after transseptal re-puncture was successful. Conclusion: The ablation of the left ventricular arrhythmia catheter by transseptal puncture is an important supplement to the retrograde approach of the aorta.
【學位授予單位】：北京協(xié)和醫(yī)學院
【學位級別】：博士
【學位授予年份】：2017
【分類號】：R541.7

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