【摘要】：研究背景心房顫動(dòng)(atrial fibrillation, AF)是臨床上最為常見的心律失常性疾病之一,且隨著人口老齡化的加劇,其發(fā)病率正在逐年增加。缺血性腦卒中(ischemic stroke)是心房顫動(dòng)的主要并發(fā)癥之一,可顯著降低心房顫動(dòng)患者的生存質(zhì)量并增加其死亡率�？诜鼓幬�(e.g.華法林、達(dá)比加群)可顯著降低心房顫動(dòng)患者缺血性腦卒中的發(fā)生率,從而改善心房顫動(dòng)患者的預(yù)后。射頻消融手術(shù)(radiofrequency catheter ablation, RFCA)是目前臨床上治療心房顫動(dòng)的主要手段之一,尤其是有明顯臨床癥狀且藥物治療無效的心房顫動(dòng)患者。然而,心房顫動(dòng)射頻消融術(shù)后仍有30%-40%的患者會(huì)出現(xiàn)心房顫動(dòng)的復(fù)發(fā)而需要藥物治療或再次行消融手術(shù)治療。目前臨床上常規(guī)應(yīng)用24小時(shí)動(dòng)態(tài)心電圖(24h-Holter)來評(píng)估心房顫動(dòng)患者射頻消融術(shù)后的復(fù)發(fā)情況。但是由于24h-Holter監(jiān)測(cè)時(shí)長相對(duì)較短,因而其對(duì)心房顫動(dòng)復(fù)發(fā)的檢出率相對(duì)較低。目前已有應(yīng)用長時(shí)程監(jiān)測(cè)設(shè)備篩查心律失常的相關(guān)報(bào)道,但尚無長時(shí)程監(jiān)測(cè)設(shè)備對(duì)射頻消融術(shù)后心房顫動(dòng)復(fù)發(fā)監(jiān)測(cè)最佳佩戴時(shí)長的報(bào)道。另外,有研究顯示射頻消融術(shù)后出現(xiàn)的早期心房顫動(dòng)(early atrial fibrillation, EAF)或早期房性心動(dòng)過速(early atrial tachycardia, EAT)可能是晚期心房顫動(dòng)復(fù)發(fā)(late atrial fibrillation, LAF)的獨(dú)立危險(xiǎn)因素之一,但不同時(shí)間段內(nèi)的早期房性心律失常與晚期房顫復(fù)發(fā)間的關(guān)系尚不明確。研究目的本研究通過應(yīng)用長時(shí)程(7天)心電監(jiān)測(cè)設(shè)備來評(píng)估：1)心房顫動(dòng)射頻消融術(shù)后7天內(nèi)早期房性心律失常的發(fā)生率及心房顫動(dòng)負(fù)荷；2)心房顫動(dòng)射頻消融術(shù)后7天內(nèi)心房顫動(dòng)相關(guān)臨床癥狀(e.g.心悸、頭暈)與房性心律失常的相關(guān)性；3)心房顫動(dòng)射頻消融術(shù)后7天內(nèi)出現(xiàn)房性心律失常的危險(xiǎn)因素；4)心房顫動(dòng)射頻消融術(shù)后長時(shí)程監(jiān)測(cè)設(shè)備的最佳監(jiān)測(cè)時(shí)長；5)不同長時(shí)程監(jiān)測(cè)設(shè)備間其有效監(jiān)測(cè)時(shí)間百分比是否存在差異。研究方法入組患者：于2016年03月01日至2016年05月31日因心房顫動(dòng)為行射頻消融手術(shù)治療而于北京協(xié)和醫(yī)院心內(nèi)科住院的患者共20例。術(shù)前記錄患者的性別、年齡、身體質(zhì)量指數(shù)(body mass index, BMI)、心房顫動(dòng)類型、患病時(shí)間、有無合并房撲、合并疾病、用藥情況、肌酐、N末端腦鈉肽原(NT-proBNP)、左房前后徑(left atrial diameter, LAD)大小和左室射血分?jǐn)?shù)(left ventricular ejection fraction, LVEF).射頻消融術(shù)后即刻予長時(shí)程心電監(jiān)測(cè),7天后床旁隨診評(píng)估患者有無心房顫動(dòng)相關(guān)臨床癥狀,拆除設(shè)備,經(jīng)公司配套軟件導(dǎo)出數(shù)據(jù),分析房性心律失常的發(fā)生率、發(fā)生時(shí)間及相應(yīng)的心房顫動(dòng)負(fù)荷。研究結(jié)果1.心房顫動(dòng)射頻消融術(shù)后7天內(nèi)早期心房顫動(dòng)的發(fā)生率為30%,早期房性心動(dòng)過速的發(fā)生率為20%,早期房性心律失常的發(fā)生率總計(jì)為45%。2.在出現(xiàn)心房顫動(dòng)相關(guān)臨床癥狀的患者中,只有33.3%的患者被檢測(cè)出早期心房顫動(dòng),11.1%的患者被檢出早期房性心動(dòng)過速；而在無心房顫動(dòng)相關(guān)臨床癥狀的患者中,有27.3%的患者被檢測(cè)出早期心房顫動(dòng),另有18.2%的患者被檢測(cè)出早期房性心動(dòng)過速。3.左室射血分?jǐn)?shù)降低是射頻消融術(shù)后早期心房顫動(dòng)的危險(xiǎn)因素；性別、年齡、BMI、心房顫動(dòng)類型、是否合并房撲、患病時(shí)間、合并疾病、左房前后徑并不是消融術(shù)后7天內(nèi)出現(xiàn)早期房性心律失常的危險(xiǎn)因素。4.心房顫動(dòng)射頻消融術(shù)后7天內(nèi),共有9名患者檢測(cè)出早期房性心律失常。其中射頻消融術(shù)后24小時(shí)內(nèi)有2名患者被檢測(cè)出早期房性心律失常,射頻消融術(shù)后3天內(nèi)有7名患者被檢測(cè)出早期房性心律失常,另有2名患者分別于射頻消融術(shù)后第5天和第7天被檢測(cè)出房性心律失常。Fisher確切概率法分析顯示5天內(nèi)和7天內(nèi)其早期房性心律失常檢出率無顯著統(tǒng)計(jì)學(xué)差異(p＞0.05)。5.射頻消融術(shù)后3天內(nèi)監(jiān)測(cè)出早期心房顫動(dòng)的患者其房顫負(fù)荷大于20%,5天內(nèi)檢測(cè)出早期心房顫動(dòng)的患者其房顫負(fù)荷均大于10%,；而在第7天被檢測(cè)出早期心房顫動(dòng)的患者的房顫負(fù)荷小于10%。6.北京歐橋公司的心衛(wèi)士設(shè)備其有效監(jiān)測(cè)時(shí)長占總監(jiān)測(cè)時(shí)長的百分比為80.5±21.5%,而上海越光公司的貼心設(shè)備其有效時(shí)長占總監(jiān)測(cè)時(shí)長的百分比為91.0±12.0%,兩者的有效監(jiān)測(cè)時(shí)長百分比無顯著的統(tǒng)計(jì)學(xué)差異(p0.05)。研究結(jié)論1.心房顫動(dòng)射頻消融術(shù)后早期房性心律失常的發(fā)生率較高。2.心房顫動(dòng)相關(guān)臨床癥狀(e.g.心悸、頭暈)并不能很好的提示射頻消融術(shù)后有無早期心房顫動(dòng)。3.左室射血分?jǐn)?shù)降低是射頻消融術(shù)后早期心房顫動(dòng)的危險(xiǎn)因素；而性別、年齡、BMI、患病時(shí)間、合并疾病、吸煙史和左房前后徑并不是射頻消融術(shù)后7天內(nèi)出現(xiàn)早期房性心動(dòng)過速的危險(xiǎn)因素。4.相較于24h-Holter,長程監(jiān)測(cè)設(shè)備可以顯著提高早期房性心律失常的檢出率；但超過一定時(shí)長后,延長監(jiān)測(cè)時(shí)長并不能顯著提高房性心律失常的檢出率。5.房顫負(fù)荷越高的患者,其早期心房顫動(dòng)出現(xiàn)的時(shí)間越早。6.不同長時(shí)程監(jiān)測(cè)設(shè)備間其有效檢測(cè)時(shí)長百分比可能無明顯差異。
[Abstract]:Background Atrial fibrillation (AF) is one of the most common arrhythmia diseases in the world, and the incidence of atrial fibrillation is increasing year by year as the aging of the population is increasing. Ischemic stroke is one of the major complications of atrial fibrillation, which can significantly reduce the quality of life and increase the mortality of patients with atrial fibrillation. Oral anticoagulants (e. g., warfarin, dabigatran) can significantly reduce the incidence of ischemic stroke in patients with atrial fibrillation, thus improving the prognosis of patients with atrial fibrillation. Radiofrequency ablation (RFCA) is one of the main methods in the treatment of atrial fibrillation, especially in patients with atrial fibrillation which have obvious clinical symptoms and are not effective in the treatment of atrial fibrillation. However,30% to 40% of patients with atrial fibrillation after radiofrequency ablation will have a recurrence of atrial fibrillation, requiring a drug treatment or a re-operation of the ablation procedure. A 24-hour dynamic electrocardiogram (24-hour-Holter) was routinely applied to assess the recurrence of atrial fibrillation in patients with atrial fibrillation. However, since the duration of the 24 h-Holter monitoring is relatively short, the detection rate of the recurrence of atrial fibrillation is relatively low. A long time history monitoring device has been used to screen the related reports of arrhythmia, but no long time history monitoring equipment has been used to monitor the best wearing time of atrial fibrillation after radiofrequency ablation. In addition, early atrial fibrillation (EAF) or early atrial tachycardia (EAT), which occurs after radiofrequency ablation, may be one of the independent risk factors for late atrial fibrillation recurrence (LAF), However, the relationship between early atrial arrhythmia and the recurrence of late AF in different time periods is not clear. The purpose of this study was to evaluate the incidence of early atrial arrhythmia and the load of atrial fibrillation in 7 days after radiofrequency ablation of atrial fibrillation by applying a long-time (7-day) ECG monitoring device. 2) The related clinical symptoms of atrial fibrillation (e. g. palpitations, dizziness) and atrial arrhythmia within 7 days after radiofrequency ablation of atrial fibrillation;3) the risk factors of atrial arrhythmia within 7 days after radiofrequency ablation of atrial fibrillation; 4) The optimal monitoring time of the long time-course monitoring equipment after radiofrequency ablation of atrial fibrillation; and 5) whether the effective monitoring time percentage among the different long-time duration monitoring devices is different. The patients were enrolled in the study: a total of 20 patients were admitted to the Department of Cardiology of Peking Union and Hospital for the treatment of atrial fibrillation from 01/03/2016 to May 31,2016 for the treatment of atrial fibrillation. The patient's sex, age, body mass index (BMI), type of atrial fibrillation, time of illness, presence or absence of concomitant atrial flutter, combined disease, medication, muscle tone, N-terminal brain natriuretic peptide (NT-proBNP) and left atrial diameter were recorded before operation. LAD) and left ventricular ejection fraction (LVEF). The clinical symptoms and the time of atrial arrhythmia, the incidence of atrial arrhythmia, the time of occurrence and the corresponding atrial fibrillation load were analyzed by means of the software derived from the company's supporting software. Study Results 1. The incidence of early atrial fibrillation was 30%, the incidence of early atrial tachycardia was 20%, and the incidence of early atrial arrhythmia was 45%. Of the patients with related clinical symptoms of atrial fibrillation, only 33.3% of the patients were detected with early atrial fibrillation, 11.1% of the patients were detected early atrial tachycardia, and 27.3% of the patients who had no clinical symptoms associated with atrial fibrillation were detected with early atrial fibrillation, An additional 18.2% of patients were detected with early atrial tachycardia. The reduction of left ventricular ejection fraction is a risk factor for early atrial fibrillation after radiofrequency ablation; sex, age, BMI, type of atrial fibrillation, whether to merge atrial flutter, time of illness, and concomitant disease, The anterior and posterior diameter of the left atrium was not a risk factor for early atrial arrhythmias within 7 days after the ablation procedure. In 7 days after radiofrequency ablation of atrial fibrillation, a total of 9 patients detected early atrial arrhythmias. Two patients were detected early atrial arrhythmias within 24 hours of RF ablation,7 patients were detected early atrial arrhythmias within 3 days of RF ablation, and 2 patients were detected atrial arrhythmias on Days 5 and 7 after RF ablation, respectively. Fisher's exact probability method showed no significant difference in the detection rate of early atrial arrhythmias within 5 and 7 days (p> 0.05). The AF burden of patients with early atrial fibrillation was greater than 20% within 3 days of RF ablation, and the AF burden in patients with early atrial fibrillation was greater than 10% within 5 days, and the AF load of patients who had been tested for early atrial fibrillation on Day 7 was less than 10%. The effective monitoring duration of the heart guard equipment of the Beijing Ouqiao Company accounts for 80.5 to 21.5% of the total monitoring duration, while the effective length of the considerate equipment of the Shanghai Yueguang Company accounts for 91.0% to 12.0% of the total monitoring duration. There was no significant difference in the percentage of effective monitoring of the two groups (p0.05). Study Conclusion 1. The incidence of early atrial arrhythmia after radiofrequency ablation of atrial fibrillation was high. Atrial fibrillation-related clinical symptoms (e. g. palpitations, dizziness) did not provide a good indication of the presence of early atrial fibrillation after radiofrequency ablation. The decrease in left ventricular ejection fraction was a risk factor for early atrial fibrillation after radiofrequency ablation; while gender, age, BMI, time of illness, combined disease, smoking history, and anterior and posterior diameters of the left atrium were not the risk factors for early atrial tachycardia within 7 days after radiofrequency ablation. Compared with the 24-hour-Holter, the long-range monitoring device can significantly improve the detection rate of the early atrial arrhythmia, but after a certain period of time, the monitoring duration can be prolonged and the detection rate of the atrial arrhythmia can not be obviously improved. The higher the AF burden, the earlier the early atrial fibrillation. There may be no significant difference in the percentage of effective detection duration between different time-history monitoring devices.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R541.75

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10 通訊員 李靜 記者 胡德榮;房顫發(fā)生機(jī)制研究取得進(jìn)展[N];健康報(bào);2012年

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9 杜新平;增齡與心房顫動(dòng)關(guān)系的實(shí)驗(yàn)研究[D];中國人民解放軍軍醫(yī)進(jìn)修學(xué)院;2005年

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