【摘要】：背景：房顫是臨床上最常見的心律失常之一,其患病率正逐年升高,常導致血栓栓塞、腦卒中等嚴重心腦血管事件。既往常用藥物治療房顫,但因其有效性和安全性逐漸受到挑戰(zhàn),射頻消融術因效率較高,副作用較低而受到廣泛青睞。研究顯示,房顫可導致左心房和左心室增大及功能降低,而增大的左心房可進一步促進房顫維持,形成一個惡性循環(huán)。因此,患者房顫控制后左心房和左心室結構和功能是否能夠恢復對房顫患者生活質量及預后均有影響。而射頻消融術控制房顫后左心房和左心室結構與功能變化情況也逐漸受到關注。目的：通過測定持續(xù)性房顫患者行環(huán)肺靜脈射頻消融術前后左心房和左心室結構和功能相關指標(左心房前后徑(LAD)、左心室舒張末內(nèi)徑(LVEDD)、左心室收縮末內(nèi)徑(LVESD)、左心室縮短分數(shù)(FS)、左心室射血分數(shù)(LVEF)以及血漿腦鈉肽(BNP)或氨基末端腦鈉肽前體(NT-proBNP)),對比手術成功組和失敗組的前后變化,探討導管射頻消融治療對房顫患者心臟結構和功能的影響。并對成功組與失敗組術前相關指標(年齡、病程、LAD、NT-proBNP等)進行對比分析,探討其對射頻消融術預后的指導意義。方法：選擇2013年1月到2015年11月間在北京協(xié)和醫(yī)院心內(nèi)科行射頻消融術的57例符合條件的持續(xù)性房顫患者,查閱病歷,獲得其性別、年齡、房顫病程、體重指數(shù)(BMI)、術前的超聲心動圖測量的LAD、LVEDD、LVESD、FS、LVEF和血漿BNP、NT-proBNP。待其手術后至少6個月之后,打電話進行隨訪,詢問癥狀,行動態(tài)心電圖檢查判斷其手術成功或者失敗,行超聲心動圖檢查其術后相關指標及抽血查BNP、NT-proBNP。分別對比成功組和失敗組手術前后的相關指標變化,以及成功組與失敗組之間手術前的相關指標。結果：1、57例患者中,有32例接受并完成了隨訪。32例入組患者基本指標,年齡58.71±12.36歲(28例集中在40-70歲),術前LAD 42.56±4.41mm(最大不超過50mm),術前LVEF 64.81±8.83%(僅3例小于55%),術前NT-proBNP 826.71±624.29pg/ml。2、入組患者中24例無復發(fā),歸入成功組,8例出現(xiàn)復發(fā),歸入失敗組,成功率75%。兩組病人在年齡、BMI、血壓、術前LAD、LVEF方面,P均0.05,都沒有顯著性差異；提示本研究入組病人的年齡、病程、術前LAD、LVEF、不能作為房顫術后復發(fā)預測因子。3、將32例患者術前指標與術后復發(fā)的相關性進行二元分析,結果顯示,年齡、病程、BMI、術前LAD、LVEF、NT-proBNP與術后房顫復發(fā)OR值各不相同,但是P均0.05,未見顯著差異,利用精確Fisher檢驗,對術前LAD正常者與增大者進行復發(fā)相關性分析,P0.05,未見顯著性差異。也提示本研究入組病人的年齡、病程、術前LAD、LVEF、NT-proBNP不能作為房顫術后復發(fā)預測因子。4、成功組LAD(術前42.63±3.91mm vs 3術后9.21±3.11mm,P0.05),有顯著性差異,提示消融成功后左心房發(fā)生可逆性重構；但是LVEDD、LVESD、FS、 LVEF的手術前后變化P值為0.535,0.507,0.914,0.448均0.05,無顯著性差異,無明顯變化。但術前LVEF降低的3例患者,在成功控制房顫后LVEF均上升。5、失敗組手術前后LAD、LVEDD、LVESD、FS、LVEF變化的P值分別為0.266,0.101,0.238,0.489,0.422,均0.05,沒有顯著性差異。提示消融失敗后房顫患者左心房和左心室結構與功能未進一步惡化。6、成功組與失敗組術前NT-proBNP對比,(成功組1014.71±601.99pg/ml vs失敗組450.71±516.27pg/ml, P=0.0480.05),有顯著性差異,但成功組術前NT-proBNP明顯高于失敗組。7、成功組術后NT-proBNP降低,(術前1014.71±601.99pg/ml vs術后123.71 ±75.99pg/ml,P0.05),有顯著性差異；失敗組術后NT-proBNP升高,(術前450.71 ±516.27pg/ml vs術后987.86±738.81pg/ml, P=0.030.05),有顯著性差異。結論：1、射頻消融術是治療房顫的有效方法,能有效維持竇律。2、射頻消融術成功后,左心房可發(fā)生逆重構；但對于術前左心室結構和功能未見明顯異常者,左心室結構和功能變化情況不明顯。尚需進一步詳細研究。3、對于研究中40-70歲之間的患者,本研究不支持年齡增大可作為房顫射頻消融術后復發(fā)的預測因子,仍需進一步研究。4、對本研究入組的持續(xù)性房顫病人,病程長短不能作為射頻消融術后復發(fā)的預測因子。5、術前左心房前后徑(LAD)未超過50mm時,本研究不支持LAD可作為房顫患者射頻消融術后復發(fā)的預測因子。6、術前左心室射血分數(shù)未降低(LVEF55%)時,本研究不支持LVEF可作為房顫患者射頻消融術后復發(fā)的預測因子。7、房顫患者血清NT-proBNP升高,射頻消融成功控制房顫后,心功能可恢復,NT-proBNP可顯著降低。8、消融后NT-proBNP降低可作為消融成敗的預測因素,而術前NT-proBNP基線水平不能作為消融成敗的預測因素9、NT-proBNP對無癥狀的心功能異常患者比左心室射血分數(shù)(LVEF)更具檢測優(yōu)勢。
[Abstract]:Background: Atrial fibrillation is one of the most common arrhythmias in the clinic. The prevalence of atrial fibrillation is increasing year by year, which often leads to serious cardiovascular and cerebrovascular events such as thromboembolic stroke and stroke. The prior commonly used drugs have been widely used for the treatment of atrial fibrillation, but due to the challenge of their effectiveness and safety, radiofrequency ablation is widely favored due to high efficiency and low side effects. The study shows that AF can lead to an increase in the left atrium and the left ventricle and a decrease in function, while the increased left atrium can further promote the maintenance of AF and form a vicious circle. Therefore, whether the left atrial and left ventricular structures and functions can be recovered after AF control has an impact on the quality of life and the prognosis of patients with atrial fibrillation. The changes of left atrium and left ventricular structure and function in the control of atrial fibrillation after radiofrequency ablation are also of concern. Objective: To determine the left atrial and left ventricular structure and function-related index (LAD), left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic internal diameter (LVESD) and left ventricular shortening fraction (FS) before and after radiofrequency ablation of pulmonary vein in patients with persistent AF. Left ventricular ejection fraction (LVEF) and plasma brain natriuretic peptide (BNP) or amino-terminal brain natriuretic peptide (NT-proBNP) were compared. The correlation between the success group and the failure group (age, course of course, LAD, NT-proBNP, etc.) was compared and analyzed, and its significance to the prognosis of radiofrequency ablation was discussed. Methods:57 eligible patients with persistent AF were selected from January 2013 to November 2015 in the cardiac internal medicine of Peking Union and Hospital, and the patient's medical records were reviewed to obtain their sex, age, course of atrial fibrillation, body mass index (BMI), LAD and LVEDD of pre-operative echocardiogram. LVESD, FS, LVEF, and plasma BNP, NT-proBNP. After at least 6 months after the operation, the patient was called for follow-up, the symptoms were inquired, the dynamic electrocardiogram of the line was determined to determine the success or failure of the operation, and the relevant index and blood draw of BNP and NT-proBNP were examined by echocardiography. The relevant index changes before and after operation of the successful group and the failure group were compared, and the related indexes before the operation between the successful group and the failure group were compared. Results: Of the 57 patients,32 patients received and completed the follow-up.32 patients had the basic index, the age was 58.71, the age was 12.36 years (28 cases were in the range of 40 to 70 years), the preoperative LAD 42.56 was 4.41 mm (not more than 50 mm), the preoperative LVEF 64.81 was 8.83% (only 3 cases was less than 55%), and the preoperative NT-proBNP 826.71 was 624.29 pg/ ml.2, Twenty-four of the enrolled patients had no recurrence, and they were included in the successful group. The 8 cases recurred, and they were included in the failure group and the success rate was 75%. There was no significant difference between the two groups in age, BMI, blood pressure, pre-operative LAD and LVEF. The relationship between preoperative and postoperative recurrence of 32 patients was analyzed. The results showed that, age, course, BMI, pre-operative LAD, LVEF, NT-proBNP were different from those of postoperative AF, but P was 0.05, no significant difference was found, and accurate Fisher's test was used. There was no significant difference in the correlation between the normal and the increase of the pre-operative LAD, P0.05. The age, course, pre-operative LAD, LVEF and NT-proBNP of the patients were also indicated to be not a predictor of the recurrence of AF.4. The successful group of LAD (42.63, 3.91 mm vs.3, 9.21, 3.11 mm, P 0.05) in the successful group showed a significant difference, indicating the reversible reconstruction of the left atrium after the successful ablation; however, the LVEDD, The post-operative changes of LVESD, FS and LVEF were 0.535, 0.507, 0.914, and 0.448, respectively. However, in 3 patients with LVEF decreased, LVEF was increased after successful control of AF. The P values of LAD, LVEDD, LVESD, FS and LVEF were 0.266, 0.101, 0.238, 0.489 and 0.422 in the failure group before and after operation, and there was no significant difference. The left atrium and left ventricular structure and function of the patients with atrial fibrillation after the ablation failure were not further deteriorated.6. The success group and the NT-proBNP in the failed group were compared with the NT-proBNP in the successful group (group 1014.71, 601.99 pg/ ml vs. the failure group 450.71, 516.27 pg/ ml, P = 0.0480.05), but the NT-proBNP was significantly higher in the successful group than in the failure group. The NT-proBNP in the successful group was decreased, (1014.71 to 601.99 pg/ ml and 123.71 to 75.99pg/ ml after operation, P0.05). There was a significant difference in the NT-proBNP after the failure group. The NT-proBNP in the failure group was increased, and the NT-proBNP in the failure group was increased (the pre-operation 450.71-516.27 pg/ ml vs. the post-operation 987.86-738.81 pg/ ml, P = 0.030.05), and there was a significant difference. Conclusion:1. Radiofrequency ablation is an effective method for the treatment of atrial fibrillation, which can be used to maintain the atrial fibrillation effectively. After the successful radiofrequency ablation, the left atrium may have an inverse reconstruction; however, the left ventricular structure and the function change are not obvious for the pre-operative left ventricular structure and function. a further detailed study is required.3. For patients in the study between 40 and 70 years of age, this study does not support an increase in age as a predictor of recurrence after radiofrequency ablation of AF, and a further study is required.4. Patients with persistent AF who are enrolled in this study, The duration of the course of course could not be a predictor of recurrence after radiofrequency ablation.5. The pre-operative left atrial diameter (LAD) was not more than 50 mm. The study did not support LAD as a predictor of recurrence after radiofrequency ablation in patients with atrial fibrillation.6. The preoperative left ventricular ejection fraction was not reduced (LVEF 55%). This study did not support LVEF as a predictor of recurrence after radiofrequency ablation in patients with atrial fibrillation.7. The increase of NT-proBNP in patients with atrial fibrillation and the success of radio-frequency ablation in the control of AF, the function of cardiac function can be recovered, and NT-proBNP can be significantly reduced.8. The decrease of NT-proBNP after ablation can be used as a predictor of the success or failure of the ablation. The pre-operative NT-proBNP baseline level could not be a predictor of success or failure of the ablation. NT-proBNP was more sensitive to asymptomatic cardiac dysfunction than the left ventricular ejection fraction (LVEF).
【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】：2016
【分類號】：R541.75

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