阵发性心房颤动合并病态窦房结综合征的导管射频消融大静脉电隔离治疗

目的总结顽固性阵发性心房颤动(房颤)伴病态窦房结综合征(病窦)患者的心电图和动态心电图特点,评价心脏起搏和导管射频消融电隔离治疗的结果.     

心室起搏依赖的心力衰竭患者应用希氏束起搏与传统起搏对心脏功能影响的对比研究

目的:探讨心室起搏依赖的心力衰竭患者应用希氏束起搏(HBP)的临床价值。方法:连续入选2017年6月至2018年6月于大连医科大学附属第一医院因心室起搏依赖(心室起搏比例高于40%)而植入永久起搏器且合并心力衰竭的患者132例。HBP成功者44例为HBP组,传统起搏组88例患者。比较两组患者治疗前后的QRS时限、NYHA心功能分级,超声心动图指标及起搏器参数的变化情况;根据基线左心室射血分数(LVEF)再将各组患者分为射血分数保留(HFpEF,LVEF≥40%)患者及射血分数降低(HFrEF,LVEF<40%)患者,再次评价两类患者中HBP和传统起搏的心功能的变化情况。结果:与术前比,HBP组患者术后(末次随访)QRS时限缩短、NYHA心功能分级改善、LVEF升高、左心室舒张末期内径(LVEDD)减小、二尖瓣反流(MR)程度减轻、左心房内径(LAD)缩小(P均<0.05);传统起搏组三尖瓣反流(TR)程度较术前加重(P<0.05),LVEF、LVEDD、MR程度、LAD均较术前无显著改善(P均>0.05)。132例患者中有HFrEF患者47例,其中HBP组20例,传统起搏组27例,HBP组HFrEF患者术后QRS时限缩短、NYHA心功能分级改善、LVEF升高、LVEDD减小、MR和TR程度均减轻、LAD缩小(P均<0.05);传统起搏组HFrEF患者QRS时限延长(P<0.05)。HFpEF患者共85例,其中HBP组24例。HBP组HFpEF患者术后NYHA心功能分级明显改善(P<0.05);而传统起搏组HFpEF患者的LVEF较术前下降、MR和TR程度均加重(P均<0.05)。结论:对于心室起搏依赖的心力衰竭患者,与传统起搏相比,HBP均能够改善患者心功能,这些临床益处在射血分数减低的患者中更为显著。     

房室结慢径区域消融对迷走神经功能及心房颤动易感性的影响

Objective Atrioventricular node reentrant tachycardia (AVNRT) ablation may effect the vagal response,which is indicated by sinus tachycardia. On the other hand,atrial fibrillation (AF) ,which was found to be associated with vagal irmervation, often coexists with AVNRT. However,little is known about the im-pact of slow pathway ablation on local vagal innervation to atria. Methods In 11 dogs, bilateral cervical sympa-thovagal trunks were decentralized and metoprolol was given to block sympathetic effects. Linear lesion was per-formed from coronary sinus (CS) ostium to the middle area of Koch triangle. Atrial effective refractory period(ERP) ,vulnerability window (VW) of AF, and sinus rhythm cycle length (SCL) were measured at high fight atrium (HRA),low right atrium (LRA), distal (CSd) and proximal CS (CSp) at baseline with and without vagal stimulation before and after ablation. The histological study was also performed. Results (1) SCL during vagal stimulation remained unchanged before and after ablation(107±19)bpm vs (108±8) bpm (P > 0.05). (2) After ablation, ERP during vagal stimulation remained unchanged at HRA (55±34) ms vs (69 ±37) ms (P >0.05),and decreased slightly at CSd (42±32) ms vs (55±30) ms (P =0.08). However,at LRA and CSp,ERP was significantly decreased after ablation (19±21) ms vs (66±24) ms (P <0.001) ; and (7± 18) ms vs (46±24) ms (P < 0.001), respectively. (3) AF was difficult to be induced at baseline before and after ablation in all sites (VW close to 0). While during vagal stimulation, after ablation VW of AF significantly decreased at LRA (1±3) ms vs (49±36) ms (P < 0.005) and CSp (10±12) ms vs (45±34) ms (P < 0.05) ,decreased slightly at CSd after ablation (35±37) ms vs (57±28) ms (P =0.07) ,and remained un-changed at HRA (63±31) ms vs (63±25) ms (P > 0.05). (4) The altered architecture of individual gan-glia was histologically observed. Conclusions The decreased ERP shortening to vagal stimulation in CS and LRA induced by slow pathway ablation indicates that ablation in such area may result in the vagal dennervation in LRA and CS,thereby attenuating the susceptibility to vagal mediated AF. While unchanged SCL,ERP short-ening and VW to vagal stimulation in sinus node area and HRA indicate that slow pathway ablation did not change the vagal innervation to these sites.     

肺静脉电隔离对犬急性心房电重构影响的实验研究

目的肺静脉电隔离（PVI）是治疗心房颤动（房颤）的重要手段，心房电重构是房颤发生和维持的重要因素。本研究旨在研究PVI对急性心房电重构的影响并揭示其可能机制。方法选取成年杂种犬18只，随机分为对照组和PVI组。应用硫代巴比妥钠麻醉后分离并结扎双侧颈交感迷走神经干。两组犬均行房间隔穿刺并以600次／min起搏右心房30min构建急性心房电重构模型，PVI组穿间隔后即行环肺静脉口部电隔离。快速心房电刺激前后于右心耳（RAA）及左心耳（LAA）处测量基础状态下（非迷走神经刺激）及颈部迷走神经干刺激时的心房有效不应期（ERP）和房颤易感窗口（VW）。结果（1）对照组快速心房电刺激后基础状态下（RAA处P〈0．01，LAA处P〈0．001）和迷走神经刺激时（RAA处P〈0．05，LAA处P〈0．05）测得的ERP均明显缩短。快速心房电刺激前后基础状态下均不能诱发房颤；快速心房电刺激后，RAA（P〈0．01）和LAA处（P〈0．05）的VW在迷走神经刺激时明显增宽。（2）PVI组快速心房电刺激后基础状态下（RAA处P=0．451，LAA处P=0．197）和迷走神经刺激时（RAA处P=0．104，LAA处P=0．231）测得的ERP较快速心房电刺激前无明显变化。快速心房电刺激前后基础及迷走神经刺激下均不能诱发房颤。（3）对照组快速心房电刺激后ERP缩短值较PVI组明显增加（基础状态时LAA处P〈0．05，RAA处P〈0．05；迷走神经刺激时LAA处P〈0．01，RAA处P〈0．05）。结论心房电重构伴随着迷走神经对心房电生理特性调节活动增强，肺静脉电隔离能减轻心房电重构，其机制可能为心房去迷走神经效应。     

冷冻消融隔离肺静脉治疗阵发性心房颤动的远期随访结果

导管消融已成为心房颤动(房颤)的重要治疗手段.对于阵发性房颤患者,肺静脉隔离仍是最主要的消融策略.但要达到充分的电隔离,往往需要较多的消融能量,造成肺静脉狭窄等并发症的风险增加.应用冷冻消融导管等新器材有望增加成功率,并降低并发症的发生率.本文报道我中心采用环形冷冻消融导管隔离肺静脉治疗阵发性房颤的远期随访结果.     

房室结慢径区域消融对迷走神经功能及心房颤动易感性的影响

Objective Atrioventricular node reentrant tachycardia (AVNRT) ablation may effect the vagal response,which is indicated by sinus tachycardia. On the other hand,atrial fibrillation (AF) ,which was found to be associated with vagal irmervation, often coexists with AVNRT. However,little is known about the im-pact of slow pathway ablation on local vagal innervation to atria. Methods In 11 dogs, bilateral cervical sympa-thovagal trunks were decentralized and metoprolol was given to block sympathetic effects. Linear lesion was per-formed from coronary sinus (CS) ostium to the middle area of Koch triangle. Atrial effective refractory period(ERP) ,vulnerability window (VW) of AF, and sinus rhythm cycle length (SCL) were measured at high fight atrium (HRA),low right atrium (LRA), distal (CSd) and proximal CS (CSp) at baseline with and without vagal stimulation before and after ablation. The histological study was also performed. Results (1) SCL during vagal stimulation remained unchanged before and after ablation(107±19)bpm vs (108±8) bpm (P > 0.05). (2) After ablation, ERP during vagal stimulation remained unchanged at HRA (55±34) ms vs (69 ±37) ms (P >0.05),and decreased slightly at CSd (42±32) ms vs (55±30) ms (P =0.08). However,at LRA and CSp,ERP was significantly decreased after ablation (19±21) ms vs (66±24) ms (P <0.001) ; and (7± 18) ms vs (46±24) ms (P < 0.001), respectively. (3) AF was difficult to be induced at baseline before and after ablation in all sites (VW close to 0). While during vagal stimulation, after ablation VW of AF significantly decreased at LRA (1±3) ms vs (49±36) ms (P < 0.005) and CSp (10±12) ms vs (45±34) ms (P < 0.05) ,decreased slightly at CSd after ablation (35±37) ms vs (57±28) ms (P =0.07) ,and remained un-changed at HRA (63±31) ms vs (63±25) ms (P > 0.05). (4) The altered architecture of individual gan-glia was histologically observed. Conclusions The decreased ERP shortening to vagal stimulation in CS and LRA induced by slow pathway ablation indicates that ablation in such area may result in the vagal dennervation in LRA and CS,thereby attenuating the susceptibility to vagal mediated AF. While unchanged SCL,ERP short-ening and VW to vagal stimulation in sinus node area and HRA indicate that slow pathway ablation did not change the vagal innervation to these sites.     

非肺静脉起源阵发性心房颤动导管消融效果的中长期随访

目的 肺静脉隔离足治疗阵发性心房颤动(房颤)的主要策略.但是部分阵发性房颤患者的房颤为非肺静脉起源.本文对非肺静脉起源阵发性房颤消融效果进行中长期随访研究.方法 入选256例阵发性房颤患者,其中女性62例,平均年龄(53±2)岁,行电生理检查,共发现27例(占10.5%)为非肺静脉起源(非肺静脉起源组),包括起源于上腔静脉(16例,占59.3%),左心房后壁(4例,占14.8%),界嵴(2例,占7.4%),冠状静脉窦(2例,占7.4%),卵圆窝(1例,占3.7%),左心耳(1例,占3.7%),左心房游离壁(1例,占3.7%).其余患者为肺静脉起源组.非肺静脉起源组中,所有病例的触发灶均在初次消融术中成功消融.4例(14.8%)需行2次消融术,其中3例为上腔静脉起源,1例为左心房后壁起源.肺静脉起源组52例(22.7%)需行2次消融术,6例需3次消融术.结果 非肺静脉起源组随访(40±12)个月,有25例(92.6%)无房颤复发,肺静脉起源组随访(44±12)个月,185例(80.8%)无房颤复发.结论 在房颤某些亚群的治疗中,标测并消融非肺静脉起源的触发灶非常重要.而且对于该类病人,中长期的随访证实中长期成功率较高,提示导管消融治疗房颤有较好的中长期治疗效果.     

重复消融对阵发性心房颤动复发患者远期获益的评估

目的:评估重复消融对阵发性心房颤动复发患者的远期获益.方法:入选2000-01-2004-12期间经导管消融(肺静脉电隔离)的阵发性心房颤动患者106例.所有患者心房颤动的症状明显,超过2种抗心律失常药物治疗无效.结果:106例中,失访9例(8.5％),非心源性死亡3例,2次消融时出现一过性脑梗死未完成完整术式1例,其余93例均纳入随访,平均随访5年.1次消融远期维持窦性心律39例,成功率为41.9％.复发者54例中39例(72.2％)进行2次消融,其中27例(69.2％)远期维持窦性心律,消融远期成功率提高了29.0％;复发者12例中5例(41.7％)进行3次消融,其中2例(40.0％)远期维持窦性心律,使远期成功率再提高2.2％;复发者3例中2例(66.7％)再行4次消融,术后均再次复发心房颤动.重复消融累计远期成功率较1次消融明显提高(73.1％:41.9％,P＜0.01).包括重复消融在内,12个月内的总成功率为81.7％,平均远期复发时间是术后(28.4±8.3)个月.1次消融因电隔离肺静脉电传导恢复导致心房颤动远期复发(6例),经重复消融均可实现远期维持窦性心律.结论:远期复发心房颤动的主要机制是电隔离肺静脉的电传导恢复,重复消融有望实现和维持远期窦性心律.