治疗顽固性高血压的一道曙光——经导管肾动脉去神经射频消融术现状与展望

顽固性高血压指尽管同时应用3种不同种类的降血压药物,血压仍然高于目标值.其中降压药物应当包括利尿剂,且所有的药物应达到理想剂量.目前顽固性高血压发病率还不清楚,但是从一些临床研究的结果来推测,其发病率可能并非少见.2003年发表的NHANES研究中,仅有53％的受试对象的血压控制在140/90 mm Hg(1 mm Hg=0.133 kPa)以下.在2002年发表的ALLHAT研究中,大约50％的受试者需要使用3种或3种以上的降压药物.顽固性高血压患者发生主要心血管事件的概率可能较高,积极控制其血压达标极其关键.早期的退伍军人管理局协作研究表明,相比安慰剂,3种降压药联合应用18个月以上,其心血管事件降低96％.但是部分患者虽经多种降血压药物联合应用仍不能达标,而且服用多种药物患者的依从性也可能受到影响,从而影响其疗效,另外长期多种药物联合应用的费用较高,特别对于部分发展中国家,给患者造成了沉重的社会负担.     

冠状窦呈偏心性激动的不典型房室结折返性心动过速的电生理特征及导管消融

目的 总结冠状窦（coronary sinus, CS）呈偏心性激动的不典型房室结折返性心动过速（atrioventricular nodal reentry tachycardia, AVNRT）的电生理特点、鉴别诊断及消融方法。方法 回顾性收集2014年1月至2018年12月在复旦大学附属中山医院心内科进行射频消融治疗的524例AVNRT患者的临床资料。其中,CS呈偏心性激动的不典型AVNRT患者共16例,男性6例、女性10例,平均年龄（56.6±11.4）岁。分析16例不典型AVNRT患者的体表心电图和腔内心电图特点、诱发方式、鉴别诊断及射频消融策略。结果 16例CS呈偏心性激动的AVNRT患者的心电图均表现为RP间期>PR间期,P波在Ⅱ、Ⅲ、aVF导联中倒置;发作时12例患者房室传导比例为1∶1,4例患者为2∶1或3∶1;13例患者可以轻易通过心室拖带的方式进行鉴别,2例患者需要多次拖带才能成功,1例患者多次拖带下心房-心室（atrioventricular,VA）仍然分离;14例患者在右心房后间隔靠近三尖瓣环处成功消融,3例患者在CS内成功消融。结论 CS呈偏心性激动的...     

心房颤动射频消融术后心包积液的处理及危险因素分析

目的 探讨心房颤动(房颤)患者导管射频消融术后发生心包积液的处理并分析其相关危险因素.方法 156例房颤患者[男108例,女48例,阵发性房颤114例,平均年龄(57.6±11.3)岁]在三维标测系统及环状标测电极导管指导下行射频消融治疗[包括环肺静脉电隔离、线性消融及(或)碎裂电位消融],记录消融过程、部位、时间等因素,对术后证实出现心包积液的患者根据不同情况(心脏压塞或单纯心包积液)进行不同处理,并门诊随访心脏超声等.对可能影响术后出现单纯心包积液的因素进行分析.结果 所有156例患者均完成肺静脉电隔离,共有16例(10.3%)出现心包积液,其中1例(0.6%)术后即刻出现心脏压塞,予心包穿刺后开胸探查抢救好转,随访18个月无特殊;另15例(9.6%)术后出现少量心包积液但无心脏压塞表现(单纯心包积液组),经保守治疗后好转,其中6例患者的心包积液在术后3个月消失,而另外9例则在术后6个月消失.单因素分析发现,单纯心包积液组与无心包积液组在性别组成(P<0.01)、有无行冠状静脉窦消融(P=0.026)、有无行碎裂电位消融(P=0.037)、有无行上腔静脉消融(P=0.041)等方面差异有统计学意义.Logistic多因素回归分析发现,女性[B=3.594,exp(b)=36.4,95%CI:4.2-312.1,P=0.001]、行冠状静脉窦消融[B=2.419,exp(b)=11.2,95%CI:1.0～124.6,P=0.049]是术后出现单纯心包积液的独立危险因素.结论 房颤射频消融术后心包积液的发生率较高,但绝大部分并不出现心脏压塞,可经保守治疗得到改善,而不需要进一步有创治疗.女性及行冠状静脉窦消融是术后出现单纯心包积液的独立危险因素,房颤射频消融时应谨慎对待该部位的消融,以减少术后心包积液的发生.     

持续性心房颤动射频消融术中不同抗凝方案与围术期血栓事件的关系

Objective The relationships between different anticoagulation methods during radiofre-quency catheter ablation(RFCA) of persistent/permanent atrial fibrillation (AF)and thromboembolic events in our center were evaluated. Methods From July 2004 to October 2007, RFCA was consecutively performed in 145 persistent/permanent AF patients. Anticoagulation with warfarin was administrated in all patients before op-eration for at least 1 month, with the international normalized ratio(INR) maintained between 2.0 and 3.0. Be-fore procedure,warfarin was discontinued and replaced by low molecular weight heparin(LMWH). After atrial septum puncture,a total of 5000 U tmfractioned heparin(UFH) were given to patients of group Ⅰ who under-went the ablation from July 2004 to January 2006,while patients of group Ⅱ who underwent the ablation from February 2006 to October 2007 were heparinized(100 U/Kg) according to their weights. During operation, 1000 U UFH was appended per hour. After procedure, LMWH was used for 3 days while warfarin was initiated at the same time and continued for at least 3 months. Results Four patients in group Ⅰ (64 patients ,51 men)experi-enced thrombosis or embolism during or after ablation. One female persistent AF patient in the group Ⅱ (81 pa-tients,67 men)who didn' t fulfill the anticoagulatian therapy experienced TIA after ablation. No thrombeembolic event was identified in other patients of group Ⅱ who fulfilled the anticoagulation therapy. The incidence of thromboembolic event of persistent/permanent AF patients who fulfilled the anticoagulation therapy in the group Ⅱwas lower than that of group Ⅰ (4/64 vs. 0/80, P = 0.037). Conclusions Strengthen the anticoagulation therapy according to patients' weights during radiofrequency ablation could significantly decrease the incidence of thromboembolic event in patients with persistent/permanent AF.     

持续性心房颤动射频消融术中不同抗凝方案与围术期血栓事件的关系

Objective The relationships between different anticoagulation methods during radiofre-quency catheter ablation(RFCA) of persistent/permanent atrial fibrillation (AF)and thromboembolic events in our center were evaluated. Methods From July 2004 to October 2007, RFCA was consecutively performed in 145 persistent/permanent AF patients. Anticoagulation with warfarin was administrated in all patients before op-eration for at least 1 month, with the international normalized ratio(INR) maintained between 2.0 and 3.0. Be-fore procedure,warfarin was discontinued and replaced by low molecular weight heparin(LMWH). After atrial septum puncture,a total of 5000 U tmfractioned heparin(UFH) were given to patients of group Ⅰ who under-went the ablation from July 2004 to January 2006,while patients of group Ⅱ who underwent the ablation from February 2006 to October 2007 were heparinized(100 U/Kg) according to their weights. During operation, 1000 U UFH was appended per hour. After procedure, LMWH was used for 3 days while warfarin was initiated at the same time and continued for at least 3 months. Results Four patients in group Ⅰ (64 patients ,51 men)experi-enced thrombosis or embolism during or after ablation. One female persistent AF patient in the group Ⅱ (81 pa-tients,67 men)who didn' t fulfill the anticoagulatian therapy experienced TIA after ablation. No thrombeembolic event was identified in other patients of group Ⅱ who fulfilled the anticoagulation therapy. The incidence of thromboembolic event of persistent/permanent AF patients who fulfilled the anticoagulation therapy in the group Ⅱwas lower than that of group Ⅰ (4/64 vs. 0/80, P = 0.037). Conclusions Strengthen the anticoagulation therapy according to patients' weights during radiofrequency ablation could significantly decrease the incidence of thromboembolic event in patients with persistent/permanent AF.     

误穿锁骨下动脉致纵膈血肿二例

2例误穿锁骨下动脉后及时退针并进行压迫止血,未进入导丝或扩张动脉,但仍导致纵膈血肿,分析其原因并根据患者具体情况进行不同处理。仅误穿锁骨下动脉致纵膈血肿的发生率较低,但需谨慎对待,并应综合考虑给予正确处理,以减少风险,同时不延误治疗。     

持续性心房颤动射频消融术中不同抗凝方案与围术期血栓事件的关系

Objective The relationships between different anticoagulation methods during radiofre-quency catheter ablation(RFCA) of persistent/permanent atrial fibrillation (AF)and thromboembolic events in our center were evaluated. Methods From July 2004 to October 2007, RFCA was consecutively performed in 145 persistent/permanent AF patients. Anticoagulation with warfarin was administrated in all patients before op-eration for at least 1 month, with the international normalized ratio(INR) maintained between 2.0 and 3.0. Be-fore procedure,warfarin was discontinued and replaced by low molecular weight heparin(LMWH). After atrial septum puncture,a total of 5000 U tmfractioned heparin(UFH) were given to patients of group Ⅰ who under-went the ablation from July 2004 to January 2006,while patients of group Ⅱ who underwent the ablation from February 2006 to October 2007 were heparinized(100 U/Kg) according to their weights. During operation, 1000 U UFH was appended per hour. After procedure, LMWH was used for 3 days while warfarin was initiated at the same time and continued for at least 3 months. Results Four patients in group Ⅰ (64 patients ,51 men)experi-enced thrombosis or embolism during or after ablation. One female persistent AF patient in the group Ⅱ (81 pa-tients,67 men)who didn' t fulfill the anticoagulatian therapy experienced TIA after ablation. No thrombeembolic event was identified in other patients of group Ⅱ who fulfilled the anticoagulation therapy. The incidence of thromboembolic event of persistent/permanent AF patients who fulfilled the anticoagulation therapy in the group Ⅱwas lower than that of group Ⅰ (4/64 vs. 0/80, P = 0.037). Conclusions Strengthen the anticoagulation therapy according to patients' weights during radiofrequency ablation could significantly decrease the incidence of thromboembolic event in patients with persistent/permanent AF.     

持续性心房颤动射频消融术中不同抗凝方案与围术期血栓事件的关系

Objective The relationships between different anticoagulation methods during radiofre-quency catheter ablation(RFCA) of persistent/permanent atrial fibrillation (AF)and thromboembolic events in our center were evaluated. Methods From July 2004 to October 2007, RFCA was consecutively performed in 145 persistent/permanent AF patients. Anticoagulation with warfarin was administrated in all patients before op-eration for at least 1 month, with the international normalized ratio(INR) maintained between 2.0 and 3.0. Be-fore procedure,warfarin was discontinued and replaced by low molecular weight heparin(LMWH). After atrial septum puncture,a total of 5000 U tmfractioned heparin(UFH) were given to patients of group Ⅰ who under-went the ablation from July 2004 to January 2006,while patients of group Ⅱ who underwent the ablation from February 2006 to October 2007 were heparinized(100 U/Kg) according to their weights. During operation, 1000 U UFH was appended per hour. After procedure, LMWH was used for 3 days while warfarin was initiated at the same time and continued for at least 3 months. Results Four patients in group Ⅰ (64 patients ,51 men)experi-enced thrombosis or embolism during or after ablation. One female persistent AF patient in the group Ⅱ (81 pa-tients,67 men)who didn' t fulfill the anticoagulatian therapy experienced TIA after ablation. No thrombeembolic event was identified in other patients of group Ⅱ who fulfilled the anticoagulation therapy. The incidence of thromboembolic event of persistent/permanent AF patients who fulfilled the anticoagulation therapy in the group Ⅱwas lower than that of group Ⅰ (4/64 vs. 0/80, P = 0.037). Conclusions Strengthen the anticoagulation therapy according to patients' weights during radiofrequency ablation could significantly decrease the incidence of thromboembolic event in patients with persistent/permanent AF.     

贝氏肌营养不良被误诊为急性心肌炎1例报告

1病史简介患者,男性,36岁,因胸闷气急1个月余加重1周入院,在外院诊断为"急性重症心肌炎"。患者自6岁起出现下肢乏力,易跌倒,症状逐渐加重,23岁时注意到上肢肌群及大腿肌群肌肉逐渐萎缩,而小腿肌群肌肉却增大,至32岁时患者完全不能行走并且下肢肌群肌肉也逐渐萎缩,依赖轮椅由别人推行,34岁时不能自行翻身,1个月前,出现胸闷气急,     

心房颤动射频消融术中出现规律性快速性房性心律失常的预测因素

目的：分析心房颤动（简称房颤）经导管射频消融术中出现心房扑动、房性心动过速等规律性快速性房性心律失常（RATs）的预测因素。方法：首次行经导管射频消融治疗的497例房颤患者（阵发性房颤333例,持续性和（或）永久性房颤164例）在三维标测系统及环状标测电极导管指导下行经导管射频消融治疗（包括环肺静脉电隔离、线性消融和（或）碎裂电位消融）。术中记录RATs的发生情况,并分析RATs的可能影响因素。结果：术中共有163例患者[32．8％;阵发性房颤92例,持续性和（或）永久性房颤71例]出现195种RATs,持续性和（或）永久性房颤术中RATs的发生率显著高于阵发性房颤（43．3％比27．6％,P〈0．001）。单因素分析发现心脏外科术后（P〈0．001）、术前有RATs（P=0．010）、持续性和（或）永久性房颤（P〈0．001）、左房内径增大（P〈0．001）、左室射血分数降低（P=0．018）是房颤术中出现RATs的影响因素。Logistic多因素回归分析发现心脏外科术后[优势比（0R）=8．14,95％可信区间（CI）：I．69～39．1,P=0．0093、术前有RATsEOR=2．15,95％CI：1．35～3．42,P=0．001]、持续性和（或）永久性房颤[0R=1．71,95％CI：1．06～2．76,P=0．029]、左房内径[0R=1．04,95％CI：1．01～1．08,P=0．025]是术中出现RATs的独立预测因素。结论：房颤射频消融术中常出现RATs,心脏外科术后、术前有RATs、持续性和（或）永久性房颤、左房内径是术中出现RATs的独立预测因素。