肥厚型心肌病合并心房颤动患者射频消融术后心律失常复发心电指标的预测

目的:探讨心电指标f QRS与QTc联合是否能更好预测肥厚型心肌病(HCM)合并心房颤动患者导管消融术后的复发。方法:纳入在北京安贞医院行导管消融术的HCM合并心房颤动患者共120例(阵发/持续性心房颤动72/48)。消融策略包括:阵发性心房颤动患者行双侧肺静脉隔离(PVI);持续性心房颤动患者行PVI加左心房顶、二尖瓣峡部和三尖瓣峡部线性消融。术前评估基线心电图,f QRS定义为常规12导联心电图中至少两个连续导联的QRS波存在≥2个R波或者R波的波顶或S波的波谷出现顿挫波。采用Bazett公式校正QT间期。术后定期随访,复发定义为导管消融术后心电图或动态心电图记录的任何类型的>30 s的房性快速性心律失常。结果:59.2%(71/120)患者f QRR阳性。f QRS最常见于下壁导联(81.7%)。QTc间期(443.90±38.59)ms。平均随访13.4个月,窦性心律维持率为42.5%。多因素Cox回归分析表明,f QRS阳性(HR=1.922,95%CI:1.151~3.210,P=0.012)和QTc>448 ms(HR=1.982,95%CI 1.155~3.402,P=0.013)分别是术后复发的危险因素。f QRS和QTc联合能更好预测心房颤动术后复发。结论:f QRS和QTc延长是HCM合并心房颤动患者导管消融术后复发的独立预测因素。f QRS和QTc联合可用于预测该类患者心房颤动射频术后转归。     

阵发性心房颤动合并左心房扩大患者单纯环肺静脉隔离和加行线性消融的长期疗效对比

目的 比较环肺静脉隔离（CPVI）和CPVI＋线性消融治疗阵发性心房颤动合并左心房扩大患者的长期疗效.方法 入选左心房内径≥40 mm的阵发性心房颤动患者188例,根据术中结果分为CPVI组（132例,CPVI后恢复窦性心律且结束手术时未诱发心房颤动心律失常者）和CPVI＋线性消融组（56例,CPVI后心房颤动未终止或诱发房性心律失常的患者继续行二尖瓣环峡部线、左心房顶部线和下腔静脉-三尖瓣环峡部线消融）.随访至术后3年.比较2组患者左心房内径、左心室射血分数（LVEF）、单次消融术中结果及并发症.结果 CPVI＋线性消融组左心房内径大于CPVI组,差异有统计学意义[（45 ±5） mm比（43 ±3） mm,P=0.011],LVEF小于CPVI组,差异有统计学意义[（61±8）％比（64±9）％,P =0.045].CPVI＋线性消融组手术时间和X线透视时间明显长于CPVI组[分别为（205 ± 67） min比（142 ±45） min;（40±16） min比（28 ±21）min,均P＜0.01].术后1年,CPVI＋线性消融组单次消融成功率低于CPVI组[66.1％ （37/56）比79.5％ （105/132）,P=0.047],但术后3年2组单次消融成功率差异无统计学意义[（57.7％ （32/56）比59.2％ （78/132）,P=0.857].术后3年成功率差异无统计学意义[60.9％ （28/46）比59.2％ （78/132）,P=0.755].结论 阵发性心房颤动合并左心房扩大患者在CPVI基础上加行线性消融近期成功率低于单纯CPVI,但远期成功率相当.     

QT延长与高血压合并心房颤动导管射频消融术后复发的相关性分析

目的 探讨高血压合并阵发性心房颤动患者的QTc是否与心房颤动导管射频消融术后复发相关.方法 回顾性分析201 1年1月至2012年12月在北京安贞医院第1次行导管射频消融术的高血压合并阵发性心房颤动心功能正常患者242例,将纳入患者按疾病复发情况分为复发组（98例）和未复发组（144例）,收集术前心电图和其他临床资料,术后定期随访.结果 随访（17±9）个月,98例患者（40.0％）心房颤动导管消融术后复发.与未复发组相比,复发组QTc明显延长[（429±26） ms比（419 ±23） ms]（P=0.004）.复发组的左心房前后径较未复发组明显增大[（41±6）mm比（38±5）mm]（P=0.003）.QTc与心率存在明显的相关性（r=0.162,P=0.011）.长QTc组（n=53）的导管消融术后心房颤动复发率明显较正常QTc组（n=165）和短QTC组（n=24）高（P =0.001、P=0.069）;左心房直径＜38.3 mm组与左心房直径≥38.3 mm组消融术后心房颤动复发率比较,左心房增大与导管消融术后复发相关（P=0.017）.多因素Cox回归分析表明QTc和左心房前后径是心房颤动复发的独立危险因素（QTc：风险比=2.361,95％置信区间：1.353 ～4.121,P=0.003;左心房前后径：风险比=1.795,95％置信区间：1.041 ～3.094,P=0.035）.长QT患者心房颤动复发的风险比为2.361（95％置信区间：1.353 ～4.121,P=0.003）.与左心房前后径单独预测术后复发相比,左心房前后径和QTc联合能更好地预测心房颤动导管消融术后复发.结论 QT延长是高血压合并心房颤动导管消融复发的独立危险因素.     

单纯环肺静脉前庭隔离术治疗持续性心房颤动:单中心三年随访结果

Objective To report the long-term outcome of catheter radiofrequency ablation treatment for patients with persistent atrial fibrillation (PerAF) and discuss the impact of PerAF duration and the termi-nation on the therapeutic outcome. Methods Eight-six consecutive PerAF patients underwent circumferential pulmonary vein antrum isolation (CPVAI) only were included in this study. Based on PerAF duration, patients were divided into two groups: short term (≤1 year, n =47) and long term (> 1 year, n =39). Results The mean follow-up period was 25-50 (36 ± 8) months. During the follow-up period, the success rate after single procedure was 30. 2% (26/86). Late recurrence phenomenon, defined as atrial tachyarrhythmias relapsed 1 year later, was observed in 9 patients (10.5%). The long-term success rate in the short term group was signifi-cantly higher than that in long term group (42.5% vs 15.4% ,P <0.01). During the first procedure, atrial fi-brillation converted into sinus rhythm or atrial tachycardia occurred in 29 patients (33.7%). Compared with the another 57 patients, the long-term outcome of these patients was much better (48.3% vs 21.1% ,P < 0.01). Redo procedures were pedormed in 24 patients (27.9%), which increased the total success rate at 3 years follow-up to 41.9% (36/86). Conclusion The long-term outcome treated with CPVAI in patients with PerAF is still unsatisfactory. In addition, the late recurrence is common. Shorter term of PerAF and terminated by ablation indicate that those patients might get more benefit from the CPVA1 treatment.     

单纯环肺静脉前庭隔离术治疗持续性心房颤动:单中心三年随访结果

Objective To report the long-term outcome of catheter radiofrequency ablation treatment for patients with persistent atrial fibrillation (PerAF) and discuss the impact of PerAF duration and the termi-nation on the therapeutic outcome. Methods Eight-six consecutive PerAF patients underwent circumferential pulmonary vein antrum isolation (CPVAI) only were included in this study. Based on PerAF duration, patients were divided into two groups: short term (≤1 year, n =47) and long term (> 1 year, n =39). Results The mean follow-up period was 25-50 (36 ± 8) months. During the follow-up period, the success rate after single procedure was 30. 2% (26/86). Late recurrence phenomenon, defined as atrial tachyarrhythmias relapsed 1 year later, was observed in 9 patients (10.5%). The long-term success rate in the short term group was signifi-cantly higher than that in long term group (42.5% vs 15.4% ,P <0.01). During the first procedure, atrial fi-brillation converted into sinus rhythm or atrial tachycardia occurred in 29 patients (33.7%). Compared with the another 57 patients, the long-term outcome of these patients was much better (48.3% vs 21.1% ,P < 0.01). Redo procedures were pedormed in 24 patients (27.9%), which increased the total success rate at 3 years follow-up to 41.9% (36/86). Conclusion The long-term outcome treated with CPVAI in patients with PerAF is still unsatisfactory. In addition, the late recurrence is common. Shorter term of PerAF and terminated by ablation indicate that those patients might get more benefit from the CPVA1 treatment.     

影像融合系统指导下导管消融伴双下肺静脉共同开口的心房颤动特点

目的探讨影像融合系统指导下导管消融伴双下肺静脉共同开口的心房颤动（房颤）的解剖学、电生理学和治疗学特点。方法1381例药物治疗无效的房颤患者在消融前接受磁共振血管造影或多排CT扫描,影像融合技术（CartoMerge^TM software）重建左心房和肺静脉。阵发性房颤者进行了触发灶的电生理标测。基本消融策略是在影像融合系统指导下“三环法”肺静脉隔离：两个环分别围绕两个上肺静脉,另一个环围绕双下肺静脉共同开口。结果影像融合系统成功重建1381例左心房和肺静脉并发现有12例（0．8％）为左、右下肺静脉共同开口,这种变异可分为两种形态：没有短共干的Ⅰ型双下肺静脉共同开口和有短共干的Ⅱ型双下肺静脉共同开口。多数阵发性房颤在共同开口内有触发灶。“三环法”肺静脉隔离术成功率83％。结论双下肺静脉共同开口可按有无短共干分为两型。共同开口内可能是阵发性房颤的重要病灶。在影像融合技术指导下进行“三环法”肺静脉隔离的消融策略可能是伴该种肺静脉变异的房颤患者较好的治疗方法。     

扩张型心肌病合并左心室血栓的研究进展

<正>左心室血栓形成是扩张型心肌病的严重并发症之一，栓子脱落可引发卒中或体循环栓塞而产生不良后果。左心室血栓的诊断、危险因素识别、预防和治疗在临床诊疗中尤为重要。本文对扩张型心肌病合并左心室血栓形成的研究现状和最新进展做一综述。扩张型心肌病是一类表现为心腔扩大、心脏收缩力下降、心力衰竭、心律失常和血栓栓塞的异质性心肌病。左心室血栓形成是扩张型心肌病的常见严重并发症，血栓脱落可导致脑、肾和肢体动脉栓塞，增加致残和死亡风险。现对扩张型心肌病合并左心室血栓形成的发生机制、危险因素、预防和治疗进展做一综述。     

QTc延长预测肥厚型心肌病合并心房颤动患者导管消融术后的复发

目的:探讨肥厚型心肌病(hypertrophic cardiomyopathy,HCM)合并心房颤动患者的QTc是否与心房颤动导管射频消融术后复发相关。方法:回顾性分析2006年11月至2013年6月,在北京安贞医院第一次行导管射频消融术的HCM合并心房颤动患者共39例,收集术前心电图和其他临床资料,术后定期随访。结果:随访(14.8±11.7)个月,23例患者心房颤动消融术后复发(复发率59%)。与未复发组相比,复发组QTc显著性延长[(461±29)vs.(434±18)ms,P=0.001)]。多因素Logistic回归分析显示QTc和左心房前后径(LAD)是心房颤动复发的独立危险因素。其中,当QTc截断值为448ms时,其预测心房颤动复发的敏感性为0.81,特异性为0.78。多因素Cox回归分析表明QTc每增加10ms,心房颤动复发的风险比为1.227(95%CI:1.053~1.431,P=0.009)。与LAD单独预测术后复发相比,LAD和QTc联合能更好地预测心房颤动消融术后复发。短QTc和左心房偏小的患者无心房颤动复发。结论:QTc延长能预测HCM合并心房颤动患者导管消融术后复发。短QTc和左心房偏小的患者导管消融术后复发率低。     

心房颤动导管消融术后早期复发的直流电复律临床分析

目的对心房颤动(简称房颤)导管消融术后1个月内复发行直流电复律的患者的临床特征进行前瞻性研究。方法丙泊酚镇静、禁食状态下,单向波同步电复律,电极板置于心尖-胸骨旁右侧,能量依次采用300,360,360J。结果共入选23例患者,年龄58±13岁,房颤病史6.8±5.0年,左房直径41.9±9.8mm,左室射血分数0.58±0.11。复发心律失常中12例为心房扑动,10例为房颤,1例为房性心动过速。共进行27次电复律,19次(70.4%)即刻复律成功,其中15次1次放电复律成功。1例复律后出现窦性心动过缓伴交界心律,1例丙泊酚镇静时出现呼吸暂停。随访8.5±3.7个月,52.2%的患者为窦性心律。即刻复律成功组其远期成功率为64.7%,即刻复律失败的远期均不成功,两组间有显著性差异(P=0.014)。1次放电即可成功者远期成功率为69.2%,需要多次放电的患者远期成功率为20.0%,两组间有显著性差异(P=0.036)。结论直流电复律可安全有效地用于房颤导管消融术后早期复发的患者,即刻电复律成功是远期成功的预测因素,复律时需要多次放电的远期成功率低。     

单纯环肺静脉前庭隔离术治疗持续性心房颤动:单中心三年随访结果

Objective To report the long-term outcome of catheter radiofrequency ablation treatment for patients with persistent atrial fibrillation (PerAF) and discuss the impact of PerAF duration and the termi-nation on the therapeutic outcome. Methods Eight-six consecutive PerAF patients underwent circumferential pulmonary vein antrum isolation (CPVAI) only were included in this study. Based on PerAF duration, patients were divided into two groups: short term (≤1 year, n =47) and long term (> 1 year, n =39). Results The mean follow-up period was 25-50 (36 ± 8) months. During the follow-up period, the success rate after single procedure was 30. 2% (26/86). Late recurrence phenomenon, defined as atrial tachyarrhythmias relapsed 1 year later, was observed in 9 patients (10.5%). The long-term success rate in the short term group was signifi-cantly higher than that in long term group (42.5% vs 15.4% ,P <0.01). During the first procedure, atrial fi-brillation converted into sinus rhythm or atrial tachycardia occurred in 29 patients (33.7%). Compared with the another 57 patients, the long-term outcome of these patients was much better (48.3% vs 21.1% ,P < 0.01). Redo procedures were pedormed in 24 patients (27.9%), which increased the total success rate at 3 years follow-up to 41.9% (36/86). Conclusion The long-term outcome treated with CPVAI in patients with PerAF is still unsatisfactory. In addition, the late recurrence is common. Shorter term of PerAF and terminated by ablation indicate that those patients might get more benefit from the CPVA1 treatment.