瓣膜置换加双极射频消融术后心房颤动复发患者电复律的护理

目的总结经胸体外直流电复律治疗心脏瓣膜置换加双极射频消融术后复发心房颤动患者的临床护理经验。方法回顾性分析2009年7月-2011年1月行心脏瓣膜置换加双极射频消融术,出院后复发心房颤动的26例患者其体外直流电复律治疗的护理措施。结果通过严密监测和有效护理26例患者均安全出院,其中24例复律成功转为窦性心律,2例复律失败。结论做好电复律前的护理准备工作,严密观察电复律对心房颤动患者的治疗效果并实施有效的护理措施,既能促使电复律达到满意的效果又能保障患者安全。     

非瓣膜性心房颤动血栓栓塞危险性研究现状及进展

心房颤动是临床最常见的持续性心律失常,其中非瓣膜性心房颤动占心房颤动的绝大多数,血栓栓塞是心房颤动最常见的并发症。抗凝治疗可减少血栓栓塞并发症,但增加了出血的风险。因此,对血栓栓塞危险性进行评估,筛选出高危患者有选择地进行抗凝治疗尤为重要。本文从血液标志物、心电图f波、超声心动图、64排CT及临床因素等方面对非瓣膜性心房颤动患者血栓栓塞危险性研究现状及进展作一综述。     

经食管超声心动图对心房颤动患者右心耳自发显影回声和血栓发生的研究

目的探讨经食管超声心动图(TEE)观察慢性心房颤动(房颤)时右心房、右心耳自发显影(SEC)和血栓发生情况。方法选取26例房颤患者和13例窦性心律患者，常规经胸超声心动图资料留取后，采用TEE充分清楚显示左、右心耳图像并采集血流流速曲线和其他相应指标。结果26例房颤患者左心耳内均可测及SEC，共测及血栓形成者10例；房颤患者右心耳内有SEC者共17例，共测及右心耳血栓形成者1例。结论房颤时右心耳内可有血栓发生，TEE检查在房颤抗凝治疗中和复律前后具有重要意义。     

心房颤动复律后心房顿抑的护理

心房颤动(房颤)是引起栓塞最常见的心律失常,药物或电复律是治疗房颤的常用方法,但房颤成功复律后短期内血栓栓塞的危险性仍较高[1]。目前认为复律后心房功能恢复不全特别是心房顿抑的发生导致复律后血栓形成[2]。我科2005年8月~2006年8月共收治房颤复律患者53例,现将复律后心房顿抑期间的护理报告如下。1临床资料1.1一般资料本组患者53例,男42例,女11例,年龄42~78岁,平均年龄51.9±5.6岁。基础心脏疾病包括风湿性心脏病21例,高血压病5例,冠心病11例,肥厚性心肌病2例,特发性房颤3例,先天性心脏病2例。经临床检查无心脏基础病9例。1.2复律方…     

心房颤动择期电复律治疗效果观察

目的观察心房颤动择期电复律治疗的效果。方法 78例持续性心房颤动患者,电复律前先给予华法林治疗,使其国际标准化比值维持在2.0～2.5,并同时口服胺碘酮;3周后行300～360J同步直流电复律;复律成功后继续口服胺碘酮3个月,并口服华法林抗凝,4周后改用阿司匹林维持治疗1a以上。结果患者择期电复律即刻成功率100%,3例于24h内心房颤动复发;随访1a,4例分别于电复律治疗后第3,5,8,10个月复发,晚期有效率94.9%;无严重不良反应发生。结论心房颤动择期电复律是治疗心房颤动的有效措施。     

射频消融术后心房颤动再发病人电复律的护理

[目的]总结射频消融术后心房颤动再发病人电复律的护理。[方法]回顾性分析2012年6月—2014年12月因持续性心房颤动行射频消融术,术后3个月内因药物难以控制的心房颤动再发行同步电复律治疗的30例病人的护理措施。[结果]经电复律后28例成功转为窦性心律,2例复律失败,经胺碘酮静脉泵入48 h后转为窦性心律。电复律后均未出现不良反应及并发症,顺利出院。[结论]电复律前做好充分准备,把握适应证与禁忌证,复律过程中严密观察治疗效果并实施有效的护理措施,复律后防治并发症并做好出院指导,可促使电复律达到满意效果并保障病人安全。     

环肺静脉消融术治疗心房颤动并发症的观察及护理

心房颤动是临床最常见的心律失常。研究证明，在未来50年中心房颤动将成为最流行的心血管疾病之一。心房颤动可不同程度影响病人的生活质量，易导致心房血栓形成，血栓一旦脱落可以引起全身各器官栓塞，尤其是脑血管栓塞，心室反应快速的心房颤动会导致心动过速性心肌病。心房颤动的治疗有电复律治疗、药物复律治疗、介入治疗，前两种治疗效果不明显，且复律后维持时间短。目前，介入治疗最有效的方法是肺静脉电隔离术和环肺静脉消融术，而环肺静脉消融术的成功率较前者高。     

胺碘酮与普罗帕酮转复阵发性心房颤动的临床观察

心房颤动是常见的心律失常，虽然心房颤动多见于器质性心脏病，但也有部分心房颤动患者不能检出任何异常，阵发性心房房颤发作通常〈24h，可自行转复或经药物转复。有症状的患者需要尽早抗心律失常治疗，包括药物及电复律，绝大多数非紧急情况下，药物复律作为首选。现将静脉胺碘酮与普罗帕酮转复阵发性房颤的临床疗效及安全性进行随机对照研究。     

经食管超声追踪评价左房血栓及抗凝溶栓疗效

目的评价经食管超声心动图(TEE)诊断左房血栓,追踪抗凝溶栓治疗效果.方法采用经胸或经食管超声诊断了33例适宜于经皮二尖瓣球囊扩张术(PBMV),又合并有左房血栓的风湿性心脏病二尖瓣狭窄患者,并用TEE随访观察抗凝溶栓治疗经过,指导决定PBMV时间.结果33例血栓患者,左房耳血栓28例,左房血栓5例.最大血栓6.0cm×4.0cm,最小血栓0.8cm×0.6cm.所有患者均用华法令进行抗凝溶栓治疗,定期复查PI及INR调整用药.治疗两周后开始反复用TEE检查,观察到左房血栓均有不同程度减小直至消失.结论TEE不仅可定性诊断左房血栓,还可评价抗凝溶栓疗效.     

经胸体外直流电复律治疗药物转复不佳持续性房颤36例临床护理

目的：探讨经胸体外直流电复律治疗药物转复不佳持续性房颤患者的护理方法。方法：对36例药物转复不佳持续性房颤患者行经胸体外直流电复律治疗,并给予相应的护理措施。结果：本组36例患者电转复均获得成功,均转为窦性心律。结论：经胸体外直流电复律是目前药物转复心房颤动无效的首选方法,通过加强电复律前、电复律中、电复律后护理及病情观察,可使转律获得理想结果。     

Left atrial appendage-flow velocity predicts cardioversion success in atrial fibrillation

Restoration of sinus rhythm by electrical cardioversion is a therapeutic option in appropriately selected patients with atrial fibrillation. It is important to determine predictors of electrical cardioversion outcome in patients with atrial fibrillation. Predictive value of clinical and conventional echocardiographic parameters for predicting cardioversion outcome is limited. The role of left atrial appendage (LAA) function, which may reflect left atrial contractile function, for prediction of cardioversion outcome remains unclear. We conducted a single center prospective study to evaluate the role of LAA function for prediction of cardioversion success in patients with atrial fibrillation. One hundred sixty three patients with atrial fibrillation underwent transthoracic and transesophageal echocardiography (TEE) before electrical cardioversion. LAA functions, including LAA peak flow velocity, LAA area and LAA ejection fraction, were examined. Cardioversion was successful in 133 patients and unsuccessful in 30 patients. Mean LAA peak emptying flow velocity was significantly higher in the patients with successful cardioversion than in those with unsuccessful cardioversion (0.34 +/- 0.14 vs 0.27 +/- 0.1 m/sec; p = 0.013). At multivariate logistic regression analysis, only LAA flow velocity (> 0.28 m/sec, odds ratio = 2.8 ; p = 0.03) proved to be an independent predictor of cardioversion success. LAA area (p = 0.18) and LAA ejection fraction (p = 0.52) were not different between successful and unsuccessful cardioversion groups. Therefore, measurement of LAA flow velocity provides valuable information for prediction of cardioversion outcome in patients with atrial fibrillation before TEE guided cardioversion.     

Cardioversion in Patients with Atrial Fibrillation and Left Atrial Thrombi on Initial Transesophageal Echocardiography: Should Transesophageal Echocardiography Be Repeated Before Elective Cardioversion? A Cost-Effectiveness Analysis

BACKGROUND: Transesophageal echocardiography (TEE) is used to expedite early cardioversion for patients with atrial fibrillation in whom TEE excludes the presence of atrial thrombi. However, the management of patients with atrial thrombi on initial TEE is controversial. Some advocate cardioversion after 3 to 4 weeks of anticoagulant therapy, whereas others perform a follow-up TEE to document thrombus resolution. We performed a cost-effectiveness analysis to compare the two strategies. METHODS AND RESULTS: A computer-based decision analysis model was used to compared 2 strategies: No Follow-up TEE-patients with thrombi on initial TEE complete 4 weeks of anticoagulation and undergo elective cardioversion. Follow-up TEE-patients undergo a follow-up TEE after 4 weeks of anticoagulant therapy. If a thrombus is detected, cardioversion is not performed and patients remain in atrial fibrillation; patients without a thrombus undergo cardioversion. Under our baseline estimates, the Follow-up TEE strategy is less costly and slightly more effective than the No Follow-up TEE strategy. The results are most sensitive to changes in the risk of postcardioversion stroke for patients with atrial thrombi on initial TEE who have completed 4 weeks of anticoagulation and to the probability of residual thrombi on follow-up TEE. CONCLUSIONS: In this cost-effectiveness analysis for patients with atrial fibrillation and left atrial thrombi detected on initial TEE, a Follow-up TEE strategy may be more cost-effective than the No Follow-up TEE strategy. However, the decision is particularly dependent on the risk of postcardioversion stroke in patients with undetected residual left atrial thrombi.     

Exclusion of atrial thrombus by transesophageal echocardiography.

To determine whether transesophageal echocardiography (TEE) is useful in ruling out the presence of atrial thrombus, we performed TEE in 20 patients immediately before valve replacement or valve repair and within 3 days of an autopsy in one patient. Mitral stenosis was the predominant lesion in three patients, mitral regurgitation was seen in 11 patients, five patients had mitral prosthesis malfunction, one patient had a tricuspid prosthesis malfunction, and one patient had aortic stenosis. Eight patients were in atrial fibrillation. Four patients demonstrated spontaneous contrast in the associated atria. Nine patients were receiving oral anticoagulation. Mean left atrial diameter was 5.3 +/- 1.3 mm. TEE revealed no evidence for atrial thrombus in 18 of the 21 patients; this finding was confirmed by careful inspection of the atria including the appendages. TEE demonstrated a left atrial thrombus in two patients and a right atrial thrombus in another (confirmed at the time of surgery or at autopsy). In all cases transthoracic echocardiography was negative. Our data suggest that TEE is useful in ruling out atrial thrombus, and therefore may be a useful test preceding interventions associated with an increased risk of embolism from the atria such as cardioversion, mitral valvuloplasty, or valve replacement.     

Safety of electrical cardioversion in patients with previous embolic events

OBJECTIVE: To assess thromboembolic complications in cardioversions in patients with atrial fibrillation or flutter and a previous embolic event. PATIENTS AND METHODS: The study population consisted of 104 patients with previous embolic events who underwent 128 electrical cardioversions for termination of atrial fibrillation or flutter. The primary outcome measure was successful cardioversion. RESULTS: Anticoagulants were administered in 118 procedures (92%). Cardioversion was successful in 108 (84%) of the 128 procedures. Only 1 embolic event occurred within 30 days after cardioversion (incidence, 0.9% of successful procedures; 95 % confidence interval, 0.02%-5.3%). The single embolic event was a transient neurologic deficit occurring 22 days after cardioversion in a patient with previous atrial fibrillation. This patient had a sub-therapeutic level of anticoagulation. Transesophageal echocardiography revealed no spontaneous echo contrast or thrombi before the procedure. No thromboembolism was noted in patients who had therapeutic anticoagulation or in those with failed cardioversion. CONCLUSION: Patients with previous embolism are not at additional risk of thromboembolic complications after cardioversion if anticoagulation is adequate.     

The ACUTE trial. Transesophageal echocardiography to guide electrical cardioversion in atrial fibrillation. Assessment of Cardioversion Using Transesophageal Echocardiography

The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) trial compared cardioversion following transesophageal echocardiography (TEE) against conventional management of atrial fibrillation (ie, cardioversion following 3 weeks of anticoagulation) in patients scheduled to undergo electrical cardioversion.     

Atrial fibrillation: current therapeutic approaches.

Atrial fibrillation is associated with potentially life-threatening strokes. Anticoagulation with warfarin or aspirin reduces the risk of embolic events in patients with chronic atrial fibrillation and mitral valve stenosis or other underlying heart disease. In patients with acute onset of atrial fibrillation, anticoagulation is not necessary before cardioversion. However, in patients with chronic atrial fibrillation, anticoagulation should be started three weeks before cardioversion and continued for four weeks after the return of normal sinus rhythm. Quinidine remains the agent most commonly used for medical cardioversion in patients who are hemodynamically stable. If a patient is hemodynamically unstable or the atrial fibrillation is not corrected with drug therapy, direct-current electrical cardioversion has a high success rate. Antiarrhythmic (quinidine) therapy is often continued indefinitely to help maintain sinus rhythm.     

Acute management of atrial fibrillation: Part II. Prevention of thromboembolic complications

Family physicians should be familiar with the acute management of atrial fibrillation and the initiation of chronic therapy for this common arrhythmia. Initial management should include hemodynamic stabilization, rate control, restoration of sinus rhythm, and initiation of antithrombotic therapy. Part II of this two-part article focuses on the prevention of thromboembolic complications using anticoagulation. Heparin is routinely administered before medical or electrical cardioversion. Warfarin is used in patients with persistent atrial fibrillation who are at higher risk for thromboembolic complications because of advanced age, history of coronary artery disease or stroke, or presence of left-sided heart failure. Aspirin is preferred in patients at low risk for thromboembolic complications and patients with a high risk for falls, a history of noncompliance, active bleeding, or poorly controlled hypertension. The recommendations provided in this article are consistent with guidelines published by the American Heart Association and the Agency for Healthcare Research and Quality.     

Use of transesophageal contrast echocardiography for excluding left atrial appendage thrombi in patients with atrial fibrillation before cardioversion

Transesophageal echocardiographic (TEE) guidance of cardioversion in patients with atrial fibrillation is an alternative method to conventional anticoagulation. Although TEE is considered the gold standard for excluding left atrial (LA) thrombi, in some patients dense spontaneous echo contrast (SEC) and artifacts may hamper the identification or exclusion of LA thrombi. Often those patients are refused cardioversion. The purpose of this study was to determine whether the application of echo contrast (Optison, Mallinckrodt, San Diego, Calif) facilitates the exclusion of LA appendage thrombi in this patient group and allows for safer cardioversion. Forty-one patients with atrial fibrillation and dense SEC or inconclusive TEE findings were given echo contrast. Fourteen patients with sinus rhythm served as control participants. Echo contrast completely reduced artifacts in 13 of 22 patients. In 12 of 19 patients with SEC, the LA appendage was completely filled after the application of echo contrast and, thus, SEC was completely suppressed. In 13 of 41 patients, it was filled incompletely and in 9 of 41 patients, a new mass resembling a thrombus was detected. In total, of 25 of 41 patients with inconclusive TEE findings an atrial thrombus was definitively excluded. Those patients underwent cardioversion. None of those patients had a cerebral embolic complication as assessed by cranial magnetic resonance imaging. Thus, the application of echo contrast may facilitate the TEE exclusion of LA appendage thrombi and, hence, improve the safety of TEE-guided cardioversion. (J Am Soc Echocardiogr 2002;15:1256-61.)     

老年人房颤与NT-ProBNP、左房大小的关系及抗凝现状分析

目的观察老年人房颤与N-末端脑钠肽前体(NT-proBNP)及左房大小的关系,并分析其抗凝现状。方法对120例老年房颤患者的临床资料进行回顾性分析,包括初发、阵发、持续性、持久性、长期持续性房颤患者的NT-proBNP水平、左房内径和抗凝方法。结果 120例老年房颤患者中,初诊房颤占15.0%,阵发性房颤占30.0%,持续性房颤、持久性房颤、长期持续性房颤占55.0%。使用华法林抗凝治疗占41%,房颤发生脑栓塞占9.1%。持续性房颤、持久性房颤、长期持续性老年房颤的患者NT-proBNP明显高于阵发性、初诊房颤患者,其左房内径明显大于阵发性、初诊房颤患者的左房内径。抗凝治疗中华法林组栓塞事件发生率(2.08%)低于阿司匹林组(13.89%),而两组出血事件发生率无显著差异。结论持续性房颤、永久性房颤、长期持续性房颤在老年患者中占主导地位。房颤时间越长,左房内径越大,NT-proBNP也越高。华法林抗凝效果优于阿司匹林,且获益超过出血风险。