心房颤动射频消融术后肺静脉狭窄的现状及进展

心房颤动是临床最常见的心律失常,近年来射频消融已成为治疗心房颤动最重要、最有效的手段,但与此同时各种并发症也随之而来.肺静脉狭窄是心房颤动射频消融术后的并发症之一,严重的肺静脉狭窄可出现患侧肺淤血及血流灌注异常,晚期可发生进展性肺循环高压.由于它是一种相对罕见的医学问题,且不具有特异性表现,因此很容易被误诊、漏诊.结合...     

环肺静脉消融术治疗老年人心房颤动的安全性分析

目的 评价老年心房颤动(房颤)患者导管消融治疗的安全性.方法 连续入选307例行环肺静脉线性消融治疗的房颤患者.比较老年组与中青年组导管消融治疗的疗效及安全性.结果 老年组的房颤病史长于中青年组,分别为(8.0±7.5)年和(6.1±5.7)年(P＜0.05);并存器质性心脏病的比例高,分别为37.2%和23.9%(P＜0.05).术后随访(13.5±6.3)个月,79例(25.7%)患者复发房性心律失常,两组复发率(30.9%和23.5%)比较,差异无统计学意义.28例(9.1%)患者出现操作相关并发症,老年组并发症发生率高于中青年组,分别为14.9%和6.6%(P＜0.05),两组间严重并发症发生率(3.2%和1.9%)比较,差异无统计学意义.结论 导管消融治疗是老年房颤患者一项可供选择的治疗措施.     

心房颤动射频消融术后的肺静脉狭窄

导管射频消融手术已经成为治疗心房颤动(简称房颤)最重要、最有效的手段,同时,各种术后并发症也随之而来。其中肺静脉狭窄为房颤射频消融术后的严重并发症之一,其临床症状往往缺乏特异性,患者可出现发热、咳嗽、咯血、呼吸困难等一系列表现,严重者可致死。其治疗方案因患者临床症状及肺静脉狭窄严重程度而异,仍为临床医生的一项挑战性工作,日益引起国内外重视。     

阵发性心房颤动射频消融术后肺静脉闭塞1例

<正>心房颤动（房颤）是临床上最常见的心律失常。房颤治疗包括节律控制,室率控制,抗凝及上游治疗等,节律控制是房颤治疗重要的环节。目前,经导管射频消融术（radiofrequency catheter ablation,RFCA）已成为治疗房颤的常用方法之一,肺静脉隔离是房颤消融基石,而与其相关的肺静脉狭窄（pulmonary vein stenosis,PVS）是房颤消融术后的并发症之一,因症状无特异性,误诊率高,     

EnSite-NavX 与CARTO系统引导对心房颤动环肺静脉消融术的初步比较

目的比较EnSite-NavX系统与CARTO系统引导进行环肺静脉消融术（CPVA）治疗心房颤动（房颤）的各自特点、CPVA技术参数和临床疗效的差别。方法75例阵发性或持续性房颤患者,随机分为EnSite—NavX（n=40）和CARTO（n=35）引导的环肺静脉消融术两组,房间隔穿刺后,重建左房三维结构和环肺静脉射频消融。对持续性房颤进行线性消融以改良左房基质。消融终点为完全肺静脉电隔离。结果74例顺利完成消融术。CARTO组的总操作时间和X线透视时间显著短于EnSite—NavX组（P=0．03、0．04）,左心房三维重建时间和X线透视时间两组差异无统计学意义。环肺静脉消融时,CARTO组的X线透视时间和操作时间显著短于EnSite-NavX组。EnSite．NavX组中14例（35％）房颤放电终止,多于CARTO组的5例（14％）,P=0．04。单纯环肺静脉消融EnSite-NavX组实现肺静脉电隔离26例（65％）,显著多于CARTO组的11例（31％）,P=0．004。平均随访7个月,EnSite—NavX组32例（80％）和CARTO组24例（69％）无房颤发作,P=0．06。CARTO组1例发生心包压塞,经开胸修补痊愈;1例发生肠系膜小动脉栓塞,经药物治疗痊愈。EnSite-NavX组1例出现血胸,经胸腔穿刺引流痊愈。两组均未见肺静脉狭窄。结论三维标测系统引导下的房颤环肺静脉消融术临床效果相似。     

阵发性心房颤动射频导管消融术后生活质量随访

目的　探讨经导管射频消融治疗阵发性心房颤动 (房颤 )的安全性、有效性以及对生活质量的影响。方法　 30例药物难治性阵发性房颤 ,在环状电极导管 (Lasso导管 )指导标测下行肺静脉或上腔静脉电隔离 ,术后随访并行隔离术前后生活质量调查。结果　有 2 9例达消融终点 ,随访 1～ 2 6个月 ,17例消融成功 ,无需药物可以维持窦性心律 ,加用以前无效的抗心律失常药物后 ,有 2 2例无房颤复发。生活质量(QOL)调查示隔离术前后相比 ,SF 36量表中除肌体疼痛差异无显著性外 ,其它 7项指标 :躯体功能、躯体角色、总的健康状况、活力、社会功能、情感角色和心理健康 ,术后均有改善 (P <0 0 5 ) ;而症状列表中除胸痛外 ,心悸、心动过速、呼吸困难、头昏、活动受限 ,术后均有改善 (P <0 0 5 )。结论　部分药物难治性房颤患者可行射频导管消融肺静脉电隔离治疗 ,成功地消除房颤可明显提高患者的QOL且改善症状。     

心房颤动肺静脉隔离术后肺静脉狭窄的诊断和治疗

肺静脉隔离术是目前心房颤动射频导管消融术（下称消融）的基本术式，随着该术式的逐渐普及，与其相关的并发症显得越来越重要。肺静脉狭窄作为心房颤动消融的重要并发症之一，也正引起越来越多的关注。     

心房颤动消融术中肺静脉传导恢复的识别及再干预对疗效的影响

目的观察阵发性心房颤动(房颤)环肺静脉电隔离术(CPVI)中不同观察时间内肺静脉传导急性恢复的发生率,并评价再次电隔离术对于临床疗效的影响。方法入选阵发性房颤患者90例,其中男性51例,女性39例,平均年龄56·4±12·3(45～73)岁;随机分为三组行CPVI,组A实现肺静脉电隔离不予观察,组B电隔离后观察时间30min,组C电隔离后观察时间60min,评价肺静脉传导恢复发生率并对其再次行电隔离术。术后随访心电图和24小时动态心电图评价疗效。结果所有患者顺利完成消融术。组A平均手术时间显著短于组B和组C。肺静脉隔离时间和X线透视时间三组中每两组差异均无统计学意义。组B左肺静脉隔离后30min传导恢复8例(25%),60min电位恢复共10例(31·2%);右肺静脉隔离后30min传导恢复6例(18·8%)。组C左肺静脉隔离后30min传导恢复9例(30%),60min传导恢复共11例(36·7%);右肺静脉隔离后30min7例(23·3%)传导恢复,60min共8例(26·7%)传导恢复。平均随访6·7±2·3(4～9)个月,组A17例(60·7%)、组B27例(84·3%)、组C26例(86·7%)无房性快速性心律失常发作,P=0·04。结论环肺静脉电隔离术中肺静脉传导急性恢复率为30%左右,多数发生在肺静脉隔离后30min内,再次电隔离术有助于提高消融成功率。     

心房颤动环肺静脉口外线性消融术后二次消融的电生理发现及随访结果

目的介绍三维导航下环肺静脉口外线性消融治疗心房颤动（房颤）术后快速房性心律失常及房颤复发患者二次消融时的电生理发现、消融策略及随访结果。方法2004年4月至2006年5月,采用左心房线性消融治疗房颤共91例。术后4例患者因心动过速反复发作或无休止发作于2周内行二次消融术。随访3个月后,25例患者有快速性心律失常发作,其中15例接受二次消融术。在所有接受二次消融的19例患者中,第一次消融前房颇为阵发性者11例,持续性2例,永久性6例,其中男性17例,女性2例,年龄25～65（53±12）岁。所有患者术中均使用环状电极行肺静脉电位探查。结果5例患者发现窦律下左侧肺静脉延迟电位,1例出现右侧肺静脉延迟电位,2例患者双侧同时出现延迟肺静脉电位;此类患者于环状电极指导下标测原消融线径的传导“缺口”并再次隔离成功。3例患者左侧肺静脉内颤动样节律,递减传导至左心房出现不规则房性心动过速;此类患者再次于三维标测指导下行左侧环状消融隔离成功;1例患者左侧肺静脉心动过速并1：1传导至左心房,经终止心动过速后隔离成功。4例患者肺静脉探查未发现肺静脉电位,但诱发出其他心动过速,包括右房瘢痕性房性心动过速、隐匿性旁路介导的室上性心动过速、右后间隔局灶性房性心动过速及三尖瓣峡部依赖的心房扑动。此4例患者在常规标测和三维标测指导下,心动过速均被成功消融。术中呈房颤节律者3例,再次于三维标测指导下行环肺静脉线性消融获成功。平均随访4～26（11．5±8．5）个月,16例患者无快速性心律失常发作,1例有频繁房性早搏,1例永久性房颤患者仍呈房颤节律,另1例永久性房颤患者转为阵发性房颤。结论肺静脉与左心房之间电传导恢复是消融术后出现快速房性心律失常的主要因素。肺静脉以外的心动过速在左心房线性消融术后可以表现为独立的心动过速,也可以触发房颤;环肺静脉口外线性消融不足以完全改良永久性房颤的维持基质。     

心房颤动导管消融术后心率的变化

目的评价心房颤动（房颤）导管消融术后心率变化的时间效应。方法入选导管消融术后随访无房性心动过速或房颤复发的症状性房颤患者52例，平均年龄64．65±10．18岁（38～76岁）。于术前、术后1周、1个月、3个月、6个月、12个月随访24小时动态心电图，观察平均心率的变化。结果52例均完成导管消融术，术前平均心室率为68．92±7．53次／min，术后1周、1个月和3个月的平均心室率分别为75．58±6．48次／min、71．13±6．45次／min和68．90±7．28次／min。43例随访6个月时的心室率为70．47±5．95次／min。22例随访12个月时的心室率为69．95±5．35次／min。除术后1周平均心率与术前相比差异有统计学意义（P〈0．05）外，余均无明显变化。结论房颤消融可引起心率增加，以术后1周最为明显。症状明显者可增服控制心率的药物。     

Asymptomatic pulmonary vein stenosis after cryoballoon catheter ablation of paroxysmal atrial fibrillation

Pulmonary vein (PV) isolation is an effective treatment option for symptomatic atrial fibrillation. PV stenosis is a well-recognized complication of radiofrequency energy application but has not been observed following cryoballoon ablation. Here, we report a case of asymptomatic PV stenosis associated with cryoballoon PV isolation, illustrating a risk that should be considered when applying this technique.     

Incidence of pulmonary vein stenosis 2 years after radiofrequency catheter ablation of refractory atrial fibrillation.

AIMS: Pulmonary vein ablation offers the potential to cure patients with atrial fibrillation. In this study, we investigated the incidence of pulmonary vein stenosis after radiofrequency catheter ablation of refractory atrial fibrillation by systematic long-term follow-up. METHODS AND RESULTS: Forty-seven patients with refractory and highly symptomatic atrial fibrillation underwent radiofrequency catheter ablation of arrhythmogenic triggers inside the pulmonary veins and/or ostial pulmonary vein isolation with conventional mapping and ablation technology. These patients had follow-up examinations at 2 years with transoesophageal doppler-echo and/or angio magnetic resonance imaging for the evaluation of the pulmonary veins. Seventy-seven percent of the patients were free from atrial fibrillation, 51% were without antiarrhythmic drugs, and 26% were on previously ineffective antiarrhythmic drug therapy. However, 13 of the 47 patients showed significant pulmonary vein stenosis or occlusion. Only three of these 13 patients complained of dyspnoea. Distal ablations inside the pulmonary vein were associated with a 5.6-fold higher risk of stenosis than ostial ablations. CONCLUSIONS: At 2-year follow-up, the risk of significant pulmonary vein stenosis/occlusion after radiofrequency catheter ablation of refractory atrial fibrillation with conventional mapping and ablation technology was 28%. Distal ablations inside smaller pulmonary veins should be avoided because of the higher risk of stenosis than ablation at the ostium.     

射频导管消融治疗肺静脉相关的心房颤动合并其他类型快速心律失常

目的　总结 9例肺静脉相关的阵发性心房颤动 (PAF)合并其他类型快速心律失常的电生理特点和射频导管消融治疗的经验。方法　 9例PAF患者 ,男性 6例 ,女性 3例 ,年龄 2 2～ 6 2(4 9 8± 12 5 )岁 ,PAF病史 3个月～ 10年。其中 3例合并预激综合征 ,2例成功阻断旁路传导 ,1例失败 ;2例合并房室结折返性心动过速 ,成功消融房室结慢径 ;3例合并的室性心律失常均起源于右心室流出道 ,2例导管消融成功 ,1例未消融 ;3例术前有典型心房扑动 (AFL)发作 ,行右心房峡部消融实现双向阻滞。经上述消融后 ,各病例仍有频繁PAF发作 ,电生理检查发现肺静脉异位冲动触发PAF发作。 8例进行了心脏大静脉电隔离 ,1例在电隔离后出现典型AFL发作 ,行右心房峡部消融成功。结果　随访 7～ 2 5个月 ,7例无PAF发作 ,2例仍有频发房性早搏和PAF发作 (包括未行肺静脉电隔离 1例 ) ,其他成功消融的室上性和室性心律失常无复发。结论　成功消融房室旁路、房室结慢径、右心房峡部、室性心律失常后不能消除或减少肺静脉相关的PAF发作 ,几种心律失常并存可以先后消融成功。肺静脉相关的PAF特点突出 ,旁路、双径路、典型AFL、室性心律失常的存在一般不会混淆其诊断的独立性     

Long-term single procedure efficacy of catheter ablation of atrial fibrillation

Background Two important limitations of the data regarding the outcomes of catheter ablation of atrial fibrillation (AF) are the short-term follow-up used in most published studies and the lack of single-procedure outcomes.Objective The objective was to report the long-term single-procedure outcomes at our center.Materials and methods The patient population was comprised of 200 consecutive patients who underwent ablation (133 men; age 56 ± 11 years). Atrial fibrillation was paroxysmal in 92 (46%). Success was defined as absence of symptomatic AF, off antiarrhythmic drug (AAD) after a single procedure.Results After a follow-up of 26 ± 11 months, the single-procedure long-term success rate was 28% with an additional 7% of patients demonstrating improvement. After including repeat procedures in 64 patients, the overall long-term success rate was 41% with 11% demonstrating improvement. Further subgroup analysis of 48 paroxysmal AF patients considered to be optimal candidates for the procedure, revealed a long-term success rate of 69% with an additional 4% demonstrating improvement. A major complication occurred in 7.9% of patients.Conclusion The results reveal that the long-term single-procedure success rate of catheter ablation of AF in a cohort of patients with predominantly non-paroxysmal AF is less than 40%. The inclusion of redo procedures resulted in an improvement in outcomes. A much higher success rate of 69% was achieved in patients with paroxysmal AF considered to be optimal candidates for this procedure. These results make it clear that further advances in the technique of catheter ablation of AF are needed to improve the safety and efficacy of this procedure. In order to be able to compare outcomes of various techniques in differing patient populations, we urge investigators to report long-term single procedure outcomes.This study was supported by The Norbert and Louise Grunwald Cardiac Arrhythmia Research Fund.     

Reversal of pulmonary vein remodeling after catheter ablation of atrial fibrillation

Background Pulmonary veins (PV) and the atria undergo electrical and structural remodeling in atrial fibrillation (AF). This study aimed to determine PV and left atrial (LA) reverse remodeling after catheter ablation for AF assessed by chest computed tomography (CT). Methods PV electrophysiologic studies and catheter ablation were performed in 63 patients (68% male; mean ± SD age: 56 ± 10 years) with symptomatic AF (49% paroxysmal, 51% persistent). Chest CT was performed before and 3 months after catheter ablation. Results At baseline, patients with persistent AF had a greater LA volume (91 ± 29 cm³ vs. 66 ± 27 cm3; P = 0.003) and mean PV ostial area (241 ± 43 mm² vs. 212 ± 47 mm²; P = 0.03) than patients with paroxysmal AF. There was no significant correlation between the effective refractory period and the area of the left superior PV ostium. At 3 months of follow-up after ablation, 48 patients (76%) were AF free on or off antiar?rhythmic drugs. There was a significant reduction in LA volume (77 ± 31 cm³ to 70 ± 28 cm³; P < 0.001) and mean PV ostial area (224 ± 48 mm² to 182 ± 43 mm²; P < 0.001). Patients with persistent AF had more reduction in LA volume (11.8 ± 12.8 cm³ vs. 4.0 ± 11.2 cm³; P = 0.04) and PV ostial area (62 mm² vs. 34 mm²; P = 0.04) than those who have paroxysmal AF. The reduction of the averaged PV ostial area was significantly correlated with the reduction of LA volume (r = 0.38, P = 0.03). Conclusions Catheter ablation of AF improves structural remodeling of PV ostia and left atrium. This finding is more apparent in patients with persistent AF treated by catheter ablation.     

Transesophageal echocardiography: A follow-up tool after catheter ablation of atrial fibrillation and interventional therapy of pulmonary vein stenosis and occlusion

Background Pulmonary vein stenosis (PVS) has been described as a complication after primary catheter ablation of atrial fibrillation (Afib). The purpose of this study was to evaluate the utility of transesophageal echocardiography (TEE) as follow-up tool after catheter ablation of Afib and interventional therapy of PVS and pulmonary vein occlusion (PVO). Methods We report on 28 patients with stenosis (PVS) of 33 pulmonary veins (PVs) and total PVO of 4 veins complicating ablation of Afib assessed by angiography and/or magnetic resonance imaging (MRI). Subsequently, transseptal PV angiograms were performed, followed by recanalization of three totally occluded PVs and balloon dilatation of seven severe PVS (in four cases combined with PV stenting). PVs were analyzed by multiplane TEE in an intraindividual comparison of preablation/preintervention and follow-up measurements of mean and peak flow velocity, velocity time integrals, and diameters. Results Of a total of 28 patients, 14 had mild PVS (n = 14), 9 had moderate PVS (n = 10), 6 had severe PVS (n = 8), and 4 patients showed totally occluded PVs (n = 4). In multivariate analysis flow velocities and vessel diameters showed significant differences (mild, moderate, and severe PVS and PVO; p = 0.001). Interventional benefits of balloon dilatation (n = 10) and stent implantation (n = 4), as well as in-stent restenosis could be detected (p = 0.014). In all recanalized vessels TEE showed reestablished flow. In occluded PVs no flow was detectable. The TEE vessel diameters correlated with angiography data (r = 0.87) and computed tomography/MRI (r = 0.90). Conclusions TEE can be used as a follow-up tool after interventional therapy in patients after catheter ablation and acquired PVS/PVO. Restenosis/in-stent restenosis can be identified by analyzing the vessel diameters and blood flow characteristics.     

环状电极标测指导射频消融治疗肺静脉起源的阵发性房颤

背景　常规方法标测射频消融治疗局灶性房颤常导致较长的手术时间及较低的成功率。环状电极标测指导射频消融能够克服这些缺点。目的　评价在 10极环状电极标测指导下射频消融电隔离肺静脉治疗阵发性房颤的可行性和有效性。方法　本组研究包括 16例抗心律失常药物治疗无效的阵发性房颤患者 [男性 11例 ,女性 5例 ,平均年龄 (5 1± 14 5 )岁 ]。 10极的环状标测电极在窦性心律或者冠状窦远端 (CSd)起搏的情况下标测肺静脉 ,确定房性早搏发生的起源 ;一旦确定靶肺静脉 ,肺静脉电位的分布及其激动顺序进行评价 ,射频消融在肺静脉口最早激动处进行。消融终点设定为 :①肺静脉电位消失 ;②肺静脉电位与心房电位无关 ;③房早消失。结果　本组研究总共消融了 36条肺静脉 ,包括 16条左上肺静脉 ,12条右上肺静脉 ,7条左下肺静脉 ,1条右下肺静脉。有 2例消融了 1条肺静脉 ;8例消融了 2条肺静脉 ;5例消融了 3条肺静脉 ;消融 4条肺静脉者 1例。手术时间以及X线曝光时间分别为 (186 7± 6 3 8)min及 (5 1 5± 15 0 )min。在随访的 1～ 12月 ,11例 (6 8 7% )在未服抗心律失常药没有房颤发作 ,其中 2例为再次手术 ,有效者 3例 (18 7% ) ,2例未成功 (12 6 % )。初次术后有 2例发作房早 ,其中 1例服用胺碘酮 ,另外 1     

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.     

心房颤动肺静脉电隔离术后房性早搏的三维标测和消融

目的 探讨心房颤动（房颤）环肺静脉电隔离术后频发房性早搏（房早）的分布特点和评价消融的效果.方法 21例患者（男性13例,女性8例）,平均年龄（51.2±8.7）岁.平均距阵发性房颤环肺静脉隔离术（2.3±1.1）个月.经24 h动态心电图检查,平均房早个数为（12110±375）个.肺静脉起源房早予以再次补点隔离肺静脉,其他部位房早采用三维激动标测和消融.消融术后随访心电图、24 h动态心电图评价消融效果.结果 肺静脉电位恢复2例,均为房早起源部位（左上肺静脉1例,左下肺静脉1例）,补点隔离肺静脉后房早消失.余19例无肺静脉电位恢复,其中起源于左心房右后上壁2例、后下壁4例,左心房顶部4例、左心房左前上壁2例,冠状静脉窦口1例,界嵴中部2例,高右心房间隔2例,高右心房后上壁1例,三尖瓣环6点位置1例.消融后共使18例（85.7%）房早消失.消融术后随访（11.7±4.2）个月,17例（81.0%）无房早复发.结论 阵发性房颤环肺静脉电隔离术后房早分布离散,主要起源于左心房（66.7%）,但多与肺静脉电位无关,其次为起源于右心房.三维标测和消融疗效良好.     

环肺静脉口部线性消融治疗心房颤动的初期体会

目的报告环肺静脉口部线性消融治疗心房颤动(房颤)的初期体会和结果。方法56例药物治疗无效的房颤患者(阵发性房颤50例,持续性房颤6例)入选,平均年龄(50.6±9.6)岁。利用三维电解剖标测系统,围绕左和右侧肺静脉口部线性消融左心房,另外二条消融线分别连接左、右环状消融线以及左环状消融线至二尖瓣环。术后服用抗心律失常药3个月。结果55例患者接受消融治疗,其中53例完成预定的线性消融,操作时间和X线曝光时间分别为(193±56)min和(35±11)min。术中14例患者为房颤心律,其中8例(57.1%)消融过程中恢复窦性心律;20例出现迷走神经反射现象。随访时间>3个月(7.3±3.4)个月的41例,其中无房颤发作者25例(包括2例仍服用胺碘酮,61.0%),房颤发作次数和持续时间明显减少者11例(26.8%),无效者5例。无1例发生肺静脉狭窄。结论纯解剖方式的环肺静脉口部线性消融治疗房颤是安全可行的。其主要治疗机制是改变房颤的心房基质和去迷走神经作用。