射频消融治疗阵发性心房颤动伴长间歇患者的长期随访研究

目的 随访射频消融治疗阵发性心房颤动（房颤）伴长间歇的临床转归.方法 2006年5月至2008年9月共入选18例（男12例,女6例）阵发性房颤伴发作终止时窦性停搏≥3 s的患者,年龄37～72（56.8±11.7）岁,病程2～276（69.6±71.3）个月.所有患者均有房颤终止时窦性停搏≥3 s的临床资料,平均长RR间期3.1～8.0（4.5±1.6）s,部分患者伴有黑矇、晕厥先兆或者晕厥症状.首次消融患者,在三维标测系统指导下行肺静脉前庭隔离术达到肺静脉-左心房电学隔离;术后常规程序刺激诱发,若合并室上性心律失常或者非肺静脉触发灶,同时消融.术前,术后3d,1、3、6个月分别常规检查动态心电图,检测心率变异性（HRV）指标.结果 18例患者共进行了27次消融,8例1次手术成功,5例行2次手术,2例行3次手术,3例复发未再行手术治疗.首次消融术中,3例诱发典型心房扑动,同时行后位峡部消融,达到双向阻滞;3例术中出现显性去迷走[血压＜ 90/60 mm Hg（1 mm Hg=0.133 kPa）,心率＜60次/min].10例复发患者中,1例合并左心房后壁的局灶房颤,第3次消融时成功.平均随访（34.1±7.5）个月,术后2例发生窦性心动过速;3例房颤复发,其中1例为起搏器植入术后,1例房颤复发患者终止后有10.4 s的长间歇,植入单腔起搏器,另外1例房颤复发但无症状,未作特殊处理,临床密切随访.共12例完成6个月动态心电图随访的患者符合分析要求.术前反应迷走神经功能的HRV指标相邻RR间期差的均方根（rMSSD）,RR间期平均值的标准差（SDNN）,高频（HF）,低频（LF）/HF分别为（42.0±11.1）ms,（136.0±24.9）ms,12.5±3.9,1.32±0.26.术后随访发现其指标均下降并持续至少3个月,但在6个月时恢复.结论 房颤发作时能够抑制窦房结功能,导致长间歇;射频消融治疗祛除房颤这一原始因素后,窦房结功能常有一定程度的恢复.     

病态窦房结综合征合并阵发性心房颤动的射频消融治疗

目的探讨病态窦房结综合征患者合并阵发性房颤的射频消融治疗效果。方法 7例病态窦房结综合征合并阵发性房颤患者,术前动态心电图诊断为病态窦房结综合征,24小时内有数次停搏及多次阵发房颤发作,其中有5例患者停搏均发生在房颤终止时,2例停搏与房颤发作无明显关联。接受环肺静脉前庭电隔离术。术后动态心电图随访。结果该7例患者,有2例房颤复发,1例再次接受手术并成功,1例拒绝再次手术。动态心电图提示有4例(考虑为快慢综合征)心动过缓明显好转,2例(考虑为慢快综合征)房颤发作明显减少但是心动过缓无改善,接受心脏永久起搏器置入治疗。此7例患者术前与术后1个月最大心率、最小心率、平均心率比较,最小心率、平均心率术后较术前增加,最大心率术后较术前无明显变化。结论快慢型病态窦房结综合征合并阵发性房颤患者对房颤射频消融治疗效果较好,大部分患者术后心动过缓明显改善,而不需要置入心脏永久起搏器。     

阵发性心房颤动肺静脉电隔离术后复发患者的处理

目的 :探讨阵发性心房颤动 (房颤 )肺静脉电隔离术后复发患者的治疗方案。方法 :4 9例术后复发患者均首先接受为期 3个月的抗心律失常药物治疗 ,之后是否行再次房颤消融术取决于以下 2个条件 :①房颤的发作频度和持续时间较术前无变化或减少程度 <5 0 % ;②出现明显药物副作用。结果 :抗心律失常药物治疗 3个月后 ,12例 (2 4 .5 % )无房颤发作 ,其中 5例在停药后亦无发作 ;17例 (34.7% )房颤虽仍有发作 ,但发作频率和持续时间较术前明显减少 (>5 0 % ) ;2 0例 (4 0 .8% )具有再次消融术指征 ,其中 5例接受手术 ,术后 2例复发 ,均可通过药物治疗得以控制。结论 :抗心律失常药物为主、再次消融术为辅的治疗方案对于多数肺静脉电学隔离术后复发的阵发性患者具有良好效果。     

阵发性心房颤动射频消融术后左房大小和机械功能变化

目的探讨经导管射频消融术对阵发性心房颤动（房颤）患者左房功能的影响,并比较肺静脉口节段性电隔离（SPVI）和环肺静脉消融（CPVA）两种术式在此方面的异同。方法66例阵发性房颤患者接受射频消融手术治疗。应用经胸心脏超声检查测量患者术前、术后1天、1个月和3个月时的左房前后径、左房面积、舒张晚期跨二尖瓣血流峰速（A峰）和舒张晚期心肌组织运动峰速（A’峰）。结果66例患者中,30例接受SPVI术,36例接受CPVA术。两组患者一般临床情况及术前超声参数相似。术后随访（315±153）d,SPVI组和CPVA组无房性心律失常复发率相似（70％与75％,P=0．650）。两组在手术后左房面积均较术前缩小,SPVI组发生于术后1个月,而CPVA组于术后3个月。SPVI组左房直径也显示出明显缩小（P〈0．05）,而CPVA组术前和术后则差异无统计学意义。左房机械功能方面,CPVA组于术后1天A峰和A’峰明显降低（P〈0．05）,两者均于3个月后较术后1天明显回升,A峰恢复至术前水平,A’峰较术前有明显升高。SPVI组术后1天没有出现A峰和A’峰明显降低;其A峰于术后1个月升高,并保持至3个月;A’峰于术后3个月时升高。结论阵发性房颤经导管SPVI术和CPVA术治疗后3个月,可以出现左房面积缩小和收缩功能改善。CPVA术比SPVI术造成了更多的左房损伤,表现为术后1天左房功能的下降以及术后左房大小、功能参数改善的延迟。     

年龄对心房颤动患者导管消融术长期预后的影响北大核心CSCD

目的探讨年龄对心房颤动导管消融术患者长期预后的影响。方法入选2009年1月至2011年6月在北京安贞医院和郑州大学第一附属医院首次接受导管消融的1283例心房颤动患者（阵发性心房颤动820例,持续心房颤动463例）,根据年龄分为4组：〈55岁组449例;55～岁组428例;65～岁组340例;≥75岁组66例。术后第1、3、6、12个月及以后每6个月行标准12导联心电图和24h动态心电图检查,随访结束比较4组患者窦性心律维持率及手术相关安全性指标。结果5年随访结束时〈55岁组、55～岁组、65～岁组、≥75岁组患者单次手术成功率分别为52．8％（237／499）、50．5％（216／428）、42．9％（146／340）及34．8％（23／66）,差异有统计学意义（P=0．014）;复发的患者中,进行二次消融患者分别为24．9％（112／499）、23．6％（101／428）、24。1％（82／340）及25．8％（17／66）（P=0．876）;最后1次消融后维持窦律分别为322例（71．7％）、301例（70．3％）、217（63．8％）及37（56．1％）的患者（P=0．267）。回归分析结果显示,年龄、性别、体质指数、心房颤动类型及左心房直径是单次手术心房颤动复发的危险因素。矫正了上述心房颤动复发关系较为密切的已知因素后,多变量回归分析结果显示,年龄仍旧是心房颤动导管消融术后长期随访复发的独立危险因素（风险比为1．011,95％CI：1．001～1．019,P=0．013）。4组间再次消融窦性心律维持率和各种并发症风险差异无统计学意义。结论年龄是心房颤动患者导管消融术后长期随访复发的独立危险因素,但再次消融术后,各年龄组窦性心律维持率无差异。     

肺静脉隔离术对阵发性心房颤动合并慢快综合征患者窦房结功能的影响

目的:探讨肺静脉隔离术对阵发性心房颤动(房颤)合并慢快综合征患者窦房结功能的影响。方法:入选于我院行肺静脉隔离术的阵发性房颤合并窦房结功能障碍的患者[校正的窦房结恢复时间(CSNRT)≥550 ms],共31例。所有患者于术前、术后2 d及术后6个月进行24 h动态心电图检查,测定平均心率、最慢心率及最快心率,测定心率变异性指标rMSSD、SDNN,并于术后6个月采用食管调搏的方法测定CSNRT,比较手术前后各项指标的变化。结果:与术前相比,患者术后2 d及术后6个月的平均心率、最慢心率及最快心率均有明显上升(P0.05);术后6个月测定CSNRT较术前有明显缩短(P0.05);与术前相比,患者术后2 d及术后6个月的rMSSD、SDNN均明显缩短(P0.05)。结论:阵发性房颤伴窦房结功能障碍的患者经肺静脉隔离术后,窦房结功能明显恢复,迷走神经张力明显减弱。     

厄贝沙坦对病态窦房结综合征患者双腔起搏后阵发性心房颤动的影响

目的观察厄贝沙坦对病态窦房结综合征（SSS）患者双腔起搏后阵发性心房颤动（Af）的影响。方法入选84例双腔起搏术后1个月仍有阵发性Af的SSS患者,随机分为治疗组（n=42）和对照组（n=42）。在治疗基础疾病的基础上,治疗组给予厄贝沙坦150mg/d,对照组不予血管紧张素转化酶抑制剂（ACEI）或血管紧张素受体拮抗剂（ARB）。随诊1年,观察左房内径、血清高敏C反应蛋白（hsCRP）水平、Af发作次数（次/d）及Af负荷（h/d）等。结果起搏器置入术后1年,治疗组左房内径、hsCRP、Af发作次数及Af负荷显著低于对照组,分别为[（3.91±0.22）cmvs.（4.48±0.46）cm],[（3.42±1.63）mg/Lvs.（5.23±2.11）mg/L],[（3.15±2.83）次/dvs.（6.46±4.28）次/d],[（0.46±0.28）h/dvs.（0.69±0.32）h/d]（P均〈0.05）;同时显著低于同组厄贝沙坦用药前水平（P均〈0.05）;对照组上述指标厄贝沙坦治疗前后变化无显著性差异（P〉0.05）。结论厄贝沙坦可减轻SSS双腔起搏后心房重构、降低hsCRP水平,减少阵发性Af的发生。     

心房颤动环肺静脉电隔离与窦房结动脉损伤的研究进展

环肺静脉电隔离术是目前广泛应用的通过消除肺静脉异位兴奋灶来治疗心房颤动的消融术式。窦房结动脉损伤是其较罕见的一种并发症,但因后果严重,近年来逐渐受到重视。本文主要综述环肺静脉电隔离术致窦房结动脉损伤的研究进展。     

逐级消融在非阵发性心房颤动中的临床应用

目的 总结三维标测系统(CARTO)指导下逐级消融策略治疗非阵发性心房颤动(房颤)的临床效果及可能机制.方法 40例非阵发性房颤患者接受逐级消融手术,第一步行环肺静脉前庭电学隔离术(PVAI),未复律者继续行线性消融,仍未复律者再继续行碎裂电位消融,直至复律或电复律.术后随访6～18个月.结果 40例患者PVAI后有11例转为窦性心律,线性消融后11例转为窦性心律,碎裂电位消融后6例转为窦性心律,其余行电复律.术后复发4例房颤,2例心房扑动,3例房性心动过速,以单纯PVAI后明显.结论 三维标测系统指导下采用逐级消融策略治疗非阵发性房颤是安全可靠的;单纯PVAI,成功率低,且易复发.     

阵发性心房颤动的治疗策略

据统计,我国30岁以上成年人心房颤动(简称房颤)的总体患病率为0.77%.这意味着我国目前已有大约1 000万的房颤患者,阵发性房颤所占的比例没有确切统计数据,可能在30%～50%之间.     

Impact of catheter ablation of the coronary sinus on paroxysmal or persistent atrial fibrillation

Objectives: This study evaluated the impact of catheter ablation of the coronary sinus (CS) region during paroxysmal and persistent atrial fibrillation (AF).
Background: The CS musculature and connections have been implicated in the genesis of atrial arrhythmias.
Methods: Forty-five patients undergoing catheter ablation of AF were studied. The CS was targeted if AF persisted after ablation of pulmonary veins and selected left atrial tissue. CS ablation was commenced endocardially by dragging along the inferior paramitral left atrium. Ablation was continued from within the vessel (epicardial) if CS electrograms had cycle lengths shorter than that of the left atrial appendage.
RF energy was limited to 35 W endocardially and 25 W epicardially. The impact of ablation was evaluated on CS electrogram cycle length (CSCL) and activation sequence, atrial fibrillatory cycle length measured in the left atrial appendage (AFCL) and on perpetuation of AF.
Results: Endocardial ablation significantly prolonged CSCL by 17 ± 5 msec and organized the CS activation sequence (from 13% of patients before to 51% after ablation); subsequent epicardial ablation further increased local CSCL by 32 ± 27 msec (P < 0.001). AFCL prolonged significantly both during endocardial and epicardial ablation (median: 152 to 167 msec P = 0.03) and was associated with AF termination in 16 (35%) patients (46% of paroxysmal and 30% of persistent AF). AFCL prolongation ≥5 msec and/or AF termination was associated with more rapid activity in the CS region originally: P ≤ 0.04.
Conclusion: Catheter ablation targeting both the endocardial and epicardial aspects of the CS region significantly prolongs fibrillatory cycle length and terminates AF persisting after PV isolation in 35% of patients.     

窦房结病与房颤之间发病的关系

近年来关于窦房结病变 (SND)和心房颤动(房颤,AF)之间发病的离子和分子机制研究很受关注。大量临床和动物实验已经证明窦房结和心房的电-解剖重构与SND和AF相关。心房结构重构与RAS激活有关;窦房结自主节律超极化激活起搏电流I_f和Ca₂ 电流异常,认为是SND和AF的一种关联;Cx40、Cx43和Cx45缝隙链接改变,可能是SND和AF的另一种关联。Emerin、SCN5A和HCN4等基因突变也与SND和AF的发病有关。本文简要概述了这方面的进展。     

Role of the coronary sinus in maintenance of atrial fibrillation

INTRODUCTION: Bursts of tachycardia arising in the pulmonary veins may play an important role in perpetuating atrial fibrillation (AF). However, the role of the coronary sinus (CS) in the perpetuation of AF has been unclear. The aim of this study was to determine whether the CS plays a role in perpetuation of AF. METHODS AND RESULTS: Pulmonary vein isolation was performed by segmental ostial ablation with radiofrequency energy in 22 consecutive patients with paroxysmal AF. Bipolar and unipolar electrograms recorded in the left atrium and CS were analyzed during atrial pacing from the mitral annulus and during AF. There was a mean of 2.5 +/- 0.5 electrical connections between the CS and the left atrium. The electrical connections between the left atrium and CS were ablated with a mean of 6.2 +/- 2.7 minutes of radiofrequency energy applied along the atrial side of the inferior mitral annulus. During AF, episodes of intermittent tachycardia alternated between the left atrium and the CS. Among the 22 patients, sustained AF was still inducible in 9 after pulmonary vein isolation. After electrical disconnection of the CS from the left atrium, sustained AF was inducible in only 3 of these 9 patients. CONCLUSION: The CS may be a source of rapid repetitive electrical activity during AF. The lower probability of inducible sustained AF after electrical disconnection of the CS from the left atrium suggests that the CS may play a role in perpetuating AF.     

Prevention of paroxysmal atrial fibrillation in patients with sinus bradycardia: role of right atrial linear ablation and pacing site

INTRODUCTION: Right atrial linear lesions (RALL), either alone or in combination with antiarrhythmic drug therapy, may modify the substrate for maintenance of atrial fibrillation (AF). The aim of this prospective randomized study was to determine whether RALL provides additional benefit to right atrial appendage pacing (RAAP) and/or interatrial septum pacing (IASP) and drug therapy in patients with symptomatic paroxysmal AF and sinus bradycardia requiring permanent atrial pacing. METHODS AND RESULTS: Sixty-four patients (33 men and 31 women, mean age 73 +/- 10 years) completed the 6-month follow-up. Patients were randomized to either RALL (n = 33) or non-right atrial linear lesions (NRALL), and then to either IASP (n = 32) or RAAP (n = 32). Fifteen RALL patients were paced at the IAS and 18 at the RAA. Seventeen NRALL patients were paced at the IAS and 14 at the RAA. No statistical difference was observed with regard to the mean atrial tachyarrhythmia (AT) burden between NRALL (84 +/- 169 min/day) and RALL patients (202 +/- 219 min/day). Mean AT burden was significantly lower in the IASP group (70 +/- 150 min/day) than in RAAP group (219 +/- 317 min/day; P < 0.016). In the RALL group, the mean AT burden was 99 +/- 180 min/day in the IASP patients and 288 +/- 372 min/day in the RAAP patients (P < 0.046). In the NRALL group, no statistical difference in the mean AT burden was observed between IASP patients (46 +/- 117 min/day) and RAAP patients (130 +/- 211 min/day). CONCLUSION: The results of the present study indicate that RALL did not provide any additional therapeutic benefit to combined antiarrhythmic drug therapy and septal or nonseptal atrial pacing in patients with sinus bradycardia and paroxysmal AF.     

Sinus node dysfunction after radiofrequency catheter ablation of atrial flutter: A case report

Atrial flutter (AFL) is the second most common atrial tachyarrhythmia after atrial fibrillation. Catheter ablation (CA) for typical AFL is well-established and has a high success rate and adequate safety. However, sick sinus syndrome (SSS) occasionally occurs when long-term, persistent AFL is terminated by ablation. Sinus node function cannot be assessed during AFL, and the preoperative prediction of underlying SSS has not yet been investigated. When this situation occurs, pacemaker implantation is often necessary. Here, we report a case of SSS after persistent AFL CA.     

Discrimination of left atrial and pulmonary vein potentials in patients with paroxysmal atrial fibrillation

INTRODUCTION: Ablation of muscular fascicles around the ostium of pulmonary veins (PVs) resulting in electrical isolation of the veins may prove to be an effective treatment for atrial fibrillation (AF). Correctly discriminating atrial and PV potentials is necessary to effectively isolate PVs from the left atrium in patients with paroxysmal AF. METHODS AND RESULTS: A training set of 151 electrode recordings obtained from 10 patients with AF was used to develop an algorithm to discriminate atrial and PV potentials. Bipolar electrograms were collected from a multielectrode basket catheter placed sequentially into each PV. Amplitude, slope, and normalized slopes of both bipolar and quadripolar electrograms (difference between adjacent bipoles) were entered into a binary logistic regression model. A receiver operating characteristic curve was used to define a threshold able to effectively discriminate atrial and PV potentials. The normalized slopes of both domains, bipolar and quadripolar, produced a logistic function that discriminated atrial and PV potentials against a threshold (0.38) with 97.8% sensitivity and 94.9% specificity. The algorithm then was evaluated on a test set of 214 electrode recordings from four patients who also had paroxysmal AF. These patient electrograms also were evaluated by two independent electrophysiologists. The algorithm and electrophysiologists matched identification of activation origin in 84% of electrograms. CONCLUSION: Atrial and PV potentials acquired from a multielectrode basket catheter can be discriminated using the normalized slopes of bipolar and quadripolar electrograms. These additional parameters need to be included by physicians determining the preferential ablation site within PVs.     

年龄对非瓣膜病心房颤动患者左心房血栓的影响

目的评价年龄对非瓣膜病心房颤动(房颤)患者左心房血栓的影响。方法选择拟行导管射频消融完成经食管超声检查的房颤患者421例,根据年龄分为老年组(108例)和年轻组(313例)。根据是否存在左心房血栓又分为血栓组(26例)和无血栓组(395例)。各组间进行一般临床资料比较。结果老年组年龄、高血压、服用血管紧张素转换酶抑制剂(ACEI)/血管紧张素Ⅱ受体拮抗剂(ARB)的比例明显高于年轻组,非阵发性房颤的比例明显低于年轻组。老年组LVEF明显高于年轻组。血栓组非阵发性房颤、心力衰竭、栓塞史、服用ACEI/ARB的比例明显高于无血栓组。血栓组左心房直径明显大于无血栓组,LVEF明显低于无血栓组。logistic多因素分析显示,校正LVEF、心力衰竭、高血压、糖尿病、服用ACEI/ARB,左心房直径、非阵发性房颤、既往栓塞史是左心房血栓独立预测因素,老年不是左心房血栓独立危险因素。结论年龄不是非瓣膜病房颤患者心房血栓的预测因素。     

Clinical outcome of very late recurrence of atrial fibrillation after catheter ablation of paroxysmal atrial fibrillation

INTRODUCTION: High recurrence rate is still a major problem associated with ablation of paroxysmal atrial fibrillation (AF). Most of the recurrences occur within 6 months after ablation. The characteristics of very late recurrent AF (>12 months after ablation) have not been reported. METHODS AND RESULTS: Two hundred seven patients with drug-refractory AF underwent successful focal ablation or isolation of AF foci. After the first ablation procedure, Holter monitoring and event recorders were used to evaluate symptomatic recurrent AF. A second ablation procedure was recommended if the antiarrhythmic drugs could not control recurrent AF. During long-term follow-up (mean 30 +/- 11 months, up to 51 months), 70 patients had recurrent AF, including 13 patients (6%) with very late (>12 months) recurrent AF (group 1) and 57 patients (28%) with late (within 12 months after ablation) recurrent AF (group 2). Group 1 patients had a significantly lower incidence of multiple (> or = 2) AF foci (23% vs 63%, P = 0.02) than group 2 patients. In addition, the incidence of antiarrhythmic drugs use (38% vs 84%, P = 0.001) to maintain sinus rhythm after the first episode of recurrent AF was significantly lower in group 1 than group 2 patients, and the incidence of a second intervention procedure (8% vs 35%, P = 0.051) tended to be lower in group 1 than group 2 patients. CONCLUSION: The incidence of very late recurrent AF after ablation of paroxysmal AF is very low, and the clinical outcome of patients with very late recurrent AF is benign.