持续性心房颤动递进式消融术后复发双环折返性房性心动过速的电生理诊断

目的 阐明递进式消融术治疗持续性心房颤动(房颤)术后复发双环折返性房性心动过速(房速)的电生理特点.方法 入选2007年7月至2012年12月持续性房颤递进式消融术后复发房速的19例患者.结果 19例患者均通过详细的三维激动标测(＞200个采集点)和在每个折返环内拖带的方法确定了双环折返的机制,其中大折返环和大折返环组成的双环折返13例,大折返环和局部小折返环组成的双环折返6例.大多数病例消融策略采取分别消融两折返环各自的峡部,先将双环折返变为单环折返(由再次拖带结果确定),最后消融单折返环峡部终止房速.结论 双环折返性房速并非是持续性房颤递进式消融术后少见的一种心律失常,详细的三维激动标测联合拖带标测是确诊的最佳方案.     

Electrophysiologic study of cibenzoline in patients with paroxysmal atrial fibrillation with special reference to atrial fibrillation threshold]

Electrophysiologic effects of cibenzoline were studied in 7 patients (6 males and one female) aged from 40 to 69 years (mean +/- SD; 52 +/- 10) with paroxysmal atrial fibrillation which was documented by 12 leads ECG or by 24 hours Holter monitoring. No organic heart diseases were found except in one patient with dilated cardiomyopathy and sick sinus syndrome (SSS). Cibenzoline (200mg) given orally increased P wave duration, PR interval and QRS duration significantly. The duration of P wave was gradually increased as the pacing frequency was increased. Neither sinus cycle length, nor sinus node recovery time (SRT), nor Wenkebach cycle length, nor atrial effective refractory period, nor QT interval was changed by the drug. One patient with SSS showed increase in SRT from 2,303 msec to 5,150 msec. The minimum current which was required to induce atrial fibrillation by rapid atrial stimulation (50 Hz, 1 sec) lasting more than 30 sec was defined as atrial fibrillation threshold (AFT). The AFT was 4.0 +/- 2.2 mA at the baseline state in 7 patients. After the oral administration of cibenzoline, 5 patients showed increase in AFT, while 1 patient showed decrease and another patient showed no change in AFT. Statistically, AFT was significantly increased to 7.3 +/- 3.4 mA in 7 patients. The results suggest that cibenzoline might be effective to prevent paroxysmal atrial fibrillation in patients without organic heart diseases.     

Electroanatomic characteristics of atrial premature beats triggering atrial fibrillation in patients with persistent versus paroxysmal atrial fibrillation

APBs in Persistent Versus Paroxysmal AF. BACKGROUND: Although the electrical disconnection between the left atrium (LA) and pulmonary veins (PVs) by radiofrequency catheter ablation has been proven to be effective in controlling atrial fibrillation (AF), the recurrence rate is higher in patients with persistent AF (PeAF) than with paroxysmal AF (PAF). We hypothesized that the origin of the atrial premature beats (APBs) that trigger AF and the pattern of their breakthrough into the LA differ between PAF and PeAF. METHODS: We mapped 75 APBs (53 APBs triggering AF, 22 isolated APBs) from the LA and PVs in 26 patients with AF (age: 49.5 +/- 9.6, males: 23, PAF = 17, PeAF = 9), using a noncontact endocardial mapping (NCM) system. The location of the preferential conduction (PC) sites and their conduction velocity (CV) were compared. RESULTS: In patients with PeAF, the earliest activation (EA) site and exit of the PC were more frequently located on the LA side of the LA-PV junction as compared with PAF (P < 0.001). Eighty-one percent of the PCs were located in the area between the left and right superior PVs. The incidence of PCs was similar between the PeAF and PAF patients (P = NS). PCs were more commonly found with APBs inducing AF (63.3%) than with those not inducing AF (35.2%, P = 0.01). The CV of the PC was slower for PeAF than PAF (P < 0.001). The CV in the LA during sinus rhythm was also slower for PeAF than PAF (P < 0.01). CONCLUSION: PeAF was more frequently triggered by APBs from the LA side of the LA-PV junction than PAF and resulted in slower conduction than did PAF. These findings may help explain the higher potential for recurrence after electrical PV isolation in patients with PeAF.     

Investigation of the predictors of transition to persistent atrial fibrillation in patients with paroxysmal atrial fibrillation

BACKGROUND: Until now, no clinically useful indicators have existed that predict the transition from paroxysmal to persistent atrial fibrillation (AF). HYPOTHESIS: The current prospective study was conducted for identifying predictors of progression to persistent AF over the long term. METHODS: We studied 102 consecutive patients (mean age: 55 +/- 10 years: 75 men and 27 women) diagnosed with paroxysmal AF. Standard 12-lead electrocardiography, echocardiography, and P-wave-triggered signal-averaged electrocardiography (P-SAECG) were performed on all patients at the time of their entry into the study. RESULTS: The mean follow-up period was 61 +/- 13 months. Group 1 (n = 66) comprised patients in whom paroxysmal AF did not progress to persistent AF, and Group 2 (n = 36) comprised those who developed persistent AF. In Group 2 the patients were significantly older, and P-wave dispersion, filtered P-wave duration (FPD), and left atrial dimension were significantly higher than in Group 1 (p < 0.05). The root mean square voltage for the last 30 ms of the filtered P-wave was also significantly lower in Group 2 (p < 0.05). Multivariate logistic regression analysis using these five factors identified left atrial dimension (odds ratio [OR] 2.29; 95% confidence interval [CI] 1.16-4.54; p = 0.02) and FPD (OR 2.71; 95% CI 1.78-4.13; p < 0.01) as independent predictors of transition to persistent AF. Left atrial dimension > or = 40 mm predicted progression to persistent AF with a sensitivity of 64%, specificity of 76%, positive predictive value of 59%, negative predictive value of 79%, and an accuracy of 71%. An FPD > or = 150 ms predicted persistent AF with a sensitivity of 81%, specificity of 91%, positive predictive value of 88%, negative predictive value of 90%, and an accuracy of 87%. Filtered P-wave duration was a significantly more sensitive and specific predictor than left atrial dimension (p < 0.05). CONCLUSION: We conclude that FPD is a clinically useful predictor of progression from paroxysmal to persistent AF over the long term.     

阵发性心房颤动进展为持续性心房颤动前的血浆醛固酮水平

目的测定阵发性心房颤动(简称房颤)进展为持续性房颤前血浆醛固酮水平变化。方法选取本院心内科阵发性房颤患者91例,所有患者入选后行心脏超声、长程心电图和血生化检查,测定空腹清晨窦性心律时血清醛固酮浓度。结果随访18±6个月,86例完成随访,其中15例进展为持续性房颤。持续性房颤组在年龄、高血压、冠心病和心功能不全和醛固酮水平(302.7±78.3 pg/ml vs 234.3±69.6 pg/ml,P<0.01)与阵发性房颤组有差异。多因素回归分析显示年龄、左房内径、左室射血分数和醛固酮是阵发性房颤进展为持续性房颤的独立危险因素。结论阵发性房颤患者进展为持续性房颤前血清醛固酮水平升高。     

Electrophysiologic properties of atrial muscle in paroxysmal atrial fibrillation

The electrophysiologic properties of atrial muscle were studied by programmed atrial stimulation in 42 patients with paroxysmal atrial fibrillation (PAF) and in 53 control patients without PAF. Single premature atrial stimulation was given at the right atrial appendage following 8 basic stimuli with a basic cycle length of 500 ms. Repetitive atrial firing (RAF) was defined as the occurrence of 2 or more successive premature atrial activations following single premature atrial stimulation. Fragmented atrial activity (FAA) was defined as an increase by more than 75% of the duration of the atrial electrogram in response to a single premature stimulation. Interatrial conduction delay was defined as an increase of the conduction time by more than 50 ms in response to a single premature stimulation. RAF was induced in 26 of 42 patients (61.9%) with PAF and in 14 of 53 control patients (26A%). FAA and interatrial conduction delay were elicited in 69.0 and 80.9% of patients with PAF and in 34.0 and 56.6% of control patients, respectively. In 16 patients with PAF in whom RAF was not induced, FAA developed in 11 patients (68.8%). In 88.1% of 42 patients with PAF and in 41.5% of 53 controls, RAF or FAA, or both, were elicited by atrial premature stimulation. It is concluded that the incidence of RAF and FAA were significantly higher in patients with PAF than in the control group, and the induction of RAF or FAA, or both, was closely related to the vulnerability of the atrial muscle to atrial fibrillation.     

Why atrial fibrillation recurs in patients who obtained current ablation endpoints with longstanding persistent atrial fibrillation

Purpose

Although several techniques for modification of atrial fibrillation (AF) substrate, such as linear ablation and complex fractionated atrial electrograms (CFAEs) ablation, have been proposed for longstanding persistent AF (LS-AF) and improved the outcome, there was still a certain recurrence rate, even if current ablation endpoints of these techniques were completely achieved. The purpose of this study was to describe the determinants of recurrent AF in patients who obtained current ablation endpoints with LS-AF.

Methods and results

In all, 208 consecutive patients who obtained current ablation endpoints with LS-AF were studied. The current ablation endpoints were defined as complete pulmonary vein isolation, bidirectional block of lines, and disappearance of CFAEs. After a follow-up of 19.9?±?4.1 months, the patients were classified as AF recurrence group and non-AF recurrence group (including patients with sinus rhythm and atrial tachycardia), and 34 (16 %) patients were in the AF recurrence group. The patients in AF recurrence group had higher rates of right atrium (RA) enlargement (67.7 vs. 45.4 %, p?=?0.018) and ≥2 procedure times (58.8 vs. 27.0 %, p?<?0.001), longer AF duration (82.4?±?44.8 vs. 50.8?±?42.8 months, p?<?0.001), and larger left atrium (LA) diameter (49.4?±?6.2 vs. 46.5?±?5.3 mm, p?=?0.007). In the multivariate analysis, RA enlargement, ≥2 procedure times, and AF duration were independent predictors of AF recurrence.

Conclusion

RA enlargement, ≥2 procedure times, and AF duration played important roles in AF recurrence in patients who obtained current ablation endpoints. For these patients with AF recurrence who had already underwent ≥2 procedure times, enlarged RA may contribute to other AF foci and/or substrate, and the ablation strategy may be transformed from LA to RA in the next ablation procedures.     

Electrophysiologic predictors of the recurrence of persistent atrial fibrillation within 30 days of cardioversion

Patients with recurrence of persistent atrial fibrillation within 30 days of cardioversion had slower atrial conduction, a slower sinus rate, no difference in the absolute value of the effective refractory period, greater early reverse remodeling of the effective refractory period, and more premature atrial contractions than those who did not. These findings highlight the role of slow conduction and premature atrial contractions in the pathophysiology of atrial fibrillation and suggest a possible proarrhythmic effect of reverse remodeling.     

已达到消融终点的长程持续性心房颤动复发危险因素分析

目的：探讨已达到消融终点的长程持续性心房颤动（房颤）患者复发的危险因素。方法：纳入达到消融终点的长程持续性房颤患者256例,消融终点定义为双侧肺静脉电隔离,二尖瓣峡部和左心房顶部线性消融双向阻断且碎裂电位消失。根据随访结果将患者分为房颤复发组（n＝43）和无复发组（n＝213）。通过多因素 COX 回归分析探讨房颤复发的独立危险因素。结果：经过（19．5±3．6）个月随访,与无复发组相比,房颤复发组患者右心房内径较大,为（53．31±6．55）mm 对（48．74±5．87）mm;房颤持续时间较长,为（81．83±45．75）个月对（53．16±40．23）个月;左心房内径较大,为（49．85±6．82）mm 对（46．77±5．83）mm,P 均＜0．01。多因素 COX 回归分析发现,左心房内径增大（OR＝1．01,95％CI：1．01～1．28,P ＜0．05）,右心房内径增大（OR＝2．85,95％CI：1．15～7．03,P ＜0．05）、房颤持续时间延长（OR＝1．01,95％CI：1．01～1．02,P ＜0．05）是房颤复发的独立危险因素。结论：除左心房内径和房颤持续时间外,右心房内径增大也是已达到消融终点的长程持续性房颤复发的独立危险因素。     

长期持续性心房颤动导管消融策略的临床研究

目的：比较导管消融治疗长期持续性心房颤动（房颤）不同消融策略的临床疗效。方法2009年5月至2011年3月,入选240例于上海市胸科医院房颤诊治中心接受三维标测系统（ Carto）指导下的导管消融治疗的长期持续性房颤患者,男138例,女102例。随机分为3组,A组：80例患者行环肺静脉前庭电隔离（ CPVA）及心房碎裂电位（ CFAE）消融,B组：80例患者行CPVA＋CFAE＋左心房线性消融,C组：80例患者行CPVA＋CFAE＋左心房线性消融＋三尖瓣峡部线性消融,消融后未能转复窦性心律患者均行直流电复律。消融术后随访心电图和24 h动态心电图评价疗效,比较3组的安全性及临床效果。结果所有患者均顺利完成导管消融术,平均随访（36±7）个月,单次消融后成功率 A 组37．5%、B组52．5%、C组55．0%,多次消融后成功率A组60．0%、B组75．0%、C组76．3%（ P〈0．05）。各组间并发症发生率差异无统计学意义。结论对于长期持续性房颤患者,在CPVA＋CFAE的基础上行左心房线性消融有助于提高成功率,而三尖瓣峡部线性消融效果不确切。     

比索洛尔对持续性非瓣膜性心房颤动患者心房结构重构的影响

目的观察比索洛尔对持续性非瓣膜性心房颤动患者心房结构重构及C反应蛋白(CRP)的影响,并探讨其可能关系。方法将85例持续性非瓣膜性心房颤动患者,分为比索洛尔组(48例)和地高辛组(37例),随访观察(9.8±1.3)个月,治疗前后检测CRP和超声心动图观察左心房结构变化。结果比索洛尔组治疗后左心房内径(41.8±4.2)mmvs(39.7±5.3)mm,CRP 3.9 mg/Lvs3.5 mg/L,均较治疗前明显下降,差异有统计学意义(P<0.01),而地高辛组治疗前后左心房内径(41.8±4.6)mmvs(42.3±5.2)mm,CRP 3.8 mg/Lvs3.5 mg/L,差异无统计学意义(P>0.05)。比索洛尔组的左心房内径和CRP下降幅度与地高辛组比较,差异有统计学意义(P<0.01)。相关分析显示,左心房内径变化与CRP变化呈显著正相关(r=0.218,P=0.045)。结论比索洛尔可改善持续性非瓣膜性心房颤动患者的心房结构重构,并减轻炎性反应。     

持续性心房颤动患者无症状心房颤动的发生情况及影响因素

目的 分析持续性心房颤动(房颤)患者中无症状房颤的发生情况及影响因素.方法 收集经24 h动态心电图监测确诊的持续性房颤患者82例,观察症状的有无及发生比例.经抗心律失常药物治疗3个月后复查24 h动态心电图监测,观察症状的变化情况.采用多无logistic回归分析持续性房颤症状与临床特征的相关性.结果 82例患者中34例(42%)无症状房颤发作,48例有症状房颤发作.应用抗心律失常药物治疗3个月后,48例有症状患者中31例症状完全消失,其中4例转复为窦性心律,27例为无症状房颤发作.34例无症状患者中,5例转复为窦性心律,24例仍为无症状房颤发作.持续性房颤中有症状和无症状患者年龄,瓣膜病比较差异有统计学意义(P＜0.05).其症状与瓣膜病呈正相关(b=1.959,P=0.001),与年龄呈负相关(b=-0.837,P=0.032).结论 持续性房颤患者中无症状房颤的发生率较高.抗心律失常药物既可减少房颤发作,又可减少房颤症状.高龄和非瓣膜病房颤患者易发生无症状房颤.     

持续性心房颤动患者无症状心房颤动的发生情况及影响因素

Objective To investigate the incidence of asymptomatic atrial fibrillation( AF) and the influence factors in patients with persistent AF. Methods A total of 82 consecutive patients with 24 h Holter monitoring identified persistent AF were observed to analyze the incidence of asymptomatic AF. 24 h Holter monitoring was performed again after three months' treatment with antiarrythmic drugs in order to identify the incidence of asymptomatic AF. Multivariate logistic regression was applied for analyzing the correlation between symptoms and clinical features. Results Thirty-four patients(42% )were asymptomatic ,24 patients were symptomatic. After antiarrythmic drugs therapy for three months, 31 patients among 48 symptomatic patients, were completely asymptomatic, 4 were converted to sinus rhythm, 27 were asymptomatic atrial fibrillation. In 34 asymptomatic patients, 5 were converted to sinus rhythm, 24 remain asymptomatic atrial fibrillation. Significant differences were found between symptomatic and asymptomatic patients with persistent AF between age and valvular heart disease( P ＜ 0. 05 ). Symptoms were positively with valvular heart disease (b = 1. 959, P = 0. 001 ),and negatively with age( b = -0. 837,P = 0. 032). Conclusion The incidence of asymptomatic persistent AF was high. Antiarrythmic drugs could not only relieve the episodes of AF, but also the symptoms of AF. Elderly and nonvalvular atrial fibrillation(NVAF) patients were often asymptomatic.     

阿托伐他汀钙在胺碘酮转复持续性心房颤动中的作用观察

目的探讨阿托伐他汀钙联合胺碘酮转复持续性心房颤动(简称房颤)及房颤复律后维持窦性心律的作用及其对血清炎症反应的影响。方法 68例持续性房颤患者,随机分为两组。对照组34例给予胺碘酮,治疗组34例给予胺碘酮和阿托伐他汀钙。两组均连续服药6个月,观察房颤转复后窦性心律维持率及转复前后血清高敏C反应蛋白(hs-CRP)、白介素6(IL-6)、肿瘤坏死因子α(TNF-α)变化。结果治疗组房颤转复率、窦性心律维持率均较对照组高(79.41%vs 61.76%,76.47%vs 55.88%,P均<0.05),对照组治疗前后hs-CRP、IL-6、TNF-α无变化(P>0.05),治疗组治疗后hs-CRP、IL-6、TNF-α明显降低(P<0.05)。结论阿托伐他汀钙可以降低房颤的复发,其机制可能与抗炎作用相关。     

Electrophysiologic testing in the management of patients with the Wolff-Parkinson-White syndrome and atrial fibrillation

Twenty patients with the Wolff-Parkinson-White (WPW) syndrome and 1 or more episodes of symptomatic atrial fibrillation (AF) due to rapid anterograde bypass tract conduction underwent electrophysiologic testing. The mean ventricular rate during spontaneous AF was 242 ± 56 beats/min (± standard deviation) and the shortest preexcited R-R interval was 194 ± 40 ms. Six patients underwent surgical bypass tract ablation and 14 were treated medically, based on the results of electropharmacologic testing. Over a mean follow-up period of 35 ± 19 months (± standard deviation), only 1 patient treated medically had a recurrence of minimally symptomatic AF. The successful chemoprophylaxis of symptomatic AF was associated with the inability to induce AF and atrioventricular reciprocating tachycardia during drug testing (7 patients) or with the induction of AF with a ventricular rate < 200 beats/min and a shortest preexcited R-R interval of > 250 ms (7 patients). Electrophysiologic testing can identify a subgroup of patients with WPW and AF in whom medical therapy is a suitable alternative to bypass tract ablation.