Myocardial injury resulting from radiofrequency catheter ablation: comparison of circumferential pulmonary vein isolation and complex fractionated atrial electrograms ablation

Background  Radiofrequency catheter ablation (RFCA) necessarily produces an area of myocardial necrosis. However, the difference of the extent of myocardial injury between circumferential pulmonary vein isolation (CPVI) and complex fractionated atrial electrograms (CFAE) ablation in patients with atrial fibrillation (AF) has not been investigated before.

Methods  Twenty-nine consecutive male patients (n=29) with either paroxysmal or persistent AF were selected for CPVI or CFAE ablation. The CPVI or CFAE ablation was performed with a three-dimensional electroanatomical mapping system (CARTO). Serum cardiac biomarkers, for example, cardiac troponin T (cTnT), aspartate transaminase (AST), lactate dehydrogenase (LDH), creatine kinase (CK), and creatine kinase myocardial bound (CKMB) were determined by the Elecsys STATE immunoassay. Cardiac structure and function were measured with echocardiography.

Results  Echocardiography showed that there was no significant difference of atrioventricular structure or function parameters between the CPVI group and the CFAE ablation group. Serum cTnT showed a significant increase in the CFAE ablation group over the CPVI group at 12 and 24 hours after the procedure (P <0.05, respectively), and then it was reduced to a normal level after 48 hours. Serum AST showed a significant increase in the CFAE ablation group over the CPVI group at post-procedure, 4 and 12 hours after the procedure (P <0.05, respectively), and then it reached to a normal level after 24 hours. There was no significant difference in LDH, CK, or CKMB levels between the CFAE ablation group and the CPVI group at any time point (P >0.05).

Conclusions  cTnT and AST other than LDH, total CK or CKMB activity significantly increased more in the CFAE ablation group than the CPVI group. However, the difference of the serum levels of cTnT, AST between two groups was temporary.

     

房颤患者环肺静脉电隔离术后快速性房性心律失常的再消融治疗效果分析

目的:观察心房颤动患者环肺静脉电隔离术(CPVI)后快速性房性心律失常(ATa)的再消融治疗效果,并探讨其可能的发生机制。方法:64例阵发性房颤患者在初次行CPVI后(3.7±2.4)个月再次行电解剖标测系统指导下ATa标测和消融。结果:共标测到78种ATa,其中48种(61.5%)为局灶性机制,30种(38.5%)折返机制。在折返机制中,12例为普通房扑,18例为左房内折返,其折返环与二尖瓣峡部、左房前壁及原环肺静脉消融线上的传导间隙有关。2例患者因ATa不稳定而无法标测。64例患者中,56例(87.5%)消融即刻成功,8例需要电复律成窦性心律。术后随访13~21个月,平均(16.5±2.9)个月,60例(93.8%)患者不再发生ATa。结论:CPVI术后ATa的机制可为折返性和局灶性,可通过CARTO系统激动顺序标测成功消融治疗。     

导管射频消融术对房颤患者左心房结构的影响

目的评价导管射频消融术对心房颤动(AF,房颤)患者左心房结构的影响。方法 43例房颤患者接受治疗,其中阵发性房颤32例,持续性房颤11例。8例行肺静脉电隔离术,35例行Carto指导下环肺静脉前庭隔离术,消融终点均为双侧肺静脉完全电隔离。应用超声心动图测定其消融术前1~3 d和术后1、3个月静息时窦性心律下左心房内径,分析消融术前、后左心房结构的变化。结果 43例房颤患者均成功施行环肺静脉左房线性消融术,随访时间(6±2)月,最短3个月,最长14个月,治愈率93.02%。左房内径消融术后1个月较术前无明显改变[(35.74±5.77)mm vs(35.69±6.25)mm,P>0.05],随访3个月时左房内径较术前显著减小[(31.99±3.66)mm vs(35.69±6.25)mm,P<0.01]。结论房颤患者于术后3个月时左房结构可逆重构。     

Linear ablation of left atrium for the treatment of atrial fibrillation guided by double Lasso catheters and three dimensional electroanatomical mapping

Catheter ablation for the treatment of atrial fibrillation (AF) was a topic of electrophy-siological study in recent years.1-4 Linear ablation of left atrium (LA) guided by three dimensional (3-D) electroanatomical mapping (Carto) has been widely accepted by electrophysiologists since the clinical use of 3-D mapping systems in catheter ablation of AF. However, the previous procedures of CPVA were mainly via pure anatomical approaches.5-8 While recent studies showed that complete isolation…     

慢性心房颤动射频消融术后应用氯沙坦联合胺碘酮治疗对心房颤动复发及心房结构的影响

目的观察慢性心房颤动射频消融术后口服氯沙坦联合胺碘酮治疗对心房颤动复发及心房结构的影响。方法拟行射频消融治疗的慢性心房颤动患者100例,随机分为射频消融组50例和射频消融+药物组(氯沙坦联合胺碘酮)50例。术后行动态心电图检查确定心律失常发作情况,超声心动图复查心脏结构和功能。结果电学隔离后15例患者转为窦性心律(射频消融组8例,射频消融+药物组7例),每组各有4例患者转为三尖瓣峡部相关心房扑动,消融三尖瓣峡部后转为窦性心律。其他患者通过进一步消融及电复律转为窦性心律。与射频消融组比较,射频消融加药物组术后1 a左心房前后径减小,而心功能无明显变化。随访过程中射频消融组心房颤动复发率为60.0%,射频消融加药物组心房颤动复发率为32.0%,2组比较差异有统计学意义(P<0.05)。结论慢性心房颤动射频消融术后口服氯沙坦联合胺碘酮可有效维持窦性心律,使左心房前后径减小。     

环肺静脉电隔离联合左心房线性消融治疗阵发性心房颤动的临床研究

目的 探讨环肺静脉电隔离联合左心房线性消融治疗阵发性心房颤动(PAF,简称房颤)的临床效果与安全性.方法 选择23例PAF患者,应用Ensite3000 Navx系统和Lasso电极指导下行环肺静脉电隔离及左房顶部线、峡部线消融.消融终点为:在消融过程中房颤终止,且肺静脉电位消失,或房颤不终止,但肺静脉电位消失;若在窦律下消融,肺静脉电位消失;左心房顶部及峡部线达到完全阻滞.结果 23例PAF患者均顺利完成手术,手术时间234～297 min,平均(277±41)min,X线暴光时间29～55 min,19例患者术中出现房颤,其中14例在消融过程中房颤终止且达到肺静脉电隔离,另外5例消融过程中房颤未终止,但肺静脉完全隔离.4例患者在窦性心律下完成了肺静脉电隔离.左心房顶部线全部达到完全阻滞,峡部线有2例未能达到完全阻滞.随访期间发现3个月后有86.9%的患者房颤消失或明显减少.结论 环肺静脉电隔离联合左心房线性消融治疗PAF 安全、可靠. Abstract： Objective To study the clinical efficacy and safety of circumferential pulmonary vein isolation of paroxysmal atrial fibrillation(PAF) combined with left atrial linear lesion. Methods Twenty-three PAF patients were performed circumferential pulmonary vein isolation combined linear lesion of left atrial isthmus and loof with Ensite 3000 Navx and Lasso electrodes guiding. Radiofrequency end point, atrial fibrillation stopped and pulmonary vein potentials(PVPs) disappeared, or atrial fibrillation did not stop, but PVPs disappeared. PVPs disappeared if atrial fibrillation was ablated during sinus rhythm. Left atrium loof and isthmus line were complete block.Results Twenty-three PAF patients were performed ablation, operation times were from 234 to 297 minutes, X ray time was from 29 to 55 minutes, 19 atrial fibrillations occurred during operation, of which 14 atrial fibrillations stopped with pulmonary vein isolation and linear lesion, the other 5 atrial fibrillations didn't stop, but which pulmonary veins were isolated. Tour patients were performed pulmonary vein isolation during sinus rhythm. All roof lines were completely block, and 2 left atrial isthmus lines were not completely block. 86.9% patients' atrial fibrillation disappeared or decreased significantly.Conclusions It is safe and efficient to treat PAF with circumferential pulmonary vein isolation combined with left atrial linear lesion.     

EnSite NavX三维电生理系统指导下环肺静脉前庭隔离导管消融治疗心房颤动

目的 探讨EnSire NavX三维电生理系统指导环肺静脉前庭隔离导管消融治疗心房颤动(房颤)的有效性和安全性.方法 在EnSite NavX三维电生理系统指导下对38例药物治疗无效的阵发性或持续性房颤患者行环肺静脉导管消融,随访观察其疗效和安全性.结果 38例患者都达到消融终点,双侧肺静脉均完全隔离.手术操作时间(233.8±31.7)min,X线曝光时间(32.5±4.7)min,左房建模时间(27.5±7.5)min.术后随访(9±3)月,单次消融的成功率为89.5%,出现并发症7.9%.结论 EnSite NavX三维电生理系统指导下环肺静脉前庭隔离导管捎融治疗房颤是一种较为有效且安全的方法.     

经导管消融治疗局灶性心房颤动的研究进展

心房或与心房相连的大静脉内存在一个或多个致心律失常的异位兴奋灶发放冲动而引发的心房颤动被称文局灶性心房颤动。经导管消融这些异位兴奋灶可根治房颤。但这种非药物性治疗存在一些问题：严重并发症、标测困难曝光时间长和复发率高。近年，新的标测及辅助手段和新的消融系统可提高治疗的成功率和安全性。     

超声斑点追踪技术评价阵发性房颤患者射频消融前后左心房功能变化

目的：探讨超声斑点追踪成像（STI）技术评价阵发性房颤患者射频消融前后左心房功能变化。方法对28例成功接受环肺静脉消融治疗的阵发性心房颤动患者于术前、术后24 h及术后3个月进行常规超声心动图检查。常规二维超声测定左心房内径（ LAD）、舒张早期跨二尖瓣血流速度（ E）、舒张晚期跨二尖瓣血流速度（ A）。应用STI技术测定左心房各壁应变率曲线,获得左心室收缩期左心房峰值应变率（ SRs）、左心室舒张早期左心房峰值应变率（SRe）、左心室舒张晚期左心房峰值应变率（SRa）,并计算左心房壁中段峰值应变率的平均值（mSRs、mSRe、mSRa）。应用改良Simpson′s 法测定左心房最大容积（LAVmax）、左心房最小容积（LAVmin）、左心房P容积（LAVp）,计算出左心房主动射血分数（LAAEF）及左心房被动射血分数（LAPEF）。结果①28例阵发性房颤患者成功实施环肺静脉消融术,LAD、LAVmax、LAVmin及LAVp术后24 h无明显变化,术后3个月较术前相比明显减小,差异有统计学意义（P＜0．05）。术后24 h LAAEF、LAPEF无明显变化,术后3个月LAAEF较术前明显增加（P＜0．05）。术后24 h二尖瓣舒张晚期A峰峰值较术前降低（P＜0．05）,术后3个月较术前明显增加（P＜0．05）。②术后24 h mSRs、mSRe及mSRa与术前相比均降低（P＜0．05）,术后3个月mSRs、mSRe恢复至术前水平,mSRa较术前明显改善（P＜0．05）。结论 STI技术可以无创评价左心房功能;成功射频消融术后对左心房功能早期虽然存在不利影响,但随时间推移左心房重构将得到恢复,左心房辅助泵功能明显改善。     

电视胸腔镜辅助下双侧肺静脉隔离治疗心房颤动的临床研究

目的总结11例电视胸腔镜辅助下双侧肺静脉隔离治疗心房颤动的临床经验。探讨该术式的特点及优势。方法选择2005年12月至2009年5月在同济大学附属东方医院心胸外科住院进行房颤治疗患者,房颤不能用药物控制．不能耐受抗心律失常或抗凝药物治疗的患者11例。在胸腔镜下通过小切口,使用AtriCure消融钳分别消融右侧和左侧上、下肺静脉,并切断Marshall韧带,切除左心耳。结果手术顺利,无围手术期死亡,均术后1周出院,随访未见肺静脉狭窄。9例即刻转为窦性心律,3个月随访维持窦性心律8例,总体房颤治愈率73％。结论电视胸腔镜辅助下双侧肺静脉隔离治疗房颤．有较高的安全性,同时技术简单,设备要求不高,是一项值得推广的房颤治疗手段。     

可调弯鞘在心房颤动环肺静脉隔离术中的应用经验

目的 使用可调弯鞘(Agilis NxT 鞘)对阵发性心房颤动(以下简称房颤)进行导管消融隔离双侧肺静脉。方法 26例阵发性房颤患者,应用可调弯鞘支持下进双侧肺静脉行隔离术。穿刺房间隔,双侧肺静脉造影后,在EnSite Velocity^TM v3.0指导下构建左心房几何模型,行双侧肺静脉电学隔离。结果 26例患者均完成环肺静脉电学隔离。平均手术时间为(165.7±48.1)min,平均放射时间为(25.0±9.4)min,其中房间隔穿刺透视时间为(1.3±0.5)s,应用环状电极建模时间(7.5±4.3)min,左肺静脉隔离时间(55±17)min,右肺静脉隔离时间(37±11)min。有1例患者发生心脏压塞,经心包穿刺后好转。随访6~12个月,有3例患者(11.5%)复发。结论 Agilis NxT可以应用于针对阵发性房颤导管消融的环肺静脉隔离,可以减少导管在心腔内的操作,简化手术过程,具有较好的安全性和有效性。     

Recurrent atrial tachycardia and atrial fribrillation after circumferential pulmonary vein ablation: What's the difference?

Background Recurrent atrial tachyarrhythmia (ATa) after circumferential pulmonary vein ablation (CPVA) includes atrial tachycardia (AT) and atrial fribrillation (AF). However, whether there are some differences in clinical course and mechanisms between the recurrent AT and the recurrent AF remained unclear. This study was conducted to investigate the incidence, mechanism, clinical course of the recurrent AT and AF in patients under CPVA.Methods One hundred and thirty consecutive patients (M/F=95/35) with highly symptomatic and multiple antiarrhythmic drugs (AADs) refractory paroxysmal (n=91) or persistent (n=39) AF were included. The ablation protocol consisted solely of two continuous circular lesions around the ipsilateral pulmonary veins (PV) guided by CARTO system. The endpoint of CPVA is PV isolation. For patients with recurrent ATa within 2 months after the initial procedure, cardioversion with direct current was attempted if the ATa lasted for more than 24 hours. A repeat ablation procedure was performed only for patients with AADs refractory recurrent ATa and at least followed up for 2 months after the initial procedure.Results Within 2 months after the initial procedure, 52 patients (40.0%) had experienced episodes of symptomatic recurrent ATa. Among them, 23 patients (44.2%) with recurred AT alone (AT group), 14 patients (26.9%) with recurred AF alone (AF group), and 15 patients (28.8%) with recurred AT and AF (AT plus AF group). The delayed cure rate (65.2%) in AT group was significant higher than that in AF group (21.4%, P<0.05) and AF plus AT group (26.7%, P<0.05). A repeat ablation was performed in 21 patients, including 6 patients with recurrent AT alone, 8 patients with recurrent AF alone, and 7 patients with recurrent AF plus AT. The mean number of PV gaps was 1.2±0.4 in AT group, which was significantly lower than that in AF group (2.6±0.7, P<0.05) and AF plus AT group (2.0±0.6, P<0.05). Delayed cure rate and number of PV gaps between AF group and AF plus AT group were comparable (P>0.05).Conclusions Present study indicates that recurrent AT and AF after CPVA have the different clinical course and different electrophysiological findings during repeat procedure as follows: ⑴After CPVA, spontaneous resolution of recurrent ATa was mainly found in patients with recurrent AT alone (about two thirds patients). ⑵The type of recurrent ATa after CPVA is associated with the number of PV gaps.     

Impact of the origin of sinus node artery on recurrence after pulmonary vein isolation in patients with paroxysmal atrial fibrillation

Background  Major atrial coronary arteries, including the sinus node artery (SNA), were commonly found in the areas involved in atrial fibrillation (AF) ablation and could cause difficulties in achieving linear block at the left atrial (LA) roof. The SNA is a major atrial coronary artery of the atrial coronary circulation. This study aimed to determine impact of the origin of SNA on recurrence of AF after pulmonary vein isolation (PVI) in patients with paroxysmal AF.

Methods  Seventy-eight patients underwent coronary angiography for suspected coronary heart disease, followed by catheter ablation for paroxysmal AF. According to the origin of SNA from angiographic findings, they were divided into right SNA group (SNA originating from the right coronary artery) and left SNA group (SNA originating from the left circumflex artery). Guided by an electroanatomic mapping system, circumferential pulmonary vein ablation (CPVA) was performed in both groups and PVI was the procedural endpoint. All patients were followed up at 1, 3, 6, 9 and 12 months post-ablation. Recurrence was defined as any episode of atrial tachyarrhythmias (ATAs), including AF, atrial flutter or atrial tachycardia, that lasted longer than 30 seconds after a blanking period of 3 months.

Results  The SNA originated from the right coronary artery in 34 patients (43.6%) and the left circumflex artery in 44 patients (56.4%). Freedom from AF and antiarrhythmic drugs (AADs) at 1 year was 67.9 % (53/78) for all patients. After 1 year follow-up, 79.4% (27/34) in right SNA group and 59.1% (26/44) in left SNA group (P=0.042) were in sinus rhythm. On multivariate analysis, left atrium size (HR=1.451, 95%CI: 1.240–1.697, P <0.001) and a left SNA (HR=6.22, 95%CI: 2.01–19.25, P=0.002) were the independent predictors of AF recurrence.

Conclusions  The left SNA is more frequent in the patients with paroxysmal AF. After one year follow-up, the presence of a left SNA was identified as an independent predictor of AF recurrence after CPVA in paroxysmal AF.

     

支架植入术治疗房颤射频消融术后严重肺静脉狭窄的疗效观察

目的：探讨支架植入术治疗房颤射频消融术(RFA)后严重肺静脉狭窄的临床疗效及安全性。方法选择接受房颤RFA 治疗的231例患者进行回顾分析,其中8例患者经 CT 血管成像(CTA)证实术后出现严重肺静脉狭窄。在行血管造影确定病变血管数量、部位及狭窄程度后,在病变部位置入支架,随访观察临床疗效。结果8例患者均顺利完成介入手术治疗,共发现病变血管19支,均植入支架。支架植入术后患者血管狭窄程度、跨狭窄压力阶差、平均肺动脉压及血浆钠尿肽(BNP)水平与支架植入术前相比均显著降低(P <0.01)。最窄处肺静脉内径与支架植入术前相比明显增宽(P <0.01)。术后半年复查 CTA,2例患者共4支血管出现轻-中度再狭窄,给予高压球囊扩张后狭窄消失。扩张术后3个月 CTA 复查,所有患者均未见明显狭窄出现。结论支架植入术治疗房颤射频消融术后严重肺静脉狭窄近期疗效满意,安全可行。     

Initial experience with circumferential pulmonary vein ablation guided by fusion of magnetic resonance imaging with three-dimensional electroanatomic mapping

Catheter ablation for the treatment of atrial fibrillation （AF） has been a focal target ofelectrophysiological study in recent years. Up to date, circumferential pulmonary vein ablation （CPVA） guided by three-dimensional （3-D） electreanatomic mapping （Carto, USA） has been one of the most favourable procedures for the treatment of AF. However, it is still difficult to acquire the detailed information on number, location, and branching pattern of all pulmonary veins （PVs） when the 3-D electroanatomic mapping system is used alone.     

灌注超声导管与冷盐水灌注射频导管电学隔离肺静脉的对比研究

目的 :对比灌注超声导管与冷盐水灌注射频导管电学隔离犬肺静脉的效果 ,以探讨灌注超声导管用于肺静脉电学隔离治疗的可行性。方法 :健康杂种家犬 2 3只 ,按不同消融方法随机分为冷盐水灌注射频导管组 (A组 ,n =12 )及灌注超声导管组 (B组 ,n =11)。房间隔穿刺后在环状电极标测指导下分别采用两种导管行肺静脉电学隔离 ,隔离 3 0min后再次评价心房与肺静脉之间 (LA -PV)电传导是否恢复。结果 :A组与B组犬肺静脉电隔离即刻成功率分别为 97. 9% (4 6/ 47)和 78 .6% (3 3 / 42 ) ,B组显著低于A组 (P <0 . 0 5 ) ;3 0min后左心房 -肺静脉电学传导恢复率分别为 71 .7% (3 3 / 46)和 2 7 .3 % (9/ 3 3 ) ,B显著低于A组 (P <0 . 0 1)。结论 :灌注超声导管电学隔离肺静脉的即刻成功率低于冷盐水灌注射频导管 ;但隔离成功后 3 0minLA -PV电传导恢复率也显著低于冷盐水灌注射频导管。     

肺静脉脂肪垫酒精消融治疗犬心房颤动的实验研究

目的探讨肺静脉脂肪垫酒精消融对左心房-肺静脉交界触发的局灶性房颤治疗的有效性。方法成年杂种犬10只,通过脂肪垫静注氯化乙酰胆碱（Ach）＋心房短阵快速电刺激（burst）诱发出左心房-肺静脉交界触发的局灶性房颤,并给予心内电生理监测。比较房颤模型建立前后及肺静脉脂肪垫酒精消融前、后,左右心房不应期、肺静脉-左房交界处不应期以及房颤诱发率。结果所有犬均能诱发房颤,左房和肺静脉-左房交界处不应期均较基线（窦性心律时）显著缩短（P〈0.0001）,右房无明显变化（P=0.343）。酒精消融后房颤诱发率显著降低（P〈0.003）;肺静脉-左房交界处不应期显著增加（P=0.037）;左房及右房不应期无变化（P=0.343）。结论肺静脉脂肪垫酒精消融对左心房-肺静脉交界触发的局灶性房颤治疗有效。     

导管射频消融术治疗特发性房颤的临床疗效和安全性分析

目的 评价导管射频消融术治疗特发性房颤的临床疗效和安全性.方法 38例房颤患者接受治疗,其中阵发性房颤29例,持续性房颤9例.6例行肺静脉电隔离术,32例行Carto指导下环肺静脉前庭隔离术,消融终点均为双侧肺静脉完全电隔离.结果 38例患者术后即刻均成功迭到消融终点,手术过程中无并发症发生.术后3～5d有8例出现了房性心律失常.2例复发患者中1例为持续性房颤转为阵发性房颤,再次行导管消融获得成功;1例阵发性房颤发作频率明显减少、口服胺碘酮可维持窦性心律.其余36例患者均无房颤复发.所有患者术后均未发生与导管消融有关的并发症.结论 导管射频消融术治疗特发性房颤是安全有效的治疗方法 .     

导管消融联合左心耳封堵在心房颤动患者中的应用进展

心房颤动是临床上常见的心律失常,其症状可导致生活质量下降,并且会增加患者缺血性卒中和心力衰竭的发生风险。导管消融术能有效缓解患者症状,但目前还没有足够的证据表明其降低卒中发生率。左心耳封堵术是心房颤动卒中预防的有效手段。导管消融联合左心耳封堵的一站式手术,适用于高卒中、高出血风险的非瓣膜性心房颤动患者。本文综述了心房颤动一站式手术的安全性、有效性及其疗效的影响因素,以供临床参考借鉴。