新型冷冻球囊消融技术治疗心房颤动的研究进展

目前经皮导管消融技术是治疗心房颤动(简称房颤)的重要手段,而肺静脉隔离是消融技术的基石。射频消融术进行肺静脉隔离耗时长、风险大、操作复杂,严重影响其临床应用,新型冷冻球囊消融技术可解决此缺点。     

阵发性房颤二代冷冻球囊消融术后复发的相关因素

目的：探讨二代冷冻球囊治疗阵发性心房颤动的有效性以及安全性,并分析其术后复发的相关危险因素。方法：研究纳入2017年2月至2021年10月于南京鼓楼医院行二代冷冻球囊消融术的阵发性心房颤动患者。记录患者的基线临床资料、术中冷冻消融参数、手术并发症和随访结果。手术后3、6、12个月及以后每12个月进行规律的门诊及电话随访。根据术后是否复发分组,比较两组患者的差异,并通过多因素Logistic回归分析术后复发的独立危险因素。房颤复发定义为术后3个月以后常规心电图或24 h动态心电图提示持续时间≥30 s的房颤、房扑、房速。结果：总共204例患者被纳入分析,年龄为(61.27±10.25)岁,中位病程为15(3,60)个月,其中110(53.9%)例为男性患者,共10(4.9%)例患者出现手术并发症。术中累计消融833根肺静脉,每根肺静脉平均消融(1.89±0.31)次,平均消融时间为(277.34±38.94) s,平均最低温度为(-48.19±3.95)℃。总计135(66.2%)例患者在冷冻过程中监测到肺静脉隔离时间（TTI）,平均TTI时间为(35.41±13.00) s。在中位随访...     

冷冻球囊导管消融治疗心房颤动的研究进展

心房颤动(AF)在临床上很常见,有较高的致死率及致残率,其引发的一系列症状及其并发症严重影响人们的生活质量及寿命。AF的治疗方法首选节律控制,节律控制又包括药物复律、电复律及导管消融。近年来,冷冻球囊导管消融治疗AF已达到与射频导管消融相同的治疗效果。冷冻球囊导管消融可提高肺静脉隔离成功率、缩短手术时间,并可提供新的消融策略和AF复发预测因素。对冷冻球囊导管消融治疗AF的发展历史、临床疗效、局限性和展望等进行阐述,可为临床实践提供一定的指导作用,安全有效地进行肺静脉隔离,从而促进冷冻球囊导管消融治疗AF的广泛应用。     

球囊冷冻消融联合左心耳封堵一站式治疗心房颤动进展

症状明显、卒中风险高危的非瓣膜性心房颤动（简称房颤）患者,可以考虑导管消融联合左心耳封堵的一站式治疗策略。近年来,球囊冷冻消融也已成为房颤的标准治疗。国内外有不少中心开展了球囊冷冻消融联合左心耳封堵的一站式手术。本文对国内外行球囊冷冻消融联合左心耳封堵治疗房颤的现状进行了综述,重点介绍这一策略的安全性和有效性。     

阵发性心房颤动肺静脉消融

在ＡＦ发病中,多折返机理已被认可,然而局部组织兴奋性增高和触发活动也起重要作用,已证实极大部分二起源于肺静脉,因此使肺静脉消融治疗ＡＦ成为可能,本文从ＡＦ的特点、病人选择、术前注意事项、消融方法、消融终点以及并发症等方面对ＰＡＦ肺静脉消融进行综合分析。     

射频消融治疗阵发性心房颤动的问题及思考

心房颤动的治疗是临床上的一个难点,也是目前关注的热点。由于药物的毒性和低效性,长期用药物来维持窦律的做法已受到了质疑。近年来,采用肺静脉电位隔离的方法消融阵发性心房颤动(简称房颤)已取得一系列进展,为阵发性房颤的治疗带来了新的希望。但该方法仍需要进一步探索,本文就房颤消融过程中常出现的问题提出几点思考:     

冷冻球囊消融治疗心房颤动合并心力衰竭患者临床疗效观察

目的评价冷冻球囊消融(CCA)治疗心房颤动合并心力衰竭患者的安全性和有效性。方法回顾性分析2020年6—11月在中国科学技术大学附属第一医院诊治的3例房颤合并心衰患者,均采用CCA治疗心房颤动,观察手术的安全性。术后收集3个月和6个月的心脏超声、动态心电图、美国纽约心脏病协会(NYHA)心功能分级和N基末端B型钠尿肽(NT-proBNP)结果,观察消融治疗有效性。结果 3例患者均成功实现全部肺静脉隔离,患者1肺静脉隔离后转为心房扑动,经激动标测和拖带标测证实为三尖瓣峡部依赖典型房扑,三尖瓣峡部隔离后转为窦性心律;患者2、3肺静脉隔离后,电复律转为窦性心律,并在窦性心律下行心房电压标测,提示心房电压正常,未行基质改良;手术顺利,无并发症发生。随访6个月内,3例患者的心超参数明显改善(左室射血分数分别增加26%、32%和21%,左室舒张末内径及左房前后径较术前明显缩小),NYHA心功能分级较术前改善1～3级,NT-proBNP均降至正常范围。患者1在6个月随访时复发,再次行消融治疗,随访6个月无房颤发生。结论冷冻球囊消融治疗房颤合并心衰是安全且有效的,可以改善心功能和心脏结构,同时可以降低...     

房颤导管消融术复发的危险因素

导管消融技术改变了心房颤动的治疗策略,且其疗效确切,手术创伤小。导管消融术治疗房颤结局显著 优于抗心律失常及控制心室率等药物的治疗方案,但其术后心房颤动的复发率高,其复发的影响因素包括年龄、性 别、体重指数、基础疾病、左心房体积、肺静脉容积、基因、房颤类型、手术方式等。针对这些因素进行相应调 整,对改善导管消融术后的临床疗效及预后至关重要。     

最大P波宽度及P波离散度对阵发性房颤环肺静脉隔离术后复发的预测作用

目的探讨最大P波宽度(Pmax)及P波离散度(Pd)对阵发性心房颤动(房颤)环肺静脉隔离术后复发的预测作用(circumferential pulmonary vein ablation,CPVA)。方法 69名因阵发性房颤接受环肺静脉隔离术的患者,在术前和术后窦性心律时分别测定记录Pmax和Pd,并对患者进行随访,了解其复发情况。结果随访8～36个月,共有16名患者房颤复发,复发组和无复发组在年龄、性别、病程、基础疾病、左房内径(LA)、左室舒张末期内径(LVed)、射血分数(EF)上差异均无统计学意义;两组术前及术后Pmanx、Pd差异均无统计学意义,但术前和术后Pmax及Pd在复发组均有高于无复发组的趋势。复发组术后Pmax小于术前(P<0.05),而无复发组术后Pmax、Pd及复发组Pd均有小于术前的趋势。结论 Pmax及Pd对预测阵发性房颤消融术后复发的作用尚不能确定,但左房内消融可能影响了折返激动的形成。仍需大规模临床试验进一步评价体表心电图对预测房颤消融术后复发的价值,从而筛选复发高风险患者,予以干预措施,减少CPVA术后房颤复发。     

糖皮质激素对阵发性心房颤动射频消融术后复发的影响

目的：探讨糖皮质激素的使用对阵发性心房颤动（AF）患者导管射频消融（RFCA）术后 AF 复发的影响。方法本研究连续入选2011年1月至2014年4月在该院心血管内科行环肺静脉 RFAC 术,并在术后使用糖皮质激素的阵发性 AF 患者50例（激素治疗组）,并选取同期行 RFCA 术,术后未使用糖皮质激素的阵发性 AF 患者37例作对照组。术后1周、1个月、3个月、6个月、9个月、12个月,由固定医生进行电话或门诊随访,询问患者有无心悸症状或脉搏不齐,收集患者院外心电图报告,行十二导联心电图和24 h 动态心电图检查,分析、比较激素治疗组和对照组的 AF 复发情况。结果术后1周,激素治疗组和对照组窦性心律维持率分别为80．0％和54．1％,两组差异有统计学意义（P＜0．05）,激素治疗组复发率显著降低;术后1个月,激素组和对照组窦性心律维持率分别为80．0％和67．6％,两组差异无统计学意义（P＝0．187）;激素组和对照组术后12个月的 AF 复发率差异无统计学意义（P＝0．711）。绘制 Kaplan-Meier 生存率曲线,行 Log-rank 检验,两组 AF 复发率差异无统计学意义（P ＝0．711）。结论术后早期小剂量糖皮质激素使用能够降低 RFCA 术后超早期（7 d 内）的房颤复发,但对术后极早期（术后1个月）和中期（术后12个月）房颤复发率无影响。     

阵发性心房颤动两种射频消融术式的随机对照研究

目的:比较优化导管射频消融术(optimized radiofrequency catheter ablation,ORFCA)和环肺静脉隔离术(circumferential pulmonary vein isolation,CPVI)治疗阵发性心房纤颤(atrial fibrillation,AF)的有效性、安全性。方法:2009年3月至2010年3月于郑州市第七人民医院心内科行射频消融术(radiofrequency cather ab-lation,RFCA)治疗的阵发性AF患者随机分为CPVI组(n=40)和ORFCA术(n=44)。两组采取不同的消融术式,观察患者的左心房直径、房颤持续时间、左心室功能,成功率、并发症发生情况、消融点数、手术时间、曝光时间等数据,并比较两组之间的差别。结果:通过对CPVI组和ORFCA组基本情况的比较我们发现两组的性别组成、年龄、发作病史、左心房直径、左心室功能、应用抗心律失常药物种类方面无差别。CPVI组在消融点数、手术时间、曝光时间、成功率上均小于ORFCA组,差异有统计学意义(P<0.05)。两组在并发症发生率上无差别。结论:ORFCA术具有和CPVI术相似的安全性,和相对较高的有效性。     

阵发性心房颤动射频消融术预后的影响因素分析

目的探讨阵发性心房颤动射频消融术预后的影响因素。方法阵发性心房颤动行环肺静脉消融术患者68例,测定消融术前患者体质量指数(BMI)、P波离散度及左房容积指数(LAVI),根据随访结果分为成功组56例,复发组12例,分析2组相关指标的差异。结果复发组BMI、P波离散度及LAVI高于成功组,环肺静脉消融后,成功组P波离散度及LAVI较消融前明显减小,且明显低于复发组(P<0.05),而复发组2指标差异无明显变化,Logistic多因素逐步回归分析显示P波离散度及LAVI是阵发性心房颤动行环肺静脉消融术复发的危险因素(分别为OR=1.263,95%CI 1.018¹.676;OR=6.372,95%CI 3.2681.676;OR=6.372,95%CI 3.268¹8.348,P均<0.05)。结论 P波离散度及LAVI是阵发性心房颤动行环肺静脉消融术复发的影响因素。     

Serum uric acid levels correlate with recurrence of paroxysmal atrial fibrillation after catheter ablation

Background  Recently there has been a great deal of interest in the role of serum uric acid (SUA) in atrial fibrillation (AF). The objective of this study was to establish whether there is a relationship between levels of SUA and recurrence of paroxysmal AF after catheter ablation.

Methods  Three hundred and thirty patients diagnosed with paroxysmal AF were analyzed. Patients were categorized into quartiles on the basis of their pre-operative SUA measurement and follow-up, and Kaplan-Meier estimation with a Log-rank test was used for the analysis of the influence of SUA on the recurrence of AF. Pre-procedural clinical variables were correlated with the clinical outcome after ablation using multivariate Logistic analysis. A Cox proportional hazards model was used to estimate the relationship between SUA and the recurrence of AF.

Results  After a mean follow-up of (9.341±3.667) (range 3.0–16.3) months, recurrence rates from the lowest SUA quartile to the highest SUA quartile were 16.0%, 26.4%, 28.3%, and 29.3% respectively (P=0.014). After adjustment for gender, body mass index (BMI), hypertension, serum levels of high sensitivity C-reactive protein (hsCRP), triglyceride (TG), left atrial diameter (LA), estimated glomerular filtration rate (eGFR), and SUA, there was an increased risk of recurrence in subjects in the highest SUA quartile compared with those in the lowest quartile (hazard ratio 2.804, 95% confidence interval 1.466–5.362, P=0.002). Following multivariate Logistical analysis, SUA was found to be an independent predictor of recurrence (hazard ratio 1.613, 95% confidence interval 1.601–1.625, P=0.014).

Conclusion  In a retrospective study of patients with paroxysmal AF undergoing catheter ablation, elevated preoperative SUA levels were associated with a higher rate of recurrence of AF.

     

Effect of anxiety and depression on the recurrence of persistent atrial fibrillation after circumferential pulmonary vein ablation

Background  The effects of anxiety and depression on the recurrence of persistent atrial fibrillation (AF) after circumferential pulmonary vein ablation (CPVA) are not clear. Whether CPVA can alleviate the anxiety and depression symptoms of persistent AF patients is unknown.

Methods  One hundred and sixty-four patients with persistent AF, of which 43 treated with CPVA (CPVA group) and 103 treated with anti-arrhythmics drugs (medicine group), were enrolled. The Zung Self-Rating Anxiety Scale (SAS), and Zung Self-Rating Depression Scale (SDS) were assessed before and 12 months after treatment in all patients.

Results  The scores of SAS (40.33±7.90 vs. 49.76±9.52, P <0.01) and SDS (42.33±8.73 vs. 48.17±8.77, P <0.01) decreased 12 months after CPVA. Over 12 months follow-up, AF relapsed in 17 patients in CPVA group. Compared with the data in the recurrent group (17 patients), the scores of SAS and SDS were significantly lower in the non-recurrent group (26 patients) at baseline. The results of multivariate Logistic regression analysis showed normal scores of SAS and SDS were the independent risk factors of AF recurrence after CPVA.

Conclusions  Anxiety and depression increase the recurrence risk of persistent AF after CPVA. CPVA can ameliorate the anxiety and depression symptoms in patients with persistent AF. 

     

Catheter ablation of persistent atrial fibrillation with and without a history of paroxysmal atrial fibrillation

Background  It is unclear whether a history of paroxysmal atrial fibrillation (PAF) would impact the effect of catheter ablation on persistent atrial fibrillation (AF). This study aimed to compare the effect of catheter ablation on persistent AF with and without a history of PAF.

Methods  One hundred and eighty-three patients underwent catheter ablation of persistent AF lasting for >1 month and were reviewed. Patients were divided into two groups according to whether they had a history of PAF or not. Group I consisted of persistent AF patients with a history of PAF, and group II consisted of persistent AF patients without such a history. All patients received catheter ablation focused on pulmonary vein isolation and were observed for arrhythmia recurrences, which were defined as documented episodes of AF or atrial tachycardia after a blanking period of 3 months.

Results  One hundred and three patients (60.9%) in group I and sixty-six patients (39.1%) in group II were successfully followed and included in analysis. There were no significant differences in clinical and echocardiographic characteristics between both groups except for a younger age and more male patients in group II. After (15.5±10.7) months of follow-up, 59 (57.3%) patients in group I and 49 (74.2%) patients in group II maintained sinus rhythm free of anti-arrhythmia drugs (P=0.025). Multivariate analyses found left atrial anteroposterior diameter (P=0.006) and persistent AF with a history of PAF (OR 1.792, 95% CI 1.019–3.152; P=0.043) as the only independent statistical predictors of arrhythmia recurrences.

Conclusion  The arrhythmia recurrence rate of catheter ablation based on pulmonary vein isolation in persistent AF with a history of PAF was higher than those without a history of PAF

     

Impact of different ablation strategies on the delayed cure after trans-catheter ablation for treating patients with atrial fibrillation

Background Delayed cure had been observed in recurrent cases after index ablation of atrial fibrillation (AF), however, its mechanism and incidence have not been elucidated in detail. This study aims to investigate the impact of different ablation strategies on the incidence of delayed cure and its possible mechanisms after trans-catheter ablation of AF. Methods One hundred and fifty-one consecutive cases with highly symptomatic, drug refractory AF were included in this study ［M/F=109/42, mean age （56.0±11.2） (18-79) years］. Segmental pulmonary vein ablation (SPVA) was performed in 83 patients with the guidance of circular mapping catheter (SPVA Group), circumferential PV linear ablation (CPVA) was carried out in the rest 68 cases under the guidance of 3 dimensional mapping system in conjunction with circular mapping catheter (CPVA Group). Delayed cure was defined as that early recurrence of atrial tachyarrhythmias (AF, atrial tachycardia, or atrial flutter) after ablation procedure was no longer observed during subsequent follow-up, and stable sinus rhythm was maintained ≥2 months. Results Early recurrence of atrial tachyarrhythmias was detected in 41 cases from SPVA group and 23 cases from CPVA group, and delayed cure occurred in 21.9% (9/41) of the cases from SPVA group and 47.8% (11/23) of the cases from CPVA group, more delayed cure in later group was observed (P&lt;0.05). Meanwhile, patients in SPVA group took a longer time to achieve a delayed cure ［(27.0±18.0) days vs （14.0±8.1） days, P&lt;0.05］, and presented more recurrent episodes ［(3.50±1.08) times a week vs （2.42±1.11） times a week, P&lt;0.05］. However, recurrent episodes after index ablation were markedly decreased in cases with delayed cure from both groups (P&lt;0.05). Conclusions Despite of an early recurrence of atrial tachyarrhythimas after index ablation of AF, delayed cure occurs in a significant number of patients undergoing either SPVA or CPVA. However, different ablation strategies place different impact on the delayed cure, more delayed cure is obtained with CPVA approach, and the delayed cure occurs earlier with this approach; the average recurrent episodes before delayed cure are also less frequently detected in CPVA group compared with those in SPVA group.     

不同消融策略治疗阵发性心房颤动的临床研究

目的 研究不同射频导管消融（RFCA）策略治疗阵发性心房颤动（PAF）的临床效果.方法 将44例PAF患者分成两组：①肺静脉电隔离组（PVI）21例,应用Ensite3000 Navx系统和Lasso电极指导下进行环肺静脉电隔离.终点消融为：若房颤发生,在消融过程中房颤终止,且肺静脉电位（PVP）消失,或房颤未终止,但PVP消失 若在窦律下消融,PVP消失.②PVI联合左房线性消融（PVI＋LALL）组23例,除完成PVI外,进行左心房顶部线和峡部线的消融并达到完全阻滞.结果 ①PVI组21例PAF患者均顺利完成手术,手术时间189～267 min,X线暴光时间24～51 min,17例患者术中出现房颤,其中9例在消融过程中房颤终止且达到肺静脉电隔离,另外8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.随访期间发现3个月后有67%的患者房颤消失或明显减少.②PVI＋LALL组23例PAF患者均顺利完成手术,手术时间234～297 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5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.与PVI组比较,PVI＋LALL组手术时间明显延长,房颤消融后的随访成功率明显增加（P＞0.05）.结论 环肺静脉电学隔离联合左心房线性消融可以明显提高房颤RFCA后的随访成功率.