冷冻球囊消融治疗心房颤动时预防膈神经麻痹的研究进展

冷冻球囊消融治疗心房颤动(简称房颤)目前已成为导管消融治疗房颤的一种新的消融方式,然而,其主要并发症——膈神经麻痹的发生率较高,限制了其在临床的进一步应用。目前临床上用于预防膈神经麻痹的方法主要有膈神经起搏、透视和触诊、心内超声心动图和胎心监护仪、膈肌复合动作电位、机械阻隔膈神经与消融导管和定位膈神经位置等方法。     

冷冻球囊导管消融术在心房颤动治疗中的应用

心房颤动（房颤）是最常见的持续性心律失常;目前其主要治疗方法包括药物治疗、导管消融治疗和外科手术治疗。近年来导管消融术得到快速发展,显示出良好的应用前景,其中环肺静脉隔离术是一种应用广泛的术式,所用能源主要为射频能源,但手术复杂,学习曲线较长,可出现血栓形成、心肌及其周围组织损伤、致命性肺静脉狭窄及心房—食道瘘等并发症,限制了该术式的普及。     

两代冷冻球囊心房颤动导管消融疗效及安全性对比的Meta分析

目的探讨第一代冷冻球囊与第二代冷冻球囊导管消融治疗房颤的疗效及安全性。方法计算机检索The Cochrane Library、Pubmed、EMBASE、中国知网、万方等数据库关于两代冷冻球囊导管消融疗效及安全对比的文献,根据纳入及排除标准,对符合要求的文献进行质量评价,提取数据,对两代球囊关于肺静脉电隔离成功率、膈神经麻痹发生率、手术时间、曝光时间、3月及1年无复发率等采用Rev Man 5.0软件进行Meta分析。结果共纳入8篇文献(共2094名患者),Meta分析结果显示两代冷冻球囊肺静脉电隔离成功率没有统计学差异(RR=0.99,95%CI:0.99~1.00,P=0.03),手术时间、曝光时间、3月及1年无复发率优于第一代冷冻球囊,而膈神经麻痹发生率却高于第一代球囊(RR=0.57,95%CI:0.41~0.80,P0.05)。结论第二代球囊能带来更好的手术疗效,而膈神经麻痹却高于第一代球囊。     

冷冻球囊消融治疗阵发性心房颤动

目的:探讨冷冻球囊消融治疗阵发性心房颤动（房颤）的方法、策略及近期结果。方法: 对2013年12月~2014年1月在本院开展的5例冷冻球囊治疗阵发性房颤进行分析。结果: 5例患者手术时间100~210（153±44） min,X线曝光时间为33~72（51±15） min。每根肺静脉平均冷冻消融时间为29~300（209±75） s ,温度-27℃~-61（-44±9）℃,每根肺静脉冷冻次数2~6（3.0±1.3）次/根。术中及术后未发生肺静脉狭窄、血栓栓塞、膈神经麻痹等并发症。术中1例患者未达到完全肺静脉隔离,用普通射频导管补点消融成功。术后3例患者出现上腹部不适,24 h内逐渐缓解。术后随访1~2个月,均无房颤发作,无相关并发症。结论: 冷冻球囊消融治疗房颤操作相对简单、无需三维标测、学习曲线可能较短;但早期X光曝光时间较长,有待进一步缩短。     

冷冻球囊消融治疗心房颤动研究进展

心房颤动是临床最常见的持续性心律失常,在心律失常相关就诊和住院中为主要病因,与活动能力、生活质量、心功能以及总生存率的下降密切相关。药物及射频消融是当前治疗心房颤动的主要方式。近几年大量临床研究及实践表明冷冻球囊消融能安全有效隔离肺静脉,从而治疗心房颤动。     

心房颤动冷冻球囊消融术中发生膈神经损伤二例

2例阵发性心房颤动患者,男女各1例,年龄分别为51、59岁,在行冷冻球囊消融术中出现膈神经损伤。1例患者3个月左右膈肌活动开始逐渐恢复,症状基本消失,5个月左右膈肌活动基本恢复正常;另1例患者术后72 h膈肌活动完全恢复正常。     

单次冷冻球囊消融治疗心房颤动长期随访效果

目的：分析冷冻球囊消融（CBA）治疗心房颤动（房颤）患者的单中心长期随访效果,探讨影响其疗效的相关临床因素。方法回顾性分析2009年1月至2013年4月接受CBA治疗的房颤患者的住院病历资料、手术记录和门诊随访资料。术前经胸超声测量左心房内径（LAD）。术后3个月后出现的房颤、心房扑动（房扑）、房性心动过速（房速）发作判定为CBA治疗失败。结果199例房颤接受CBA治疗,术中并发膈神经麻痹3例（1.5％）,术后发生心包积液1例（0.5％）、短暂性脑缺血发作1例（0.5％）,均自行缓解。在平均（23±14）个月随访中152例患者完成随访,其中65例（42.8％）治疗成功,失败患者中75例（86.2％）为术后12个月内复发。失败患者年龄较大[（62±7）比（52±10）,P=0.0379]、LAD较大[（47±7）mm比（43±6）mm,P＜0.0001],持续性房颤患者治疗成功率（29.5%）明显低于阵发性房颤患者（48.1％）。Logistic回归分析显示年龄[OR=1.037（1.000,1.076）,P=0.0488]和LAD[OR=0.896（0.842,0.953）,P=0.005]能独立预测初次CBA治疗效果。结论 CBA治疗房颤安全有效,长期随访效果较好。房性心律失常复发主要发生在术后12个月内。年龄和LAD是预测术后复发的独立危险因素。     

冷冻球囊消融在心房颤动治疗中的应用

对于药物治疗无效的阵发性心房颤动（paroxysmal atrial fibrillation, PAF）的患者,指南推荐导管消融为首选治疗方案【1-3】。对于PAF以及持续性心房颤动（persistent AF）的患者行导管消融时,肺静脉隔离（pulmonary vein isolation, PVI）为治疗的基础【4-5】。目前,临床上最常用的导管消融为逐点的射频消融（radiofrequency ablation, RFCA）。RFCA通过组织加热损伤达到肺静脉隔离的效果,虽然应用广泛,但是逐点消融很难对肺静脉进行连续性环状透壁损伤,即使对于大中心有经验的术者来讲仍旧是一项挑战。 1978年Gallagher报道了第一例使用冷冻消融治疗药物无效的反复发作的室性心动过速【6】;2010年,第一代冷冻球囊系统（Arctic Front）应用于临床;2012年,第二代冷冻球囊系统（Arctic Front Advance）开始于临床应用。冷冻球囊消融（cryoballoon ablation, CBA）技术学习曲线短,易于被电生理医生掌握。2016年发表的FIRE AND ICE试验证实了与盐水灌注大头射频消融相比,CBA在PAF治疗的安全性以及有效性发面不劣于RFCA【7】。CBA作为一项新兴的房颤治疗技术引起了电生理医生的普遍关注。     

冷冻球囊导管消融治疗心房颤动的学习曲线分析

目的：探讨应用冷冻球囊导管消融术（ CBCA）行初次肺静脉电隔离（ PVI）治疗心房颤动（房颤）的学习曲线、即刻有效性及安全性。方法分析2013年12月11日至2014年2月28日由单一术者利用CBCA行初次PVI治疗的连续20例房颤患者的资料。将病例按手术先后编号,观察手术时间及X线透视时间变化。并将病例分为2组（前10例：A组,后10例：B组）,比较两组的手术时间、X线透视时间及即刻PVI的成功率的差异。结果20例患者[男12例,平均年龄（55．4±11．6）岁,阵发性房颤19例、持续性房颤1例）房颤病程的中位数为24个月。 A、B两组平均冷冻次数[（10．5±2．1）次对（9．3±1．7）次,P=0．180]差异无统计学意义。与A组相比,B组平均冷冻时间[（46．5±11．4）min 对（36．7±4．4）min, P=0．021]、手术时间[（150．0±27．6）min对（123．4±19．8）min, P=0．023]及X线透视时间[（62．5±15．7）min对（47．2±9．7）min, P=0．018]均减少。单纯行CBCA治疗,B组在患者水平及肺静脉水平上达到即刻PVI的成功率较A组高（ P＜0．05）。围术期出现1例（5%）主要并发症为膈神经麻痹（ PNP）。结论应用CBCA行PVI治疗房颤具有近期安全性和即刻有效性。术者可以通过较少病例很快完成学习曲线。 PNP作为主要并发症值得注意。     

房颤冷冻消融中右侧膈神经稳定起搏的方法探讨

目的右侧膈神经麻痹是冷冻球囊消融治疗房颤时最常见并发症。消融时监测膈神经活动是预防该并发症的有效措施。本研究通过测量上腔静脉区域起搏阈值和不同部位起搏的膈肌复合运动动作电位的方法,探讨膈神经的影像学的最佳起搏部位。方法前瞻性入选了32例接受冷冻球囊治疗的房颤患者。将可调弯标测电极导管以倒"U"字形放置到上腔静脉区域,使导管头端指向上腔静脉游离壁侧,右前斜造影判断上腔静脉形态,以及前壁、游离壁和后壁三个位点,将胸锁关节下第一、第二和第三椎间隙分别定义为上腔静脉区域的上、中、下三段。在各部位予以膈神经起搏(固定脉宽2 ms、起搏周长1 000 ms),通过改良的Ⅰ导联监测起搏膈神经时膈肌复合运动动作电位。检测各部位起搏阈值和各部位起搏输出5 m A时,膈肌复合运动动作电位的大小。结果采用倒"U"字形放置膈神经起搏导管可以达到稳定起搏。在32例患者中没有患者出现持续性膈神经麻痹。起搏位点共285个。可以发生膈神经夺获的位点占61.4%(175/285)。游离壁、后壁能够发生膈神经夺获的起搏位点显著多于前壁[游离壁为80.0%(76/95)、后壁为84.2%(80/95)、前壁为20.0%(19/95),P<0.001]。改良Ⅰ导联记录的后壁和游离壁起搏能够记录到膈肌复合运动动作电位的起搏点显著多于前壁起搏点(P<0.001)。膈神经起搏阈值和膈肌复合运动动作电位存在负相关性(r=-0.267,P=0.005)。结论通过倒"U"字形放置起搏导管于上腔静脉的后壁和游离壁,可以达到稳定的膈神经起搏。在起搏阈值最低的部位进行起搏可以展现更加清晰的膈肌复合运动动作电位,有助于冷冻消融时监测膈神经麻痹的发生。     

Acute pericarditis following second-generation cryoballoon ablation for atrial fibrillation

Purpose

Acute pericarditis is a minor complication following atrial fibrillation (AF) ablation procedures. The aim of the study was to evaluate the incidence and clinical aspects of pericarditis following cryoballoon (CB) ablation of AF investigating a possible association with procedural characteristics and a possible relationship with post-ablation recurrences.

Methods

Four hundred fifty consecutive patients (male 73%, age 59.9?±?11.2 years) with drug-resistant paroxysmal AF who underwent CB ablation as index procedure were enrolled. Exclusion criteria were any contraindication for the procedure including the presence of intracavitary thrombus and uncontrolled heart failure and contraindications to general anesthesia.

Results

Acute pericarditis following CB ablation occurred in 18 patients (4%) of our study population. Pericardial effusion occurred in 14 patients (78%) and was mild/moderate. The total number of cryoapplications and the total freeze duration were significantly higher in patients with pericarditis compared with those without (respectively, p?=?0.0006 and p?=?0.01). Specifically, the number of applications and freeze duration in right inferior pulmonary vein were found significantly higher in patients with pericarditis (p?=?0.007). The recurrence rate did not significantly differ between the two study groups (respectively, 16.7 vs 18.1%; p?=?0.9).

Conclusions

The incidence of acute pericarditis following CB ablation in our study population accounted for 4% and was associated with both total freezing time and number of cryoapplications. The clinical course was favorable in all these patients and the occurrence of acute pericarditis did not affect the outcome during the follow-up period.

     

Improvement in renal function following cryoballoon ablation for atrial fibrillation

Purpose

Patients with chronic kidney disease are predisposed to heart rhythm disorders including atrial fibrillation (AF). Several studies have suggested that radiofrequency catheter ablation of AF improves renal function. However, little data exists for pulmonary vein isolation with cryoballoon ablation (CBA). The purpose of this study is to assess change in renal function following CBA for AF.

Method

This is a single-center retrospective study that included patients who underwent CBA for AF between 2011 and 2016. Patients were grouped by baseline-estimated glomerular filtration rate (eGFR): ≥?90 (Stage G1), 60–89.9 (Stage G2), and 30–59.9 mL/min/1.73 m² (Stage G3). Change in eGFR was assessed >?3 months post-ablation.

Results

A total of 306 patients with both pre- and post-ablation serum creatinine measurements available were included. Baseline eGFRs for Stages G1, G2, and G3 patients were 103.5?±?12.9 (n?=?82), 74.7?±?8.2 (n?=?184), and 52.6?±?6.6 mL/min/1.73 m² (n?=?40), respectively. Renal function was assessed 310.8?±?104.2 days post-ablation. Average intra-procedural contrast use was 58.4?±?23.8 mL. There was no significant change in eGFR following CBA in Stage G1 patients (p?=?0.10). For those with Stages G2 and G3 renal function, eGFR improved by 6.1% (4.2 mL/min/1.73 m², p?<?0.01) and 13.8% (7.2 mL/min/1.73 m², p?<?0.01), respectively. This improvement was seen regardless of the presence or absence of recurrent atrial arrhythmias.

Conclusions

CBA for AF may be associated with an improvement in renal function, particularly among those with a reduced baseline eGFR despite recurrence of atrial arrhythmias and intra-procedural contrast use.

     

心房颤动冷冻消融方法的应用进展

肺静脉隔离是心房颤动（房颤）导管消融的基石,冷冻球囊是专门为肺静脉解剖结构设计的工具,应用冷冻球囊 导管进行肺静脉隔离（PVI）的有效性和安全性获得了临床研究证实,国内外指南都已将冷冻球囊消融作为房颤消融 PVI的标准疗法。冷冻球囊消融具有持久肺静脉隔离、安全性高、操作简便、患者感受好、学习曲线短等优势,因此, 近10年在临床得以迅速普及应用。随着技术的不断创新和临床研究的深入,冷冻球囊消融疗法也在不断拓展。文 章就房颤冷冻球囊消融方法及应用进展进行论述。     

Quick,safe, and effective maneuver to prevent phrenic nerve injury during cryoballoon ablation of atrial fibrillation

Purpose

Phrenic nerve (PN) injury is a typical complication of cryoballoon ablation (CBA) of pulmonary veins. The PN function is monitored by palpating the abdomen during PN pacing, and freezing is prematurely terminated when a reduction in the diaphragm movement is recognized. This study aimed to investigate the efficacy and safety of a “pull-back” maneuver to prevent PN injury.

Methods

A total of 284 patients were included, and the PN function was monitored by recording the diaphragmatic compound motor action potentials (CMAP) during the cryoballoon applications for pulmonary vein (PV) isolation. When the CMAP amplitude was reduced by more than 30% compared to the control, the “pull-back” maneuver (PBM) was undertaken to prevent PN injury.

Results

The average CMAP amplitude significantly decreased from 0.81?±?0.04 to 0.31?±?0.21 (p?<?0.01) mV during the cryoballoon applications of PVs in 92 PVs. The PBM was employed in all cases, and the average CMAP amplitude recovered to 0.87?±?0.31 mV (p?<?0.01) in 79 out of 92 PVs (85.9%), accomplishing the CBA. Cryofreezing had to be prematurely terminated due to failure of the PBM in 13 out of 92 cases (14.1%).

Conclusions

The PBM was an effective maneuver to prevent PN injury by creating a distance between the PN and location of the cryoballoon. No adverse events were provoked by this procedure.