心房颤动的复律

一、电转复　　 1 .直流电体外转复　　适用于以下情况[1] :持续性心房颤动 (房颤 )伴有血流动力学恶化 ,药物转复失败 ,房颤转复的一线治疗。　　方案 :转复前需检查甲状腺功能、血清肌酐和血钾。食管超声应用于血栓栓塞高危患者 (有脑血管事件、左室功能不全或瓣膜疾病 )。房颤≥ 48h转复前抗凝 3周 ,转复后继续抗凝 1个月。直接电转复必须与心电图的 R波同步 ,避免在心室的易损期放电 ,引起心室颤动 (室颤 )。技术上需考虑电极大小和电极位置 ,输出波形和储存能量。起始能量 2 0 0 J,75%以上患者能够转复 [2 ] ,不成功时第 2次可用 360 …     

心房颤动复律后抗心律失常药物应用

心房颤动 (房颤 )是一常见心律失常 ,且随年龄增加 ,至今缺少有效的处理措施 ,成为心血管病领域的重要社会课题。房颤发生后不同程度地损伤心脏。房颤使心房收缩力丧失 ,减低心室收缩后期流入心室的血流 ,也妨碍房室瓣的关闭和协调 ,这些都减低心排出量 ,在老年人或已有心脏功能障碍的患者中可诱发心力衰竭。其次 ,房颤突发时心室率往往快速 ,>1 1 0次 /min,除产生症状外也影响血流动力学。长期心室率 >1 0 0次 /min可能是引起心动过速心肌病的一个因素。在电生理学及组织学上 ,房颤必然引起心房重构 ,严重时成为不可逆性。扩大的心房内血流…     

持续性心房颤动药物复律后心房收缩功能恢复的观察

目的　观察持续性心房颤动药物复律后心房收缩功能的恢复过程。方法　5 3例持续性心房颤动患者在药物复律后第1、1 4、2 8天运用超声心动图检测舒张期跨二尖瓣血流。结果　复律后A峰、A波积分逐步升高(0 . 3 5±0 . 1 0cm/s至0 . 62±0 . 1 1cm/s、4 .43±1 . 3 6cm/s2至6. 0 2±1. 5 0cm/s2 ) ,A波积分占总积分比例由2 6±7%上升至3 4±8%。结论　持续性心房颤动经药物复律后心房收缩功能逐步缓慢恢复。     

甲状腺机能亢进并发心房颤动自主复律与药物复律的比较

报告 31例甲状腺机能亢进 (甲亢 )并发心房颤动 (房颤 )患者 ,对比观察房颤的复律情况及血栓栓塞发生情况。1 对象 :31例患者 ,男性 9例 ,年龄 2 7～ 4 7岁 ,平均 34岁 ;女性 2 2例 ,年龄 2 7～ 6 9岁 ,平均 4 3岁 ;男女之比为 1∶2 4。甲亢诊断标准 :(1)临床甲亢症状 ;(2 )血清游离三碘甲状腺原氨酸 (ＦＴ3 ) >11ｐｍｏｌ/Ｌ ,血清游离四碘甲状腺原氨酸(ＦＴ4) >30ｐｍｏｌ/Ｌ ,促甲状腺激素 (ＴＳＨ) >8ＩＵ/Ｌ ,抗甲状腺抗体 (抗ＴＧ) >35 % ,抗甲状腺微粒体抗体 (抗ＴＭ) >18% ;检测结果 :Ｔ3 型甲亢 7例 ,Ｔ4型甲亢 5例 ,混合型甲亢 1…     

心房颤动的复律探析

心房颤动（房颤）是最常见的基本异位心律和持续性心律。人群房颤的发生率在50～59岁为0．5％，60～69岁为1．8％，70～79岁为4．8％，80～89岁为8．8％；60岁以上老年人房颤发生率为3％～4％，随年龄的增加房颤的发病率增加，80岁以上约为9％。房颤危害严重，房颤是非房颤心力衰竭患者死亡率的2倍；非瓣膜病性房颤患者发生脑卒中的危险是无房颤者的5～7倍，房颤合并瓣膜病时脑卒中的比例比窦性心律高17倍。房颤是缺血性卒中的独立危险因素。     

心房颤动的电击复律治疗

电击终止AF的机制不甚明了。对于心室颤动（VF）电击使颤动的心肌同步除极，完全或部分地减少于波，使之低于持续VF的阈值。对于AF也可复制出同样的结果。研究证明电击后心室的有效不应期延长、波长增长，使折返不能持续。如同VF一样，AF除颤的绝对阈值也还不清楚。对羊慢性AF模型进行研究发现成功除颤的电能量与AF颤动波周期的长度及心房有效不应期均呈反比，这可能用以说明为何房扑转复能量较AF能量低；也可用以解释为何同样的能量对不同病人产生不同的效果。AF存在传出裂隙，因而快速起搏心房常可呈现拖带现象，暂时或持久地部分…     

心房颤动的同步直流电心脏复律

心房颤动因心房规则有序的电活动丧失,代之以无序的快速颤动波。致使心房不能产生有效的收缩与舒张。令心室出现极不规律的反应。其造成的影响是：①心房电重构及心房肌重构加重心房电生理及病理改变：②心房泵血功能丧失;③快速且不规则的心室率可致心输出量显著下降引起低血压、心肌缺血和心力衰竭。使原有的心脏病迅速恶化;④持续快速的心室率,可致心动过速性心肌病：⑤左心耳及心房血流淤滞,易发生心房血栓及栓塞事件。     

联合应用伊布利特与普罗帕酮转复持续性心房颤动的临床研究

目的观察伊布利特和普罗帕酮联合应用转复持续性心房颤动的有效性和安全性。方法选择房颤持续时间在1个月~1年之间的患者共47例,随机分为伊布利特和普罗帕酮联合治疗组及单独伊布利特治疗组。联合治疗组先口服普罗帕酮600 mg,20分钟后首次给予伊布利特1 mg/次静推;如用药后10分钟仍为房颤,再次静脉给1 mg/次。中途转复则立即停用。单独伊布利特治疗组伊布利特给药方法同上。结果伊布利特和普罗帕酮联合治疗组房颤的转复率明显高于单独伊布利特组(P<0.01)。两组平均转复时间比较,单独伊布利特组短于联合治疗组(P<0.01)。两组用药后QTc均明显延长,但两组比较无差异(P>0.05)。随访2~15个月,无患者房颤复发。结论伊布利特和普罗帕酮联合应用对持续性房颤的转复作用是安全有效的,其疗效优于单独应用伊布利特。     

胺碘酮在心房颤动复律和预防复发中的作用

探讨胺碘酮在心房颤动 (简称房颤 )复律和预防复发中的作用。 10年间共 10 8例房颤患者给予胺碘酮负荷剂量治疗共 10天进行房颤复律 ,9例房颤 (8.3% )持续 2周以内的患者自动复律 ,99例房颤再进行改良的胸背前后位贴片法电复律 ,94例 (94.9% )复律成功 ,复律成功能量为 78.1± 40 .6J。复律成功的 10 3例给予胺碘酮 0 .2 ,每日一次 ,预防复发 ,其后 1个月 ,0 .5年 ,1年 ,2年 ,维持窦律者分别为 98.1% ,88.3% ,71.8% ,5 6 .3% ;而早期用奎尼丁标准法复律共 36例 ,2 0例 (5 5 .6 % )自动复律 ;另 16例再行电复律 ,12例 (75 .0 % )复律成功 ,复律后在相应随访时间维持窦律者分别为 6 5 .0 % ,2 0 .0 % ,0 % ,0 %。结论 :胺碘酮药物复律房颤成功率低于奎尼丁 ,而预防复发却远优于奎尼丁 ;低能电复律法辅助胺碘酮复律是房颤复律的良好选择。慢性房颤心功能良好可用胺碘酮复律并预防复发。     

单剂量伊布利特即时转复射频消融术后持续性心房颤动临床观察

目的:本研究旨在检验伊布利特即时转复射频消融术后持续性或永久性心房颤动(房颤)的有效性.方法:2008-10至2009-09连续34例持续性或永久性房颤患者[平均年龄(50.7±8.5)岁,其中男性27例],在Carto三维标测系统下行双侧肺静脉大环消融术,直至双侧肺静脉电位消失,同时附加左心房顶部和沿二尖瓣环心内膜面线性消融,如房颤不能终止,则消融复杂碎裂电位(CAFE),术后对未转为窦性心律的30例患者均予单剂量伊布利特静脉注射进行药物转复,1 mg伊布利特用10 ml生理盐水稀释静脉注射10 min,给药后30 min以内转成窦性心律被视为转复成功,药物转复失败的患者,则予直流电复律.测量冠状窦电极记录的房颤波平均A-A间期和转复即刻及给药后2小时QT间期.结果:34例患者4例消融术后转复为窦性心律.30例术后仍为房颤律的患者经伊布利特静脉注射进行药物转复,有18例成功转复为窦性心律(转复率为60%),平均转复时间是(10.2±5.2)min(从给药始计时);药物转复成功的患者房颤病史明显短于转复失败患者[(4.2±2.9)年VS(9.4±4.3)年,P＜0.05],而在性别、年龄、体重指数、左心功能及左心房内径差异无统计学意义;与静脉注射药前相比静脉注射药后伊布利特显著延长平均A-A间期[(171.8±29.5)msVS(242.0±40.1)ms,P＜0.001],给药后2小时的QTc间期与转复即刻的QTc间期相比明显缩短(441.0±37.4)ms VS(421.5±24.7)ms,P＜0.05].30例患者均没有出现不良反应或并发症.结论:在导管室中应用伊布利特即时转复射频消融术后持续性或永久性房颤是一种可供选择的、有效的治疗方法.     

依布利特与普罗帕酮转复心房颤动的临床研究

目的　研究和比较新型Ⅲ类抗心律失常药物依布利特与普罗帕酮转复心房颤动 (房颤 )的有效性及安全性。方法　采用随机、单盲对照研究。共入选房颤持续 1 5h~89d的患者 69例,其中男性 28例,女性 41例,随机进入依布利特组(n=34)、普罗帕酮组(n=35)。前者于 10min内静脉注射依布利特 1mg,后者于 10min内静脉注射普罗帕酮 70mg,如给药结束 10min后仍未转复为窦性心律,各组重复前述治疗 1次。观察开始给药后 1 5h内房颤的转复率及 4h内的不良反应。结果　(1)依布利特转复房颤的成功率明显高于普罗帕酮(70 .59% vs42 .86%,P<0. 05); (2)房颤的转复率与房颤的持续时间有关,持续时间低于 24h的房颤转复率 ( 71 05%, 27 /38 )明显高于持续时间超过 24h者(38 71%, 12 /31,P<0. 01),其中依布利特对持续 24h之内的房颤转复率高达 83 .33% (15 /18); (3)房颤的转复率与左心房直径呈负相关,左心房直径 <4 0cm患者的转复率 ( 75 68%, 28 /37 )明显高于左心房直径≥4 0cm患者的转复率(34. 38%, 11 /32,P<0 01); (4)依布利特最严重的不良反应为非持续性单形室性心动过速,发生率为 8 .82% (3 /34);普罗帕酮最严重的不良反应为低血压 (2. 86%, 1 /35)及长间歇(RR间期>2 .0s, 11 .43%, 4 /35)。结论　依布利特是一种快速转复     

Flecainide versus ibutilide for immediate cardioversion of atrial fibrillation of recent onset.

AIMS: This study compared the efficacy and safety of intravenous flecainide and ibutilide for immediate cardioversion of atrial fibrillation (AF). METHODS AND RESULTS: We conducted a prospective, randomised trial, including 207 patients with AF of recent onset (< or = 48 h). Flecainide was given over 20 min at a dose of 2 mg/kg body weight (maximum 200 mg), ibutilide was infused at a dose of 1 mg (or 0.01 mg/kg if less than 60 kg) over 10 min, followed by a 10 min observation period and an identical second dose if AF did not convert to sinus rhythm (SR). Treatment was considered successful if SR occurred within 90 min of starting medication. The conversion rates were 56.4% in patients given flecainide and 50.0% in patients given ibutilide (P=0.34). Multivariate analysis revealed that a lower age for women independently increased the probability of conversion. None of the other variables, including left atrial size, left ventricular systolic function, presence of left ventricular hypertrophy, plasma levels of potassium or magnesium at baseline, or concomitant use of digoxin, beta-blocker, diltiazem or verapamil were predictors of conversion. The frequency of adverse events was comparable in the two treatment groups. CONCLUSIONS: There was no significant difference in the cardioversion efficacy or in the risk of adverse events between flecainide and ibutilide in patients with AF of recent onset. In patients without contraindications to both medications, the physician's choice has to be governed by other factors.     

伊布利特与胺碘酮转复持续性心房颤动的疗效和安全性对比研究

目的 比较伊布利特和胺碘酮转复持续性心房颤动（PAF）的疗效和安全性.方法 2012年3月至2014年5月选取郑州市第十人民医院心内科住院的72例PAF患者,随机分为2组.伊布利特组（33例）采用伊布利特静脉注射转复窦性心律,用量：体质量≥60kg的患者,首次剂量1 mg,体质量＜60kg的患者,首次剂量0.01 mg/kg.胺碘酮组（39例）采用胺碘酮静脉注射转复窦性心律,用量：体质量≥60 kg的患者,首次剂量300 mg,体质量＜60 kg的患者,首次剂量5 mg/kg.比较两组患者用药后30 min内、3h内、12 h内、24h内的转复率,并记录两组患者用药过程中的不良反应.结果 伊布利特组患者用药后30 min内、3h内、12h内、24h内转复率均明显高于胺碘酮组（x2=10.7330,10.6500,8.4538,5.1932,P＜0.01或P＜0.05）;伊布利特组患者的平均转复时间明显短于胺碘酮组（t=7.9009,P＜0.01）;伊布利特QTc平均恢复时间短于胺碘酮（t=15.783,P＜0.01）;两组患者不良反应发生率比较差异无统计学意义（x2=0.4690,P＞0.05）,但伊布利特组的不良反应持续时间较胺碘酮组更短[（0.38±0.10）h比（16.75±8.39）h,t=11.195,P＜0.01].结论 与胺碘酮相比,伊布利特对持续性房颤的转复率高,转复时间短,不良反应消失快.     

26例心房颤动患者心律转复前后心肺运动试验分析

目的探讨心房颤动对心脏功能的影响及心房颤动患者转复心律前后摄氧量等运动参数的改变。方法采用美国MedGraphics公司心肺运动仪和活动平板,在Bruce改良方案的基础上,对26例心房颤动患者分别进行心律转复前后心肺运动试验。结果26例心房颤动患者心律转复后,静息心率(HRrest)平均由109次min减慢到83次min(P<0001),最大运动时心率(HRmax)平均由182次min减慢到141次min(P<0001);最大每搏摄氧量(VO2maxHR)平均由788mL提高到109mL(P<0001);运动总时间(TET)平均由81min增加到88min(P<0001);最大运动速度(Speed)平均由30mph增加到33mph(P<001);斜度(Elevation)由1315%提高到1385%(P<001),试验过程中无并发症发生。结论心房颤动患者转复窦性心律后,心率明显减慢,最大每搏摄氧量增加,运动时间延长,运动耐力提高,心功能得到改善。     

Increased P-wave dispersion predicts recurrent atrial fibrillation after cardioversion

Atrial fibrillation (AF) will recur in a number of patients treated with cardioversion. Being able to identify reliable risk factors would be useful for making management decisions. P-wave dispersion (PWD) is an electrocardiographic measurement, which reflects a disparity in atrial conduction. P-wave dispersion has been shown to be increased in patients with paroxysmal AF. This pilot study aims to determine the role of PWD in predicting AF recurrence in patients who underwent elective cardioversion. Forty-five patients who were successfully cardioverted for persistent AF were included for study. Eighteen patients had a PWD greater than 80 ms; of these 13 had AF recurrence. Of the 25 patients with PWD less than 80 milliseconds, 12 had recurrent AF. P-wave dispersion values greater than 80 milliseconds were found more frequently in patients with AF recurrence (P = .05), supporting the use of this parameter in predicting return of AF. Larger studies are needed for further evaluation.     

Supraventricular ectopy and recurrence of atrial fibrillation after electrical cardioversion.

AIMS: Paroxysmal atrial fibrillation (AF) is usually preceded by a premature atrial complex (PAC). We hypothesized that patients with a high frequency of atrial ectopic activity after restoration of sinus rhythm following direct current cardioversion would be more likely to experience recurrence of AF. METHODS AND RESULTS: Forty-four patients with documented persistent AF were studied. A 24 h Holter recording was performed from the day of external direct current cardioversion. Patients were reviewed at 1 week, 1 month, and 6 months. After 6 months, 59% of patients had experienced a recurrence of AF. Neither the frequency of PACs nor the frequency or duration of supraventricular tachycardia (SVT) episodes predicted AF recurrence (P=0.60, 0.30, and 0.42, respectively). There was a trend towards maximum rate of SVT predicting recurrence of AF (P=0.08). CONCLUSION: Frequency of supraventricular ectopy or the number and length of SVT runs in the 24 h after restoration of sinus rhythm are not strong predictors of recurrence of AF after electrical cardioversion. A larger study would be required to detect a small predictive effect.     

New drugs for atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. Epidemiologic studies suggest that the number of patients with AF will triple in the next 30 years, and therefore, its impact on medical and economic issues will further increase. Due to the limited efficacy and significant side effects of antiarrhythmic drugs, much effort has been made to develop alternative pharmacologic treatments for AF. Novel approaches include new antiarrhythmic drugs and novel drug targets involved in molecular, proarrhythmogenic, atrial remodeling. Furthermore, novel anticoagulants are now clinically studied. This review briefly summarizes new developments in the pharmacotherapy for AF.     

伊布利特在持续性心房颤动射频消融术中转律的疗效特点

目的 评价伊布利特在持续性心房颤动(房颤)射频消融术中应用的有效性及影响因素.方法 入选接受射频消融手术的持续性房颤患者18例,男性16例,女性2例,平均年龄(56.3±14.0)岁,体质量(81.22±8.93) kg,合并原发性高血压3例、肥厚型心肌病2例.所有患者术中经环肺静脉电隔离、线性消融、碎裂电位消融后房颤未终止,或者转为心房扑动,给予伊布利特l mg、10min内静脉注射,观察开始给药后30 min内的转复率及4h内的不良反应.根据用药后是否成功转律分为转律组与非转律组.结果 (1)18例患者用药后30 min内成功转律11例,转复律为61.11％,平均转律时间为(13.80 +7.64) min,转复剂量为(0.94±0.13)mg.1例患者用药后15 min时出现窦性停搏16 s,后恢复稳定窦性心律,术后观察4h无不良反应,另1例患者用药后出现窦性心动过缓,持续约lh后恢复正常心率,期间无低血压等血流动力学改变.余16例患者术中及术后4h内无室性心动过速及低血压等不良反应.(2)使用伊布利特后30 min的AA间期(0.51±0.08)s,明显长于用药前的AA间期(0.39±0.21)s,P＜0.01;用药后30 min的QTc(0.51±0.08)s,明显长于用药前QTc(0.39±0.21)s,P＜0.01.(3)两组临床资料差异无统计学意义.转律组患者左房瘢痕区比例(5.12±3.83)％,明显小于非转律组左房瘢痕区比例(12.40±11.03)％,P＜0.01.(4)左心房内径＜40mm患者的转复率(75.00％)与内径≥40 mm患者的转复率(50.00％)差异无统计学意义(P＞0.05).结论 静脉注射伊布利特在持续性房颤射频消融术中应用疗效迅速,对消融后心房扑动转复率更高.转律的成功率与术中标测瘢痕区面积所占比例相关.     

Acute beta-adrenoceptor blockade improves efficacy of ibutilide in conversion of atrial fibrillation with a rapid ventricular rate

Aims: Activation of beta-adrenoceptors attenuates prolongation ofaction potential duration induced by blockade of the delayedrectifier potassium current. We examined whether acute administrationof beta-blocker could enhance ibutilide (IB) efficacy in conversionof atrial fibrillation (AF) with a rapid ventricular rate. Methods and results: Ninety patients (aged 63 ± 13.5 years) with rapidly conductingAF were randomized in to two groups. Group A (n = 44) receivedesmolol titrated to achieve a heart rate of <100 bpm followedby IB co-administration, while Group B (n = 46) were treatedwith IB as monotherapy. In Group A, 29 patients (67%) convertedto sinus rhythm (SR) compared with 21 (46%) in Group B (P =0.04). The use of esmolol was the most important predictor forcardioversion (P = 0.009). The slower the heart rate at thetime of IB initiation, the higher the likelihood for cardioversion(P = 0.015). Patients in Group A had significantly shorter correctedQT interval (QTc) at the time of conversion than those in GroupB (433 vs. 501 ms, P = 0.003). Two patients in Group A developedsevere bradycardia, whereas three patients in Group B developedsevere ventricular tachycardia (VT). Conclusion: Compared with IB monotherapy, the combination therapy of esmololand IB appears to be more effective in conversion of rapidlyconducting AF back to SR. The addition of beta-blocker reducesQTc prolongation and diminishes the risk of VT at the expense,however, of increased bradycardic events.     

Atrial stunning as predictor of early relapse into atrial fibrillation after cardioversion

Although the high rate of success after cardioversion, less than 50% of patients maintain sinus rhythm for the first year. In view for the high percentage of relapse into atrial fibrillation, it is interesting to analyze the relationship between atrial stunning after cardioversion and relapse into atrial fibrillation. Thus, we evaluated 101 patients with atrial fibrillation and successful cardioversion. Atrial mechanical function was assessed by measures of transmitral peak A wave velocity, determined before and weekly after cardioversion during 1 month. Fifty-five percent of patient relapse into atrial fibrillation during follow-up. No significant differences were found in clinical and echocardiographic variables between the group with and without relapse. However, the group of patients who relapsed into atrial fibrillation showed a lower peak A wave velocity immediately after cardioversion than patients who maintain in sinus rhythm at month (0.44 ± 0.27 vs. 0.60 ± 0.38 m/s p < 0.01). Impaired atrial function improves during the first 14 days after cardioversion.