心房颤动患者左心耳血栓的研究进展

经食管超声心动图是诊断左心耳血栓的"金标准",心脏声学造影结合能量多普勒、心脏CT延迟成像、二维增强单相心脏CT等检测左心耳血栓的敏感性和特异性也都非常高。左心耳血流速度降低、左心耳壁运动速度降低、左心耳射血分数降低、左心耳应变降低、左心室肥大、左心室射血分数降低、左心房增大等都是左心耳血栓的预测因子,有助于指导心房颤动患者的抗凝治疗和预防血栓栓塞事件。     

非瓣膜性心房颤动左心耳血栓形成的研究进展

非瓣膜性心房颤动（non-valvular atrial fibrillation,NVAF）患者血栓事件发生率高、预后差、复发率高,其中90%的NVAF患者血栓来源于左心耳。通过分析左心耳解剖结构、左心耳功能以及部分生物学指标等,对近年来国内外研究NVAF病人左心耳血栓形成进展进行综述。     

CT技术在左心耳封堵术中的应用研究进展

左心耳封堵术(LAAC)是预防心房颤动患者发生卒中的治疗手段。心脏CTA因其无创性和高分辨率等优势在LAAC中显示出较好的应用效果,在评价左心耳解剖、血栓、尺寸、周围结构及LAAC术后等方面有较高的应用价值。近年来,心脏CTA以其诸多优势有望成为心脏彩超的有效替代方案,其有效性和安全性已得到证实,本文就CT在左心耳封堵术中的应用现状作一综述。     

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。     

左心耳封堵术在非瓣膜性心房颤动患者卒中预防中的价值

心房颤动（房颤）的最大危害是引起卒中或血栓栓塞事件,临床上常以抗凝药物,包括华法林或新型口服抗凝药物来有效降低血栓栓塞事件,但药物治疗有增加出血的风险。基于非瓣膜性房颤患者90％的血栓是来自左心耳,近年有些临床研究显示,左心耳封堵术（ LAAC）可用于卒中风险高危、不能耐受华法林治疗或不愿长期口服抗凝药物的房颤患者的治疗,不仅能减少卒中、体循环栓塞与心血管死亡复合事件,而且在降低心血管死亡与全因死亡事件方面较口服华法林有更优的结局。但LAAC的远期预后、与新型口服抗凝药物的比较以及在国人房颤患者的应用经验仍需进一步研究。     

左心耳闭塞预防心房颤动血栓的研究进展

心房颤动(简称房颤)患者易发生血栓栓塞,超过90%的心源性血栓来自左心耳.而很多情况房颤的心室率控制可作为治疗首选,故预防血栓尤为重要,华法林是目前公认的有效抗凝用药,但使用有局限性,目前可通过外科手术及介入方法闭塞左心耳减少房颤血栓的发生率.现就左心耳的解剖和血栓栓塞的关系、闭塞左心耳的方法、封堵装置的研究现状及进展作一综述.     

舒张功能指标对非瓣膜性心房颤动患者左心耳血栓形成的影响

目的 探讨舒张功能指标对非瓣膜性心房颤动患者左心耳血栓(left atrial appendage thrombus,LAAT)形成的影响.方法 收集我院2017年1月～2018年10月行经食道超声心动图检查的非瓣膜性心房颤动患者152例,根据是否有LAAT分为血栓组和对照组,比较舒张功能指标在两组间的差异并分析对LA...     

左心耳及其毗邻形态结构对心房颤动导管射频消融术后复发的预测价值

目的:探讨左心耳及其毗邻形态结构对心房颤动(房颤)导管射频消融术后复发的预测价值.方法:选取2018年1月至12月接受射频消融术的110例房颤患者,术前均接受256层螺旋CT心脏检查,测量左心耳嵴长度和宽度,左心耳体积和开口面积,肺静脉开口面积.在术后第3、6、9、12个月进行门诊或电话随访.以消融术后1 a房颤复发为...     

不同评分系统对非瓣膜性心房颤动患者左心耳血栓状态的预测效果研究

目的 探讨不同评分系统在预测非瓣膜性心房颤动(NVAF)患者左心耳血栓状态(LAATM)上的差异。方法 选取2015年1月1日至2020年12月31日在该院住院并完成经食管超声心动图(TEE)的NVAF患者为研究对象,根据TEE结果将其分为LAATM组和非LAATM组。收集患者的一般资料(包括性别、年龄、合并疾病等),所有患者均采用CHA₂DS₂-VASc评分、CHA₂DS₂-VASc-RAF评分、CHA₂DS₂-VASc-60评分及ABC卒中评分进行评价,分析不同评分系统对LAATM的预测价值。结果 共纳入1 217例NVAF患者,其中男647例、女570例。持续性心房颤动529例,阵发性心房颤动688例。TEE示LAATM患者112例,非LAATM患者1 105例。LAATM组患者年龄,持续性心房颤动、吸烟、糖尿病、冠心病、卒中/短暂性脑缺血发作(TIA)、他汀发生率,N末端B型利钠肽原(NT-proBNP)、估算肾小球滤过率(eGFR)等均高于非LA...     

心房颤动左心耳封堵联合冷冻消融术后器械相关血栓发生及预后研究

目的 探讨非瓣膜性心房颤动(房颤)缺血性脑卒中高危患者左心耳封堵(1eft atrial appendage closure, LAAC)联合二代球囊冷冻消融术发生封堵器械相关血栓(device-related thrombus, DRT)的病例特点及药物调整后疗效.方法 2018年1月—2019年6月期间上海健康医学...     

Left atrial appendage morphology in patients with atrial fibrillation in China: implications for stroke risk assessment from a single center study

Background The left atrial appendage (LAA) is thought to be the main source of thrombi in patients with atrial fibrillation (AF). The purpose of this study was to describe the LAA orifice diameter, LAA length, and morphologic type of the LAA in Chinese patients with AF as well as to evaluate whether these LAA parameters are associated with a history of stroke in patients with AF from a single center in China.

Methods The study population consisted of 219 consecutive patients with drug-refractory, symptomatic paroxysmal, or persistent AF scheduled to undergo radiofrequency catheter ablation in our single center. All patients underwent extensive clinical assessment and multidetector computed tomography to fully explore the anatomy of the LAA.

Results Of the 219 patients who underwent catheter ablation procedures, chicken wing LAA morphology was found in 114 patients (52.2%), windsock in 52 (23.9%), cauliflower in 29 (13.0%), and cactus in 24 (10.9%). Compared with the windsock LAA morphology, cactus had a larger left atrial diameter ((42.40±3.68) and (37.91±4.32) mm, P=0.005) and LAA orifice diameter ((27.38±3.70) and (24.14±3.58) mm, P=0.048). The LAA length was significantly larger in the chicken wing morphology than in the windsock ((37.50±6.74) and (31.33±3.92) mm, P=0.015) and cauliflower morphologies ((37.50±6.74) and (31.33±3.92) mm, P=0.015). According to their medical records, 26 patients (11.9%) had suffered a prior stroke. Compared with patients who had no history of stroke, the prior-stroke patients were older (62.04±8.07 and 58.24±9.24, P=0.047) and there were fewer patients with chicken wing (23.1% and 59.1%, P=0.001) and more patients with cauliflower (26.9% and 9.8%, P=0.046). Multivariate Logistic regression analysis demonstrated that age (odds ratio (OR) 1.26; 95% confidence interval (CI) 1.08–1.47; P=0.003), non-chicken wing morphology (OR 5.82; 95% CI 1.61–21.03; P=0.007), and LAA orifice diameter (OR 1.25; 95% CI 1.05–1.49; P=0.014) were independent predictors of stroke after adjusting for all parameters that emerged as potential confounders with univariate analysis.

Conclusion LAA analysis can potentially be used to inform guidance on the implication for stroke risk assessment.

     

射频消融联合左心耳闭合术治疗瓣膜病房颤疗效观察

目的:研究射频消融联合左心耳闭合术治疗瓣膜病房颤的手术疗效.方法:收集瓣膜病合并房颤患者120例,观察组56例(射频消融联合左心耳闭合+瓣置换术),对照组64例(瓣置换术).观察2组手术指标、窦性转复率、心功能指标、血液中相关因子及并发症.结果:观察组手术和体外循环时间长于对照组(t=3.129,P=-0.002;t=5.873,P=0.000),其他指标无统计学差异;观察组手术结束时、术后3d、出院前、术后3个月、术后6个月及术后1年转复率分别是83.3％、57.4％、59.3％、72.2％、74.1％及75.9％,对照组为14.5％、11.3％、11.3％、8.1％、9.7％及8.1％,2组比较均具有统计学差异(P=-0.000);观察组心功能指标和血液中相关因子变化均优于对照组.随访统计,观察组患者并发症(脑梗死和出血)发生率较低(x2=4.551,P=-0.033;x2=5.716,P=0.017).结论:射频消融联合左心耳闭合术是安全可靠的,在预防血栓栓塞中具有特殊意义.     

HDL-C与非瓣膜性心房颤动左心房/左心耳血栓形成的关系

目的:探讨高密度脂蛋白胆固醇（HDL-C）与非瓣膜性心房颤动（AF）左心房（LA）/左心耳(LAA)血栓形成的关系。方法:试验共纳入非瓣膜性AF患者188例,根据HDL-C水平分为低HDL-C组44例（23.4%）,正常HDL-C组144例（76.6%）;根据LA/LAA血栓分为血栓组（n=39例）和非血栓组（n=139例）。详细记录患者既往病史、实验室检验结果、经胸心脏彩超及经食管心脏超声(TEE)结果,比较两组的一般资料、LA或LAA血栓等。进一步单因素及多因素Logistic回归分析探讨LA/LAA血栓形成的相关危险因素。结果:（1）入选的188例患者中男108例、女80例,年龄（60.88±9.63） ( 29～78) 岁。低HDL-C组男性、糖尿病、LA/LAA血栓比例及体质量指数、甘油三酯（TG）、空腹血糖（FBG）、左心房内径（LAD）大小、CHADS₂评分高于正常HDL-C组（P＜0.01或0.05）。（2）Pearson相关分析显示,HDL-C水平与LA/LAA血栓形成负相关(r＝-0.231,P＝0.001)。（3）与非血栓组患者比较,LA/LAA血栓组患者既往脑卒中或一过性脑缺血发作（TIA）史、周围血管病史、持续性或永久性AF、低HDL-C血症比例、CHADS₂评分较高,LAD较大,HDL- C水平比非血栓组显著偏低（P＜0.01或0.05）。（4）多因素Logistic回归分析显示,HDL-C（OR＝0.046,95%CI :0.007～0.300,P＝0.001）、持续性或永久性AF(OR ＝0.306,95% CI:0.116～0.808,P＝0.017)、脑卒中或TIA(OR ＝15.657,95% CI:2.525～97.069,P＝0.003)、周围血管病(OR ＝5.817,95% CI:1.123～30.145,P＝0.036)与AF患者LA/LAA血栓形成独立相关。结论:HDL-C水平与LA/LAA血栓形成负相关,低HDL-C血症是LA/LAA血栓形成的高危因素。     

心房颤动导管消融术式的进展

心房颤动(房颤)的主要治疗手段有抗栓法、控制心室率法、电复律法和导管消融术等,其中导管消融术的应用为房颤的治疗提供了新的方式.随着对房颤产生机制及维持机制的深入探讨,导管消融术不断完善,发展出心房内线性消融、针对肺静脉触发灶的导管消融、心房复杂碎裂电位消融、房颤转子消融等多种术式.本文综述了目前房颤导管消融术不同术式的研究进展,为临床房颤的治疗提供参考.     

二尖瓣机械瓣置换术中闭塞左心耳预防风湿性心房颤动患者脑栓塞的临床研究

目的  探讨在二尖瓣机械瓣置换术中采用丝线结扎闭塞左心耳的安全性,并评价其预防风湿性心房颤动（AF）患者脑栓塞的有效性。方法  2012年4月-2014年3月,258例风湿性AF患者在该院接受二尖瓣机械瓣置换术治疗,129例术中采用双十号丝线从心外结扎闭塞左心耳（结扎组）,129例未行左心耳结扎术（对照组）,通过观察两组手术相关指标、术后并发症以及随访期内脑栓塞发生率,并进行分析。结果  两组手术时间、体外循环时间、阻断时间、ICU入住时间、术后住院时间,以及术后再次开胸止血、低心排血量综合征、急性肾功能衰竭、肺部感染、胸骨切口裂开发生率比较,差异无统计学意义;结扎组死亡2例,而对照组死亡3例,差异无统计学意义。结扎组127例随访（23.6±11.3）个月,无一例发生脑栓塞,而对照组126例随访（22.9±12.1）个月,5例发生脑栓塞,差异有统计学意义（P <0.05）。结论  二尖瓣机械瓣置换术中采用丝线结扎闭塞左心耳,简单安全,可降低风湿性AF患者脑栓塞的发生率。

     

Left atrial wall thickness: anatomic aspects relevant to catheter ablation of atrial fibrillation

Background  The success and complication rates of atrial fibrillation (AF) ablation may be related to regional differences in left atrial (LA) wall thickness. The purpose of this study was to investigate the transmural LA wall thickness in various regions.

Methods  We measured LA wall thickness in 36 human heart specimens using calipers at three planes including left pulmonary veins (PVs) vestibule plane, right PVs vestibule plane and the middle plane between the two. In each plane, eight points were selected, including superior, middle and inferior levels at anterior and posterior wall, roof and bottom.

Results  The anterior and posterior wall thickness displayed gradient from superior to inferior level (anterior wall: (2.73±1.01) mm, (2.08±0.91) mm and (1.54±0.69) mm; posterior wall: (1.74±0.68) mm, (1.48±0.39) mm and (1.27±0.42) mm). At the roof, LA wall thickness was thickest in middle plane ((2.01±1.02) mm) and was thinnest in left PVs vestibule plane ((1.29±0.41) mm). The posterior wall thickness in left PVs vestibule plane was thinner than in the other two planes (P <0.05–0.001), and was thinner in right PVs vestibule plane than in middle plane (P <0.01–0.001). Whereas in anterior wall, the wall thickness in left PVs vestibule plane was thicker than in middle and right PVs vestibule plane.

Conclusions  Significant variations exist for mean LA wall thickness at different regions which are often targeted during circumferential pulmonary venous ablation (CPVA). Appreciating these differences may have significant implications in catheter ablation of AF.

     

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。     

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.