三种影像学测量技术对左心耳封堵器尺寸选择的指导价值

  目的  初步探讨CT血管造影(CT angiography, CTA)、经食管超声心动图(transesophageal echocardio-graphy, TEE)和术中数字减影血管造影(digital subtraction angiography, DSA)3种方法测量左心耳开口直径对选择适宜尺寸左心耳封堵器的指导价值。  方法  回顾性收集2015年12月1日至2019年3月31日在解放军总医院第一医学中心接受经皮左心耳封堵术的非瓣膜性房颤患者临床资料。所有入选患者同时采用CTA、TEE、DSA 3种方法测量左心耳开口直径, 记录植入封堵器尺寸, 采用Pearson相关性分析比较3种方法测量值与植入封堵器尺寸的相关性, 采用Bland-Altman一致性分析法比较3种方法测量值与所植入封堵器尺寸的一致性。  结果  共102例符合纳入和排除标准的患者入选本研究, 均成功植入WATCHMAN封堵器。平均年龄(70.1±9.8)岁, CHA2DS2-VASc评分(评估非瓣膜性房颤成年患者发生卒中的风险)为(5.11±1.43)分, HAS-BLED评分(评估出血风险)(3.61±1.18)分。CTA测量左心耳开口直径[(22.51±3.55)mm]与DSA[(22.22±3.73)mm]接近, 无统计学差异(q=0.81, P=0.12), 两种方法的测量值均大于TEE[(20.82±0.36)mm, P均 < 0.01]。封堵器尺寸与CTA、DSA、TEE测量的左心耳开口直径呈正相关(r=0.93、0.87、0.83, P均 < 0.01)。封堵器尺寸与CTA测量值的一致性界限最窄(-7.83 mm, -2.56 mm), 差值为(-5.19±1.35)mm, 95%置信区间为(-5.46 mm, -4.93 mm); 与TEE测量值的一致性界限最宽(-11.00 mm, -2.77 mm), 差值为(-6.88±2.10)mm, 95%置信区间为(-7.29 mm, -6.47 mm)。  结论  CTA、DSA、TEE测量左心耳开口直径能为选择左心耳封堵器适宜尺寸提供较好依据, 其中CTA测量值与封堵器尺寸的相关性和一致性最佳。     

房颤患者左心耳血栓形成与结构功能的关系

目的 分析房颤患者血栓形成与左心耳结构功能的关系。方法 采用经食管超声心动图检测88例房颤患者及18例对照组患者的左心腔前后径(LA-D)、左心耳入口宽度(LAA-W)、左心耳长度(LAA-L)、左心耳前壁、后壁及顶部的运动速度及左心耳充盈及排空速度等指标。根据左心耳内透声,将房颤患者分为无自发显影(NO SEC)亚组、自发显影(SEC)亚组、泥浆样改变(sludge)亚组和血栓(thrombosis)亚组,并将各指标与对照组进行比较。结果 与对照组相比,房颤组患者左心耳结构及功能均有不同程度的改变;sludeg亚组及thrombosis亚组的LAA-W均较对照组增大,差异有统计学意义(P均<0.05);血栓亚组的LAA-L较对照组增大,差异有统计学意义(P<0.01);房颤各亚组的LA-D均较对照组扩大(P均<0.05);房颤各亚组的左心耳充盈及排空速度均较对照组降低(P均<0.05),在血栓亚组降低更为明显;除无自发显影亚组外,余各亚组的左心耳各壁运动速度差异均有统计学意义(P均<0.01)。结论 房颤患者左心耳内血栓形成与左心耳的结构以及功能改变密切相关。     

实时三维经食管超声心动图在经皮左心耳封堵术治疗非瓣膜病性心房颤动患者中的应用价值

目的 探讨实时三维经食管超声心动图（RT-3D-TEE）在经皮左心耳封堵术（PLAATO）治疗非瓣膜病性心房颤动中的应用价值。方法 对62例接受PLAATO的非瓣膜病性心房颤动患者行二维经食管超声心动图（2D-TEE）、RT-3D-TEE和心血管造影（CAG）检查,分别测量左心耳口最大径、左心耳口最小径、左心耳口深度,并比较三者的差异。以RT-3D-TEE测量的左心耳口最大径测量值为依据,选择适当封堵器型号,并在RT-3D-TEE、CAG引导下进行左心耳封堵术。术后进行随访。结果 62例均封堵成功,成功率为100%,封堵压缩率为（19.78±6.92）%;术中、术后随访期内均未发生严重并发症。2D-TEE、RT-3D-TEE及CAG测量的左心耳口最大径总体差异有统计学意义（P=0.029）,RT-3D-TEE测值高于2D-TEE而低于CAG;三者测量的左心耳口最小径和左心耳深度总体差异均无统计学意义（P均>0.05）。CAG、RT-3D-TEE和2D-TEE测量的左心耳口最大径与封堵器尺寸均呈正相关（r=0.925、0.841、0.716,P均≤ 0.001）。结论 RT-3D-TEE可用于PLAATO治疗非瓣膜病性心房颤动术前筛选、术中引导和术后随访,能准确观察左心耳口形态并评估封堵效果。     

持续性心房颤动导管消融术强化间隔消融与术后左心耳激动延迟的关系

  目的  探讨持续性心房颤动(简称房颤)导管消融术后左心耳激动显著延迟与术中强化间隔消融的关系。  方法  对2007年6月至2009年2月在本科接受导管消融术的201例持续性房颤患者行步进式导管消融, 术后行左房激动标测并记录左心耳电活动, 术后1月行经胸心脏超声评估左房功能。  结果  术后23例出现左心耳激动显著延迟, 其中14例为初次消融病例, 9例接受了间隔线消融(OR 15.2, 95%CI 4.6~50.8, P < 0.001);另9例为第2次消融(包括2例左房隔离)病例, 9例患者也于初次消融中行广泛间隔复杂碎裂电位消融(P=0.002)。激动标测提示21例患者中18例(85.7%)左房最早激动部位转向冠状窦。术后1个月二尖瓣前向血流A峰为(18.2±17.0)cm/s, 与术前为窦性心律者比较显著下降, (20.2±19.1)cm/s vs.(58.2±17.9)cm/s(P=0.037)。随访(10.6±6.2)个月, 14例患者维持窦性心律。  结论  持续性房颤导管消融术行间隔线或广泛间隔复杂碎裂电位消融可导致左心耳激动显著延迟, 可能影响左房功能, 持续性房颤患者采用此术式应该慎重。     

经食管超声心动图在经皮WATCHMAN 左心耳封堵术中的应用体会

目的 通过对经食管超声心动图（transesophageal echocardiography ,TEE）获取的一组真实的临床数据的分析,认识TEE在心房颤动患者左心耳封堵术中及随访中的应用价值。方法 选取2015年3月至2017年4月于我院确诊房颤且行WATCHMAN左心耳经皮介入封堵术的患者为对象,通过TEE观察记录术中、随访45天、6个月封堵器效果,包括残余分流、有无血栓及封堵器压缩径。结果 共收集243例行左心耳经皮介入封堵术的房颤病例,成功植入WATCHMAN封堵器的病例为241例（99.2%）,围术期发现心脏压塞2例（0.83%）,发现器械血栓1例（0.41%）;随访45天时,发现器械血栓3例（1.36%）;随访6个月时,未发生器械相关血栓事件、死亡等重大不良事件。结论 TEE在WATCHMAN左心耳封堵术中及术后起到了重要的作用,其对手术效果及术后并发症的评估准确、客观、及时,值得推荐临床应用。     

应用TEE数据源的左心耳3D模型开口参数指导LAmbreTM封堵器型号选择

目的探讨左心耳开口的多个解剖参数与术中最终置入心房颤动(以下简称房颤)患者体内的LAmbre TM封堵器型号之间的关系。方法选取在我院成功进行左心耳LAmbre TM封堵的23例房颤患者,应用交互式医学影像控制系统软件对其左心耳3D经食管超声心动图(TEE)医学数字成像和通信容积数据进行阈值分割等操作,重建左心耳3D模型,测量左心耳开口最大径、周长及面积,并与手术最终选择封堵器型号进行相关性分析。将与封堵器固定盘大小相关性较好的前15例患者的左心耳开口参数与所选择封堵器大小进行线性回归分析。抽取术中更换封堵器2例患者,制作左心耳3D打印模型,并进行体外封堵器释放试验。结果成功对23例房颤患者的左心耳超声容积数据进行后处理,并获取了包括左心耳开口形态在内的5个开口参数。左心耳开口最大径、面积及周长与相应LAmbre TM封堵器固定盘大小的相关性较好(r=0.85、0.74、0.89,均P0.01)。以与封堵器固定盘大小相关性较好的前15例房颤患者的左心耳开口最大径及周长作为预测变量,封堵器型号为因变量,建立的回归方程分别为:封堵器固定盘最大径预测值=11.22+0.71×开口最大径;封堵器固定盘周长预测值=12.71+1.06×开口周长。通过对左心耳开口参数的综合评估,体外试验中成功封堵了所抽取的2例患者的左心耳模型,且所选择的封堵器与手术最终应用的型号一致。结论综合分析左心耳3D模型开口解剖参数可以更好地指导LAmbre TM封堵器型号的选择。     

多层螺旋CT评价不同类型心房颤动患者左心房和左心耳功能

目的 采用多层螺旋CT定量测量心房颤动（AF）患者左心房、左心耳功能,探讨不同类型AF患者之间左心房及左心耳功能的差异。方法 收集71例AF患者,包括阵发性房颤（PAF）40例（PAF组）,持续性房颤（PeAF）31例（PeAF组）。应用心功能后处理软件测量AF患者左心耳最大容积（LAAV_max）、左心耳最小容积（LAAV_min）、左心房最大容积（LAV_max）和左心房最小容积（LAV_min）,并计算左心耳射血分数（LAAEF）、左心耳射血量（LAAEV）、左心房射血分数（LAEF）、左心房射血量（LAEV）。结果 PeAF组LAAEF、LAEF、LAEV均小于PAF组（P均<0.01）,LAAV_max、LAAV_min、LAV_max、LAV_min均大于PAF组（P均<0.05）。2组间LAAEV差异无统计学意义（P=0.23）。AF患者LAAEF与LAEF呈正相关（r_s=0.57,P<0.01）,与AF持续时间呈负相关（r_s=－0.26,P=0.03）。结论 应用多层螺旋CT可以客观评价左心房和左心耳功能,对认识不同分型AF患者左心耳和左心房功能改变有重要临床意义。     

经胸体外直流电复律治疗药物转复不佳持续性房颤36例临床护理

目的：探讨经胸体外直流电复律治疗药物转复不佳持续性房颤患者的护理方法。方法：对36例药物转复不佳持续性房颤患者行经胸体外直流电复律治疗,并给予相应的护理措施。结果：本组36例患者电转复均获得成功,均转为窦性心律。结论：经胸体外直流电复律是目前药物转复心房颤动无效的首选方法,通过加强电复律前、电复律中、电复律后护理及病情观察,可使转律获得理想结果。     

经食管超声心动图在房颤患者左心耳封堵Watchman植入术中的初步应用

目的初步探讨经食管超声引导下封堵左心耳对预防房颤患者中风的临床意义。方法利用经食管超声观察左心耳形态、功能、测量左心耳大小。在TEE引导下经皮左心耳封堵,选用美国波士顿Watchman封堵伞。结果 2例住院心房颤动患者,成功植入Watchman封堵伞,分别选用的直径为24、27mm封堵器至左心耳根部,其位置正常,无残余分流。结论超声引导下经皮左心耳封堵术将成为预防房颤患者卒中治疗的新趋势。     

房颤患者行导管消融联合左心耳封堵术“一站式”治疗的护理配合

目的探讨房颤患者行导管消融联合左心耳封堵术"一站式"治疗的围术期护理。方法选取在本院心律失常中心住院的27例房颤患者,术前做好各项检查配合,完善术前准备工作及术中护理配合,术后做好活动指导、饮食指导、并发症防治,工作重点是心房食道瘘、心包填塞的预防与处理以及随访知识宣教等。结果本组27例患者均成功完成房颤导管消融联合左心耳封堵术,其中1例术中左心耳封堵器型号不合予9 d后重新更换封堵器手术成功,1例患者手术当天出现进食后胸骨后疼痛不适,胃镜检查提示食道黏膜损伤,予禁食补液、抑酸护胃等治疗后好转出院;术后随访均显示封堵器在位功能正常,无新的栓塞事件发生,未出现房性心律失常。结论房颤导管消融联合左心耳封堵术是近年开展的新技术,对操作者技术和围术期护理的要求都很高,护理人员应具备丰富的心脏介入知识、良好的沟通能力、敏锐的观察力、专业的救治力,以确保手术顺利完成。     

Efficacy and safety of catheter ablation combined with left atrial appendage occlusion for nonvalvular atrial fibrillation: A systematic review and meta-analysis

Atrial fibrillation (AF) is currently the most prevalent arrhythmia in clinical practice, with stroke being one of its major complications. Combining catheter ablation and percutaneous left atrial appendage occlusion (LAAO) into a “one-stop” intervention could reduce stroke incidence in selected high-risk patients and, at the same time, relieve AF symptoms in a single procedure. This meta-analysis analyzed the efficacy and safety of catheter ablation combined with LAAO for nonvalvular AF. PubMed, EMBASE, and the Cochrane Library were searched from inception to April 2019 to identify relevant citations. Efficacy indexes were procedural success, AF recurrence, stroke/transient ischemic attacks (TIA), and device-related thrombus (DRT). Safety indexes were all-cause death, major hemorrhagic complications, and pericardial effusion/cardiac tamponade. The incidence rate of events (ratio of events to patients) and 95% confidence interval (CI) were calculated as summary results. A forest plot was constructed to present pooled rates. Eighteen studies (two randomized controlled trials and 16 observational studies) were included. The results showed that one-stop intervention has significant efficacy and safety, with procedural success of .98 (95% CI, .97-1.00), AF recurrence of .24 (95% CI, .15-.35), stroke/TIA of .01 (95% CI, .00-.01), DRT of .00 (95% CI, .00-.01), all-cause mortality of .00 (95% CI, .00-.00), cardiac/neurological mortality of .00 (95% CI, .00-.00), major hemorrhagic complications of .01 (95% CI, .00-.02), and pericardial effusion/cardiac tamponade of .01 (95% CI, .00-.01). A single procedure with catheter ablation and LAAO in AF is a feasible strategy with significant efficacy and safety.     

Electrical cardioversion of persistent atrial fibrillation: acute and long-term results stratified according to arrhythmia duration

Background: Current definition of persistent atrial fibrillation (PAF) enrolls a heterogeneous population with different atrial fibrillation (AF) exposure and degree of atrial substrate. Study aims were to evaluate acute and long-term results of electrical cardioversion (ECV) and to identify temporal cutoff of previous AF exposure to reclassify PAF in subgroups with different chance of sinus rhythm (SR) maintenance. Methods: Five hundred twenty-one patients (66% men; age 69 ± 10 years) with PAF undergoing ECV, were divided in four groups according to AF duration at the time of ECV: group A with AF ≤2 months (141 patients); group B with AF >2 and ≤4 months (176 patients); group C with AF >4 and ≤6 months (89 patients); and group D with AF >6 months and <1 year (115 patients). Results: There was no difference in term of acute success among groups (98.5% vs 97.1% vs 98.9% vs 96.5%, respectively, P = 0.95). At 5-year follow-up, 198 (41%) patients were in SR: 50% in group A, 44% in group B, 42% in group C, and 25% in group D (P < 0.001). At the multivariate analysis, previous ECV (hazard ratio [HR] 1.55, P < 0.001), left atrium enlargement (HR 1.39, P = 0.013), and AF duration >6 months at time of procedure (HR 1.59, P = 0.001) independently predict ECV failure. Conclusion: ECV is associated with high acute success rate and low complications rate. Long-term results are strongly related with AF duration at time of ECV: a cutoff of >6 months helps in selecting patients that can take greater advantage of the procedure. (PACE 2012; 35:1126-1134).     

Transthoracic versus transesophageal cardioversion of atrial fibrillation under light sedation: a prospective randomized trial

BACKGROUND: Electrical cardioversion (ECV) of atrial fibrillation (AF) is limited by a 5-10% failure rate and by the expense arising from a perceived need for general anesthesia. A transesophageal approach using light sedation has been proposed as a means of augmenting the success rate and avoiding the need for general anesthesia. We hypothesized that the high rate of success and the lower energy requirement associated with biphasic cardioversion might eliminate any advantage of the transesophageal approach. METHODS: We randomly assigned 60 patients attending for ECV of persistent AF to a transesophageal or a transthoracic approach. Sedation of moderate depth was achieved with intravenous midazolam. The dose of midazolam was titrated in the same manner in both groups. RESULTS: Sinus rhythm was restored in 29/30 patients (97%) in each group using a similar number of shocks for both groups (1.3 +/- 0.6 transesophageal vs 1.4 +/- 0.7 transthoracic, P = NS) with a similar procedure duration (14.1 +/- 8.2 minutes vs 13.8 +/- 7.5 minutes, P = NS). Both groups received similar doses of midazolam (4.2 +/- 2.7 mg vs 4.4 +/- 2.8 mg, P = NS) and both reported a similar discomfort score in (0.9 +/- 1.3 vs 1.1 +/- 1.8, P = NS). No complication occurred in either group. CONCLUSION: AF may be cardioverted safely and effectively by either a transthoracic or a transesophageal approach. The use of sedation of moderate depth renders cardioversion by either approach acceptable. As transesophageal ECV shows no clear advantage, transthoracic cardioversion should remain the approach of first choice.     

Noninvasive time and frequency predictors of long-standing atrial fibrillation early recurrence after electrical cardioversion

Background: Several clinical factors have been studied to predict atrial fibrillation (AF) recurrence after electrical cardioversion (ECV) with limited predictive value. Methods: A method able to predict robustly long‐standing AF early recurrence by characterizing noninvasively the electrical atrial activity (AA) with parameters related to its time course and spectral features is presented. To this respect, 63 patients (20 men and 43 women; mean age 73.4 ± 9.0 years; under antiarrhythmic drug treatment with amiodarone) who were referred for ECV of persistent AF were studied. During a 4‐week follow‐up, AF recurrence was observed in 41 patients (65.1%). Results: RR variability and the studied AA spectral features, including dominant atrial frequency (DAF), its first harmonic and their amplitude, provided poor statistical differences between groups. On the contrary, f waves power (fWP) and Sample Entropy (SampEn) of the AA behaved as very good predictors. Patients who relapsed to AF presented lower fWP (0.036 ± 0.019 vs 0.081 ± 0.029 n.u.², P < 0.001) and higher SampEn (0.107 ± 0.022 vs 0.086 ± 0.033, P < 0.01). Furthermore, fWP presented the highest predictive accuracy of 82.5%, whereas SampEn provided a 79.4%. The remaining features revealed accuracies lower than 70%. A stepwise discriminant analysis (SDA) provided a model based on fWP and SampEn with 90.5% of accuracy. Conclusions: The fWP has proved to predict long‐standing AF early recurrence after ECV and can be combined with SampEn to improve its diagnostic ability. Furthermore, a thorough analysis of the results allowed outlining possible associations between these two features and the concomitant status of atrial remodeling. PACE 2011; 34:1241–1250)     

Ventricular Pauses during Atrial Fibrillation Predict Relapse after Electrical Cardioversion: A Prospective Study

Aims: To investigate the use of ambulatory electrocardiogram (ECG) monitoring in atrial fibrillation (AF) to predict recurrence after electrical cardioversion (ECV). Methods: RR interval variables were obtained from 24 hours ECGs recorded before ECV in 119 patients (85 men, age 66 ± 10 years) with persistent AF. Patients were followed for 1 month. Results: Of the 119 patients, 16 (13%) failed ECV and 65 (55%) were in AF at 1 week and 81 (68%) at 1 month after ECV. The maximum RR interval (RR‐max) and the minimum RR interval (RR‐min) during AF were found to be reproducible. The RR‐max was longer in those who had AF 1 week (2.55 ± 0.49 vs 2.01 ± 0.52 seconds, P = 0.005) and 1 month (2.56 ± 0.50 vs 1.89 ± 0.43 ms; P < 0.001) after ECV than in those who maintained sinus rhythm. Those in AF at 1 month included more patients with RR‐max ≥ 2.8 seconds (31% vs 11% P = 0.021). The average heart rate was lower in patients with RR‐max ≥ 2.8 seconds, but the average rate was not predictive of AF recurrence. Conclusion: Ventricular pauses during AF predict relapse after ECV. (PACE 2010; 934–938)     

Duration of P-wave is associated with atrial fibrillation hospitalizations in patients with atrial fibrillation and paced for bradycardia

BACKGROUND: Atrial fibrillation (AF) is a common problem in pacemaker patients. We conducted a prospective observational study in patients paced for bradycardia with associated paroxysmal or persistent AF, to determine whether P-wave duration may stratify patients at higher risk for AF recurrences and AF-related hospitalizations. The patients were evaluated for the prevalence, cause, and predictors of hospitalization. METHODS: We studied 660 consecutive patients (50% male, 72 +/- 9 years) who received a dual-chamber pacemaker. Median value of baseline P-wave duration was equal to 100 ms (25%-75% quartile range equal to 80-120 ms). We used this cut-off to divide the patients into group A (P < or = 100 ms), composed of 385 (58.3%) patients, and group B (P>100 ms), composed of 275 (41.7%) patients. RESULTS: In a median follow-up of 19 months, 173 patients were hospitalized for all causes, 130 for cardiovascular causes, and 85 for AF-related hospitalizations. Multivariate logistic analysis showed that P-wave duration >100 ms identified patients at higher risk (OR = 1.6, 95% confidence interval (1.1-2.8), P = 0.044) for AF-related hospitalizations. Patients in group B (P > 100 ms) more frequently suffered AF-related hospitalizations (16.4% vs 10.4%, P = 0.02) and underwent more frequent cardioversions (14.5% vs 9.1%, P = 0.029) compared with group A (P < or = 100 ms). CONCLUSIONS: P-wave duration may define the risk of persistent AF requiring cardioversion or AF-related hospitalization in patients with a pacemaker for bradycardia with associated paroxysmal or persistent AF.     

Antithrombotic strategies after interventional left atrial appendage closure: an update

Introduction: Interventional left atrial appendage occlusion (LAAO) has emerged as a valid alternative to oral anticoagulation (OAC) therapy for the prevention of ischemic stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF).

Areas covered: Antithrombotic therapy following interventional LAAO is critical in balancing the risk of thromboembolism and bleeding during the endothelialization of the implanted devices. In this article, the most recent clinical trials are reviewed and the current real-world antithrombotic strategies following LAAO device implantation are discussed.

Expert commentary: For patients eligible for OAC and receiving a Watchman device, the most solid scientific evidence exists for warfarin plus aspirin for 45 days followed by dual antiplatelet therapy (DAPT) for 6 months and a lifelong aspirin therapy. In real-world most patients are being treated with DAPT for 3–6 months. Alternatively, the Watchman was approved for 3 months of novel OAC (NOAC) therapy in conjunction with aspirin. For all other devices, DAPT for 1–6 months has been used in the vast majority of cases. Considering major bleeding as the predominant complication following LAAO, evidence suggests that short-term DAPT (6 weeks) or single antiplatelet therapy using aspirin may be a viable option.     

Development of atrial fibrillation in patients with atrioventricular block after atrioventricular synchronized pacing

Many studies have evidenced an increased incidence of AF in patients receiving single chamber ventricular pacing (VVI) when compared with those undergoing an atrial-based system (AAI or DDD). However, the difference in incidence of AF between two atrial-based systems (VDD, DDD) in patients with AV block was still controversial. This study was conducted to compare the development of AF between different modes of pacemakers (VDD and DDD) in patients with symptomatic AV block. A retrospective review was conducted of the detailed records of all consecutive patients who received permanent pacemakers due to symptomatic bradycardia from March 1995 to March 2000. The occurrence of AF was documented when there was presence of AF in the free-run or 12-lead ECG, any ECG strips, or persistent AF on 24-hour Holter ECG during the follow-up. The study included 152 patients (44 women, 108 men; mean age 73). The patients were divided into two groups: VDD (n = 100) and DDD (n = 52). The mean follow-up was 48.9 +/- 22.9 months. The incidence of AF was 7.9%. A higher incidence of AF was noted in the DDD group (15.4%) when compared with the VDD group (4.0%, P = 0.023). The incidence of development of AF in patients with AV block was higher in those receiving DDD cardiac pacing when compared with those who received the VDD system. The authors suggest that VDD pacing may be a better choice than the DDD system for patients with AV block, but without clinical evidence of sinus node dysfunction, and if an atrial lead is required, it should be placed close to the Bachmann's bundle.     

左心耳封堵在非瓣膜性心房颤动卒中的预防作用

血栓栓塞事件是心房颤动(房颤)最严重的并发症,及早识别并预防其栓塞风险至关重要。传统的抗凝治疗在预防非瓣膜性房颤患者的血栓栓塞事件方面存在一定局限性。左心耳部被证实为房颤患者血栓形成的主要部位,这一发现促使了经皮左心耳封堵技术的迅速发展。与抗凝药物相比,经皮左心耳封堵术可有效降低房颤患者血栓栓塞事件的发生率,且适用于抗凝禁忌的房颤患者。目前,WATCHMAN与ACP封堵装置已被授权进入欧盟市场,LARIAT左心耳结扎装置也因其有效性及安全性被美国FDA批准应用。经皮左心耳封堵及结扎术的适应证广,安全性高,有望成为多数房颤患者预防血栓栓塞事件的选择。     

Noncavotricuspid isthmus-dependent right atrial tachycardia after paroxysmal atrial fibrillation ablation

Background: Atrial tachycardia (AT) is commonly encountered after atrial fibrillation (AF) ablation. But no study exclusively on noncavotricuspid isthmus‐dependent right AT (NCTI‐RAT) post‐AF ablation has been reported. The present study aims to describe its prevalence, electrophysiological mechanisms, and ablation strategy and to further discuss its relationship with AF. Methods: From July 2006 to November 2009, 350 consecutive patients underwent catheter ablation for paroxysmal AF. A total of seven patients (2.0%) developed NCTI‐RAT after left atrium ablation for AF. In these highly selected patients (two male, mean age 54 ± 11 years, mean left atrium diameter of 34 ± 7 cm), all had circumferential pulmonary vein isolation in their initial procedures and three of them had additional complex fractionated electrograms ablation in the left atrium and the coronary sinus. Results: Totally, nine NCTI‐RATs were mapped and successfully ablated in the right atrium with a mean cycle length of 273 ± 64 ms in seven patients. Five ATs in three patients were electrophysiologically proved to be macroreentry and the remaining four were focal activation. All the ATs were successfully abolished by catheter ablation. After a mean follow‐up of 29 ± 15 months post‐AT ablation, all patients were free of AT and AF off antiarrhythmic drugs. Conclusions: NCTI‐RAT is relatively less common post‐AF ablation. Totally, 2.0% of paroxysmal AF patients were revealed to have NCTI‐RAT. (PACE 2011; 34:391–397)