血浆脑利钠肽与房颤病人复律和复发的临床研究

目的研究阵发性或持续性房颤(Af)病人转复窦性心律时,血浆脑利钠肽(BNP)水平及其临床意义。方法选取62例心功能(1~3)级病人,采用放免法测定房颤及窦性心律时病人血浆中BNP的浓度,观察两组BNP水平、房颤发作次数。结果病人房颤发生时BNP浓度为(88.36±22.32)pg/mL,比复律后窦性心律时(57.48±20.32)pg/mL明显增高(P<0.05),高BNP水平病人组房颤发生次数较低BNP水平病人多。多因素分析显示血浆BNP水平与Af持续时间是转律后窦性心律维持的独立影响因子。结论血BNP浓度增高是发生心房颤动的预告因子,高水平的BNP更容易复发房颤,血浆BNP水平低或Af持续时间短者转律后窦性心律较易维持。     

Left Atrial Appendage Wall‐Motion Velocity Associates with Recurrence of Nonparoxysmal Atrial Fibrillation after Catheter Ablation

Catheter ablation (CA) for nonparoxysmal atrial fibrillation (AF) is controversial due to its high recurrence rate. The aim of this study was to assess retrospectively the diagnostic value of preprocedural left atrial appendage (LAA) wall‐motion velocity in predicting recurrence of AF within 1 year after CA. We hypothesized that tissue Doppler‐derived measurement of LAA wall‐motion velocity associate with recurrence of AF within 1 year after CA. We retrospectively reviewed 47 consecutive patients with nonparoxysmal AF (defined as AF lasting for 1 week or longer) who underwent both transthoracic and transesophageal echocardiography before their first treatment by CA in a single center. Forty‐one patients aged 58 ± 10 years were included, and variables predicting the recurrence of AF within 1 year after CA were evaluated. Seventeen patients (41%) developed recurrence of AF within 1 year after CA. Univariate analyses showed that preprocedural LAA upward wall‐motion velocity at the apex assessed by transesophageal echocardiography was significantly lower in patients with recurrence of AF than those without recurrence (OR = 1.45, 95% CI: 1.13–2.01, P = 0.009). Multivariate logistic analyses including other potential predictors (duration of AF, left ventricular ejection fraction, E‐wave deceleration time, and left atrial wall‐motion velocity) identified LAA upward wall‐motion velocity at the apex as an independent predictor of outcome. These data suggest in patients with nonparoxysmal AF, preprocedural LAA upward wall‐motion velocity at the apex, as determined by tissue Doppler imaging during transesophageal echocardiography, may be a useful indicator for predicting recurrence of AF within 1 year after CA.     

Association of Left Atrial Strain and Strain Rate Assessed by Speckle Tracking Echocardiography with Paroxysmal Atrial Fibrillation

Background: We hypothesized that contraction of the LA wall could be documented by speckle tracking and could be applied for assessment of LA function. This study tried to identify the association between LA longitudinal strain (LAS) and strain rate (LASR) measured by speckle tracking with paroxysmal atrial fibrillation (PAF). Methods: Fifty‐two patients (61 ± 17 years old, 23 men) with sinus rhythm at baseline referred for the evaluation of episodic palpitation were included. Standard four‐chamber and two‐chamber views were acquired and analyzed off‐line. Peak LAS and LASR were carefully identified as the peak negative inflection of speckle tracking waves after P‐wave gated by electrocardiography. Results: Ten patients (19%) had PAF. LAS, LASR, age, left ventricular end‐diastolic dimension, left ventricular mass, LA volume, and mitral early filling‐to‐annulus early velocity ratio were different between patients with and without PAF. After multivariate analysis, LASR was significantly independently associated with PAF (OR 8.56, 95% CI 1.14–64.02, P = 0.036). Conclusion: Speckle tracking echocardiography could be used in measurements of LAS and LASR. Decreased negative LASR was independently associated with PAF. (ECHOCARDIOGRAPHY, Volume 26, November 2009)     

Increased Plasma Levels of Atrial Natriuretic Peptide (ANP) in Patients with Paroxysmal Supraventricular Tachyarrhythmias

ABSTRACT. Nilsson G, Pettersson A, Hedner J, Hedner T (Department of Internal Medicine, Central Hospital, Halmstad and Department of Clinical Pharmacology, Sahlgrenska University Hospital, Göteborg, Sweden). Increased plasma levels of atrial natriuretic peptide (ANP) in patients with paroxysmal supraventricular tachyarrhythmias. Acta MedScand 1987; 221:15–21. Atrial natriuretic peptide (ANP) is a cardiac hormone originating from atrial cardiocytes. It seems to be involved in the regulatory control of circulating volume and vascular tone. Plasma immunoreactive atrial natriuretic peptide (IrANP) was investigated in 22 patients with paroxysmal supraventricular tachyarrhythmia (16 with atrial fibrillation, 4 with atrial flutter, one with a Wolf-Parkinson-White syndrome (WPW) and one with atrial tachycardia). During the aute attack, IrANP was significantly increased (125.3± 11.4 pmol/1) compared to samples obtained during convalescence (55.9±4.7 pmol/1). Heart rate (HR) was 144±4.3 beats/min during the arrhythmia and 75±2.6 during convalescence. The reduction of IrANP in plasma from the acute attack of tachycardia to follow-up was significantly related to the reduction of HR (p<0.05). Irrespective of type of paroxysmal supraventricular tachyarrhythmia, 50% of the patients experienced polyuria during the attack. This symptom was more frequent in younger patients with a shorter duration of tachycardia. Polyuria patients had a higher HR during the attack of supraventricular tachycardia. Even though polyuria was not alwavs found in the patients with the highest IrANP values, the symptom was associated with significantly higher concentrations of Ir ANP in plasma compared to the non-polyuria group. We conclude that Ir ANP is increased in plasma during acute attacks of paroxysmal supraventricular tachycardia. Furthermore, the polyuria frequently associated with this condition may partly be due to excess release of ANP from cardiac myocytes.     

Gene Expression of the Natriuretic Peptide System in Atrial Tissue of Patients with Paroxysmal and Persistent Atrial Fibrillation

INTRODUCTION: Circulating cardiac natriuretic peptides play an important role in maintaining volume homeostasis, especially during conditions affecting hemodynamics. During atrial fibrillation (AF), levels of plasma atrial natriuretic peptide (ANP) becomes elevated. The aim of this study was to gather information about gene expression of the natriuretic peptide system on the atrial level in patients with AF. METHODS AND RESULTS: Right atrial appendages of 36 patients with either paroxysmal or persistent AF were compared with 36 case matched controls in sinus rhythm for mRNA expression of pro- atrial natriuretic peptide (pro-ANP), pro-brain natriuretic peptide (pro-BNP), and their natriuretic peptide receptor type-A (NPR-A). We investigated patients without (n = 36) and with (n = 36) valvular disease. Persistent AF was associated with higher mRNA expression of pro-BNP (+66%, P = 0.04, in patients without valvular disease, and +69%, P < 0.01, in patients with valvular disease) and lower mRNA expression of NPR-A (-58%, P = 0.02, in patients without valvular disease, and -62 %, P < 0.01, in patients with valvular disease). The mRNA content of pro-ANP was only increased in patients with valvular disease (+12%, P = 0.03). No changes were observed in patients with paroxysmal AF. CONCLUSION: This study demonstrates that persistent, but not paroxysmal, AF induces alterations in gene expression of pro-BNP and NPR-A on the atrial level. Although AF generally is associated with an increase of plasma ANP level, a change in mRNA content of pro-ANP is only observed in the presence of concomitant valvular disease and is of minor magnitude.     

健心平律丸对阵发性房颤患者BNP、Ald的影响

目的：观察健心平律丸联合小剂量胺碘酮对阵发性房颤患者脑钠肽（BNP）、醛固酮（Ald）的影响。方法采用随机分组对照方法,分为治疗组30例,对照组32例。观察对象2周内未服用抗心律失常药物及影响心率、心电图、血脂的药物。治疗组在对照组治疗基础上,服用健心平律丸6 g,每天3次。对照组服用胺碘酮,从200 mg,每天3次开始,5 d后减为200 mg,每天2次,再5 d后减为200 mg,每天1次维持。治疗开始前及治疗结束后记录主要症状（心悸、胸闷、气短、疲倦乏力、头晕、舌脉象）、证候（心阳不振、气阴两虚、痰瘀阻滞）、体征、心电图、BNP、Ald。结果治疗组与对照组阵发性房颤患者BNP、Ald治疗前无统计学意义（P〉0.05）;治疗组用药3个月后,与治疗前比较,BNP、Ald有统计学意义（P〈0.05）;用药3月后,治疗组与对照组 BNP、Ald 相比较有统计学意义（P〈0.05）。结论健心平律丸联合小剂量胺碘酮能够降低阵发性房颤患者 BNP、Ald 水平,优于常规单用西药组,且无任何毒副反应。     

Left Ventricular Lateral Annulus and Left Atrial Free‐Wall Velocity Time Integral Indicate Thromboembolism in Patients with Rheumatic Atrial Fibrillation

Background: Low wall motion and stasis increase the likelihood of clot formation. We hypothesized that tissue Doppler indices of left atrial (LA) motion are reduced in the presence of LA thrombi and may be predictive for clot formation in patients with atrial fibrillation (AF). Methods: We did an observational study for 3 years in 118 patients with rheumatic mitral valve disease in chronic AF who had not received anticoagulation, with (Group 1, n = 36) and without (Group 2, n = 82) thromboembolism. Pulsed tissue Doppler systolic velocities and velocity time integrals (VTIs) were measured in all four chambers. A mean LA VTI was calculated. LA strain during ventricular systole was calculated using VTI and distance between two LA locations. Results: Logistic regression analysis showed that, after adjusting for age, gender, diabetes, hypertension, LA size, and left ventricular (LV) ejection fraction, mean LA VTI [Odds ratio (OR) 0.69, 95%CI (0.56–0.86, P = 0.03)] and lateral mitral annulus VTI [OR 0.15 (0.04–0.56, P = 0.03)] were associated with clot formation. The addition of these two parameters to the conventional risk factors increased the ability to predict thromboembolism (Nagelkerke R²= 0.32–0.50, P = 0.01; area under the curve 0.83 by receiver operating characteristic analysis, P = 0.01). LA strain also had potential to indicate clot formation (0.9 ± 13.8 vs. ?8.2 ± 15.1%, group 1 vs. 2, respectively, P = 0.01). Conclusion: Patients with chronic AF and thromboembolism have reduced LA and LV motion independently of LA size and LV ejection fraction. Tissue Doppler parameters may have potential to predict clot formation in these patients. (Echocardiography 2010;27:1038‐1048)     

Prevalence and Clinical Characteristics Associated With Left Atrial Appendage Thrombus in Fully Anticoagulated Patients Undergoing Catheter‐Directed Atrial Fibrillation Ablation

LAA Thrombus Among Anticoagulated AF Patients. Introduction: Catheter‐directed atrial fibrillation (AF) ablation is contraindicated among patients with left atrial appendage (LAA) thrombus. The prevalence of LAA thrombus among fully anticoagulated patients undergoing AF ablation is unknown. Methods and Results: We retrospectively evaluated the prevalence of LAA thrombus among 192 consecutive patients undergoing AF ablation between July 2006 and January 2009. Seven of 192 patients (3.6%) had evidence of thrombus on transesophageal echocardiogram (TEE) despite being fully anticoagulated on warfarin (international normalized ratio [INR] 2–3) for 4 consecutive weeks prior to echocardiogram. Univariate analysis demonstrated that structural heart disease, large left atrial dimension, and number of AF ablations were associated with thrombus. Three patients with thrombus had paroxysmal AF with normal LV function. Conclusion: Despite full anticoagulation, 3.6% of patients undergoing AF ablation had LAA thrombus. We recommend that all patients, regardless of LV function or left atrial size, should undergo preprocedural TEE to exclude the presence of LAA thrombus. (J Cardiovasc Electrophysiol, Vol. 21, pp. 849‐852, August 2010)     

Three‐Dimensional Speckle Tracking Echocardiography–Derived Left Atrial Strain Parameters Are Reduced in Patients with Atrial Fibrillation (Results from the MAGYAR‐Path Study)

Objective: Three‐dimensional (3D) speckle tracking echocardiography (3DSTE) is a novel imaging modality for assessing cardiac function. We aimed to analyze left atrial (LA) function using 3DSTE in patients with atrial fibrillation (AF). Methods: 3DSTE was performed in 20 patients prior to their pulmonary vein isolation for AF. Every patient underwent a complete two‐dimensional echocardiographic study at the same time. 3DSTE‐derived circumferential (CS), longitudinal (LS), radial (RS), 3D (3DS), and area strain (AS) values were measured in the basal (b), mid (m), and superior (s) regions of the LA. 3DSTE‐defined maximal (LA_max) and minimal LA volumes (LA_min) and LA total emptying fraction were calculated automatically. Eleven randomly selected age‐ and gender‐matched healthy volunteers served as controls. Results: Patients with AF had significantly larger LA_max and LA_min and reduced LS, RS and CS.3DS and AS were significantly lower throughout the LA in cases with AF (3DS?b, ?m, ?s [AF patients vs. controls]: ?18 ± 8% vs. ?29 ± 8%, P = 0.001; ?14 ± 6% vs. ?22 ± 7%, P = 0.002; ?10 ± 7% vs. ?20 ± 9%, P = 0.002; AS?b, ?m, ?s [AF patients vs. controls]: 35 ± 15% vs. 52 ± 13%, P = 0.004; 50 ± 21% vs. 72 ± 19%, P = 0.009; 31 ± 21% vs. 65 ± 27%, P < 0.0001, respectively). Conclusions: 3DSTE‐derived “uni‐dimensional” LS, RS, CS, as well as novel strain parameters (3DS, AS) are significantly reduced in patients with AF compared to matched controls. 3DS and AS might be new strain parameters providing further insights into the alterations of LA function in patients developing AF.     

Comparison of Cryoballoon and Radiofrequency Ablation of Pulmonary Veins in 40 Patients with Paroxysmal Atrial Fibrillation: A Case‐Control Study

Introduction: Ablation of pulmonary veins (PV) is an established therapeutic option for patients with symptomatic drug‐refractory paroxysmal atrial fibrillation (AF). Radiofrequency (RF) is currently the most widespread energy source for PV ablation. Cryothermal energy applied with a cryoballoon technique as an alternative has recently evolved. Methods and Results: In a case‐control setting, we compared 20 patients with paroxysmal AF who underwent their first PV ablation with the cryoballoon technique to 20 matched patients with conventional RF ablation. In the case of persistent electrical potentials after cryoballoon ablation, it was combined with ablation with a conventional cryocatheter. All patients performed daily event recording for 3 months after ablation procedure. Ablation parameters and success rate after 3 and 6 months were compared. In the cryoballoon group, the overall success rate was 55% (50% in the cryoballoon only group [14 patients] and 66% in the combination group [6 patients]), as opposed to the RF group with 45%. AF episode burden was lower after cryoballoon ablation. There was no significant difference between cryoballoon and RF ablation regarding procedure parameters. In the cryoballoon group, 3 phrenic nerve palsies occurred using the 23 mm balloon that resolved spontaneously. Conclusion: PV ablation with the cryoballoon technique is feasible and seems to have a similar success rate in comparison to RF ablation. Procedure‐ and fluoroscopy duration are not longer than in conventional RF ablation.     

Long‐Term Results of Transcatheter Atrial Fibrillation Ablation in Patients with Impaired Left Ventricular Systolic Function

AF Ablation and Impaired Left Ventricular Function. Introduction: Long‐term outcome of AF ablation in patients with impaired LVEF is unknown. The aim of this study is to evaluate sinus rhythm (SR) maintenance, clinical status, and echocardiographic parameters over a long‐term period following atrial fibrillation (AF) transcatheter ablation in patients with left ventricular ejection fraction (LVEF) <50%. Methods and Results: A total of 196 patients (87.2% males, age 60.5 ± 10.2 years) with LVEF <50% underwent radiofrequency transcatheter ablation for paroxysmal (22.4%) or persistent (77.6%) AF. Patients were followed up for 46.2 (16.4–63.5) months regarding AF recurrences, functional class, and echocardiographic parameters. All patients underwent pulmonary vein isolation, while 167 (85.2%) required additional atrial lesions. Eleven (5.6%) patients suffered procedural complications. During follow‐up, 58 (29.6%) patients required repeated ablations. At the follow‐up end, 15 (7.7%) patients died, while 74 (37.8%) documented at least one episode of AF, atrial flutter, or atrial ectopic tachycardia. Eighty‐three (47.2%) patients maintained antiarrhythmic drugs. During follow‐up, NYHA class improved by at least one class more frequently among patients maintaining SR compared to those experiencing relapses (70.6% vs 47.9%, P = 0.003). LVEF showed a broader relative increase in patients maintaining SR (32.7% vs 21.4%; P = 0.047) and mitral regurgitation grading significantly decreased (P <0.001) only within these patients. At multivariable analysis SR maintenance emerged as an independent predictor (odds ratio 4.26, 95% CI 1.69–10.74, P = 0.002) of long‐term clinical improvement (reduction in NYHA class ≥1 and relative increase in LVEF ≥10%). Conclusions: Although not substantially worse than in patients with preserved LVEF, AF ablation in patients with impaired LVEF is affected by high long‐term recurrence rate. Among these patients SR maintenance is associated with greater clinical improvement. (J Cardiovasc Electrophysiol, Vol. 24, pp. 24‐32, January 2013)