Long-term single procedure efficacy of catheter ablation of atrial fibrillation

Background Two important limitations of the data regarding the outcomes of catheter ablation of atrial fibrillation (AF) are the short-term follow-up used in most published studies and the lack of single-procedure outcomes.Objective The objective was to report the long-term single-procedure outcomes at our center.Materials and methods The patient population was comprised of 200 consecutive patients who underwent ablation (133 men; age 56 ± 11 years). Atrial fibrillation was paroxysmal in 92 (46%). Success was defined as absence of symptomatic AF, off antiarrhythmic drug (AAD) after a single procedure.Results After a follow-up of 26 ± 11 months, the single-procedure long-term success rate was 28% with an additional 7% of patients demonstrating improvement. After including repeat procedures in 64 patients, the overall long-term success rate was 41% with 11% demonstrating improvement. Further subgroup analysis of 48 paroxysmal AF patients considered to be optimal candidates for the procedure, revealed a long-term success rate of 69% with an additional 4% demonstrating improvement. A major complication occurred in 7.9% of patients.Conclusion The results reveal that the long-term single-procedure success rate of catheter ablation of AF in a cohort of patients with predominantly non-paroxysmal AF is less than 40%. The inclusion of redo procedures resulted in an improvement in outcomes. A much higher success rate of 69% was achieved in patients with paroxysmal AF considered to be optimal candidates for this procedure. These results make it clear that further advances in the technique of catheter ablation of AF are needed to improve the safety and efficacy of this procedure. In order to be able to compare outcomes of various techniques in differing patient populations, we urge investigators to report long-term single procedure outcomes.This study was supported by The Norbert and Louise Grunwald Cardiac Arrhythmia Research Fund.     

小影像Koch三角及其房室结射频消融应注意的问题

为探讨小影像Koch三角房室结折返性心动过速 (AVNRT)病人射频消融时应注意的问题 ,右前斜位 30°透视下 ,将最大希氏束 (HBE)电位记录处与冠状静脉窦口 (CSo)处的影像距离容纳不下 3个 8F加硬大头电极者定义为小影像Koch三角 ,对 16例小影像Koch三角的AVNRT病人 ,参照慢径消融法行射频消融。结果 :16例病人中 ,成功消融靶点位于CSo水平以下者 12例 ,与CSo位于同一水平者 3例 ,位于CSo水平以上者 1例。 16例病人经消融后房室传导跳跃现象消失者 14例 ;跳跃现象存在 ,但无心房回波 ,异丙肾上腺素亦不能诱发AVNRT者 2例。上述 12例中有 1例于术中出现一过性房室阻滞 (AVB) ,术后 2 4h发生Ⅱ度Ⅱ型AVB ,出院后随访 3个月未能恢复正常 ,因心率为 38～ 5 0次 /分 ,并伴有脑供血不足症状 ,遂置入永久心脏起搏器。其余病人经过 3.5± 1.2 (0 .5～ 5 )年的随访 ,无AVNRT复发 ,亦无AVB发生。结论 :对于小影像Koch三角AVNRT病人的射频消融 ,应突破常规消融时的区位划分概念 ,主要在CSo前下方寻找并消融慢径 ,并根据放电后反应及时调整消融参数。     

肺静脉电隔离术后房性心律失常风暴现象的机制及对策

目的回顾分析阵发心房颤动(房颤)肺静脉电隔离术后早期房颤频繁复发并加重的病例,研讨此现象发生的机制和治疗对策。方法对连续54例药物治疗无效的阵发性房颤患者行肺静脉电隔离术,观察术后两周内的房颤复发情况。结果消融术后两周内10例(18.5%)有房颤早期复发或合并快速房性心律失常发作,其中4例(7.4%)出现肺静脉电隔离术后房性心律失常风暴现象。此4例患者联合使用抗心律失常药物两周左右心律逐渐恢复正常,继续服药至3个月,停药后房性心律失常风暴患者仅有1例仍有房颤发作,行二次肺静脉电隔离消融术,术后无房颤发作。结论消融术后早期房颤发作较常见,少数患者短期内房颤发作更加频繁,表现为房性心律失常风暴现象。其可能为多种因素联合作用所致,联合抗心律失常药物治疗有效,不必急于短时间内二次消融。     

全军心律失常介入治疗资料总汇

目的汇总分析全军心律失常介入治疗资料,了解此领域工作的现状与不足。方法由全军心血管内科专业委员会组织对2005年1月1日至2006年12月31日期间全军医疗单位心律失常介入治疗资料进行注册登记和统计分析。结果①此次注册共收到全军40家医院共9 934例注册资料。开展射频消融(RFCA)工作的医院共33家,注册病例数6 242例,其中开展三维标测技术治疗快速心律失常的医院有9家,病例数达180例;开展心脏器械置入治疗工作的医院共39家,病例数3 656例。②6 242例RFCA注册资料总成功率97.45%,复发率2.12%,并发症发生率0.54%。各类心律失常中,房室折返性心动过速(AVRT)最多,房室结折返性心动过速(AVNRT)次之,AVRT和AVNRT成功率始终保持在较高的水平,而心房颤动(AF)的复发率最高。34例并发症中血管并发症和完全性房室传导阻滞占绝大部分。③多家单位开展了新型三维标测系统治疗复杂快速性心律失常。180例注册病例中,AF最多、共110例(61.11%),成功率99.09%,复发率24.55%;非特发性室性心动过速(non-IVT)次之、共26例(14.44%),成功率88.46%,复发率8.33%;其余类型心律失常完成例数较少。④3 656例心脏器械置入病例总成功率99.92%(3 653/3 656),并发症发生率1.94%(71/3 653)。在各种器械置入适应证中,病窦综合征占最大比例,其次为房室传导阻滞。双腔起搏比例远超过心室单腔起搏。三腔双心室起搏器及埋藏式心脏转复除颤器的临床应用尚较少。结论全军心律失常介入治疗发展迅速。     

Peripherally Inserted Central Catheter Thrombosis After Placement via Electrocardiography vs Traditional Methods

BackgroundPeripherally inserted central catheter tip placement at the cavoatrial junction is associated with reduced catheter-related deep vein thrombosis. Electrocardiographic tip confirmation purportedly improves accuracy of tip placement, but whether this approach can reduce deep vein thrombosis is unknown.MethodsProspectively collected data from patients that received peripherally inserted central catheters at 52 Michigan hospitals were analyzed. The method used to confirm tip confirmation at insertion and deep vein thrombosis outcomes were extracted from medical records. Multivariate models (accounting for the clustered nature of the data) were fitted to assess the association between peripherally inserted central catheter-related deep vein thrombosis and method of tip confirmation (electrocardiographic vs radiographic imaging).ResultsA total of 42,687 peripherally inserted central catheters (21,098 radiology vs 21,589 electrocardiographic) were included. Patients receiving electrocardiographic-confirmed peripherally inserted central catheters had fewer comorbidities compared with those that underwent placement via radiology. Overall, deep vein thrombosis occurred in 594 (1.3%) of all peripherally inserted central catheters. Larger catheter size (odds radio [OR] 1.32; 95% confidence interval [CI], 0.93-1.90 per unit increase in gauge), history of deep vein thrombosis, and cancer were associated with increased risk of deep vein thrombosis (OR 2.00; 95% CI, 1.65-2.43 and OR 1.62; 95% CI, 1.16-2.26, respectively) using logistic regression. Following adjustment, electrocardiographic guidance was associated with a significant reduction in peripherally inserted central catheter-related deep vein thrombosis compared with radiographic imaging (OR 0.74; 95% CI, 0.58-0.93; P = .0098).ConclusionThe use of electrocardiography to confirm peripherally inserted central catheter tip placement at the cavoatrial junction was associated with significantly fewer deep vein thrombosis events than radiographic imaging. Use of this approach for peripherally inserted central catheter insertion may help improve patient safety, particularly in high-risk patients.     

预激综合征患者多旁路的射频消融

１７４例预激综合征患者中１３例（７．５％）具有多旁路（２９条）。２９条旁路中２１条由基础电生理检查证实，８条在阻断其它旁路后显现。４例在双侧，９例在单侧消融。平均放电３２±１４次后将２７条（９３．１％）旁路阻断。多旁路与单旁路消融成功率相似（９３．１％ＶＳ９４．０％，Ｐ＞０．０５）；但放电次数多（３２±１４ＶＳ１４±１１，Ｐ＜０．０５），消融时程长（３．６±０．８ｈＶＳ２．１±０．９ｈ，Ｐ＜０．０１）；多旁路组复发率高（７．６％ＶＳ１．９％，Ｐ＜０．０１）．本研究证实射频消融是根治多旁路患者的有效方法。     

Radiofrequency catheter ablation within the coronary sinus eliminates a macro-reentrant atrial tachycardia: Importance of mapping in the coronary sinus

We describe a patient who underwent radiofrequency (RF) catheter ablation of symptomatic atrial fibrillation. After left atrial (LA) catheter ablation and pulmonary vein isolation, a macro-reentrant atrial tachycardia (AT) with a critical isthmus at the mitral isthmus was induced by incremental atrial pacing from the coronary sinus. Extensive RF energy applications from endocardial sites using ablation catheters with 4 mm- and 8 mm- tips resulted in no discrete potentials being recorded from the endocardial sites of the isthmus, but the tachycardia could not be terminated. However, discrete potentials were recorded within the CS, and epicardial RF energy applications from the CS eliminated the tachycardia. Thus, mapping in the CS is useful for detecting residual conduction at epicardial sites along the mitral isthmus. RF catheter ablation within the CS should be considered when no distinct electrograms are recorded after extensive ablation from the endocardial sites and when distinct electrograms are recorded within the CS.     

Interatrial septal tachycardias following atrial fibrillation ablation or cardiac surgery: Electrophysiological features and ablation outcomes

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Interatrial septal tachycardia (IAS-AT) represented 9% of organized atrial tachycardia (AT) following atrial fibrillation (AF) ablation or cardiac surgery referred for radiofrequency catheter ablation (RFCA). The majority (93%) were targeted from the superior interatrial septum (IAS) limbus and the remaining 7% from the inferior limbus (left). Multiple interatrial septal connections at the level of the superior (red dotted lines) and inferior limbus (red circle) (right) may provide the anatomic substrate for IAS-AT. BB = Bachmann bundle; ICV = inferior vena cava; LA = left atrium; LAA = left atrial appendage; LS = left superior pulmonary vein; RA = right atrium; RAA = right atrial appendage; RI = right inferior pulmonary vein; RS = right superior pulmonary vein; SCV = superior vena cava; SP = septopulmonary bundle. (Anatomic image reproduced with permission from Ho and Sanchez-Quintana.¹⁵)

     

短期留置导尿管拔除在泌尿外科肾部分切除术后患者中的应用研究

【目的】 将短期留置导尿管拔除的最佳证据应用于临床,提高护士在肾部分切除术后尿管拔除实践活动中证据应用的依从性,降低留置尿管感染风险发生率,提高患者舒适度。【方法】 遵循JBI循证护理中心的临床证据实践应用系统(JBI-PACES)的标准程序,采用现场观察、查阅护理病历及资料收集等方法,以护士行为依从性水平、留置导尿管感染风险发生率、患者舒适度改变程度评价证据应用前后的有效性。【结果】 基线审查标准中护士对“肾部分切术后患者在午夜拔尿管”“护士主导评估尿管拔除时机”“拔除导尿管前给予单剂量a受体阻滞剂”等3条标准中在证据应用后依从性显著提高(p≤0.005);平均留置尿管时间由证据应用前的平均(135.75±11.70)h缩短至(90.45±9.62)h(p＜0.005);患者舒适度明显提高。【结论】 本课题研究应用于临床,提高了护士在主导短期尿管拔除实践中的依从性,帮助形成导尿管拔除和管理规范,降低留置尿管感染风险发生率,并提高患者舒适度。