不同类型心房颤动导管消融治疗的对比研究

目的探讨三维标测系统指导下对阵发性、持续性和长程持久性心房颤动(房颤)行导管消融治疗的有效性和安全性。方法选择2008年1月—2010年12月在我院行导管消融治疗的持续性及长程持久性房颤患者55例为组1,选取同期住院的阵发性房颤患者55例为组2。在CARTO或ENSITE 3000系统标测下行射频消融治疗,术中采用CARTO-Merge或Ensite Fusion图像融合技术,持续性和长程持久性房颤采用步进式消融策略,在进行环肺静脉电隔离的基础上,进一步行复杂心房碎裂电位(CFAE)或高频电位消融、对规律的房性心动过速或心房扑动(房扑)进行标测和消融,主要是线性消融,包括左房顶部线、二尖瓣环峡部线、左房间隔线和(或)三尖瓣环峡部线等其中之一或不同组合,消融至实现窦性心律,对于呈持续性房扑者经静脉推注伊布利特或直流电转复窦性心律;阵发性房颤仅行环肺静脉电隔离术。所有患者术后继续服用华法林抗凝,停服抗心律失常药物,采用门诊随访,于术后3个月、6个月随访采用动态心电图监测评价心律失常情况,术后6个月复查超声心动图评价左房直径。结果 (1)组1中17例(30.9%)消融过程中直接转复窦性心律;29例(52.7%)消融过程中房颤转变为房扑,经三维激动标测及拖带标测证实其中22例(22/29)为左房大折返房扑,余7例(7/29)为右房三尖瓣峡部依赖的典型房扑,左房房扑经静脉推注心律平或胺碘酮或伊布利特转复5例,直流电转复窦性心律15例,快速起搏拖带转复2例,7例右房房扑行三尖瓣峡部线性消融均转复窦性心律;9例(16.4%)至消融结束仍为房颤律经直流电复律。组2中18例术中发生房颤,其中13例完成环肺静脉消融后恢复窦性心律,2例采用高频刺激转复窦性心律,3例静脉推注心律平转复。(2)组1术后3个月内随访发生房性心动过速29例,不典型房扑9例,房颤13例;术后6个月房颤复发19例,一次消融成功率为65.5%。3个月内组2发生房性心动过速16例,不典型房扑8例,房颤8例;术后6个月时房颤复发7例,一次消融成功率为87.3%。两组一次消融成功率比较差异有统计学意义(P<0.01)。结论对持续性和长程持久性房颤行三维标测系统指导下射频导管消融治疗较为安全,但与阵发性房颤比较,手术时间和X线曝光时间较长,消融步骤较复杂,一次消融成功率较阵发性房颤低;消融术后发生大折返房速或不典型房扑较为常见,部分可在术后3个月减少或消失,往往需再次导管消融治疗。持续性房颤和慢性房颤射频消融治疗转复窦性心律后,左房容积减小,提示有利于心房重构的减轻或逆转。

Comparison of Effectiveness and Safety of Catheter Ablation for Different Types of Atrial Fibrillation

Objective To evaluate the effectiveness and safety of catheter ablation under three-dimensional mapping system for paroxysmal,persistent and long-standing atrial fibrillations(AF).Methods Fifty-five patients with persistent or long-standing AF who underwent catheter ablation between January 2008 and December 2010 in our hospital were enrolled into group A,and another 55 patients with paroxysmal AF into group B.Catheter ablation was conducted under CARTO or Ensite 3000 three-dimensional mapping system using CARTO-Merge or Ensite Fusion technique,stepwise ablation for group A and circumferential pulmonary vein isolation for group B.Warfarin intake was continued and antiarrhythmic agents were stopped after the procedure.Follow-ups were carried out at three and six months after the procedure using DCG to monitor the cardiac rhythm;echocardiography was used to evaluate the diameter of the left atrium at six months after the procedure.Results In group A,17(30.9%) patients regained sinus rhythm during ablation,AF turned into atrial flutter in 29(52.7%) patients during ablation,and 9 still needed direct current countershock after ablation.In group B,18 patients had AF episode during ablation and regained sinus rhythm under different treatment(13 by circumferential pulmonary vein isolation,2 by high-frequency stimuli,and 3 by propafenone).The three-month follow-up results showed 29 cases of atrial tachycardia,9 atypical atrial flutter,and 13 AF in group A,and 16 cases of atrial tachycardia,8 atypical atrial flutter,and 8 AF in group B.The six-month follow-up results showed 19 cases of AF reoccurrence in group A and 7 in group B.The non-reoccurrence rate of group B(87.3%) was significantly higher than that of group A(65.5%).Conclusion Catheter ablation is safe for persistent and long-standing AF,but longer and more complex with longer X-ray exposure and lower initial non-recurrence rate than that for paroxysmal AF.Macroreentrant atrial fibrillation and atypical atrial flutter are common after catheter ablation and may be alleviated or even disappeared at three months after the procedure.The decrease of left atrial volume after effective catheter ablation for persistent and long-standing AF indicates chances of atrial remodeling.