【作者】 刘飞；

【导师】 徐健；

【作者基本信息】 安徽医科大学 ， 内科学， 2015， 硕士

【摘要】 目的：环肺静脉隔离术(Circumferential pulmonary vein isolation, CPVI)联合碎裂电位(Complex fractionated atrial electrograms, CFAEs)单极标测QS型CFAEs分布区域的线性消融术与CPVI联合传统心房线性消融术(左房顶部线、二尖瓣峡部线、三尖瓣峡部线)治疗持续性心房颤动(Persistent atrial fibrillation, PeAF)的临床效果相比较,探讨前者消融方法的安全性和有效性。初步探讨CFAEs分布区域中单极图电位呈QS形态的CFAEs形成机制,有助于理解CFAEs在PeAF中发挥的作用。方法：连续入选2012年12月至2014年2月在我院住院的99例PeAF患者分为CPVI+CFAEs单极标测QS型线性消融组(A组)51例和CPVI+传统线性消融组(B组)48例。对CFAEs的分布区域进行单极标测,根据单极图标测的结果是否呈QS型分为Al组(单极图呈QS型)35例行CPVI+QS型CFAEs分布区域的线性消融术,A2组(单极图非QS型)16例单纯行CPVI术。术中消融步骤：A1组：CPVI完成后,定义CFAEs标准,应用Ensite-Velocity系统标测AF患者心房的CFAEs分布区域,环肺电极的每个电极作为标测电极和位于下腔静脉的四极电极连接构成单极,在CFAEs分布区域采集单极图,消融单极图上呈QS型分布的CFAEs区域。A1组消融路线：若呈QS型CFAEs区域行片状消融,若消融区域靠近肺静脉前庭、二尖瓣环、左房间隔面、左心耳者,二者之间行线性消融连接；位于左心房顶部或两上肺静脉口之间者,行左房顶部线性消融；位于后壁或前壁中心区域者行片状消融。B组采用CPVI术+心房传统线性消融术。消融终点：消融步骤完成后如仍为AF者直流电复律转复窦性心律后,环肺电极验证肺静脉电位完全电隔离,环肺静脉消融线的完整性及消融径线的双向阻滞。统计分析A1组、A2组、B组间的手术消融总时间、辅助术式操作时间、X线曝光时间、术中房性心动过速发生率、消融过程中直接转复窦性心律的成功率,手术并发症的发生率,术后随访房颤复发率。患者术后均服用胺碘酮或索他洛尔共3个月；华法林应用6个月(若AF复发继续服用)。术后第3、6、12月分别行心电图和动态心电图检查。随访1年以后每6个月随访一次。结果：CPVI+CFAEs联合单极标测消融组(A组=51例)：CPVI+QS型CFAEs的线性消融术组(A1组=35例),无QS形态CFAEs的分布区域行单纯CPVI术组(A2组=16例),CPVI+传统线性消融组(B组=48例),以P<0.05,有统计意义。1.A组与B组术中消融直接转为窦性心律成功率、房性心动过速的发生率无统计学意义(P>0.05)。A组及亚组A1组的消融总时间、X线曝光时间均小于B组,A1组QS消融时间小于B组线性消融时间(P<0.001),A1组消融直接转复窦性律成功率高于B组(P=0.035)。2.A组和B组随后随访3个月、6个月、12个月房颤(atrial fibrillation,AF)的复发率、房性心动过速发生率无统计学意义(P>0.05),术后第12个月A2组的AF复发率最高达56.2%(PA2-B,=0.013,PA1-A2=0.002,PAl-B=0.750)。3.随访12个月后有27例患者复发,为AF节律患者16例,肺静脉电位(pulmonary vein potentials,PVP)恢复者12例(75%)。A1组复发为AF者4例：2例原QS形CFAEs分布的消融区域单极图再次呈现QS形态,其中1例原非QS形CFAEs分布区域单极标测单极图呈QS型；1例无QS形态CFAEs分布区域,1例无CFAEs分布。A2组6例复发为AF：有3例患者单极图呈QS形CFAEs分布区域。B组中6例复发为AF(二尖瓣峡部线未阻滞3例,顶部线未阻滞2例,三尖瓣峡部1例),4例CFAEs区域中单极图QS形分布区域。4.11例复发为房性心动过速[房扑6例,(A组2例,B组4例),房速5例(A组4例,B组1例)]无统计学意义(P>0.05),A组术中出血心包穿孔1例。结论：1.CPVI+CFAEs单极标测QS型的线性消融术治疗PeAF术中消融时间短、并发症发生率低,术后维持窦性心律成功率家较高,该术式有较好的安全性和有效性。2.CFAEs的分布区域是PeAF维持的重要心房基质,其中单极图呈QS型CFAEs分布的区域可能是PeAF维持的关键基质所在部位,也可能是功能性阻滞传导区及主动折返环形成的焦点区域,消融此部位能破坏破坏了AF维持的基质和主动折返环的形成,该消融术式对心房基质的改良术可能更具针对性、个体化摧毁了维持AF的关键的心房基质,有较高的临床应用价值。更多还原

【Abstract】 Objective:To explore safety and validity of performing linear ablation of CFAEs (Complex fractionated atrial electrograms) displaying QS morphology of the atrial wave on unipolar electrogram combined with circumferential pulmonary vein isolation(CPVI) in patients with persistent atrial fibrillation(PeAF), comparing CPVI combined with traditional linear ablation. Meanwhile, exploring the formation mechanism of CFAEs displaying QS morphology on unipolar electrogram, which maked for illustrating the effect of fragmented potential on PeAF.Methods:99 patients with PeAF successively seen at our hospital from Sep 2012 to Feb 2014 were enrolled in our study, those cases were divided into two groups, group A received CPVI+ablation of CFAEs displaying QS morphology on on unipolar electrogram (51 cases), group B received CPVI+traditional linear ablation (48 cases). In group A, unipolar mapping was performed to identify the distribution of CFAEs, whose were divided into two groups based on whether the unipolar electrogram displayed QS morphology or not, group A1(displaying QS morphology) had 35 cases whose were received routine CPVI+linear ablation area of CFAEs by unipolar mapping QS-type; group A2(without displaying QS morphology) had 16 cases whose were underwent only CPVI. Procedure of ablation: in group A1, after beening performed CPVI, the standard of CFAEs was defined, Ensite-Velocity electroanatomic mapping system was applied to identify the distribution of CFAEs of AF patients, circumferential pulmonary lead was linked with quadrupole electrodes to form unipolar electrogram, ablating the CFAEs displaying QS morphology on unipolar electrogram. Ablation line design of group Al:if unipolar electrogram displays QS morphology in CFAEs areas, we performed lamellar ablation, if ablation area was close to pulmonary vein antrum, mitral ring, atria sinistrum septal surface, left auricle, we performed linear ablation between them; if ablation area located on left atrial cupular part or between the two orifices of left superior pulmonary vein, we perform linear ablation via left atrial cupular part; if ablation area located on posterior wall or central zone of anterior wall, we perform lamellar ablation. If the patients presented AF after ablation, they need be performed direct current countershock; after converting to sinus rhythm, In group B, we performed CPVI+left atrial linear catheter ablation. The endpoint of ablation:circumferential pulmonary lead identified electrical isolation of pulmonary vein electrical, the integrity of circumferential pulmonary ablation line and bidirectional block of ablation line. Total ablation time, auxiliary operation time, X-ray exposure time, the incidence of intraoperative atrial tachycardia, the ratio of conversion from atrial fibrillation to sinus rhythm after ablation, the incidence of surical complications, the recurrence rate of AF after operation were analyzed statistically in group A1,A2 and group B. After surgery, all patients have taken amiodarone or sotalol for 3 months; some patients could stop taking warfarin if they didn’t recur after 6-month treatment of warfarin. The patients received resting electrocardiogram and dynamic electrocardiogram at 6th,12th month after surgery. After one year’s follow-up, the patients reveived a follow-up every 6 months.Results:There was statistical significance in group A(51 cases), including 16 cases underwent only CPVI, and 35 cases underwent routine CPVI+linear ablation area of CFAEs displaying QS morphology on unipolar electrogram, and in group B(48 cases); in group A, group Al and group B, the incidence of conversion to sinus rhythm or atrial tachycardia has no statistical significance (P> 0.05); the total ablation time and X-ray exposure time in group A and group A1 are shorter than those in group B (P< 0.05); moreover, the ablation time of QS in group Al is shorter than linear ablation time in group B (P< 0.001).2. the recurrence rate of AF is recorded at 3 months,6 months,12 months after operation in group A and group B, the incidence of atrial tachycardia has no statistical significance (P> 0.05);12 months after surgery, the recurrence rate of AF reaches up to 56.2%in group A2(Pa2-B,=0.013,PA1-A2=0.002,PA1-b=0.750).3. after 12 months follow-up, 27 patients recurred, whose heart rhythm was AF in 16 patients(10 in group A,6 in group B), pulmonary vein potential (PVP) recovered in 12 patients(75%). The 4 patients with AF of group Al, two cases of whose the distribution of CFAEs area by unipolar mapping on QS-type recoveried, one case of non-QS-shaped CFAEs original distribution area which unipolar mapping was presenting QS-type,and one case no CFAEs area, the 6 patients with AF of group A2 (4 cases with PeAF,2 cases with PAF),three cases of who were mapped by unipolar mapping on QS-type in the distribution of CFAEs area.in group B, AF recurred in 6 patients(Mitral isthmus line unblocked 3cases, Left atrial top line unblocked 2cases and Tricuspid isthmus line unblocked 1 case), four patients of who were mapped by unipolar mapping on QS-type in the distribution of CFAEs area.4, atrial tachycardia recurred in 11 patients, among them,6 patients with auricular flutter(2 in group A,4 in group B),5 patients with atrial tachycardia (4 in group A,1 in group B). Conclusion:1, there was better safety and efficacy of performing CPVI+linear ablation of CFAEs presenting QS morphology on unipolar electrogram on patients with PeAF, with shorter ablation time, lower incidence of complication.2, the distributution area of CFAEs is the major atrial substrate of maintaining PeAF, the distribution area of CFAEs displaying QS morphology on unipolar electrocardiogram may be not only the key positon of maintaining PeAF, but also the core area between functional block area and initiative reentrant cycle, it may be more targeted to perform ablation on this region, in order to destroy the substrate of AF and the foundation of initiative reentrant cycle, hence, it would have higher clinical application value.更多还原