【作者】 杨美玲；

【导师】 赵青； 王茂敬；

【作者基本信息】 青岛大学 ， 内科学（心血管系病）（专业学位）， 2019， 硕士

【摘要】 目的:心房颤动(简称房颤)和心力衰竭(简称心衰)是医疗工作中常见心脏疾病,具有较高的发病率,两者有一些共同的危险因素,同时存在可相互影响,加重病情,影响生存质量,因此针对房颤合并心衰患者的治疗显得颇为重要。随着导管射频消融技术的发展与成熟,被逐渐应用于房颤合并心衰的患者,而且更多的研究表明该类患者可从导管消融术中获益。本文在此基础上,研究不同射血分数的三组持续性房颤患者导管消融术中事件发生情况、术后心脏功能及结构指标的变化,以及是否能改善预后,从而探讨射血分数下降与射血分数正常的持续性房颤患者射频手术风险及其预后。方法:选择2015年2月至2018年2月于青岛大学附属医院住院的持续性房颤患者200例。根据术前心脏超声LVEF值将研究对象分为实验组和对照组,实验组根据LVEF值分为A和B两个亚组,A组为LVEF<40%的持续性房颤患者,B组为LVEF40%-49%之间的持续性房颤患者;C组对照组为LVEF≥50%的持续性房颤患者。术前完善检查,排除手术禁忌,由同一医师在CARTO三维标测系统下完成射频消融术。第一,比较三组患者的左心房建模时间、消融时间、总手术时间、术中发生急性心衰、其他房性心律失常(RATs)、脑血管事件、心包积液事件例数及平均住院日,观察A组与C组、B组与C组、A与B组患者之间上述指标是否具有统计学差异。第二,首先比较每组患者术前及术后3、6、12个月时左心房前后径(LAD)、左心室舒张末期长径(LVEDd)、左心室射血分数(LVEF)、NYHA心功能分级变化,观察三组患者射频消融术后心脏结构与功能指标的变化;其次比较三组患者术后再住院率(%)、复发率(%)是否具有统计学意义。术后3-12月期间复发患者作为晚期复发组,将研究对象分为晚期复发组和非复发组,探讨性别、年龄、房颤持续时间、术前心室率、术前NYHA心功能分级、术前LAD、术前LVEF、术前中性粒与淋巴细胞比值(NRL)、术后转复后心电图P波离散度(Pd)是否具有预测持续性房颤射频消融术后晚期复发作用。结果:1.三组患者的一般资料如年龄、性别、高血压病史等无统计学差异(P>0.05),NRL、术前LAD、LVEF、LVEDd、房颤持续时间、术前NYHA心功能分级三组患者之间存在统计学差异(P<0.05)。2.三组患者左心房建模时间、消融时间、总手术时间无明显差异(P>0.05)。3.术中不良事件发生情况:RATs发生率,A组与B组(3/20 vs.1/65,P<0.05),A组与C组(3/20 vs.3/115,P<0.05);心衰急性发作患者,A组与B组(5/20 vs.4/65,P<0.05);A组患者发生1例短暂性脑缺血发作(TIA),B组及C组无脑血管事件发生。4.手术前后心脏结构与功能指标变化:A组患者术前与术后6个月相比,LVEF增高(37.1±1.4 vs.40.7±2.4,P<0.05)、LAD缩小(45.5±1.9 vs.44.2±2.1,P<0.05)、LVEDd缩小(53.8±3.4 vs.51.2±3.6,P<0.05)、NYHA心功能分级下降(2.5±0.6 vs.2.0±0.3,P<0.05);B组患者术前与术后3个月相比,LVEF增高(45.7±2.3 vs.47.8±3.9,P<0.05)、NYHA心功能分级下降(1.9±0.6 vs.1.5±0.5,P<0.05),术前与术后6个月相比,LAD缩小(43.5±1.7 vs.42.5±3.6,P<0.05)、LVEDd缩小(51.8±4.8 vs.50.1±4.6,P<0.05);C组患者上述心脏结构指标手术前后改善无统计学差异,NYHA心功能分级较术前明显改善(P<0.05)。5.再住院率:A组和B组患者术后6、12个月再住院率较C组略高,术后12个月,A组与C组(12/20 vs.35/115)差异具有统计学意义(P<0.05)。成功率:A组患者术后6、12个月成功率分别为75.00%、45.00%;B组患者术后6、12个月成功率分别为80.00%、61.54%;C组患者术后6、12个月成功率分别为81.74%、69.57%,上述数据表示A组患者术后12个月复发率显著高于其他两组患者(P<0.05)。6.单因素统计分析表明晚期复发与房颤持续时间、术前LVEF、术前LAD、NRL、术后恢复窦律后心电图Pd相关(P<0.05),可作为评估持续性房颤术后复发风险指标。结论:1.射频消融术是治疗持续性房颤的有效措施,恢复窦性心律后左心房发生电重构、结构重构。LVEF下降的患者,术后心脏结构与功能指标明显改善;术前上述指标无明显异常患者,术后指标变化不明显。2.LVEF<40%的持续性房颤患者导管射频术后心脏结构及功能改善,减少心衰发作再住院次数,可从射频消融术中获益,但术中发生急性心衰、其他房性心律失常、脑血管事件的风险相对较高,本文为单中心小样本临床研究,需要更多多中心研究证明。3.对比LVEF下降与LVEF保留的持续性房颤患者,前者的远期手术成功率明显低于后者,对于该类患者可延长随访时间,加强术后药物治疗。4.房颤持续时间、术前LVEF、LAD、NRL、恢复窦性心律后心电图Pd对持续性房颤导管消融术后晚期复发有一定的预测价值,指导术后患者随访及药物治疗。更多还原

【Abstract】 Objective:Atrial fibrillation and heart failure are common heart diseases in medical work and have a high incidence.They have some common risk factors,affect each other,and effect quality of survival.The treatment of patients with atrial fibrillation and heart failure appears to be very important.With the development and maturity of catheter radiofrequency ablation technology,it is gradually applied to patients with atrial fibrillation and heart failure,and more studies have shown that such patients can benefit from catheter ablation.On this basis,we studied the change of cardiac function and structural indexes after catheter ablation in patients with persistent atrial fibrillation owning different LVEF.To compare the risk and efficacy of Catheter Radiofrequency Ablation on persistent atrial fibrillation patients with normal cardiac function and dysfunction.Method:Two hundred Persistent Atrial Fibrillation patients who underwent Catheter Radiofrequency Ablation in the Affiliated Hospital of Qingdao University from February2015 to February 2018 were enrolled.They were divided into experimental group and control group according to LVEF level measured by cardiac ultrasound before Catheter Radiofrequency Ablation.The experimental group was divided into two subgroups of group A and group B according to LVEF level.Group A is persistent AF patients with LVEF < 40%,group B is persistent AF patients with LVEF between 40% and 49%,and Group C was persistent AF patients with LVEF ≥ 50%.Firstly,Recording left atrial modeling time,ablation time,and total operative time,intraoperative acute heart failure,other atrial arrhythmias(RATs),cerebrovascular events,pericardial effusions,average hospitalization day,average hospitalization expenses in three groups.Compared whether the above indicators are statistically different between patients in group A and group C,group B and group C,and patients in group A and group B.Secondly,Recording left atrial anterior-posterior diameter(LAD),left ventricular end-diastolic long-term diameter(LVEDd),left ventricular ejection fraction(LVEF),and NYHA cardiac function grading of Persistent Atrial Fibrillation patients who received the Catheter Radiofrequency Ablation,then compare the change before and 3 months,6 months,and 12 months after the operation.Follow-up of 12 months after the operation,patients were divided into two groups of successful group and failure group.comparing the preoperative indexes(gender,age,duration of atrial fibrillation,ventricular rate,NYHA cardiac function grading,LAD,LVEF,NRL,Pd)between the successful and failure groups to study whether they can be the predicting factors of recurrence after the Catheter Radiofrequency Ablation.Results:1.The general data of the three groups,such as age,gender,history of hypertension are without the statistic significance(P>0.05).LAD,LVEF,NRL,LVEDd,duration of atrial fibrillation,and NYHA cardiac function grade of three groups are significantly different(P<0.05).2.There were no significant differences in left atrial modeling time,and total operative time between the three groups(P>0.05).3.The incidence of RATs,group A and group B(3/20 vs.1/65,P<0.05),group A and group C(3/20 vs.3/115,P<0.05);patients with acute heart failure,group A and group B(5/20 vs.4/65,P<0.05);One case of TIA occurred in group A,and no cerebrovascular events occurred in group B and group C.4.Compared with pre-operation,after 6 months,the A group showed LVEF increased(37.1±1.4 vs.40.7±2.4,P<0.05),LAD decreased(45.5±1.9 vs.44.2±2.1,P<0.05),and LVEDd decreased(53.8±3.4 vs.51.2±3.6,P<0.05),NYHA cardiac function grade decreased(2.5±0.6 vs.2.0±0.3,P < 0.05).Compared with pre-operation,after 3 months,the B group showed LVEF increased(45.7±2.3 vs.47.8±3.9,P<0.05),NYHA cardiac function grade decreased(1.9±0.6 vs.1.5±0.5,P<0.05).After 6 months LAD decreased(43.5±1.7 vs.42.5±3.6,P<0.05),LVEDd decreased(51.8±4.8 vs.50.1±4.6,P<0.05).There was no statistical difference between the above-mentioned indexes in group C.5.There was no significant difference in the rate of rehospitalization between the three groups after 6 months.But after 12 months,group A and group C(12/20 vs.35/115,P>0.05).In group A,the successful rate was 75.00% after 6 months,and 45.00% after 12 months.In group B was 80.00% after 6 months,and 61.54% after 12 months.In group C was 81.74% after 6 mouth,and 69.57% after 12 months.The success rate of group A after12 months was significantly lower than that of the other two groups(P<0.05).6.Univariate statistical analysis showed that late recurrence was associated withduration of atrial fibrillation,LVEF,LAD,NRL,and immediate postoperative electrocardiogram Pd(P<0.05),which can be used as indicator to assess the risk of recurrence after radiofrequency ablation of continuous atrial fibrillation.Conclusion1.Radiofrequency ablation is an effective treatment for persistent AF.The left atrial structure can be remodeling after sinus rhythm recovery.For patients with LVEF decline,the cardiac structure and function index are significantly improved after operation.However,for other patients,the change was not obvious after surgery.2.Persistent AF patients with LVEF <40% benefited from radiofrequency ablation.It can improve cardiac structure and function,reduce the rate of rehospitalization.But acute heart failure,RATs and cerebrovascular events occurred during surgery.The risk is high and may be associated with fewer cases in this study.3.Contrast patients with LVEF <40% and LVEF ≥40%,the success rate of the former will be lower than the latter with the extension of follow-up time.4.The duration of atrial fibrillation,preoperative LVEF,LAD,NRL,and Pd have certain value for predicting postoperative recurrence of persistent AF.更多还原