【作者】 刘爱华；

【导师】 钟敬泉；

【作者基本信息】 山东大学 ， 内科学（心血管病）（专业学位）， 2022， 硕士

【摘要】 背景:心房颤动(房颤)的复发是导管消融术后的一种常见现象,临床中需要进行再次导管消融术的患者不在少数。但是,目前仍缺乏关于再次导管消融术安全性和有效性研究的报道,因此,本研究的目的是对房颤再次导管消融术的有效性和安全性进行评估,并探索既往消融手术史与房颤复发是否存在相关性。方法:本研究为回顾性队列研究,收集了自2015年1月至2018年12月期间在我院行房颤导管消融手术患者的基线资料和随访资料,并根据是否存在既往房颤消融史分为再次导管消融组(Repeat catheter ablation,RECA)和首次导管消融组(First-time catheter ablation,FTCA)。对于入组患者的随访终止于2020年12月31日,随访终点包括房颤复发、卒中、死亡和出血事件。房颤的复发通过定期进行12导联动态心电图检查以及症状介导的即时12导联心电图检查进行监测,将发生在3个月空白期后的持续时间≥30秒的房颤/心房扑动/房性心动过速定义为房颤复发。结果:共867例患者被纳入本研究,其中RECA组有78例,FTCA组有789例。纳入病例的平均年龄为59.24±10.68岁,64.71%为男性,阵发性房颤患者占比88.00%,平均房颤病程为47.56±61.00个月,平均随访时间为42.57±15.26个月,共29例患者失访,失访率为3.34%。32例(3.69%)患者出现了手术并发症,严重并发症包括2例心包填塞和1例严重消化道出血。共有267例(31.86%)患者发生了房颤复发,其中RECA组有40例,FTCA组有227例,RECA组患者复发率显著高于FTCA组(52.63%vs.29.79%;P<0.001),并且,无论是房颤首年复发率[37.33%(28/75)vs.20.82%(163/783);P=0.001],还是房颤晚期复发率[21.74%(10/46)vs.10.68%(64/599);P=0.023],RECA组患者都更高,不过,两组患者的消融术后卒中发生率和死亡率均没有显著差异。Kaplan-Meier曲线也表明,RECA组的房颤复发率显著高于FTCA组(log-rank检验,P<0.001)。通过单因素及多因素Cox回归分析发现,既往消融史是房颤复发、房颤首年复发以及房颤晚期复发的独立危险因素。多因素Cox回归分析表明RECA组的房颤复发风险是FTCA组的1.731倍(95%可信区间1.171-2.559,P=0.006),RECA组的首年复发风险是FTCA组的1.643倍(95%可信区间1.066-2.531,P=0.024),RECA组的晚期复发风险是FTCA组的2.213倍(95%可信区间1.132-4.325,P=0.020)。结论:与进行首次导管消融术的患者相比,再次消融术后患者的房颤复发风险更高,既往消融史是导管消融术后房颤复发的独立危险因素。再次消融患者与首次消融患者在术后卒中、死亡、出血等安全性终点事件的发生率方面无显著差异。更多还原

【Abstract】 Background:Atrial fibrillation(AF)recurrence is common after catheter ablation,with many patients requiring repeat procedures.Few studies reported the prognostic outcomes of redo-ablation,including the risks of recurrence,stroke,and death.Thus,our objective was to assess the efficacy and safety associated with the repeat ablations and investigate the previous ablations as a predictor of AF recurrence in a long-term follow-up.Methods:The retrospective cohort study enrolled consecutive patients who underwent AF ablation at our institution from January 2015 to December 2018 and divided them into the repeat catheter ablation(RECA)and the first-time catheter ablation(FTCA)groups.A follow-up continued for six years with the endpoints of AF recurrence,stroke,and death.Scheduled and symptom-driven 12-lead electrocardiography(ECG)and 24h Holter-monitoring were performed to diagnose AF recurrence,and the recurrence was defined as AP,atrial flutter or atrial tachycardia,lasting ≥30 seconds outside the 90-day blanking period.Results:A total of 867 patients were included in our analysis,of which 78 patients were included in the RECA group and 789 in the FTCA group.Entire cohort was with a mean age of 59.24±10.68 years,male predominance(n=561,64.71%),more commonly with paroxysmal AF(n=763,88.00%),mean duration time 47.56±61.00 months.Only 29(3.34%)patients lost to follow-up.Procedural complications were observed in 32(3.69%)patients involving life-threatening complications:cardiac tamponade and major gastrointestinal bleeding.Over an average of 42.57±15.26 months,AF recurrence occurred in 267(31.86%)patients,40(52.63%)patients in the RECA group compared with 227(29.79%)patients in the FTCA group,P<0.001.This difference was observed not only in one-year recurrence[37.33%(28/75)vs.20.82%(163/783);P=0.001]but also very late recurrence[21.74%(10/46)vs.10.68%(64/599);P=0.023],New-onset stroke and death arose after ablation was equal between the two groups.Kaplan-Meier curves illustrated the significant differences of AF-free survival between RECA and FTCA groups with more risk of AF recurrence linked with patients in the RECA group(log-rank test,P<0.001).By univariate and multivariate Cox regression,we found previous ablation was an independent predictor of AF recurrence.In multivariate Cox regression,patients in RECA group have more risks of AF recurrence with HR=1.731[95%CI(1.171-2.559);P=0.006],have more risks of one-year AF recurrence with HR=1.643[95%CI(1.066-2.531);P=0.024],have more risks of very late AF recurrence with HR=2.213[95%CI(1.132-4.325);P=0.020].Conclusions:The repeat ablation was associated with a significant increase of AF recurrence compared with the first-time procedure,but the endpoints of stroke and death were equal regardless of the number of ablations.Furthermore,the previous ablation predicted AF recurrence independently no matter when the recurrence occurred.更多还原