三维标测系统指引导管消融治疗心房颤动——单中心800例总结Transcatheter Ablation for Atrial Fibrillation Therapy Guided by 3-D Mapping Systems:Experience of 800 cases from single center
刘旭,王新华,施海峰,顾佳宁,孙育民,王如兴,周立,胡伟,李恒栋
摘要(Abstract)：
目的评价三维标测系统(CARTO或EnSite-NavX)指引导管消融治疗心房颤动(房颤)的总体疗效和安全性。方法2004年9月至2006年12月期间入选800例房颤患者,男性482例,女性318例,平均年龄62.1±15.6(18～82)岁。其中阵发性房颤611例,持续性房颤189例,平均左心房内径38.4±9.2(30～60)mm。采用EnSite-NavX系统260例,CARTO系统540例。对于阵发性房颤采取环肺静脉前庭电隔离,对于持续性房颤采取环肺静脉前庭电隔离+心房碎裂电位消融+二尖瓣峡部消融。术后口服华法林及ⅠC类和Ⅲ类抗心律失常药物1～3个月,每月随访心电图、24小时动态心电图一次。对于术后1个月的房颤或房性心动过速(房速)复发进行再次标测和消融。结果795例完成手术。平均手术时间161±33(140～245)min,X线透视时间17±13(12～45)min。左肺静脉电隔离率为96.5%,右肺静脉电隔离率为98.6%。阵发性房颤术中发作98例,消融终止房颤90例。阵发性房颤术后2周内早期复发137例(22.5%),103例2周后不再发作,共57例接受再次消融(6例接受三次消融)。持续性房颤环肺静脉消融恢复窦性心律30例(16.1%),转变为房速/心房扑动(房扑)15例(8.1%)。心房碎裂电位消融恢复窦性心律20例(10.8%),转变为房速/房扑23例(12.4%)。持续性房颤术后早期复发78例(41.9%),14例随访中不再发作。65例再次消融(10例接受三次消融)。所有病例房颤消融术后房扑/房速104例(13.1%),68例随访中自愈,30例再次消融,23例消融成功。并发症:心脏压塞5例(0.6%,3例内科保守治疗成功,2例外科修补),肺静脉狭窄6例(0.7%),一过性脑缺血(TIA)1例,脑栓塞2例,肠系膜动脉栓塞1例。血胸1例,气胸1例。股动脉假性动脉瘤3例,股动静脉瘘1例。术后平均随访16.2±5.7(3～27)个月,阵发性房颤550例(90.3%)无房性快速性心律失常发作(9.4%再次消融,11.5%口服抗心律失常药物);持续性房颤159例(85.5%)无房性快速心律失常发作(34.9%再次消融,28.5%服用抗心律失常药物)。结论三维标测系统(CARTO或EnSite-NavX)指引导管消融治疗房颤疗效较高,安全性好。对于阵发房颤采用环肺静脉前庭电隔离术式即有良好效果;对于持续性房颤结合碎裂电位消融、二尖瓣峡部消融等方法,而且40%患者需要多次消融以提高成功率。
关键词(KeyWords)： 心房颤动;肺静脉;导管消融术
基金项目(Foundation):
作者(Author): 刘旭,王新华,施海峰,顾佳宁,孙育民,王如兴,周立,胡伟,李恒栋
参考文献(References)：
- [1]Haissaguerre M,Jais P,Shah DC,et al.Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins.N Engl J Med,1998,339:659-666.
- [2]Chen SA,Hsieh MH,Tai CT,et a1.Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins:Electro-physiological characteristics,pharmacological responses,and effects of radio frequency ablation.Circulation,1999,100:1879.
- [3]Ouyang F,B nsch D,Ernst S,et al.Complete isolation of the left atrium surrounding the pulmonary veins:new insights from the double Lasso technique in paroxysmal atrial fibrillation.Cir-culation,2004,110:2090-2096.
- [4]Ouyang F,Antz M,Ernst S,et al.Recovered pulmonary vein conduction as a dominant factor for recurrent atrial tachycardias after complete circular isolation of the pulmonary veins:lessons from double Lasso technique.Circulation,2005,111:127-135.
- [5]Haissaguerre M,Hocini M,Sanders P,et al.Catheter Ablation of Long-Lasting Persistent Atrial Fibrillation:Clinical Outcome and Mechanisms of Subsequent Arrhythmias.J Cardiovasc Elec-trophysiol,2005,16:1138-1147.
- [6]Konings KTS,Smeet JRLM,Penn OC,et al.Configuration of u-nipolar atrial electrograms during electrically induced atrial fibril-lation in humans.Circulation,1997,95:1231.
- [7]Nademanee K,Schwab MC,Kosar E,et al.Anewapproach for catheter ablation of atrial fibrillation:Mapping of the electrophys-iological substrate.J Am Coll Cardiol,2004,43:2044-2053.
- [8]Chugh A,Oral H,Lemola K,et al.Prevalence,mechanisms,and clinical significance of macroreentrant atrial tachycardia dur-ing and following left atrial ablation of atrial fibrillation.Heart Rhythm,2005,2:464-471.