江平,刘启明,涂涛,孙超,刘振江,阳辉,李旭平,秦奋

• 1:中南大学湘雅二医院心内科

摘要(Abstract)：

目的探讨P波电轴、P波时限(PWD)及左心耳排空速度(LAAEV)对阵发性心房颤动(房颤)导管消融术后复发的预测价值。方法序贯选择2014年1月至2016年8月于中南大学湘雅二医院心内科住院,并行三维标测指导下环肺静脉电隔离术的阵发性房颤患者78例。收集患者临床基线及术前窦性心律时心电图、超声心动图检查资料,记录并分析P波电轴、P波平均时限(mPWD)、P波最大时限(PWDmax)以及LAAEV。出院后随访,详细记录患者症状、心电信息等资料;导管消融术后3个月(3个月内为空白期)如出现持续时间超过30 s的快速型房性心律失常则定义为复发。依据随访结果分为成功组和复发组,比较两组患者P波指数及LAAEV等,绘制受试者工作特征曲线(ROC)曲线、计算ROC曲线下面积(AUC),取得界值,根据界值形成预测房颤复发方法,并计算其敏感度、特异度、阳性预测值、阴性预测值及准确度。采用logistic多因素回归分析房颤复发的独立预测因子。结果 (1)导管消融术后情况:成功组62例,复发组16例(复发率20.5%),其中复发组4例再次行导管消融术,术后无再复发者(两次导管消融术总成功率84.6%)。(2)两组患者基线资料比较:两组患者包括年龄、性别、体重指数、肾功能、房颤病史、基础疾病构成及临床用药情况等比较,差异均无统计学意义(均P>0.05)。(3)两组患者P波指数结果比较:复发组和成功组的P波电轴分别为(76.0°±16.8°)、(54.6°±22.8°),差异有统计学意义(P=0.013)。P波电轴预测房颤复发的ROC曲线的AUC及95%CI为0.778(0.654～0.902),界值为75°。P波电轴>75°预测房颤复发的敏感度、特异度、阳性预测值、阴性预测值及准确度分别为68.8%、87.1%、52.6%、89.8%和80.7%。复发组和成功组的mPWD分别为(111.8±13.4)ms和(94.5±17.6)ms,差异有统计学意义(P<0.001);PWDmax分别为(127.1±8.6)ms和(108.2±18.4)ms,差异有统计学意义(P<0.001)。mPWD和PWDmax预测房颤复发的ROC曲线的AUC及95%CI分别为0.767(0.643～0.890)和0.789(0.691～0.888),界值分别为105.8 ms和117.5 ms。mPWD>105.8 ms预测房颤复发的敏感度、特异度、阳性预测值、阴性预测值、准确度分别为75.0%、72.6%、41.3%、91.0%和73.0%;PWDmax>117.5 ms预测房颤复发的敏感度、特异度、阳性预测值、阴性预测值和准确度分别为93.8%、62.3%、55.8%、97.7%和74.3%。(4)两组患者LAAEV结果比较:复发组与成功组的LAAEV分别为(39.0±3.5)cm/s和(44.8±6.3)cm/s,差异有统计学意义(P<0.001)。LAAEV预测房颤复发的ROC曲线的AUC及95%CI为0.792(0.677～0.907),界值为40.5cm/s。LAAEV≤40.5cm/s预测房颤复发的敏感度、特异度、阳性预测值、阴性预测值和准确度分别为66.1%、81.2%、38.2%、93.3%和70.0%。(5)logistic多因素回归分析结果:P波电轴>75?、PWDmax>1175ms和LAAEV≤40.5cm/s的OR值及95%CI分别为5.331(1.077～26.395)、10.286(1.550～45.101)和6.108(1.153～32.359)。结论 P波电轴和PWD与LAAEV可以有效预测房颤导管消融术后复发,可以作为房颤导管消融术后复发的独立预测因子。

关键词(KeyWords)： P波电轴;P波时限;左心耳排空速度;心房重构

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 江平,刘启明,涂涛,孙超,刘振江,阳辉,李旭平,秦奋

参考文献(References)：

• [1]Fukushima K,Fukushima N,Ejima K,et al.Left atrial appendage flow velocity and time from P-Wave onset to tissue doppler-derived A'predict atrial fibrillation recurrence after radiofrequency catheter ablation.Echocardiography,2015,32(7):1101-1108.
• [2]Iwasaki YK,Nishida K,Nattel S,et al.Atrial fibrillation pathophysiology:implications for management.Circulation,2011,124(20):2264-2274.
• [3]黄从新,张澍,黄德嘉,等.心房颤动:目前的认识和治疗建议(2018).中华心律失常学杂志,2018,22(4):279-346.
• [4]Kizilirmak F,Demir GG,Gokdeniz T,et al.Changes in electrocardiographic P wave parameters after cryoballoon ablation and their association with atrial fibrillation recurrence.Ann Noninvasive Electrocardiol,2016,21(6):580-587.
• [5]Allessie M,Ausma J,Schotten U.Electrical,contractile and structural remodeling during atrial fibrillation.Cardiovasc Res,2002,54(2):230-246.
• [6]Hwang SH,Oh YW,Kim MN,et al.Relationship between left atrial appendage emptying and left atrial function using cardiac magnetic resonance in patients with atrial fibrillation:comparison with transesophageal echocardiography.Int J Cardiovasc Imaging,2016,32(Suppl 1):163-171.
• [7]Conte G,Luca A,Yazdani S,et al.Usefulness of P-wave duration and morphologic variability to identify patients prone to paroxysmal atrial fibrillation.Am J Cardiol,2017,119(2):275-279.
• [8]Rangel MO,O'Neal WT,Soliman EZ.Usefulness of the electrocardiographic P-wave axis as a predictor of atrial fibrillation.Am J Cardiol,2016,117(1):100-104.
• [9]Prabhu S,McLellan AJ,Walters TE,et al.Atrial structure and function and its implications for current and emerging treatments for atrial fibrillation.Prog Cardiovasc Dis,2015,58(2):152-167.
• [10]Camm AJ,Lip GY,De Caterina R,et al.2012 focused update of the ESC Guidelines for the management of atrial fibrillation:an update of the 2010 ESC Guidelines for the management of atrial fibrillation--developed with the special contribution of the European Heart Rhythm Association.Europace,2012,14(10):1385-1413.
• [11]Pálinkás A1,Antonielli E,Picano E,et al.Clinical value of left atrial appendage flow velocity for predicting of cardioversion success in patients with non-valvular atrial fibrillation.Eur Heart J,2001,22(23):2201-2208.
• [12]Mugnai G,Chierchia GB,de Asmundis C,et al.P-wave indices as predictors of atrial fibrillation recurrence after pulmonary vein isolation in normal left atrial size.J Cardiovasc Med(Hagerstown),2016,17(3):194-200.
• [13]Ma XX,Zhang YL,Hu B,et al.Association between left atrial appendage emptying velocity,N-terminal plasma brain natriuretic peptide levels,and recurrence of atrial fibrillation after catheter ablation.J Interv Card Electrophysiol,2017,48(3):343-350.
• [14]Abe Y,Fukunami M,Yamada T,et al.Prediction of transition to chronic atrial fibrillation in patients with paroxysmal atrial fibrillation by signal-averaged electrocardiography:a prospective study.Circulation,1997,96(8):2612-2616.
• [15]Thomas L,Abhayaratna WP.left atrial reverse remodeling.JACC,2017,10(1):65-77.
• [16]Nielsen JB,Kühl JT,Pietersen A,et al.P-wave duration and the risk of atrial fibrillation:results from the Copenhagen ECG Study.Heart Rhythm,2015,12(9):1887-1895.
• [17]Opacic D,van Bragt KA,Nasrallah HM,et al.Atrial metabolism and tissue perfusion as determinants ofelectrical and structural remodelling in atrial fibrillation.Cardiovasc Res,2016,109(4):527-541.
• [18]Janin S,Wojcik M,Kuniss M,et al.Pulmonary vein antrum isolation and terminal part of the P wave.Pacing Clin Electrophysiol,2010,33(7):784-789.
• [19]Soliman EZ,Cammarata M,Li Y.Explaining the inconsistent associations of PR interval with mortality:the role of P-duration contribution to the length of PR interval.Heart Rhythm,2014,11(1):93-98.
• [20]Magnani JW,Wang N,Nelson KP,et al.Electrocardiographic PRinterval and adverse outcomes in older adults:the Health,Aging,and Body Composition study.Circ Arrhythm Electrophysiol,2013,6(1):84-90.
• [21]German DM,Kabir MM,Dewland TA,et al.Atrial fibrillation predictors:importance of the electrocardiogram.Ann Noninvasive Electrocardiol,2016,21(1):20-29.
• [22]Yoshida N,Okamoto M,Beppu S,et al.Validation of transthoracic tissue doppler assessment of left atrial appendage function.J Am Soc Echocardiogr,2007,20(5):521-526.
• [23]Antonielli E,Pizzuti A,Palinkas A,et al.Clinical value of left atrial appendage flow for prediction of long-term sinus rhythm maintenance in patients with nonvalvular atrial fibrillation.J Am Coll Cardiol,2002,39(9):1443-1449.
• [24]Handke M,Harloff A,Hetzel A,et al.Left atrial appendage flow velocity as a quantitative surrogate parameter for thromboembolic risk:determinants and relationship to spontaneous echocontrast and thrombus formation--a transesophageal echocardiographic study in500 patients with cerebral ischemia.J Am Soc Echocardiogr,2005,18(12):1366-1372.
• [25]Pandit,Workman A,Sandeep V,et al.Atrial electrophysiological remodeling and fibrillation in heart failure.Clin Med Insights Cardiol,2016,10(Suppl 1):41-46.
• [26]Medi C,Sparks PB,Morton JB,et al.Pulmonary vein antral isolation for paroxysmal atrial fibrillation:results from long-term follow-up.JCardiovasc Electrophysiol,2010,22(2):137-141.
• [27]Kistler PM,Sanders P,Fynn S P,et al.Electrophysiologic and electroanatomic changes in the human atrium associated with age.JAm Coll Cardiol,2004,44(1):109-116.