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持续房颤射频消融128例临床观察

2015-01-31孙俊华袁义强赵育洁于力王瑞敏孙运

中国继续医学教育 2015年17期
关键词:射频消融临床观察

孙俊华 袁义强 赵育洁 于力 王瑞敏 孙运

持续房颤射频消融128例临床观察

孙俊华 袁义强 赵育洁 于力 王瑞敏 孙运

【摘要】目的 探讨持续房颤射频消融治疗临床效果。方法 本次选取128例持续房颤患者,均为我院2012年5月~2014年2月收治,采用射频消融治疗。结果 相较术前,患者术后均觉心悸症状持续时间及发作次数明显改善。术后1 d有阵发性房颤发作5例,行1年随访,房颤持续明显减少,经二次射频消融治疗治愈。术后有频发房速15例,口服抗心律失常药,随访2个月,房早(155±71)个,12个月时为(54±16)个,自觉症状明显改善。手术中有心包填塞出现1例,采用外科手术治疗,达治愈效果。结论 针对持续性房颤,在CARTO三维立体电标测指导下,实施环肺静脉消融治疗,可获得理想预后,为治愈提供有力的保障。

【关键词】持续房颤;射频消融;临床观察

作者单位: 450017 河南省郑州市心血管病医院心内科

Clinical Observation of 128 Cases of Sustained Atrial Fibrillation Radiofrequency Ablation

SUN Junhua YUAN Yiqiang ZHAO Yujie YU Li WANG Ruimin SUN Yun, Cardiology Cardiovascular Hospital of Zhengzhou City, Zhengzhou 450017, China

[Abstract]Objective To explore the clinical therapeutic effect of persistent atrial fibrillation radiofrequency ablation. Methods 128 cases of persistent atrial fibrillation patients were selected, who were admitted in our hospital from May 2012 to February 2014, were treated with radiofrequency ablation. Results In comparison with pre-operation, all the patients felt that the palpitation duration and the onset frequency were obviously improved. There were 5 cases with onset of paroxysmal atrial fibrillation one day after operation, the duration of atrial fibrillation was significantly reduced after one year follow-up visit, and the atrial fibrillation was cured by second radiofrequency ablation. There were 15 cases of frequent postoperative atrial tachycardia, they were treated with oral Antiarrhythmic agent, there were (155±71) cases of atrial premature beat after 2 months follow-up visit, and (54±16) cases of atrial premature beat after 12 months follow-up visit, the patients felt that the symptoms improved significantly. There was one case with pericardial tamponade during the Surgery, and it was treated with surgical treatment, the curative effect was achieved. Conclusion Under three-dimensional electric CARTO mapping guidance, the implementation of circumferential pulmonary vein ablation for persistent atrial fibrillation patients can achieve ideal prognosis and can also provide strengthful security for the cure of the disease.

[Key words]Persistent atrial fibrillation, Radiofrequency ablation, Clinical observation

心房颤动(房颤)采用经导管射频消融(RFCA)治疗近年已趋成熟,相较常规用药,效果显著,且缩短了治疗时间,避免了长期用药引发的并发症和副作用,有广阔的应用前景。本次研究选取持续房颤病例,采用射频消融治疗,现总结如下。

1 资料与方法

1.1 一般资料

选取持续房颤128例,男80例,女48例,年龄45~79岁,平均(60.2±6.3)岁,房颤病史平均(3.4±1.9)年。排除半年内有脑卒中病史及瓣膜性疾病者,术前均经食道超声证实,无附壁血栓在左房内发生,在消融前,取华法林应用3~4周,手术前4 d,调整为皮下注射低分子肝素。

1.2 方法

局部麻醉,将10级电极导管经左锁骨下静脉成功穿刺后,送入冠状静脉窦内,房间隔经右股静脉穿刺,取多功能长鞘管在左心房放置,取普通肝素3 000 u静脉注射,利用环状标测电极和EnSite3000三维立体标测系统在左心耳内部和左房内左下、左上、右下、右上肺静脉开口及内部行几何学构建。完整、闭合环状线性围绕左、右上下肺静脉消融。在上述消融基础上,分别再对左房峡部、上下肺静脉间、上腔静脉与右房峡部、右房连接处消融。取抗心律失常药在消融后继续口服2个月。手术后前3 d取低分子肝素进行抗凝治疗,维持INR在2~3。术后行12个月随访,对患者自觉症状改善情况、有无房颤复发、心律失常情况进行观察记录。

2 结果

相较术前,患者术后均觉心悸症状持续时间及发作持数明显

改善。术后1 d有阵发性房颤发作5例,采用胺碘酮药物转复后,取胺碘酮维持剂量长期口服,行1年随访,房颤持续明显减少,经二次射频消融治疗治愈。术后有频发房早15例,口服抗心律失常药,随访2个月,房早(155±71)个,12个月时为(54±16)个,自觉症状明显改善。手术中有心包填塞出现4例,均采用外科手术治疗,达治愈效果。

3 讨论

分析房颤病发原因,多与局灶驱动伴颤动样传导相关,在驱动和异位过程中,可能有肺静脉异位快速激动点的参与。目前,导管射频电隔离肺静脉为较为常用的消融手段,主要有两种肺静脉电隔离的策略,一为对所有肺静脉口分别消融,发挥左心房肺静脉完全双向隔离效果;二是仅隔离局灶驱动肺静脉,手术达91%成功率,仅有15%病例需再次实施消融操作。为防肺静脉狭窄等不良事件发生,可应用左、右侧肺静脉前庭外线性、双环形消融法,消融线分别对单侧上、下肺静脉包绕,进而提高消融成功率[1-2]。

鉴于阵发性房颤主要发生机制源于肺静脉和胸腔其他静脉触发灶,故单对胸腔内形成的心律失常静脉消融手段对大部分阵发性房颤病例有效。相较单纯环肺静脉隔离,阵发性房颤病例中,环肺静脉隔离结合左心房线性消融有较高的房性心律失常率,但就持续性房颤病例而言,单对肺静脉触发灶消除是不行的,还需对左心耳、左心房间隔等处碎裂电位消融,对房颤的发作有终止效果。持续性房颤病例多在对左心房碎裂电位消融后,房颤终止,表明左心房电位的不均一和离散的状态在持续性房颤的维持中有所参与[3]。本次研究选取的病例,相较术前,患者术后均觉心悸症状持续时间及发作持数明显改善。术后1 d有阵发性房颤发作5例,采用胺碘酮药物转复后,取胺碘酮维持剂量长期口服,行1年随访,仍有反复发作的阵发生房颤,但心悸等不适症状改善,持续明显减少,经二次射频消融治疗治愈。

综上,针对持续性房颤,在CARTO三维立体电标测指导下,实施环肺静脉消融治疗,可获得理想预后,为治愈提供有力的保障作用。

参考文献

[1]黄志华,李平,刘广交,等. 经导管射频消融治疗老年持续性心房颤动的疗效[J]. 中国老年学杂志,2013,33(15):3571-3573.

[2]荆朝辉,李明秋,荣晓松,等. 射频消融迷宫手术治疗长期持续性房颤[J]. 中国医药指南,2013(12):520-521.

[3]孙俊华,袁义强,赵育洁,等. 持续心房颤动伴心力衰竭患者的射频消融治疗[J]. 中国实用医药,2015,10(10):178-179.

doi:10.3969/j.issn.1674-9308.2015.17.088

【文章编号】1674-9308(2015)17-0115-02

【文献标识码】B

【中图分类号】R541

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