【作者】 麻付胜；

【导师】 张澍； 马坚； 陈柯萍；

【作者基本信息】 中国协和医科大学 ， 内科学， 2008， 博士

【摘要】 背景心房颤动(房颤)为一种发病率较高的室上性快速性心律失常,可发生于无器质性心脏病患者,但更常发生于二尖瓣病变、高血压、心力衰竭和缺血性心脏病,随年龄增大,发病率增加。随着对房颤发病机制的研究进展,对于药物控制疗效差、症状显著的患者,房颤的导管消融治疗成为房颤的非药物治疗的重要组成部分。通过介入导管消融方法治疗房颤已经形成了2种主要的术式,肿静脉节段隔离(SPVI)和环肺静脉射频消融(CPVA),均经心腔内操作,术中有血栓栓塞等并发症。外科治疗由早期针对瓣膜置换术中的房颤病人的Maze术式或Cox-MazeⅢ术式发展到通过不需体外循环的微创手术进行心外膜侧消融治疗无器质性心脏病的孤立性房颤。随着外科微创心外膜消融的发展趋势增加,介入治疗方法亦应展开新的方法学探索。目的本试验采用介入方法对两组犬的心房进行心外膜和心内膜侧的环肺静脉消融术,对采用介入方法行心外膜侧导管消融的安全性和可行性进行初步探索,并比较二种术式对房颤诱发率和心房电生理特性影响的异同。方法将20条人随机分为A、B两组,术前均进行64-CT扫描,进行左心房三维重建,并将数据导入Carto系统,术中在Carto Merge影像融合技术的指导下分别行心外膜侧(A组)与心内膜侧(B组)的环肺静脉消融,对比观察消融前、后心房颤动的诱发率、去迷走神经效应、肺静脉电隔离率、心房不应期和心房不应期离散度等指标的变化。结果消融前、后房颤诱发率A组(66/100;18/100,P＜0.05):B组(60/100;20/100,P＜0.05)。去迷走神经效应(A组8/10;B组5/10,P=0.1749)。左上肺静脉电隔离率(A组1/10;B组4/10,P=0.1517);右上肺静脉电隔离率(A组2/10;B组5/10,P=0.1749)。消融前、后心房不应期A组[(95.5±10.9)ms;(101±3.2)ms,P=0.185];B组[(90.5±10.7)ms;(105±4.1)ms,P＜0.05]。消融前、后心房不应期离散度A组[(28.5±8.12)ms;(8.5±4.74)ms,P＜0.05];B组[(27±6.32)ms;(9.5±4.38)ms,P＜0.05]。两组消融后均无急性冠状动脉损伤。结论采用介入导管消融的方法在Carto Merge影像指导下心外膜侧和心内膜侧进行环肺静脉消融均可以降低房颤的诱发率,心外膜侧消融可以相对安全的进行。更多还原

【Abstract】 Background atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with associated deterioration of atrial mechanical function. It is the most common cardiac arrhythmia, becomes more prevalent with age, and is associated with an increased long-term risk of stroke, heart failure, and all-caused mortality. AF can occur in the absence of underlying heart disease but is more frequent in connection with mitral valve disease, heart failure, ischemic heart disease, and hypertension. It is well accepted that the development AF requires both a trigger and a susceptible substrate. The goals of AF ablation procedures are to prevent AF by either eliminating the trigger that initiates AF or by altering the arrhythmogenic substrate. The most commonly employed ablation strategy today, which involves the electrical isolation of the PVs by segmental ablation incision (SPVI) or by creation of circumferential lesions around the right and the left PV ostia (CPVA), probably impacts both the trigger and substrate of AF. The classic Maze procedure can eliminate AF in more than 90% of patients. A complex but safe operation, the maze procedure has been applied by relatively few surgeons. However, recent advances in the understanding of the pathogenesis of AF and development of new ablation technologies enable surgeons to perform pulmonary vein ablation, create linear left atrial lesions, and remove the left atrial appendage rapidly and safely. Recently developed surgical instrumentation now enable thoracoscopic and keyhole approaches, facilitating extension of epicardial AF ablation and excision of the left atrial appendage to patients with isolated AF and no other indication for cardiac surgery.Objective To compare the effect of ablation on atrium between epicardial circumferential pulmonary vein ablation (CPVA) and endocardial CPVA to cure atrial fibrillation (AF).Methods Twenty canines were divided into two groups randomly. All of them underwent 64-slice multislice computed tomography (64-CT) before catheter ablation. Guided by image fusing of 64-CT with electroanatomic mapping, group A underwent epicardial CPVA and group B underwent endocardial CPVA. We observed inducibility of AF, vagal denervation, isolation of pulmonary vein, atrial effective refractory period (AERP), AERP dispersion before and after ablation.Results Inducibility of AF before and after ablation (group A 66/100 vs 18/100, P<0.05; group B 60/100 vs 20/100, P<0.05), vagal denervation (group A 8/10 vs group B 5/10, P=0.1749), isolation of left super pulmonary vein (LSPV) (group A 1/10 vs group B 4/10, P=0.1517), isolation of RSPV(group A 2/10 vs group B 5/10, P=0.1749), AERP (group A 95.5±10.9ms vs 101±3.2ms , P=0. 185; group B 90.5±10.7ms vs 105±4.1ms, P<0.05), AERP dispersion (group A 28.5±8.12ms vs 8.5±4.74 ms, P<0.05; group B 27±6.32ms vs 9.5±4.38ms, P<0.05). No acute injure happened to coronary artery in two groups.Conclusion Both epicardial CPVA and endicardial CPVA can suppress the inducibility of AF. Epicardial CPVA can be performed guided by Carto Merge image safely.更多还原