左房内环肺静脉口线性消融治疗阵发性心房颤动对窦性心率震荡及心率变异性影响的研究

【作者】 居维竹；

【导师】 陈明龙；

【作者基本信息】 南京医科大学 ， 心血管内科学， 2007， 硕士

【摘要】 第一部分左房内环肺静脉口外线性消融术治疗阵发性心房颤动的去迷走效应研究目的通过观察左房内环肺静脉口外线性消融术对窦性心率震荡的影响，间接反映消融术治疗心房颤动时心脏迷走神经活动即刻的改变。方法2006年3月至2006年12月间至南京医科大学第一附属医院心脏科行射频消融术的阵发性心房颤动患者44名(男性26例，女性18例)，年龄24～76(53±13)岁，左房直径27～50(36±5)cm，射血分数0.49～0.71(0.65±0.04)。消融前及消融后即刻呈稳定的窦性心律，无任何异常搏动，此时于右室心尖部引入RS2期前刺激，偶联间期为刺激当时窦性周期的60％，输出电压为2倍舒张期阈值，并以5次早搏平均为基础测量术前术后震荡初始(TO)及震荡斜率(TS)。结果射频消融前后HRT有明显变化，其中TO为-0.0216±0.0236VS0.0009±0.0133(P值＜0.01)；TS 7.3318±6.9835VS2.0553±2.1724(P值＜0.01)，为差异有统计学意义。结论HRT的变化趋势表明环肺静脉左房线性消融术中发生去迷走效应是普遍的现象，而并非一定表现为生命体征的改变。这种变化本身也提示射频能量引起迷走反射主要为损伤或者刺激了迷走传入支而非传出支。第二部分左房线性消融治疗阵发性心房颤动对心率变异性的影响目的通过观察左心房线性消融术治疗阵发性心房颤动术后心率变异性的变化来评价其对自主神经系统的影响。方法2006年1月至2006年6月于南京医科大学第一附属医院心脏科行射频消融术的阵发性心房颤动患者25名，年龄28-66(51±12)岁，术前及术后三天行24小时动态心电图检查，分别测定最大心率MaxHR，最小心率MinHR，平均心率MeanHR，时域指标NN间期标准差(SDNN)，NN间期平均值的标准差(SDANN)，相邻NN间期差的均方根(RMMSD)，相邻NN间期差值超过50ms的NN间期所占百分数(PNN50)，频域指标低频功率(LF)，高频功率(HF)，低频高频比值(LF／HF)。结果患者术前MaxHe，MinHR，MeanHR，SDNN，SDANN，RMSSD，PNN50，LF，HF，LF／HF分别为154±40，47±5，69±9，125±26，110±25，27±7，6±5，94±67，110±45，0.9±0.7。术后各指标分别为129±37，66±8，84±9，59±17，53±17，15±7，2±3，17±19，11±10，2.0±2.2。差异有统计学意义。结论左心房线性消融术造成了心率变异性的明显变化，反映了其对交感和迷走两系统都有损伤作用。而对两神经系统的损伤可能是射频消融治疗心房颤动的机制之一。更多还原

【Abstract】 Part one Alterations of Heart rate turbulence: immediate vagal reflex during left atrium circumferential pulmonary vein ablationPurpose To observe the alteration of Heart rate turbulence(HRT) before and after left atrium circumferential ablation surrounding pulmonary veins(LACA) in patients with paroxysmal atrial fibrillation(PAF) to indicate whether concealed vagal denervation happened during the procedure.Methods Forty four(26 male, aged 53±11 years) patients with paroxysmal atrial fibrillation were included in the study referred for catheter ablation treatment from Mar 2006 to Dec 2006. The left atrium circumferential ablation surrounding pulmonary veins were done in every patients to achieve complete electrical isolation of both ipsilateral pulmonary veins. RS2 extrastimulus were delivered from right ventricular apex to obtain heart rate turbulence with 60％of basic sinus cycle length and at twice diastolic threshold before and after the procedure. Turbulence onset[To(％)] and Turbulence slope[TS(msec/beat)] were obtained averagely from five respective ventricular premature beats.Results TO and TS significantly changed after LACA[-0.0216±0.0236 to 0.0009±0.0133(P＜0.001)]and [7.3318±6.9835VS2.0553±2.1724 respectively (P＜0.001)].Conclusion Though vagal reflex with significant bradycardia and hypotension might happen during LACA procedure, HRT alteration, which indicates the concealed vagal denervation, is more common. This might contribute to the long term success of LACA treatment of PAF to some extent. Alteration itself also illustrates that the ablation damages or stimulates not the efferent but the afferent limb of the vagal reflex. Part two The effect of left atrium linear lesion encircling Pulmonary veins on the heart rate variabilityPurpose To evaluate the effect of left atrium linear lesion encircling pulmonary veins on the autonomic nervous system via the alternations of the heart rate variability.Methods Twenty five patients with paroxysmal atrial fibrillation were referred for catheter ablation treatment from Jan 2006 to Jun 2006. The left atrium linear lesion encircling pulmonary veins were done in every patients to achieve the disappearance of the pulmonary vein potentials. The maximal heart rate, minimal heart rate, mean heart rate, time domain and frequency domain analyses of HRV were obtained by use of 24-hour ambulatory electrocardiogram before and 3 days after the procedure.Results The parameters of MaxHR, MinHR, MeanHR, SDNN, SDANN, RMSSD, PNNS0, LF, HF, LF/HF were151, 47, 70, 126, 111, 27, 6, 98, 86, 2.4 before theprocedure, and 136, 66, 84, 57, 53, 16, 2, 18, 16, 1.2 after the ablation(P＜0.05).Conclusion The left atrium linear lesion encircling pulmonary veins significantly altered the heart rate variability which demonstrated the damage to the cardiac nervous system and this "neurogenic substrate modification" might be one of the mechanism of catheter ablation of atrial fibrillation.更多还原