Advances in Clinical Medicine
Vol.
10
No.
12
(
2020
), Article ID:
39304
,
7
pages
10.12677/ACM.2020.1012463
持续性房颤患者首次射频消融术后复发风险相关因素分析
韩伟东1,赵青1,郭艳杰2,窦菁菁3,张鹏1,孙品4*
1青岛大学附属医院心血管内科,山东 青岛
2潍坊市人民医院心脏超声科,山东 潍坊
3青岛大学附属心血管病医院心脏超声科,山东 青岛
4青岛大学附属医院心脏超声科,山东 青岛
收稿日期:2020年11月21日;录用日期:2020年12月16日;发布日期:2020年12月23日
摘要
目的:分析持续性心房颤动(Persistent atrial fibrillation, PAF)患者首次射频消融术后房颤复发的影响因素,为临床提供参考依据。方法:选取60名于2018-07至2019-07于青岛大学附属医院住院行射频消融术的PAF患者。根据患者1年内是否复发分为复发组(n = 30)、非复发组(n = 30)。比较两组患者临床资料,分析持续房颤患者射频消融术后复发的影响因素,采用logistic回归分析确定PAF患者射频术后复发的独立危险因素。结果:复发组的病程、术前左心房内径(left atrial diameter, LAD)、N端脑钠肽前体(N-terminal pro-brain natriuretic peptide, NT-proBNP)、白蛋白、术后P波离散度、早期复发均显著高于未复发组,复发组的高密度脂蛋白显著低于未复发组,差异有统计学意义(P < 0.05)。logistic回归分析显示,病程、术前LAD、术后P波离散度共三个指标是影响PAF患者射频消融术后复发的独立危险因素(OR > 1)。结论:病程、术前左心房内径、术后P波离散度可在一定程度上评估PAF患者射频消融术后复发风险。
关键词
房颤,射频消融术,复发,病程,左心房内径,P波离散度
Analysis of Relevant Risk Factors for Recurrence after First Radiofrequency Ablation in Patients with Persistent Atrial Fibrillation
Weidong Han1, Qing Zhao1, Yanjie Guo2, Jingjing Dou3, Peng Zhang1, Pin Sun4*
1Department of Cardiovascular Medicine, Affiliated Hospital of Qingdao University, Qingdao Shandong
2Department of Cardiac Ultrasound, Weifang People’s Hospital, Weifang Shandong
3Department of Echocardiography, Affiliated Hospital of Cardiovascular Disease, Qingdao University, Qingdao Shandong
4Department of Cardiac Ultrasound, Affiliated Hospital of Qingdao University, Qingdao Shandong
Received: Nov. 21st, 2020; accepted: Dec. 16th, 2020; published: Dec. 23rd, 2020
ABSTRACT
Objective: To analyse Persistent atrial fibrillation (PAF) in patients with the influence factors of atrial fibrillation recurrence after radiofrequency ablation for the first time. Methods: 60 PAF patients who underwent radiofrequency ablation in The Affiliated Hospital of Qingdao University from 2018-07 to 2019-07 were selected. Patients were divided into recurrent group (n = 30) and non-recurrent group (n = 30) according to whether they had recurred within 1 year. The clinical data of the two groups were compared to analyze the factors influencing the recurrence of patients with continuous atrial fibrillation after radiofrequency ablation. Results: Recurrence group of course, left atrium diameter (LAD), N-terminal pro-brain natriuretic peptide (NT-proBNP), albumin, P-wave dispersion (PWD), early recurrence rate were significantly higher than non-recur- rence group, the difference was statistically significant (P < 0.05), recurrence group of high-density lipoprotein cholesterol (HDL-c) significantly below non-recurrence group, the difference was statistically significant (P < 0.05). Logistic regression analysis showed that there was a significant positive correlation between disease course, LAD and P-wave dispersion and recurrence (P < 0.05), and they were independent risk factors for recurrence (OR > 1). Conclusion: The course of disease, preoperative left atrial diameter, and postoperative P-wave dispersion can be used to evaluate the possibility of recurrence in patients with PAF after radiofrequency ablation.
Keywords:Atrial Fibrillation, Radiofrequency Ablation, Recurrence, Course, Left Atrium Diameter, P-Wave Dispersion
Copyright © 2020 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
1. 引言
心房颤动(Atrial fibrillation, AF)是临床常见的心律失常,胡大一等对我国29079例30~85岁人群的流行病学调查显示,房颤年龄校正后患病率为0.65%,随年龄增长患病率增加,在>80岁人群中高达7.5% [1]。房颤患者发生缺血性脑卒中及体循环动脉栓塞的风险是非房颤患者的4~5倍,其年发生率分别为1.92%和0.24%,近20%的致死率及近60%致残率 [2]。近年来大量研究显示导管消融治疗在维持窦性心律和改善生活质量等方面优于抗心律失常药物治疗 [3] - [9],随着导管消融技术的发展,已有越来越多的房颤患者选择行导管消融术。然而研究显示单次导管消融术后1~5年复发率为11%~29%,重复消融后复发率为7%~24% [10]。因此如何预测房颤复发风险及减少房颤复发率是目前亟待解决的问题之一。目前房颤的发生、维持及复发机制仍无定论,有研究提示可能与多发子波折返、局灶激动、转子样激动、心房电重构与结构重构等因素有关 [11] [12] [13]。本研究分析PAF患者临床资料,探讨射频消融术后复发的危险因素,旨在为临床诊治提供参考。
2. 对象与方法
2.1. 研究对象
收集自2018年7月至2019年7月于青岛大学附属医院心血管内科住院的所有行射频消融术的PAF患者共60例。其中男性40名,女性20名,复发组男性22名,女性8名,平均年龄62.400 ± 7.735岁,非复发组男性18名,女性12名,平均年龄60.500 ± 12.311岁。纳入标准:1) 持续性心房颤动患者2) 无其他器质性心脏病3) 术前行经食道超声排除左房血栓。排除标准:1) 合并其他心律失常;2) 非首次行射频消融术;3) 有抗凝禁忌症;4) 严重慢性疾病;5) 预期寿命小于1年。根据1年内是否复发分为复发组30例与非复发组30例。
2.2. 研究方法
2.2.1. 术前准备
患者在术前均行超声心动图检查评估心脏情况,行超声心动图检查排除左心房血栓,抽取静脉血化验。
2.2.2. 手术方式
患者取平卧位,连接多导电生理及CARTO三维标测系统,常规消毒双侧腹股沟区,给予局麻,穿刺成功后置入鞘管,送入冠状窦电极,房间隔穿刺成功后置入8.5F房间隔鞘,沿鞘送LASSO电极至左心房,应用swartz鞘行肺动脉造影,在CARTO系统指导下建立左房模型,行双侧肺静脉前庭隔离,观察30分钟,送LASSO电极至右上肺静脉、右下肺静脉、左上肺静脉、左下肺静脉,均达到双向阻滞。必要时加左心房线性消融,消融部位为左心房顶部或左心房峡部,终点为消融径线完整,达到双向阻滞。导管消融结束后心电监护如果仍为房颤律,则行同步电复律。
2.2.3. 术后处理及数据收集
所有患者术后均给予新型口服抗凝药抗凝治疗3个月,同时口服胺碘酮抗心律失常治疗3个月。收集患者术后1、3、6、12个月复查时的十二导联心电图或动态心电图检查结果,以及患者在术后1年内出现心慌等不适时的心电图检查结果。射频消融术后3个月内出现的房性心律失常多可自行恢复,因此将其定义为“空白期”,在此时间内出现房性心律失常不视为复发。将射频消融术3个月后出现房性心律失常,包括房速、房扑、房颤,持续时间大于等于30秒,定义为房颤复发 [10]。根据是否复发分为复发组与非复发组。
2.3. 统计学方法
采用SPSS21.0软件进行数据统计分析,以a = 0.05作为组间比较的检验水准。对于描述性统计量,计量资料用均数 ± 标准差 表示,计数资料用例数和百分数(%)表示。
1) 计量资料组间比较,采用两样本t检验,不满足条件的则用非参数秩和检验。
2) 计数资料组间比较,采用卡方检验。
3) 多因素相关性分析用二元Logistic回归模型选择向前模型分析,自变量为单因素分析有意义的因素,结果用校正后的优势比(OR)和与之相应的95%可信区间(CI)表示。
3. 结果
3.1. 射频消融术后复发单因素分析
将60名患者根据1年内是否复发分为复发组和非复发组,由表1结果可得,两组患者在性别、年龄、糖尿病病史、高血压病病史、射血分数、BMI、C反应蛋白(CRP)、促甲状腺激素(TSH)、CHA2DS2-VASC评分、低密度脂蛋白(LDL-C)、肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)、谷丙转氨酶(ALT)、谷草转氨酶(AST)、肌酐(Cr)、尿素氮(BUN)等方面无明显差异(P > 0.05),而两组患者在病程、术前左心房内径(LAD)、N末端B型脑钠肽前体(NT-proBNP)、白蛋白(ALB)、高密度脂蛋白(HDL-C)、术后P波离散度、早期复发共7个指标间的差异有统计学意义(P < 0.05),且复发组的病程、LAD、NT-proBNP、ALB、术后P波离散度、空白期发作率均显著高于未复发组,复发组的高密度脂蛋白显著低于未复发组。
Table 1. Comparison of indexes between the two groups with or without recurrence [n (%), x ¯ ± s ]
表1. 有无复发两组间各指标比较[n (%), ]
注:*:卡方检验;#:t检验;D:Z检验。
3.2. 射频消融术后复发Cox回归分析
为了进一步检验单因素有差异的7个观察指标与PAF患者射频术后是否复发之间的相关性,寻求它们之间的关系,我们选择二元logistic回归选择向前模型,表2示:病程、术前LAD、术后P波离散度共三个指标是影响复发的独立危险因素(OR > 1)。
Table 2. Logistic regression analysis of whether recurrence
表2. 是否复发logistic回归分析
b:系数估计;Wald:卡方值;OR:优势比;CI:可信区间。
4. 讨论
房颤因其高发病率、高致残率而受到广泛关注,目前,射频消融是房颤最有效的治疗方式,然而其仍有较高的复发率,这给患者及术者都带来了较大的困扰。到目前为止,房颤的发生、维持及复发机制并没有明确定论。其中肺静脉异常电活动是近年来被公认的房颤重要发生机制,黄从新等通过大量的研究证实入心大静脉肌袖内的具有异常自律性的细胞,在特定的情况下,会自发的产生快速电活动,从而导致房颤的发生,这也为射频消融治疗房颤奠定了理论基础 [14] [15]。而既往的一些研究则认为,左心房与肺静脉的电传导重连是房颤复发的重要机制,另外非肺静脉起源的病灶也可能与房颤复发有重要关系。本研究共纳入60名PAF患者,分析患者的临床资料,多因素回归分析显示,PAF病程、术前LAD及术后P波离散度是PAF患者射频消融术后复发的独立危险因素。
本研究显示,PAF患者的病程、LAD均为射频消融术后复发的独立危险因素,该结果与既往研究结果一致 [16] [17]。虽然目前房颤的发生及维持机制并无定论,但多认为心房电重构与结构重构可能在其中扮演了重要角色 [18]。随着房颤的发生及病程的延长,心房的电重构与结构重构程度逐渐增加,而心房的电重构及结构重构又进一步促使了房颤的恶化,即著名的“房颤致房颤”理论 [19]。多发子波折返假说同样被广泛接受,当兴奋在心房内传导时,因心肌结构及功能受损,导致心房肌各部分的兴奋性、不应期及传导速度不同,兴奋波碎裂为许多小波,众多小波延不同的路径折返形成房颤。而当左心房扩大时,心肌各部分兴奋性、不应期及传导速度差异进一步增大,且可同时容纳的子波数量增多,也可容纳相对于正常心房过长的波长,进而导致房颤,增加房颤射频消融术后的复发率。Matsuo [20] 等研究显示,对于房颤病程大于5年的患者,通过射频消融转复窦律的概率较低。
此外,本研究多因素分析结果显示,术后P波离散度同样是PAF患者射频消融术后复发的独立危险因素。这同Amir [21] 等的研究结果相一致。P波离散度是同步记录的12导联心电图中,不同导联中测定的P波最大时限与最小时限的差值,其反映了心房传导的不均质性。P波离散度越大,代表心房各部位间电活动差异越大,更容易引起心房电活动的折返,进而导致房颤的复发。
综上所述,PAF患者病程、术前LAD及术后P波离散度是射频消融术后复发的独立危险因素。在临床工作中应注意识别这些危险因素,对于具有高复发风险的患者应加强管理,进行术前评估,以避免术后复发。
本研究为单中心回顾性研究,可能出现信息偏倚,且样本量较小,需进一步增加样本量,进行多中心前瞻性研究,以进一步验证结论。本研究随访时间较短,未能对1年后的患者复发情况进行研究,需增加随访时间,以进一步探究远期复发的影响因素。
文章引用
韩伟东,赵 青,郭艳杰,窦菁菁,张 鹏,孙 品. 持续性房颤患者首次射频消融术后复发风险相关因素分析
Analysis of Relevant Risk Factors for Recurrence after First Radiofrequency Ablation in Patients with Persistent Atrial Fibrillation[J]. 临床医学进展, 2020, 10(12): 3096-3102. https://doi.org/10.12677/ACM.2020.1012463
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NOTES
*通讯作者。