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Relationship between Aggressive Septal Ablation and Significant Left Atrial Appendage Activation Delay following Catheter Ablation of Persistent Atrial Fibrillation
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摘要:目的 探讨持续性心房颤动(简称房颤)导管消融术后左心耳激动显著延迟与术中强化间隔消融的关系。方法 对2007年6月至2009年2月在本科接受导管消融术的201例持续性房颤患者行步进式导管消融, 术后行左房激动标测并记录左心耳电活动, 术后1月行经胸心脏超声评估左房功能。结果 术后23例出现左心耳激动显著延迟, 其中14例为初次消融病例, 9例接受了间隔线消融(OR 15.2, 95%CI 4.6~50.8, P < 0.001);另9例为第2次消融(包括2例左房隔离)病例, 9例患者也于初次消融中行广泛间隔复杂碎裂电位消融(P=0.002)。激动标测提示21例患者中18例(85.7%)左房最早激动部位转向冠状窦。术后1个月二尖瓣前向血流A峰为(18.2±17.0)cm/s, 与术前为窦性心律者比较显著下降, (20.2±19.1)cm/s vs.(58.2±17.9)cm/s(P=0.037)。随访(10.6±6.2)个月, 14例患者维持窦性心律。结论 持续性房颤导管消融术行间隔线或广泛间隔复杂碎裂电位消融可导致左心耳激动显著延迟, 可能影响左房功能, 持续性房颤患者采用此术式应该慎重。Abstract:Objective To elucidate the significant left atrial appendage activation following ablation of persistent atrial fibrillation, and explore its relationship with aggressive septal ablation.Methods A total of 201 patients with persistent atrial fibrillation underwent catheter ablation from June 2007 to February 2009. Action mapping of left atrium was performed and the local potential of left atrial appendage was recorded at the end of the procedure. Transthroacic ultrasound was performed one month later to evaluate the function of left atrium.Results Significant left atrial appendage activation delay was found in 23 out of 201 patients undergoing persistent atrial fibrillation ablation. Of these 23 patients, 14 patients suffered from this condition in their first were found at index procedures, of whom septal line ablation was performed in nine (odds ratio 15.2, 95% confidence interval 4.6-50.8, P < 0.001). The delay was found in another 9 patietns during their redo procedures (including two with biatrial activation dissociation), all of whom received extensive left septal complex fractionated elegrams ablation in their prior procedures (P=0.002). Activation mapping demonstrated the earliest breakthrough of the left atrium changed to coronary sinus in 18 (85.7%) patients. After 1 month, the mitral A wave velocity was 18.2±17.0 cm/s, and decreased significantly as compared with preablation (20.2±19.1 vs. 58.2±17.9 cm/s, P=0.037) in patients undergoing redo procedures. Fourteen (60.9%) remained arrhythmia-free during follow-up, which lasted 10.6 ±6.2 months.Conclusion Septal line ablation and extensive septal complex fractionated elegrams ablation are correlated with significant left atrial activation delay or even biatrial activation dissociation, and should be performed with prudent consideration.
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临床上用131I治疗甲状腺功能亢进(主要指Graves病)方便、安全、有效, 在发达国家已成为治疗Graves病的首选方法, 在国内也已广泛开展。但是这种疗法关键的半衰期的测量需要等待数天时间, 患者治疗前需来院4次, 增加了患者和医生的负担。北京协和医院核医学科康增寿教授在国际上首先发现131I有效半衰期与转换率呈负相关, 并与北京核仪器厂合作研发出了131I有效半衰期测定软件(EHL软件), 将测定时间缩短到24 h。
康增寿教授介绍说, 131I治疗甲亢的4个主要步骤为:测定甲状腺摄取131I率、测定有效半衰期、甲状腺显像估算重量和设计口服剂量。其中有效半衰期测定是指24 h最高摄131I率降至一半时的天数。第1天, 医生需要测定患者2、4、6、24 h的吸碘率, 找出这4个值的最大值。48 h后, 医生需要再次测定患者的吸碘率, 查看吸碘率是否降到了首日最大值的一半。如果没有降到一半, 则需要在72 h后再次测定并比较。以此类推, 直到测定的吸碘率降到一半, 取当时的天数为有效半衰期。用以上传统做法测定131I有效半衰期一般需要5 ~ 7 d, 这是131I治疗甲亢的一大弊病。
根据多年临床经验, 康增寿教授发现摄131I转换率(4 h吸131I率与24 h吸131I率的比值)与有效半衰期间呈负相关。对已治疗的1044例Graves病患者的摄131I转换率和实测有效半衰期进行回顾性总结的结果, 证实了二者间的负相关关系。
康教授根据1044例患者的大样本量分析, 推算出回归方程式为:Y=-4.551X+9.1693, R= -0.664。其中X表示摄131I转换率, Y就是有效半衰期的天数。R=-0.664表示X与Y的相关系数。根据以上公式, 用第1天测定的摄131I转换率就可以直接推算出有效半衰期, 将测定时间缩短至24 h。在北京核仪器厂协助下, 131I治疗甲亢有效半衰期测定软件———EHL软件研发成功, 医生只需将第1天测定的吸碘率输入EHL软件, 就可以立即得到有效半衰期的数值。康教授进一步对300例131I治疗的Graves病患者实测有效半衰期的数值与EHL软件测定值进行比较, 结果证实了EHL软件的科学性与准确性。
EHL软件可在24 h内测出131I治疗的有效半衰期, 为医生和患者节省了120 h, 工作效率提高了4倍, 同时还避免了多次实测的误差, 使数据更加科学有效。目前, EHL软件已在北京协和医院核医学科推广使用, 患者和医生都深深受益。
(北京协和医院宣传处 何帆)
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图 1 间隔线消融所致左心耳激动显著延迟
A.间隔线消融后左心耳根部电位显著延迟（蓝点），术后一个月心脏超声示二尖瓣前向血流A峰显著下降；B.窦性心律下激动标测示左房最早激动点转为冠状窦附近，在后壁沿足头方向传导，左心耳最晚激动
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图 2 导管消融术后左心耳隔离
A.双侧肺静脉隔离、左房顶部线和二尖瓣环部线阻滞及广泛间隔复杂破裂电位消融后左心耳电位消失；B.窦性心律下激动标测示左房最早激动点位于冠状窦，间隔部存在大范围低点位区
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图 3 第2次消融术后左房隔离
患者在首次消融中接受了双侧肺静脉隔离、间隔线、左房顶部线、二尖瓣环峡部线和三尖瓣环峡部线消融; 第2次消融中行广泛左房后下部复杂碎裂电位和冠状窦内消融后右房恢复窦性心律(绿点), 但左房仍为房性心律支配(蓝点, 箭头所示为A波), 冠状窦A波显著延迟
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