張 芳 夏振偉 馮 磊 王小斌

陣發(fā)性房顫射頻消融術(shù)后電復(fù)律與胺碘酮復(fù)律的對(duì)比研究

張 芳 夏振偉 馮 磊 王小斌

目的比較電復(fù)律和胺碘酮復(fù)律治療陣發(fā)性心房顫動(dòng)(房顫)射頻消融術(shù)后復(fù)發(fā)的效果。方法42例陣發(fā)性房顫射頻消融術(shù)后患者, 術(shù)前常規(guī)停用抗心律失常藥物, 術(shù)中采用環(huán)肺靜脈隔離方法,術(shù)后第一次復(fù)發(fā)時(shí)隨機(jī)分為電復(fù)律組(行電復(fù)律治療)和胺碘酮復(fù)律組(行胺碘酮復(fù)律治療), 各21例。比較兩組患者成功率、轉(zhuǎn)復(fù)時(shí)間、住院時(shí)間以及不良反應(yīng)情況。結(jié)果兩組成功率比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。胺碘酮復(fù)律組轉(zhuǎn)復(fù)時(shí)間為(4.09±0.23) h, 住院時(shí)間為(4.65±0.85)d。電復(fù)律組轉(zhuǎn)復(fù)時(shí)間為(3.02±0.16) h, 住院時(shí)間(3.18±0.57)d。電復(fù)律組轉(zhuǎn)復(fù)時(shí)間、住院時(shí)間均短于胺碘酮復(fù)律組, 差異具有統(tǒng)計(jì)學(xué)意義(P＜0.05)。兩組不良反應(yīng)發(fā)生情況比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。結(jié)論電復(fù)律成功率與胺碘酮復(fù)律組相同, 轉(zhuǎn)復(fù)時(shí)間短于胺碘酮, 所以電復(fù)律有效、快速。

陣發(fā)性房顫；射頻消融；電復(fù)律；胺碘酮

心房顫動(dòng)是臨床最常見的一種心律失常。它不但增加了患者心力衰竭和腦卒中的風(fēng)險(xiǎn), 而且增加了患者的死亡風(fēng)險(xiǎn)［1］。近年來, 雖然房顫導(dǎo)管消融技術(shù)發(fā)展迅猛, 但是其總體成功率還不盡如人意［2］。陣發(fā)性房顫導(dǎo)管消融術(shù)后多出現(xiàn)快速性房型心律失常, 可反復(fù)發(fā)作, 患者耐受性差, 并且容易引起血流動(dòng)力學(xué)變化, 因此需要盡快轉(zhuǎn)律。術(shù)后復(fù)發(fā)的患者多采用電復(fù)律和藥物復(fù)律。本文通過對(duì)照研究, 分析電復(fù)律和藥物復(fù)律的成功率、轉(zhuǎn)復(fù)所需時(shí)間?，F(xiàn)報(bào)告如下。

1 資料與方法

1.1 一般資料 對(duì)2014年11月～2015年8月本院連續(xù)收治的42例陣發(fā)性房顫行射頻消融術(shù)治療后3個(gè)月內(nèi)復(fù)發(fā)房顫、房速的患者。其中男28例, 女14例, 年齡50～74歲。術(shù)后第一次復(fù)發(fā)時(shí)隨機(jī)分為電復(fù)律組和胺碘酮復(fù)律組, 各21例。所有復(fù)發(fā)患者發(fā)作時(shí)均行12導(dǎo)心電圖檢查, 快速性房性心律失常持續(xù)時(shí)間5 min～24 h；無血鉀異常(4.0～5.0 mmol/l)；無肝腎衰竭；無甲狀腺功能異常；QTc<550 ms；復(fù)律時(shí)所有患者行心電監(jiān)護(hù)、簽署復(fù)律同意書。

1.2 方法

1.2.1 手術(shù)方法 所有患者術(shù)前常規(guī)停用抗心律失常藥物1周, 所有患者術(shù)前行超聲心動(dòng)圖檢查排除瓣膜性心臟病,行肺靜脈增強(qiáng)CT明確有無左房血栓。對(duì)發(fā)作頻繁或發(fā)作持續(xù)時(shí)間較長(zhǎng)者需經(jīng)食管超聲除外心房血栓, 其他術(shù)前準(zhǔn)備同普通射頻消融術(shù)。所有患者在三維標(biāo)測(cè)系統(tǒng)指導(dǎo)下, 在肺靜脈外口0.5～1.0 cm的左心房完成環(huán)狀消融。消融終點(diǎn)是消融線兩側(cè)雙向傳導(dǎo)阻滯。對(duì)復(fù)發(fā)的患者進(jìn)行再次消融時(shí), 都再次行電生理檢查, 術(shù)中所用標(biāo)測(cè)及消融設(shè)備相同, 并由同一術(shù)者完成。所有病例未發(fā)生心包填塞。術(shù)后華法令抗凝3個(gè)月, 維持國(guó)際標(biāo)準(zhǔn)化比值(INR)1.8～2.5。

1.2.2 復(fù)律方法 胺碘酮復(fù)律組在開始10min內(nèi)給予負(fù)荷量(3 mg/kg)靜脈推注, 然后維持24 h(前6 h 1 mg/min, 后18 h 0.5 mg/min)。電復(fù)律組靜脈推注地西泮(5～10 mg), 如患者睫毛反射消失, 雙向波同步直流電復(fù)律, 起始能量為200 J,放電兩次仍為房顫的患者則放棄。即刻復(fù)律成功的定義:復(fù)律后轉(zhuǎn)為竇性心律并持續(xù)24 h以上。

1.3 觀察指標(biāo) 復(fù)律治療成功后, 心電、血壓監(jiān)測(cè)持續(xù)2 h,沒有異常情況可于24 h后出院, 如出現(xiàn)異常情況則停藥并持續(xù)監(jiān)護(hù)至異常情況消失后24 h。異常情況包括嚴(yán)重的心動(dòng)過緩、高度房室傳導(dǎo)阻滯、血栓栓塞性疾病、嚴(yán)重出血。多次復(fù)律的患者只統(tǒng)計(jì)第一次復(fù)律情況。復(fù)律后胺碘酮復(fù)律組患者可繼續(xù)口服胺碘酮3個(gè)月。

1.4 統(tǒng)計(jì)學(xué)方法 采用SPSS11.0統(tǒng)計(jì)學(xué)軟件對(duì)研究數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析。計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差表示, 采用t檢驗(yàn)；計(jì)數(shù)資料以率(%)表示, 采用χ2檢驗(yàn)。P＜0.05表示差異具有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 成功率 電復(fù)律組成功率為85.7%(18/21), 其中2例在復(fù)律后24 h內(nèi)再發(fā)房顫, 1例因房速難以終止, 于2 d內(nèi)再次行射頻消融術(shù), 成功終止房速。胺碘酮復(fù)律組成功率為85.7%(18/21), 其中2例在復(fù)律后24 h內(nèi)再發(fā)房顫, 1例在持續(xù)用藥24 h后自行轉(zhuǎn)為竇性心律。兩組成功率比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。

2.2 治療時(shí)間 胺碘酮復(fù)律組轉(zhuǎn)復(fù)時(shí)間為(4.09±0.23) h, 住院時(shí)間為(4.65±0.85)d。電復(fù)律組轉(zhuǎn)復(fù)時(shí)間為(3.02±0.16) h,住院時(shí)間(3.18±0.57)d。電復(fù)律組轉(zhuǎn)復(fù)時(shí)間、住院時(shí)間均短于胺碘酮復(fù)律組, 差異具有統(tǒng)計(jì)學(xué)意義(P＜0.05)。

2.3 不良反應(yīng) 胺碘酮復(fù)律組患者均采用頸外靜脈途徑給藥, 未發(fā)生靜脈炎。1例患者復(fù)律后出現(xiàn)竇性心動(dòng)過緩, 最小心律38次/min, 停藥后逐漸恢復(fù)。電復(fù)律組1例復(fù)律即刻出現(xiàn)交界性心律, 持續(xù)約20 s, 最長(zhǎng)RR間期2.62 s, 患者無不適感覺。所有患者未出現(xiàn)血栓栓塞性疾病、嚴(yán)重出血性疾病、高度房室傳導(dǎo)阻滯。兩組不良反應(yīng)發(fā)生情況比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。

3 討論

目前, 射頻消融是治療陣發(fā)性房顫的Ⅰ類適應(yīng)證, 也是國(guó)內(nèi)外多個(gè)心臟電生理中心的研究熱點(diǎn)。隨著消融技術(shù)和經(jīng)驗(yàn)的積累, 術(shù)后遠(yuǎn)期復(fù)發(fā)的原因也越來越清晰。常見原因有消融徑線不完整、肺靜脈電連接傳導(dǎo)的恢復(fù)以及肺外靜脈起源的房顫［3,4］。此外, 由于消融時(shí)肺靜脈或心房肌受損、迷走神經(jīng)受破壞、交感神經(jīng)被激活, 術(shù)后患者可在3個(gè)月(空白期)內(nèi)出現(xiàn)房顫、房速發(fā)作, 少數(shù)患者可出現(xiàn)心室率較術(shù)前更快、發(fā)作更頻繁的“電風(fēng)暴”。因此, 迅速恢復(fù)竇性心律不但改善患者癥狀, 而且減少血栓栓塞性疾病等多種常見并發(fā)癥的風(fēng)險(xiǎn)。臨床研究也證實(shí), 對(duì)于術(shù)后3個(gè)月內(nèi)復(fù)發(fā)的患者, 早期接受復(fù)律治療, 可阻止心臟電生理重構(gòu), 改善預(yù)后［5］。

既往研究顯示, 對(duì)于心房顫動(dòng)患者, 電復(fù)律的成功率在80%～100%, 其影響因素有房顫或房撲的持續(xù)時(shí)間、左心房?jī)?nèi)徑及射頻術(shù)后心肌的炎癥狀態(tài)等［6-8］。目前, 在復(fù)律藥物中,胺碘酮應(yīng)用最廣泛。ESC指南中因其安全性好, 將其作為Ⅰ類推薦。胺碘酮靜脈給藥10～30 min起效, 半衰期長(zhǎng), 即使是停藥后的清除半衰期也長(zhǎng)達(dá)50～60 d, 少數(shù)人長(zhǎng)達(dá)3～4個(gè)月［9］, 因而, 多數(shù)研究顯示胺碘酮可以減少射頻術(shù)后的早期復(fù)發(fā), 而不影響晚期復(fù)發(fā)［10,11］。本研究中電復(fù)律的成功率較高,可能與入選的患者要求嚴(yán)格相關(guān)。

本研究中電復(fù)律組的成功率較高, 可能與入組標(biāo)準(zhǔn)嚴(yán)格相關(guān)。從兩組的數(shù)據(jù)來看, 兩組成功率比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。電復(fù)律組轉(zhuǎn)復(fù)時(shí)間、住院時(shí)間均短于胺碘酮復(fù)律組, 差異具有統(tǒng)計(jì)學(xué)意義(P＜0.05)。兩組不良反應(yīng)發(fā)生情況比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。此外, 為避免胺碘酮所致靜脈炎, 本研究均采用頸外靜脈輸注, 護(hù)理難度高于普通靜脈輸液。

射頻術(shù)后患者復(fù)發(fā)時(shí)應(yīng)盡快轉(zhuǎn)復(fù)。目前多數(shù)指南推薦房顫射頻消融術(shù)后電復(fù)律和藥物復(fù)律, 兩者的推薦級(jí)別無差異。本研究結(jié)果提示：相對(duì)于藥物復(fù)律, 電復(fù)律安全、有效、轉(zhuǎn)復(fù)時(shí)間短、不良反應(yīng)少、費(fèi)用少、易于廣大醫(yī)護(hù)人員掌握,推薦用于房顫射頻消融術(shù)后的心律轉(zhuǎn)復(fù)。

對(duì)于第一次復(fù)律即刻成功, 在隨后持續(xù)觀察的24 h中有再次復(fù)發(fā)的患者繼續(xù)行復(fù)律治療, 或者在術(shù)后口服胺碘酮3個(gè)月的期間出現(xiàn)復(fù)發(fā)的患者, 立即行電復(fù)律治療, 是否提高轉(zhuǎn)復(fù)的成功率, 將納入后續(xù)研究。此外, 電復(fù)律對(duì)射頻消融遠(yuǎn)期成功率的影響也將在后續(xù)研究中繼續(xù)進(jìn)行。

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Comparative research of electrical conversion and amiodarone conversion after radiofrequency ablationfor paroxysmal atrial fibrillation

ZHANG Fang, XIA Zhen-wei, FENG Lei, et al.Department of Cardiology, Liaoning Dalian City Central Hospital, Dalian 116033, China

ObjectiveTo compare effects by electrical conversion and amiodarone conversion in the treatment of recurrence of paroxysmal atrial fibrillation after radiofrequency ablation.MethodsA total of 42 patients with paroxysmal atrial fibrillation after radiofrequency ablation received preoperative conventional antiarrhythmic drugs withdrawal and intraoperative circumferential pulmonary vein isolation.They were randomly divided during first postoperative recurrence into electrical conversion group (received electrical conversion for treatment) and amiodarone conversion group (received amiodarone conversion for treatment), with 21 cases in each group.Comparison was made on success rate, conversion time, hospital stay time and adverse reactions between the two groups.ResultsThere was no statistically significant difference of success rate between the two groups (P＞0.05).The amiodarone conversion group had conversion time as (4.09±0.23) h and hospital stay time as (4.65±0.85) d.The electrical conversion group had conversion time as (3.02±0.16) h and hospital stay time as (3.18±0.57) d.The electrical conversion group had all shorter conversion time and hospital stay time than the amiodarone conversion group, and their difference had statistical significance (P＜0.05).The difference of adverse reactions had no statistical significance between the two groups (P＞0.05).ConclusionElectrical conversion shows the same success rate as amiodarone conversion, while it has shorter conversion time than amiodarone conversion.Therefore electrical conversion is effective and quick.

Paroxysmal atrial fibrillation; Radiofrequency ablation; Electrical conversion; Amiodarone

10.14164/j.cnki.cn11-5581/r.2017.07.009

2017-02-21］

116033 遼寧省大連市中心醫(yī)院心內(nèi)科