中文摘要

第一部分  阵发性心房颤动单次肺静脉电隔离优化消融顺序的有效性研究

 

目的：本研究目的是前瞻性评估优化肺静脉隔离消融顺序是否对阵发性心房颤动患者的术中观察期肺静脉急性恢复传导及长期成功率是否有影响。

方法：连续入选2013年1月至2016年12月期间拟在我院行射频消融的100名阵发性房颤。上述病例随机分成两组，优先消融组首先消融左右肺静脉交界处和左心耳与左肺静脉之间的嵴部，再消融其他区域；传统顺序消融组从右下肺静脉开始消融，逆时针方向形成连续的大环隔离。主要终点是在单次消融术后空白期后的1年随访期内，有无持续30秒以上的房性快速心律失常发生。次要终点为手术时间，X线暴露时间及安全性。

结果：优先组有49名患者和传统顺序组有48名患者最终纳入分析。优先消融组消融左心房停留时间为81.2 ± 24.7 分钟，顺序消融组消融左心房停留时间为76.9 ± 16.4分钟。优先消融组X线暴露时间为4.2± 0.9 分钟，顺序消融组所用时间为4.1± 0.6分钟，两组无明显统计学差异。顺序消融组有8名患者，优先消融组有9患者在术中观察期出现了肺静脉急性恢复传导。肺静脉恢复传导点主要分布在左肺静脉和左心耳之间，左上肺静脉顶部，左肺前脊部及右肺后脊部。随访中两组共有25名患者出现了房颤远期复发，总体的房颤复发率为25.7%。其中顺序消融组房颤复发率为27.1%，优先消融组房颤复发率为25.5%，两组间无明显差异(p = 0.77)。Cox回归分析只有肺静脉急性期恢复传导(HR:1.152, p=0.065)具有预测房颤术后晚期复发的趋势，但未达到统计学意义。

结论：优化调整肺静脉隔离消融顺序在本研究中并没有带来明显的1年期随访的成功率优势，但仍需大样本随机对照研究进一步验证。

关键词：心房颤动；肺静脉隔离；消融顺序；房颤复发

 

第二部分

心房颤动消融术后复发二次手术采用“冷冻与射频”交替消融策略研究

研究背景：肺静脉重新恢复电传导是房颤射频消融或者冷冻球囊消融术后房颤复发的常见原因，二次消融中对于复发的患者采用何种消融方式目前仍未充分研究。本研究目的是结合患者首次消融方式，二次消融采用射频消融或者冷冻交替消融策略，比较两组间肺静脉恢复电传导情况及远期成功率。

方法：入选自2016年9月至2021年6月因为心房颤动首次消融后复发来我院二次消融的156名患者，原先采用射频消融复发的患者，二次消融采用二代冷冻球囊消融，作为 RFC-CB-redo 组，有96名患者；原先采用二代冷冻球囊消融后复发的患者，二次消融采用射频消融技术，作为 CB- RFC-redo组，有60名患者。

结果：两组的患者首次房颤消融后的早期复发率无显著统计学的差异性（CB-RFC-redo 组vs RFC-CB-redo 组, 31.7% vs 27.1%，p=0.515）。首次采用冷冻消融的患者平均恢复传导的肺静脉数量相比首次消融采用射频消融的患者明显少(CB-RFC-redo 1.50 ± 0.81 支vs  RFC-CB-redo 3.36 ± 0.95 支, p=0.01)。但是，冷冻消融后发现非肺静脉起源触发灶比首次采用射频消融的患者多。二次消融后，经过平均10.7±2.41月随访期后，有40例患者在随访期出现了复发，总体远期术后复发率为25.6% (RFC-CB-redo:27.1% vs CB-RFC-redo:23.3%,p=0.594)，两组无明显差异性。多因素Cox回归分析提示持续性房颤和首次房颤消融后出现早期复发（HR=2.112, 95%CI:1.082-4.091，P=0.029；HR=2.421，95%CI:1.259-4.612，P=0.008）是二次消融后的房颤复发的风险因素,不管采用何种消融方式。

结论：房颤射频消融和冷冻球囊消融术后复发患者有不同的肺静脉恢复电传导特点；结合首次不同消融方式，二次消融术中采用“冷冻”与“射频消融”交替消融策略是安全和有效的，两者临床效果基本相似。

关键词：房颤复发；二次消融；冷冻消融；射频消融；交替消融策略

 

 

 

 

 

 

 

 

第三部分

 

甘油三酯葡萄糖指数预测非糖尿病患者房颤射频消融术后晚期复发的价值研究

 

研究背景：目前风险预后评分系统和相关生物标志物已被常规用于评估房颤患者

导管射频消融(RFCA)后房颤(AF)晚期复发。本研究旨在探讨甘油三酯-葡萄糖（TyG）指数对非糖尿病人群患者RFCA术后房颤晚期复发的预测价值。

方法：共有275例房颤患者自2016年1月至2018年12月期间在我院接受过房颤导管射频消融入选。在随访期间，根据心电图（ECG）检查或48小时动态心电图监测是否出现房颤晚期复发，将患者分为晚期房颤复发组和非晚期房颤复发组。甘油三酯葡萄糖指数通过公式ln[空腹甘油三脂 [mg/dL]×快速空腹血糖 [mg/dL]/2]计算。根据术前甘油三酯-葡萄糖（TyG）指数水平，将患者分成三组(T1,T2,T3组)。

结果：在平均26.1±9.1个月的随访后，与最低水平TyG指数组（T1组）相比，最高水平TyG指数组（T3）的晚期房颤复发率显著增加（分别为54%和12%；p<0.001）。晚期房颤复发组的平均TyG指数水平高于无晚期房颤复发组（分别为9.42±0.6和8.68±0.70；p<0.001）。多因素Cox回归分析显示，消融前TyG指数水平是RFCA后房颤晚期复发的独立危险因素(危险比[HR]1.478[95%可信区间(CI): 1.130-1.942];p = 0.012)。受试者工作特征(ROC)曲线分析显示，TyG指数在ROC曲线下面积(AUC)为0.737 (95%CI:0.657-0.816;p<0.001)，是RFCA术后晚期AF复发的显著预测因子，左心房直径在ROC曲线下面积(AUC)为0.780 (95%CI:0.703-0.857, p<0.001)。并且，TyG指数与LAD (r=0.133, p=0.027)、高敏C反应蛋白(r=0.132, p=0.028)、N -末端B型利钠肽前体(r=0.291,p<0.001)水平呈正相关。

结论: 根据上述研究，消融前TyG指数升高与非糖尿病患者人群中射频消融术后房颤晚期复发风险增加相关。TyG指数可能作为一种潜在的新型生物标志物，用于非糖尿病患者房颤消融术后晚期复发的风险分层。

关键词:心房颤动;甘油三酯-葡萄糖指数;生物标志物;房颤复发预测;导管消融

 

 

 

 

 

 

 

 

 

 

 

第四部分 心房颤动导管消融在肥胖人群中有效性及预后分析

 

目的：本研究目的在评估心房颤动导管消融在肥胖人群中有效性及相关预后分析。

方法：连续入选2019年1月至2021年12月在本院接受初次导管射频消融治疗的非瓣膜性房颤患者。根据体重指数(BMI), 将他们分为三组：正常体重组（BMI：18.5kg/m²-25kg/m²）92名、超重组（BMI：25kg/m²-30kg/m²）86名和肥胖组（BMI≥30kg/m²）52名。房颤消融方式均采用标准的肺静脉前庭消融隔离术。

结果：三组患者均成功地进行了双侧肺静脉前庭隔离术。肥胖组患者手术时间时间(85.6±18.5分钟)相比其他两组组使用时间长 (p=0.035)。肥胖组患者房颤导管射频消融术后有21名患者(39.5%)出现了早期复发，超重组有17名患者(19.8%)出现了早期复发，正常体重组有18名患者(19.6%)出现了早期复发。一年的随访期后，肥胖组患者房颤导管射频消融术后有19名患者(37 %)出现了晚期复发，超重组有10名患者(11.6%)出现了晚期复发，正常体重组有13名患者(14.1%)出现了晚期复发。Cox回归分析提示房颤消融后空白期早期复发(HR=2.156，95%CI:1.259-3.728,p=0.001),体重指数(HR=1.038，95%CI:1.009-1.067,p=0.011),左心房直径(HR=1.184,95%CI: 1.101-1.273,  p=0.010)，甘油三酯葡萄糖指数(HR=1.508，95%CI:1.924-2.461,p=0.025)和游离脂肪酸(HR=1.125, 95%CI:1.115-1.425, p=0.02）是房颤晚期复发的危险因素。围手术期均无严重并发症发生。

结论：相对于正常体重患者，肥胖患者行首次房颤射频消融术后早期复发率和晚期复发率明显升高,进一步控制体重有利于消融术后维持窦律。

关键词：肥胖；房颤导管消融；复发；体重指数

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

第五部分

 

缺血性和非缺血性心肌病合并室速患者消融电生理特征、消融策略及预后分析  

 

目的：评价缺血性心肌病与非缺血性心肌病的室性心动过速电生理特征与导管射频消融预后。

方法：回顾性分析自2019年6月至2021年5月在我院进行射频消融的29例器质性室速患者。术中若诱发出室速则采用传统的激动或者拖带标测，联合窦律下标测心室局部异常(LAVPs)电位进行补充消融；若电生理刺激不能够诱发出室速，则采用窦律下标测LAVPs电位结合起搏标测进行消融。研究终点为室性心动过速复发与死亡。  

结果：接受室速消融的29名器质性心脏病患者中，27名患者进行了心内膜标测，2名患者进行了心外膜标测。缺血性心肌病组标测到平均低电压面积(86±65cm² )明显大于非缺血性心肌病组(38±28cm² ,p=0.001)。同样，与非缺血性心肌病组患者相比，缺血性心肌病组的患者致密瘢痕区占据心室的面积比例更大(45 ± 35% vs 26± 15%；p =0.01)。术中11例缺血性心肌病，共有6例（54.5%）诱发出持续性室速，有4例（36.3%）病例诱发出临床室速。18例非缺血性心肌病，共有9例（50%）病例诱发出持续性室速。缺血性心肌病组诱发出的室速84.2%为折返相关室速，而非缺血性心肌病组诱发出的室速50%为折返相关室速.10例缺血性心肌病患者可以标测到LAVPs电位，10例非缺血性心肌病可以记录到LAVPs电位. 缺血性心肌病共5名患者采用了联合LVAPs电位+室速发作时拖带激动标测消融，其中1名患者消融后能够诱发出非临床发作室速，4名患者术中不能够诱发室速只采用基于窦律下LAVPs电位消融。非缺血性心肌病有9名患者诱发出室速，4名患者采用了联合LVAPs电位+室速发作时拖带激动标测消融，其中 2 名消融后能够诱发出非临床发作室速；5名患者不能够标测到LAVPs电位仅在室速发作采用激动标测消融，消融后1名患者能够诱发出非临床发作室速,1名患者因解剖困难消融失败。非缺血性心肌病有6名患者术中不能够诱发室速只采用基于窦律下LAVPs电位消融，5名患者LAVPs电位消融消失，1名患者LAVPs电位消融后下降. 所有患者于末次射频消融后随访，缺血性心肌病组有2例病例出现了室速，非缺血性心肌病组4例病例出现了室速复发，总体远期成功率为76%，缺血性心肌病总体远期成功率为 80%，非缺血性心肌病为 73.3%。

结论：缺血性心肌病和非缺血性心肌病室速有不同的电生理特征，缺血性心肌病相对非缺血性心肌病消融远期成功率高。

 

关键词：器质性心脏病；室速；射频消融；局部心室异常电位

Section I Clinical study of optimizing ablation sequence strategy of single pulmonary vein isolation in paroxysmal atrial fibrillation

 

Objective: The purpose of this study was to investigate whether optimizing ablation sequence of circumferential pulmonary vein (CPV) isolation had an effect on the acute pulmonary vein reconnection and long-term effect in patients with paroxysmal atrial fibrillation.

Method: One hundred consecutive patients with paroxysmal atrial fibrillation who underwent circumferential pulmonary vein isolation in our hospital from January 2013 to December 2016 were enrolled. The above patients were randomly divided into two groups: In the optimized ablation group, the anterior/posterior carina and the ridge between the left atrial (LA) appendage and the left pulmonary vein (LPV) were firstly ablated, and then other areas were ablated; In the conventional sequential ablation group, started from the site of right inferior PV and continuous circular lesions were created counter-clockwise. The primary end point was the recurrence of atrial tachyarrhythmia lasting more than 30 seconds during the 1-year follow-up period after the blank period after PV isolation. The secondary end points were operation time, X-ray exposure time and safety.

Results: 49 patients in the optimized ablation group and 48 patients in the sequential ablation group were for analysis. LA dwelling time was 81.2 ± 24.7 min in the optimized ablation group and 76.9 ± 16.4 min in the sequential group . X-ray exposure time were 4.2± 0.9 min in optimized group and 4.1± 0.6 min in sequential group, respectively. Eight patients in sequential group and nine patients in optimized group experienced acute PV reconnection, which clustered at the ridge between the LPV and the LAA, the roof of the left superior PV, left anterior and right posterior carina. During one-year follow up, 25 patients(25.7%)developed AF recurrence, 27.1% patients in the sequential group and 25.5% patients in the optimized group. There was no significant difference between the two groups (P = 0.77). Cox regression analysis indicated that acute PV reconnection had the potential to predict long-term recurrence, but without significant difference(HR:1.152, p=0.065).

Conclusion: Optimizing ablation sequence of pulmonary vein isolation did not show significant advantage during 1-year follow-up in this study, but it still needs to be further verified by large-sample randomized controlled studies.

 

Key word: Atrial fibrillation; Pulmonary vein isolation; Ablation sequence; Recurrence of atrial fibrillation

 

 

 

 

Section II   

An alternately energy source strategy for re-ablation of patients with recurrent atrial fibrillation—cryoballoon or radiofrequency current energy ablation.

 

Background: Pulmonary vein (PV) reconnection is the typical electrophysiological finding in the patients with recurrence of AF after index radiofrequency current energy or cryoballoon ablation. Which ablation technique is better for repeat ablation in patients with recurrent atrial fibrillation (AF) remains unclear. We aimed to investigate long-term efficacy of repeat ablation using an alternately energy source sequence for re-ablation of patients with recurrent atrial fibrillation

Method: A total of 156 patients with recurrent AF after index radiofrequency ablation or cryoballoon ablation from September 2016 to June 2021 received repeat ablation were enrolled into the study. Cryoballoon (CB) re-ablation for 96 patients with a failed index radiofrequency (RFC) ablation (RFC-CB- redo group); radiofrequency re- ablation for 60 patients with a failed index cryoballoon ablation (CB-RFC -redo group).

Results: Early recurrence rates of atrial fibrillation following initial ablation were equal(CB-RFC-redo group vs RFC-CB-redo group, 31.7% vs 27.1%，p=0.515). The number of reconnected PVs was significantly lower in the CB-RFC-redo group than the RFC- CB-redo group (1.50 ± 0.81vs 3.36 ± 0.95, p=0.01). More trigger foci of non pulmonary vein origin were found after index cryoablation than patients with index radiofrequency ablation. During the average follow-up of 10.7 ±2.41 months, 40 patients develop AF recurrence and the overall AF recurrence rate was 25.6% ((RFC-CB-redo:27.1% vs CB-RFC-redo:23.3%, P =0.594), there was no significant difference between the two groups. In the Cox multivariate analysis, AF type and early recurrence after the initial ablation were independent predictors of AF recurrence after re-ablation（HR=2.112, 95%CI:1.082-4.091，P=0.029；HR=2.421,95%CI:1.259-4.612，P=0.008）.

Conclusions: The extent and distribution of PV reconnection was different between patients who firstly underwent cryoballoon ablation and radiofrequency catheter ablation. Alternately energy source sequence strategy for re-ablation of patients with recurrent atrial fibrillation was safe and effective, with similar results regardless the technique used for initial procedure.

Keywords: AF Recurrence, Repeat Ablation, Cryoballoon, Radiofrequency Ablation, Alternate energy sequence ablation strategy.

 

Section III

The pre-ablation triglyceride-glucose index predicts late recurrence of atrial fibrillation after radiofrequency ablation in non-diabetic adults

 

Background: Current prognostic risk scoring systems and biomarkers have been routinely used as noninvasive methods for assessing late recurrence of atrial fibrillation (AF) in patients who have undergone radiofrequency catheter ablation (RFCA). This study aimed to investigate the predictive value of the triglyceride-glucose (TyG) index for late recurrence of AF after RFCA in non-diabetic patients.

Methods: A total of 275 patients with AF, who underwent RFCA at our hospital between January 2016 and December 2018, were enrolled. During follow up, patients were divided into late and non-late AF recurrence groups based on whether they had experienced late AF recurrence determined by electrocardiography (ECG) examine or 48 h Holter monitoring. The TyG index was calculated using the equation: ln [fasting triglycerides [mg/dL]×fasting glucose [mg/dL]/2].

Results: During a mean follow-up of 26.1±9.1 months, late AF recurrence event rates significantly increased in the highest TyG index tertile group (tertile 3) compared to those in the lowest TyG index tertile group (tertile 1) (54% versus 12%, respectively; p<0.001).The mean TyG index was higher in the late AF recurrence group than non- late AF recurrence group (9.42 ±0.6 versus 8.68 ±0.70, respectively; p<0.001). On multivariate Cox regression analysis, the pre-ablation TyG index was an independent risk factor for late recurrence of AF after RFCA (hazard ratio [HR]1.478 [95% confidence interval (CI): 1.130-1.942]; p=0.012). Receiver operating characteristic (ROC) curve analysis revealed that TyG index was a significant predictor of late AF recurrence after RFCA , at an area under the ROC curve (AUC) of 0.737 (95%CI:0.657-0.816;p<0.001) and that of left atrial diameter(LAD) was 0.780 (95%CI:0.703-0.857, p<0.001). Furthermore, TyG index was positively correlated with LAD (r=0.133, p=0.027), and high sensitivity C-reactive protein (r=0.132, p=0.028) and N-terminal pro b-type natriuretic peptide (r=0.291,p<0.001) levels.

Conclusions: Based on observations, an elevated pre-ablation TyG index was associated with an increased risk for late AF recurrence after RFCA in non-diabetic patients. The TyG index may be useful as a potentially novel biomarker for the risk stratification of late AF recurrence in non-diabetic patients.

Key words: Atrial fibrillation; triglyceride-glucose index; Biomarkers; Predictors of rhythm outcome; Catheter ablation.

 

 

                             Section IV

 

Effectiveness and prognosis of catheter ablation of atrial fibrillation in obese population

 

Objective: To evaluate the efficacy and prognosis of catheter ablation of atrial fibrillation in obese population.

Method: Patients with non valvular atrial fibrillation who received index radiofrequency catheter ablation in our hospital from January 2019 to December 2021 were enrolled. According to body mass index (BMI), they were divided into three groups: 92 in normal weight group (BMI: 18.5kg/m² to 25kg /m²), 86 in overweight group (BMI :25kg / m² to <30kg / m²) and 52 in obese group (BMI ≥ 30kg / m²).

Results: Patients in three groups underwent bilateral pulmonary vein isolation successfully. The operation time of obese patients (85.6± 18.5 minutes) was longer than that of the other two groups(P = 0.035). Early recurrence occurred in 21 patients (39.5%) in obese group, 17 patients (19.8%) in overweight group and 18 patients (19.6%) in normal weight group. After one-year follow-up , 19 patients (37%) in the obese group developed late recurrence after RFCA, 10 patients (11.6%) in the overweight group and 13 patients (14.1%) in the normal weight group developed late recurrence after RFCA. Cox regression analysis showed early recurrence after RFCA (HR = 2.156, 95% CI: 1.259-3.728, P = 0.001), body mass index (HR = 1.038, 95% CI: 1.009-1.067, P = 0.011), left atrial diameter (HR = 1.184, 95% CI: 1.101-1.273, P = 0.010), Triglyceride glucose index (HR = 1.508, 95% CI: 1.924-2.461, P = 0.025) and free fatty acids (HR = 1.125, 95% CI: 1.115-1.425, P = 0.02) were risk factors for late recurrence of atrial fibrillation. There were no serious complications during the perioperative period.

Conclusion: Compared with normal weight patients, the early recurrence rate and late recurrence rate of obese patients after first AF radiofrequency ablation were significantly higher. Body weight control is helpful to maintain sinus rhythm after ablation.

Key words: Obesity; Catheter ablation of atrial fibrillation; Recurrence; Body mass index

 

                     

 

 

 Section V

Electrophysiological characteristics，Ablation strategy and Outcome of Catheter Ablation Therapy for Ventricular Tachycardia in Ischemic and Nonischemic Cardiomyopathy

 

Objective: To evaluate electrophysiological characteristics of ventricular tachycardia(VT) and prognosis of radiofrequency catheter ablation in ischemic (ICM) and non-ischemic cardiomyopathy(NICM).

Method: 29 patients with organic heart disease (NICM, n = 18; ICM, n =11) referred for catheter ablation of ventricular tachycardia in our hospital from June 2019 to May 2021 were studied. If ventricular tachycardia was induced, activation or entrainment mapping was used, combined with elimination of local ventricular abnormal potential (LAVPs); If electrophysiological stimulation cannot induce ventricular tachycardia, elimination of local ventricular abnormal potential under sinus rhythm was performed. The end point was ventricular tachycardia recurrence and death.

Result: Of those 29 patients, 27 underwent endocardium mapping and 2 underwent epicardium mapping. The mean low voltage area measured in the ischemic cardiomyopathy group (86±65cm²) was significantly larger than that in non-ischemic cardiomyopathy group (38±28cm², p=0.001). Similarly, patients with ischemic cardiomyopathy had a greater proportion of the ventricular area occupied by dense scar areas (45 ± 35% vs. 26± 15%; P = 0.01). Of the 11 cases of ischemic cardiomyopathy, 6 cases (54.5%) induced sustained ventricular tachycardia and 4 cases (36.3%) induced clinical ventricular tachycardia. Sustained ventricular tachycardia was induced in 9 (50%) patients of non ischemic cardiomyopathy. 84.2% of ventricular tachycardia induced in ischemic cardiomyopathy group was reentry , while 50% of ventricular tachycardia induced in non ischemic cardiomyopathy group was reentry. LAVPs were recorded in 10 patients with ischemic cardiomyopathy and 10 patients with non-ischemic cardiomyopathy. A total of 5 patients with ischemic cardiomyopathy were treated with combined LAVPs potential elimination+ activation or entrainment mapping ablation during ventricular tachycardia . One patient was able to induce non -clinical ventricular tachycardia after ablation. Four patients with ICM were unable to induce ventricular tachycardia and were only performed with elimination of LAVPs under sinus rhythm. Ventricular tachycardia was induced in 9 NICM patients and 4 patients were treated with combined LAVPs potential elimination+ activation or entrainment mapping ablation during ventricular tachycardia, and two patients were able to induce non -clinical ventricular tachycardia after ablation. Five patients in the NICM group could not record LAVPs, and was ablated by activation mapping during ventricular tachycardia . After ablation, one patient in the NICM group could induce non clinical ventricular tachycardia and one patients failed due to anatomical difficulties. Six patients with NICM were unable to induce ventricular tachycardia and were only performed with elimination of LAVPs under sinus rhythm, LAVPs disappeared in 5 patients and reduced in 1 patients after ablation. All patients were followed up after ablation, ventricular tachycardia occurred in 2 cases in the ischemic cardiomyopathy group and 4 cases in the non-ischemic cardiomyopathy group. The total long-term success rate was 76% (80% in ICM and 73.3% in NICM).

Conclusions: For most organic heart disease patients with ventricular tachycardia , ischemic cardiomyopathy and non ischemic cardiomyopathy have different electrophysiological characteristics. The long-term success rate of ablation of VT in ischemic cardiomyopathy is higher than that of non ischemic cardiomyopathy.

Key Word: Organic heart disease; Ventricular tachycardia; Radiofrequency ablation; local ventricular abnormal potential.