房颤肺静脉电隔离术中迷走神经反射的识别和处理

Identification and Treatment of Vasovagal Depression during Segmental Electrical Isolation of Pulmonary Veins

目的:分析心房颤动肺静脉电隔离术中血管迷走性神经反射导致心率、血压降低的临床特征,了解识别的要点和处理方法。方法:顽固性阵发性房颤患者90例(男性66例,女性24例,年龄38～72岁),在Lasso环状标测电极导管指导下行常规肺静脉射频导管消融电隔离治疗,术中行血氧饱和度和无创袖带血压监测,并密切观察患者的症状、体征。结果:发生迷走神经反射8例,迷走神经反射表现为窦性心动过缓和低血压者7例,其中3例因消融肺静脉诱发不能忍受的疼痛;单纯表现为心电监测PR间期延长者1例。心率减慢-低血压反应经静脉注射阿托品和多巴胺等治疗后好转。其中5例在行左上肺静脉消融时发生迷走神经反射,3例发生于消融其他肺静脉时。心包积血或心脏压塞3例,均经急诊床旁超声心动图检查确诊,1例行心包穿刺引流后好转,心包穿刺引流并外科开胸行左心耳修补术1例,观察1例,经保守治疗痊愈。平均随访29±10个月,无死亡病例。结论:房颤肺静脉电隔离术过程中,发生血管迷走性神经反射有多种临床表现,是良性过程,但易与心包积血或心脏压塞相混淆,准确判断、采取相应的治疗措施十分重要。

Objective：The purpose of this study was to investigate the clinical features of reflex bradycardia and hypotension response during segmental electrical isolation of pulmonary veins （PVI） in paroxysmal atrial fibrillation （AF） patients and how to identify and treat it. Methods：We studied 90 patients with paroxysmal AF （66 men, 38-72 years） who had undergone a successful PVI guided by Lasso mapping catheter. We routinely performed segmental PVI using thermo-control or irrigated RF catheter. The psymptom, saturation of blood oxygen and cuff blood pressure was monitored closely during the procedure. Resuits： 8 patients （9%） developed vasovagal depression during the procedure. 7 of 8 patients developed bradycardia-hypotension syndrome, 3 of 7 patients were induced by intolerant chest pain during RF application. 1 patient had transient 1 degree AV block. These patients made quick recovery by being treated with intravenous administration of atropine and dopamine. 5 of 8 patients developed vasovagal depression during left super pulmonary vein isolation. 3 of 90 patients developed cardiac tamponade. Urgent pericardial drainage was taken in 2 patients. 1 of 2 patients had surgery. 1 patient was treated with expectant treatment. Follow up （mean 29 ＋/-10 months） was complete and no patient died. Conclusion：Vasovagal depression has a variety of clinical features during RF catheter ablation of the pulmonary vein tissues. It can be confused with cardiac tamponade easily, suggesting that it might be very important to identify accurately and treat immediately.