心房颤动射频消融术后心包积液的处理及危险因素分析

Incidence, risk factors and management of pericardial effusion post radiofrequency catheter ablation in patients with atrial fibrillations

目的探讨心房颤动（房颤）患者导管射频消融术后发生心包积液的处理并分析其相关危险因素。方法156例房颤患者[男108例，女48例，阵发性房颤114例，平均年龄（57．6±11．3）岁]在三维标测系统及环状标测电极导管指导下行射频消融治疗[包括环肺静脉电隔离、线性消融及（或）碎裂电位消融]，记录消融过程、部位、时间等因素，对术后证实出现心包积液的患者根据不同情况（心脏压塞或单纯心包积液）进行不同处理，并门诊随访心脏超声等。对可能影响术后出现单纯心包积液的因素进行分析。结果所有156例患者均完成肺静脉电隔离，共有16例（10．3％）出现心包积液，其中1例（0．6％）术后即刻出现心脏压塞，予心包穿刺后开胸探查抢救好转，随访18个月无特殊；另15例（9．6％）术后出现少量心包积液但无心脏压塞表现（单纯心包积液组），经保守治疗后好转，其中6例患者的心包积液在术后3个月消失，而另外9例则在术后6个月消失。单因素分析发现，单纯心包积液组与无心包积液组在性别组成（P〈0．01）、有无行冠状静脉窦消融（P=0．026）、有无行碎裂电位消融（P=0．037）、有无行上腔静脉消融（P=0．041）等方面差异有统计学意义。Logistic多因素回归分析发现，女性[β=3．594，exp（b）=36．4，95％CI：4．2—312．1。P=0．001]、行冠状静脉窦消融[β=2．419，exp（b）=11．2，95％CI：1．0—124．6，P=0．049]是术后出现单纯心包积液的独立危险因素。结论房颤射频消融术后心包积液的发生率较高，但绝大部分并不出现心脏压塞，可经保守治疗得到改善，而不需要进一步有创治疗。女性及行冠状静脉窦消融是术后出现单纯心包积液的独立危险因素，房颤射频消融时应谨慎对待该部位的消融，以减少术后心包积液的发生。

Objective Pericardial effusion （PE） is a major complication of atrial fibrillation ablation （AFB）. We analyzed the incidence, risk factors and managements of PE post AFB （radiofrequency catheter ablation）. Methods A total of 156 consecutive patients with AF [ male 108, paroxysmal AF 114, （57. 6 ± 11.3 ） years ], who underwent AFB guided by a three-dimensional mapping system （CARTO or CARTO-Merge, Biosense-Webster Inc. , Diamond Bar, California） and a circular mapping catheter （Lasso, Biosense-Webster Inc., Diamond Bar, California）, were included in this study. The ablation strategy included circumferential pulmonary veins isolation （ CPVI）, linear ablation and/or complex fractionated atrial electrograms （CFAEs） ablation. Electrophysiological data and vital signs of patients were recorded by a multiple physiological recorder （Prucka, GE Medical Systems） during ablation. Ablation process, sites, duration and other related factors were also recorded. Echocardiography and other examinations were performed for diagnosing and monitoring PE. Results CPVI were achieved in all 156 patients. Incidence of PE was 10. 3% （16/156） post AFB. One patient developed acute cardiac tamponade and emergency drainage of the pericardial effusion was performed through a median sternotomy and patient recovered without complications during the 18 months follow-up. The rest 15 PE patients with small PE received outpatient care and no invasive treatment was needed and PE disappeared after 3 months in 6 patients and after 6 months in 9 patients. Univariate analysis showed that the composition of gender （P 〈0.01 ）, ablation in coronary sinus （ CS, P = 0. 026）, ablation of CFAEs （ P = 0. 037 ） and superior vena cava （ SVC, P = 0. 041 ） were risk factors for PE. Logistic regression analysis showed that female gender [ β =3. 594, exp （b） =36. 4, 95% confidence interval （CI） ：4. 2 - 312. 1, P = 0. 001 ] and ablation in CS [ β = 2. 419, exp （b） = 11.2, 95% CI： 1.0 - 124. 6, P =0. 049] were independent risk factors for PE post AFB. Conclusions PE is a common complication of AFB, female gender and ablation in CS were independent risk factors for PE. Most PE patients experienced spontaneous recovery but emergency treatment was needed for patient with cardiac tamponade.