射频消融治疗阵发性心房颤动伴长间歇患者的长期随访研究

Long-term outcome of catheter ablation for paroxysmal atrial fibrillation in patients with prolonged post-conversion pauses

目的 随访射频消融治疗阵发性心房颤动（房颤）伴长间歇的临床转归.方法 2006年5月至2008年9月共入选18例（男12例,女6例）阵发性房颤伴发作终止时窦性停搏≥3 s的患者,年龄37～72（56.8±11.7）岁,病程2～276（69.6±71.3）个月.所有患者均有房颤终止时窦性停搏≥3 s的临床资料,平均长RR间期3.1～8.0（4.5±1.6）s,部分患者伴有黑矇、晕厥先兆或者晕厥症状.首次消融患者,在三维标测系统指导下行肺静脉前庭隔离术达到肺静脉-左心房电学隔离；术后常规程序刺激诱发,若合并室上性心律失常或者非肺静脉触发灶,同时消融.术前,术后3d,1、3、6个月分别常规检查动态心电图,检测心率变异性（HRV）指标.结果 18例患者共进行了27次消融,8例1次手术成功,5例行2次手术,2例行3次手术,3例复发未再行手术治疗.首次消融术中,3例诱发典型心房扑动,同时行后位峡部消融,达到双向阻滞；3例术中出现显性去迷走[血压＜ 90/60 mm Hg（1 mm Hg=0.133 kPa）,心率＜60次/min].10例复发患者中,1例合并左心房后壁的局灶房颤,第3次消融时成功.平均随访（34.1±7.5）个月,术后2例发生窦性心动过速；3例房颤复发,其中1例为起搏器植入术后,1例房颤复发患者终止后有10.4 s的长间歇,植入单腔起搏器,另外1例房颤复发但无症状,未作特殊处理,临床密切随访.共12例完成6个月动态心电图随访的患者符合分析要求.术前反应迷走神经功能的HRV指标相邻RR间期差的均方根（rMSSD）,RR间期平均值的标准差（SDNN）,高频（HF）,低频（LF）/HF分别为（42.0±11.1）ms,（136.0±24.9）ms,12.5±3.9,1.32±0.26.术后随访发现其指标均下降并持续至少3个月,但在6个月时恢复.结论 房颤发作时能够抑制窦房结功能,导致长间歇；射频消融治疗祛除房颤这一原始因素后,窦房结功能常有一定程度的恢复.

Objective Whether sinus node dysfunction can be completely reversible after ablation treatment in patients with prolonged sinus pauses immediately following the termination of atrial fibrillation （AF） is not sufficiently understood.Methods Eighteen patients （12 men,mean age 56.8 years） with paroxysmal atrial fibrillation （PAF） and prolonged sinus pauses （≥3 s） on termination of AF were included in this study.Circumferential pulmonary vein antrum isolation was performed guided by a 3 D mapping system.Aggressive high right atrium programmed stimulation and burst pacing were performed before and after isoproterenol infusion.Additional ablation was performed if other trigger foci were found or other sustained tachycardias could be induced.Sinus node function was assessed by 24 h ambulatory monitoring 3 days,and 1,3,6 months post-ablation.Results Total 27 ablations were performed in all patients.During （34.1 ±-7.5）months of follow-up,15 patients had no recurrence and no symptoms attributable to bradycardia or sinus pauses after last ablation,the remaining three patients with recurrence of AF refused repeat procedure.Attenuation of heart rate variability was detected for up to 3 months,but returned to pre-ablation levels by 6 months in the 12 patients who were suitable for analysis.Conclusion Transient sinus node dysfunction caused by PAF suppression is reversible when AF is cured by catheter ablation.