迷走神经反射对心房颤动消融效果的预测作用

Predictive role of vagal reflex in outcomes after atrial fibrillation ablation

目的对比研究迷走反射阳性与阴性患者心房颤动（AF）的消融效果，分析可能的机制。方法入选209例AF患者进行射频消融，术中标测103例为迷走反射阳性，106例迷走反射阴性。其中男性63例，女性146例；年龄24～77（534-10）岁。术前纽约心脏联合会（NYHA）心功能分级Ⅲ级或Ⅳ级144例。AF病史（36±43）个月。随访6～34（18．9±9．0）个月。结果全组无手术死亡，两组术后并发症无统计学差异。Kaplan．Meier曲线分析，非AF心律为60．8％，迷走反射阳性组和迷走反射阴性组分别为68．2％和53-3％（P=0．0004）。Cox回归分析发现，迷走反射是除左房大小外AF复发的又一预测因子（Wald=9．71，P=0．002，95％CI：0．081～0．563）。左房大小和迷走反射有交互作用（Wald：4．45，P=0．035，95％CI：0．965～0．999），迷走反射阴性组中左房〉70mm的比例大于迷走反射阳性组（48．1％vs30．1％，P=0．008）。结论迷走神经在持续性AF的维持中起重要作用，去神经化能提高AF转复率；迷走反射是除左房大小外AF复发的又一预测因子；迷走反射阳性与左房大小显著相关，迷走反射阳性组的左房小于阴性组。

Objective To compare the outcome of ablation of atrial fibrillation （AF） between ganglionated plexi （GP） positive and negative and investigate the possible underlying mechanism. Methods Between September 2007 and May 2009, 209 patients （63 males and 146 females） with age of （53± 10） （ranging from 24 to 77） years undergoing radiofrequency ablation for AF in our hospital were enrolled in this study. Intraoperative high-frequency stimulation showed that positive vagal reflex was seen in 103 patients and negative in 106 patients. Their average history of AF was （36± 43） months. Preoperatively, 144 patients （68.9%） were in New York Heart Association （NYHA） functional class Ⅲ or IV. They were followed up for （18.9 ± 9.0） （ranging from 6 to 34） months. Results There was no in-hospital death, and no significant difference in mortality or incidence of complications between the 2 groups during the postoperative or follow-up period. The Kaplan-Meier survival curve indicated that 60.8% of patients had freedom from AF, with a higher percentage in the patients with positive vagal reflex than those with negatives （68.2% vs 53.3%, P = 0.0004）. Cox analyses identified positive vagal reflex as another predictor of late recurrence of AF besides left atrium size （Wald = 9.71, P = 0.002, 95% CI： 0.081 to 0.563]. ）. Vagal reflex and left atrium size were 2 predictors affecting each other （Wald = 4.45, P= 0.035, 95% CI： 0.965 to 0.999）. There were more patients with left atrial dimension 〉 70mm in the patients with negative vagal reflex than in those with positives （48.1% vs 30.1%, P = 0.008）. Conclusion Vagal reflex plays an important role in the maintenance of AF, and denervation will improve converting AF to a normal rhythm. Vagal reflex is another predictor of late recurrence of AF besides left atrium size, and is significantly correlated with the latter. The left atrium size is smaller in patients with positive vagal reflex than in those with negatives.