改良房间隔穿刺术学习曲线研究

The learning process of transseptal puncture using a modified technique

目的 评价初学者应用改良的房间隔穿刺术的学习曲线.方法 改良的房间隔穿刺术仅应用冠状静脉窦导管作为解剖标志即可完成房间隔穿刺.选择2011年5月至2011年12月阜外心血管病医院心律失常中心的房颤患者120例.3名既往无房间隔穿刺经验的初学者各接受30例穿刺培训,1名经验丰富的培训者完成30例房间隔穿刺作为对照组.分析下列参数：1针穿刺成功率、总操作时间、透视时间和操作过程中放射剂量.应用曲线拟合统计方法分析学习曲线重要参数（平均初始穿刺时间、平均学习平台穿刺时间和平均学习率）.结果 初学者的1针穿刺成功率为82.2％ （74/90）,第2针穿刺成功率12.2％（11/90）,5例患者穿刺失败.平均初始穿刺时间（4.1±0.8）min,平均学习平台穿刺时间（1.2±0.2）min.穿刺时间平均学习率（25±3）例.初学者房间隔穿刺学习曲线的重要参数可以通过反向拟合曲线统计方法计算得出.结论 对于初学者,改良的房间隔穿刺技术是一项简单、易学、经济和有效的培训和学习方法.基于本研究结果,初学者通过29例房间隔穿刺操作可以通过学习曲线的陡直区域,基本掌握房间隔穿刺技术.

Objective Our laboratory adopted a modified technique which uses only coronary sinus catheter as the landmark to accomplishing trasseptal （TS） punctures under fluoroscopy.The aim of this study was prospectively to evaluate the training and learning process for TS puncture guided by this modified technique.Methods Guided by the training protocol,transseptal puncture was performed in 120 consecutive patients by 3 trainees without previous personal experience in transseptal catheterization and one experienced trainer as a controller.We analyzed the following parameters：one puncture success rate,total procedure time,fluoroscopic time,and radiation dose.The learning curve was analyzed using curve-fitting methodology.Results The first attempt at transseptal crossing was successful in 74（82.2%）,a second attempt was successful in 11 （12.2%）,the interatrial septal puncture was failed in 5 patients finally.The average starting process time was（4.1±0.8）min,and the estimated mean learning plateau was（1.2 ±0.2）min.The estimated mean learning rate for process time was（25±3）cases.Important aspects of learning curve can be estimated by fitting inverse curves for TS puncture.Conclusion This study demonstrated that this technique was a simple,safe,economic and effective approach for learning of transseptal puncture.Base on the statistical analysis,approximately 29 transseptal punctures will be needed for trainee to pass the steepest area of learning curve.