心房颤动无痛化消融的临床分析

Clinical characteristics and outcome comparison between atrial fibrillation patients underwent catheter ablation under general aesthesia or local anesthesia and sedation

目的比较止痛镇静与全身麻醉两种方式对心房颤动射频消融术临床效果的影响。 方法回顾性按顺序选取2014年1月至2015年12月于大连医科大学附属第一医院行导管射频消融手术的498例心房颤动患者，其中全身麻醉组220例，止痛镇静组278例。于术后1、3、6、9、12个月定期随访，出现心悸、胸闷症状时，立即于门诊行心电图检查。主要终点事件：术后3个月心电图或动态心电图记录的〉30 s的心房颤动、房性心动过速和心房扑动等房性心律失常。术后3个月定义为空白期。对两组患者手术时间、消融时间、透视时间、术中室上性心动过速检出率、手术成功率和严重并发症发生率等进行统计学分析。 结果两组患者年龄、性别、体重指数、合并症、左心室射血分数、左心房内径等一般临床资料比较差异均无统计学意义（P均〉0.05）。平均随访时间（356±92）d。两组患者手术时间[（117.8±51.7）min比（115.4±36.9）min，P＝0.791]、透视时间[（12.5±11.2）min比（10.4±10.2）min，P＝0.354]和消融时间[（40.1±12.9）min和（48.6±44.3） min，P＝0.482]差异均无统计学意义。全身麻醉组麻醉下房室结折返性心动过速（AVNRT）的检出率明显低于止痛镇静组[0比3.6%（10/278），P〈0.01]，但全身麻醉组患者清醒后再次行心内电生理检查，两组AVNRT检出率差异无统计学意义[3.2%（7/220）和3.6%（10/278），P＝0.311]。两组房室折返性心动过速（AVRT）检出率差异无统计学意义[0.9%（2/220）和0.7%（2/278），P＝0.841]。全身麻醉组术中迷走神经反射发生率较低[1.4%（3/220）和8.6%（24/278），P＝0.026]。两组患者手术成功率差异无统计学意义[77.9%（162/208）和79.9%（215/269），P＝0.818]。 结论全身麻醉下行房颤射频消融术，患者状态稳定，能保证手术顺利进行。全身麻醉或止痛镇静在手术并发症、术后房性心律失常复发率方面无明显差异，但全身麻醉下房室结折返性心动过速检出率下降。

ObjectiveTo compare the outcome of radiofrequency catheter ablation under local anesthesia/sedation （S） or general anesthesia（GA） in atrial fibrillation patients. MethodsData of 498 patients with atrial fibrillation undergoing radiofrequency catheter ablation in our departmentfrom January 2014 to December 2015 were retrospectively analyzed. Two hundred and twenty patients assigned to the GA group, the other 278 patients to the S group. Patients were followed clinically every 3 months within one year after procedure. Immediate electrocardiogram was performed in patients with palpitation or choking sensation in chest. The end point of the study was recurrence of any atrial tachyarrhythmia lasting 〉30 seconds in device interrogation, 24-hour Holter monitoring or 12-lead electrocardiogram after a single procedure. After the ablation procedure, a blanking period of 3 months was allowed according to the guidelines. Procedure time, radiofrequency time, fluoroscopy time, the detection of paroxysmal supraventricular tachycardia, the success rate and the complications were compared between the two groups. ResultsThere was no difference in the baseline characteristics between the two groups, such as age, gender, BMI, complications, LVEF, LAD （all P〉0.05）. The duration of procedure （（117.8±51.7）minutes vs.（115.4±36.9）minutes, P=0.79）, duration of fluoroscopy（（12.5±11.2）minutes vs. （10.4±10.2）minutes, P=0.35）, duration of radiofrequency（（40.1±12.9）minutes vs. （48.6±44.3）minutes, P=0.48） were similar between the two groups （P〉0.05）. Compared with S group, discovery of the frequency of atrioventricular node reentrant tachycardia （AVNRT） was significantly lower in GA group （0 vs. 3.6%（10/278）, P〈0.01）, but the difference disappeared with repeat electrophysiological examination when patients become conscious from GA（3.2%（7/220） vs. 3.6%（10/278）, P=0.311）. The difference of atrioventricular reentrant tachycardia （AVRT） was similar between the two groups（0.9%（2/220） vs. 0.7%（2/278）, P=0.841）. Compared with S group, reflection of vagus nerve was less in GA group （1.4%（3/220） vs. 8.6%（24/278）, P=0.026）. After following up of （356±92） days, freedom from atrial fibrillation/atrial flutter/atrial tachyarrhythmia was similar between the two groups（77.9%（162/208） vs. 79.9%（215/269）, P=0.818）. ConclusionGeneral anesthesia is a promising method to atrial fibrillation ablation, in view of stable patient status and safety for the procedure. There is no difference in complications, recurrence of arrhythmia between the two groups, but detection rate of AVNRT is lower in GA group.