冷冻球囊消融术中膈神经麻痹发生、治疗与预防

Occurrence,management and precautionary measures of phrenic nerve paralysis during cryoballoon ablation for atrial fibrillation

目的探讨冷冻球囊消融(CBA)治疗心房颤动(房颤)术中膈神经麻痹(PNP)的发生、处理及预防措施。方法回顾性分析沈阳军区总医院心血管内科自2013年12月至2017年6月行CBA的551例房颤患者的临床资料,记录并分析PNP的发生率及处理方法。结果本研究551例CBA房颤患者,6例发生PNP,发生率1.09%(6/551),其中,应用一代球囊2例(0.62%,2/322),应用二代球囊4例(1.75%,4/229)。PNP均发生在第1次冷冻右上肺静脉过程中,且均为应用28 mm冷冻球囊。3例温度达到-50℃^-40℃,3例温度<-50℃。从冷冻开始至PNP时间,除1例98 s外,其余均时间>100 s。两例PNP患者手术结束时均未恢复,予地塞米松10 mg静脉注射或甲基强的松龙40 mg静脉注射,术后口服维生素B1及维生素B12营养神经,分别于术后1个月及术后6个月胸闷、气短症状消失。结论 OBA治疗房颤时,严密监测膈肌运动情况,避免球囊过深,温度过低,膈神经损伤时及时停止消融,可有效避免PNP的发生。

Objective To investigate the occurrence,management and precautionary measures of phrenic nerve paralysis（PNP） during cryoballoon ablation（CBA） for atrial fibrillation.Methods A retrospective study was performed on 551 cases of patients with atrial fibrillation（AF） who were admitted and underwent CBA from December 2013 to June 2017,the occurrence rate and management of PNP were recorded and analyzed.Results In 551 cases of CBA patients,6 cases had PNP,the occurrence rate was 1.09%（6/551）,including 2 cases with first generation balloon（0.62%,2/322） and 4 cases with second generation balloon（1.75%,4/229）.PNP occurred in 6 patients who received CBA in RSPV for the first time with 28 mm cryoballoon.The lowest temperature reached-50℃ ^-40℃ in3 cases and below-50℃ in the other 3 cases.The time from initiation of ablation to occurrence of PNP was all more than 100 seconds except 1 case was in 98 seconds.PNP occurred in 2 cases and was not recovered after the ablation process.Dexamethasone 10 mg or methylprednisolone 40 mg was injected intravenously and vitamin B1 and vitamin B12 were taken orally for neurotrophy after the CBA therapy.The symptoms of chest distress and shortness of breath in the 2 cases disappeared 1 month and 6 months after CBA,respectively.Conclusion PNP during CBA for atrial fibrillation could be avoided effectively in case of monitoring diaphragm movement strictly,refraining the balloon from positioning too deeply,preventing the temperature decreasing too lowly and stopping the ablation as soon as the PNP occurred.