冷冻球囊消融治疗阵发性心房颤动过程中肺静脉消融顺序对术中迷走神经反射的影响

Influence of pulmonary vein ablation sequences on vagal reflex during cryoballoon ablation of paroxysmal atrial fibrillation

目的阐述冷冻球囊消融阵发性心房颤动(房颤)过程中,改变左、右侧肺静脉消融顺序对术中迷走神经反射发生率的影响。方法连续入选北部战区总医院心内科2017年1月~2017年5月应用第二代冷冻球囊消融的阵发性房颤患者90例,按入选时间顺序将患者依次分为对照组(以左上肺静脉为初始消融组,56例)和实验组(以右上肺静脉为初始消融组,34例)。对照组行冷冻消融时,首先行左侧肺静脉冷冻消融治疗,再行右侧肺静脉冷冻消融;实验组首先行右侧肺静脉冷冻消融,后对左侧肺静脉冷冻消融。两组术中均记录迷走神经反射发生情况。比较两组患者的基线资料、术前基础心率、术中参数(冷冻消融时间、冷冻次数)及迷走神经反射(窦性心动过缓、窦性停搏以及房室传导阻滞)发生情况。结果实验组与对照组患者在合并高血压、糖尿病、脑梗死、左心房内径、心功能等方面差异均无统计学意义。两组手术时间、X线曝光时间、曝光量均差异无统计学意义。两组患者在术前基线心率及术后心率变化也差异无统计学意义。对照组于术中消融左上肺静脉后球囊复温过程中出现迷走神经反射15例,实验组1例首先消融右侧肺静脉,后于首次消融左上肺静脉后、球囊复温过程中出现迷走神经反射。两组间迷走神经反射的发生率存在差异有统计学意义(26.8%对2.94%,P=0.004)。结论冷冻球囊消融治疗阵发性房颤过程中,首先对左上肺静脉进行消融常可引起迷走神经反射;然而首先对右上肺静脉进行消融,可以显著减少消融左上肺静脉时迷走神经反射的发生。

Objective To evaluate the influence of changing pulmonary vein(PV)ablation sequences from left PV to right PV on vagal reflex during cryoballoon ablation of paroxysmal atrial fibrillation(AF).Methods A total of 90 patients with paroxysmal AF underwent the second generation cryoballoon ablation were enrolled in General Hospital of Northern Theater Command from January 2017 to May 2017.The first 56 patients were Group A,in which left superior PV(LSPV)was ablated first,followed by right PV ablation.The other 34 patients were Group B,in which right superior PV(RSPV)was initially ablated,followed by left PV ablation.Vagal reflex occurred was monitored and recorded in all patients in two groups.Baseline data,preoperative baseline heart rate,intraoperative parameters(ablation time and times)and intraoperative vagal reflex(sinus bradycardia,sinus arrest,atrioventricular block)were compared between the two groups.Results There was no significant difference between the two groups in the aspects of hypertension,diabetes,cerebral infarction,left atrium diameter,heart function,operation time,X-ray exposure time,exposure amount,baseline heart rate and postoperative heart rate.During operation,vagal reflex occurred after rewarming in LSPV in 15 of the 56(26.8%)cases in Group A.In contrast,vagal reflex occurred in only 1 of the 34(2.9%)patients in Group B after rewarming in LSPV(P=0.004).Conclusion In the process of cryoballoon ablation for paroxysmal atrial fibrillation,LSPV ablation first often lead to vagal reflex.Initial RSPV ablation could significantly reduce the incidence of vagal reflex.