心律失常导管消融治疗中并发心包填塞的识别及处理

Diagnosis and Management of Periprocedural Cardiac Tamponade in Patients With Cardiac Arrhythmias Undergoing Catheter Ablation Intervention

目的:总结心律失常导管消融治疗中并发心包填塞的识别及处理方法。方法:回顾性分析我院1999年12月至2017年12月连续完成的12 959例心律失常导管消融患者并发心包填塞30例患者[其中男性17例,女性13例,平均年龄(59.5±9.7)岁]的临床特点、诊断及处理方法。结果:(1)12 959例心律失常导管消融患者并发心包填塞30例,发生率0.2%;其中心房颤动(房颤)消融并发心包填塞19例,左侧旁路消融并发心包填塞6例,右心室流出道室性早搏消融并发心包填塞5例。(2)29例(96.7%)为在导管室诊断的早发心包填塞,1例(3.3%)为术后1小时发生的延迟心包填塞。(3)首诊早发心包填塞的临床表现包括主诉胸闷、胸痛2例;术中血压、心率异常11例。X线胸片显示:心影搏动减弱或消失12例;穿刺房间隔出现造影剂渗漏2例;射频消融过程中出现爆裂音2例。(4)2例患者接受药物保守治疗,其余28例均行心包穿刺引流术。共4例患者接受外科开胸手术。全部抢救成功。结论:早期识别心包填塞的临床表现,及早实施心包穿刺引流,必要时外科开胸手术是抢救成功的关键。

Objectives: To summarize the clinical experience on the diagnosis and management of periprocedural cardiac tamponade in patients with cardiac arrhythmias undergoing catheter ablation intervention.Methods: The clinical characteristics, diagnosis and management of 30 patients with cardiac tamponade complications during perioperative period of catheter ablation in our center between December 1999 and December 2017 were analyzed retrospectively.Results: Among the 12 959 consecutive patients with cardiac arrhythmias who underwent catheter ablation in our center between December 1999 and December 2017, 30 patients were suffered from cardiac tamponade and the occurrence rate was0.2%(30/12 959). Nineteen patients underwent catheter ablation for atrial fibrillation, 6 for left accessory pathway and 5 for right ventricular outflow tract ventricular premature. Twenty-nine(96.7%)cases were diagnosed as early cardiac tamponade in the catheterization laboratory. The initial clinical manifestation was presented as chest distress and chest pain in 2 cases,abnormal blood pressure and heart rate in 11 cases, decreasing or disappearing of podoid beat under fluorography in 12 cases,leakage of contrast medium observed during atrial septostomy in 2 cases and audible "steam-pops" during ablation in 2 cases.One case(3.3%) was diagnosed as delayed cardiac tamponade at 1 h post-procedural. Conservative medication was given to 2 patients and pericardiocentesis was performed in the remaining 28 patients. Four patients required further cardiac surgery. All patients were recovered successfully.Conclusions: The key points for successful treatment of cardiac tamponade include early identification of clinical manifestation suggestive of cardiac tamponade, timely pericardiocentesis and readily accessible surgical intervention if necessary.