经右侧颈内静脉行右心室心内膜心肌活检的可行性及安全性探讨

Feasibility and safety of right ventricular endomyocardial biopsy via the right internal jugular vein approach

目的探讨经右侧颈内静脉行右心室心内膜心肌活检的可行性和安全性。方法该研究为回顾性描述性研究。以2014年12月至2020年6月在中国医学科学院阜外医院及北京协和医院接受心内膜心肌活检的患者为研究对象,这些患者初步临床诊断为疑诊心肌炎、心肌病、不明原因心力衰竭等,研究排除了冠心病患者。收集入选患者的一般临床资料,包括人口统计学资料(年龄、性别、身高、体重)、纽约心脏协会(NHYA)心功能分级、血N末端B型利钠肽原(NT-proBNP)水平、胸片、超声心动图、血流动力学指标等。所有患者均经右侧颈内静脉在X线透视、双体位引导下行右心室心内膜心肌活检。计算右心室心内膜心肌活检的成功率。观察患者心内膜心肌活检并发症的发生情况,主要并发症包括死亡、需要紧急心脏手术或高级生命支持、心包填塞需心包穿刺引流、永久性房室传导阻滞需安装永久起搏器等;次要并发症包括不需要心包穿刺的心包积液、暂时(持续<24 h)或永久的右束支传导阻滞、一过性莫氏Ⅱ型2∶1房室传导阻滞需要阿托品治疗或需安装临时起搏器、非持续≥10个QRS波的室性心动过速、持续<12 h心房颤动(房颤)或需要转复的房颤;其他并发症包括心内膜心肌活检后新出现的三尖瓣腱索断裂或反流。另外,分别观察操作第1、2和3年的术者操作后患者并发症的发生情况。结果研究共入选272例接受右心室心内膜心肌活检的患者,其中270例成功完成操作,成功率99.3%。入选患者的年龄(42.7±16.9)岁,其中男性164例(60.3%)。21例(7.7%)患者出现并发症,其中2例(0.7%)出现大量心包积液,属于主要并发症,均行心包穿刺引流后缓解;18例(6.6%)出现微量心包积液,1例(0.4%)三尖瓣前叶腱索断裂,均属于次要并发症。无患者出现死亡、需紧急心脏手术抢救或需要永久起搏器置入等严重并发症。术者进行右心室心内膜心肌活检操作后的第1、2、3年并发症发生率分别为9.3%(13/140)、7.8%(7/90)和2.4%(1/42)。结论经右侧颈内静脉入路X线引导下行右心室心内膜心肌活检安全、可行,且随着操作者熟练程度的提高其并发症发生率有降低的趋势。

Objective To evaluate the feasibility and safety of right ventricular endomyocardial biopsy(EMB)via the right internal jugular vein approach.Methods It was a retrospective and descriptive study.A total of 272 patients,who underwent right ventricular EMB from December 2014 to June 2020 in Fuwai Hospital and Peking Union Medical College Hospital were enrolled.The preliminary diagnosis included suspected myocarditis,myocardiopathy,unexplained heart failure etc after exclusion of coronary heart disease.Clinical characteristics including age,sex,height,weight,NYHA functional class,NT-proBNP,chest radiography,echocardiography,and hemodynamics parameters were collected at baseline.EMB was performed via right internal jugular vein approach under the biplane fluoroscopic guidance.Success rate was calculated in this study.Complications related to operation were recorded according the following definitions.Major complications included death,urgent cardiac surgery,advanced cardiac life support,pericardiocentesis in cardiac tamponade,permanent complete atrioventricular block requiring permanent pacing etc.Minor complications included pericardial effusion without pericardiocentesis,temporary(lasting less than 24 hours)or permanent right bundle-branch block,temporary Mobitz typeⅡatrioventricular block(AV block)with AV conduction 2∶1 requiring medical treatment with atropine,or additive temporary pacing,non-sustained ventricular tachycardia with long runs of more than 10 ventricular complexes,and an episode of atrial fibrillation lasting less than 12 hours or cardioversion of atrial fibrillation.Other complications included tricuspid anterior chorda rupture and new onset tricuspid regurgitation after EMB.Results In this study,right ventricular EMB were performed successfully in 270 patients,the total success rate was 99.3%(270/272),and EMB were failed in 2(0.7%)patients.Age of the enrolled patients was(42.7±16.9)years,and there were 164(60.3%)males.Major complication including cardiac tamponade requiring pericardiocentesis occurred in 2(0.7%)patients.Minor complications such as small amount pericardial effusion occurred in 18(6.6%)patients,tricuspid anterior chorda rupture occurred in 1(0.4%)patient.No patient died,or requiring permanent pacing,or requiring emergency cardiac surgery.The complication rate was 9.3%(13/140),7.8%(7/90),and 2.4%(1/42)in operators with 1,2,and 3 years′experience.Conclusions EMB via the right jugular vein approach under fluoroscopic guidance is a simple,safe and feasible procedure.The complication rates decrease significantly with increasing operator experience.