左心耳峰值流速对肺静脉隔离术后成功维持窦性心律的预测价值

Predictive value of left atrial appendage emptying peak flow velocity for successful maintenance of sinus rhythm after pulmonary vein isolation

目的评估接受肺静脉隔离术的心房颤动(房颤)患者,术前临床特征和超声心动图参数,尤其是左心耳峰值流速(left atrial appendage emptying peak flow velocity,LAAEV)对术后成功维持窦性心律的预测价值。方法纳入2018年1月至2019年1月就诊于武汉亚洲心脏病医院房颤中心的房颤患者共362例,术后随访1年。临床终点事件为房颤复发。使用Logistic回归分析评估窦性心律至少成功维持一年的独立预测因素。使用受试者工作特征(receiver operating characteristic,ROC)曲线评估LAAEV、左心房直径、房颤持续时间对窦性心律至少成功维持一年的诊断价值。结果术后成功维持窦性心律的患者(n=252)和房颤复发的患者(n=110)比较,术前LAAEV更高[(40.8±16.5)cm/s vs.(22.3±10.9 cm/s),P<0.001],左心房直径更小[(42.5±5.1)mm vs.(54.7±6.6)mm,P=0.001],房颤持续时间更短[(11.2±5.7)个月vs.(21.7±6.3)个月,P=0.001],阵发性房颤更多见(77.8%vs.25.5%,P<0.001),而与接受肺静脉隔离术的手术方式无关(P=0.414)。术后复查超声心动图,成功维持窦性心律的患者,左心房直径更小[(30.6±6.4)mm vs.(43.7±5.2)mm,P=0.001],LAAEV更高[(49.4±20.3)cm/s vs.(30.7±19.3)cm/s,P<0.001]。多元Logistic回归分析显示,术前LAAEV>40 cm/s(OR=8.716,95%CI:5.243-14.490,P<0.001),左心房直径<44 m(OR=3.046,95%CI:1.905-4.870,P<0.001),房颤持续时间<15个月(OR=2.535,95%CI:1.602-4.010,P<0.001),是术后窦性心律能成功维持的独立预测因素,敏感性分别是82.1%、74.6%、67.1%;特异性分别是65.5%、50.9%、55.5%;阳性预测值分别是84.5%、77.7%、77.5%;阴性预测值分别是61.5%、46.7%、42.4%;ROC曲线下面积分别是0.738、0.628、0.613。结论接受肺静脉隔离术的房颤患者,术前LAAEV、左心房直径、房颤持续时间是术后窦性心律能否成功维持的独立预测因素。其中,LAAEV>40 cm/s的预测价值最大。

Objectives To evaluate the predictive value of preoperative clinical features and echocardiographic parame⁃ters,especially the left atrial appendage emptyingpeak flow velocity(LAAEV),in patients with atrial fibrillation(AF)undergoing pulmonary vein isolation for successful maintenance of sinus rhythm.Methods A total of 362 patients with AF were included from January 2018 to January 2019 in the AF center of Wuhan Asian Heart Hospital which were followed up for one year.The clinical end point was recurrence of AF.Logistic regression analysis was used to evaluate the independent predictors of successful maintenance of sinus rhythm for at least one year.Receiver operating characteristic(ROC)curve was used to evaluate the diagnostic value of LAAEV,left atrial diameter and duration of atrial fibrillation for successful maintenance of sinus rhythm for at least one year.Results Before operation,the patients with successful maintenance of sinus rhythm(252 cases)were compared with those with recurrence of AF(110 cases),LAAEVof those with successful maintenance of sinus rhythm was higher[(40.8±16.5)cm/s vs.(22.3±10.9)cm/s,P<0.001],left atrial diameter was smaller[(42.5±5.1)mm vs.(54.7±6.6)mm,P=0.001],duration of AF was shorter[(11.2±5.7)months vs.(21.7±6.3)months,P=0.001],paroxysmal atrial fibrillation was more common(77.8%vs.25.5%,P<0.001),but there was not related to the methods of pulmonary vein isolation(P=0.414).After operation,compared with those with recurrence of AF,left atrial diameter was smaller[(30.6±6.4)mm vs.(43.7±5.2)mm,P=0.001],LAAEV was higher[(49.4±20.3)cm/s vs.(30.7±19.3)cm/s,P<0.001]in patients with successful maintenance of sinus rhythm.Multivariate Logistic regression analysis showed that LAAEV>40 cm/s(OR=8.716,95%CI:5.243-14.490,P<0.001),left atrial diameter<44 m(OR=3.046,95%CI:1.905-4.870,P<0.001),duration of AF<15 months(OR=2.535,95%CI:1.602-4.010,P<0.001),were independent predictors of successful maintenance of sinus rhythm,sensitivities of which were 82.1%,74.6%,67.1%respectively;specificities of which were 65.5%,50.9%,55.5%respectively;positive predictive values of which were 84.5%,77.7%,77.5%respectively;negative predictive values of which were 61.5%,46.7%,42.4%respectively;the areas under ROC curve were 0.738,0.628 and 0.613 respectively.Conclusions LAAEV,left atrium diameter and duration of AF before operation are independent predictors of successful maintenance of sinus rhythm in patients with AF undergoing pulmonary vein isolation,among which,LAAEV>40 cm/s is the most valuable.