心脏神经消融术对神经反射性缓慢性心律失常的治疗价值

The value of cardioneuroablation in the treatment of autonomic neuroreflex bradyarrhythmia

目的回顾性分析心脏神经消融术在治疗神经反射性缓慢性心律失常的有效性和安全性。方法入选2017年12月至2020年1月在中国医学科学院阜外医院心律失常中心行心脏神经消融术治疗的39例神经反射性缓慢性心律失常的患者。术前22例诊断为间歇性高度房室传导阻滞,7例诊断为窦性停搏,6例诊断为窦性心动过缓,3例患者同时有高度房室传导阻滞和窦性停搏,1例患者同时有窦性停搏和窦性心动过缓。术前通过直立倾斜试验及心率减速力(deceleration capacity,DC)证实患者存在迷走神经张力异常升高。经左心房心内膜途径完成左上神经节丛、左下神经节丛、右下神经节丛和右前神经节丛的消融。术后常规临床随访,每6个月复查1次12导联心电图和动态心电图。结果经过(30.6±23.5)个月的随访,8例患者有缓慢性心律失常的复发,术后心电图及动态心电图提示高度房室传导阻滞、窦性停搏和窦性心动过缓的患者例数较术前差异有统计学意义(8例对39例,P<0.0001)。术后12个月最低心率由(39.9±9.0)次/min升至(48.2±12.6)次/min(P=0.008),平均心率由(66.3±10.3)次/min升至(74.6±12.1)次/min(P=0.001);术后24个月最低心率由(40.4±9.0)次/min升至(50.8±10.0)次/min(P=0.001),平均心率由(64.3±8.6)次/min升至(70.8±12.0)次/min(P=0.047)。除2例患者存在局部穿刺点血肿,无其他手术并发症。结论心脏神经消融术可以安全有效地抑制自主神经失衡导致的间歇性窦性停搏、窦性心动过缓及高度房室传导阻滞。

Objective The purpose of the present study was to retrospectively analyze the efficacy and safety of cardioneuroablation in the treatment of autonomic neuroreflex bradyarrhythmia.Methods A total of 39 patients with autonomic neuroreflex bradyarrhythmia who underwent cardioneuroablation in Center of Arrhythmia,Fuwai Hospital from December 2017 to January 2020 were enrolled.Preoperatively,22 patients were diagnosed with intermittent advanced atrioventricular block,7 with sinus arrest,and 6 with sinus bradycardia,3 patients had both advanced atrioventricular block and sinus arrest,and 1 patient had both sinus arrest and sinus bradycardia.Preoperative upright tilt test and heart rate deceleration capacity(DC)confirmed that the patient had abnormal vagal tone.The 12-lead electrocardiogram and 24-hour Holter were reexamined every 6 months during clinical follow-up.Results During follow-up of(30.6±23.5)months,8 patients had recurrence of bradyarrhythmia.The number of patients with advanced atrioventricular block,sinus arrest and sinus bradycardia were significantly improved compared with those before cardioneuroablation(8 vs.39,P<0.0001).Twelve months after cardioneuroablation,the minimum heart rate increased from(39.9±9.0)bpm to(48.2±12.6)bpm(P=0.008),and the mean heart rate increased from(66.3±10.3)bpm to(74.6±12.1)bpm(P=0.001).Twenty-four months after cardioneuroablation,the minimum heart rate increased from(40.4±9.0)bpm to(50.8±10.0)bpm(P=0.001),and the mean heart rate increased from(64.3±8.6)bpm to(70.8±12.0)bpm(P=0.047).There were no other surgical complications except 2 patients with hematoma at the femoral venipuncture sites.Conclusion Cardioneuroablation can safely and effectively inhibit intermittent sinus arrest,sinus bradycardia and advanced atrioventricular block caused by autonomic nervous imbalance.