心腔内超声心动图在心房颤动射频消融联合左心耳封堵术中的应用

Application of intracardiac echocardiography in atrial fibrillation radiofrequency ablation combined with left atrial appendage occlusion: XR-STAR technique

目的探讨应用心腔内超声心动图(ICE)模拟传统经食管超声心动图(TEE)各角度影像并替代TEE进行心房颤动(房颤)射频消融联合左心耳封堵手术(一站式)的新术式——XR-Star术式的有效性及安全性。方法本研究为前瞻性研究,顺序入选2018年4月至2021年4月于河北医科大学第二医院心内一科接受一站式手术的非瓣膜性房颤患者,应用倾向性评分进行1∶2匹配,分别接受XR-Star术式(ICE组)和传统的TEE辅助方式(TEE组)的治疗。比较两组患者术中参数(如手术时间、曝光量等)及术后1年随访中残余分流(PDL)、封堵器相关血栓、封堵器移位及复发等情况的差异。结果共纳入165例患者,其中ICE组46例,年龄(63.70±7.16)岁,男26例;TEE组92例,年龄(63.27±7.81)岁,男49例。①两组患者首次选伞成功率差异无统计学意义(84.78%对91.30%,P=0.284)。②与TEE组相比,ICE组的总手术时间[(160.62±23.20)min对(177.72±19.53)min,P<0.001],总曝光量[(172.84±46.49)mGy对(253.98±99.76)mGy,P<0.001]、封堵时间[(36.03±11.37)min对(47.60±15.56)min,P=0.001]、封堵曝光量[(124.85±41.01)mGy对(198.83±84.57)mGy,P<0.001]、造影剂用量[(100.00±26.52)ml对(152.26±49.70)ml,P<0.001]均明显低于TEE组。③与术前TEE各个角度测量值相比,术中ICE测量左心耳开口在135°较大[(21.32±3.42)mm对(19.26±4.01)mm,P=0.027]。ICE 135°与透视下左心耳测量值显著相关(Person相关系数r=0.83,双尾检验P<0.0001)。④PDL发生率,两组在封堵后即刻及术后3个月差异无统计学意义(10.87%对14.13%,P=0.592;19.56%对22.83%,P=0.661);术后3个月ICE组有1例存在3 mm PDL,TEE组有3例存在(3.2±0.3)mm PDL;术后1年ICE组PDL下降至1.8 mm,TEE组仍有1例存在3 mm PDL。⑤两组患者均未发生心包积液、脑卒中、大出血、器械脱位等严重并发症,TEE组1例患者发现器械相关血栓。结论基于XR-Star术式ICE引导下的一站式手术是安全有效的,与传统TEE相比可以明显减少手术时间、曝光量,其左心耳开口测量结果与透视下测量结果高度相关,术后残余分流方面无明显差异。

Objective To explore the effectiveness and safety of intracardiac echocardiography(ICE)guidance of combined catheter ablation and left atrial appendage occlusion(LAAO,one-stop procedure)for atrial fibrillation(AF)to simulate and replace traditional transesophageal echocardiography(TEE)image.Methods In this prospective study,patients with non-valvular atrial fibrillation(NVAF)in The First Department of Cardiology,The Second Hospital of Hebei Medical University from April 2018 to April 2021 who received one-stop procedure were sequentially enrolled,and matched with a propensity score of 1∶2,respectively receiving XR-Star technique(ICE group)and traditional TEE assisted treatment(TEE group).The differences in intraoperative parameters(such as procedure time,fluoroscopy radiation dose,etc.),peridevice leakage(PDL),device-related thrombosis,device displacement and recurrence in 1-year follow-up were compared between the two groups.Results A total of 165 patients were included,46 in the ICE group,aged(63.70±7.16)years,26 males;and 92 patients in TEE group,aged(63.27±7.81)years,49 males.①There was no significant difference in successful rate of first device chosen between the two groups(84.78%vs.91.30%,P=0.284).②Compared with TEE group,the total procedure time of ICE group[(160.62±23.20)min vs.(177.72±19.53)min,P<0.001],fluoroscopy radiation dose[(172.84±46.49)mGy vs.(253.98±99.76)mGy,P<0.001],LAAO procedural time[(36.03±11.37)min vs.(47.60±15.56)min,P=0.001],LAAO fluoroscopy radiation dose[(124.85±41.01)mGy vs.(198.83±84.57)mGy,P<0.001]and contrast usage[(100.00±26.52)ml vs.(152.26±49.70)ml,P<0.001]were significantly lower than those in TEE group.③The measurements of left atrial appendage(LAA)in ICE group were larger than that in TEE especially at 135°[(21.32±3.42)mm vs.(19.26±4.01)mm,P=0.027].The measured value of ICE 135°was significantly correlated with LAA measurements under fluoroscopy(Person correlation coefficient r=0.83,P<0.0001 for two-tailed test).④There was no significant difference in the incidence of PDL between the two groups immediately after occlusion and 3 months after procedure(10.87%vs.14.13%,P=0.592;19.56%vs.22.83%,P=0.661).After 3 months,1 patient in ICE group had 3 mm PDL,and 3 patients in TEE group had(3.2±0.3)mm PDL.One year after procedure,PDL in ICE group decreased to 1.8 mm,while 3 mm PDL was still present in 1 case of TEE group.⑤No serious complications such as pericardial effusion,stroke,massive hemorrhage or device dislocation occurred in both groups,and 1 patient in TEE group was found to have device-related thrombosis.Conclusion ICE-guided one-stop procedure based XR-Star technology was effective and safe,which can significantly reduce the procedure time and radiation exposure.The measurements obtained by ICE of LAA ostium were highly correlated with fluoroscopy,but there was no significant difference in residual shunt ratio comparing with traditional TEE.