经导管射频消融术治疗儿童快速性心律失常972例临床分析

A clinical analysis of radiofrequency catheter ablation of tachyarrhythmia in 972 children in a single center

目的探讨经导管射频消融术(RFCA)治疗儿童不同类型快速性心律失常的疗效与安全性。方法回顾性分析2000年8月至2021年8月山东第一医科大学附属省立医院小儿心脏科接受电生理检查及RFCA的快速性心律失常患儿972例,其中男580例,女392例,2岁6个月~18岁,年龄中位数10岁,体质量中位数38 kg。总结不同心动过速类型RFCA即刻成功率、复发率、并发症、合并先天性心脏病患儿的消融疗效、不同时期消融手术疗效和手术时间、射线暴露时间变化趋势。结果972例快速性心律失常患儿,心脏功能和结构均正常935例,发生扩张型心肌病6例,心动过速性心肌病5例,致心律失常性右室心肌病1例,合并先天性心脏病25例,以房间隔缺损多见。经电生理检查证实为房室折返性心动过速(AVRT)444例(45.68%),房室结折返性心动过速(AVNRT)221例(22.74%),室性心动过速/室性期前收缩(VT/PVC)232例(23.87%),房性心动过速(AT)62例(6.38%),心房扑动(AF)9例(0.92%),电生理检查过程中反复刺激不能诱发心动过速发作,无法明确心动过速机制4例(0.41%)。938例患儿接受射频消融术,首次消融即刻成功率99.04%(929/938例),复发率6.89%(64/929例),手术时间100(70~120)min,射线暴露时间3.30(0.50~9.41)min。AVRT接受RFCA 437例,消融即刻成功率98.86%,复发率6.48%,AVNRT接受RFCA 219例,消融即刻成功率100%,复发率5.02%,VT/PVC接受RFCA 225例,消融即刻成功率99.11%,复发率8.97%,AT接受RFCA 49例,消融即刻成功率97.96%,复发率10.42%,AF接受RFCA 8例,消融即刻成功率87.50%,随访无复发。RFCA并发症10例(1.07%),其中左侧气胸5例、完全性左束支传导阻滞1例、Ⅱ°房室传导阻滞1例、血栓1例、心包积液1例及胸腔积液1例,无死亡及其他并发症。合并先天性心脏病和心肌病儿童的射频消融,与心脏结构、功能正常的快速性心律失常儿童相比,消融即刻成功率相同,但复发率偏高,差异有统计学意义(P<0.05)。按早期(2000—2010年)与后期(2011—2021年)RFCA即刻成功率比较,差异无统计学意义(P>0.05),随着技术逐步成熟,后期RFCA总体复发率降低,消融射线暴露时间减少,差异均有统计学意义(P<0.05)。结论儿童快速性心律失常经导管射频消融治疗临床成功率高,复发率低,并发症少,具有良好的有效性及安全性。

Objective To investigate the efficacy and safety of radiofrequency catheter ablation(RFCA)for children with tachyarrhythmia of various types.Methods A total of 972 patients with tachyarrhythmia who underwent electrophysiological study and RFCA during Aug.2000 and Aug.2021 were selected,including 580 males and 392 females,median age 10 years,median body weight 38 kg.The immediate success rate of the procedure,recurrence rate and complications were summarized.The ablation efficacy in children with congenital heart disease(CHD)and cardiomyopathy,the overall procedure time,fluoroscopy time and success rate in different periods were analyzed.Results Among the 972 patients,6 were complicated with dilated cardiomyopathy,5 with tachycardia cardiomyopathy,1 with arrhythmogenic right ventricular cardiomyopathy,and 25 with CHD,mostly atrial septal defects.Atrioventricular reentrant tachycardia(AVRT)was observed in 444(45.68%)patients,atrioventricular nodal reentrant tachycardia(AVNRT)in 221(22.74%)patients,ventricular tachycardia/premature ventricular contraction(VT/PVC)in 232(23.87%)patients,atrial tachycardia(AT)in 62(6.38%)patients,and atrial flutter(AF)in 9(0.92%)patients.The mechanism of tachycardia could not be determined in 4(0.41%)patients.Totally 938 children underwent RFCA.The immediate success rate was 99.04%,and recurrence rate was 6.89%.The mean procedure duration was 100(70-120)min,and the mean fluoroscopy time was 3.30(0.50-9.41)min.The 437 AVRT patients had an immediate success rate of 98.86%,and a recurrence rate of 6.48%.The 219 AVNRT patients had an immediate success rate of 100%,and a recurrence rate of 5.02%.The 225 VT/PVC patients had an immediate success rate of 99.11%,and a recurrence rate of 8.97%.The 49 AT patients had an immediate success rate of 97.96%,and a recurrence rate of 10.42%.The 8 AF patients had an immediate success rate of 87.50%,with no recurrence.Major complications occurred in 10(1.07%)patients,including left pneumothorax in 5 cases,complete left bundle branch block in 1 case,Ⅱ°atrioventricular block in 1 case,thrombus in 1 case,pericardial effusion in 1 case and pleural effusion in 1 case.Compared with children with normal cardiac structure and function,children with CHD and cardiomyopathy had the same immediate success rate but significantly higher recurrence rate(P<0.05).There was no significant difference in the immediate success rate between the early stage(2000—2010)and late stage(2011—2021)(P>0.05).However,as the technology matured,the recurrence rate and the radiation exposure time were significantly reduced(P<0.05).Conclusion RFCA is safe and effective for children with tachyarrhythmia,with high success rate and low recurrence and complication rates.