导管消融术治疗心房颤动性心肌病的效果及预后的影响因素

Effect of catheter ablation on atrial fibrillation-mediated cardiomyopathy and its prognostic influencing factors

目的 观察心房颤动性心肌病(AF-CM)患者的临床特点、行导管消融术治疗的效果及预后的影响因素,探讨早期诊断AF-CM的指标及诊断价值。方法 2018年3月—2023年2月阜外华中心血管病医院行导管消融术治疗的心房颤动(AF)合并心力衰竭(HF)患者210例,术后6个月内左室射血分数(LVEF)升高15%或恢复正常者158例为AF-CM组,LVEF升高<15%或未改变者52例为扩张型心肌病(DCM)合并AF(DCM-AF)组。比较2组年龄、性别、体质量指数(BMI)、AF病程、AF类型、吸烟史、饮酒史、既往史;记录2组入院时NYHA心功能分级、CHA_2DS_2-VASc评分、HAS-BLED评分、低密度脂蛋白胆固醇(LDL-C)水平,术前动态心电图结果,术后HF药物应用情况;分别于术前及术后1个月检测N末端脑钠肽前体(NT-proBNP)、血肌酐水平;分别于术前及术后6个月行超声心动图检查,记录LVEF、左心室舒张末期内径(LVEDD)、左心房内径(LAD)、室间隔厚度、二尖瓣反流面积、二尖瓣反流程度;采用多因素logistic回归分析AF合并HF患者为AF-CM的影响因素;绘制ROC曲线,评估LVEDD及NYHA心功能分级诊断AF-CM的效能。随访至2023年9月1日,比较2组AF复发、心血管事件再住院及无事件生存情况。结果 (1)AF-CM组患者年龄[(59.260±12.442)岁]大于DCM-AF组[(53.980±13.220)岁](t=2.613,P<0.001),最慢心率[(59.200±13.776)次/min]快于DCM-AF组[(54.810±12.720)次/min](t=0.203,P=0.043),入院时CHA_2DS_2-VASc评分、HAS-BLED评分、LDL-C水平及术后HF药物应用情况等与DCM-AF组比较差异均无统计学意义(P>0.05)。(2)AF-CM组术前NT-proBNP [976.500(564.175,1 799.250) ng/L]、血肌酐[(81.300±25.190)μmol/L]水平低于DCM-AF组[1 231.000(838.275, 2 093.250) ng/L、(91.710±27.186)μmol/L](P<0.05),NYHA心功能Ⅰ~Ⅱ级比率(7 7.8%)高于DCM-AF组(30.8%)(P<0.05)。术后1个月,AF-CM组NT-proBNP [225.000(100.500, 450.000) ng/L]、血肌酐[(76.386±16.167)μmol/L]水平低于术前(P<0.05),NYHA心功能Ⅰ~Ⅱ级比率(100.0%)高于术前(P<0.05);DCM-AF组NT-proBNP水平[679.100(392.525, 1 047.250) ng/L]低于术前(P<0.05),NYHA心功能Ⅰ~Ⅱ级比率(55.8%)高于术前(P<0.05),血肌酐与术前比较差异无统计学意义(P>0.05)。术后1个月,AF-CM组NT-proBNP、血肌酐水平低于DCM-AF组,NYHA心功能Ⅰ~Ⅱ级比率高于DCM-AF组(P<0.05)。(3)AF-CM组术前LVEDD[(53.470±6.112)mm]、LAD[(43.342±6.427)mm]均小于DCM-AF组[(62.650±9.452)、(45.587±6.646)mm](P<0.05),LVEF[(38.920±4.616)%]大于DCM-AF组[(34.540±6.652)%](P<0.05),二尖瓣重度反流比率(26.6%)低于DCM-AF组(48.1%)(P<0.05),室间隔厚度、二尖瓣反流面积与DCM-AF组比较差异无统计学意义(P>0.05)。术后6个月,AF-CM组LVEDD[(49.820±4.624)mm]、LAD[(37.910±4.568)mm]、二尖瓣反流面积[1.900(1.100, 3.100)cm^(2)]均小于术前(P<0.05),LVEF[(57.580±4.351)%]大于术前(P<0.05),二尖瓣重度反流比率(1.3%)低于术前(P<0.05);DCM-AF组LVEDD[(60.000±8.586)mm]、LAD[(41.940±5.903)mm]小于术前(P<0.05),LVEF[(40.790±6.690)%]大于术前(P<0.05)。术后6个月,AF-CM组LVEDD、LAD、二尖瓣反流面积均小于DCM-AF组,LVEF大于DCM-AF组,二尖瓣重度反流比率低于DCM-AF组(P<0.05)。(4)随访至2023年9月1日,2组均无死亡病例,AF-CM组AF复发率(8.2%)、心血管事件再住院率(16.5%)均低于DCM-AF组(25.0%、65.4%)(P<0.05),无事件生存率(83.5%)高于DCM-AF组(34.6%)(P<0.05)。(5)LVEDD(OR=0.853,95%CI:0.788~0.923,P<0.001)、NYHA心功能分级(OR=0.243,95%CI:0.140~0.420,P<0.001)是AF合并HF患者为AF-CM的影响因素。(6)LVEDD、NYHA心功能分级分别以58.5 mm、2.5为最佳截断值,诊断AF合并HF患者为AF-CM的AUC分别为0.789(95%CI:0.711~0.868,P<0.001)、0.810(95%CI:0.745~0.875,P<0.001),灵敏度分别为69.0%、69.0%,特异度分别为79.0%、78.2%;二者联合诊断的AUC为0.887(95%CI:0.840~0.933,P<0.001),灵敏度为74.7%、特异度为86.5%。结论 LVEDD<58.5 mm、NYHA心功能≤Ⅱ级的AF合并HF患者AF-CM的可能性大,行导管消融术后心脏结构和功能改善较DCM-AF明显;LVEDD联合NYHA心功能分级对AF-CM的诊断有较高价值。

Objective To observe the clinical characteristics of patients with atrial fibrillation-mediated cardiomyopathy(AF-CM), the effect of catheter ablation and the influencing factors of prognosis, and to explore the indicators and diagnostic value. Methods Totally 210 patients with AF combined with heart failure(HF) underwent catheter ablation in Fuwai Central China Cardiovascular Hospital from March, 2018 to February, 2023, among whom 158 patients had ≥15% increased left ventricular ejection fraction(LVEF) or normal LVEF 6 months after catheter ablation(AF-CM group), and the other 52 patients had <15% increased LEVF or no changed LVEF [dilated cardiomyopathy(DCM) combined with AF(DCM-AF) group]. The age, gender, body mass index(BMI), duration of AF, AF type, smoking habits, acholic consumption history, and previous disease history were compared between two groups. The NYHA classification, CHA_2DS_2-VASc score, HAS-BLED score and low-density lipoprotein cholesterol(LDL-C) on admission, preoperative ambulatory electrocardiography results and postoperative HF medication were recorded. The levels of N-terminal pro-brain natriuretic peptide(NT-proBNP) and blood creatinine were detected before and one month after operation. Ultrasonography was performed before and 6 months after operation to record LVEF, left ventricular end-diastolic dimension(LVEDD), left atrial diameter(LAD), ventricular septal thickness and mitral regurgitation area and degree. Multivariate logistic regression was used to analyze the influencing factors of AF-CM in patients with AF combined with HF. ROC curves were plotted to assess the efficiencies of LVEDD and NYHA classification on diagnosing AF-CM. Follow-up was performed till September 1, 2023, and the AF recurrence, rehospitalization due to cardiovascular events and event-free survival were compared between two groups. Results(1) The patients were older in AF-CM group [(59.260±12.442) years] than DCM-AF group [(53.980±13.220) years](t=2.613, P<0.001). The slowest heart rate was faster in AF-CM group [(59.200±13.776) beats/min]than that in DCM-AF group [(54.810±12.720) beats/min](t=0.203, P=0.043). There were no significant differences in the CHA_2DS_2-VASc score, HAS-BLED score, LDL-C level, and HF medication application on admission between two groups(P>0.05).(2) Before operation, the levels of NT-proBNP and blood creatinine were lower in AF-CM group [976.500(564.175, 1 799.250) ng/L,(81.300±25.190) μmol/L] than those in DCM-AF group [1 231.000(838.275, 2 093.250) ng/L,(91.710±27.186) μmol/L](P<0.05), and the rate of NYHA class Ⅰ-Ⅱ was higher in AF-CM group(77.8%) than that in DCM-AF group(30.8%)(P<0.05). In AF-CM group, the levels of NT-proBNP and blood creatinine were lower one month after operation [225.000(100.500, 450.000) ng/L,(76.386±16.167) μmol/L] than those before operation(P<0.05), and the rate of NYHA class Ⅰ-Ⅱ was higher one month after operation(100.0%) than that before operation(P<0.05). In DCM-AF group, the level of NT-proBNP was lower one month after operation [679.100(392.525, 1 047.250) ng/L] than that before operation(P<0.05), the rate of NYHA class Ⅰ-Ⅱ(55.8%) was higher than that before operation(P<0.05), and the blood creatinine level showed no significant difference(P>0.05). One month after operation, the levels of NT-proBNP and blood creatinine were lower in AF-CM group than those in DCM-AF group, and the NYHA class Ⅰ-Ⅱ was higher in AF-CM group than that in DCM-AF group(P<0.05).(3) Before operation, LVEDD and LAD were shorter in AF-CM group [(53.470±6.112),(43.342±6.427) mm] than those in DCM-AF group [(62.650±9.452),(45.587±6.646) mm](P<0.05), the LVEF was larger in AF-CM group [(38.920±4.616)%] than that in DCM-AF group [(34.540±6.652)%](P<0.05), the rate of severe mitral regurgitation was lower in AF-CM group(26.6%) than that in DCM-AF group(48.1%)(P<0.05), and there were no significant differences in the ventricular septal thickness and mitral regurgitation area between two groups(P>0.05). In AF-CM group, the LVEDD, LAD and mitral regurgitation area were smaller 6 months after operation [(49.820±4.624) mm,(37.910±4.568) mm, 1.900(1.100, 3.100) cm^(2)] than those before operation(P<0.05), LVEF was larger after operation [(57.580±4.351)%] than that before operation(P<0.05), and the rate of severe mitral regurgitation was lower after operation(1.3%) than that before operation(P<0.05). In DCM-AF group, the LVEDD and LAD were shorter after operation [(60.000±8.586),(41.940±5.903) mm] than those before operation(P<0.05), and the LVEF was larger after operation [(40.790±6.690)%] than that before operation(P<0.05). The LVEDD, LAD and mitral regurgitation area were smaller in AF-CM group than those in DCM-AF group 6 months after operation, the LVEF was larger and the rate of severe mitral regurgitation was lower after operation than that before operation(P<0.05).(4) The follow-up till September 1, 2023 showed no death in two groups, the rates of AF recurrence and rehospitalization due to cardiovascular events were lower in AF-CM group(8.2%, 16.5%) than those in DCM-AF group(25.0%, 65.4%)(P<0.05), and the event-free survival rate was higher in AF-CM group(83.5%) than that in DCM-AF group(34.6%)(P<0.05).(5) LVEDD(OR=0.853, 95%CI: 0.788-0.923, P<0.001), and NYHA classification(OR=0.243, 95%CI: 0.140-0.420, P<0.001) were the influencing factors of AF-CM in AF patients with HF.(6) When the optimal cut-off values of LVEDD and NYHA classification were 58.5 mm and 2.5, the AUCs for diagnosing AF-CM were 0.789(95%CI: 0.711-0.868, P<0.001) and 0.810(95%CI: 0.745-0.875, P<0.001), the sensitivities were 69.0% and 69.0%, and the specificities were 79.0% and 78.2%, respectively. The AUC of the combination of them two was 0.887(95%CI: 0.840-0.933, P<0.001), with a sensitivity of 74.7% and a specificity of 86.5%. Conclusions LVEDD <58.5 mm and NYHA class ≤Ⅱ indicate a risk of AF-CM in patients with AF combined with HF. The cardiac structure and function improve more obviously after catheter ablation in AF-CM patients than in DCM-AF patients. LVEDD in combination with NYHA clasification is of high value to the diagnosis of AF-CM.