高功率短时程在持续性心房颤动改良BOXI术式中的有效性和安全性

doi:10.3969/j.issn.1004-583X.2024.10.008

摘要/Abstract

摘要：

目的评估在持续性心房颤动(房颤)中应用高功率短时程(high-power short-duration,HPSD)的改良的左心房后壁盒式隔离(box isolation,BOXI)术式的有效性和安全性。方法纳入2020年6月至2022年11月就诊于福建省漳州市医院心血管内二科的持续性房颤患者122例,随机分为HPSD组(n=61)和常规组(n=61)。HPSD组和常规组分别以HPSD和低功率长时程消融完成双侧肺静脉隔离(pulmonary venous isolation,PVI)和改良的BOXI消融。HPSD组使用冷盐水灌注压力感应导管,功率设定为45 W,以消融指数作为指导。常规组以35 W进行消融25~30 s,消融指数、压力指数和HPSD组的设置一致。比较两组基线资料、完成PVI和改良的BOXI的时间、手术总时间、围手术期并发症、单次术后12个月无房性心律失常率等指标。结果 HPSD组完成PVI和改良的BOXI的时间和手术总时间均短于常规组(P<0.05)。常规组术后发生心包压塞1例。两组均未出现食管损伤、中风或短暂性脑缺血发作和肺静脉狭窄或死亡。HPSD组和常规组单次手术后12个月的无房性心律失常率分别为70.5%和63.9%,差异无统计学意义(P=0.440)。术后复发第二次手术中,两组肺静脉和改良的BOX电位恢复率差异无统计学意义(P>0.05)。结论持续性房颤改良的BOXI术式采用HPSD是有效、可行且安全的,能缩短总消融时间和手术总时间,且不降低临床疗效。

关键词: 心房颤动, BOXI, 导管消融, 高功率

Abstract:

Objective To evaluate the efficacy and safety of high-power short-duration (HPSD) on the modified box isolation (BOXI) for persistent atrial fibrillation (AF). Methods A total of 122 patients with persistent AF who were admitted to the Second Department of Cardiovascular Medicine, Zhangzhou Municipal Hospital of Fujian Province from June 2020 to November 2022 were randomly divided into HPSD group (n=61) and routine group (n=61). Bilateral pulmonary venous isolation (PVI) by the modified BOXI ablation in the HPSD group, and that by low-power long-term ablation in the routine group were performed. A cold saline perfusion pressure sensing catheter with a power setting of 45 W, guided by the ablation index was given in the HPSD group. Ablation at 35 W for 25-30 seconds was performed in the routine group, and the ablation index and pressure index were consistent with those of the HPSD group. Baseline data, time to complete PVI and modified BOXI, total operation time, perioperative complications, and non-atrial arrhythmia rate at 12 months after a single operation were compared between the two groups. Results The time to complete bilateral pulmonary vein isolation and modified BOXI and the total operation time in the HPSD group were significantly shorter than those of the routine group (P<0.05). There was 1 case of postoperative pericardial tamponade in the routine group. No esophageal injury, stroke or transient ischemic attack and pulmonary vein stenosis or death occurred in both groups. The non-atrial arrhythmia rate was 70.5% in the HPSD group and 63.9% in the routine group at 12 months after a single surgery, showing no significant difference (P=0.440). There was no significant difference in the recovery rate of pulmonary vein and modified BOX potential between the two groups during the second operation (P>0.05). Conclusion The use of HPSD in the modified BOXI procedure for persistent AF is effective, feasible, and safe, which significantly reduces total ablation time and procedure time without compromising clinical efficacy.

Key words: atrial fibrillation, BOXI, catheter ablation, high power

中图分类号:

R541.75

朱春瑜, 林春艺, 翁兰, 杨洵杰, 董帝辉. 高功率短时程在持续性心房颤动改良BOXI术式中的有效性和安全性[J]. 临床荟萃, 2024, 39(10): 915-920.

Zhu Chunyu, Lin Chunyi, Weng Lan, Yang Xunjie, Dong Dihui. Efficacy and safety of high-power short-duration on the modified box isolation for persistent atrial fibrillation[J]. Clinical Focus, 2024, 39(10): 915-920.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2024.10.008

https://huicui.hebmu.edu.cn/CN/Y2024/V39/I10/915

图/表 5

图1 肺静脉+改良的BOX隔离三维图 a.右前斜位;b.后前位注:红点(点直径6 mm)表示以45 W,AI维持在400~450的消融点;粉红点表示左心房后壁以45 W, AI维持在360~380的消融点,压力5~20 g。LSPV:左上肺静脉;LIPV:左下肺静脉;RSPV:右上肺静脉;RIPV:右下肺静脉;LAPW:左心房后壁; RL:左心房顶部线;MPL:改良的左心房后壁底部线。

Fig.1 Three-dimensional visualization of the pulmonary vein and the modified BOX isolation a.in the right anterior oblique position; b.posterior anterior position Note: The ablation point at 45 W with an AI of 400-450 in a diameter of 6 mm is labeled in a red point; the ablation point at 45 W with an AI of 360-380 and pressure of 5-20 g on the posterior wall of the left atrium is labeled in a pink point. LSPV: left superior pulmonary vein; LIPV: left inferior pulmonary vein; RSPV: right superior pulmonary vein; RIPV: right inferior pulmonary vein; LAPW: left atrial posterior wall; RL: left atrial roof line; MPL: modified bottom line of left atrial posterior wall.

表1 两组术前临床特征比较

Tab.1 Preoperative clinical features between the two groups

组别	例数	年龄 (岁)	男性 [例(%)]	房颤类型[例(%)]		左心房前后径 (mm)	左室舒张末径 (mm)	左室射血分数 (%)	CHA2DS2-VASc 评分(分)
组别	例数	年龄 (岁)	男性 [例(%)]	持续性房颤	长程持续性房颤	左心房前后径 (mm)	左室舒张末径 (mm)	左室射血分数 (%)	CHA2DS2-VASc 评分(分)
HPSD组	61	61.9±10.5	43(70.5)	40 (65.6)	33(54.1)	37.6±6.6	47.1±6.4	58.1±8.4	1.6±1.3
常规组	61	60.1±10.8	46(75.4)	21 (34.4)	28(45.9)	31.9±5.8	46.1±4.0	60.3±6.3	1.4±1.1
t/χ²值		0.902	0.374	1.671		4.979	1.031	-1.713	1.044
P值		0.925	0.541	0.196		0.234	0.304	0.089	0.299

表2 两组术中消融数据比较

Tab.2 Intraoperative ablation data between the two groups

组别	例数	每个位点消融时间(s)	消融时间 (min)	手术总时间 (min)	射频总能量 (kJ)	射线时间 (min)	射线量 (mGy)	BOX内补点数(个)	房性心律失常诱发[例(%)]	POP数 (个)
HPSD组	61	14.3±3.7	103.0±30.4	204.4±28.7	159.5±19.6	3.2±1.7	3.9±5.1	11.9±2.6	9(14.8)	1.2±1.0
常规组	61	30.3±2.9	126.3±31.4	233.1±30.6	193.0±21.2	3.0±1.7	6.9±17.2	18.6±3.6	13(21.3)	1.0±1.1
t/χ²值		-26.345	-4.164	-5.343	-9.082	0.673	-1.315	-11.701	0.887	0.743
P值		<0.001	<0.001	<0.001	<0.001	0.502	0.191	<0.001	0.346	0.459

图2 两组房颤单次消融术后无房性心律失常复发的Kaplan-Meier生存曲线

Fig.2 Kaplan-Meier survival curve of non-atrial arrhythmia rate in two groups after single AF ablation procedure

表3 两组二次手术肺静脉和改良BOX电位恢复情况比较[例(%)]

Tab.3 Recovery rate of pulmonary vein and modified BOX potential between the two groups during the second operation

组别	例数	肺静脉恢复	LSPV	LIPV	RSPV	RIPV	BOX恢复
HPSD组	8	4(50.0)	4(50.0)	2(25.0)	2(25.0)	2(25.0)	6(75.0)
常规组	12	8(66.7)	6(50.0)	4(33.3)	4(33.3)	4(33.3)	8(66.7)
χ²值		0.556	0.000	0.000	0.000	0.000	0.159
P值		0.456	1.000	1.000	1.000	1.000	0.690

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