无射线射频消融术治疗妊娠合并快速心律失常的疗效及安全性分析

doi:10.3969/j.issn.1006-7795.2021.02.007

摘要/Abstract

摘要： 目的探讨妊娠合并快速心律失常患者孕期行无射线射频消融手术的疗效及安全性。方法将2016年1月至2020年1月首都医科大学附属北京安贞医院收治的31例妊娠合并快速心律失常者行射频消融术,分析其疗效、安全性,并比较于不同孕期行手术的疗效和预后差异。结果 ①共31例患者,均为0射线在三维电磁导航标测系统下操作,27例治愈(87.1%)、3例好转(9.7%)、1例无效(3.2%)、1例复发(3.7%);治疗后心功能有明显好转(P=0.000)。②31例患者分娩时及分娩后均无心律失常再发作。③有1例自然流产、1例早产、29例孕足月分娩,平均分娩孕周(38.3±1.4)周,21例行足月剖宫产,8例阴道分娩,各孕期治疗后妊娠结局差异无统计学意义(P=0.107)。新生儿平均体质量(3280±489)g,5 min Apgar评分均为10分,无小于胎龄儿,无新生儿窒息死亡,随访1~5年幼儿均未发现生长发育异常,各孕期治疗后胎儿结局差异无统计学意义(P=0.527)。结论三维电磁导管标测系统指导下行无射线射频消融术,患者依从性好、治愈率高、复发率低,母儿预后良好,是一项治疗药物不耐受的妊娠合并持续性快速心律失常的安全有效的方式。于孕早中期或晚期行手术预后差别无统计学意义。对于术后治愈患者,心功能良好,经多学科评估无禁忌证,可阴道分娩。

关键词: 快速心律失常, 妊娠, 无射线射频消融术

Abstract: Objective To investigate the efficacy and safety of catheter ablation without fluoroscopy in pregnancy with tachyarrhythmia.-Methods- From January 2016 to January 2020, 31 pregnancies with tachycardia were treated by radiofrequency ablation in Beijing Anzhen Hospital, Capital Medical University. The efficacy and safety of radiofrequency ablation were analyzed, and the differences in efficacy and prognosis were compared with those at different stage of pregnancy.Results ①A total of 31 patients were treated with 0 ray under the three-dimensional electromagnetic navigation mapping system. 27 patients were cured (87.1%), 3 patients were improved (9.7%), 1 patient was ineffective (3.2%), and 1 patient relapsed (3.7%). Cardiac function was improved significantly after treatment (P=0.000). ② There was no recurrence of arrhythmia in 31 cases during and after delivery. ③ There were 1 case of spontaneous abortion, 1 case of premature delivery, 29 cases of full-term delivery. The average gestational age was (38.3±1.4) weeks, 21 cases of full-term cesarean section, and 8 cases of vaginal delivery. There was no significant difference in pregnancy outcome after different pregnancy treatments(P=0.107). The average weight of the newborn was (3280±489)g. The Apgar score of the fifth minutes was 10. There was no small for gestational age infant and no neonatal asphyxia death. No abnormal growth and development was found during the follow-up of 1-5 years. There was no significant difference in fetal outcomes after different pregnancy treatments(P=0.527). Conclusion Catheter ablation without fluoroscopy guided by three-dimensional electromagnetic catheter mapping system has good compliance, high cure rate, low recurrence rate and good prognosis of mother and infant. It is a safe and effective way to treat drug intolerant sustained tachyarrhythmia.There was no significant difference in the prognosis of the operation in the middle or late trimester. For patients who were cured after operation and had good cardiac function, vaginal delivery could be performed after multidisciplinary evaluation without contraindications.

Key words: tachyarrhythmia, gestation, catheter ablation without fluoroscopy

中图分类号:

包照亮, 李松南, 段娜, 张豪锋, 龚静, 张军. 无射线射频消融术治疗妊娠合并快速心律失常的疗效及安全性分析[J]. 首都医科大学学报, 2021, 42(2): 204-209.

Bao Zhaoliang, Li Songnan, Duan Na, Zhang Haofeng, Gong Jing, Zhang Jun. Efficacy and safety of catheter ablation without fluoroscopy in the treatment of pregnancy complicated with tachyarrhythmia[J]. Journal of Capital Medical University, 2021, 42(2): 204-209.

参考文献

[1] Vaidya V R, Arora S, Patel N, et al.Burden of arrhythmia in pregnancy[J].Circulation, 2017,135(6):619-621.
[2] 许静. 妊娠期心律失常的发生机制及处理[J]. 中华心律失常学杂志, 2014,18(4):260-262.
[3] Li M M, Sang C H, Jiang C X,et al.Maternal arrhythmia in structurally normal heart: prevalence and feasibility of catheter ablation without fluoroscopy[J]. Pacing Clin Electrophysiol, 2019,42(12):1566-1572.
[4] Brugada J,Katritsis D G,Arbelo E,et al.2019 ESC Guidelinesfor the management of patients with supraventricular tachycardia[J].Eur Heart J,2020,41(5):655-720.
[5] Gaita F,Guerra P G,Battaglia A,et al.The dream of near-zero X-rays ablation comes true[J]. Eur Heart J,2016,37(36):2749-2755.
[6] Regitz-Zagrosek V, Roos-Hesselink J W,Bauersachs J, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy[J].Eur Heart J, 2018,39(34):3165-3241.
[7] Hurst J W.The value of using the entire New York Heart Association's classification of heart and vascular disease[J]. Clin Cardiol, 2006,29(9):415-417.
[8] 谢幸,孔北华,段涛.妇产科学[M].9版.北京:人民卫生出版社,2018:204-209,175.
[9] Nakamura H, Kurokawa J,Bai C X, et al.Progesterone regulates cardiac repolarization through a nongenomic pathway: an in vitro patch-clamp and computational modelingstudy[J].Circulation,2007,116(25):2913-2922.
[10] Ruys T P,Roos-Hesselink J W,Hall R,et al. Heart failure in pregnant women with cardiac disease: data from the ROPAC[J].Heart,2014,100(3):231-238.
[11] 韩凤珍, 赵杨, 卢聪. 妊娠合并心脏病的手术干预治疗[J].实用妇产科杂志, 2010,26(3):225-228.
[12] Bigelow A M, Crane S S, Khoury F R, et al.Catheter ablation of supraventricular tachycardia without fluoroscopy during pregnancy[J]. Obstet Gynecol,2015,125(6):1338-1341.
[13] European Society of Gynecology(ESG); Association for Europan Paediatric Cardiology (AEPC);German Society for Gender Medicine(DGesGM),et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC)[J]. Eur Heart J, 2011, 32(24):3147-3197.
[14] 中国生物医学工程学会心脏起搏与电生理分会, 中华医学会心电生理和起搏分会,《中国心脏起搏与心电生理杂志》编辑辑部. 射频导管消融治疗快速心律失常指南(修订版)[J]. 中国心脏起搏与心电生理杂志, 2002,16(2):81-95.
[15] Andreassi M G,Foffa I,Manfredi S,et al.Genetic polymorphismsin XRCC1,OGG1,APE1 and XRCC3 DNA repair genes,ionizingradiation exposure and chromosomal DNA damage in interventionalcardiologists[J]. Mutat Res,2009, 666(1-2):57-63.
[16] Hirshfeld J W Jr,Ferrari V A,Bengel F M,et al. 2018 ACC/HRS/NASCI/SCAI/SCCT expert consensus document on optimal use ofionizing radiation in cardiovascular imaging: best practices for safety and effectiveness: a report of the American College of Cardiology Task Force on expert consensus decision pathways[J]. J Am Coll Cardiol,2018, 71(24): e283-e351.
[17] 喻荣辉,马长生.绿色电生理: 梦想照进现实[J].中华内科杂志,2018,57(8): 549-551.
[18] 喻荣辉,赵欣.无射线导管消融的有效性和安全性[J]. 临床心血管病杂志,2019,35(11) : 975-978.
[19] Huo Y,Christoph M,Forkmann M,et al.Reduction of radiationexposure during atrial fibrillation ablation using a novel fluoroscopyimage integrated 3-dimensional electroanatomic mapping system: aprospective,randomized,single-blind,and controlled study[J].Heart Rhythm,2015,12(9):1945-1955.
[20] Zhang J Q,Yu R H,Liang J B,et al.Reconstruction left atriumand isolation pulmonary veins of paroxysmal atrial fibrillation usingsingle contact force catheter with zero x-ray exposure: ACONSORT Study[J]. Medicine (Baltimore),2017,96(41): e7726.
[21] 胡宇才,白融,许丰强,等. 全三维技术在老年心房颤动射频消融术中的安全性及有效性研究[J]. 中国介入心脏病学杂志,2017,25(11): 622-627.