左心耳封堵联合射频消融心房颤动一站式治疗的手术策略优化

摘要

目的 经皮左心耳封堵联合射频消融心房颤动(房颤)一站式治疗技术的有效性及安全性已得到临床认可,但其手术策略有待进一步优化.本研究旨在通过对不同联合治疗策略的临床结果进行比较,探讨一站式治疗的最优化手术策略.方法 研究入选2015年11月至2018年12月114例连续收住宁波市第一医院的症状性房颤患者[CHA2 DS2-VASc评分平均(4.5±1.4)分,HAS-BLED评分平均(3.3±1.0)分)],根据左心耳封堵器(Watchman)植入在房颤射频消融前后不同分为先封堵组(61例)和先消融组(53例).回顾性分析两组消融成功率、封堵成功率及封堵器边缘分流(pri-device leak,PDL)等数据,并讨论两种联合策略的优势.结果 两组术中完全封堵率均较高(93.4％对92.5％,P=0.837).术中即刻及术后随访均未发现≥5 mm的PDL.除2例(每组各1例)无症状性封堵器相关血栓患者外,其余患者均顺利停用口服抗凝药.经过平均(21.4±10.2)个月随访,两组房颤消融成功率未见差异(77.0％对69.8％,log-rank P=0.772),但先封堵组术后45 d新发PDL的患者比例明显更低(6.6％对22.6％,P=0.014).多因素回归分析显示,联合策略与术后新发PDL独立相关(P=0.007,OR=6.13).结论 对于合并高卒中和/或高出血风险的房颤患者而言,先封堵或先消融的联合手术策略均安全、有效,但先封堵策略术后45 d的新发PDL风险更低.%Objective The efficacy and safety of one-stop combination of left atrial appendage closure (LAAC) in combination with catheter ablation(CA)of atrial fibrillation(AF) has been established clinically,but the optimal procedural strategy has not been thoroughly elucidated.We aimed to optimize thecombination strategy.Methods One hundred and fourteen consecutive patients with symptomatic AF (mean CHA2DS2-VASc score 4.5±1.4,mean HAS-BLED score 3.3±1.0) were enrolled in Ningbo First Hospital from November 2015 to December 2018.LAAC with the Watchman device was performed either before (occlusion-first group,n =61)or after(ablation-first group,n =53)CA.The clinical data of the two groups were retrospectively analyzed the advantages of two combined strategies were analyzed.Results The complete device occlusions were achieved in 93.4％ and 92.5％ of the patients,respectively(P=0.837).Neither acute nor chronic peri-device leak greater than 5 mm was detected.All the other patients stopped taking oral anticoagulants,except two(one in each group)with asymptomatic device-related thrombi.AF-free rates were comparable between the two groups during a mean follow-up of 21.4± 10.2 months (77.0％ vs.69.8％,log-rank P =0.772).However,the proportion of new peridevice leak patients in the first occlusion group was significantly lower in the occlusion-first group (6.6％vs.22.6％,P=0.014)45 days after operation.Multivariate logistic regression showed that the combination strategy was independently associated with the new peri-device leak (P =0.007,OR =6.13).Conclusion Both occlusionfirst and ablation-first strategies were efficacious and safe for the combination one-stop procedures in AF patients with high stroke and/or bleeding risks.However,the occlusion-first strategy was independently associated with lower new peri-device leak rates during the 45 days follow-up.