陣發(fā)性心房顫動(dòng)患者左右心房電傳導(dǎo)特點(diǎn)的臨床研究

林明寬，劉 浩，周 婷

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·全科醫(yī)生知識(shí)窗·

陣發(fā)性心房顫動(dòng)患者左右心房電傳導(dǎo)特點(diǎn)的臨床研究

林明寬，劉 浩，周 婷

目的 探討陣發(fā)性心房顫動(dòng)患者左右心房電傳導(dǎo)的特點(diǎn)。方法 選取2012年4月—2013年5月廣西醫(yī)科大學(xué)第一附屬醫(yī)院住院行射頻消融術(shù)的陣發(fā)性心房顫動(dòng)患者19例為心房顫動(dòng)組，另選取同時(shí)期住院的陣發(fā)性室上性心動(dòng)過(guò)速或室性期前收縮患者23例為對(duì)照組，應(yīng)用固定程序SIS，500、400、350、300、280 ms分別起搏高位右心房、低位右心房，分別測(cè)量冠狀竇近端、遠(yuǎn)端不應(yīng)期，高位、低位右心房到冠狀竇近端、遠(yuǎn)端傳導(dǎo)時(shí)間。結(jié)果 對(duì)照組與心房顫動(dòng)組冠狀竇近端、遠(yuǎn)端不應(yīng)期比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。對(duì)照組與心房顫動(dòng)組不同起搏時(shí)間高位右心房到冠狀竇近端傳導(dǎo)時(shí)間比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；對(duì)照組與心房顫動(dòng)組起搏時(shí)間500、400、350 ms時(shí)高位右心房到冠狀竇遠(yuǎn)端傳導(dǎo)時(shí)間比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；心房顫動(dòng)組起搏時(shí)間300、280 ms時(shí)高位右心房到冠狀竇遠(yuǎn)端傳導(dǎo)時(shí)間較對(duì)照組延長(zhǎng)(P<0.05)。心房顫動(dòng)組起搏時(shí)間500、400 ms時(shí)低位右心房到冠狀竇近端、遠(yuǎn)端傳導(dǎo)時(shí)間較對(duì)照組延長(zhǎng)(P<0.05)；對(duì)照組與心房顫動(dòng)組起搏時(shí)間350、300、280 ms時(shí)低位右心房到冠狀竇近端、遠(yuǎn)端傳導(dǎo)時(shí)間比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論 陣發(fā)性心房顫動(dòng)患者冠狀竇組織和冠狀竇心房交界處存在傳導(dǎo)延緩，可能參與心房顫動(dòng)的促發(fā)及維持。

心房顫動(dòng)；脈沖射頻術(shù)；不應(yīng)期,電生理學(xué)

林明寬，劉浩，周婷.陣發(fā)性心房顫動(dòng)患者左右心房電傳導(dǎo)特點(diǎn)的臨床研究[J].中國(guó)全科醫(yī)學(xué)，2015，18(24)：2997-3000.[www.chinagp.net]

Lin MK,Liu H,Zhou T.Clinical study of the characteristics of electrical conduction between left and right atriums in patients with paroxysmal atrial fibrillation[J].Chinese General Practice，2015，18(24)：2997-3000.

冠狀竇是心房間傳導(dǎo)通路之一，尤其在心房下部間的傳導(dǎo)中占據(jù)優(yōu)勢(shì)地位。冠狀竇肌肉組織連接右心房和左心房，是心房間電傳導(dǎo)的部分，也是Bachmann束的一部分[1]。Saremi等[2]研究65例正常竇性心律患者及7例心房顫動(dòng)患者的冠狀動(dòng)脈CT，發(fā)現(xiàn)正常組58例顯示有冠狀竇-左心房肌性連接存在，心房顫動(dòng)組患者均顯示有冠狀竇-左心房肌性連接。陳芳等[3]研究發(fā)現(xiàn)，冠狀竇內(nèi)存在1條左右心房間的特殊傳導(dǎo)束，可能是一定條件下誘發(fā)并維持房性心律失常的心房間傳導(dǎo)通路之一。冠狀竇肌肉組織也是觸發(fā)活動(dòng)和房性心律失常的根源[4-6]。冠狀竇肌肉組織傳導(dǎo)延緩還與折返傾向和房性心律失常相關(guān)[7-9]。本課題組前期研究表明，陣發(fā)性心房顫動(dòng)患者中，冠狀竇肌肉組織存在傳導(dǎo)延遲[10]。關(guān)于陣發(fā)性心房顫動(dòng)患者左右心房電傳導(dǎo)特點(diǎn)未見(jiàn)報(bào)道。本文探討陣發(fā)性心房顫動(dòng)患者左右心房電傳導(dǎo)的特點(diǎn)，為明確陣發(fā)性心房顫動(dòng)的發(fā)生機(jī)制提供一定的理論依據(jù)。

1 資料與方法

1.2 電生理檢查 以1%利多卡因局部麻醉，分別穿刺右側(cè)股靜脈及右側(cè)頸內(nèi)靜脈。置入6 F鞘管，放置電生理導(dǎo)管于希氏束和冠狀竇。冠狀竇電極(圣猶達(dá)生物科技有限公司，美國(guó)，電極間距2-8-2-8-2-8-8-2 mm)放置良好。記錄電生理儀為電生理及導(dǎo)管工作站Combolab 7000(USA G.E)、心臟電生理刺激儀為東方DF-5A型(蘇州市東方電子儀器廠)。希氏束電極放置：電極進(jìn)入右心室后回撤，使導(dǎo)管頂端位于右房室瓣口處，頭端指向后上方，可同時(shí)記錄到大致相等的A波和V波，在A波和V波之間可見(jiàn)H波。冠狀竇電極放置：(1)左前斜位透視冠狀竇口位于膈肌上2～3 cm，第9胸椎左側(cè)緣。(2)心內(nèi)電生理圖顯示右心房為大A波，冠狀竇近端及遠(yuǎn)端為大A波小V波，A波時(shí)相在P波終末，V波與QRS波同相。(3)行冠狀竇造影證實(shí)冠狀竇位置，以確認(rèn)冠狀竇近端電極在冠狀竇口。高位右心房電極放置：經(jīng)股靜脈送至右心房與上腔靜脈交界處，貼近心房外側(cè)壁，導(dǎo)管尾端1～2極與多導(dǎo)記錄儀連接，顯示大A波，與體表心電圖P波起點(diǎn)同相。低位右心房電極放置：電極頂端置于下腔靜脈與右心房側(cè)面交界處，既可記錄到A波，也可記錄到V波。

1.3 刺激方案 消融前，固定程序SIS。500、400、350、300、280 ms分別起搏冠狀竇近端(9～10極)、冠狀竇遠(yuǎn)端(1～2極)。電壓4～8 V，脈寬0.5 ms，測(cè)量時(shí)紙速400 mm/s。程控刺激：分別于冠狀竇近端、遠(yuǎn)端行S1S1刺激和S1S2刺激，S1S1刺激：刺激周長(zhǎng)為500 ms；S1S2刺激，按8∶1比例釋放，聯(lián)律周期從350 ms開(kāi)始遞減，步長(zhǎng)-10 ms，直至局部心肌組織有效不應(yīng)期。

1.4 高位、低位右心房到冠狀竇近端、遠(yuǎn)端傳導(dǎo)時(shí)間測(cè)量 起搏高位右心房及低位右心房時(shí)，分別測(cè)量高位右心房A波起始到冠狀竇近端A波起始、遠(yuǎn)端A波起始的傳導(dǎo)時(shí)間；測(cè)量低位右心房A波起始到冠狀竇近端A波起始、遠(yuǎn)端A波起始的傳導(dǎo)時(shí)間。連續(xù)測(cè)量3個(gè)心動(dòng)周期取其平均值。

2 結(jié)果

2.1 對(duì)照組與心房顫動(dòng)組冠狀竇近端、遠(yuǎn)端不應(yīng)期比較 對(duì)照組與心房顫動(dòng)組冠狀竇近端、遠(yuǎn)端不應(yīng)期比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05，見(jiàn)表1)。

Table 1 Comparison of the refractory period in the proximal end and the distal end of coronary sinus between control group and AF group

組別例數(shù)冠狀竇近端冠狀竇遠(yuǎn)端對(duì)照組23224±22230±33心房顫動(dòng)組19228±34219±28t值-0.4200.837P值 0.6770.407

2.2 對(duì)照組與心房顫動(dòng)組不同起搏時(shí)間高位右心房到冠狀竇近端、遠(yuǎn)端傳導(dǎo)時(shí)間比較 對(duì)照組與心房顫動(dòng)組不同起搏時(shí)間高位右心房到冠狀竇近端傳導(dǎo)時(shí)間比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；對(duì)照組與心房顫動(dòng)組起搏時(shí)間500、400、350 ms時(shí)高位右心房到冠狀竇遠(yuǎn)端傳導(dǎo)時(shí)間比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；對(duì)照組與心房顫動(dòng)組起搏時(shí)間300、280 ms時(shí)高位右心房到冠狀竇遠(yuǎn)端傳導(dǎo)時(shí)間比較，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05，見(jiàn)表2)。

2.3 對(duì)照組與心房顫動(dòng)組不同起搏時(shí)間低位右心房到冠狀竇近端、遠(yuǎn)端傳導(dǎo)時(shí)間比較 對(duì)照組與心房顫動(dòng)組起搏時(shí)間500、400 ms時(shí)低位右心房到冠狀竇近端、遠(yuǎn)端傳導(dǎo)時(shí)間比較，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)；對(duì)照組與心房顫動(dòng)組起搏時(shí)間350、300、280 ms時(shí)低位右心房到冠狀竇近端、遠(yuǎn)端傳導(dǎo)時(shí)間比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05，見(jiàn)表3)。

3 討論

冠狀竇有助心房顫動(dòng)的促發(fā)和維持通過(guò)其傳導(dǎo)特性[11]。冠狀竇提供右心房和左心房的傳導(dǎo)緩慢連接，導(dǎo)致冠狀竇和冠狀竇左心房交界處激動(dòng)延遲。冠狀竇的慢傳導(dǎo)和傳導(dǎo)阻滯便于折返性心動(dòng)過(guò)速沿冠狀竇和冠狀竇心房交界處傳導(dǎo)。冠狀竇肌肉組織的折返電路可能是心房顫動(dòng)的機(jī)制。

Table 2 Comparison of the conduction time from HRA to the proximal end and the distal end of coronary sinus at different time points of pacemaking between control group and AF group

組別例數(shù)冠狀竇近端500ms 400ms 350ms 300ms 280ms冠狀竇遠(yuǎn)端500ms 400ms 350ms 300ms 280ms對(duì)照組2376±1675±1575±1574±1675±16102±18101±17100±18100±19101±16心房顫動(dòng)組1981±2583±2784±2885±3286±32112±22113±23112±23116±29117±30t值-0.898-1.219-1.229-1.527-1.434-1.616-1.917-1.916-2.176-2.187P值0.3750.2300.2260.1350.1590.1140.0620.0630.0360.035

Table 3 Comparison of the conduction time from LRA to the proximal end and the distal end of coronary sinus at different time points of pacemaking between control group and AF group

組別例數(shù)冠狀竇近端500ms 400ms 350ms 300ms 280ms冠狀竇遠(yuǎn)端500ms 400ms 350ms 300ms 280ms對(duì)照組2363±1963±1863±1964±2065±21101±19100±19100±18100±19102±20心房顫動(dòng)組1978±2279±2776±2678±3079±27116±23117±26114±27117±30116±29t值-2.426-2.197-1.976-1.947-1.865-2.275-2.408-1.993-2.217-1.864P值0.0200.0340.0550.0590.0690.0280.0210.0530.0520.070

研究發(fā)現(xiàn)，持續(xù)性心房顫動(dòng)患者和陣發(fā)性心房顫動(dòng)患者Bachmann束不應(yīng)期較對(duì)照組長(zhǎng)，持續(xù)性心房顫動(dòng)患者冠狀竇口有效不應(yīng)期較對(duì)照組長(zhǎng)[12]。本研究發(fā)現(xiàn)，陣發(fā)性心房顫動(dòng)組和對(duì)照組冠狀竇近端和遠(yuǎn)端不應(yīng)期無(wú)差異，和上述研究結(jié)果不一致。主要考慮以下原因：樣本量小不足以產(chǎn)生統(tǒng)計(jì)學(xué)差異；與入選的心房顫動(dòng)類(lèi)型有關(guān)，國(guó)外試驗(yàn)入選的是持續(xù)性心房顫動(dòng)患者，而本研究入選的是陣發(fā)性心房顫動(dòng)患者。

本研究發(fā)現(xiàn)，對(duì)照組和心房顫動(dòng)組高位右心房到冠狀竇遠(yuǎn)端傳導(dǎo)時(shí)間有差異,起搏時(shí)間300、280 ms時(shí)顯著；對(duì)照組和心房顫動(dòng)組低位右心房到冠狀竇近端、遠(yuǎn)端傳導(dǎo)時(shí)間有差異,起搏時(shí)間500、400 ms時(shí)顯著,說(shuō)明心房顫動(dòng)患者左右心房間存在傳導(dǎo)延緩或阻滯。本研究和國(guó)外Platonov等[13]研究發(fā)現(xiàn),對(duì)冠狀竇遠(yuǎn)端進(jìn)行程序刺激，陣發(fā)性心房顫動(dòng)患者右心房到冠狀竇近端傳導(dǎo)時(shí)間比對(duì)照組長(zhǎng)〔(110±47)ms與(69±16)ms,P<0.05〕相似。遞減起搏，持續(xù)性心房顫動(dòng)患者在Bachmann束和冠狀竇口的傳導(dǎo)時(shí)間比陣發(fā)性心房顫動(dòng)或?qū)φ战M延長(zhǎng)[12]。研究發(fā)現(xiàn)，89%存在冠狀竇遠(yuǎn)端-左心房傳導(dǎo)阻滯的患者，均有心房顫動(dòng)或非典型房撲發(fā)作史[8]。冠狀竇組織的傳導(dǎo)延緩增加了房性心律失常的傾向[7]。Morita等[14]研究發(fā)現(xiàn)，犬冠狀竇-心房連接處的電傳導(dǎo)變慢。所以，冠狀竇與左右心房間發(fā)生傳導(dǎo)延緩或傳導(dǎo)阻滯，易導(dǎo)致折返形成，繼而誘發(fā)心房顫動(dòng)。

本研究證實(shí)，心房顫動(dòng)患者冠狀竇存在電傳導(dǎo)延緩或傳導(dǎo)阻滯，但具體機(jī)制仍不清楚，可能與心房顫動(dòng)患者的電重構(gòu)和解剖重構(gòu)有關(guān)，還有待進(jìn)一步試驗(yàn)研究證實(shí)。

綜上所述，冠狀竇組織和冠狀竇心房交界的電傳導(dǎo)延緩或傳導(dǎo)阻滯可能是心房顫動(dòng)促發(fā)和維持的潛在機(jī)制。在心房顫動(dòng)患者中，冠狀竇局部存在電傳導(dǎo)延緩或傳導(dǎo)阻滯，通過(guò)改變這些電傳導(dǎo)特性，可為心房顫動(dòng)射頻消融術(shù)提供新的治療策略。本研究還存在一定局限性：樣本量少對(duì)結(jié)果可能產(chǎn)生一定的誤差，今后還需進(jìn)一步大樣本的前瞻性研究。

利益沖突聲明：本課題未涉及任何廠家及相關(guān)雇主或其他經(jīng)濟(jì)組織直接或間接的經(jīng)濟(jì)或利益的贊助。無(wú)利益沖突。

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修回日期：2015-06-15)

(本文編輯：陳素芳)

Clinical Study of the Characteristics of Electrical Conduction Between Left and Right Atriums in Patients With Paroxysmal Atrial Fibrillation

LINMing-kuan,LIUHao,ZHOUTing.

Post-GraduateofElectrophysiology,GuangxiMedicalUniversity,Nanning530021,China

Objective To study the characteristics of electrical conduction between left and right heart atriums in patients with paroxysmal atrial fibrillation (PAF).Methods Enrolled 19 PAF patients who received pulsed radiofrequency treatment into the First Affiliated Hospital of Guangxi Medical University from April 2012 to May 2013 as AF group.And another 23 patients with paroxysmal supraventricular tachycardia or ventricular premature contraction were enrolled as control group.A fixed program of SIS was applied.At 500,400,350,300 and 280 ms,pace-making was made in high right atrium (HRA) and low right atrium (LRA),and we measured the refractory period in the proximal end and the distal end of coronary sinus and the conduction time from HRA and LRA to the proximal end and the distal end of coronary sinus.Results Control group and AF group were not significantly different (P>0.05) in the refractory period in the proximal end and distal end of coronary sinus.Control group and AF group were not significantly different (P>0.05) in the conduction time from HRA to the proximal end of coronary sinus at different time points of pace-making;control group and AF group were not significantly different (P>0.05) in the conduction time from HRA to the distal end of coronary sinus at 500,400,350 ms of pace-making;the AF group was higher (P<0.05) than control group in the conduction time from HRA to the distal end of coronary sinus at 300 and 280 ms of pacemaking.AF group was higher (P<0.05) than the control group in the conduction time from LRA to the proximal end and the distal end of coronary sinus at 500 and 400 ms of pacemaking;the control group and the AF group were not significantly different (P>0.05) in the conduction time from LRA to the proximal end and the distal end of coronary sinus.Conclusion Conduction delay exists in the coronary sinus and the junction of coronary sinus and heart atrium,which may be involved in the onset and sustaining of atrial fibrillation.

Atrial fibrillation；Pulsed radiofrequency treatment；Refractory period,electrophysiological

廣西醫(yī)療衛(wèi)生重點(diǎn)科研課題資助項(xiàng)目(桂衛(wèi)重200923)

530021廣西南寧市，廣西醫(yī)科大學(xué)電生理專(zhuān)業(yè)碩士研究生(林明寬)；廣西醫(yī)科大學(xué)第一附屬醫(yī)院心內(nèi)科(劉浩)，胸外科(周婷)

劉浩，530021廣西南寧市，廣西醫(yī)科大學(xué)第一附屬醫(yī)院心內(nèi)科；E-mail:Liuhaomd@163.com

R 541.75

A

10.3969/j.issn.1007-9572.2015.24.026

2014-12-21；