2020 年第 3 期 第 15 卷

妊娠期快速心律失常零射线导管消融的可行性分析

Feasibility of catheter ablation of maternal tachyarrhythmia without fluoroscopy

作者：桑才华李梦梦龙德勇赖一炜蒋晨曦郭雪原赵欣李松南王伟汤日波杜昕董建增马长生

英文作者：

单位：首都医科大学附属北京安贞医院心内科北京市心肺血管疾病研究所100029

英文单位：

关键词：心律失常；妊娠；导管消融

英文关键词：

• 摘要：

• 【摘要】目的    研究零射线导管消融在妊娠合并快速心律失常患者中的作用与方法。方法    本研究连续纳入2015年1月至2018年12月于首都医科大学附属北京安贞医院就诊的无基础心脏疾病的妊娠期女性，通过回顾性分析电子病历，筛选出患有持续性心律失常且不伴有器质性心脏疾病的妊娠期患者。仅症状性心动过速发作频繁且药物治疗无效的患者接受了心腔内超声及三维电解剖标测系统指导下的零射线导管消融治疗。分析患者资料、电生理检查及射频消融结果和随访情况。结果    在12 584例因妊娠住院的患者中，156例存在持续性快速心律失常，其中最常见的心律失常为室性期前收缩（75例，48.1%），其次为室上性心动过速（32例，20.5%）、无症状心室预激（24例，15.4%）、心房颤动/心房扑动（8例，5.1%）、房性期前收缩（7例，4.5%）、室性心动过速（5例，3.2%）及房性心动过速（5例，3.2%）。28例患者最终接受了射频消融治疗，平均年龄（30±5）岁，射频消融时中位孕龄24周（四分位间距为17～29周）。其中2例为反复电复律无效的心房颤动患者，且发作时伴快心室率（＞200 次/min）而导致血流动力学不稳定。所有患者均在零射线下顺利完成手术，平均手术时间（72±25）min。电生理检查结果示室性心律失常13例、典型房室结折返性心动过速4例、无休止房性心动过速6例、WPW综合征3例、阵发性心房颤动2例。11例患者术中行心腔内超声指导下的零射线房间隔穿刺，3例患者围术期使用低分子肝素抗凝。28例患者均顺利分娩，中位分娩孕龄37周（四分位间距为34～39周）,分娩过程中无心血管不良事件。后续随访患者无心律失常复发，婴儿健康状况良好。结论    对于心动过速频发且药物治疗无效的症状性心律失常患者，零射线导管消融是安全、有效的治疗方案。

• 【Abstract】Objective    To investigate the feasibility of radiofrequency catheter ablation with zero fluoroscopy in pregnant patients with rapid arrhythmia. Methods    Electronic medical records of pregnant women admitted to Beijing Anzhen Hospital, Capital Medical University from January 2015 to December 2018 were retrospectively reviewed. Patients who had sustained tachycardia episodes with structurally normal heart were identified. Intracardiac echocardiography and catheter ablation under the guidance of electroanatomical mapping system were performed in those with drug-resistant and severely frequent tachyarrhythmia. Clinical data, electrophysiological examination, radiofrequency ablation results and patient outcomes were analyzed. Results    In 12 584 pregnant women there were 156 cases of persistent tachyarrhythmia, including ventricular premature contraction(75 cases, 48.1%), supraventricular tachycardia(32 cases, 20.5%), asymptomatic ventricular preexcitation(24 cases, 15.4%), atrial fibrillation/flutter(8 cases, 5.1%), atrial premature contraction(7 cases, 4.5%), ventricular tachycardia(5 cases, 3.2%) and atrial tachycardia(5 cases, 3.2%). Twenty-eight patients were treated with radiofrequency catheter ablation, with an average age of (30±5)years and a median gestational age of 24 weeks(interquartile range 17-29 weeks); 2 of them had no response to repeated cardioversion and instable hemodynamics caused by rapid ventricular rate (>200 times/min). Catheter ablation was successful performed in all patients without fluoroscopy, with a average operation time of (72±25)min. Electrophysiological examination showed 13 cases of ventricular arrhythmia, 4 cases of typical atrioventricular nodal reentrant tachycardia, 6 cases of sustained atrial tachycardia, 3 cases of WPW syndrome and 2 cases of paroxysmal atrial fibrillation. Trans-septal puncture was performed in 11 patients under the guidance of intracardiac echocardiography. Anticoagulation with low molecular weight heparin was used in 3 patients. Twenty-eight patients delivered healthy infants in a median of 37 weeks(interquartile range 34-39 weeks) without any cardiac adverse event. All patients were free of arrhythmia and the infants were well developed during follow-up. Conclusion    Sustained maternal tachyarrhythmia is not rare in clinical practice. To those with drug-resistant and severely frequent arrhythmia, radiofrequency catheter ablation with zero fluoroscopy could be safely performed with acceptable efficacy.