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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2020, Vol. 17 ›› Issue (12) : 1220 -1226. doi: 10.3877/cma.j.issn.1672-6448.2020.12.014

所属专题： 文献；

心血管超声影像学

阵发性心房颤动患者环肺静脉射频消融术后复发的预测因素研究
徐敏1, 刘飞1, 葛志翔1, 缪羽霞1, 孟军1, 杨珍妮1,†()   
  1. 1. 213003 苏州大学附属第三医院 常州市第一人民医院心超室
  • 收稿日期:2020-02-14 出版日期:2020-12-01
  • 通信作者: 杨珍妮
  • 基金资助:
    国家自然科学青年基金项目(81701734); 常州市卫健委指导项目(WZ201804); 常州市科技局应用基础研究(CJ20190086)

Predictors of recurrence in patients with paroxysmal atrial fibrillation after circumferential pulmonary vein radiofrequency ablation

Min Xu1, Fei Liu1, Zhixiang Ge1, Yuxia Miao1, Jun Meng1, Zhenni. Yang1,†()   

  1. 1. Echocardiogram Room of Changzhou First People's Hospital, the Third Affiliated Hospital of Suzhou University, Changzhou 213003, China
  • Received:2020-02-14 Published:2020-12-01
  • Corresponding author: Zhenni. Yang
  • About author:
    Corresponding author: Yang Zhenni, Email:
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引用本文：

徐敏, 刘飞, 葛志翔, 缪羽霞, 孟军, 杨珍妮. 阵发性心房颤动患者环肺静脉射频消融术后复发的预测因素研究[J]. 中华医学超声杂志（电子版）, 2020, 17(12): 1220-1226.

Min Xu, Fei Liu, Zhixiang Ge, Yuxia Miao, Jun Meng, Zhenni. Yang. Predictors of recurrence in patients with paroxysmal atrial fibrillation after circumferential pulmonary vein radiofrequency ablation[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2020, 17(12): 1220-1226.

目的

探讨阵发性心房颤动（PAF）患者左心房功能联合B型脑钠肽（BNP）预测环肺静脉射频消融术（CPVA）后复发的意义。

方法

选取2017年1月至2018年12月在常州市第一人民医院住院的拟行第一次CPVA术的PAF患者201例。CPVA术前测定患者血液BNP水平；实时三维超声心动图（RT-3DE）获取左心房时间-容积曲线；根据术后3个月动态心电图结果，将PAF患者分为窦性心律组和复发组。应用多因素Logistic回归分析影响CPVA术后PAF复发的独立危险因素；对获得的独立危险因素行预测PAF复发的ROC曲线，比较不同指标的效能。

结果

201例PAF患者完成CPVA术，随访中36例（17.9%）复发，复发组BNP高于窦性心律组（P＜0.05）。2组间左心房最大容积指数（LAVImax）、左心房最小容积指数（LAVImin）差异有统计学意义（均P＜0.05）；2组间膨胀指数（EI）、舒张期射血指数（DEI）、被动射血指数（PEI）、主动射血指数（AEI）差异均有统计学意义（均P＜0.05）。多因素Logistic回归分析表明：术前BNP、DEI及PAF病史是PAF复发的独立预测因素（均P＜0.05）。ROC曲线显示：DEI及联合指标（DEI+BNP）预测CPVA术后复发的效能均优于LAVImin（AUC：0.881 vs 0.686、0.901 vs 0.686，均P<0.05）；联合诊断的特异性优于DEI及BNP（89.7% vs 79.4%、89.7% vs 72.7%，均P＜0.05）。

结论

CPVA术治疗的PAF患者中，左心房存储功能受损及BNP增高均是CPVA术后PAF复发的独立预测因素，两者联合可提高预测复发的特异度。

关键词: 心房颤动, B型脑钠肽, 环肺静脉射频消融术, 复发, 超声心动描记术
Objective

To observe the significance of left atrial (LA) function combined with B-type natriuretic peptide (BNP) in predicting the recurrence of paroxysmal atrial fibrillation (PAF) after cardiopulmonary vein ablation (CPVA).

Methods

A total of 201 PAF patients from Changzhou NO.1 People's Hospital who planned to receive the first CPVA operation were selected. According to the results of dynamic electrocardiogram 3 months after CPVA, AF patients were divided into either a sinus rhythm group or a recurrence group. Multivariate logistic regression analysis was performed to analyze the independent factors influencing the recurrence of PAF after CPVA. Receiver operating characteristic (ROC) curve analysis was used to compare the diagnostic efficiency of each index.

Results

Of the 201 AF patients who underwent CPVA, 36 (17.9%) experienced recurrent AF during follow-up. BNP in the recurrence group was significantly higher than that of the sinus rhythm group (P＜0.05). There were significant differences in LA minimum volume index (LAVImin), LA maximum volume index (LAVImax), expansion index (EI), diastolic ejection index (DEI), passive ejection index (PEI), and active ejection index (AEI) between the two groups P＜0.05 for all). Multivariate logistic regression analysis showed that BNP, DEI, and history of PAF were independent predictors of AF recurrence (P＜0.05). ROC curve analysis showed that the areas under the ROC curves (AUCs) of DEI and combination index (DEI+BNP) were both better than LAVImin (AUC: 0.881 vs 0.686, 0.901 vs 0.686, P＜0.05 for both), and the specificity of the combination index (DEI+BNP) was better than either of them alone (89.7% vs 79.4%, 89.7% vs 72.7%, P＜0.05 for both).

Conclusions

In patients with PAF treated by CPVA, impaired LA storage function and increased BNP are independent predictors of AF recurrence after CPVA. The combination of the two can improve the specificity of diagnosis.

Key words: Atrial fibrillation, B-type natriuretic peptide, Circumferential pulmonary vein ablation, Recurrence, Echocardiography
表1 行环肺静脉射频消融术（CPVA）的201例阵发性心房颤动患者临床资料
变量 总体(n=201) 复发组(n=36) 窦性心律组(n=165) 统计值 P值
年龄(岁，
x¯
±s)		 63±10 61±12 64±9 t=1.408 0.161
年龄≥65岁[例(%)] 95(47.3) 20(55.6) 75(45.5) x2=0.838 0.360
BMI(kg/m2，
x¯
±s)		 23.5±3.0 23.4±3.7 23.6±2.9 t=-0.370 0.712
女性[例(%)] 29(14.4) 4(11.1) 25(15.2) x2=0.132 0.716
房颤病程(月，
x¯
±s)		 7.8±4.2 9.7±4.8 7.4±4.0 t=2.994 0.003
高血压[例(%)] 51(25.4) 9(25.0) 42(25.5) x2=0.024 0.877
糖尿病[例(%)] 44(21.9) 6(16.7) 38(23.0) x2=0.377 0.539
高胆固醇血症[例(%)] 30(14.9) 6(16.7) 24(14.5) x2=0.004 0.948
阻塞性睡眠呼吸暂停[例(%)] 18(9.0) 4(11.1) 14(8.5) x2=0.032 0.859
饮酒[例(%)] 41(20.4) 5(13.9) 36(21.8) x2=0.708 0.400
中风或TIA史[例(%)] 19(9.5) 4(11.1) 15(9.1) x2=0.004 0.951
血管疾病史[例(%)] 18(9.0) 4(11.1) 14(8.5) x2=0.032 0.859
CHADS2[M(QR)] 1.0(0,1.0) 1.0(0,1.0) 1.0(0,1.0) Z=0.133 0.894
CHA2DS2-VASc[M(QR)] 1.0(0,1.0) 1.0(1.0,3.0) 1.0(1.0,2.0) Z=0.206 0.837
心率[次/分,M(QR)] 78(63,92) 80(64,92) 78(63,92) Z=0.869 0.862
血肌酐(μmol/L，
x¯
±s)		 61±18 62±12 61±19 t=0.514 0.608
左心耳射血速度(cm/s，
x¯
±s)		 56±8 55±7 57±8 t=1.465 0.145
表2 201例阵发性心房颤动患者术前常规超声及容积、功能指标比较(
xˉ
±s)
变量 总体(n=201) 复发组(n=36) 窦性心律组(n=165) 统计值 P值
BNP[μg/L,M(QR)] 348(208,572) 530.5(378,671) 285(192,451) Z=4.235 0.000
LVEF[%,M(QR)] 56(51,60) 56(51,60) 56(51,60) Z=0.350 0.727
LAVImax(ml/m2) 34.5±4.5 35.9±4.6 34.2±4.4 t=2.035 0.043
LAVImin(ml/m2) 20.9±3.0 22.5±3.1 20.5±2.9 t=3.635 0.001
LAVIpre-a(ml/m2) 27.3±4.1 28.5±3.2 27.0±4.3 t=1.912 0.057
EI(%) 63.9±14.1 48.2±11.5 67.4±12.2 t=8.687 0.000
DEI(%) 38.5±5.4 32.1±5.4 40.0±4.3 t=9.434 0.000
PE(%) 52.7±14.7 48.7±15.6 53.6±14.4 t=1.821 0.115
PEI(%) 20.3±6.2 15. 5±5.3 21.3±5.9 t=5.449 0.000
AE(%) 47.3±14.7 51.3±15.6 46.4±14.4 t=1.821 0.115
AEI(%) 22.7±7.0 19.5±6.5 23.4±6.9 t=3.065 0.000
表3 多因素Logistic回归分析射频消融术后心房颤动复发的影响因素
变量 回归系数 Sem OR值(95%CI) P值
BNP(μg/L) 0.003 0.001 1.003(1.001~1.006) 0.002
DEI(%) -0.401 0.072 0.670(0.582~0.771) 0.001
病程(月) 0.139 0.058 1.150(1.027~1.288) 0.016
图1 LAVImin、BNP、DEI及联合方法（DEI+BNP）预测心房颤动患者环肺静脉射频消融术后复发的ROC曲线
表4 ROC曲线评价术前各指标预测心房颤动复发的价值
变量 截断值 AUC 敏感度(%) 特异度(%) 95%CI
LAVImax(ml/m2) 33.5 0.601 72.2 48.5 0.530~0.669
LAVImin(ml/m2) 21.9 0.686 61.1 72.1 0.617~0.749
LAVIpre-a(ml/m2) 27.2 0.633 72.2 56.4 0.562~0.700
DEI(%) 36.7 0.881 88.9 79.4 0.828~0.922
BNP(μg/L) 432 0.731 72.2 72.7 0.664~0.791
BNP(μg/L)＋DEI(%) ≥432＋≤36.7 0.901 77.8 89.7 0.851~0.938
1
Morillo CA, Verma A, Connolly SJ, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial [J]. JAMA, 2014, 311(7):692-700.
2
Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design [J]. J Interv Card Electrophysiol, 2012, 33(2):171-257.
3
Iwasaki YK, Nishida K, Kato T, et al. Atrial fibrillation pathophysiology: implications for management [J]. Circulation, 2011, 124(20): 2264-2274.
4
Mor-Avi V, Yodwut C, Jenkins C, et al. Real-time 3D echocardiographic quantification of left atrial volume: multicenter study for validation with CMR[J]. JACC Cardiovasc Imaging, 2012, 5(8): 769-777.
5
Zhang Y, Chen A, Song L, et al. Association between baseline natriuretic peptides and atrial fibrillation recurrence after catheter ablation [J]. Int Heart J, 2016, 57(2): 183-189.
6
Thomas L, Marwick TH, Popescu BA, et al. Left atrial structure and function, and left ventricular diastolic dysfunction: JACC state-of-the-art review [J]. J Am Coll Cardiol, 2019, 73(15): 1961-1977.
7
Miyasaka Y, Tsujimoto S, Maeba H, et al. Left atrial volume by real-time three-dimensional echocardiography: validation by 64-slice multidetector computed tomography [J]. J Am Soc Echocardiogr, 2011, 24(6): 680-686.
8
Geelhoed B, Börschel CS, Niiranen T, et al. Assessment of causality of natriuretic peptides and atrial fibrillation and heart failure: a Mendelian randomization study in the FINRISK cohort [J]. Europace, 2020, 22(10): 1463-1469.
9
Allessie M, Ausma J, Schotten U. Electrical, contractile and structural remodeling during atrial fibrillation [J]. Cardiovasc Res, 2002, 54(2):230-246.
10
Pathak R, Lau DH, Mahajan R, et al. Structural and functional remodeling of the left atrium: clinical and therapeutic implications for atrial fibrillation[J]. J Atr Fibrillation, 2013, 6(4): 986.
11
Fornengo C, Antolini M, Frea S, et al. Prediction of atrial fibrillation recurrence after cardioversion in patients with left-atrial dilation[J]. Eur Heart J Cardiovasc Imaging, 2015, 16(3): 335-341.
12
Olsen FJ, Bertelsen L, de Knegt MC, et al. Multimodality cardiac imaging for the assessment of left atrial function and the association with atrial arrhythmias[J]. Circ Cardiovasc Imaging, 2016, 9(10): e004947.
13
Nagaya M, Kawasaki M, Tanaka R, et al. Quantitative validation of left atrial structure and function by two-dimensional and three-dimensional speckle tracking echocardiography: a comparative study with three-dimensional computed tomography [J]. J Cardiol, 2013, 62(3): 188-194.
14
Habibi M, Lima J, Gucuk Ipek E, et al. The association of baseline left atrial structure and function measured with cardiac magnetic resonance and pulmonary vein isolation outcome in patients with drug-refractory atrial fibrillation[J]. Heart Rhythm, 2016, 13(5): 1037-1044.
15
Degiovanni A, Boggio E, Prenna E, et al. Association between left atrial phasic conduit function and early atrial fibrillation recurrence in patients undergoing electrical cardioversion[J]. Clin Res Cardiol, 2018, 107(4): 329-337.
16
Gould PA, Gula LJ, Bhayana V, et al. Characterization of cardiac brain natriuretic peptide release in patients with paroxysmal atrial fibrillation undergoing left atrial ablation[J]. Circ Arrhythm Electrophysiol, 2010, 3(1): 18-23.
17
Bernard-Brunet A, Saint Etienne C, Piver E, et al. Incomplete recovery of mechanical and endocrine left atrial functions one month after electrical cardioversion for persistent atrial fibrillation: a pilot study [J]. J Transl Med, 2014, 12: 51.
18
Xu X, Tang Y. Relationship between brain natriuretic peptide and recurrence of atrial fibrillation after successful electrical cardioversion: an updated meta-analysis [J]. Braz J Cardiovasc Surg, 2017, 32(6): 530-535.
19
Silvet H, Young-Xu Y, Walleigh D, et al. Brain natriuretic peptide is elevated in outpatients with atrial fibrillation [J]. Am J Cardiol, 2003, 92(9): 1124-1127.
20
Jiang H, Wang W, Wang C, et al. Association of pre-ablation level of potential blood markers with atrial fibrillation recurrence after catheter ablation: a meta-analysis [J]. Europace, 2017, 19(3): 392-400.
21
Springer J, Azer J, Hua R, et al. The natriuretic peptides BNP and CNP increase heart rate and electrical conduction by stimulating ionic currents in the sinoatrial node and atrial myocardium following activation of guanylyl cyclase-linked natriuretic peptide receptors [J]. J Mol Cell Cardiol, 2012, 52(5): 1122-1134.
22
Sramko M, Wichterle D, Melenovsky V, et al. Independent effect of atrial fibrillation on natriuretic peptide release [J]. Clin Res Cardiol, 2019, 108(2): 142-149.
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