房颤冷冻消融中右侧膈神经稳定起搏的方法探讨  

Method discussion for steadily right phrenic nerve pacing with cryoballoon ablation for atrial fibrillation

作　　者：刘铮[1] 贺嘉[1] 方丕华[1] 陈雄彪[1] 周公哺[1] 李崇强[2] 唐闽[1] 张竟涛 贾玉和[1] 任岚[3] 张澍[1] 

机构地区：[1]中国医学科学院北京协和医学院国家心血管病中心心血管疾病国家重点实验室阜外医院心律失常中心,100037 [2]中国医学科学院北京协和医学院国家心血管病中心心血管疾病国家重点实验室阜外医院介入导管室,100037 [3]北京积水潭医院心内科

出　　处：《中国心血管杂志》2015年第6期429-433,共5页Chinese Journal of Cardiovascular Medicine

基　　金：国家自然科学基金资助项目(81270241)~~

摘　　要：目的右侧膈神经麻痹是冷冻球囊消融治疗房颤时最常见并发症。消融时监测膈神经活动是预防该并发症的有效措施。本研究通过测量上腔静脉区域起搏阈值和不同部位起搏的膈肌复合运动动作电位的方法,探讨膈神经的影像学的最佳起搏部位。方法前瞻性入选了32例接受冷冻球囊治疗的房颤患者。将可调弯标测电极导管以倒"U"字形放置到上腔静脉区域,使导管头端指向上腔静脉游离壁侧,右前斜造影判断上腔静脉形态,以及前壁、游离壁和后壁三个位点,将胸锁关节下第一、第二和第三椎间隙分别定义为上腔静脉区域的上、中、下三段。在各部位予以膈神经起搏(固定脉宽2 ms、起搏周长1 000 ms),通过改良的Ⅰ导联监测起搏膈神经时膈肌复合运动动作电位。检测各部位起搏阈值和各部位起搏输出5 m A时,膈肌复合运动动作电位的大小。结果采用倒"U"字形放置膈神经起搏导管可以达到稳定起搏。在32例患者中没有患者出现持续性膈神经麻痹。起搏位点共285个。可以发生膈神经夺获的位点占61.4%(175/285)。游离壁、后壁能够发生膈神经夺获的起搏位点显著多于前壁[游离壁为80.0%(76/95)、后壁为84.2%(80/95)、前壁为20.0%(19/95),P<0.001]。改良Ⅰ导联记录的后壁和游离壁起搏能够记录到膈肌复合运动动作电位的起搏点显著多于前壁起搏点(P<0.001)。膈神经起搏阈值和膈肌复合运动动作电位存在负相关性(r=-0.267,P=0.005)。结论通过倒"U"字形放置起搏导管于上腔静脉的后壁和游离壁,可以达到稳定的膈神经起搏。在起搏阈值最低的部位进行起搏可以展现更加清晰的膈肌复合运动动作电位,有助于冷冻消融时监测膈神经麻痹的发生。Objective Cryoballoon ablation to achieve pulmonary vein isolation is effective for patients with atrial fibrillation. Right phrenic nerve palsy （PNP） is a common complication during the procedure. Continuous monitoring the right phrenic nerve activity can reduced incidence of PNP. We try to explore an effective method for sustained right phrenic nerve pacing. Methods The 32 patients underwent cryoballoon ablation of atrial fibrillation were enrolled in the study. The deflectable pacing catheter were placed in the supra vena cava （SVC） region in an inverted ＂ U＂ shape. In the right anterior oblique position, the SVC region was longitudely divided into upper, medium, and lower regions according to the subclavian intervertebral space, and was horizontally separated into posterior, free, and anterior wall. The modified lead I was used to record the diaphragmatic compound motor action potential （CMAP） when pacing with 5 mA output. Results The phrenic nerve could be steadily captured by the pacing catheter in the SVC region with the inverted ＂U＂ fashion. No persistent PNP was observed in any of the 32 patients. A total of 285 pacing sites were tested. The phrenic nerve was captured in 175 sites （61.4% , 175/285 ）. Pacing at the posterior （84.2% , 80/95） and the free wall （80.0% , 76/95） of the SVC region were more easily to capture the phrenic nerve than at anterior wall （20.0%, 19/95）. With the stable pacing output of 5 mA, the CMAP was significantly higher when pacing at the posterior and free wall than in the anterior wall （P 〈0. 001 ）. The CMAP amplitude was negatively correlated with the pacing threshold （r = -0. 267, P = 0. 005）. Conclusions The phrenic nerve can be steadily captured with pacing catheter placed at the posterior and free wall of the SVC region with inverted ＂U＂ fashion. And pacing at site with lowest threshold can be present with clear CMAP in modified lead I, which can be helpful to predict PNP during cryoablation.

关 键 词：心房颤动 导管消融术 膈神经麻痹 膈神经起搏 起搏阈值 复合运动动作电位 

分 类 号：R541.7[医药卫生—心血管疾病]