杨丽红;王庆义;李涵;杨蕊珂;张恒源;丁婧;陈嘉楠;张路明;刘小静;徐金义;

• 1:河南省人民医院郑州大学人民医院

摘要(Abstract)：

目的通过直立倾斜试验(HUTT)探究自主神经功能障碍对阵发性房颤(PAF)患者射频导管消融术后房颤复发的独立预测价值。方法连续纳入2016-01—2019-12在河南省人民医院心内科首次成功完成环肺静脉射频消融术治疗的阵发性房颤患者208例。所有患者术前行HUTT,根据试验结果分为阳性组(67例)及阴性组(141例)。所有患者在出院前及消融后1、3、6、9、12个月进行十二导联心电图和24 h动态心电图记录,术后由一名医生每月通过电话或门诊随访,了解有无房颤复发,如果患者出现心悸,则追加十二导联心电图和24 h动态心电图。根据术后随访结果将患者分为房颤复发组(n=73)和未复发组(n=135)。采用多因素Cox回归分析评估HUTT对导管消融后房颤复发的独立预测作用。结果复发组PAF患者HUTT阳性率明显高于未复发组,差异有统计学意义(47.9%vs 23.7%,P<0.001)。多因素Cox回归分析显示HUTT阳性(HR:0.433,95%CI:0.240～0.783,P=0.006)、睡眠呼吸暂停(HR:1.966,95%CI:1.025～3.770,P=0.042)、左房内径(HR:1.068,95%CI:1.018～1.121,P=0.007)和房颤持续时间(HR:1.327,95%CI:1.188～1.483,P<0.001)是阵发性房颤射频消融术后临床复发的独立预测因子。HUTT阴性组患者消融成功率73.0%,而HUTT阳性组患者消融成功率47.8%(Log-Rank P<0.001)。结论 HUTT阳性的PAF患者射频消融术后房颤复发的风险增加,HUTT是PAF患者射频消融术后房颤复发的重要预测因子,自主神经功能障碍可能会增加PAF患者CVPI术后的临床复发风险。

关键词(KeyWords)： 自主神经功能障碍;直立倾斜试验;射频导管消融术;房颤;复发

Abstract:

Keywords:

基金项目(Foundation): 河南省教育厅重点科研立项(编号：18A320053)

作者(Authors): 杨丽红;王庆义;李涵;杨蕊珂;张恒源;丁婧;陈嘉楠;张路明;刘小静;徐金义;

参考文献(References)：

• [1]ZIMETBAUM P.Atrial Fibrillation[J].Ann Intern Med,2017,166(5):ITC33-ITC48.DOI:10.7326/AITC201703070.
• [2]AGARWAL S K,NORBY F L,WHITSEL E A,et al.Cardiac Autonomic Dysfunction and Incidence of Atrial Fibrillation[J].J Am Coll Cardiol,2017,69(3):291-299.DOI:10.1016/j.jacc.2016.10.059.
• [3]KALLISTRATOS M S,POULIMENOS L E,MANOLIS AJ.Atrial fibrillation and arterial hypertension[J].Pharmacol Res,2018,128:322-326.DOI:10.1016/j.phrs.2017.10.007.
• [4]GONG K Z,YAN Q D,HUANG R D,et al.The impact of echocardiographic parameter ratio of E/E’on the late recurrence paroxysmal atrial fibrillation in patients accepted radiofrequency catheter ablation[J].Medicine(Baltimore),2020,99(17):e19897.DOI:10.1097/MD.0000000000019897.
• [5]XI Y,CHENG J.Dysfunction of the autonomic nervous system in atrial fibrillation[J].J Thorac Dis,2015,7(2):193-198.DOI:10.3978/j.issn.2072-1439.2015.01.12.
• [6]ZHOU Z,LI S Y,SHENG X,et al.Interactions between metabolism regulator adiponectin and intrinsic cardiac autonomic nervous system:A potential treatment target for atrial fibrillation[J].Int J Cardiol,2020,302:59-66.DOI:10.1016/j.ijcard.2019.12.031.
• [7]STAVRAKIS S,NAKAGAWA H,PO S S,et al.The role of the autonomic ganglia in atrial fibrillation[J].JACCClin Electrophysiol,2015,1(1/2):1-13.DOI:10.1016/j.jacep.2015.01.005.
• [8]GUSSAK G,PFENNIGER A,WREN L,et al.Region specific parasympathetic nerve remodeling in the left atrium contributes to creation of a vulnerable substrate for atrial fibrillation[J].JCI Insight,2019,4(20):e130532.DOI:10.1172/jci.insight.130532.
• [9]HARVEY W.Classic pages in obstetrics and gynecology.Exercitatio anatomica de motu cordis et sanguinis in animalibus[J].Am J Obstet Gynecol,1975,121(7):1007.
• [10]LEVY M N.Sympathetic-parasympathetic interactions in the heart[J].Circ Res,1971,29:437-445.
• [11]MARTINS J B,ZIPES D P.Effects of sympathetic and vagal nerves on recovery properties of the endocardium and epicardium of the canine left ventricle[J].Circ Res,1980,46:100-110.DOI:10.1161/01.res.46.1.100.
• [12]YUAN B X,ARDELL J L,HOPKINS D A,et al.Gross and microscopic anatomy of the canine intrinsic cardiac nervous system[J].Anat Rec,1994,239:75-87.DOI:10.1002/ar.1092390109.
• [13]CHEN P S,CHEN L S,FISHBEIN M C,et al.Role of the autonomic nervous system in atrial fibrillation pathophysiology and therapy[J].Circ Res,2014,114(9):1500-1515.
• [14]QIN M,ZENG C,LIU X.The cardiac autonomic nervous system:A target for modulation of atrial fibrillation[J].Clin Cardiol,2019,42(6):644-652.DOI:10.1002/clc.23190.
• [15]ARORA R.Recent insights into the role of the autonomic nervous system in the creation of substrate for atrial fibrillation:implications for therapies targeting the atrial autonomic nervous system[J].Circ Arrhythm Electrophysiol,2012,5(4):850-859.DOI:10.1161/CIR-CEP.
• [16]VOLDERS P G.Novel insights into the role of the sympathetic nervous system in cardiac arrhythmogenesis[J].Heart Rhythm,2010,7(12):1900-1906.DOI:10.1016/j.hrthm.2010.06.003.
• [17]PATTERSON E,PO S S,SCHERLAG B J,et al.Triggered firing in pulmonary veins initiated by in vitro autonomic nerve stimulation[J].Heart Rhythm,2005,2(6):624-631.DOI:10.1016/j.hrthm.2005.02.012.
• [18]CHOI E K,CHANG P C,LEE Y S,et al.Triggered firing and atrial fibrillation in transgenic mice with selective atrial fibrosis induced by overexpression of TGF-β1[J].Circ J,2012,76(6):1354-1362.DOI:10.1253/circj.cj-11-1301.
• [19]LU Z,SCHERLAG B J,LIN J,et al.Autonomic mechanism for initiation of rapid firing from atria and pulmonary veins:evidence by ablation of ganglionated plexi[J].Cardiovasc Res,2009,84(2):245-252.DOI:10.1093/cvr/cvp194.
• [20]STAVRAKIS S,HUMPHREY M B,SCHERLAG B J,et al.Low level transcutaneous electrical vagus nerve stimulation suppresses atrial fibrillation[J].J Am Coll Cardiol,2015,65(9):867-875.DOI:10.1016/j.jacc.2014.12.026.
• [21]POKUSHALOV E,ROMANOV A,CORBUCCI G,et al.A randomized comparison of pulmonary vein isolation with versus without concomitant renal artery denervation in patients with refractory symptomatic atrial fibrillation and resistant hypertension[J].J Am Coll Cardiol,2012,60(13):1163-1170.DOI:10.1016/j.jacc.2012.05.036.
• [22]YU L L,HUANG B,WANG Z,et al.Impacts of Renal Sympathetic Activation on Atrial Fibrillation:The Potential Role of the Autonomic Cross Talk Between Kidney and Heart[J].J Am Heart Assoc,2017,6(3):e004716.DOI:10.1161/JAHA.116.004716.
• [23]KIM W,OH NA J,THOMAS R J,et al.Impact of Cathe ter Ablation on Sleep Quality and Relationship Between Sleep Stability and Recurrence of Paroxysmal Atrial Fibrillation After Successful Ablation:24-Hour HolterBased Cardiopulmonary Coupling Analysis[J].J Am Heart Assoc,2020,9(23):e017016.DOI:10.1161/JAHA.120.017016.
• [24]杨丽红,王庆义,李涵,等.儿童直立倾斜试验操作标准的临床研究[J].中国实用神经疾病杂志,2019,22(18):2032-2036.DOI:10.12083/SYSJ.2019.18.338.
• [25]ISHBULATOV Y M,KARAVAEV A S,KISELEV A R,et al.Mathematical modeling of the cardiovascular autonomic control in healthy subjects during a passive headup tilt test[J].Sci Rep,2020,10(1):16525.DOI:10.1038/s41598-020-71532-7.