The effectiveness and safety of X-ray guided left atrial appendage occlusion combined with catheter ablation
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摘要: 目的 评估X线引导下左心耳封堵联合导管消融术的有效性和安全性。方法 纳入2017年3月—2022年4月在郑州市第七人民医院住院并接受导管消融的非瓣膜性心房颤动(房颤)患者，通过倾向性评分匹配，分为经食管超声心动图联合X线组(TEE组，73例)和单用X线组(DSA组，73例)。随访12个月，比较两组围手术期与随访期资料，评估单用X线指导左心耳封堵联合导管消融术的有效性、安全性以及经济效益。结果 两组患者均成功完成导管消融和左心耳封堵。DSA组少量心包积液事件发生率(20.5% vs 8.2%)、住院时间[(10.5±2.7)d vs (9.3±2.6)d]和住院花费[(156 517.7±13 271.2)元vs (146 028.1±12 481.1)元]均显著低于TEE组(均P < 0.05)。两组随访期间终点事件发生率均差异无统计学意义。结论 对于左心耳封堵联合导管消融，X线单独引导的有效性和安全性并不劣于X线联合经食管超声心动图，且在减少住院花费和住院时间上具有一定的优势。Abstract: Objective To explore the effectiveness and safety of X-ray guided left atrial appendage occlusion combined with catheter ablation.Methods Patients with non-valvular atrial fibrillation who underwent catheter ablation and were admitted to the 7th People's Hospital of Zhengzhou from March 2017 to April 2022 were included. These patients were divided into the transesophageal echocardiography combined with X-ray group (TEE group, n=73) and the X-ray group (DSA group, n=73) using propensity score matching. Followed up for 12 months, perioperative and follow-up data were compared between the two groups, the effectiveness, safety, and economic benefits of using X-ray guidance alone for left atrial appendage occlusion combined with catheter ablation were evaluated.Results Patients in both groups successfully completed catheter ablation and left atrial appendage occlusion. The incidence of small pericardial effusion (20.5% vs 8.2%), hospitalization duration [(10.5±2.7)d vs (9.3±2.6)d], and expenses [￥(156 517.7±13 271.2) vs ￥(146 028.1±12 481.1)] in the DSA group were significantly lower than those in the TEE group (all P < 0.05). There was no statistically significant difference in the incidence of endpoint events during the followup period between the two groups.Conclusion For left atrial appendage occlusion combined with catheter ablation, the effectiveness and safety of X-ray guidance alone are not inferior to that of X-ray combined with transesophageal echocardiography guidance, and it has certain advantages in reducing hospitalization costs and length of stay.
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表 1 PSM前后患者基线资料
Table 1. Baseline data before and after PSM
例(%), X ± S, M(P25, P75) 项目 PSM前 PSM后 总体(244例) DSA组(104例) TEE(140例) P 总体(146例) DSA组(73例) TEE组(73例) P 年龄/岁 66.2±10.2 66.0±10.0 66.2±10.3 0.910 66.2±10.2 67.4±9.4 65.1±11.0 0.180 男性 134(54.9) 57(54.8) 77(55.0) 0.976 82(56.2) 40(54.8) 42(57.5) 0.878 BMI/(kg/m2) 25.3±3.7 24.8±3.9 25.7±3.6 0.080 25.1±3.7 24.8±3.6 25.3±3.8 0.401 持续性房颤 173(70.9) 86(82.7) 87(62.1) < 0.001 118(80.8) 57(78.1) 61(83.6) 0.388 CHA2DS2-VASc评分 4.0(3.0，5.0) 4.0(3.0，5.0) 4.0(3.0，5.0) 0.628 4.0(3.0，5.0) 4.0(3.0，5.0) 4.0(3.0，5.0) 0.583 HAS-BLED评分 2.0(2.0，3.0) 2.0(2.0，3.0) 2.0(2.0，3.0) 0.463 2.5(2.0，3.0) 2.0(2.0，3.0) 3.0(2.0，3.0) 0.877 NT-proBNP/(pg/mL) 678.3(432.5，1 030.8) 678.0(346.0，1 030.8) 682.8(463.7，1 035.9) 0.330 693.0(449.2，1 061.8) 688.7(375.0，1 044.7) 740.0(460.0，740.0) 0.893 肌酐/(μmol/L) 65.0(54.0，77.0) 64.0(53.0，75.8) 64.0(54.0，80.0) 0.592 65.0(55.8，77.0) 65(57.0，77.0) 64.0(54.0，79.0) 0.686 尿素氮/(mmol/L) 5.5(4.6，7.3) 5.5(4.5，7.5) 5.6(4.7，7.2) 0.588 5.5(4.7，7.4) 5.9(4.8，7.5) 5.3(4.6，7.3) 0.093 ALT/(U/L) 23.0(16.0，37.0) 21.0(15.0，35.8) 24.5(17.6，37.8) 0.289 22.5(15.0，35.3) 22.0(15.0，35.5) 23.0(14.5，34.5) 0.931 AST/(U/L) 24.5(19.0，34.8) 24.0(20.0，32.5) 25.0(19.0，35.0) 0.999 25.0(20.0，32.3) 26.0(20.5，34.0) 24.0(19.0，32.0) 0.534 HCT/‰ 4.2±0.5 4.1±0.6 4.2±0.5 0.900 4.1±0.05 4.2±0.06 4.2±0.05 0.956 左心房内径/mm 40.9±5.8 40.7±5.5 41.1±6.1 0.543 40.9±5.6 40.9±5.6 40.8±5.6 0.928 LVEF/% 58.0(54.0，63.0) 58.0(54.0，63.0) 58.0(54.0，63.0) 0.772 57.8±6.5 57.9±6.5 58.0±6.5 0.721 高血压病史 144(59.0) 57(54.8) 87(62.1) 0.249 78(53.4) 40(54.8) 38(52.1) 0.868 糖尿病病史 55(22.5) 23(22.1) 32(22.9) 0.891 27(18.5) 17(23.3) 10(13.7) 0.248 冠心病史 96(39.3) 35(33.7) 61(43.6) 0.117 55(37.7) 28(38.4) 27(37.0) 1.000 心力衰竭病史 86(35.2) 33(31.7) 53(37.9) 0.322 48(32.9) 27(37.0) 21(28.8) 0.418 卒中病史 58(23.8) 24(23.1) 34(24.3) 0.826 37(25.3) 17(23.3) 20(27.4) 0.701 大出血史 10(4.1) 1(1.0) 9(6.4) 0.033 2(1.4) 1(1.4) 1(1.4) 1.000 BMI：体重指数；NT-proBNP：氨基末端B型利钠肽前体；ALT：谷丙转氨酶；AST：谷草转氨酶；HCT：红细胞比容；LVEF：左心室射血分数。 
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表 2 患者手术相关资料
Table 2. Surgical data
例(%), X ± S, M(P25, P75) 项目 总体(146例) DSA组(73例) TEE组(73例) P 手术总时间/min 238.8±63.6 244.3±65.1 233.3±62.0 0.299 LAAO时间/min 80.3±17.3 79.7±17.2 80.9±17.4 0.674 左心耳形态 0.801 鸡翅型 33(22.6) 14(19.2) 19(26.0) 仙人掌型 19(13.0) 10(13.7) 9(12.3) 风向袋型 32(21.9) 17(23.3) 15(20.5) 菜花型 62(42.5) 32(43.8) 30(41.2) 封堵器尺寸/mm 27(24，30) 27(24，30) 27(24，30) 0.141 手术成功 146(100) 73(100) 73(100) 术中电复律 67(45.9) 35(47.9) 32(43.8) 0.618 安全事件 迷走反射 1(0.7) 1(1.4) 0 1.000 PDL 0 0 0 心包积液 少量 21(14.4) 6(8.2) 15(20.5) 0.034 心包填塞 4(2.7) 1(1.4) 3(4.1) 0.620 术后抗凝药物 1.000 利伐沙班 120(82.2) 60(82.2) 60(82.2) 达比加群酯 21(14.4) 11(15.1) 10(13.7) 华法林 5(3.4) 2(2.7) 3(4.1) 住院时间/d 9.9±2.7 9.3±2.6 10.5±2.7 0.006 花费/元 151 272.9±13 874.6 146 028.1±12 481.1 156 517.7±13 271.2 < 0.001
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表 3 随访期间安全性和有效性事件发生情况
Table 3. The occurrence of safety and effectiveness events during the follow-up period
例(%) 事件 总体(138例) DSA组(65例) TEE组(73例) P 疗效评价 房颤/房扑复发 15(10.9) 7(10.8) 8(11.0) 0.971 再次消融 5(3.1) 2(3.1) 3(4.1) 1.000 安全性评价 全因死亡 1(0.7) 0 1(1.4) 1.000 全因再住院 30(21.7) 13(20.0) 17(23.3) 0.640 心血管事件再住院 24(17.4) 10(15.4) 14(19.2) 0.557 大出血 2(1.4) 0 2(2.7) 0.498 TEE/CTA随访 完成随访 115(83.3) 52(80.0) 63(86.3) 0.321 TEE 84(73.0) 34(65.4) 18(34.6) CTA 31(27.0) 50(79.4) 13(20.6) PDL 0.512 < 3 mm 28(24.3) 10(19.2) 18(28.6) 3~5 mm 4(3.5) 2(3.8) 2(3.2) DRT 3(2.6) 3(5.8) 0 0.090
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