磁导航指导特发性室性心律失常消融手术的学习曲线分析

doi:10.16138/j.1673-6087.2021.03.006

摘要/Abstract

摘要：

目的：评估磁导航指导特发性室性心律失常（idiopathic ventricular arrhythmia, IVA）消融手术的学习曲线及其对手术参数的影响。方法：纳入249例应用磁导航指导IVA消融的患者,比较起始标测右心室（右室组）和起始标测左心室（左室组）的并发症发生率和手术相关参数。按时间顺序将右室组患者的手术时间进行曲线拟合,获得其学习曲线,再将这些患者平均分为P1、P2、P3三期,分析学习曲线对手术相关参数的影响。结果：磁导航指导IVA消融手术急性成功率为91%,并发症发生率为0.4%。左室组的手术时间、标测时间、消融时间以及X线暴露时间均显著高于右室组（P<0.05）,但2组的并发症发生率差异无统计学意义（P=0.313 3）。右室组按时间顺序分组, P3较P2和P1学习时间分别减少24%（P<0.01）和41%（P<0.000 1）;尽管X线暴露时间在学习曲线初期已相对较低[（3.8±4.1） min],但仍可在通过学习曲线后明显下降[（1.3±1.0） min, P<0.001]。结论：磁导航指导IVA消融手术的学习曲线相对较短,且在学习曲线内手术安全性高。即使在学习曲线初期,磁导航指导IVA消融手术X线暴露时间仍较短,学习曲线后有助于进一步降低术者和患者的X线暴露时间。

关键词: 磁导航, 导管消融, 室性心律失常, 学习曲线

Abstract:

Objectives To determine the learning curve of remote magnetic navigation (RMN)-guided ablation for idiopathic ventricular arrhythmias (IVA) and its implications on the outcomes of the procedures. Methods A total of 249 IVA patients undergoing catheter ablation with RMN were divided into two groups: right ventricle (RV) and left ventricle (LV) group regarding to the initially mapping from RV or LV. Procedural outcomes and complications were compared between two groups. The learning curve was determined by plotting procedure time of the consequentially performed procedures in RV group patients. These patients were then divided equally into 3 phases (P1, P2, P3) to determine the effect of learning curve on procedure outcomes. Results The acute success rate reached 91% and complication rate was only 0.4%. The procedure time, mapping time, ablation time and X-ray time of LV group was significantly higher than RV group (P<0.05), but no significant difference was detected in the complication rate of the two groups(P=0.313 3). The procedure time of RV group patients decreased significantly along the learning curve. Compared with P2 and P1, the procedure time of P3 was decreased by 24% (P<0.01) and 41% (P<0.000 1) respectively. The X-ray time was relatively low [(3.8±4.1) min] at the very beginning and dropped significantly along the learning curve [(1.3±1.0) min, P<0.001]. Conclusions It takes rather short term to establish the learning curve of RMN-guided IVA with low rate of complication. The radiation exposure for both patient and operator is low during the establishment of learning curve and could be further reduced later on.

Key words: Remote magnetic navigation, Catheter ablation, Ventricular arrhythmia, Learning curve

中图分类号:

R541.7

李翔, 金奇, 潘文麒, 贾康妮, 张凝, 林长坚, 凌天佑, 陈康, 谢玉才, 吴立群. 磁导航指导特发性室性心律失常消融手术的学习曲线分析[J]. 内科理论与实践, 2021, 16(03): 167-171.

LI Xiang, JIN Qi, PAN Wenqi, JIA Kangni, ZHANG Ning, LIN Changjian, LING Tianyou, CHEN Kang, XIE Yucai, WU Liqun. The learning curve of remote magnetic navigation-guided ablation for idiopathic ventricular arrhythmias[J]. Journal of Internal Medicine Concepts & Practice, 2021, 16(03): 167-171.

图/表 4

图1

表1

表2

图2

参考文献 14

[1]	Shivkumar K. Catheter ablation of ventricular arrhythmias[J]. N Engl J Med, 2019, 380(16): 1555-1564. doi: 10.1056/NEJMra1615244 URL
[2]	Dinov B, Fiedler L, Schönbauer R, et al. Outcomes in catheter ablation of ventricular tachycardia in dilated nonischemic cardiomyopathy compared with ischemic cardiomyopathy: results from the Prospective Heart Centre of Leipzig VT (HELP-VT) Study[J]. Circulation, 2014, 129(7): 728-736. doi: 10.1161/CIRCULATIONAHA.113.003063 URL
[3]	Sapp JL, Wells GA, Parkash R, et al. Ventricular tachycardia ablation versus escalation of antiarrhythmic drugs[J]. N Engl J Med, 2016, 375(2): 111-121. doi: 10.1056/NEJMoa1513614 URL
[4]	Aryana A, D’avila A, Heist EK, et al. Remote magnetic navigation to guide endocardial and epicardial catheter mapping of scar-related ventricular tachycardia[J]. Circulation, 2007, 115(10): 1191-1200. pmid: 17296855
[5]	Virk SA, Kumar S. Remote magnetic versus manual catheter navigation for atrial fibrillation ablation: a meta-analysis[J]. Circ Arrhythm Electrophysiol, 2019, 12(10): e007517. doi: 10.1161/CIRCEP.119.007517 URL
[6]	Xie Y, Jin Q, Zhang N, et al. Strategy of catheter ablation for para-Hisian premature ventricular contractions with the assistance of remote magnetic navigation[J]. J Cardiovasc Electrophysiol, 2019, 30(12): 2929-2935. doi: 10.1111/jce.14245 URL
[7]	Qian P, De Silva K, Kumar S, et al. Early and long-term outcomes after manual and remote magnetic navigation-guided catheter ablation for ventricular tachycardia[J]. Europace, 2018, 20 Suppl 2: ii11-ii21.
[8]	Aagaard P, Natale A, Briceno D, et al. Remote magnetic navigation: a focus on catheter ablation of ventricular arrhythmias[J]. J Cardiovasc Electrophysiol, 2016, 27(S1): S38-S44. doi: 10.1111/jce.12938 URL
[9]	Qiu X, Zhang N, Luo Q, et al. Remote magnetic navigation facilitates the ablations of frequent ventricular premature complexes originating from the outflow tract and the valve annulus as compared to manual control navigation[J]. Int J Cardiol, 2018, 267: 94-99. doi: 10.1016/j.ijcard.2018.03.105 URL
[10]	Shauer A, De Vries LJ, Akca F, et al. Clinical research: remote magnetic navigation vs. manually controlled catheter ablation of right ventricular outflow tract arrhythmias: a retrospective study[J]. Europace, 2018, 20 Suppl 2: ii28-ii32.
[11]	Davis DR, Tang AS, Gollob MH, et al. Remote magnetic navigation-assisted catheter ablation enhances catheter stability and ablation success with lower catheter temperatures[J]. Pacing Clin Electrophysiol, 2008, 31(7): 893-898. doi: 10.1111/j.1540-8159.2008.01105.x URL
[12]	Xie Y, Jin Q, Zhang N, et al. Strategy of catheter ablation for para-Hisian premature ventricular contractions with the assistance of remote magnetic navigation[J]. J Cardiovasc Electrophysiol, 2019, 30(12): 2929-2935. doi: 10.1111/jce.14245 URL
[13]	Hosseini SM, Rozen G, Saleh A, et al. Catheter ablation for cardiac arrhythmias: utilization and in-hospital complications, 2000 to 2013[J]. JACC Clin Electrophysiol, 2017, 3(11): 1240-1248.
[14]	Turagam MK, Atkins D, Tung R, et al. A meta-analysis of manual versus remote magnetic navigation for ventricular tachycardia ablation[J]. J Interv Card Electrophysiol, 2017, 49(3): 227-235. doi: 10.1007/s10840-017-0257-3 pmid: 28624892

项目	总计(n=249)	RV组(n=171)	LV组(n=78)	P
手术时间(min)	93.8±50.0	86.8±48.3	109.3±50.7	0.000 1
临床时间(min)	63.7±44.5	58.4±42.1	75.4±47.7	0.002 1
标测时间(min)	22.7±16.4	21.4±16.0	25.6±17.0	0.002 7
消融次数(n)	14±11	12±10	17±13	0.011 7
消融时间(min)	9.4±7.8	8.7±7.5	11.0±8.2	0.009 7
总X线暴露时间(min)	3.7±4.2	2.7±3.2	5.9±5.3	<0.000 1
操作者X线暴露时间(min)	2.3±2.9	1.5±1.9	3.9±3.9	<0.000 1
控制室X线暴露时间(min)	1.5±2.5	1.2±2.1	2.1±3.0	<0.000 1
并发症[n (%)]	1 (0.4)	0	1 (1.3)	0.313 3

项目	P1	P2	P3	P
手术时间(min)	109.9±59.1	85.3±40.7	65.1±30.1	<0.000 1
临床时间(min)	70.7±51.9	59.8±38.3	44.6±29.4	0.011 1
标测时间(min)	26.3±17.6	24.6±17.6	13.4±7.3	<0.000 1
消融时间(min)	12.5±10.2	6.8±5.5	6.8±4.0	0.001 1
消融次数(n)	14±11	10±10	12±7	0.127 1
X线暴露时间(min)	3.8±4.1	3.0±3.3	1.3±1.0	0.000 1

[1]	吴立群. 大道至简——肺静脉隔离新技术[J]. 内科理论与实践, 2022, 17(05): 357-359.
[2]	费镇涛, 陈牧, 李毅刚. 心房颤动导管消融后复发机制的研究进展[J]. 内科理论与实践, 2022, 17(05): 396-399.
[3]	张芝, 汤学超, 黄新苗, 秦永文. 脉冲电场消融在心房颤动中的应用[J]. 内科理论与实践, 2022, 17(05): 400-404.
[4]	罗晓颖, 许燕, 张凤如, 吴立群, 戚文航. P波离散度和N端脑钠肽前体预测房颤冷冻球囊导管消融术后复发的价值[J]. 诊断学理论与实践, 2020, 19(1): 32-36.
[5]	陈信光, 张凤祥. 特定人群室性心律失常风险评估进展及策略[J]. 诊断学理论与实践, 2020, 19(06): 549-554.
[6]	孙寒星, 高浩基, 应夏洋, 黄海燕, 吕恬, 陈曦, 李勤裕, 邱伟华, 严佶祺. 机器人甲状腺切除手术学习曲线：单个术者的研究[J]. 外科理论与实践, 2019, 24(04): 320-324.
[7]	刘傲, 金奇, 张凝, 林长坚, 罗庆志, 邱筱炜, 吉懿, 邢超凡, 叶佳雯, 凌天佑, 陈康, 潘文麒, 谢玉才, 吴立群,. 单用磁导航导管法和联合Lasso法行射频消融治疗阵发性心房颤动[J]. 内科理论与实践, 2018, 13(04): 231-235.
[8]	吴庆华, 俞黎, 包皙婷, 孔雷, 刘鑫, 邱伟华, 项明, 赵任. 单中心分化型甲状腺癌全乳晕径路内镜手术学习曲线分析[J]. 外科理论与实践, 2018, 23(04): 363-368.
[9]	戴秋艳,. 高血压与心律失常2017年欧洲专家共识解读[J]. 内科理论与实践, 2018, 13(01): 20-23.
[10]	吉懿, 凌天佑, 张凝, 卫越, 刘傲, 罗庆志, 叶佳雯, 刑超凡, 邱筱炜, 于姝姝, 林长坚, 潘文麒, 金奇, 吴立群,. 冷冻球囊消融治疗阵发性心房颤动的长期临床结果[J]. 内科理论与实践, 2018, 13(01): 24-29.
[11]	吴庆华, 包皙婷, 孔雷, 刘玉祥, 陈勇, 王赭, 项明,. 常规器械经脐腹腔镜胆囊切除术学习曲线分析[J]. 外科理论与实践, 2016, 21(02): 161-165.
[12]	袁义强,. 持续性心房颤动导管消融策略[J]. 内科理论与实践, 2016, 11(01): 11-14.
[13]	马长生, 郭雪原,. 心房颤动治疗:抗凝、左心耳封堵还是导管消融?[J]. 内科理论与实践, 2016, 11(01): 1-2.
[14]	董建增, 崔晶, 马长生,. 心力衰竭合并心房颤动的导管消融治疗[J]. 内科理论与实践, 2016, 11(01): 3-6.
[15]	鲁超, 金巍巍, 牟一平, 徐晓武, 张人超, 周育成, 严加费, 周家瑜, 陈荣高, 王京瑞, 夏涛,. 腹腔镜胰十二指肠切除术的学习曲线[J]. 外科理论与实践, 2015, 20(06): 485-489.