GW-ICC 2020:苏晞:冷冻消融并发症的真实数据和管理

2020-10-29 《门诊》杂志 门诊新视野

肺静脉隔离(PVI)是心房颤动导管消融的基石,应用冷冻球囊导管进行肺静脉隔离的有效性和安全性获得了临床研究证实,国内外指南已将冷冻球囊消融(CBA)作为房颤消融的标准疗法。

肺静脉隔离(PVI)是心房颤动导管消融的基石,应用冷冻球囊导管进行肺静脉隔离的有效性和安全性获得了临床研究证实,国内外指南已将冷冻球囊消融(CBA)作为房颤消融的标准疗法。冷冻球囊消融具有持久肺静脉隔离、安全性高、操作简便、患者感受好、学习曲线短等优势,因此,近10年在临床得以迅速普及应用。为了进一步提高手术安全性,应详细分析围术期并发症发生的原因并加以管理预防,降低手术风险。在第31届长城心脏病学大会(GW-ICC 2020)上,来自武汉亚洲心脏病医院苏曦教授对冷冻消融并发症的真实数据和管理方面进行了详细报告。

导管消融的常见并发症

Fire and Ice研究是目前最大型、多中心、前瞻性、随机对照研究,目的是比较冷冻球囊与射频消融(IR-RF)在药物不敏感的阵发性房颤患者中进行PVI的有效性和安全性。主要研究结果显示:应用冷冻球囊导管进行PVI治疗阵发性房颤患者,在有效性和安全性上均不劣于射频消融,但两者的并发症方面差异较大:冷冻球囊最常见的并发症为短暂性膈神经麻痹,出院时发生率为2.7%,1年随访时则仅为0.3%;而射频消融最常见并发症为心包填塞(1.3%)、消融术后的房扑/房速(2.7%)等。

膈神经损伤(PNI)是冷冻消融最常发生的并发症。PNI通常根据损伤的程度及持续时间进行分类:

短暂性膈神经功能损伤(TPND):手术结束或患者出院前膈神经功能恢复;

膈神经麻痹(PNP):冷冻球囊手术结束时或患者出院时膈神经损伤未恢复;

持续性或永久性膈神经麻痹(PPNP):术后12个月膈神经损伤仍未恢复。

临床中发生PNI以短暂膈神经损伤为主,持续性或永久性膈神经损伤比例较低。随着冷冻消融经验的积累,技术的进步,器械的改进,临床对并发症的认知不断深入,PNI发生率呈逐年下降趋势。

心包积液和心包填塞常见于射频消融,大型研究结果显示冷冻消融心包填塞的发生率不足1%。严重并发症中,心房食道瘘(AEF)危险性高,发生AEF的患者死亡率可达60%~80%。MAUDE数据库共报道了78例AEF的患者,在不良事件中,压力导管AEF的发生率(65例,5.4%)较非压力导管(13例,0.9%)更高。冷冻消融AEF的发生部位分布在左下肺静脉,射频消融则发生在左房后壁多个部位,考虑与导管的特性与两种术式术中的操作有关。

并发症的预防与处理

经冷冻球囊导管消融房颤中国专家共识详述了CBA术并发症的预防策略,将并发症分为7大类:膈神经损伤、心包填塞/心包积液、肺静脉狭窄、食道损伤、股动脉损伤、血栓/气栓栓塞、迷走神经反射引起的严重心动过缓。

膈神经损伤

PNI是冷冻球囊消融最常见的并发症,主要发生在右侧肺静脉消融的过程中,膈神经走形在右上肺静脉与腔静脉之间,消融过程中应注意对膈神经的保护,避免损伤的发生。PNI发生后,轻者可无症状表现;重者可出现严重呼吸困难、活动后气急等临床表现。临床中,PNI以短暂膈神经损伤以及膈神经麻痹(PNP)常见,PNP的发生主要与消融导管与膈神经的距离相关。研究发现,起搏导管头端作垂线与冷冻球囊侧壁间的距离,可准确预测PNP的发生(P<0.01),右上肺静脉与膈神经距离较近,是易发生损伤的部位;其次身材较矮的患者,发生PNP的风险相对较高。同时,消融的温度以及到达最低温度所需的时间,反复的消融都与造成PNP密切相关。手术中需将球囊始终定位在肺静脉前庭部,同时密切监测膈神经起搏情况,如注意到膈神经起搏反应减弱,应立刻停止消融,从而最小化膈神经的损伤。

食道损伤

食道的位置邻近左房后壁,射频消融和冷冻球囊消融均可导致食道损伤。食道损伤可按程度不同,分别表现为食道红斑、食道溃疡或心房食道瘘,临床中食道红斑最为常见。二代球囊房颤术后,食道内镜观察到食道损伤3.2%~19%,以局限的食道病变损伤为主,多数可在术后自行愈合;一代和二代球囊房颤术后,心房食道瘘发生率为近0.005%。心房食道瘘是严重的并发症,多发生于左下肺静脉,不良事件中,压力导管发生心房食道瘘的比例较非压力导管更高(5.4% VS 0.9%)。

尽管冷冻消融AEF的发生率较低,但一旦发生食道瘘,死亡率可达80%以上,临床上应尽可能避免AEF发生。临床上可通过控制食道温度(LET,应不低于15℃),从而预防食道损伤,同时避免同一靶静脉连续的反复消融,以保证肺静脉邻近组织有复温时间。2012年HRS/EHRA/ECAS专家共识给出了最小化食道损伤的建议:减小导管推送的力量,减少消融持续时间,并借助影像学技术如食道造影进行监测,合理使用质子泵抑制剂。因此,尽管AEF是危险的严重并发症,术中仍可以采取各种手段有效规避食道瘘发生,降低手术风险。

肺静脉狭窄

肺静脉狭窄(PVS)定义为肺静脉管腔直径减少50%以上,多数患者表现为术后一周至数月内出现活动后气促、咳嗽、咳血和反复发生抗生素治疗无效的肺炎等,少数轻度狭窄的患者可无症状。PVS主要是由术中球囊位置处于肺静脉而非前庭引起,因此准确的识别肺静脉前庭并采用禁断封堵技术、减少导管接触力,可有效预防和最小化PVS。随着临床认识的不断充分,冷冻消融所致的静脉狭窄病例已十分稀少,针对有明显症状的PVS且药物治疗效果不良的患者可考虑进行导管介入治疗,而对无明显症状PVS者,给予持续抗凝治疗预防血栓栓塞外,建议密切观察而不过度干预,部分患者服用抗凝药物后PVS可改善或再通。

心脏压塞

基于冷冻消融与射频消融的不同原理机制,前者发生此类并发症的概率理论上为零。在此前提下,冷冻消融中心包填塞与心包积液的发生往往与导管操作不当相关,应特别注意的是,由于消融过深造成的肺静脉撕裂需要通过外科手术修补。

股动脉损伤

消融术中,股动脉损伤一般由Flexcath导管误穿股动脉引起,因破损口径大以及患者本身处于进行抗凝治疗状态,严重者可能导致巨大血肿、失血性休克从而危及生命。避免误穿是预防股动脉损伤的关键,应在超声引导下完成穿刺:股静脉穿刺时通过回血颜色、压力、穿刺针或导丝旁出血速度,透视导丝走形等确保未损伤股动脉后再进行后续置换Flexcath导管等操作。

迷走神经反射

冷冻消融过程中,迷走神经反射常发生在左侧肺静脉冷冻复温,球囊回缩后的数分钟内,以窦性停搏或房室传导阻滞、低血压、严重迷走反射出现休克为主的一过性应激反应,放置临时起搏、提前准备好阿托品等药物可针对性地解决迷走神经反射的一过性症状。

总 结

冷冻球囊导管消融具有良好的安全性与有效性,目前在多本临床指南中已作为房颤管理的推荐治疗方案。冷冻消融最常见的并发症为短暂性的膈神经麻痹,其余并发症多具备一过性的特点,AEF是重大严重并发症,但临床发生率较低。手术过程中预防并发症的发生是关键,规范的操作是核心内容,应谨记并遵守球囊导管操作建议,从而保证手术的顺利进行,最终保护患者的安全。

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    2021-06-21 dahonghuayang

    学习了

    0

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    2021-04-08 丁鹏鹏
  3. [GetPortalCommentsPageByObjectIdResponse(id=975409, encodeId=671a9e540900, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bb81518090, createdName=dahonghuayang, createdTime=Mon Jun 21 11:54:44 CST 2021, time=2021-06-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1758293, encodeId=15bf1e5829353, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Thu Apr 08 06:42:33 CST 2021, time=2021-04-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=896530, encodeId=22f8896530eb, content=冷冻球囊导管消融具有良好的安全性与有效性,目前在多本临床指南中已作为房颤管理的推荐治疗方案。, beContent=null, objectType=article, channel=null, level=null, likeNumber=139, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ae205385871, createdName=Lexi, createdTime=Tue Nov 03 10:42:07 CST 2020, time=2020-11-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1421825, encodeId=73b5142182524, content=<a href='/topic/show?id=4bc865819d2' target=_blank style='color:#2F92EE;'>#消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65819, encryptionId=4bc865819d2, topicName=消融)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1a193676008, createdName=xiangyuzhou972, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1462083, encodeId=6507146208350, content=<a href='/topic/show?id=32fd933505' target=_blank style='color:#2F92EE;'>#ICC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9335, encryptionId=32fd933505, topicName=ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=36506466438, createdName=zhs3884, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1527221, encodeId=52b4152e221fd, content=<a href='/topic/show?id=81ca834123' target=_blank style='color:#2F92EE;'>#GW-ICC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8341, encryptionId=81ca834123, topicName=GW-ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=00e511815854, createdName=chenwq12, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=895659, encodeId=f941895659bb, content=手术过程中预防并发症的发生是关键,规范的操作是核心内容,应谨记并遵守球囊导管操作建议,从而保证手术的顺利进行,最终保护患者的安全。, beContent=null, objectType=article, channel=null, level=null, likeNumber=141, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b58d5402080, createdName=咻凡, createdTime=Fri Oct 30 16:07:14 CST 2020, time=2020-10-30, status=1, ipAttribution=)]
    2020-11-03 Lexi

    冷冻球囊导管消融具有良好的安全性与有效性,目前在多本临床指南中已作为房颤管理的推荐治疗方案。

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=975409, encodeId=671a9e540900, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bb81518090, createdName=dahonghuayang, createdTime=Mon Jun 21 11:54:44 CST 2021, time=2021-06-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1758293, encodeId=15bf1e5829353, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Thu Apr 08 06:42:33 CST 2021, time=2021-04-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=896530, encodeId=22f8896530eb, content=冷冻球囊导管消融具有良好的安全性与有效性,目前在多本临床指南中已作为房颤管理的推荐治疗方案。, beContent=null, objectType=article, channel=null, level=null, likeNumber=139, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ae205385871, createdName=Lexi, createdTime=Tue Nov 03 10:42:07 CST 2020, time=2020-11-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1421825, encodeId=73b5142182524, content=<a href='/topic/show?id=4bc865819d2' target=_blank style='color:#2F92EE;'>#消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65819, encryptionId=4bc865819d2, topicName=消融)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1a193676008, createdName=xiangyuzhou972, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1462083, encodeId=6507146208350, content=<a href='/topic/show?id=32fd933505' target=_blank style='color:#2F92EE;'>#ICC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9335, encryptionId=32fd933505, topicName=ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=36506466438, createdName=zhs3884, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1527221, encodeId=52b4152e221fd, content=<a href='/topic/show?id=81ca834123' target=_blank style='color:#2F92EE;'>#GW-ICC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8341, encryptionId=81ca834123, topicName=GW-ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=00e511815854, createdName=chenwq12, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=895659, encodeId=f941895659bb, content=手术过程中预防并发症的发生是关键,规范的操作是核心内容,应谨记并遵守球囊导管操作建议,从而保证手术的顺利进行,最终保护患者的安全。, beContent=null, objectType=article, channel=null, level=null, likeNumber=141, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b58d5402080, createdName=咻凡, createdTime=Fri Oct 30 16:07:14 CST 2020, time=2020-10-30, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=975409, encodeId=671a9e540900, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bb81518090, createdName=dahonghuayang, createdTime=Mon Jun 21 11:54:44 CST 2021, time=2021-06-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1758293, encodeId=15bf1e5829353, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Thu Apr 08 06:42:33 CST 2021, time=2021-04-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=896530, encodeId=22f8896530eb, content=冷冻球囊导管消融具有良好的安全性与有效性,目前在多本临床指南中已作为房颤管理的推荐治疗方案。, beContent=null, objectType=article, channel=null, level=null, likeNumber=139, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ae205385871, createdName=Lexi, createdTime=Tue Nov 03 10:42:07 CST 2020, time=2020-11-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1421825, encodeId=73b5142182524, content=<a href='/topic/show?id=4bc865819d2' target=_blank style='color:#2F92EE;'>#消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65819, encryptionId=4bc865819d2, topicName=消融)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1a193676008, createdName=xiangyuzhou972, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1462083, encodeId=6507146208350, content=<a href='/topic/show?id=32fd933505' target=_blank style='color:#2F92EE;'>#ICC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9335, encryptionId=32fd933505, topicName=ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=36506466438, createdName=zhs3884, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1527221, encodeId=52b4152e221fd, content=<a href='/topic/show?id=81ca834123' target=_blank style='color:#2F92EE;'>#GW-ICC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8341, encryptionId=81ca834123, topicName=GW-ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=00e511815854, createdName=chenwq12, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=895659, encodeId=f941895659bb, content=手术过程中预防并发症的发生是关键,规范的操作是核心内容,应谨记并遵守球囊导管操作建议,从而保证手术的顺利进行,最终保护患者的安全。, beContent=null, objectType=article, channel=null, level=null, likeNumber=141, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b58d5402080, createdName=咻凡, createdTime=Fri Oct 30 16:07:14 CST 2020, time=2020-10-30, status=1, ipAttribution=)]
    2020-10-31 zhs3884
  6. [GetPortalCommentsPageByObjectIdResponse(id=975409, encodeId=671a9e540900, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bb81518090, createdName=dahonghuayang, createdTime=Mon Jun 21 11:54:44 CST 2021, time=2021-06-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1758293, encodeId=15bf1e5829353, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Thu Apr 08 06:42:33 CST 2021, time=2021-04-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=896530, encodeId=22f8896530eb, content=冷冻球囊导管消融具有良好的安全性与有效性,目前在多本临床指南中已作为房颤管理的推荐治疗方案。, beContent=null, objectType=article, channel=null, level=null, likeNumber=139, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ae205385871, createdName=Lexi, createdTime=Tue Nov 03 10:42:07 CST 2020, time=2020-11-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1421825, encodeId=73b5142182524, content=<a href='/topic/show?id=4bc865819d2' target=_blank style='color:#2F92EE;'>#消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65819, encryptionId=4bc865819d2, topicName=消融)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1a193676008, createdName=xiangyuzhou972, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1462083, encodeId=6507146208350, content=<a href='/topic/show?id=32fd933505' target=_blank style='color:#2F92EE;'>#ICC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9335, encryptionId=32fd933505, topicName=ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=36506466438, createdName=zhs3884, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1527221, encodeId=52b4152e221fd, content=<a href='/topic/show?id=81ca834123' target=_blank style='color:#2F92EE;'>#GW-ICC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8341, encryptionId=81ca834123, topicName=GW-ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=00e511815854, createdName=chenwq12, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=895659, encodeId=f941895659bb, content=手术过程中预防并发症的发生是关键,规范的操作是核心内容,应谨记并遵守球囊导管操作建议,从而保证手术的顺利进行,最终保护患者的安全。, beContent=null, objectType=article, channel=null, level=null, likeNumber=141, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b58d5402080, createdName=咻凡, createdTime=Fri Oct 30 16:07:14 CST 2020, time=2020-10-30, status=1, ipAttribution=)]
    2020-10-31 chenwq12
  7. [GetPortalCommentsPageByObjectIdResponse(id=975409, encodeId=671a9e540900, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4bb81518090, createdName=dahonghuayang, createdTime=Mon Jun 21 11:54:44 CST 2021, time=2021-06-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1758293, encodeId=15bf1e5829353, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Thu Apr 08 06:42:33 CST 2021, time=2021-04-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=896530, encodeId=22f8896530eb, content=冷冻球囊导管消融具有良好的安全性与有效性,目前在多本临床指南中已作为房颤管理的推荐治疗方案。, beContent=null, objectType=article, channel=null, level=null, likeNumber=139, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ae205385871, createdName=Lexi, createdTime=Tue Nov 03 10:42:07 CST 2020, time=2020-11-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1421825, encodeId=73b5142182524, content=<a href='/topic/show?id=4bc865819d2' target=_blank style='color:#2F92EE;'>#消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65819, encryptionId=4bc865819d2, topicName=消融)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1a193676008, createdName=xiangyuzhou972, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1462083, encodeId=6507146208350, content=<a href='/topic/show?id=32fd933505' target=_blank style='color:#2F92EE;'>#ICC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9335, encryptionId=32fd933505, topicName=ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=36506466438, createdName=zhs3884, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1527221, encodeId=52b4152e221fd, content=<a href='/topic/show?id=81ca834123' target=_blank style='color:#2F92EE;'>#GW-ICC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=98, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8341, encryptionId=81ca834123, topicName=GW-ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=00e511815854, createdName=chenwq12, createdTime=Sat Oct 31 14:42:33 CST 2020, time=2020-10-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=895659, encodeId=f941895659bb, content=手术过程中预防并发症的发生是关键,规范的操作是核心内容,应谨记并遵守球囊导管操作建议,从而保证手术的顺利进行,最终保护患者的安全。, beContent=null, objectType=article, channel=null, level=null, likeNumber=141, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b58d5402080, createdName=咻凡, createdTime=Fri Oct 30 16:07:14 CST 2020, time=2020-10-30, status=1, ipAttribution=)]
    2020-10-30 咻凡

    手术过程中预防并发症的发生是关键,规范的操作是核心内容,应谨记并遵守球囊导管操作建议,从而保证手术的顺利进行,最终保护患者的安全。

    0

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