BELIEF研究:左心耳隔离术显著减少长时程持续性房颤患者房颤复发

2015-09-07 吕瑞芳 报道 中国医学论坛报

2015欧洲心脏病学会年会(ESC2015)专题报道数项研究结果证实,除肺静脉之外,上腔静脉、左心耳其他区域也可能是房颤发生和持续的原因。BELIEF研究旨在探讨持续性房颤患者在肺静脉的基础上进行左心耳电隔离术,是否可以改善患者房颤的复发率。该研究入组173例长时程持续性房颤患者,随机分为两组,一组在标准消融的基础上,进行左心耳经典隔离术;另一组仅进行标准消融(肺静脉前庭隔离和非肺静脉触发灶消融)

2015欧洲心脏病学会年会(ESC2015)专题报道

数项研究结果证实,除肺静脉之外,上腔静脉、左心耳其他区域也可能是房颤发生和持续的原因。BELIEF研究旨在探讨持续性房颤患者在肺静脉的基础上进行左心耳电隔离术,是否可以改善患者房颤的复发率。

该研究入组173例长时程持续性房颤患者,随机分为两组,一组在标准消融的基础上,进行左心耳经典隔离术;另一组仅进行标准消融(肺静脉前庭隔离和非肺静脉触发灶消融),结果显示,前6个月,两组房颤复发率无显著差异,随访至12个月时数据显示,左心耳隔离术组患者无房颤复发比例显著高于对照组(56%对28%,HR=1.92,P=0.001),且随着时间延长差异显著增大。最终所有患者都进行了左心耳隔离术,24个月时,两组多次手术后的成功率分别为76%和56%(P=0.003,HR=2.24)。



应用Cox多因素回归分析校正年龄、性别、左心房内径等因素后,在标准消融术基础上进行左心耳隔离术可使房颤复发率降低55%[ HR=0.45,(0.26-0.77)]。

对于行左心耳隔离术患者进行经食管超声心动图(TEE)结果显示,52%患者左心耳功能受损,其中,12.5%患者出现A峰不连续现象;87.5%的患者左心耳内峰流速度减慢(<0.4 m/s)、8.3%患者以上两种损伤状况都有。

左心耳隔离组与对照组住院率及心衰住院率无显著差异,但有升高趋势。

结论:对于长时程持续房颤患者来说,左心耳经典隔离术可显著降低其房颤复发率,且同时并未显著增加并发症发生率,未来需要进行更多研究进一步探讨这一结论的病理生理基础。

北京清华长庚医院张萍教授点评指出,对于阵发性房颤患者来说,肺静脉触发灶占主导,非肺静脉触发灶占次要地位,而对于持续性房颤患者来说,其触发因素相对复杂,肺静脉触发灶比例降低,非肺静脉触发灶比例升高,左心耳参与比例增加,还有一部分为心房基质异常。对于长时程持续性房颤患者,肺静脉触发灶比例显著降低,左心耳触发灶比例显著升高。这一研究正是探讨左心耳隔离术对于长时程持续性房颤患者的有效性和安全性。

总的来说,这一研究的设计和结果比较客观,应用TEE评价了进行隔离术后左心耳功能的变化,显示了左心耳隔离术在降低卒中复发率方面的优势,但左心耳功能受损后是否会增加血栓栓塞的发生?这还需要进一步的研究证实。

本研究中虽然并未观察到并发症发生,但是结果显示了左心耳隔离术后其功能的变化:峰流速度减缓、出现血栓及烟雾状改变、A波连续性不良,这可能是未来发生并发症的基础。因此,未来对于左心耳隔离术疗效和安全性的评价还需要更长时程随访时间的临床研究,甚至还应该回归到机制性研究,对其进行全方位的评价。进一步的研究设计不仅需要增加随访时间,还需要进一步对其机制层面的指标进行观察,如内皮功能的破坏、对心房内分泌系统的影响等,以全面地评估该治疗方案的疗效和安全性。

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    2015-10-11 hlycom3356

    感谢作者分享

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    2015-09-09 jxrzshh
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