 图4 大环技术 A/B:X线图，C：示意图。A：球囊不能帖靠右下肺静脉下缘，两者间存在较大空隙（白色箭头所指）。B:使用大环技术后球囊与右下肺静脉前庭嵌合良好。 根据肺静脉的解剖特点，灵活使用上述技术，可以大大提高28mm球囊的消融成功率，Chun等报道，27例阵发性房颤患者，左心房平均直径42±5mm，共99根肺静脉，97根达到完全隔离，隔离成功率达到98％。4 并发症的预防 冷冻消融的并发症主要有膈神经损伤，食道损伤等。其中膈神经损伤远较使用射频能行环肺静脉消融为多，达到7.5％。从解剖上看，膈神经走行主要邻近右上、右下肺静脉。前文已经述及，使用23mm球囊时，消融位置深入右侧肺静脉，易于导致膈神经损伤。使用28mm球囊，则此并发症发生率显著减少。Chun等报道3例膈神经损伤。2例为消融右上肺静脉所致，1例为消融右下肺静脉导致。3例患者分别在消融终止后384天、28及3分钟恢复正常[11]。预防膈神经损伤的方法除使用大球囊、避免消融位置过深外，最有效的方法是消融的同时起搏膈神经，可及时发现膈神经损伤，及时终止消融。 冷冻消融也可导致食道损伤，有报道冷冻消融的患者17％有食道溃疡形成，这与射频消融的发生率相似。迄今为止，冷冻消融还没有导致心房食管瘘的报道。 最近，有学者又报道了冷冻导管消融治疗典型心房扑动的研究，其结果令人满意[12]。可以肯定，冷冻消融在房颤消融乃至整个心律失常的消融中会逐步发挥更大的作用。参考文献 1. Zhou L, Keane D, Reed G, et al. Thromboembolic complications of cardiac radiofrequency catheter ablation. J Cardiovasc Electrophysiol. 1999, 10: 611–620. 2. Dhruvakumar S, Gerstenfeld EP. Complications associated with catheter ablation of atrial fibrillation. Minerva Cardioangiol, 2007, 55:353-368. 3. Malamis AP, Kirshenbaum KJ, Nadimpalli S. CT radiographic findings: atrio-esophageal fistula after transcatheter percutaneous ablation of atrial fibrillation. J Thorac Imaging, 2007, 22:188-191. 4. Rodriguez LM, Geller JC, Tse HF,et al.Acute results of transvenous cryoablation of supraventricular tachycardia (atrial fibrillation, atrial flutter, Wolff-Parkinson-White syndrome, atrioventricular nodal reentry tachycardia). J Cardiovasc Electrophysiol, 2002, 13: 1082-1089. 5. Rewcastle JC, Sandison GA, Muldrew K, et al. A model for the time dependent three-dimensional thermal distribution within iceballs surrounding multiple cryoprobes. Med Phys, 2001, 28:1125-1137. 6. Khairy P, Chauvet P, Lehmann J, et al. Lower Incidence of Thrombus Formation With Cryoenergy Versus Radiofrequency Catheter Ablation. Circulation, 2003, 107:2045-2050. 7.Tse HF, Reek S, Timmermans C, et al. Pulmonary vein isolation using transvenous catheter cryoablation for treatment of atrial fibrillation without risk of pulmonary vein stenosis. J Am Coll Cardiol, 2003, 42:752–758. 8. Hoyt RH, Wood M, Daoud E, et al. Transvenous catheter cryoablation for treatment of atrial fibrillation: results of a feasibility study.Pacing Clin Electrophysiol. 2005, 28, Suppl 1:S78-82. 9. an Belle Y, Janse P, Rivero-Ayerza MJ, et al. Pulmonary vein isolation using an occluding cryoballoon for circumferential ablation: feasibility, complications, and short-term outcome. European Heart Journal, 2007, 28: 2231-2237. 10.Neumann T, Vogt J, Schumacher B, et al. Circumferential pulmonary vein isolation with the cryoballoon technique results from a prospective 3-center study. J Am Coll Cardiol, 2008, 52: 273-278. 11. Chun KJ, Schmidt B, Metzner A, et al. The ‘single big cryoballoon’ technique for acute pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a prospective observational single centre study. European Heart Journal, 2009, 30: 699–709. 12. Kuniss M, Vogtmann T, Ventura R, et al. Prospective randomized comparison of durability of bidirectional conduction block in the cavotricuspid isthmus in patients after ablation of common atrial flutter using cryothermy and radiofrequency energy: the CRYOTIP study. Heart Rhythm, 2009, 6:1699-1705.2010/3/19 14:38:48 访问数：1366 转载请注明：内容转载自365医学网 |
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来自： doudou0427 > 《冷冻球囊消融》
