| Atrial fibrillation(AF)is a common arrhythmia in clinical work.In recent years,its incidence is increasing year by year.The incidence of atrial fibrillation increases as the population ages,and the incidence of atrial fibrillation can be as high as 15.0% in people over 80 years of age,even in the absence of other underlying diseases.The incidence is higher in people with hypertension,coronary heart disease,heart failure and other diseases.Atrial fibrillation has great harm to human health.After atrial fibrillation,the formation of thrombus in the left atrial appendage will lead to embolism of various important organs,resulting in loss of body function,and lifethreatening in severe cases.In addition,the occurrence of atrial fibrillation can aggravate the original heart disease,which further leads to the decrease of patients’ quality of life,the increase of hospitalization times,the extension of hospitalization days,the increase of medical expenditure,the long-term prognosis of patients,the increase of mortality,and the aggravation of family social burden.At present,there are many treatment methods for atrial fibrillation,including drug cardioversion,electrical cardioversion,surgical treatment and so on.With the deepening of the understanding of the disease and the continuous improvement of the level of medical technology,the surgical treatment of atrial fibrillation is becoming more and more simple.From the initial surgical treatment to the interventional catheter ablation,the ablation operation has become more and more simple,convenient and safer with the improvement of instruments.At present,catheter ablation surgery has gradually become the first choice for patients with atrial fibrillation with severe symptoms and difficult to control with drugs.The theoretical basis of this treatment method is the theory of pulmonary vein triggering atrial fibrillation,which makes pulmonary vein isolation(PVI)become the fundamental treatment of atrial fibrillation.Under the guidance of this theory,in recent years,PVI has been increasingly applied to patients with atrial fibrillation who have poor drug treatment effect.Initially,this procedure was used to catheter the pulmonary vein "point-by-point" ablation with Radiofrequency energy through controlled ablation catheters,known as Radiofrequency ablation(RFCA).However,this procedure is highly manipulative,takes a long time to operate,has a long fluoroscopy time,and the patient has significant pain.Subsequently,the Cryoballoon catheter ablation(CBCA)technique appeared and developed rapidly,and the Cryoballoon catheter ablation method was easy to learn and master with a short learning curve.Up to now,a number of clinical trials at home and abroad have proved that cryo-ablation is safe and effective.Follow-up results of radiofrequency ablation and cryo-ablation isolation of pulmonary veins in the treatment of atrial fibrillation show no significant difference in the short-term and long-term results.For these reasons,more and more clinicians are choosing the cryoballoid technique for the treatment of atrial fibrillation.Regardless of the technique used,the first step in PVI ablation is to conduct an atrial septal puncture through an atrial septal needle to establish the right atrial to left atrial passage.During follow-up,we found that some patients had persistent ASD(Atrial Septal Defect),and the incidence of ASD in patients with crony balloon ablation was significantly higher than that in patients with radiofrequency ablation.Based on this finding,we designed this study.The study is divided into three parts:In the first part,patients with atrial fibrillation who underwent different ablation procedures were followed up and observed to compare the incidence of atrial septal defect(ASD)between the two ablation procedures,and to explore the high risk factors and protective factors for the occurrence of ASD,as well as the clinical significance of this iatrogenic ASD;The second part explores whether atorvastatin treatment can improve the occurrence of iatrogenic atrial septal defect after catheter ablation,reduce the recurrence of atrial fibrillation and improve the prognosis;The third part explores whether ACEI/ARB treatment can improve the incidence of iatrogenic atrial septal defect after catheter ablation,reduce the recurrence of atrial fibrillation,and improve the prognosis.Part One The influence of iatrogenic atrial septal defect on the progn-osis of patients with atrial fibrillation between cryoablation and radiofrequency ablationObjective: Through the follow-up observation of patients with atrial fibrillation who underwent cryoablation and radiofrequency ablation,the incidence of atrial septal defect was compared between the two ablation methods,and the risk factors and protective factors for the occurrence of atrial septal defect were discussed.The clinical significance of iatrogenic atrial septal defect was observed through the follow-up.Methods:A total of 293 patients with atrial fibrillation receiving PVI treatment in our center were selected and divided into two groups according to different ablation methods,including 152 patients in the radiofrequency ablation group and 141 patients in the cryo-ablation group.Before treatment,all patients underwent history inquiry,physical examination,laboratory examination,routine ECG and Holter examination,and color Doppler ultrasound examination.BNP,Hs-CRP,Tn I and CKMB were detected in all patients before and 24 hours after operation.All patients were examined by Cardiac ultrasonography,Left atrial diameter(LAD),Right atrial diameter(RAD),left atrial ejection fraction(LAEF),early ventricular filling peak(E peak)and late ventricular filling peak(A peak),E / A ratio,left atrial strain(S%),strain rate(SR): left ventricular systolic(SRs),left ventricular early diastolic(SRe),left atrial systolic(SRa)were measured before ablation,3months after ablation and 1 year after ablation.The patients were followed up for statins,ACEI / ARB medication,recurrence of atrial fibrillation,6-minute walk test,stroke,any symptoms caused by arrhythmia and readmission.Spss19.0 statistical software was used for data analysis.Results: Ablation of atrial fibrillation was successfully performed in all cases,without pulmonary vein stenosis,thromboembolism,pericardial tamponade,left atrial rupture,left atrial esophageal fistula and other complications.There were no significant differences in age,gender,body mass index,hypertension,diabetes,cerebrovascular disease,cardiac insufficiency,basal heart rate,the proportion of paroxysmal and persistent atrial fibrillation,the use of statins and ACEI/ARB,and the levels of BNP,Hs-CRP,TNI and CKMB at baseline between the two groups.At 3 months after operation,the incidence of atrial septal defect in the cryoablation group was significantly higher than that in the radiofrequency ablation group(24.11% VS 11.84%,P<0.05),and the difference was statistically significant.At 1 year,the incidence of atrial septal defect in the cryoablation group was still significantly higher than that in the radiofrequency ablation group(15.60% VS6.58%,P<0.05),and the difference was statistically significant.There was no statistically significant difference in postoperative BNP levels between the two groups.The levels of Hs-CRP,TNI and CKMB in the cryoablation group were significantly higher than those in the radiofrequency ablation group(5.79±2.28 VS 4.52±2.05;6.06±2.72 VS 1.84±1.08;50.10±16.34 VS 22.60±8.64,P<0.001),and the differences were statistically significant.The exposure time of the cryoablation group was significantly higher than that of the radiofrequency ablation group(9.74±3.44 VS 3.51±1.34,P<0.001),and the difference was statistically significant.The left atrial operation time of the cryoablation group was significantly shorter than that of the radiofrequency ablation group(74.43±25.44 VS 114.09±28.26,P<0.001),and the difference was statistically significant.There was no statistical difference in the recurrence rate between the two groups.At 1 year,LAD was higher in the cryoablation group than in the radiofrequency ablation group(35.87±3.55VS35.07±3.31,P<0.05),and the difference was statistically significant.There were no significant differences in RAD,E peak,A peak,E / A ratio,S%,SRs,LVEF between the groups at 3 month and 1 year.There was no significant difference in SRe between groups at 3 months,but the difference was statistically significant at 1 year(-1.73±0.56 VS-1.95±0.81,P<0.05).SRa in the cryoablation group were lower than that in the radiofrequency group both at 3 months and 1 year(-1.84±0.64 VS-2.04±0.83,-2.31±0.63 VS-2.53±0.75,P<0.05),and the differences were statistically significant.LAEF was lower in the cryoablation group than that in the radiofrequency ablation group at 3months(53.35±11.89 VS 56.54±11.83,P<0.05),and there was no significant difference between the two groups at 1 year.There was no significant difference in preoperative indexes between the i ASD group and the non-i ASD group.After 1 year,LAD in i ASD group was higher than that in the non-i ASD group(37.44±4.55 VS 35.21±3.21,P<0.05),and the difference was statistically significant.After 1 year,RAD in i ASD group was higher than that in the non-i ASD group(35.19±2.80 VS 34.12±2.61,P<0.05),the difference was statistically significant.At 1 year,Peak A in the i ASD group was lower than that in the non-i ASD group(67.17±11.73 VS 72.96±18.29,P<0.05),and the difference was statistically significant.Similarly,SRa in i ASD group was lower than in the non-i ASD group at 1year(-2.14±0.69VS-2.45±0.69,P<0.05),and the difference was statistically significant.There were no significant differences in 6-minute walk test and ACEI / ARB medication between the two groups before and 1 year after alation.The incidence of non-arrhythmic palpitation symptoms in i ASD group was higher than that in non-i ASD one year after ablation(34.38%VS 24.14%,P<0.05),and the difference was statistically significant.The recurrence rate of atrial fibrillation in patients with i ASD was higher than that in the non-i ASD group(53.13% VS 28.74%,P<0.05),and the difference was statistically significant.There was no significant difference in rehospitalization rate and new stroke rate between the two groups.Binary logistic analysis showed that statins and ACEI / ARB were protective factors,while hypertension,left atrial diameter,left atrial operation time and operation mode were risk factors for i ASD,and hypertension(OR=2.606,P=0.039)and operation mode(OR=6.111,P=0.001)were independent risk factors.Summary:1.The atrial damage caused by cryoablation was significantly higher than that of the radiofrequency ablation group,which was more likely to lead to atrial remodeling and affect left atrial function in a certain period of time,and the incidence of atrial septal defect was significantly higher than that of the radiofrequency ablation group.2.The occurrence of atrial septal defect will affect the left atrial function and increase the risk of atrial fibrillation recurrence.Patients are more prone to some discomfort symptoms,which have no significant impact on patients’ exercise tolerance,stroke,and re-hospitalization.3.Hypertension,left atrial diameter,left atrial operation time,and operation mode are the high risk factors of atrial septal defect,while statins and ACEI/ARB drugs can reduce the occurrence of atrial septal defect.Part Two Effect of statin treatment on the incidence of iatrogenic atrial septal defect and the prognosis of patients after atrial fibrillation ablationObjective: To observe the changes of indexes in the statin treatment group and the control group by comparison.To explore whether statin treatment has an effect on the incidence of iatrogenic atrial septal defect after atrial fibrillation ablation,whether it has a preventive effect on recurrence after atrial fibrillation ablation,and whether it has an effect on the long-term prognosis of patients.Methods: Ninety-seven patients with atrial fibrillation who received PVI treatment in our center were selected and divided into two groups:50 cases in the statin treatment group and 47 cases in the non-statin treatment group.All the selected patients undergo medical history inquiry,physical examination,laboratory examination,routine ECG and Holter examination,cardiac color Doppler ultrasound examination,and cardiac CT before treatment.All patients were drawn blood for BNP,Hs-CRP,TNI and CKMB before and 24 hours after surgery.All patients underwent cardiac color Doppler ultrasound to check the healing of the atrial septal defect before surgery,3 months after surgery,and one year after surgery.The left atrial diameter(LAD),left atrial ejection fraction(LAEF),left ventricular ejection fraction(LVEF),the filling peak(peak E)of rapid ventricular filling in the early diastole,the filling peak(peak A)of the left ventricular filling in the late diastole(atrial contraction),Left atrial strain(S%),strain rate(SR): left ventricular systole(SRs),left ventricular early diastole(SRe),and left atrial systole(SRa)were measured.The patients were followed up for recurrence of atrial fibrillation,6-minute walk test,stroke,any symptoms caused by arrhythmia,and rehospitalization.Results: All cases successfully completed atrial fibrillation ablation without complications such as pulmonary vein stenosis,thromboembolic events,pericardial tamponade,left atrial rupture,and left atrial esophageal fistula.There was no statistically significant difference between the two groups of patients in preoperative baseline data including biochemical results,cardiac color Doppler ultrasound and other indicators.At 3 months after ablation,most of the atrial septal defects in the two groups could be closed.The incidence of atrial septal defect in the non-statin treatment group was significantly higher than that in the statin treatment group,but the difference was not statistically significant.At 1 year,the incidence of atrial septal defect in the non-statin treatment group was still significantly higher than that in the statin treatment group,but the difference was still not statistically significant.The levels of BNP,Hs-CRP,TNI and CKMB in the non-statin treatment group were significantly higher than those in the statin treatment group(125.33 ±89.39 VS 167.90 ± 114.18,9.52 ± 4.86 VS 5.99 ± 4.79,2.36 ± 0.73 VS 1.92 ±1.00,27.29 ± 8.25 VS 21.11 ± 8.66,P<0.05),and the differences between the two groups were statistically significant.The early recurrence rate of the statin treatment group was significantly lower than that of the non-statin treatment group,but the difference was not statistically significant.One-year later,the recurrence rate of the statin treatment group was significantly lower than that of the non-statin treatment group(22.00% VS 40.43%,P<0.05),and the difference was statistically significant.One year after atrial fibrillation ablation,the 6-minute walk distance of patients in the statin treatment group was significantly greater than that in the non-statin treatment group(698.37±110.84 VS 657.55 ±96.53,P < 0.05),and the difference between the two groups was statistically significant.One year after ablation,the LAD in statin treatment group was significantly lower than that in the non-statin group(34.99±3.45 VS6.77±4.14,P<0.05),and the difference was statistically significant.Both at 3months and 1 year after ablation,the left ventricular early diastolic atrial strain rate(SRe)(-2.13±0.824 VS-1.82±0.67,-2.03±0.0.73 VS-1.74±0.67,P<0.05)and left atrial systolic atrial strain rate(SRa)(-2.14±0.837 VS-1.77±0.840,-2.36±0.882 VS-1.98±0.75,P<0.05)were significantly higher in the statin treatment group than in the non-statin treatment group,and the differences were statistically significant.Summary:1.Atorvastatin treatment can reduce the levels of serum BNP,Hs-CRP,TNI,CKMB,etc.after ablation,reduce LAD,increase SRe,SRa,improve the results of the patient’s 6-minute walk experiment,and reduce the recurrence rate after atrial fibrillation.2.Atorvastatin treatment will reduce inflammation,reduce myocardial damage.It will reduce the incidence of i ASD in a certain extent,improve left atrial remodeling,and increase left atrial strain,thereby improving patient exercise tolerance and reducing recurrence of atrial fibrillation.Part Three The influence of ACEI/ARB treatment on the incidence of iatrogenic atrial septal defect and the prognosis of patients after atrial fibrillation ablationObjective: By comparing and observing the changes of related indicators between the ACEI/ARB treatment group and the control group,we explored whether ACEI/ARB treatment had an effect on the incidence of iatrogenic atrial septal defect after ablation of atrial fibrillation,whether it could reduce the recurrence after ablation of atrial fibrillation,and whether it could improve the prognosis of patients.Methods: A total of 87 patients with atrial fibrillation receiving PVI treatment in our center were divided into two groups: 45 cases in the ACEI/ARB treatment group and 42 cases in the control group.All enrolled patients underwent medical history inquiry,physical examination,laboratory examination,routine ECG and Holter examination,cardiac color Doppler ultrasound examination,and cardiac CT before treatment.All patients were drawn blood for BNP,Hs-CRP,TNI and CKMB before and 24 hours after ablation.All patients underwent cardiac color Doppler ultrasound to check the healing of the atrial septal puncture before ablation,3 months after ablation,and one year after ablation.The left atrial diameter(LAD),left atrial ejection fraction(LAEF),left ventricular ejection fraction(LVEF),the filling peak(peak E)of rapid ventricular filling in the early diastole,the filling peak(peak A)of the left ventricular filling in the late diastole(atrial contraction),Left atrial strain(S%),strain rate(SR): left ventricular systole(SRs),left ventricular early diastole(SRe),left atrial systole(SRa)were measured each time.The patients were followed up for recurrence of atrial fibrillation,6-minute walk test,stroke,any symptoms caused by arrhythmia,and rehospitalization.Results: All cases successfully completed atrial fibrillation rablation without complications such as pulmonary vein stenosis,thromboembolic events,pericardial tamponade,left atrial rupture,and left atrial esophageal fistula.There was no statistically significant difference between the two groups of patients in preoperative baseline data including biochemical results,cardiac color Doppler ultrasound and other indicators.At 3 months after surgery,most of the atrial septal defect in the two groups could be closed.The incidence of atrial septal defect in the control group was significantly higher than that in the ARB/ACEI treatment group,but the difference was not statistically significant.At 1 year,the incidence of atrial septal defect in the control group was still higher than that in the treatment group,but the difference was still not statistically significant.The levels of BNP,Hs-CRP,TNI and CKMB in the control group were significantly higher than those in the treatment group(188.31±94.76 VS 147.78±92.05,6.40±3.46 VS 5.02±2.69,2.16±0.892 VS 1.81±0.685,22.46±7.64 VS 19.12±5.60,P<0.05),and the differences between the two groups were statistically significant.The early recurrence rate of the treatment group was significantly lower than that of the control group,but the difference was not statistically significant;The recurrence rate of the treatment group was lower than that of the control group at one year,but the difference was not statistically significant.At 1 year after atrial fibrillation ablation,the 6-minute walk distance of patients in the treatment group was significantly greater than that in the control group,(688.45±98.63 VS 643.23±101.52,P < 0.05),and the difference between the two groups was statistically significant.Both at 3months and one year after ablation,the LAD of patients in treatment group was significantly lower than the control group(38.10±3.91 VS 39.76±3.81,36.62±3.54 VS 38.21±3.57,均P<0.05),and the difference was statistically significant.At 1 year,the S% of patients in the treatment group was higher than that in the control group33.84±8.82 vs 30.33±6.60,P<0.05),and the difference was statistically significant.The left ventricular early diastolic atrial strain rate(SRe)in the treatment group was higher than the control group(-1.96±0.73 VS-1.66±0.61,P < 0.05),and the difference was statistically significant.Both at 3 months and1 year after atrial fibrillation ablation,the left atrial systolic atrial strain rate(SRa)was significantly higher in the treatment group than in the control group(-2.13±0.78 VS-1.81±0.59,-2.32±0.53 VS-2.04±0.72,P<0.05),and the differences were statistically significant.At 1 year,the LAEF between the two groups of patients was significantly higher in the treatment group than in the control group(52.86±11.18 VS 47.62±10.47,P<0.05),and the difference was statistically significant.Summary:1.The level of BNP,Hs-CRP,TNI,CKMB can be reduce after atrial fibrillation ablation in ACEI/ARB treatment group.ACEI/ARB treatment can also reduce LAD,increase SRe,SRa,LAEF,and improve the results of the patient’s 6-minute walk experiment.2.ACEI/ARB treatment can reduce inflammation after atrial fibrillation ablation,reduce myocardial damage,.It will reduce the incidence of i ASD in a certain extent,improve left atrial remodeling,and increase left atrial strain,thereby improving patient exercise tolerance.Conclusions:1.Cryoablation has significantly higher atrial damage than the radiofrequency ablation group,and is more likely to cause atrial remodeling and affect left atrial function in a certain period of time.The incidence of atrial septal defect is signif-icantly higher than that of the radiofrequency ablation group.2.The occurrence of atrial septal defect will affect the function of the left atrium and increase the risk of atrial fibrillation recurrence.The patient is more likely to have some uncomfortable symptoms,which has no significant impact on the patient’s exercise tolerance,stroke,and rehospitalization.3.Hypertension,left atrial diameter,left atrial operation time,and operation mode are high-risk factors for atrial septal defect,and the application of statins and ACEI/ARB drugs can reduce the occurrence of atrial septal defect.In clinical work,we should pay full attention to the preoperative blood pressure control of patients with atrial fibrillation,as well as the selection of surgical procedures,and give statins and ACEI/ARB drug interventions as soon as possible for the high-risk population of i ASD.4.Statins can reduce the postoperative inflammatory response,reduce the degree of myocardial injury,reduce the incidence of i ASD in a certain degree,improve left atrial remodeling and left atrial strain,so as to improve exercise tolerance and reduce the recurrence of AF.5.ACEI/ARB can reduce the inflammatory response,reduce the degree of myocardial injury,reduce the incidence of i ASD in a certain degree,improve the reconstruction of left atrial,improve the left atrial strain and left atrial function,so as to improve the patient’s exercise tolerance. |
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