| Atrial fibrillation is a kind of supraventricular tachyarrhythmia,which is characterized by uncoordinated atrial electrical stimulation and ineffective atrial contraction.Atrial fibrillation,which lasted more than 7 days,including more than 7 days after cardioversion,became persistent atrial fibrillation.And with the growth of age,its incidence rate gradually increased.With the coming of aging in China,atrial fibrillation has caused a greater and greater impact on people’s health.The Asia Pacific region may underestimate the prevalence of atrial fibrillation.With the application of various monitoring methods,more and more atrial fibrillation has been detected.The main hazards of atrial fibrillation include: stroke and thromboembolism;Aggravate the symptoms of patients with heart failure;The risk of myocardial infarction in patients with atrial fibrillation increased by 2 times;Atrial fibrillation increases the risk of cognitive decline,dementia,Alzheimer’s disease and vascular dementia;Atrial fibrillation increases the risk of renal insufficiency;This leads to a significant decline in the quality of life.People pay more and more attention to the treatment of atrial fibrillation.At present,the treatment of atrial fibrillation mainly includes restoring sinus rhythm,controlling ventricular rate and preventing thromboembolic disease.Both antiarrhythmic drug therapy and catheter ablation can restore patients to sinus rhythm.More and more clinical trials have confirmed that catheter ablation of atrial fibrillation is superior to drug therapy in maintaining sinus rhythm.In patients with atrial fibrillation and heart failure,catheter ablation can significantly reduce the composite end point of all-cause death and worsening of heart failure hospitalization.If atrial fibrillation does not return to sinus rhythm,according to CHA2DS2-VASC score,anticoagulation treatment is required to reduce the risk of thromboembolism.Anticoagulant drugs mainly include warfarin and new oral anticoagulants.The dietary diversity of Chinese residents has a great impact on the warfarin treatment window,leading to the unstable efficacy of warfarin.In addition,warfarin needs regular blood sampling to monitor INR.Because of the cumbersome blood sampling test,some patients stopped taking drugs,which limits its application.Compared with warfarin,the efficacy of new oral anticoagulant drugs is no less than that of warfarin,and it does not need frequent blood sampling monitoring.The blood concentration is stable,but it is expensive and lacks effective antagonists.Warfarin and new oral anticoagulants have certain bleeding risks.Thromboembolic events are the main hazards caused by atrial fibrillation,while patients with non-valvular atrial fibrillation have ischemic stroke,and90% of the thrombus originates from left atrial appendage.Compared with warfarin,LAAC can significantly reduce the incidence of hemorrhagic stroke,disabling/fatal stroke,cardiovascular and all-cause death.CA combined with LAAC can not only improve the symptoms of heart failure,but also prevent the occurrence of cardiogenic thromboembolism.It can also further reduce bleeding events caused by long-term use of anticoagulants.Multi-center study confirmed the safety and effectiveness of CA combined with LAAC in the treatment of atrial fibrillation.At present,the consensus of experts on left atrial appendage occlusion in 2019 in China suggests that for patients with non-valvular atrial fibrillation who have high risk of stroke(CHA2DS2-VASc score≥2),cannot tolerate or comply with long-term anticoagulation treatment,if they have symptoms,and have the indications of radiofrequency ablation and LAAC,the qualified centers can implement one-stop treatment.The formation of the left atrial appendage is caused by part of the myocardium originating from the coronary sinus,which begins to atrophy continuously at the time of embryonic formation.After the formation of the original left atrium,it continues to wrap and surround the left atrium.As a part of the left atrium,the left atrial appendage is not only a subsidiary structure of the left atrium,but also has a certain capacity.It plays an important role in regulating the pressure and volume of left atrium,including the function of storing blood in ventricular systole;At the early stage of diastole,the blood of pulmonary vein was diverted to the left ventricle,and at the end of diastole,the left ventricular filling was increased by contractility;The experiment showed that the left atrial pressure could be increased after the left atrial appendage was temporarily emptied;In atrial fibrillation,left atrial appendage systolic function and compliance decreased,left ventricular filling capacity decreased,and flow rate decreased.Some studies have proved that after the patients with persistent atrial fibrillation recovered to sinus rhythm after CA,the left atrial volume decreased significantly compared with that before operation,and the left atrial function also improved,suggesting that catheter ablation has a positive effect on the structure and function of the left atrium.However,the influence of LAAC on left atrial structure and function is controversial.The previous study of our center has confirmed that the structure and function of LA are improved after CA combined with LAAC and restored to sinus rhythm.This improvement mainly comes from CA,After addition of LAAC,it will not affect the improvement of left atrial structure and function after CA.Moreover,LAAC combined with CA did not affect the recurrence rate of AF after RFA alone.The left atrial appendage emptying rate can be accurately measured by transesophageal color Doppler ultrasound,and is one of the indicators reflecting the left atrial appendage systolic function.Patients with atrial fibrillation with low left atrial appendage emptying rate have high sensitivity and specificity for left atrial appendage thrombosis;Even patients with atrial fibrillation at low risk of stroke should receive anticoagulant therapy to avoid embolic events.The motion function of the left atrial appendage wall can be obtained by tissue Doppler imaging(TDI),Doppler tissue velocity imaging(TVI),strain rate imaging(SRI)and speckle tracking imaging(STI).This study started with the emptying rate of left atrial appendage to study the changes of left atrial structure and function and the safety of patients with persistent non-valvular atrial fibrillation after LAAC combined with CA.The study mainly includes three parts.In the first part,patients with persistent atrial fibrillation were divided into two groups according to LAAEV<25cm/s and LAAEV≥25cm/s.After one-stop operation,the changes of left atrial structure were studied.To investigate the effect of combined operation on left atrial structure in patients with persistent atrial fibrillation with different left atrial appendage emptying velocities.The second part discusses the changes of left atrial function in patients with different left atrial appendage emptying speeds after one-stop operation.Recently,it has been proved that catheter ablation(CA)combined with left atrial appendage occlusion(LAAC)can improve the structure and function of left atrium.However,there is no study on the effect of left atrial appendage emptying velocity(LAAEV)on the changes of left atrial structure and function after combined operation.The third part is to compare the difference of surgical safety and recurrence rate between the two groups through one-year follow-up observation.The quality of life of the two groups was compared.If it is proved that there is no significant difference between LAAEV<25cm/s group and LAAEV ≥ 25cm/s group in terms of postoperative safety,sealing and thrombosis.If LAAEV<25cm/s is confirmed in long-term follow-up,combined surgery will not only reduce the risk of atrial fibrillation thrombosis to a greater extent,but also improve the structure and function of the left atrium more significantly.It can also improve the quality of life of patients.Compared with LAAEV≥25cm/s group,there was no significant difference in the safety of surgery and the recurrence rate of postoperative atrial fibrillation.For patients with non-valvular atrial fibrillation who are not suitable for long-term standard anticoagulation treatment,it is more worthy of reasonable choice.Part One Effect of percutaneous left atrial appendage closure combinedwith radiofrequency ablation on left atrial structure inpatients with persistent atrial fibrillation with different leftatrial appendage emptying velocitiesObjective:Atrial fibrillation is a kind of supraventricular tachyarrhythmia,which is characterized by uncoordinated atrial electrical stimulation and ineffective atrial contraction.And with the growth of age,its incidence rate gradually increased.With the coming of aging in China,atrial fibrillation has caused a greater and greater impact on people’s health.The Asia Pacific region may underestimate the prevalence of atrial fibrillation.The main hazard of atrial fibrillation is the occurrence of thromboembolism,and 90% of the thrombus in patients with non valvular atrial fibrillation originates from left atrial appendage.Compared with warfarin,LAAC can significantly reduce the incidence of hemorrhagic stroke,disabling/fatal stroke,cardiovascular and all-cause death.CA combined with LAAC to restore sinus rhythm can not only improve the symptoms of heart failure,but also prevent the occurrence of cardiogenic thromboembolism.It can also further reduce bleeding events caused by long-term use of anticoagulants.Our previous research has confirmed that the LA structure and function of persistent atrial fibrillation are improved after CA combines with LAAC and recovers to sinus rhythm.This improvement mainly comes from CA,and the additional LAAC procedures will not affect the improvement of LA structure after CA.However,there is no study on the effect of LAAEV on left atrial structure after combined operation.We studied the changes of left atrial structure in patients with persistent atrial fibrillation with different LAAEVs after receiving LAAC and CA treatment.Methods: This is a single center prospective cohort study.163 patients with persistent nonvalvular atrial fibrillation who received CA combined with LAAC treatment in our hospital from January 2017 to September 2020 were selected.The patients with complete data and sinus rhythm recovery were followed up regularly for 12 months.They were divided into LAAEV<25cm/s group and LAAEV ≥ 25cm/s group,and tendency scores were matched according to gender,age,CHA2DS2-VASc score and HAS-BLEED score.A total of 82 patients were enrolled,41 in each group.Two dimensional echocardiography was used to compare the changes of left atrial structure between the two groups.The maximum volume(LAVmax),minimum volume(LAVmin)and LAD of the left atrium were measured by two-dimensional echocardiography before operation,one week,one month,three months,six months,and 12 months after operation to evaluate the structure of the left atrium.Results: We followed up 201 patients.During the follow-up,we excluded 38 patients with incomplete data.The remaining 163 patients were divided into two groups according to LAAEV<25cm/s and LAAEV ≥ 25cm/s.There were 83 patients in LAAEV<25cm/s group.80 patients in LAAEV ≥25cm/s.During the follow-up,45 patients were found to have atrial fibrillation recurrence by dynamic electrocardiogram,including 25 patients(30%)in the LAAEV<25cm/s group and 20patients(25%)in the LAAEV ≥ 25cm/s group,which were excluded by us.There was no significant difference in the recurrence rate of atrial fibrillation between the two groups(P=0.503).The other 118 patients were matched according to gender,age,CHA2DS2-VASc score and HAS-BLEED score by 1:1.A total of 82 patients were matched,41 in each group.The results showed that the maximum volume(LAVmax)and the minimum volume(LAVmin)of left atrium in LAAEV<25cm/s and LAAEV ≥ 25cm/s groups decreased significantly after combined operation.The left atrium was remodeled inversely.The maximum volume(LAVmax)and minimum volume(LAVmin)of left atrium in LAAEV<25cm/s group were higher than those in LAAEV ≥ 25cm/s group(91.46 ± 16.17 vs 81.49 ±14.28P=0.004)(65.85 ± 18.17 and 56.02 ± 16.21 P=0.012).It proved that the left atrial remodeling was more obvious in the group with LAAEV<25cm/s before operation,and the LAVmax and LAVmin in both groups decreased after combined operation.One month after operation,there was no significant difference in LAVmax between the two groups.There was no significant difference in LAVmin between the two groups 3 months after operation.In LAAEV<25cm/s group,the left atrial structure was improved more significantly.Conclusions: In patients with persistent nonvalvular atrial fibrillation,LAAEV<25cm/s group had more significant left atrial remodeling than LAAEV ≥ 25cm/s group.After CA combined with LAAC and recovered to sinus rhythm,left atrial remodeling occurred in both groups.Compared with LAAEV ≥ 25cm/s group,LAVmax and LAVmin in LAAEV<25cm/s group decreased more significantly.Part Two Effect of percutaneous left atrial appendage closure combinedwith radiofrequency ablation on left atrial function in patientswith persistent atrial fibrillation with different left atrialappendage emptying velocitiesObjective: Atrial fibrillation is a kind of supraventricular tachyarrhythmia,which is characterized by uncoordinated atrial electrical stimulation and ineffective atrial contraction.And with the growth of age,its incidence rate gradually increased.With the coming of aging in China,atrial fibrillation has caused a greater and greater impact on people’s health.The Asia Pacific region may underestimate the prevalence of atrial fibrillation.The main hazard of atrial fibrillation is the occurrence of thromboembolism,and90% of the thrombus in patients with non valvular atrial fibrillation originates from left atrial appendage.Compared with warfarin,LAAC can significantly reduce the incidence of hemorrhagic stroke,disabling/fatal stroke,cardiovascular and all-cause death.CA combined with LAAC to restore sinus rhythm can not only improve the symptoms of heart failure,but also prevent the occurrence of cardiogenic thromboembolism.It can also further reduce bleeding events caused by long-term use of anticoagulants.Our previous research has confirmed that the LA function of persistent atrial fibrillation is improved after CA combined with LAAC and restored to sinus rhythm.This improvement mainly comes from CA,and the additional LAAC procedures will not affect the improvement of LA structure after CA.However,there is no study on the effect of LAAEV on left atrial function after combined operation.We studied the changes of left atrial function in patients with persistent atrial fibrillation with different LAAEVs after receiving LAAC and CA treatment.Methods: This is a single center prospective cohort study.163 patients with persistent nonvalvular atrial fibrillation who received CA combined with LAAC treatment in our hospital from January 2017 to September 2020 were selected.The patients with complete data and sinus rhythm recovery were followed up regularly for 12 months.They were divided into LAAEV<25cm/s group and LAAEV ≥ 25cm/s group,and tendency scores were matched according to gender,age,CHA2DS2-VASc score and HAS-BLEED score.A total of 82 patients were enrolled,41 in each group.Two dimensional echocardiography was used to compare the changes of left atrial structure between the two groups.The left atrial function was evaluated by spot tracking echocardiography before operation,one week,one month,three months,six months,and twelve months after operation.Total systolic strain and SR reflecting left atrial storage function were measured;SRe in early diastole reflects the catheter function of left atrium;The end diastolic SRa showed the left atrial pumping function.Results: We followed up 201 patients.During the follow-up,we excluded 38 patients with incomplete data.The remaining 163 patients were divided into two groups according to LAAEV<25cm/s and LAAEV ≥ 25cm/s.There were 83 patients in LAAEV<25cm/s group.80 patients in LAAEV ≥25cm/s.During the follow-up,45 patients were found to have atrial fibrillation recurrence by dynamic electrocardiogram,including 25 patients(30%)in the LAAEV<25cm/s group and 20patients(25%)in the LAAEV ≥ 25cm/s group,which were excluded by us.There was no significant difference in the recurrence rate of atrial fibrillation between the two groups(P=0.503).The other 118 patients were matched according to gender,age,CHA2DS2-VASc score and HAS-BLEED score by 1:1.A total of 82 patients were matched,41 in each group.The results show that: left atrial storage function(? And SRs):four chambers in LAAEV<25cm/s group before operation ? And SRs were lower in LAAEV ≥ 25cm/s group(14.22 ± 4.26 vs 19.51 ± 7.78 P=0.001)and(0.92 ± 0.26 vs 1.15 ± 0.44 P=0.004)? 、 SRs increased.There was no significant difference between the two groups in the four chamber SRs(1.32 ±0.33 vs 1.45±0.38 P=0.113)from the third time after operation.Left atrial channel function(SRe): SRe in LAAEV<25cm/s group was lower than that in LAAEV ≥ 25cm/s group before operation(-1.32±0.61 vs-1.64±0.52 P=0.012),and SRe in both groups increased after operation.At 12 months,there was no significant difference between the two groups(-1.63 ± 0.47 vs-1.83±0.51P=0.062).Left atrial systolic function(SRa): SRa in LAAEV<25cm/s group was lower than that in LAAEV ≥ 25cm/s group before operation(-1.05 ± 0.44vs-1.35 ± 0.48 P=0.005),and SRa in both groups increased after operation.From 6 months after operation,there was no statistical difference between the two groups(-1.73 ± 0.69 vs-1.98 ± 0.59 P=0.09).Conclusion: In patients with persistent nonvalvular atrial fibrillation,the overall left atrial function in LAAEV<25cm/s group was worse than that in LAAEV ≥ 25cm/s group.After CA combined with LAAC and recovered to sinus rhythm,left atrial function was improved in both groups.The storage function,channel function and pump function of LAAEV<25cm/s group increased more significantly than that of LAAEV ≥ 25cm/s.Part Three Effect of percutaneous left atrial appendage occlusioncombined with radiofrequency ablation on the success rate,safety and quality of life of patients with persistent atrialfibrillation with different left atrial appendage emptyingvelocityObjective: Atrial fibrillation is a supraventricular tachyarrhythmia characterized by uncoordinated atrial electrical stimulation and ineffective atrial contraction.And with the growth of age,its incidence rate gradually increased.With the arrival of aging in China,atrial fibrillation has caused more and more serious impact on people’s health.The Asia-Pacific region may underestimate the prevalence of atrial fibrillation.The main hazard of atrial fibrillation is the occurrence of thromboembolic events,while 90% of thrombus in patients with non-valvular atrial fibrillation originates from left atrial appendage.Compared with warfarin,LAAC can significantly reduce the incidence of hemorrhagic stroke,disabling/fatal stroke,cardiovascular and all-cause death.CA combined with LAAC can not only improve the symptoms of heart failure,but also prevent the occurrence of cardiogenic thromboembolism.It can also further reduce bleeding events caused by long-term use of anticoagulants.However,there is a certain risk of recurrence after atrial fibrillation surgery.It has been proved that the quality of life of patients with atrial fibrillation has been improved after CA combined with LAAC.We studied whether there was any difference in the AF reexamination rate and the improvement of patients’ quality of life in patients with persistent AF with different LAAEV after receiving LAAC combined with CA treatment.Methods: A total of 201 patients were followed up.During the follow-up,38 patients were excluded because of incomplete data.The remaining 163 patients were divided into two groups according to LAAEV<25cm/s and LAAEV ≥ 25cm/s.There were 83 patients in LAAEV<25cm/s.80 patients in LAAEV ≥ 25cm/s group.The 24-hour ambulatory ECG was recorded one month,three months,six months and twelve months after the operation.If atrial arrhythmia(including atrial fibrillation,atrial flutter and atrial tachycardia)is found for more than 30 seconds,it is considered as recurrence of atrial fibrillation.The recurrence of atrial fibrillation within 3 months(i.e.blank period)and 3 months to 12 months was analyzed.We excluded patients with recurrent atrial fibrillation during regular follow-up from 3 to 12 months.A total of 118 patients remained.(There were 58 patients in the LAAEV<25cm/s group and 60 patients in the LAAEV ≥ 25cm/s group.)According to gender,age,CHA2DS2-VASc score and HAS-BLEED score,the propensity score matching analysis was performed according to 1:1.A total of82 patients were matched,41 in each group.At 3 months after operation,all patients after CA combined with LAAC underwent routine transesophageal echocardiography to determine whether the occluder position is appropriate,whether there is residual shunt and whether there is device-related thrombus.The patients were followed up regularly 6 months and 1 year after the operation to determine whether there were adverse events such as thromboembolism,stroke,cerebral hemorrhage,vascular complications at the puncture site,pericardial tamponade and so on.The patient’s physical component summary PCS and mental component summary MCS were recorded by asking the patient to fill in the MOS item short from health survey SF-36 before operation,3 months after operation and 12 months after operation.The differences of PCS and MCS between the two groups before operation,three months after operation and 12 months after operation were analyzed.Results: During the three-month blank period,there were 25 patients with atrial arrhythmias,including 11 patients in the LAAEV<25cm/s group and 14 patients in the LAAEV ≥ 25cm/s group.There was no significant difference in the occurrence of early events between the two groups(P=0.519).In the follow-up,27 patients were found to have atrial fibrillation recurrence by dynamic electrocardiogram,including 11 patients(27%)in the LAAEV<25cm/s group and 14 patients(34%)in the LAAEV ≥ 25cm/s group.There was no significant difference in the recurrence rate of atrial fibrillation between the two groups(P=0.519).There was no significant difference in the operative complications between the two groups.There was no significant difference in the incidence of postoperative adverse events between the two groups.There was no significant difference in preoperative PCS between the two groups.PCS(physical health score)was significantly improved at 3 and12 months after operation.At 3 and 12 months after operation,the PCS of LAAEV<25cm/s group was higher than that of LAAEV ≥ 25cm/s group,and there was still statistical significance between the two groups.There was no significant difference in preoperative MCS(mental health score)between the two groups.MCS(mental health score)was significantly improved at 3 and 12 months after operation.However,there was no statistical difference between the two groups.Conclusion: The surgical safety and recurrence rate of patients with persistent atrial fibrillation with LAAEV<25cm/s were consistent with those with LAAEV ≥ 25cm/s.The quality of life of patients in both groups can be improved significantly.However,the quality of life of patients with persistent atrial fibrillation in the group with LAAEV<25cm/s was improved more significantly,and greater benefits could be obtained from CA combined with LAAC. |
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