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目的右侧膈神经麻痹是冷冻球囊消融治疗房颤时最常见并发症。消融时监测膈神经活动是预防该并发症的有效措施。本研究通过测量上腔静脉区域起搏阈值和不同部位起搏的膈肌复合运动动作电位的方法,探讨膈神经的影像学的最佳起搏部位。方法前瞻性入选了32例接受冷冻球囊治疗的房颤患者。将可调弯标测电极导管以倒“U”字形放置到上腔静脉区域,使导管头端指向上腔静脉游离壁侧,右前斜造影判断上腔静脉形态,以及前壁、游离壁和后壁三个位点,将胸锁关节下第一、第二和第三椎间隙分别定义为上腔静脉区域的上、中、下三段。在各部位予以膈神经起搏(固定脉宽2 ms、起搏周长1 000 ms),通过改良的Ⅰ导联监测起搏膈神经时膈肌复合运动动作电位。检测各部位起搏阈值和各部位起搏输出5 m A时,膈肌复合运动动作电位的大小。结果采用倒“U”字形放置膈神经起搏导管可以达到稳定起搏。在32例患者中没有患者出现持续性膈神经麻痹。起搏位点共285个。可以发生膈神经夺获的位点占61.4%(175/285)。游离壁、后壁能够发生膈神经夺获的起搏位点显著多于前壁[游离壁为80.0%(76/95)、后壁为84.2%(80/95)、前壁为20.0%(19/95),P<0.001]。改良Ⅰ导联记录的后壁和游离壁起搏能够记录到膈肌复合运动动作电位的起搏点显著多于前壁起搏点(P<0.001)。膈神经起搏阈值和膈肌复合运动动作电位存在负相关性(r=-0.267,P=0.005)。结论通过倒“U”字形放置起搏导管于上腔静脉的后壁和游离壁,可以达到稳定的膈神经起搏。在起搏阈值最低的部位进行起搏可以展现更加清晰的膈肌复合运动动作电位,有助于冷冻消融时监测膈神经麻痹的发生。
The right phrenic paralysis is the most common complication of cryoablation for atrial fibrillation. Monitoring phrenic nerve activity during ablation is an effective measure to prevent this complication. In this study, by measuring the superior vena cava pacing threshold and different parts of the pacing diaphragmatic motor activity of the complex approach to explore the phrenic nerve imaging best pacing site. Methods prospectively enrolled 32 patients with atrial fibrillation treated with frozen balloon. The adjustable curved calibration electrode catheter inverted “U” shaped placed in the vena cava region, the catheter tip to point to the superior vena cava free wall side, the right anterior oblique angiography to determine superior vena cava morphology, and the anterior wall, free wall And the posterior wall of the three sites, the sternoclavicular joint under the first, second and third intervertebral space were defined as the superior vena cava region of the upper, middle and lower three. Phrenic nerve pacing (fixed pulse width 2 ms, pacing perimeter 1 000 ms) was performed in all the parts. The composite motor action potentials of the diaphragmatic muscles were monitored by the modified Ⅰ lead. Detection of various parts of the pacing threshold and the various parts of the pacing output 5 m A, the diaphragm movement motor action potential size. The results of inverted “U ” glyph placement of phrenic nerve pacing catheter can achieve stable pacing. No patient had persistent phrenic nerve paralysis in 32 patients. A total of 285 pacing sites. Phrenic nerve can take place accounted for 61.4% (175/285). There were significantly more pacing sites for phrenic nerve entrapment in the free wall and the posterior wall than in the anterior wall (80.0% (76/95) for the free wall, 84.2% (80/95) for the posterior wall, and 20.0% for the anterior wall 19/95), P <0.001]. Compared with anterior wall pacemakers (P <0.001), the posterior wall and free wall pacing recorded by improved lead Ⅰ recorded more pacing motions of diaphragmatic motor. There was a negative correlation between phrenic nerve pacing threshold and diastolic action potential (r = -0.267, P = 0.005). Conclusions Stenting of phrenic nerve pacing can be achieved by placing the pacing catheter on the posterior wall and the free wall of the superior vena cava by inverting the “U” glyph. Pacing at the site of the lowest pacing threshold can reveal a clearer diastolic action potential of the diaphragm and help monitor the onset of phrenic nerve paralysis during cryoablation.