致心律失常性右室发育不良室性心动过速的电生理检…

报告药物治疗无效、射频导管消融失败的致心律失常性右室发育不良（ＡＲＶＤ）顽固性室性心动过速（简称室速）１例患者，在电生理导引下行右室前游离壁隔离术治疗成功。术后随访７个月无室速发作，右室收缩功能正常。提示部分右室隔离术对有生命危险和药物治疗无效及射频导管消融失败的ＡＶＲＤ室速患者是安全、有效的。     

导管射频消融治疗顽固性多形性室性心动过速一例

报道 1例右室心肌病所致的多形性室性心动过速 (简称室速 )的导管射频消融治疗 ,探讨此类室速的治疗方法。患者女性、6 8岁 ,反复发作多形性持续性室速 ,多种抗心律失常药物疗效较差或无效。采用激动标测行导管射频消融 ,依次在右室游离壁、流出道后壁、前下近间隔、前上近间隔标测到 4种不同形态的室速并消融成功。随访12个月 (停用抗心律失常药物 9个月 )无室速发作。结论 :对于药物治疗无效 ,又不适合置入埋藏式心脏复律除颤器的反复发作的多形性室速 ,可采用导管射频消融治疗     

室性心动过速起源点标测与电消融及手术治疗

作者对８例室性心动过速（ＶＴ）患者进行９次ＶＴ起源点标测与电消融及手术治疗，其中１例直流电导管消融手术（ＤＣＣＡ）后１５个月复发，再次行消融术。８例中，１例为开胸术中心外膜标测，１例由体表ＥＣＧ定位，其余均为导管电极心内膜标测。８例共标出９个ＶＴ起源点，左室４个，右室５个。１例在开胸术中施行心外膜ＤＣＣＡ，２例手术切除ＶＴ起源点，其余５例６个起源点施行ＤＣＣＡ，其中３例次先行导管射频消融术（ＲＦＣＡ），不成功者而改用ＤＣＣＡ。结果显示，１例心内膜ＤＣＣＡ后１５个月ＶＴ复发，进行第２次心内膜ＤＣＣＡ后控制（术中先施行ＲＦＣＡ无效），２例分别施行心外膜与心内膜ＤＣＣＡ后仍发ＶＴ，分别服美西律与维拉帕米即可控制。前者随访１９个月、后者１２个月未再发作，其余５例随访１４～３４个月（２１．６±７．６）均未服药而无ＶＴ发作。这提示，对于顽固性ＶＴ患者，只要准确定位ＶＴ起源点，电消融或外科手术可望获得满意疗效。     

射频消融治疗快速性心律失常的体会

临床安全应用射频导管消融（ＲＦＣＡ）治疗各类快速性心律失常７８０例，总成功率９７．８％。其中房室折返性心动过速（ＡＶＲＴ）５５４例；房室结折返性心动过速（ＡＶＮＲＴ）１８２例；房扑１５例；房颤５例；特发性室速８例；右室流出道室速、室早１４例；致心律失常性右室心肌病（ＡＲＶＣ）２例。本组患者无一例发生血胸、气胸、心包填塞、动脉拴塞、３°房室传导阻滞、室颤等严重并发症。本文特别强调了术前充分准备、术中精确标测定位、细心轻巧操作、严谨控制消融能量和时间，术中与术后严密监护，可以最大程度地降低并发症的发生率。     

射频导管消融器质性心脏病室性心动过速9例临床观察

目的评价射频导管消融器质性心脏病室性心动过速(室速)的疗效。方法总共9例器质性心脏病患者(男7例,女2例),接受射频导管消融手术,其中肥厚型心肌病4例,扩张性心肌病2例,冠状动脉粥样硬化性心脏病1例,先天性心脏病、室间隔缺损修补术后1例,致心律失常性右室心肌病1例。所有患者术前心电图和动态心电图均提示为单形性室速。9例患者均在窦性心律下行起搏标测室速折返环出口或病灶起源点,如果起搏QRS波形态至少有11导联与诱发室速QRS波形态相同,且S-QRS间期≤20ms,则判断为消融靶点,在此部位行多靶点消融。结果 9例患者中,4例为右室流入道室速,3例为右室流出道室速,1例为左室流入道室速,1例为左室流出道室速。其中1例致心律失常性右室心肌病患者术中出现三种室速形态而放弃手术。其余8例患者分别消融3~11个靶点,其中2例手术失败。1例患者1周后再次行射频消融手术失败。所有患者术中、术后均无并发症发生。随访20~42(30.65±8.72)月,其中6例患者(包括1例2次手术者)无室速复发。结论射频导管消融能有效治疗器质性心脏病单形性室速;起搏标测手段在器质性心脏病室速射频消融中有其应用价值。     

右室室性心动过速的射频消融及其随访结果

目的观察右室室性心动过速(简称室速)射频消融的近、远期疗效。方法34例右室室速患者经受了射频消融，其中诊断为特发性右室室速29例，致心律失常性右室发育不全(ARVD)5例。结果28例特发性右室室速消融成功，1例失败；5例ARVD患者诱发出9种室速，5种室速消融成功，另4种室速失败。随访显示，28倒特发性右室室速中2例分别于射频消融术后的12和15个月发生新的室性心律失常，进一步检查证实1例为ARVD，另1例为扩张型心肌病。ARVD患者组中2例室速复发。结论右室室速射频消融的结果取决于有无器质性心脏病，对于特发性右室室速消融术后再发或出现新的室性心律失常患者，需注意排除ARVD或心肌病等器质性心脏病的存在。     

特发性室性心动过速靶点标测与射频消融方法研究

目的探讨特发性室性心动过速（ＩＶＴ）有效靶点标测与射频导管消融（ＲＦＣＡ）放电方法。方法６７例ＩＶＴ病人行ＲＦＣＡ治疗。右室ＩＶＴ（ＩＲＶＴ）和左室ＩＶＴ（ＩＬＶＴ）采用激动标测和起搏标测相结合方法寻找靶点,右室流出道（ＲＯＴ）ＩＲＶＴ用双大头导管交替标测或放置１根４极或１０极电极导管于ＲＯＴ作为参考电极。采用预设６０～７０℃渐增功率温控放电进行消融。结果６７例ＩＶＴ消融成功６２例,成功率９２．５％,其中２３例ＩＲＶＴ成功２１例,１例靶点位于右室流入道,消融成功,２２例位于ＲＯＴ,２０例消融成功;４４例ＩＶＴ成功４１例,１例靶点位于左室游离壁,消融成功,４３例位于左室室间隔部,４０例成功。４例术后出现少量心包积液。结论激动标测和起搏标测相结合是提高ＩＶＴ消融成功率的有效方法。渐增功率温控放电安全可靠。     

心脏电生理学新概念 (7)伴有器质性心脏病室性心动过速消融治疗的现状与评价

临床上常见的器质性心脏病室性心动过速（室速）主要为冠心病、心肌病、先天性心脏病（尤其是矫正术后）和致心律失常右心室发育不良（ＡＲＶＣ）。与室上性折返性心动过速射频导管消融（射频消融）相比，射频消融器质性心脏病室速的成功率明显较低，且复发率和并发症均较高。１　　冠心病室性心动过速的射频导管消融　　　　研究证实，持续性单形性冠心病室速通常由折返引起。其折返环路可有不同构型，但均具有共同特征，即存在于疤痕区域内或疤痕边缘区的缓慢传导区（ＳＣＺ）。ＳＣＺ既是折返环路的关键组成部分，也是射频消融的靶点。…     

136例冠心病患者室性心动过速的导管消融：结果及长期随访

０６９１３６例冠心病患者室性心动过速的导管消融：结果及长期随访［ＧｏｎｓｋａＢＤ等．ＪＡｍＣｏｌｌＣａｒｄｉ－ｏｌ．１９９４，２４：１５０６（英文）」本研究的目的是通过射频或直流电导管消融的方法治疗冠心病患者药物治疗无效的、单形性持续性室性心动过速，...     

射频消融治疗频发单源性室性期前收缩（附三例报告）

采用起搏标测法对３例有明显症状的频发单源性室性期前收缩（下称室早）患者进行射频导管消融（ＲＦＣＡ）治疗。经标测２例定位于右室流出道、１例定位于左室间隔。以３０～４０Ｗ的功率消融，持续时间３０～６０ｓ，获得成功。术后５～７ｄ复查动态心电图未发现室早。随访１～１１个月，２例未复发，１例出现偶发室早。认为对有明显临床症状且药物难以奏效或不能耐受其副作用的单源性室早患者，可考虑ＲＦＣＡ治疗。该疗法有可能成为根治室早的有效方法     

An Unusual Case Of Right Ventricular Outflow Tract Tachycardia

In this report, we describe an unusual case of right ventricular outflow tract (RVOT) tachycardia with episodes of repetitive monomorphic ventricular tachycardia (VT), paroxysmal sustained VT and incessant monomorphic VT of the same morphology. Diltiazem, adenosine, or metoprolol failed to interrupt these arrhythmias. However, administration of intravenous propafenone completely eliminated all ventricular ectopic activity. Electrophysiologic study performed off propafenone showed that the ventricular ectopic activity originated from a single locus at the anterior wall of the RVOT. Two radiofrequency applications at this site resulted in complete elimination of ventricular ectopic activity.     

Isolated Right Ventricular Myocardial Infarction

Abstract Isolated right ventricular infarction is uncommon. A 73-year-old man without previous cardial complaints was admitted pulseless to hospital. An infarct of the left ventricle was suspected. Autopsy showed a fresh thrombus located in a small branch artery of the right coronary artery accompanied by a fresh infarction of the anterior free wall of the right ventricle. Only 8 cases of isolated right ventricular infarction located in the anterior free wall were found in a review of the literature of right ventricular infarction. The diagnosis, treatment and prognosis of right ventricular infarction are discussed.     

Ablation of Ventricular Arrhythmias in Arrhythmogenic Right Ventricular Dysplasia

VT Ablation in Right Ventricular Dysplasia. Arrhythmogenic right ventricular dysplasia (ARVD) is a genetically determined myocardial disease characterized by fibrofatty replacement of the right ventricular wall. Ventricular tachyarrhythmias can be seen in the early stages of the disease, which is one of the most important causes of sudden death in young healthy individuals. Radiofrequency (RF) catheter ablation is an option for the treatment of medically refractory ventricular arrhythmias and it has shown to successfully abolish recurrent ventricular tachycardias (VT) as well as reduce the frequency in defibrillator therapies. However, variable acute and long‐term success rates have been reported. The current mapping and ablation techniques include activation and entrainment mapping during tolerated VT and substrate ablation using 3‐dimensional electroanatomic mapping systems. This article aims at providing a comprehensive review of RF catheter ablation of ventricular arrhythmias in the context of ARVD. (J Cardiovasc Electrophysiol, Vol. 21, pp. 473‐14, April 2010)     

射频消融室性早搏治疗特发性和心肌梗死后恶性室性心动过速

报道射频消融室性早搏 (简称室早 )治疗特发性或心肌梗死 (MI)后恶性室性心动过速 (VT)各 1例。例 1女性 2 6岁 ,因阵发性心悸 1年 ,加重伴晕厥 4天入院。动态心电图示频发单形室早和短阵VT。无器质性心脏病证据。入院后第 3天无诱因出现意识丧失 ,持续约 2min自行缓解 ,心电图示多形性VT ,导致VT的室早形态与临床中频发室早相同。例 2男性 6 4岁 ,急性广泛前壁MI半个月后出现VT ,尽管经冠状动脉血运重建、纠正心力衰竭、多种抗心律失常药物等治疗 3个月 ,VT仍频繁发作 ,VT发作时伴明显血流动力学障碍 ,有时转为心室颤动 ,多需直流电复律。 2例消融术中均出现频发室早 ,形态与临床上诱发VT的室早形态相同。例 1心室猝发刺激诱发出多形性VT伴阿 斯综合征发作。例 2心室程序电生理刺激可诱发出 4种形态持续性VT。例 1结合激动和起搏标测 ,在右室流出道消融室早成功 ;例 2在左室间隔部向右室凸出的室壁瘤周围标测到室早时提前体表QRS波 5 0ms的Purkinje纤维电位 ,在此处消融室早成功。例 1随访 2 1个月无晕厥。例 2术后继续口服抗心律失常药物治疗 ,随访 10个月无晕厥和持续性VT。结论 :在部分特发性或急性MI患者中消融诱发VT的室早可能根治恶性VT。     

Long-Term Results of Visually Guided Left Ventricular Reconstruction as Single Therapy to Treat Ventricular Tachycardia Associated with Postinfarction Anteroseptal Aneurysm

Visually Guided Left Ventricular Reconstruction for Recurrent VT. Introduction: Postinfarction ventricular tachycardia (VT), anteroseptal aneurysm. and ventricular dysfunction are commonly associated and predict a poor long-term prognosis. Surgical left ventricular reconstruction, which includes double plication of the anterior and septal wall, can improve ventricular function. This article analyzes the long-term efficacy of such a procedure to control recurrence of VT in a group of 50 consecutive patients.
Methods and Results: The study group consisted of 50 consecutive patients operated on between December 1986 and December 1994. The group comprised 44 men and 6 women. The mean age was 56 ± 11 years. All patients had spontaneous VT following an anterior myocardial infarction. Twenty-five patients had two or more episodes of VT (eight presented as cardiac arrest, nine as syncope). Coronary artery disease was limited to the left anterior descending artery in 27 patients. An anteroseptal aneurysm was present in 49 patients. All patients had VT induced by programmed ventricular stimulation before surgery, and left ventricular reconstruction was performed without intraoperative mapping in all cases. Total mortality, VT recurrence, and sudden death rate were the endpoints of the study. In-hospital mortality was 8%. Postoperative left ventricular ejection fraction improved from 0.38 to 0.50 ( P < 0.05). Only two patients had postoperative inducible VT. Overall survival, VT recurrence rate, and sudden death rate were 73%, 12%, and 10%, respectively, after a median follow-up period of 6.25 years (0 to 8 years).
Conclusion: Visually guided left ventricular reconstruction with septal and anterior wall plicature can he utilized effectively to treat recurrent VT associated with postinfarction anteroseptal aneurysm.     

伴右心室出口的左心室起源缺血性室性心动过速的标测和消融

目的折返性的缺血性室性心动过速（VT）绝大多数发生于左心室并表现为右束支阻滞（RBBB）图形。本文报道1组VT折返环位于左心室但出口在右心室且表现为左束支阻滞（LBBB）的病例。方法32例因陈旧性心肌梗死伴VT而接受电生理检查和射频消融的患者,其中4例临床有LBBB形态的VT。使用非接触等电位和虚拟单极标测判断VT起源,结合舒张中期电位（MDP）和拖带标测确定折返关键通路和消融靶点。用盐水冲洗电极导管在折返环的关键峡部行线性消融。结果全部32例患者中,4例临床有LBBB型VT者均成功被诱发,其中1例有两种LBBB型VT,1例同时有RBBB型VT但周长与LBBB型相同;另有1例共有6种形态的VT,包括RBBB和LBBB型。在右心室内的非接触式等电位标测可迅速确定VT在右心室的传出部位,该处的虚拟单极标测显示rS型提示左心室起源。3例在左心室成功拖带并消融成功,靶点均紧邻左心室间隔,其中1例位于下壁,1例在前壁,1例两种LBBB型VT分别在前壁和下壁间隔旁消融成功。随访1～4．2年,未服抗心律失常药无VT发作。而1例诱发出6种单形（包括RBBB和LBBB型）VT患者因巨大室壁瘤及心功能障碍不能耐受而中途放弃消融。结论紧邻室间隔的前壁和下壁心肌梗死后的左心室起源VT可能因在右心室有出口而表现为LBBB型,需要在标测和消融时予以注意。     

Localization of cardiac arrhythmias: conventional noninvasive methods

Noninvasive localization of the accessory pathway (AP) in patients with the Wolff-Parkinson-White syndrome and of the site of origin of ventricular tachycardia (VT) is reviewed. 12-lead electrocardiography (ECG) is the most readily available method for localization of both the AP and the site of VT origin. Many published ECG criteria are introduced. The application of body surface potential mapping, vectocardiography, nuclear phase imaging, echocardiography, computed tomography, nuclear magnetic resonance, and signal-averaged ECG in the localization of these arrhythmogenic substrates is also described. We believe that ECG is the most sensitive noninvasive method for AP localization as well as being convenient and simple; it may be used as the only noninvasive method for the initial evaluation. The left lateral AP, which occurs with an incidence of more than 40%, could be localized preoperatively by noninvasive methods only. For localization of the site of VT origin, none of the noninvasive methods is accurate enough for guiding the surgical and catheter-mediated ablative therapies so far.Abbreviations AP accessory pathway - ARVD arrhythmogenic right ventricular dysplasia - BSPM body surface potential mapping - LFW left free wall - LAW left anterior wall - LLW left lateral wall - LPW left posterior wall - LPS left posteroseptal - NMR nuclear magnetic resonance - PS posteroseptal - RFW right free wall - RAS right anteroseptal - RAW right anterior wall - RLW right lateral wall - RPW right posterior wall - RPS right posteroseptal - VPB ventricular premature beats     

Electroanatomic mapping characteristics of ventricular tachycardia in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia.

BACKGROUND: Ventricular tachycardia (VT) in arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVD) has been previously explored using entrainment mapping techniques but little is know about VT mechanisms and the characteristics of their circuits using an electroanatomical mapping system. METHODS AND RESULTS: Three-dimensional electroanatomical mapping was performed in 11 patients with well tolerated sustained VT and ARVD. Sinus rhythm mapping of the right ventricle was performed in eight patients showing areas of low bipolar electrogram voltage (<1.2 mV). In total 12 tachycardias (mean cycle length 382+/-62 ms) were induced and mapped. Complete maps demonstrated a reentry mechanism in eight VTs and a focal activation pattern in four VTs. The reentrant circuits were localized around the tricuspid annulus (five VTs), around the right ventricular outflow tract (one VT) and on the RV free lateral wall (two VTs). The critical isthmus of each peritricuspid circuit was bounded by the tricuspid annulus with a low voltage area close to it. The isthmus of tachycardia originating from the right ventricular outflow tract (RVOT) was delineated by the tricuspid annulus with a low voltage area localized on the posterior wall of the RVOT. Each right ventricular free wall circuit showed an isthmus delineated by two parallel lines of block. Focal tachycardias originated on the right ventricular free wall. Linear radiofrequency ablation performed across the critical isthmus was successful in seven of eight reentrant tachycardias. The focal VTs were successfully ablated in 50% of cases. During a follow-up of 9-50 months VT recurred in four of eight initially successfully ablated VTs. CONCLUSIONS: Peritricuspid ventricular reentry is a frequent mechanism of VT in patients with ARVD which can be identified by detailed 3D electroanatomical mapping. This novel form of mapping is valuable in identifying VT mechanisms and in guiding RF ablation in patients with ARVD.     

动态基质标测在致心律失常右室心肌病患者室性心动过速射频消融中的应用

目的　探讨应用非接触球囊导管标测系统行动态基质标测,指导对致心律失常右室心肌病(ARVC)患者室性心动过速(室速)消融的价值。方法　应用非接触球囊导管标测系统在窦律下对 3例ARVC室速患者行动态基质标测,在确定室速的最早激动点、出口部位和传导顺序后,寻找与室速相关的峡部并行线性消融。结果　3例患者存在 3种不同形态的基质,分别位于右室流出道、右室前壁和右室前侧壁。共诱发 5种室速,平均心动周期为(348±65)ms,其中 3种室速起源于基质或基质边缘, 2种室速的起源远离基质; 1种室速经基质传导。5种室速全部消融成功。平均随访 20个月,无心动过速发作。结论　应用非接触球囊导管标测系统确定异常电生理基质有助于理解ARVC室速的发生机制和制定消融策略,行室速相关峡部的线性消融可有效治疗室速。     

右室流出道心律失常的发作方式与单导管消融治疗

报道 33例右室流出道心律失常的发作方式与单导管消融治疗。 3例仅室性早搏 (简称室早 )发作 ,30例室早与室性心动过速 (简称室速 )或心室颤动 (简称室颤 )并存。其中室早合并短阵单形室速 17例 ,合并持续单形室速 6例 ,合并多形室速 4例 ,合并快速室速或心室扑动 2例 ,合并室颤 1例。单点穿刺股静脉后 ,行右房或心室造影 ,将单根多枚电极导管按需放置于右室心尖部或流出道 ,行电生理检查、起搏与激动顺序标测和消融治疗。结果 :消融成功 30例 ,成功率 91%。靶点电图较体表QRS波始点早 38± 12 .4ms。 12例成功靶点位于右室流出道游离壁、9例位于间隔部、5例在游离壁和间隔部作多点片状消融、3例位于肺动脉瓣上、1例在右室流出道间隔部和左室间隔部消融成功。操作时间 5 2± 2 2 .2min ,X线透照时间 2 6± 18.0min ,放电时间 373± 111.7s。术中 1例未诱发心律失常 ,未行消融。 3例发生并发症 ,2例终止消融。 1例右室流出道穿孔 ,心包压塞。 1例多形室速 ,消融中室早多次触发室颤。 1例剧烈胸痛 ,冠状动脉造影示前降支近端 5 0 %局限狭窄。随访 14± 4 .5个月 ,无死亡病例 ,3例复发 ,1例消融 3次均复发 ,复发率 10 %。住院总花费人均 9133± 12 0 0元。结论 :右室流出道心律失常发病形式多种多样 ,单导?