非接触标测系统用于典型心房扑动的右房标测和导航消融

应用非接触标测系统实施典型心房扑动 (AFL)的右房 (RA)全心腔标测和导航射频消融。 6例典型AFL ,男 5例、女 1例 ,年龄 5 6 .2± 15 .3(35～ 76 )岁。常规放置冠状静脉窦和His束电极 ,将标测球囊置于RA中下部 ,构建RA心内膜模型 ,分别于低位RA和冠状窦口 (CSO)S1S16 0 0ms起搏观察峡部传导 ,诱发并标测AFL的激动顺序和折返路径。 1例为顺钟向AFL ,4例为逆钟向AFL ,1例未能诱发AFL。AFL周期 2 0 7± 34ms,非接触标测可显示整个折返环路、激动顺序和缓慢传导区。AFL的激动可以穿过界嵴上部并且传导相对缓慢 ,提示RA平滑部是折返环的一部分。后位峡部线性消融在导航系统指导下进行 ,无需X线透视。消融完成后重复上述起搏验证峡部双向传导阻滞。除 1例术中出现心房颤动 (AF)外 ,其余病例即刻均达到峡部双向阻滞 ,未出现其他并发症 ,随访 8.1± 6 .7(3～15 )个月未见复发。非接触标测系统可安全、有效和直观地实现典型AFL的右房全心腔标测并导航消融 ,验证峡部双向阻滞 ,减少X线曝光时间和无效放电次数。界嵴在典型AFL时具备传导功能 ,RA平滑部和粗糙部共同参与折返环的组成。     

非接触球囊导管标测系统指导心房扑动消融的初步经验

目的　评价非接触球囊导管标测系统在心房扑动 (房扑 )标测和射频消融中的临床应用。方法　 7例房扑患者 ,年龄 (6 0± 10 )岁 ,男 4例 ,女 3例。其中 1例为房间隔缺损修补术后 ,2例为采用常规方法消融典型房扑后复发患者。应用非接触球囊导管标测系统构建右房三维几何模型 ,标测心动过速的折返激动顺序和关键峡部 ,并利用其导航系统指导峡部的线性消融。消融后分别于峡部两侧起搏判断峡部阻滞情况。结果　 6例患者诱发出房扑 ,心动过速周长 (2 16± 2 2 )ms。6例房扑均为峡部依赖型 ,2例呈逆钟向传导 ,4例呈顺钟向传导 ;4例房扑呈双环折返激动 ;7例消融均成功 ,房扑不再诱发 ,峡部呈完全双向传导阻滞 ;手术时间 (30 0± 12 9)min ,X线曝光时间 (2 5 0± 6 5 )min ,放电次数 (2 5 7± 12 1)次。无手术并发症。随访 3～ 14个月无复发病例。结论　在房扑标测和消融中应用非接触球囊导管标测系统是安全有效的 ,不仅能确定折返环路 (特别是双环折返激动 )的顺序和关键峡部 ,而且能准确判断线性损伤的连续性 ,同时可减少X线曝光时间。     

心内非接触式标测指导右心房峡部依赖型心房扑动的消融

目的 心内非接触式标测能提供高密度的心内膜等电位标测,可采用此技术指导对有大折返环路的右心房峡部依赖型心房扑动(atrial flutter, AFL)进行消融。方法 22例患者(男性21例,女性1例)平均年龄15～65(38.0±12.8)岁。全部患者均在术前记录到典型的峡部依赖型AFL心电图。其中6例有心脏外科手术史,1例有复杂先天性心脏病,2例伴有明显的心脏扩大,8例患者曾经导管消融失败或复发。全部患者均采用右心房内非接触式标测引导在三尖瓣环-下腔静脉口(TVA-IVC)之间进行线性消融并检验消融线的完整性。结果 22例患者中18例标测到自发的AFL,4例由心房刺激诱发。全部病例中20例为逆钟向型AFL,2例顺钟向型。心内非接触式标测在所有病例均观察到经过峡部的大折返环路且行进方向与体表心电图吻合。在峡部进行TVA-IVC线性消融后,分别在冠状静脉窦口和右心房下外侧起搏时以非接触式标测证实消融线的完整性,全部患者的消融均获得即时成功,且不再服用抗心律失常药物,平均随访3～36(21.1±9.1)个月,无AFL复发,2例心脏扩大者均基本恢复正常。结论 心内非接触式标测技术可以直观、准确地观察到心房扑动的折返环路且指导进行有效的线性消融。     

心房颤动消融术后二尖瓣峡部房性心动过速的发生机制及消融治疗

目的探讨心房颤动(简称房颤)患者环肺静脉左房线性消融术后二尖瓣峡部房性心动过速(简称房速)的发生机制及其消融策略。方法122例房颤患者采用EnSite-NavX和环状电极行环肺静脉左房线性消融,术后32例复发房颤或房速,8例经EnSite-NavX激动标测及拖带标测证实存在二尖瓣峡部房速,在三维导航下于左下肺静脉口部下缘至二尖瓣环之间行线性消融,对不能成功阻断二尖瓣峡部传导者予以冠状静脉窦内消融。术中同时探查双侧肺静脉电位,如传导恢复予以再次隔离。结果8例中2例呈无休止性发作,6例为阵发性,可被程序刺激诱发。房速的周长217.5±20.6ms,其中顺钟向折返5例,逆钟向折返3例。二尖瓣峡部线性消融至完全性双向传导阻滞5例,3例心内膜途径失败者经冠状静脉窦内消融,其中1例获得成功。术后随访5.5±4.3个月,6例无房颤及房速发作,1例仍有阵发性房速发作。另1例术后房速呈无休止发作,予以胺碘酮及美托洛尔控制心室率治疗。结论环肺静脉线性消融术后发生的二尖瓣峡部房速与左房线性消融治疗房颤的致心律失常作用有关,其主要的机制是消融线相关的大折返性心动过速,阻断峡部传导可以治疗此类房速。     

大折返房性心动过速的电解剖标测和导管射频消融

目的应用电解剖标测系统分析3例大折返房性心动过速(房速)的电生理机制并导航消融。方法3例房速患者(男1例,女2例),平均年龄51±12岁,心动过速病史19±11年。常规电生理检查初步确定房速所在心腔,使用电解剖标测系统构建心房三维模型,完成电压和激动标测,分析心动过速的机制并确定缓慢传导区(即关键峡部),使用冷生理盐水灌注导管消融。结果3例患者临床常规检查初步排除结构性心脏病,电压标测均显示被标测心房存在疤痕区。病例1为围绕三尖瓣环顺钟向的大折返房速,关键峡部位于三尖瓣环与后侧壁的疤痕之间。病例2为围绕上腔静脉逆钟向的大折返房速,关键峡部位于右房侧壁疤痕与上腔静脉之间。病例3为左房8字形折返,关键峡部位于左房顶部的两片疤痕之间。3例患者均在关键峡部消融成功,随访9～10个月未见复发。结论电解剖标测可以揭示大折返房速的基质,阐明折返机制,并有效指导消融。     

三维标测系统指导下多环心房扑动的射频消融治疗

目的探讨三维标测系统指导下多环心房扑动(AFL)的射频消融疗效。方法 4例AFL患者,在三维标测系统(CARTO或EnSite Array)指导下建立相应心房三维模型并进行激动标测及电压标测,并对折返的关键峡部作线性消融。结果 4例患者均显示出多个折返环,其中1例标测出右房3个折返环、左房1个折返环,分别围绕上腔静脉、三尖瓣环、下腔静脉及左房房顶共4种折返环;其余3例患者每例均标测出2种折返环,分别为环绕上腔静脉与三尖瓣环的8字折返、环绕下腔静脉与三尖瓣环的8字折返及环绕上腔静脉、环绕右心耳的折返环。4例消融均获成功。其中1例AFL终止后窦性静止,提示病窦综合征,术后1周安置永久起搏器。随访2～9个月,无复发。结论多环AFL的心房内折返错综复杂,应用三维标测系统可清楚地显示折返途径及关键峡部。     

非接触心内膜激动标测系统指导房间隔缺损修补术后Ⅱ型心房扑动的射频消融(附一例报道)

评价非接触球囊导管标测系统 (EnSite 30 0 0 )在指导房间隔缺损 (ASD)修补术后心房扑动 (简称房扑 )的射频消融中的临床应用。 1例女性患者 ,41岁 ,ASD修补术后 2 2年开始频繁发作心动过速 ,体表心电图示Ⅱ型房扑。应用EnSite 30 0 0构建右房三维几何模型 ,标测心动过速的折返激动顺序 ,发现手术疤痕与三尖瓣环之间、下腔静脉与三尖瓣环之间为折返环路的关键峡部 ,应用导航系统指导峡部消融 ,成功阻断心动过速 ;消融后通过起搏标测判定峡部已达完全双向阻滞。随访 2 0个月 ,无心动过速复发。结论 :在ASD修补术后房扑的标测和消融中应用EnSite30 0 0系统是安全有效的 ,不仅能确定折返环路的关键峡部 ,而且能准确判断线性损伤的连续性。     

典型心房扑动消融术后峡部计时间期的变化预测双向阻滞的价值

典型的心房扑动(房扑)是右心房内的大折返所致已成共识，下腔静脉、三尖瓣环峡部是折返环的一部分。因此，射频消融下腔静脉、三尖瓣环峡部并产生峡部双向阻滞，是成功消融典型房扑和减少复发的可靠标志。目前，多采用心房激动顺序或消融部位的双电位技术确定峡部双向阻滞的存在。通过比较房扑成功消融前、后右心房峡部传导时间，从而提出峡部传导时间的延长程度对峡部完全性     

普通型心房扑动的新现象

普通型心房扑动 (AFL)的完整折返环路以及界嵴 (CT)和AFL的关系仍不太清楚 ,笔者应用电解剖 (CARTO)标测系统执行两项研究。Ⅰ :对 12例持续AFL的病人实施右房CARTO标测及多部位拖带。于三尖瓣环 (TA)周围测量传导速度。双电位 (DP)位于右房后下壁 ,相当于解剖上的界嵴 ,从下腔静脉 (IVC)与心房肌的连接处向上、稍前延伸 ,其长度为 40 .9± 7.9mm。所有病人的DP间期从上至下逐渐增加。在 9例逆向AFL病人中 ,右心耳后基底部的后方一狭长心肌位于折返环内 ,结果来自右心耳基底前、后方的两个心房激动波融合于右房下游离壁。在另 3例病人中 (1例顺钟向、2例逆钟向 )右心耳基底部后方未发现位于折返环内 ,迫使折返环仅绕三尖瓣与右心耳基底部前方之间的心肌兴奋右房下游离壁。在AFL的折返环中 ,没有固定的缓慢传导区 ,大部分病人的缓慢传导区位于间隔部和侧壁。Ⅱ :对 7例普通型AFL及 6例非AFL病人 ,在冠状窦起搏下 ,标测右房后壁。通过在右房重建中出现DP确认CT。以 6 0 0 ,30 0ms周长以及静脉注射氟卡胺 (1mg/kg)后以 6 0 0ms周长起搏冠状窦 ,分别测量CT上、中、下部位的刺激信号至双电位中第一及第二个心房激动波的传导时间 (SD1及SD2 )和此部位的电位间期 (DPI)。在AFL病例中 ,与以 6 0 0ms周长起搏冠状     

非接触心内膜激动标测系统指导房间隔缺损修补术后H型心房扑动的射频消融（附一例报道）

评价非接触球囊导管标测系统(EnSite 3000)在指导房间隔缺损(ASD)修补术后心房扑动(简称房扑)的射频消融中的临床应用。1例女性患者，41岁，ASD修补术后22年开始频繁发作心动过速，体表心电图示H型房扑。应用EnSite 3000构建右房三维几何模型，标测心动过速的折返激动顺序，发现手术疤痕与三尖瓣环之间、下腔静脉与三尖瓣环之间为折返环路的关键峡部，应用导航系统指导峡部消融，成功阻断心动过速；消融后通过起搏标测判定峡部已达完全双向阻滞。随访20个月，无心动过速复发。结论：在ASD修补术后房扑的标测和消融中应用EnSite 3000系统是安全有效的，不仅能确定折返环路的关键峡部，而且能准确判断线性损伤的连续性。     

Open-window mapping of accessory pathways utilizing high-density mapping

Journal of Interventional Cardiac Electrophysiology - Accessory pathway (AP) mapping is currently based on point-by-point mapping and identifying if a local electrogram’s origin is atrial,...     

非接触球囊导管标测系统指导心律失常的心内膜标测和导航消融

目的:观察非接触球囊导管标测系统指导疑难心律失常的标测与射频消融的有效性与优越性。方法:6例患者,男5例,女1例,年龄28~50(36.2±12.3)岁。电生理检查为右室特发性室性期前收缩1例,左房房性心动过速1例,右房房性心动过速2例,左房心房颤动2例。其中3例常规电生理标测消融未获成功。经股静脉置入64极球囊电极和射频消融导管至同一心腔,计算机标测系统首先构建心腔几何构型,然后建立心动过速的腔内等电势图,分析心动过速的起源点及关键峡部,利用计算机导航系统指导消融导管至拟定靶点处进行消融。结果:1例起源于右室流出道偏间隔的室性期前收缩患者行片状消融获得成功,1例左房房性心动过速标测其心动过速起源于右肺下静脉间隔部,并指引消融导管行右肺下静脉至二尖瓣之间线性消融获得成功,2例右房房性心动过速中1例标测其最早激动点位于下腔静脉口,此处行环状消融获得成功,另1例位于上腔静脉后方穿过界嵴中部线性消融获得成功。2例左房心房颤动患者,1例在窦性心律下其致心房颤动房性期前收缩起源于左右上肺静脉之间,行线性消融成功;另1例在心房颤动持续发作下行左上下肺静脉环状消融及左右上肺静脉间线性消融成功。6例患者术中、术后均无并发症发生,随访4~13个月,无一例复发。结论:非接触球囊导管标测指导心律失常的心内膜标测与消融是安全有效的,对复杂、难治性心律失常的电生理机制的阐明和指导消融具有较好的临床应用价值。     

Endocardial mapping of right ventricular outflow tract tachycardia using noncontact activation mapping

INTRODUCTION: Activation mapping and pace mapping identify successful ablation sites for catheter ablation of right ventricular outflow tract (RVOT) tachycardia. These methods are limited in patients with nonsustained tachycardia or isolated ventricular ectopic beats. We investigated the feasibility of using noncontact mapping to guide the ablation of RVOT arrhythmias. METHODS AND RESULTS: Nine patients with RVOT tachycardia and three patients with ectopic beats were studied using noncontact mapping. A multielectrode array catheter was introduced into the RVOT and tachycardia was analyzed using a virtual geometry. The earliest endocardial activation estimated by virtual electrograms was displayed on an isopotential color map and measured 33 +/- 13 msec before onset of QRS. Virtual unipolar electrograms at this site demonstrated QS morphology. Guided by a locator signal, ablation was performed with a mean of 6.9 +/- 2.2 radiofrequency deliveries. Acute success was achieved in all patients. During follow-up, one patient had a recurrence of RVOT tachycardia. Compared with patients (n = 21) who underwent catheter ablation using a conventional approach, a higher success rate was achieved by noncontact mapping. Procedure time was significantly longer in the noncontact mapping group. Fluoroscopy time was not significantly different in the two groups. CONCLUSION: Noncontact mapping can be used as a reliable tool to identify the site of earliest endocardial activation and to guide the ablation procedure in patients with RVOT tachycardia and in patients with ectopic beats originating from the RVOT.     

Body surface potential mapping for mapping and treatment of persistent atrial fibrillation

Techniques facilitating individual mapping and ablation of arrhythmogenic substrates are desired to enhance our understanding of persistent atrial fibrillation (persAF) mechanisms as a prerequisite to increasing the success rates of single procedure persAF catheter ablation. The technique of body surface potential mapping (BSM) involves the use of multiple electrodes to collect the potentials over a large body surface area and, with the use of a computed tomography scan, it facilitates their correlation to a 3D model of the atrial structures. During AF,the visualization and localization of AF driver activity, both reentrant and focal wavefronts, is possible with this technique. The ECVUE system from CardioInsight was examined for this indication in clinical studies and showed a termination rate of persAF of 63?% in a large multicenter trial (AFACART) with a promising low recurrence rate during follow-up. From our initial experience, the system appears to be effective in persAF patients who have continuous AF for less than ?1 year. However, the utility of the system for highly challenging cases like long-standing persistent AF and patients with very short AF cycle length remains to be explored. Further studies are needed to confirm these data and answer the multitude of open questions in this field.     

Degree of mapping for nonlinear mappings of monotone type: Densely defined mapping

The classical degree function constructed earlier for pseudomonotone mappings has been used to develop a broader degree theory of classical type for the sum of a maximal monotone map from a reflexive Banach space to its dual together with a bounded pseudomonotone map. The proof uses the generalized Yosida approximation of the maximal monotone mapping.     

Degree of mapping for nonlinear mappings of monotone type: Strongly nonlinear mapping

The classical degree function constructed earlier for pseudomonotone mappings has been used to develop a broader degree theory of classical type for the sum of a maximal monotone map from a reflexive Banach space to its dual together with a bounded pseudomonotone map. The proof uses the generalized Yosida approximation of the maximal monotone mapping.     

Phylogenetic fate mapping

Cell fate maps describe how the sequence of cell division, migration, and apoptosis transform a zygote into an adult. Yet, it is only in Caenorhabditis elegans where microscopic observation of each cell division has allowed for construction of a complete fate map. More complex, and opaque, animals prove less yielding. DNA replication, however, generates somatic mutations. Consequently, multicellular organisms comprise mosaics where most cells acquire unique genomes that are potentially capable of delineating their ancestry. Here we take a phylogenetic approach to passively retrace embryonic relationships by deducing the order in which mutations have arisen during development. We show that polyguanine repeat DNA sequences are particularly useful genetic markers, because they frequently change length during mitosis. To demonstrate feasibility, we phylogenetically reconstruct the lineage of cultured mouse NIH 3T3 cells based on mutations affecting the length of polyguanine markers. We then employ whole genome amplification to genotype polyguanine markers in single cells taken from a mouse and use phylogenetics to infer the developmental relationships of the sampled tissues. The result is consistent with the present understanding of embryogenesis and demonstrates the large scale potential of this method for producing a complete mammalian cell fate at the resolution of a single cell.     

Epicardial isopotential mapping from body surface isopotential mapping in myocardial infarction

It is useful to construct the epicardial isopotential mapping (the Ep Map) from the body surface isopotential mapping (the Body Map) for clinical diagnosis of cardiac disease, even though there are many unsolved problems in using the inverse solution. Yamashita et al. carried out this solution by using the finite element technique. In the present study, the clinical value of that method has been investigated in cases of myocardial infarction. The Ep Maps at 20, 25 and 30 msec. from the beginning of the QRS complex were obtained from the Body Map at the same time by using that method; the infarcted areas on the Ep Map were determined by using Toyama's method which was reported in a previous study. The infarcted area at 30 msec. on the Ep Map was located at the anterior wall along the ventricular septum in anterior infarction and at the posterior wall of the left ventricle in inferoposterior infarction. Patients were independently examined with the scintigram with thallium-201 and the infarcted area was coincident to the location of the abnormal findings of the scintigram. Moreover, the size of the infarcted area on the Ep Map and the size of the abnormal findings of the scintigram were parallel in most cases except one.