Electrode catheter ablation of resistant ventricular tachycardia in arrhythmogenic right ventricular dysplasia

Supported in part by grants from: Centre de Recherche sur les Maladies Cardiovasculaires de l'Association Claude Bernard, La Fondation de Cardiologie, and L'Institut National de la Santé et de la Recherche Médicale (INSERM Contrat N°865005).     

Carto系统电解剖标测和射频消融治疗致心律失常性右心室心肌病的室性心动过速

目的 评价在致心律失常性右心室心肌病(ARVC)患者,应用Carto系统进行电解剖标测并指导射频消融治疗室性心动过速(室速)的有效性.同时探讨其室速发生机制.方法 伴有室速反复发作的19例ARVC患者入选,平均年龄(35±13)岁,男性15例,女性4例.消融术前1例植入植入型心律转复除颤器(ICD),因放电频繁行消融治疗.1例为无休止型室速,发作持续2 d.在窦性心律和/或心动过速时,电解剖标测三维重建右心室,根据双极电压高低确定疤痕区、正常心肌和临界边缘区.对于折返性室速,在关键峡部或在疤痕区与三尖瓣环之间或两疤痕区间行线性消融,对于局灶性室速,在局部最早激动区域点消融.结果 每个患者有1～5种室速,共在19例患者记录到36种室速.16种血流动力学稳定的室速于心动过速发作时行电解剖标测.可确定为折返性12种(75%),其中8种室速围绕三尖瓣环,另4例患者4种室速为局灶性.即时消融成功率为74%(14/19).随访1～46个月,原成功消融的4例室速复发.无消融术相关并发症发生.结论 应用Carto系统电解剖标测可安全有效指导射频消融治疗.ARVC患者的室速,有相对较高的失败和复发率.折返性和局灶性室速均可发生该类器质性心脏病患者,折返性多见.     

致心律失常性右室心肌病的CARTO系统电生理基质标测和射频导管消融

目的应用CARTO系统对致心律失常性右室心肌病(ARVC)患者进行电解剖标测并指导射频消融治疗其室性心动过速(简称室速)。方法入选伴有室速反复发作的25例ARVC患者,年龄36±12岁,男性17例,有家族成员35岁以下早发猝死史3例。术前行常规心电图、心室晚电位、心脏B超检查。在窦性心律或/和心动过速时,电解剖标测三维重建右室。术中6例同时行右室造影检查。根据双极电图电压高低确定疤痕区、正常心肌和临界边缘区。对于折返性室速,线性消融关键峡部或疤痕区与三尖瓣环之间或两疤痕区间;对于局灶性室速,点消融局部最早激动区域。结果 20%(5/25)体表心电图发现前壁或下壁导联Epsilon波,心室晚电位阳性占88%(21/25),心脏B超发现右室不同程度的局部或整体扩张,56%(14/25)可见局部囊袋状向外膨出。所有患者均出现1～5(2±1)种左束支阻滞型室速,其中5例合并频发室性早搏,1例伴心房扑动,1例伴左后间隔旁道。即时消融成功率为72%(18/25)。随访14±10(4～36)个月,原消融成功的5例室速复发。1例消融失败伴晕厥史的患者植入ICD治疗。无手术相关并发症和死亡发生。结论应用CARTO系统电解剖标测可安全有效指导射频消融治疗ARVC患者的室速,有相对较高的失败和复发率。CARTO系统标测的电压图,参考术前心电图、心脏B超及右室造影可了解病变心肌的分布范围,对初步确定室速的病理基质有帮助。     

右心室流入道室性心动过速的心电图特点及射频消融治疗

特发性室性心动过速 (室速 )常起源于右心室流出道及左心室间隔部 ,少见于左心室游离壁、左心室流出道[1] ;而起源于右心室流入道的室速则更少报道。在共 5 0例消融手术中遇到 5例起源于右心室流入道的室速 ,其中特发性室速 4例 ,另 1例为致心律失常性右心室心肌病 (ＡＲＶＣ)。本文就其心电图特点及射频消融治疗的体会进行总结。临床资料　 5例患者 ,男性 4例 ,女性 1例 ,年龄 2 2～ 38岁 ,均有阵发性室速病史 ,呈突发突止 ,发作间期无室性早搏 ,曾用多种抗心律失常药物治疗无效或效果不佳。超声心动图和Ｘ线检查 ,4例未发现有器质性心脏病…     

射频导管消融致心律失常性右心室发育不良合并的室性心动过速

在致心律失常性右心室发育不良(ARVD)患者中的室性心动过速(VT)多为折返机制，关于其射频消融较少报告，现报道2例应用拖带标测技术指导消融ARVD合并的右心室流入道VT。     

Long-term results of catheter ablation for ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy/dysplasia

AimsThis study analyzed the arrhythmogenic substrates and mechanisms of ventricular tachycardia (VT), and long-term outcomes of catheter ablation in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D).MethodsNine patients (1 female, 40±17 years) with ARVC/D and sustained monomorphic VT (SMVT) exhibiting left bundle branch block morphology of the QRS complex were studied. The diagnosis of ARVC/D was confirmed by means of echocardiography, magnetic resonance imaging, and electroanatomic mapping in all patients.ResultsThe patients underwent 10 ablation procedures. At the initial ablation, the mean VT rate was 196±21 (170–240) bpm. In total, 17 VT types were observed. One VT type with left axis (+I, aVL), or right axis (+II,III,aVF) of the QRS complex was present in 3 and 1 patient, respectively. Two VT types of left and intermediate (+I, II, aVL) axis or of left and right axis of the QRS complex were observed in 3 and 2 patients, respectively. Multiple VT types with left axis QRS complex recurred in 1 patient. One VT displayed characteristics of focal arrhythmia, the mechanism of remaining VTs was clearly macroreentrant. The critical slow-conducting isthmus of the reentry circuit was located at the infero-lateral aspect of tricuspid annulus and was bounded by the annulus and baso-lateral wall scar in 7 VTs; the isthmus was located within the scars in the remaining VTs. During 52±31 (12–93) month follow-up since the last ablation, 8 (89%) patients remained free from any VT recurrence without antiarhythmic drug.ConclusionsPatients with ARVC/D frequently presented ≥1 SMVT type. The critical isthmus of reentry circuit was dominantly located close to the tricuspid annulus. Long-term outcome of extensive endocardial ablation was favorable with isolated VT recurrences in one patient.     

Epicardial mapping and radiofrequency catheter ablation of ischemic ventricular tachycardia using a three-dimensional nonfluoroscopic mapping system

Endocardial radiofrequency catheter ablation of ischemic left ventricular tachycardia has been of variable success due to multiple factors. Two such factors include the location of the reentrant circuit in the deep myocardium or on the epicardial surface and the inherent limitations of fluoroscopy as a guide for target localization. We report a patient in whom successful epicardial mapping and radiofrequency catheter ablation of an ischemic left ventricular tachycardia was performed using pericardial access and the CARTO electroanatomic mapping system.     

Catheter ablation of ventricular tachycardia in arrhythmogenic right ventricular dysplasia

Arrhythmogenic right ventricular dysplasia (ARVD) is a progressive, genetically determined fibro-fatty infiltrative myocardial disease with an estimated prevalence in the general population to be 1:5,000 to 1:10,000. ARVD leads to electrical instability that may predispose to life-threatening ventricular arrhythmia, heart failure, and sudden death. We reviewed the pathological substrate for ventricular arrhythmias, ECG findings and treatment modalities in ARVD. Importantly, novel techniques such as electroanatomic and voltage mapping has greatly improved the identification of the scared substrate in the settings of ARVD and have improved safety and efficacy of VT ablation procedures associated with this entity.     

采用心内非接触式标测的右心室流出道室性心动过速的射频消融

目的 右心室流出道(right ventricular outflow tract,RVOT)的解剖结构使得对该部位的室性心动过速(ventricular tachyeardia,VT,室速)标测定位的难度较大,远期成功率也较低,为此,采用心内非接触式标测指导导管消融。方法 20例患者(男性12例,女性8例),年龄14～59(35.1±12.3)岁。其中6例有晕厥或黑矇史,7例既往曾接受射频消融未获成功。全部患者均在RVOT内放置EnSite3000标测导管,在窦性心律下进行疤痕标测和心动过速时进行最早激动标测,并根据标测结果使用EnSite 3000导管的导航功能指导消融定位。消融前并进行起搏标测。结果 20例患者共诱发出22种RVOT室速,其中3例还伴其它起源的室性早搏(室早)。疤痕标测提示,13例患者有电学意义上的疤痕区域,且有11例室速起源于该疤痕区域。25个室速或室早起源点中1例起源于近肺动脉瓣口部,10个位于间隔侧,其余均偏游离壁,其中7个偏RVOT后壁中、下部,4个偏前壁中、下部,3个位于游离壁侧;病变基质的直径为6～42 mm,平均(16.8±9.2)mm。非接触式标测所确定的最早激动处电位平均领先体表20～62(41.0±13.8)ms;与自发的室性心动过速相比,起搏标测下14例的12个导联QRS形态完全一致,11/12个导联一致的为10例,1例有10/12导联一致。全部室速和室早均消融成功。在标测确定的     

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。     

Ventricular tachycardia catheter ablation in arrhythmogenic right ventricular dysplasia: A 16-year experience

Arrhythmogenic right ventricular dysplasia (ARVD) is a structural heart disease affecting young adults that leads to cardiac rhythm disorders including supraventricular and mostly ventricular arrhythmias. Sudden death may be the first presentation of the disease. Ablation techniques have been used for the treatment of ventricular tachycardia in cases resistant to drug therapy. Radiofrequency is appropriate as a first approach for ventricular tachycardia ablation in ARVD; however, its effectiveness is less than 40% at the first session. Fulguration is effective for ventricular tachycardia ablation and should be used in the same session after ineffective radiofrequency ablation. However, fulguration requires expertise, general anesthesia, and more than one session in half of all patients. Radiofrequency and fulguration plus other common forms of treatment including pacemakers and automatic implantable cardioverter defibrillators provides a clinical success rate of 81% to 93% in a series of 50 consecutive patients studied during 16 years. Earlier poor reputation of fulguration was the result of poorly understood technical problems concerning the physics and biophysics of the procedure under control with presently available methods. This in-depth study of a large population over a long time period demonstrates that fulguration should be rehabilitated.     

心脏病外科术后右房房性心动过速的标测及射频消融

目的总结分析心脏病外科术后右房起源房性心动过速(简称房速)的标测及射频消融结果。方法共入选27例心脏外科术后持续性右房房速患者,在心动过速状态下采用三维电解剖标测系统建立右房激动标测图和电压图,标示出疤痕区及双电位区,并揭示心动过速的机制。根据标测结果选择心动过速的关键峡部或起源点进行消融。结果心动过速机制分为以下几种类型:单环折返包括右房峡部依赖性心房扑动(15例)和切口折返性房速(5例);双环折返性房速(3例);两种以上机制(包括局灶性)的复杂房速(4例)。术中即时手术成功率100%。随访过程中5例复发房速,3例再次消融成功。结论心脏外科术后右房房速多数与外科手术切口疤痕相关,在三维电解剖标测系统指导下射频消融治疗效果满意。     

Epicardial catheter mapping and ablation of ventricular tachycardia.

Percutaneous entry into the pericardial space allows epicardial catheter mapping and ablation in the electrophysiology laboratory, opening a perspective on cardiac electrophysiology that previously was limited largely to the operating room. Scar-related reentry after myocardial infarction usually involves the subendocardium but in some patients can only be ablated from the epicardium. Epicardial, scar-related reentry also is an important cause of ventricular tachycardia in nonischemic cardiomyopathies. Rare supraventricular tachycardias and idiopathic ventricular tachycardia that cannot be defined from the endocardium sometimes can be ablated from the epicardium. With appropriate precautions the procedural risks are low. Epicardial catheter techniques expand the options for investigating cardiac electrophysiology and treating arrhythmias in humans and may lead to insights into transmural properties influencing repolarization and the genesis of arrhythmias.     

特发性室性心动过速的临床特点和射频消融治疗

目的对经射频消融术证实的特发性室性心动过速的病例进行总结分析,探讨室性心动过速的发病状况、心电图特点和消融结果.方法对127例特发性室性心动过速的发病年龄、性别、室性心动过速的起源部位和心电图进行分析,观察室性心动过速的诱发率,射频消融的成功率和复发率,分析消融术失败或室性心动过速复发的原因.结果经消融治疗的特发性室性心动过速好发于年轻人,左心室室性心动过速较右心室室性心动过速多见,11.8%的患者室性心动过速发作时可出现11室房逆传.右心室室性心动过速男女比例为1.01.3,额面QRS波平均心电轴为(+82.96±26.18),诱发率为90.2%,射频消融的成功率为85.4%.左心室室性心动过速男女比例为8.61.0,额面QRS波平均心电轴为(-88.15±43.73),诱发率为96.5%,射频消融成功率为93.0%.结论射频消融术是治疗特发性室性心动过速的一项成功率高、并发症少的相对成熟的技术,可以作为特发性室性心动过速的首选治疗手段.     

Ventricular tachycardia mapping and ablation in arrhythmogenic right ventricular cardiomyopathy/dysplasia:Lessons Learned

Arrhythmogenic right ventricular cardiomyopathy/dysplasia(ARVC/D) is primarily believed to be an inherited cardiomyopathy that subsequently results in significant myocardial fibrosis. The arrhythmogenic consequences that result from the development of fibrosis are similar to other nonischemic cardiomyopathies, but the unique endocardial-epicardial disease process of ARVC/D requires a specialized approach for arrhythmia treatment in the electrophysiology laboratory. Although the association between ARVC/D and development of ventricular arrhythmias has become increasingly clear over the last 2 decades, our understanding of the arrhythmia mechanisms, underlying electrophysiologic substrate, and treatment strategies were significantly limited. Prospective studies performed in the electrophysiology laboratory allowed detailed characterization of the electrophysiologic and electroanatomic substrate underlying ventricular tachycardia in patients with ARVC/D. Thishas allowed clinician scientists to better characterize the arrhythmia mechanism and develop the necessary strategies to perform successful catheter ablation. Early in this experience, catheter ablation was considered a limited and largely unsuccessful treatment for patients experiencing painful and recurrent defibrillator therapy. Through our increased understanding of the disease process, catheter ablation has evolved to become an effective and preferred therapy for a majority of these patients. Our understanding of the disease and necessary approaches to provide successful treatment continues to evolve as the clinical experience grows. This article will review these important insights from the electrophysiology laboratory and how application of this knowledge has facilitated the development of a methodical approach to successfully perform ventricular tachycardia ablation in patients with ARVC/D.