特殊类型“慢——快”型室上性心律失常的临床特点及射频消融治疗后的随访

目的探讨特殊类型"慢--快"型室上性心律失常的临床特点与治疗方法.方法以射频导管消融为主的方法控制快速性心律失常治疗4例特殊类型"慢--快"型室上性心律失常患者.结果4例特殊类型"慢--快"型室上性心律失常,2例为房室折返性心动过速(AvRT),1例房室结折返性心动过速(AVNRT),于长时间心动过速发作终止时均有心脏停搏伴有晕厥或黑朦,经射频导管消融根除室上性心动过速后,由其引起的症状不复存在,随访窦房结功能正常;另1例左侧显性旁道、AVRT,心房扑动伴晕厥,在临时心脏起搏保护下,同步直流电复律终止心房扑动,口服乙胺碘酮有效控制心动过速发作,未再发生缓慢性心律失常和晕厥.结论以射频导管消融为主的方法控制快速性折返性心律失常对特殊类型"慢--快"型室上性心律失常患者具有十分重要的临床意义.     

心律失常药物治疗的现状与展望

本世纪８０年代以来，快速心律失常的非药物治疗取得了重大进展。射频导管消融可根治房室结折返性心动过速、房室旁路相关的快速心律失常、心房扑动和心脏正常的室性心动过速（以下简称室速）。埋藏式自动心脏复律除颤器（ＩＣＤ）可明显改善恶性室性心律失常病人的预后，优于抗心律失常药物胺碘酮。但抗心律失常药物仍是治疗快速心律失常的主要手段。因为：（１）心房颤动（以下简称房颤）常见；经射频消融所根治者很少。（２）恶性室性心律失常的射频消融成功率低；即使接受ＩＣＤ治疗，为了减少心律失常的频繁发作而控制放电复律除颤次数…     

特发性室性心动过速治疗的临床研究

目的：研究特发性室性心动过速(IVT)的临床治疗方法。方法：共收集28例临床诊断为IVT患者，男性11例，女性17例。年龄36．7±14．5(9～58)岁，病史6．33±8．33(1～26)年，心动过速时RR间期为317±5897(250～420)ms。心动过速时心电图呈右束支阻滞(RBBB)型12例，左柬支阻滞昏(LBBB)型16例。对心动过速发作频繁药物治疗难麒终止或终止后很快复发的病例进行心电生理检查及导管射频消融治疗(16例)。对心动过速发作不频繁或有心动过速频繁发作但药物很容易终止者，在心动过速终止后给予口服维拉帕米或普罗帕酮预防治疗(12例)。结果：药物治疗组6例患者仍有室性心动过速(室速)发生，但发作次数较前明显减少。6例患者未再发生室速。射频消融治疗组1例起源于左室间隔之室速于术后7天复发，余病例无室速复发。无并发症。结论：药物及导管射频消融治疗对IVT均有教，射频消融治疗的成功率更高，临床上应针对具体情况选择治疗方法。     

“快－慢”型室上性心律失常的射频导管消融治疗及随访

目的：探讨射频导管消融在治疗“快—慢”型室上性心律失常中的作用。方法：用射频导管消融的方法治疗了４例“快—慢”型室上性心律失常病人。结果：１９９１年１月至１９９６年１月间，对２４１例次各种快速性心律失常进行了射频导管消融治疗。其中４例为“快—慢”型室上性心律失常，２例为反复发作性房室结折返性心动过速（ＡＶＮＲＴ），终止时有长时间的心脏停搏并引起晕厥，原准备安装永久性心脏起搏器，ＡＶＮＲＴ根治后，由其引起的症状不复存在，电生理检查窦房结功能正常，故未安装起搏器；另２例均已植入永久性心脏起搏器，１例频繁发作快速心室率心房颤动并经常引起急性心功能不全，１例反复发作ＡＶＮＲＴ、心房扑动和心房颤动且有明显的症状，射频导管消融治疗后症状均消失，射频导管消融术对起搏器的功能无影响。３例平均随访３１±２个月，１例随访２个月未见并发症和临床症状复发。结论：射频导管消融法治疗“快—慢”型室上性心律失常具有重要的临床价值。     

射频消融术对特发性室性心动过速患者QT离散度的影响

ＱＴ离散度（ＱＴｄ）反映了心室肌复极的不均匀性,许多研究表明,室性心律失常患者的ＱＴｄ显著高于无心律失常者。Ｇｉｌ等的研究也证实特发性室性心动过速（特发性室速）伴晕厥患者的ＱＴｄ显著增加。射频消融是目前治疗特发性室速的最有效的根治性手段,本研究旨在通...     

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     

器质性心脏病疤痕相关的室性心动过速导管消融的策略

疤痕相关的折返激动是器质性心脏病室性心动过速(室速 )最常见的机制。心肌梗死是形成心脏区域性疤痕最常见的原因 ,其它病因包括致心律失常右心室发育不良、心脏肿瘤、非缺血性心肌病和先天性心脏病心室修补术后。疤痕相关性室速的治疗相当困难。抗心律失常药物治疗对30 %的患者无效。植入型心律转复除颤器 (ＩＣＤ)可有效地终止室速发作和防止猝死 ,却不能预防室速的发生。 4 0 %～ 70 %植入ＩＣＤ的患者需要同时服用抗心律失常药物以减少室速的发作[1] 。尽管一些经过选择的患者 ,射频导管消融技术能达到根治室速的目的 ,但成功率仅为 6 …     

快速性心律失常终止后长时间窦性停搏的电生理特征

目的 分析快速性心律失常终止后出现长时间窦性停搏的电生理特征.方法 观察有快速性心律失常终止后出现长时间窦性停搏(＞3 s)的25例患者,25例患者根据年龄分为2组,≤60岁14例(中青年组),＞60岁11例(老年组).对这些患者行导管消融治疗,在消融前后行心内电生理检查.在消融术后的1、3、6、12和24个月行动态心电图检查.结果 25例患者中,12例为房室折返性心动过速(AVRT),2例为房室结折返性心动过速(AVNRT),3例为房性心动过速,3例为Ⅰ型心房扑动(房扑),5例为阵发性心房颤动(房颤).在快速性心律失常终止时,记录到窦性停搏时间为3.2 ～9.4(5.6±2.7)s.窦房结恢复时间(SNRT),矫正SNRT及窦房传导时间(SACT)等在两组间差异无统计学意义(P＞0.05).两组患者消融前后的心内电生理检查比较发现,中青组患者消融前后,SNRT、矫正的SNRT及SACT差异均无统计学意义(P＞0.05).老年组患者消融前后,SNRT差异有统计学意义(P＜0.05),而矫正的SNRT及SACT差异无统计学意义(P＞0.05).23例患者射频消融术成功后未再发心动过速,也没有出现＞3 s的窦性停搏.1例持续性房扑患者在射频消融术后半个月,房扑反复发作并在终止时出现长时间的窦性停搏并伴晕厥,植入永久性心脏起搏器.1例阵发性房颤患者在术后仍有房颤间断发作,房颤终止时仍有窦性停搏现象,但停搏时间＜3 s,并且没有晕厥或近似晕厥的症状.结论 快速心律失常后出现窦性停搏患者的窦房结功能大多是正常的,消融治疗快速性心律失常后患者心律失常相关的窦性停搏随之消失了,如果患者存在窦房结病变,则可考虑植入永久性心脏起搏器.     

应用非接触球囊导管标测系统指导心动过速的心内膜标测与消融

目的观察非接触球囊导管标测系统指导难治性室性心动过速的标测与射频消融的有效性和优越性。方法5例患者均为男性，平均年龄33.2岁。经股静脉或股动脉置入64极球囊电极和射频消融导管至同一心室，计算机标测系统首先构建心腔的几何构型，然后建立心动过速的腔内等电势图，分析心动过速的最早起源点及折返激动的关键峡部，最终利用计算机导航系统指导消融导管至拟定靶点处进行环状或线形消融。结果5例患者共诱发出6种心动过速，心动过速平均周期为（336.6±42.7）ms。2例特发性左室室性心动过速及1例隐匿性束室纤维患者均消融成功。1例扩张型心肌病患者共有两种心动过速，一种起源于右室流出道，另一种起源于左室间隔部，前者消融成功，后者因导管操作致心动过速持续发作伴血流动力学不稳定而终止手术。1例致心律失常性右室心肌病患者于最早激动点处做环状消融，未获成功。5例患者术中和术后均无并发症发生。随访4个月，所有消融成功患者均未再有心动过速发作。结论非接触性球囊导管标测系统指导心律失常的心内膜标测与消融是安全、有效的，与常规的标测和消融方法比较，该系统有一定的优越性，尤其适用于复杂病例、血流动力学不稳定和非持续性室性心律失常的标测及指导射频消融。     

网篮电极导管临床使用的初步经验

目的：评价64极网篮电极导管在电生理检查及射频消融中的实用价值。方法：4例患者,根据发作时心电图诊断为房性心动过速（房速）3例,左心室室性心动过速1例,网篮电极导管分别经右侧股静脉或股动脉送入右心房或左心室,选择记录双极心电信号,对每1例患者均进行窦性心律及心动过速时的标测,并在网篮电极导管指引下进行消融,结果：4例患者网篮电极导管均顺利送入,术中及术后无明显并发症发生,通过网篮电极所记录心电信号清晰,稳定,根据计算机所绘制等时标测图及网篮在心腔内的影像位置,可准确地判断除极波传播顺序,方向及最早激动点,确定心律失常的起源部位及发生机制,2例房速及1例室性心动过速患者消融成功,另1例房速患者消融失败。结论：利用网篮电极导管进行心内膜高密度标测,有助于提高心脏电生理检查及射频消融手术的效率。     

Procainamide-lnduced polymorphous ventricular tachycardia

Seven cases of procainamide-induced polymorphous ventricular tachycardia are presented. In four patients, polymorphous ventricular tachycardia appeared after intravenous administration of 200 to 400 mg of procainamide for the treatment of sustained ventricular tachycardia. In the remaining three patients, procainamide was administered orally for treatment of chronic premature ventricular contractions or atrial flutter. These patients had Q-T prolongation and recurrent syncope due to polymorphous ventricular tachycardia. In four patients, the arrhythmia was rapidly diagnosed and treated with disappearance of further episodes of the arrhythmia. In two patients, the arrhythmia degenerated into irreversible ventricular fibrillation and both patients died. In the seventh patient, a permanent ventricular pacemaker was inserted and, despite continuation of procainamide therapy, polymorphous ventricular tachycardia did not reoccur. These seven cases demonstrate that procainamide can produce an acquired prolonged Q-T syndrome with polymorphous ventricular tachycardia.     

Malignant entity of idiopathic ventricular fibrillation and polymorphic ventricular tachycardia initiated by premature extrasystoles originating from the right ventricular outflow tract.

OBJECTIVES: The aim of this study was to assess the clinical characteristics and the efficacy of radiofrequency catheter ablation (RFCA) for idiopathic ventricular fibrillation (VF) and/or polymorphic ventricular tachycardia initiated by ventricular extrasystoles originating from the right ventricular outflow tract (RVOT). BACKGROUND: Ventricular fibrillation and/or polymorphic ventricular tachycardia are occasionally initiated by ventricular extrasystoles originating from the RVOT in patients without structural heart disease. METHODS: Among 101 patients without structural heart disease in whom RFCA was conducted for idiopathic ventricular tachyarrhythmias arising from the RVOT, we examined the clinical characteristics and the efficacy of RFCA in 16 patients with spontaneous VF and/or polymorphic ventricular tachycardia initiated by the ventricular extrasystoles originating from the RVOT. RESULTS: Among 16 patients, spontaneous episodes of VF were documented in 5 patients, and 11 patients had prior episodes of syncope. Holter recordings showed frequent isolated ventricular extrasystoles with the same morphology as that of initiating ventricular extrasystoles, and non-sustained polymorphic ventricular tachycardia with short cycle length (mean of 245 +/- 28 ms) in all 16 patients. Radiofrequency catheter ablation by targeting the initiating ventricular extrasystoles eliminated episodes of syncope, VF, and cardiac arrest in all patients during follow-up periods of 54 +/- 39 months. CONCLUSIONS: Our data suggest that the malignant entity of idiopathic VF and/or polymorphic ventricular tachycardia was occasionally present in patients with idiopathic ventricular arrhythmias arising from the RVOT. Radiofrequency catheter ablation was effective as a treatment option for this entity.     

Catheter ablation of a polymorphic ventricular tachycardia inducing monofocal premature ventricular complex

Ventricular tachycardia originating from the right ventricular outflow tract (RVOT) is considered benign, but sometimes it causes polymorphic ventricular tachycardia and ventricular fibrillation, resulting in sudden cardiac death. A 58-year-old woman without structural heart disease was admitted for evaluation of recurrent episodes of syncope. Surface ECG showed frequent repetitive premature ventricular contraction (PVC) of RVOT origin. Polymorphic ventricular tachycardia triggered by the same PVC was documented by Holter ECG during an episode of syncope. Radiofrequency catheter ablation was performed to eradicate this PVC. No polymorphic ventricular tachycardia has developed after the procedure, and the patient has had no recurrence of syncope.     

Ventricular tachycardia and ventricular fibrillation in a young population.

In this study, we describe the findings in 18 young patients (age range 4 days to 24 years, mean 16.6 years) who had ventricular tachycardia and/or ventricular fibrillation and were followed for 4--70 months (mean 22.4 months). Patients had a variety of problems associated with their arrhythmia, including mitral valve prolapse, cardiomyopathy, myocarditis, prolonged QT syndrome and hypokalemia. Six patients had no clinically recognizable cardiac abnormality. The ventricular tachycardia showed a left bundle branch block contour in 10 of 17 patients, right bundle branch block in four, was multiform in two and had an indeterminate contour in one. Sustained ventricular tachycardia was initiated and terminated reproducibly by atrial and ventricular stimulation in three of seven patients who did not have spontaneous episodes of ventricular tachycardia during the electrophysiologic study. In one other patient, short bursts of ventricular tachycardia were induced. Patients who had ventricular fibrillation, those who died, and those who are still symptomatic with poorly controlled ventricular arrhythmias had significant heart disease. In one patient, a ventricular tachyarrhythmia that had required more than 100 electrical cardioversions spontaneously disappeared after requiring 1 year of antiarrhythmic therapy.     

Clinical investigation on the patients with tachyarrhythmic syncope with special reference to comparative study between long QT syndrome and ventricular tachycardia without long QT interval

The long QT syndrome (LQTS) is one of the important diseases that may lead to sudden death mainly in childhood, however etiology and pathogenesis are still poorly understood. The group studied consisted of 6 patients with a history of ventricular tachyarrhythmic syncope, 3 with long QT syndrome (LQTS) and 3 without long QT interval, and of 4 patients with ventricular tachycardia without syncopal episode. Their ages ranged from 5 years to 17 years. Histopathology of endomyocardial biopsy was nonspecific and mild in two cases but in one patient with LQTS, who had several episodes of syncope and refractory ventricular arrhythmia, remarkable subendocardial fibrosis, interstitial fibrosis and hypertrophy of myocytes were demonstrated. As far as ventricular tachycardia without long QT interval was concerned, in the patients with VT with syncope, histopathological abnormalities were more remarkable than in those without syncope. Electrophysiological findings in the patients with LQTS showed no characteristic findings, but only mild abnormalities with functional atrioventricular conduction disturbance on programmed atrial pacing. No inducible VT was demonstrated. Although electrophysiologic study and endomyocardial biopsy are of limited value, such studies are considered to be worthwhile for treating ventricular arrhythmias, and making a prognosis of the patients with tachyarrhythmic syncope and LQTS.     

Atrial fibrillation ablation

Atrial fibrillation is the commonest cardiac arrhythmia, with significant morbidity related to symptoms, heart failure, and thromboembolism, which is associated with excess mortality. Over the past 10 years, many centers worldwide have reported high success rates and few complications after a single ablation procedure in patients with paroxysmal atrial fibrillation. Recent studies indicate a short-term and long-term superiority of catheter ablation as compared with conventional antiarrhythmic drug therapy in terms of arrhythmia recurrence, quality of life, and arrhythmia progression. As a result, catheter ablation is evolving to a front-line therapy in many patients with atrial fibrillation. However, in patients with persistent long-standing atrial fibrillation catheter ablation strategy is more complex and time-consuming, frequently requiring repeat procedures to achieve success rates as high as in paroxysmal atrial fibrillation. In the near future, however, with growing experience and evolving technology, catheter ablation of atrial fibrillation may be extended also to patients with long-standing atrial fibrillation.     

Radiofrequency catheter ablation in the treatment of supraventricular tachycardia in the elderly

Objectives. The purpose of this study was to evaluate the efficacy and safety of radiofrequency catheter ablation for the treatment of supraventricular tachycardias in an elderly (≥70 years of age) group of patients.Background. Supraventricular tachycardias are the most common form of cardiac arrhythmia and affect all age groups. Although usually well tolerated in youth, supraventricular tachycardias may be associated with disabling symptoms and have lifethreatening potential 10 the elderly. In addition, antiarrhythmic agents are less well tolerated and may be associated with a higher incidence of toxicity in the elderly.Methods. From May 1989 to March 1993, 454 patients underwent a radiofrequency catheter ablation procedure at the University of California, San Francisco, for the treatment of symptomatic supraventricular tachycardia. Sixty-seven of these patients were ≥70 years of age and constituted the study group. Patients underwent one of the following catheter ablation procedures: complete atrioventricular (AV) junctional ablation for ventricular rate control in patients with atrial fibrillation (37 patients), AV node modification for the treatment of AV node reentrant tachycardia (17 patients), accessory pathway ablation (9 patients), ablation of the “slow zone” to cure atrial flutter (4 patients) and atrial tachycardia ablation (1 patient). One patient underwent ablation for both AV node reentrant tachycardia and atrial flutter.Results. Success was achieved in 67 (98.5%) of 68 ablation procedures. There were no procedural or early deaths. The overall complication rate was 7.4%, and only one patient (1.5%) had long-term sequelze (permanent cardiac pacing for complete heart block). At a mean (±SD) follow-np of 22.1 ± 12.9 months, 63 (94%) of 67 patients were alive, with no antiarrhythmic agents for the treatment of their presenting arrhythmia.Conclusions. In this series radiofreqnency catheter ablation appears to be an effective and safe treatment option for elderly patients (≥70 yean of age) with a variety of symptomatic, drug-resistant supraventricular tachycardias. Because of the high incidence of severe symptoms associated with tachycardic episodes, the expense and the possible severe proarrhythmic problems associated with antiarrhythmic medications in this age group, catheter ablation may be considered an early rather than a “last resort” treatment option.     

The contribution of artificial pacemaking to understanding the pathogenesis of arrhythmias

Right atrial or ventricular pacing was performed on 36 occasions in 26 patients in an attempt to terminate a variety of tachyarrhythmias. Of 16 episodes of atrial flutter, 13 were terminated successfully; in 9 of the 13, sinus rhythm or the patient's pre-flutter rhythm was restored immediately, whereas in 4 patients, intervening atrial fibrillation or unstable atrial flutter occurred. Pacing terminated paroxysmal atrioventricular junctional or paroxysmal atrial tachycardia on 3 occasions; in a fourth patient, this tachyarrhythmia terminated during catheter manipulation. Six episodes of pacemaker-induced ventricular tachycardia were abolished by ventricular pacing. In 2 patients, atrial tachycardia was only transiently suppressed, and in 1 of these patients, d-c cardioversion produced a similar effect. Atrial fibrillation, spontaneously converting to atrial flutter, resulted during pacing for atrial tachycardia with block; the latter arrhythmia returned when the atrial flutter was terminated. Atrial fibrillation in 7 patients remained unaffected by atrial pacing. Based on the different electrophysiologic mechanisms responsible for reentrant excitation and automatic pacemaker discharge, an attempt has been made to determine the pathogenesis of the tachyarrhythmia by its response to pacing.     

Treatment of catecholamine-sensitive right ventricular tachycardia by endocardial catheter ablation.

Endocardial catheter ablation with direct current high voltage shocks was performed in a patient with recurrent syncope due to a catecholamine-sensitive ventricular tachycardia that was drug refractory and occurred in the absence of identifiable heart disease. Pace mapping and catheter activation mapping of the spontaneous and isoproterenol-induced ventricular tachycardia located the tachycardia origin in the right ventricular outflow tract. Ablation dramatically reduced spontaneous ventricular tachycardia and ectopic activity (from 50,000 to less than 100 ectopic beats/24 h). The patient has remained symptom free and without ventricular tachycardia recurrence for 3 years. These observations and review of previous studies suggest that catheter mapping can easily locate the arrhythmia focus in the right ventricular outflow tract and that catheter ablation can be performed at low risk. Catheter ablation is a viable option for the treatment of right ventricular catecholamine-sensitive tachycardias that are unresponsive to antiarrhythmic drugs.     

应用三维磁导航系统标测和消融快速性心律失常的初步经验

目的观察三维磁导航系统标测和消融快速性心律失常的疗效。方法结合NiobeII磁导航系统和CARTO-RMT电解剖标测系统,采用4mm-顶端的NaviStar-RMT标测和消融导管进行射频消融治疗快速性心律失常。结果10例患者,男6例,女4例。房室结折返性心动过速4例,其中1例合并阵发性心房颤动,左侧房室旁道2例,右侧房室旁道1例,典型心房扑动2例,右室流出道室性心动过速1例。磁导航系统遥控操作,10例均完成电生理标测。9例消融成功,失败1例为心房扑动患者,换用NaviStar盐水灌注导管后消融成功。导管操作时间93±33.1min,X线曝光时间12.5±6.5min。随访6个月无复发。结论对于快速性心律失常,应用磁导航系统可进行有效和安全的三维标测和消融。