希氏束旁起源房性心动过速心电生理特征及射频消融疗效

目的分析起源于希氏束旁房性心动过速(房速)的心电生理特征及射频消融治疗效果。方法选自2009年1月至2014年5月在首都医科大学附属北京安贞医院心内科就诊的经心内电生理检查和射频消融证实起源点位于希氏束旁的房速,简称希氏束旁房速18例,其中男2例,女16例,年龄31~68(40±9)岁,病史1~10年。对患者临床特征、心电生理特点及射频消融疗效进行分析。结果希氏束旁房速大多为女性,16例表现为阵发性,为心房或心室程序刺激诱发和终止,2例为无休止心动过速。所有患者房速心电图P波窄而低幅,Ⅱ,Ⅲ,a VF和V1导联P波负正双向,Ⅰ、a VL导联为直立,V2~V6导联P波负向。右房激动标测示心内最早激动位于希氏束附近,并领先于体表P波起始(15±3)ms。16例患者于无冠窦内消融成功,2例于右房希氏束旁消融成功,均无并发症,随访12个月所有患者均无心动过速复发。结论希氏束旁房速有独特的临床特征,心电图特征及心房内激动顺序,应首选无冠窦途径消融,长期随访房速行射频消融治疗安全有效。     

三维电解剖标测指导射频导管消融治疗起源于主动脉无冠窦房性心动过速

目的探讨起源于主动脉无冠窦房性心动过速（房速）的电生理特征及三维激动标测指导射频导管消融治疗无冠窦房速的安全性和有效性。方法43例局灶性房速经普通电生理检查及三维电解剖激动标测明确起源于无冠窦者7例。结果7例患者均于心动过速发作时消融10s内心动过速终止。所有患者于消融即刻心动过速终止或出现心动过速加速。在（20±6）个月的随访中心动过速未复发。结论三维激动标测指导射频导管消融治疗起源于主动脉无冠窦房速是安全有效的。     

射频消融术治疗主动脉无冠窦房性心动过速方法学特点

目的:探讨射频消融术治疗无冠窦房性心动过速(房速)的方法学特点.方法:分析14例无冠窦房速患者发作时体表心电图P波特点,展示发作时无冠窦、左房前间隔和希氏束最早激动的时间差异,5例患者采用三维(EnSite 3000 NavX)建模标测.结果:房速发作时P波时限(83±4)ms明显短于窦性心律时P波时限(106±9)ms,P＜0.05;右房最早激动点位于希氏束或其附近;无冠窦内最早心房激动较希氏束提前(10.8±7.2)ms,先于体表心电图P波提前(20.8±7.2)ms,5例患者通过房间隔穿刺术在左房前间隔测及的最早激动点较右房晚(4±2)ms.12例患者均在无冠窦内消融成功,2例患者在无冠窦内和希氏束后上方与无冠窦相对应处同时消融成功.随访4～30个月均无复发.结论:射频消融术是根治无冠窦房速的有效方法,对于房速消融不成功者,可选择在无冠窦内和希氏束后上方与无冠窦相对应处同时消融.     

经主动脉窦途径射频消融心动过速临床研究

目的:探讨经主动脉窦途径导管射频消融治愈的快速性心律失常患者的心电图特点及射频消融情况.方法:回顾性分析17例室性心动过速/室性期前收缩、前间隔房性心动过速及前间隔旁路等该类患者的体表心电图、及消融成功时靶点电图等心电生理学特征.结果:经主动脉窦途径导管射频消融治愈室性心动过速/室性期前收缩12例,其中起源于左冠状动脉窦(左冠窦)10例、右冠状动脉窦(右冠窦)2例;源于无冠状动脉窦(无冠窦)的局灶性前间隔房性心动过速3例及前间隔旁路2例.室性心动过速/室性期前收缩心电图特点:Ⅱ、Ⅲ和aVF导联为高大R波,胸导联R波移行较早,V1导联r/S波振幅比≥30%,r波时限(82.2±16.4)ms,V1导联中r/QRS波时限比≥50%,V5、V6导联为高振幅R波、无s波.有效消融靶点心内电图示心室波明显比体表心电图QRS波提前(35.2±21.6)ms.前间隔房性心动过速均能被心房刺激反复诱发和终止,其心电图特点:房性心动过速时P波间期明显窄于窦律时P波间期,Ⅰ、aVL导联P波正向,Ⅱ、Ⅲ和aVF导联P呈负正双向.在心房标测中提示最早的心房激动在希氏(His)束区,但在主动脉无冠窦内标测的心房激动较His束区的心房波提前,其解剖定位于His束上后方,消融靶点无His束电位.前间隔旁路心电图示:窦性心律时呈窄QRS波形,未见预激波,心动过速呈窄QRS形,在无冠窦内记录到最早心房激动点,且无His束电位.17例均消融成功.结论:源于主动脉窦内的室性心动过速/室性期前收缩、前间隔房性心动过速和前间隔旁路具有相对的心内电生理学特征,常规心内膜途径消融困难时应该考虑从主动脉窦途径标测消融策略,把握消融导管与冠状动脉的关系,导管消融治疗安全而有效.     

His束旁起源房性心动过速的电生理特征及射频消融

目的回顾性分析His束旁房性心动过速(简称房速)的心电生理特征并探讨射频消融策略。方法连续入选经心电生理检查和射频消融证实起源点位于His束旁的房速,对患者的临床特征、心电生理特点及射频消融策略进行回顾性分析。结果共入选23例,其中男7例,女16例,年龄(59.9±16.6)岁,病史6个月至5年。His束旁房速女性较男性多见,20例为阵发性, 3例为无休止心动过速。所有患者的心电图特征为:P波窄而低幅,Ⅱ、Ⅲ、aVF和V_1导联P波负正双向,Ⅰ、aVL导联直立,V_2～V_6导联P波负向。右房激动标测示心内最早激动位于His束附近,仅比冠状窦近端提前(15±3)ms(始终找不到最早提前的A波),20例于右房His束旁消融成功,3例于主动脉无冠窦内消融成功,均无并发症。结论 His束旁房速有独特的心电图特征及心房内激动顺序,经右房His束旁消融治疗是安全有效的方法。     

经主动脉无冠窦内射频消融局灶性房性心动过速

目的探讨起源于主动脉无冠窦或其邻近组织的局灶性房性心动过速(简称房速)心脏电生理特点及经射频导管消融方法。方法 13例患者男3例,女10例,年龄52.7±9.8岁,阵发性房速病史4.2±4.5年。心房刺激诱发房速后,分析体表心电图P′波特点并于右房及主动脉无冠窦内进行激动标测。均于无冠窦内进行射频消融治疗。结果 13例心房刺激均能反复诱发或终止房速,平均周长340.9±46.0ms,房速时P′波时限77.8±14.4ms,明显短于窦性心律时P波时限111.2±10.3ms(P0.05)。常规激动标测,所有患者于His束处标测到相对提前的心房激动。经主动脉逆行方法 ,所有患者于无冠窦内标测到心房激动较His束处的心房激动提前9.3±6.1ms,放电1～2次于2～8s内终止房速。随访3～36个月,无复发病例及手术相关合并症。结论起源于主动脉无冠窦或其邻近组织的房速具有窄P′波及常规标测相对提前的心房激动位于His束处的特点。经主动脉无冠窦内标测消融是一种根治此类房速安全有效的方法 。     

三维标测下主动脉无冠窦起源局灶性房性心动过速的射频消融效果

目的:分析主动脉无冠窦起源房性心动过速(房速)的心内电生理标测特点及射频消融疗效。方法:对11例主动脉无冠窦起源房速在三维标测系统引导下行心内电生理标测及射频消融治疗。术中构建右心房、希氏束及主动脉根部电解剖模型,测量最早激动点与希氏束的距离,在房速最早激动部位行射频消融治疗。结果:心内电生理检查11例房速皆为局灶起源,右心房激动标测最早激动部位均在希氏束左侧或左后上方,领先冠状窦近端参照A波(21.0±7.9)ms,距希氏束(6.9±3.4)mm。主动脉根部标测房速最早激动部位皆位于无冠窦内,领先冠状窦近端参照A波(35.0±8.6)ms,距希氏束(7.3±4.6)mm;消融终止房速,巩固消融后重复术前诱发条件刺激不能诱发出房速。术中及术后无房室阻滞发生。术后随访6个月,房速无复发。结论:无冠窦起源房速消融安全性和成功率高,标测要点为右心房房速最早激动位于希氏束左侧或左后上方时应常规于主动脉根部标测明确是否无冠窦激动最为领先。     

主动脉无冠窦内和二尖瓣环-主动脉连接处射频导管消融局灶性房性心动过速

目的报告18例主动脉无冠窦内和1例二尖瓣环-主动脉连接(MAAJ)处成功消融局灶性房性心动过速(房速),探讨该类房速的电生理特点及标测和消融方法。方法 18例患者,女性14例,平均年龄41-71岁,均有阵发性房速病史。心房刺激诱发房速后,分析体表心电图P波特点并于右房进行激动标测,如果最早心房激动邻近希氏束附近,少数患者在此处消融,其他患者和上述消融不成功患者,经主动脉逆行途径,在无冠窦内标测和消融。如果消融不能成功,则经房间隔穿刺途径至左房标测最早激动部位处消融。结果房速发作时体表心电图P波明显变窄(77.8±14.4)ms。右房激动标测均在希氏束附近标测到相对提前的心房激动,3例于此处消融失败。18例经主动脉逆行途径于无冠窦内标测到最早心房激动提前希氏束处心房激动0～20.0(平均10 ms),17例于无冠窦内消融成功,包括1例改用盐水灌注导管后消融成功。1例经无冠窦消融失败后,经穿刺房间隔于MAAJ处标测到最早心房激动处消融成功。随访3～38个月,均无复发。结论对于具有窄P波及标测右房最早激动位于希氏束附近的局灶性房速,经主动脉逆行途径在无冠窦内标测和消融具有很高的成功率,经穿刺房间隔在左侧MAAJ处消融或应用盐水灌注导管无冠窦内消融可能进一步提高消融成功率。     

主动脉无冠窦内和二尖瓣环-主动脉连接处射频导管消融局灶性房性心动过速

目的报道13例主动脉无冠窦内和1例二尖瓣环一主动脉连接（MAAJ）处成功消融局灶性房性心动过速（房速）,探讨该类房速的电生理特点及标测和消融方法。方法14例患者,男性3例女性11例,平均年龄（54．4±10．4）岁,均有阵发性房速病史。心房刺激诱发房速后,分析体表心电图P’波特点并于右心房进行激动标测,如果最早心房激动邻近希氏束附近,少数患者在此处消融,其他患者和上述消融不成功患者,经主动脉逆行途径,在无冠窦内标测和消融。如果消融不能成功,则经房间隔穿刺途径至左心房标测最早激动部位处消融。结果房速发作时体表心电图P’波明显变窄（77．8±14．4）ms。右心房激动标测均在希氏束附近标测到相对提前的心房激动,3例于此处消融失败。14例经主动脉逆行途径于无冠窦内标测到最早心房激动提前希氏柬处心房激动0～20．0（10．1±6．3）ms,13例于无冠窦内消融成功,包括1例改用盐水灌注导管后消融成功。1例经无冠窦消融失败后,经穿刺房间隔于MAAJ处标测到最早心房激动处消融成功。随访3～38个月,均无复发。结论对于具有窄P’波及标测右心房最早激动位于希氏束附近的局灶性房速,经主动脉逆行途径在无冠窦内标测和消融具有很高的成功率,经穿刺房间隔在左侧MAAJ处消融或应用盐水灌注导管无冠窦内消融可能进一步提高消融成功率。     

三尖瓣环游离壁起源房速的电生理特征

目的报道一组起源于三尖瓣环(TA)游离壁房性心律失常的心电生理特征及射频消融治疗。方法7例患者经心内电生理检查和射频消融证实的起源于三尖瓣环游离壁的房性心律失常,对其心电生理特点及射频消融进行分析。结果三尖瓣环房速表现为阵发性,为心房程序刺激诱发(4例)或静滴异丙肾上腺素后自发(3例)。三尖瓣环房速有独特的体表心电图特征,所有患者I,aVL导联P波直立,TA11点起源房速II,III,aVF导联P波直立;TA9点起源房速II,III,aVF导联P波低幅直立;TA7点起源房速II,III,aVF导联P波倒置。TA11点起源房速胸导V1导为负向,V2～V6导P波逐渐移行为正向。其余部位TA房速V1～V6P波均为负向。7例患者均消融成功,随访12月均无房速复发。结论三尖瓣环房速有独特的心电图特征和房内激动顺序,长期随访这类房速射频消融有较好的治疗效果。     

Focal atrial tachycardia originating from the non-coronary aortic sinus: electrophysiological characteristics and catheter ablation.

OBJECTIVES: We sought to investigate electrophysiological characteristics and catheter ablation in patients with focal atrial tachycardia (AT) originating from the non-coronary aortic sinus (AS). BACKGROUND: In patients with failed ablation of focal AT near the His bundle (HB) region, an origin from the non-coronary AS should be considered because of the close anatomical relationship. METHODS: This study included 9 patients with focal AT, in 6 of whom attempted radiofrequency (RF) ablation had previously failed. Activation mapping was performed during tachycardia to identify an earliest activation in the atria and the AS. The aortic root angiography was performed to identify the origin in the AS before RF ablation. RESULTS: Focal AT was reproducibly induced by atrial pacing. Mapping in atria demonstrated that the earliest atrial activation was located at the HB region, whereas mapping in the non-coronary AS demonstrated that an earliest atrial activation preceded the atrial activation at the HB by 12.2 +/- 6.9 ms and was anatomically located superoposterior to the HB in all 9 patients. Also, His potentials were not found at the successful site in the non-coronary AS in all 9 patients. The focal AT was terminated in <8 s in all 9 patients. Junctional beats and PR prolongation did not occur during RF application in all 9 patients. No complications occurred in any of the nine patients. All 9 patients were free of arrhythmias without antiarrhythmic drugs during a follow-up of 9 +/- 3 months. CONCLUSIONS: In patients with focal AT near the HB region, mapping in the non-coronary AS can improve clinical outcome.     

经主动脉无冠状窦内射频消融治疗房性心动过速

目的:报告经主动脉无冠状窦内射频消融6例局灶性房性心动过速(房速)的消融结果。方法:6例患者中男女各3例。阵发性房速病史(6±3)年。常规心电图、心内电生理,术中心房和心室刺激诱发房速,分别在右心房、左心房和主动脉无冠状窦内标测最早心房激动,并进行射频消融。结果:心房刺激能反复诱发和终止6例患者的房速。心房内的前间隔部位标测相对提前的心房激动,但多次消融未成功。经主动脉无冠状窦内消融成功。平均随访3~17个月,无1例房速复发。结论:经主动脉无冠状窦消融前间隔房速是安全,有效的。     

Focal atrial tachycardia from the ostium of the coronary sinus: electrocardiographic and electrophysiological characterization and radiofrequency ablation

OBJECTIVES: The goal of this study was to characterize the electrocardiographic and electrophysiologic features and frequency of focal atrial tachycardia (AT) originating from the coronary sinus ostium (CS). BACKGROUND: The ostium of the coronary sinus has been described as a site of origin of AT, but detailed characterization of these tachycardias is limited. METHODS: Thirteen patients (6.7%) of 193 undergoing radiofrequency ablation (RFA) for focal AT are reported. Endocardial activation maps (EAM) were recorded from catheters at the CS (10 pole), crista terminalis (20 pole), and His positions. The P waves were classified negative, positive, isoelectric, or biphasic. RESULTS: The mean age was 41 +/- 6 years, seven female patients, with symptoms for 8 +/- 3 years. Tachycardia was induced by programmed extra-stimuli in eight patients, was spontaneous in three patients, and in response to isoproterenol in two patients. These foci had a characteristic P-wave morphology. At the CS ostium, the P-wave was deeply negative in all inferior leads, negative or isoelectric becoming positive in lead V(1), then progressively negative across the precordium. Lead aVL was positive in all patients. Earliest EAM activity occurred at the proximal CS at 20 +/- 3 ms ahead of P-wave. Mean activation time at the successful RFA site = -36 +/- 8 ms; RFA was acutely successful in 11 of 13 patients. Long-term success was achieved in 11 of 11 over a median follow-up of 25 +/- 4 months. CONCLUSIONS: The CS ostium is an uncommon site of origin for focal AT (6.7%). It can be suspected as a potential anatomic site of AT origin from the characteristic P-wave and activation timing. Long-term success was achieved with focal ablation in the majority of patients.     

起源于左心耳局灶性房性心动过速的电生理特征和射频消融治疗

目的 报道一组起源于左心耳局灶性房性心动过速(房速)的电生理特征和射频消融治疗.方法 9例患者中男性5例,平均年龄(21±9)岁,经心内电生理检查和射频消融证实为起源于左心耳的房速,对其电生理特点及射频消融进行分析.结果 左心耳房速表现为无休止性或静脉滴注异丙肾上腺素诱发,程序刺激不能诱发或终止房速.左心耳房速有独特的体表心电图特征,所有患者P波Ⅰ、aVL导为负向,Ⅱ、Ⅲ、aVF导联P波高而直立.V_1导P波为直立或正负双向(以直立为主),V_2～V_6导P波为等电位线(5例)或<0.1 mV低幅直立(4例).常规心内标测,最早心房激动为CS远端.成功靶点处局部心房激动领先P波起始(36.7±7.9)ms.5例患者最终使用盐水灌注导管消融成功,随访(12 ±5)个月无房速复发.结论 左心耳房速有独特的心电图特征和房内激动顺序,对这类房速盐水灌注导管可能是更好的选择,左心耳内局灶消融长期随访安全有效.     

起源于冠状静脉窦口的房性心动过速九例

目的报道9例起源于冠状静脉窦口附近的房性心动过速(简称房速)。方法回顾分析2005年11月至2009年1月行射频消融治疗的59例房速患者,发现9例起源于冠状静脉窦口。其定义为标测的最早激动点位于冠状静脉窦口周1 cm范围以内的区域并在此消融成功。结果9例靶点局部A波激动时间领先体表P波起点39±12(30~53)m s。房速体表P波具有以下特点:Ⅱ、Ⅲ、aVF导联P波呈负向波,I导联呈等电位线或低幅正向波,aVL导联呈正向波,多数病例V1导联P波前半部分为等电位线,后半部分为正向波,胸前导联P波由右向左在V3~V6导联逐渐移行为负向。结论冠状静脉窦口是右房房速的一个重要起源点,其体表心电图有明确特征。     

Focal atrial tachycardia arising from the mitral annulus: electrocardiographic and electrophysiologic characterization

OBJECTIVES: The study was done to characterize the electrocardiographic and electrophysiologic features of focal atrial tachycardia originating at the mitral annulus (MA). BACKGROUND: Though the majority of left atrial tachycardias originate around the ostia of the pulmonary veins, only isolated reports have described focal tachycardia originating from the MA. METHODS: Seven patients of a consecutive series of 172 patients undergoing radiofrequency ablation for focal atrial tachycardia are reported. Electrophysiologic study involved catheters positioned along the coronary sinus (CS), crista terminalis (CT), His bundle, and a mapping/ablation catheter. RESULTS: All seven patients had tachycardia foci originating from the superior region of the MA in close proximity to the left fibrous trigone and mitral-aortic continuity. These foci demonstrated a characteristic P-wave morphology and endocardial activation pattern. The P-wave morphology in the precordial leads typically showed a biphasic pattern, with an inverted component followed by an upright component. The P-wave was consistently of low amplitude in the limb leads. Earliest endocardial activity occurred at the His bundle region in all seven patients. In general, CS activation was proximal to distal, and mid-CT activation was earlier than high or low CT. Ablation was successful at the superior aspect of the MA in all patients. CONCLUSIONS: The MA is an unusual but important site of origin for focal atrial tachycardia, with a propensity to be localized to the superior aspect. It can be suspected as a potential anatomic site of tachycardia origin from analysis of P-wave morphology and the atrial endocardial activation sequence map. Using mapping targeted to anatomic structures achieved a high success rate for ablation.     

阵发性房颤患者射频消融术后心电图P波离散度的变化

目的：探讨阵发性房颤射频消融术对 P 波离散度（最大、最小 P 波时限之差）的影响。方法：对95例有阵发性房颤病人行环肺静脉电隔离术,记录术前及术后24h 十二导心电图,测量最大、最小 P 波时限,计算 P 波离散度。从术后3个月开始,每月门诊随访,并行动态心电图检查,随访6个月。根据房颤症状及动态心电图随访资料判断手术成功与否分为成功组（70例）和复发组（25例）。结果：所有房颤患者射频消融术后 P 波离散度较术前均有下降[（42.22±4.02）ms 比（48.84±4.08）ms,P ＜0.01]。成功组 P 波离散度较术前明显下降[（40.67±4.82）ms 比（47.63±3.58）ms,P ＜0.01],复发组较术前有所下降[（48.26±3.48）ms 比（49.51±1.64） ms],但无显著性差异（P ＝0.346）。环肺静脉电隔离术后,成功组 P 波离散度显著低于复发组 P 波离散度（P ＜0.01）。结论：环肺静脉电隔离术可改善房颤患者 P 波离散程度,成功组 P 波离散度改善更加明显。环肺静脉电隔离术后 P 波离散度对房颤的复发有预测作用。