Bundle branch re-entry ventricular tachycardia in a patient with complete heart block.

A 58-year-old male patient presented episodes of palpitations in the context of atrioventricular block treated by a dual-chamber pacemaker. Clinical and electrophysiological studies identified the tachyarrhythmia to be bundle branch re-entrant ventricular tachycardia, which was successfully treated by radiofrequency ablation of the proximal right bundle branch.     

Incidence and significance of pleomorphism in patients with postmyocardial infarction ventricular tachycardia. Acute and long-term outcome of radiofrequency catheter ablation.

AIMS: The prognostic significance of multiple ventricular tachycardia (VT) morphologies, whether spontaneous or induced, was investigated in patients who underwent radiofrequency catheter ablation (RFCA) for postinfarction ventricular tachycardia. METHODS AND RESULTS: We studied 137 patients with postinfarction ventricular tachycardia. Catheter ablation of all induced ventricular tachycardias was attempted. A single ventricular tachycardia morphology was documented in 102/137 patients (MONO group); 35 patients had spontaneous pleomorphism (PLEO group). Multiple VT morphologies were induced in 58/102 (57%) MONO patients and in all PLEO patients. A higher rate of arrhythmia suppression was obtained in MONO as compared to PLEO patients (162/212 [76%] vs. 43/110 [39%]). Clinical presentation (VT pleomorphism) (OR: 0.22, CI: 0.08-0.62) and the induced VT cycle (mean PLEO/MONO: 338/385 ms, OR: 1.06) were independent predictors of acute RFCA success. Among MONO patients, the procedure was successful in 75% of the patients with a single induced ventricular tachycardia compared to 64% of those with multiple tachycardias. The acute success rate was lower in PLEO patients (23%). PLEO patients had a significantly higher 3- and 5-year arrhythmia recurrence rate than MONO patients. RFCA acute success was the only independent predictor of long-term outcome in multivariate analysis. CONCLUSIONS: Spontaneous, but not induced, VT pleomorphism in patients with prior myocardial infarction adversely affects the acute and long-term success rate of RFCA.     

室性心动过速合并室上性心动过速的射频消融

目的报道7例室性心动过速（VT）合并室上性心动过速（sVT）的射频消融。方法7例患者男6例,女1例,平均年龄（21±9）岁。阵发性心动过速病史（3．7±2．0）年。术中心房和心室刺激诱发VT和SVT,并进行消融。结果7例患者心房或心室刺激能反复诱发和终止VT合并SVT。法洛四联症矫治术后右心室VT合并三尖瓣环峡部依赖性心房扑动（AFL）1例,其余6例均为维拉帕米敏感性左心室特发性室速（ILVT）,分别合并AFL1例,左后间隔旁路参与的顺向型房室折返性心动过速（AVRT）1例,冠状静脉窦口慢旁路参与的顺向型AVRT1例,慢慢型房室结折返性心动过速（AVNRT）1例,左侧游离壁旁路参与的顺向型AVRT2例。7例患者的两种心动过速均成功消融,所有患者消融术后随访2年,无一例VT或SVT复发。结论VT合并SVT并不少见,消融术中应放置必需的心腔内电极导管,完成详细电生理检查,避免漏诊。一次消融应根除两种疾病。     

经导管射频消融治疗室性心动过速的疗效观察

室性心动过速是临床上较常见的心律失常,可发生于健康人群和各种心脏病患者。由于其可造成严重的症状甚至危及生命,因而需要积极处理,目前导管射频消融已逐渐成为首选治疗。我院近2年经导管射频消融治疗室性心律失常患者11例,现报道如下,以评价其临床疗效及安全性。     

Myocardial dissection following successful chemical ablation of ventricular tachycardia.

We describe a case of fatal myocardial rupture and tamponade following a successful transcoronary chemical ablation of incessant ventricular tachycardia. Pathological examination showed a subepicardial dissection of the heart at the ablation site with fibrous and fatty degeneration of the myocardium. The present report calls for caution, underlying a possible lethal complication of ethanol ablation which has not been described before.     

Electrocardiographic predictors of long-term outcomes after radiofrequency ablation in patients with right-ventricular outflow tract tachycardia.

AIMS: The objectives of this study were to identify electrocardiographic (ECG) predictors of long-term outcomes after radiofrequency (RF) ablation in patients with right-ventricular outflow tract (RVOT) tachycardia. METHODS AND RESULTS: We correlated ECG characteristics with RF ablation outcomes in 144 patients with RVOT tachycardia who underwent RF ablation for >1 year. Unfavourable RF ablation outcomes were predefined as unsuccessful RF ablation or recurrence of tachycardia requiring repeated ablation. RF ablation was not successful in 11 (7.6%) patients and 16 (12%) patients had arrhythmia recurrence requiring repeated ablation. Average follow-up time was 72.2+/-28.4 months. Selected parameters from univariate analysis included number of RF applications, pacemapping, application of bonus burn, procedure time, monophasic R-wave in lead I, QS pattern in leads I and aVL, QRS duration in leads II and V(2), and right axis deviation, in ventricular tachycardia. From logistic regression analysis, only monophasic R-wave in lead I remained in the final equation (P=0.004, odds ratio 12.9). CONCLUSION: Monophasic R-wave in lead I during RVOT tachycardia is associated with unfavourable outcomes after RF ablation. This finding may help clinicians in the selection of patients for RF ablation and for the prediction of RF ablation outcome.     

Clinical and electrophysiological differences between patients with arrhythmogenic right ventricular dysplasia and right ventricular outflow tract tachycardia.

AIMS: Radiofrequency catheter ablation is considered first line treatment for symptomatic patients with right ventricular outflow tract tachycardia (RVOT). The role of ablation in arrhythmogenic right ventricular dysplasia (ARVD) is more limited. As such, differentiating between the two conditions is essential. METHODS AND RESULTS: This study compared non-invasive findings, magnetic resonance images (MRI), invasive electrophysiological characteristics, results of ablation and long-term outcome in 50 consecutive patients with RVOT (33) or ARVD (17). Structural abnormalities were uniform in the ARVD group; in addition 18 (54%) of the RVOT tachycardia group had MRI abnormalities. At electrophysiological study the tachycardia in the ARVD group displayed features of re-entry in over 80%, but behaved with a triggered automatic basis in 97% with RVOT. Ablation was complete or partial success in 12 (71%) patients with ARVD and ventricular tachycardia (VT) recurred in eight (48%). In the RVOT patients, ablation was a complete success in 97% with recurrent VT in 6%. Long-term success in the RVOT patients was 95% in both patients with and without MRI abnormalities. CONCLUSIONS: Electrophysiological characterization can differentiate ARVD from RVOT. The finding of abnormalities on MRI does not have any bearing on arrhythmia mechanism, acute or long-term success of RFA.     

特发性束支折返性室性心动过速的临床特点(附二例报道)

通过对两例特发性束支折返性室性心动过速 (BBR VT)的临床、心电图及电生理特性进行分析 ,提出该类病人的临床特点。两例病人均无器质性心脏病的证据。例 1男性 ,VT发作最长持续达 2 7h ,体表心电图呈近似心室扑动的图形 ,心内电生理检查证实为类左束支阻滞图形 ,QRS波宽 2 6 0ms。平时体表心电图QRS波正常 ,心内电图提示HV间期延长 ,VT可稳定诱发和终止 ,存在V3 现象 ,右束支消融成功。例 2女性 ,VT发作病史 7年 ,呈无休止性VT发作 ,平时体表心电图为完全性右束支传导阻滞伴左前分支阻滞图形 ,VT可稳定诱发和终止 ,发作时其QRS波宽为 14 0ms ,呈类完全性右束支传导阻滞伴左前分支阻滞图形 ,V波前有稳定的H波 ,消融左后分支后可导致Ⅲ度房室阻滞而终止VT。结论 :束支折返性VT可见于无器质性心脏病病人 ,有独特的电生理特性 ;是一种特殊类型的特发性VT     

射频导管消融治疗顽固性频发室性早搏伴短阵室性心动过速的体会

报道 2 5例 (男 14例、女 11例 ,年龄 15～ 6 7岁 )顽固性频发室性早搏 (简称室早 )伴短阵室性心动过速 (简称室速 )接受RFCA的治疗结果。采用心室激动顺序与起搏标测法进行室早标测定位 ,标测到室早最早激动点较体表心电图QRS波提前 30ms以上或消融电极起搏心电图QRS波图形与室早图形完全一致时放电消融。结果 :2 5例患者室早起源分别为右室流出道 12例、右室心尖部 5例、左室游离壁 5例、左室近后间隔部 3例。 2 5例中 2 1例成功 (包括 1例频发室早伴短阵多形性室速患者 ) ,成功率为 84 % ,无并发症发生。结论 :RFCA治疗频发单形性室早伴短阵室速安全、有效。     

Radiofrequency catheter ablation of ventricular tachycardia in a patient with dermatomyositis

Dermatomyositis is an idiopathic systemic inflammatory disorder that rarely affects the cardiac muscles. It has shown to be associated with various arrhythmias frequently manifesting as conduction disturbances. There are few case reports regarding dermatomyositis and ventricular tachyarrhythmias. Moreover, data regarding clinical experiences and outcome of radiofrequency catheter ablation (RFCA) for ventricular tachycardia (VT) in dermatomyositis is limited. We report a 51-year old male patient with dermatomyositis presented at our hospital for recurrent palpitation caused by VT.The VT was isoproterenol-triggered, adenosine-suppressed, and focally originating from the posteroinferior right ventricular septal area. The most likely mechanism is abnormal automaticity. A successful 3D-electroanatomical mapping-guided RFCA at the earliest activation sites cured VTs with no recurrence. It suggests that RFCA is safe and effective for focal VTs in dermatomyositis patients.     

起搏标测指导下射频消融器质性心脏病并发单形性室性心动过速

目的探讨起搏标测指导下射频消融器质性心脏病并发单形性室性心动过速(室速)的可行性和有效性。方法7例器质性心脏病患者,包括肥厚型心肌病4例,扩张型心肌病1例,冠心病、陈旧性心肌梗死1例,室间隔缺损修补术后1例。所有患者均为单形性室速。7例患者均在起搏标测下在室速折返环出口或病灶起源点行多靶点消融。以标测过程中出现与临床QRS波形态相同或相似的短阵室速或频发室性期前收缩为有效消融靶点。结果7例患者中4例为右室流入道室速,2例为左室流出道室速,1例为左室流入道室速。其中1例室速发生时血流动力学不稳定,1例程序刺激及药物不易诱发(术中仅记录到1次与临床发作相同的短阵室速)。7例患者分别完成消融3~10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24~38(平均29.5)个月,其中6例患者在未服用抗心律失常药情况下(包括1例2次手术者)无室速复发。结论起搏标测指导下行多靶点消融能有效治疗器质性心脏病单形性室速;对于血流动力学不稳定性室速或程序刺激及药物不易诱发的室速起搏标测更有其应用价值。     

射频消融治疗特发性室性心动过速疗效观察

目的 :评价射频消融术治疗特发性室性心动过速 (室速 )临床疗效。方法 :5 6例特发性室速患者中 ,34例左室特发性室速采用EPT小、中弯大头导管 (或Webstr小弯大头 ) ,在左室行激动顺序标测和消融 ,以P电位较QRS起点提前 2 0ms以上作为消融靶点。 2 2例右室流出道室速采用Webster加硬导管在右室流出道行起搏标测 ,以起搏时与心动过速时体表 12导联QRS形态完全相同或最接近处为消融靶点 ,成功标准为放电过程中心动过速终止且不能诱发。结果 :5 1例患者消融成功 ,成功率 91.1%。 34例左室特发性室速中 30例靶点位于左室间隔中下部 ,2例近左室心尖 ,1例左室流出道 ,1例位于间隔高位。 31例消融成功 ,1例失败 ,2例因导管到达间隔处机械刺激终止室速而不能再诱发 ,于终止室速处作为靶点射频消融 ,1例于术后第 2天、另 1例半年后室速复发。 2 2例右室流出道室速 ,16例位于流出道间隔侧 ,6例位于流出道游离侧壁。 19例起搏标测到与心动过速 12导联QRS形态完全相同靶点 ,1例形态接近 ,消融获成功。 2例未能诱发室速 ,射频消融 1个月心动过速重新出现 ,所有患者无并发症出现。结论 :射频消融术对特发性室速是一种安全有效的治疗方法 ,可作为首选治疗。电生理未诱发室速或机械刺激终止室速不宜尝试射频消融治疗。     

Percutaneous epicardial ablation reverses ventricular tachycardia mediated cardiomyopathy

We report on the case of an 18-year-old girl with asymptomatic incessant ventricular tachycardia. Initial attempts at endocardial ablation failed and she was monitored until her cardiac function deteriorated. A percutaneous epicardial approach with electroanatomical mapping was then used which successfully terminated the tachycardia. Left ventricular size and function subsequently returned to normal. This case demonstrates that percutaneous epicardial ablation of ventricular tachycardia is safe and feasible in young patients and highlights the importance of recognising this at an early stage.     

室性心动过速及顽固性室性早搏的导管消融治疗

回顾分析 1991年 3月～ 1999年 10月导管消融治疗 6 7例室性心律失常患者的临床结果。按患者接受治疗的时间顺序 ,将 1991年 3月～ 1993年 10月定为前期阶段 ,共 2 4例 ;1993年 11月～ 1999年 10月定为后期阶段 ,共 43例。采取心内激动和 (或 )起搏标测的方法进行标测 ,行直流电消融 (DCCA)或射频消融 (RFCA)治疗。前期阶段RFCA治疗的成功率 40 % (4/ 10 ) ,低于后期阶段RFCA治疗的成功率 95 % (41/ 43) ,P <0 .0 5。前期阶段DCCA治疗的复发率 10 % (2 / 2 0 )、并发症发生率 2 0 % (4/ 2 0 )和术后血CPK峰值 10 32± 36 9U/L分别高于后期阶段RFCA治疗的 2 % (1/ 43)、5 % (2 / 43)和 16 3± 82U/L(P均 <0 .0 5 )。 6 7例患者中 ,特发性室性心动过速 (IVT) 5 2例。右室IVT 2 4例 ,19例 (79% )起源于右室流出道 ;其中 2 1例成功靶点局部电图较体表QRS波群提前 2 5 .3± 5 .6ms。左室IVT 2 8例 ,2 1例 (75 % )起源于左室后间隔 ;其中 2 5例成功靶点局部电图提前 2 9.1± 6 .0ms;仅 1例记录到孤立的浦肯野纤维除极电位。前期DCCA治疗IVT成功率为 94% (17/ 18) ;后期RFCA治疗IVT成功率 10 0 % (30 / 30 )。合并器质性心脏病的室性心动过速 (VT) 10例 ,前期DCCA治疗 2例 ,成功 1例 ;后期RFCA治疗 8例 ,成功 6     

特发性左心室性心动过速经导管射频消融后的心电图变化

目的 :观察特发性左心室性心动过速 (ILVT)患者经导管射频消融术 (RFCA)后体表心电图的变化 ,探讨RFCA手术成功的心电图观察指标。方法 :分析 2 0例ILVT患者RFCA术前和术后 12导联体表心电图的变化 ,并随访 3个月。结果 :2 0例ILVT患者的消融手术均获成功。术后 19例呈左后分支起源的患者Ⅱ、Ⅲ、aVF导联新出现 q波 ,R波电压较前增高 ,Ⅰ、aVL导联的S波加深 ;QRS波群电压增加 ,心电轴度数不同程度增加 ;1例呈左前分支起源的患者术后Ⅱ、Ⅲ、aVF导联S波加深 ,aVL导联R波增高伴有电轴左偏。 2 0例患者术前、术后QT间期 ,QTd和QTc间期、QTcd均差异无统计学意义 (P >0 .0 5 ) ,随访 3个月 ,以上体表心电图未见进一步改变。结论 :体表心电图新出现左侧分支阻滞图形可作为ILVT患者成功RFCA的重要观察指标 ,术中标测最早肯浦野 (P)电位比最早心室激动点处消融更有效 ,术中体表心电图肢体导联的QRS波群电压幅值的改变 ,可作为消融成功的指征。ILVT经RFCA后不会影响心室肌复极离散度     

Ablação epicárdica percutânea em arritmias ventriculares

IntroductionReentrant circuits of ventricular tachycardia may involve not only the endocardium but also the epicardium. Epicardial ablation can be useful in these situations.ObjectiveThe aim of this study was to assess efficacy, safety and complications in a series of consecutive patients who underwent ablation of ventricular tachycardia with epicardial mapping.MethodsThe study included all patients undergoing ventricular tachycardia ablation with epicardial mapping from 2004 to 2012. Of a total of 95 ablations, an epicardial approach was attempted in nine patients, eight male, mean age 58±12 years. Endocardial mapping was performed in all patients previously or simultaneously. The etiology of the arrhythmia was non‐ischemic in eight patients and ischemic in one. We compared the number of events in the six months prior to the epicardial procedure and six months after.ResultsPercutaneous epicardial access was achieved in eight patients. In one case it was not possible due to the presence of adhesions. In none of the patients was the procedure repeated and there were no major complications during hospitalization. In a mean follow‐up of 3.5±1.2 years, one patient suffered stroke; there were no other medium‐to‐long‐term complications and the number of ventricular tachycardia episodes was reduced in all patients after ablation.ConclusionsEpicardial radiofrequency ablation of ventricular tachycardia was effective in reducing morbidity in eight patients, with a low risk of complications in the short and medium‐to‐long term.