单导管射频消融治疗主肺动脉干室性早搏／室性心动过速临床观察

目的探讨起源于主肺动脉干（MSPA）室性早搏（PVCs）/室性心动过速（VT）的心电图特征、标测方法及单导管射频消融治疗的疗效与安全性。方法选取经肺动脉造影证实起源于MSPA的PVCs／VT患者12例（MSPA组）以及右心室流出道（RVOT）前间隔起源的PVCs／VT患者59例（RVOT组）,均采用单导管常规标测技术进行标测、消融。比较分析两组患者心电图特征,随访MSPA组患者的疗效。结果MSPA组患者体表心电图具有下壁导联R波振幅高以及胸前导联移形较早（多位于V2～V3）的特点,其有效靶点高电压（8V）可起搏心室,并与自发PVCs/VT的QRS波形12导联完全相同,有效靶点心室电位较PVCs／VT体表心电图QRS波起始点提早（33.91±3.69）ms,10例可记录到远场A、V波,6例可记录到融合或分离的尖峰或碎裂电位。所有消融治疗均成功,无并发症发生,随访期间无复发病例。结论起源于MSPA的PVCs／VT并非罕见．单导管标测及消融安全、有效．     

Stepwise approach to substrate modification of ventricular tachycardia after myocardial infarction

Background Recently, substrate mapping (SM) has been described to facilitate catheter ablation of stable and unstable ventricular tachycardia (VT) after myocardial infarction. However, SM is time consuming with potential disadvantages of multiple ablation lines such as impairment of ventricular function or proarrhythmia. The aim of the present study was to delineate a stepwise approach to SM to shorten procedure time and limit the possibility of complications. Methods SM was performed in 14 infarct survivors referred for VT ablation using an electroanatomical mapping system (CARTO) to define infarct regions. A new stepwise approach for SM was designed as follows. The initial ablation site was identified by pace- and entrainment mapping in case of stable VT and by pace mapping only in case of unstable VT. Based on the CARTO voltage mapping, linear ablation was done from this site to the center of the scar and perpendicular to the boundary of the scar or to the mitral annulus. Additional lines were performed only when VT remained inducible. A maximum of 3 ablation lines were created during one procedure. Results A total of 57 VTs (21 stable, 36 unstable) were induced during the procedures. VT was no longer inducible after the first linear ablation in 2 patients, after the second linear ablation in 6 patients and after the third linear ablation in 3 patients. Either VT or ventricular fibrillation was still inducible at the end of the procedure in 3 patients. Procedure time averaged (291 + 85) minutes, fluoroscopy time (10+7) minutes. VT recurred in 3 patients. Following a second procedure in 2 patients, there were no further VT recurrences. Overall, there was a significant reduction in VT episodes 3 months after [median: 0, interquartile ranges (IQR): 0-1] compared with 3 months before ablation (median: 25, IQR: 16-105, P<0.01). Conclusions This stepwise approach to SM is effective in facilitating ablation of stable and unstable VT. It reduces procedure and fluoroscopy time, and may help to improve the risk-benefit ratio of VT ablation.     

用体表心电图定位研究室性心动过速起源点

作采用心内膜导管起搏时的体表心电图ＱＲＳ波与自发室性心动过速时的体表心电图ＱＲＳ波形进行比较，作为ＶＴ起源点的定位方法，并以电消蚀ＶＴ成功为金标准，对８例ＶＴ患进行定位研究并评价，结果显示心内膜起搏时心电图ＱＲＳ波形有９个导联以上为自发ＶＴ时ＱＲＳ波符合时，起搏点在ＶＴ起源点附近，直流电消蚀成功，射频电则不行，当心电图ＱＲＳ１２个联符合时，起搏占即ＶＴ起源点，射频消蚀成功，表明我们采用的ＶＴ     

Study on the localization of the origin of ventricular tachycardia with surface electrocardiogram

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维拉帕米敏感性室性心动过速的射频消融术治疗

目的 探讨射频消融术治疗维拉帕米敏感性室性心动过速（室速）的有效性和安全性。方法 选择本院18例确诊为维拉帕米敏感性室速的患者为研究对象。入院后行相关检查排除器质性心脏病后接受射频消融术。术中寻找Purkinje电位（P电位）,标测到P电位较体表的QRS波提前≥20 ms为理想消融靶点。在25 ～35 W,60℃左右的设置下行消融。其周围位置在同样的设置下消融。达到消融终点后,行右心室刺激或者异丙肾上腺素静滴后再行右心室刺激检验消融效果。术后给予常规治疗及护理。出院后随访3～6个月。结果 18例患者中,17例起源左后分支,1例起源左前分支,室速,分别在左中后间隔及前间隔消融成功。术中全部达到消融终点,均未再能诱发室速。理想靶点的P电位较体表QRS波提前(24.0±3.5)ms。发现提前越多,消融所需时间越少。术后有2例患者出现穿刺口血肿,无其他并发症出现。随访3～6个月,有2例多次心动过速发作,发作性质及心电图同前。治愈率达88.9％。结论 射频消融手术治疗维拉帕米敏感性室速是安全有效的,可以达到根治的目的,但有一定的复发率。     

心大静脉不同部位室性心律失常的心电图特征及射频导管消融治疗

目的 探讨心大静脉（GCV）不同部位室性期前收缩（PVCs）和室性心动过速（VT）的心电图特征及射频导管消融治疗的疗效与安全性.方法 4例经GCV标测和消融患者,其中持续及短阵性VT各1例,PVCs2例.经左、右心室流出道（LVOT、RVOT）及二尖瓣环心内膜标测与试消融无效各2例,最后均经GCV标测与消融,并对GCV远端（前室间静脉分支前-二尖瓣环前壁心外膜）及最远端（前室间静脉分支后-LVOT）消融成功者的心电图特征进行分析.结果 首次均采用普通温控导管仅1例消融成功,因阻抗太高无法放电失败3例,其中2例再次经三维标测系统EnSite3000-NavX指导下,采用盐水灌注导管标测与消融均成功,1例放弃再次消融,成功率75.00%.经GCV远端及最远端消融成功各1及2例.激动顺序标测有效靶点心内电图较体表心电图QRS波群起始点提早（36.00±2.65）ms,可见A波及V波（V＞A） 起搏标测的QRS波群与自发PVCs/VT形态12及11导联相同各2例.GCV远端及最远端消融成功者体表12导联心电图特征不同：（1）前者假性＂δ＂波时间≥75ms而后者＜75ms （2）前者V1呈R型无S波群而V4～V6有S波（呈Rs型）,后者则相反.结论 部分体表心电图特征符合LVOT或二尖瓣环前壁起源的PVCs/VT,经上述部位标测与消融无效者,应考虑经GCV采用盐水灌注导管进行标测与消融,且安全有效.     

Left posterior fascicular block: a new endpoint of ablation for verapamil-sensitive idiopathic ventricular tachycardia

Verapamil-sensitive idiopathic left ventricular tachycardia with a right bundle-branch block and left-axis deviation morphology, which occurs in young adults without structural heart disease is an uncommon but well described clinical arrhythmia. This ventricular tachycardia (VT) is known to be due to re-entry mechanism and the re-entrant circuit is localized in the left ventricular septum.1-10 However, the relationship between Purkinje potential and the reentrant circuit is still controversia…     

顽固性频发性室性早搏的射频消融治疗

目的：了解射频消融治疗顽固性频发室性早搏的效果。方法：采用心室激动顺序与起搏标测法进行室性早搏标测定位，标测到室性早搏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：16例中15例成功，成功率93．3％。无并发症发生。结论：射频消融治疗频发单形室性早搏安全有效。     

右房双室起搏治疗慢性心力衰竭的近期疗效

目的:观察右房双室起搏治疗慢性心力衰竭的近期疗效.方法:选择NYHAⅢ级-Ⅳ级、LVEF≤35%、QRS时限≥120 ms、窦性心律的CHF患者30例,成功植入三腔起搏器后,以起搏器植入术前及术后1月的6 min步行距离、MQOL、QRS波时限、LVEDD、LVEF、TPSD、NT-proBNP为评价指标,观察右房双室...     

激光治疗致命性心律失常的实验研究：心外膜标测...

To find the exact location of the ventricular arrhythmogenic myocardium, we mapped activation times of local epicardial electrograms (ATLE: 16 bipolar electrodes, 2 x 2 cm2) aided by an on-line computer and guided laser ablation of lethal ventricular arrhythmias induced by aconitine. Thirty-six tests involved 12 dog hearts. Nd:YAG laser application converted ventricular tachycardias and fibrillation to sinus rhythm in all tests. Epicardial mapping results showed: Taking ECG lead II as reference, the differences among all ATLE were within 15ms, and there was no obvious conduct slow zone before drugging and after resuming sinus rhythm, even though 298 +/- 157 mm2 photocoagulation areas (n = 36) resulted from laser irradiation; During VT, the majority of ATLE were preexcited from 90 to 30 ms, and more than one breakthrough point existed, with one predominating; ATLE changed significantly after laser. The ectopic foci were located exactly by using ATLE for laser treatment.     

窦性心律下射频导管消融起源于希蒲系统特发性室性心动过速的临床观察

目的:探讨窦性心律下射频导管消融(RFCA)起源于希蒲系统特发性室性心动过速(IVT)的临床结果.方法:23例起源于希蒲系统IVT,按消融方法分为两组:(1)心动过速消融组,为9例患者,以心动过速下最早提前P电位为靶点,在心动过速下进行消融;(2)窦性心律消融组,为14例患者,以心动过速下记录最早P电位且窦律下试放电过程中出现同形或近似室性早搏及短阵室性心动过速为靶点,在窦律下进行消融.术后反复程序刺激不能诱发心动过速为消融终点.观察两种不同消融方法的临床结果.结果:两组在手术成功率、手术时间、X线曝光时间、并发症发生率及复发率方面无明显差别.结论:窦性心律下射频消融起源于希蒲系统IVT安全、有效.     

Evaluation of transisthmus conduction interval in predicting bidirectional block after ablation of typical atrial flutter

Objective To determine whether the extent of prolongation of the transisthmus interval after ablation predicts complete bidirectional block. Methods Since 1996 to 2002, 30 consecutive patients underwent ablation procedures for isthmus-dependent atrial flutter. There were 23 males and 7 females ［mean age (47.85±9.35) years］. With the use of fluoroscopic view of anatomy, radiofrequency ablation was performed during coronary sinus pacing at a cycle length of 600 ms. Results Bidirectional block was achieved with ablation in 29 (97%) of 30 patients. The transisthmus intervals before ablation and after complete transisthmus block were (73.82±13.01) ms and (140.47±20.48) ms, respectively, in the clockwise direction (P&lt;0.0001), and (77.63±8.36) ms and (138.17±15.55) ms, respectively, in the counterclockwise direction (P&lt;0.0001). A period of incomplete isthmus block was observed during 17 (58%) of the 29 ablation procedures. The clockwise transisthmus intervals during incomplete block ［(107.65±21.33） ms］ were (45.5±8.7)% longer than the baseline transisthmus intervals. An increase in the transisthmus interval by ≥50% in both directions after ablation predicted complete bidirectional block with 100.0% sensitivity and 83.3% specificity. The positive and negative predictive values were 90.6% and 100.0%, repectively. The diagnostic accuracy of a≥50% prolongation in the transisthmus interval was 83.3%.Conclusion The analysis of transisthmus interval is a valuable method for determining complete bidirectional isthmus block.     

China＇s quality watchdog： Latest tests show infant formula milk safe

Background Radiofrequency catheter ablation （RFCA） has been established as an effective and curative therapy for ventricular tachycardia （VT） and severely symptomatic premature ventricular contraction （PVC） from the outflow tract in structurally normal hearts. This study aimed to investigate electrophysiologic characteristics and effects of RFCA for patients with idiopathic VT and symptomatic PVC originating from the valve annulus. Methods Characteristics of body surface electrocardiogram （ECG） and endocardiogram in a successful RFCA target were analyzed in 16 patients with idiopathic VT and symptomatic PVC originating from the valve annulus. Additionally, the ECG characteristics of VT or PVC were compared with those of manifest Wolff-Parkinson-White （WPW） syndrome originating from the same site of origin in 15 patients. Results Thirteen patients were successful, 2 recurrent and 1 failed. The recurrent cases underwent successful ablation the second time guided by the Ensite 3000 mapping system. In all patients with the WPW syndrome, the characteristics of QRS morphology were well matched with those of the VT and PVC that originated from corresponding sites of origin. Conclusions RFCA is an effective curative therapy for VT and There are specific characteristics in ECG and the ablation site accessory pathway＇s algorithm. symptomatic PVC originating from the valve annulus. could be located by means of the WPW syndrome     

右心室流入道起搏QRS波时限与心功能的关系

目的观察采用右心室流入道起搏治疗缓慢性心律失常时,QRS时限对心功能的影响及与心力衰竭的关系。方法随意选用44例病态窦房结综合征或三度房室传导阻滞的患者,采用右心室流入道起搏治疗,将患者起搏时QRS时限〈133ms的分为A组（n=28）;起搏时QRS时限≥133ms的分为B组（n=16）,测量起搏器植入时、起搏3个月和6个月不同时期,QRS时限、血浆心钠肽（BNP）、心排血量（CO）、每搏输出量（SV）、射血分数（EF）和左室舒张末内径（LVDd）的变化。结果术后即刻测两组QRS时限、BNP值和心脏超声指标无显著性差异（P〉0.05）,术后3个月、6个月QRS时限、LVDd、BNP,B组明显高于A组,而EF、SV、CO,B组明显低于A组。结论右室流入道起搏部位QRS时限和心功能密切相关,QRS时限越宽,心功能纠正就越不明显或心衰进一步加重,反之,QRS时限越窄,心功能改善就越明显。     

心房起搏对老年睡眠呼吸暂停综合征作用的影响

目的:探讨老年睡眠呼吸暂停综合征(sleep apnea syndrome,SAS)患者睡眠时用心房起搏方式增加心率的治疗作用。方法:因症状性心动过缓行心房心室同步起搏的中枢型或阻塞型老年SAS患者16例,每例患者连续3晚经多导睡眠图检查等监测,第1晚所有患者进行基础评估后随机分组,第2晚一组自身心律模式、另一组心房超速起搏模式(夜间基础平均窦性心率基础上增加15次/min)下评估,第3晚两组监测模式互换,分析比较两种不同模式总的睡眠呼吸暂停和低通气事件。结果:基础评估24h自身平均窦性心率为(55±9)次/min,较心房超速起搏模式频率[(72±4)次/min]差异有统计学意义(P<0.05);自身节律模式时总的睡眠时间为(322±48)min,与心房超速起搏模式[(330±52)min]比较差异无统计学意义(P>0.05);低通气指数从自身节律模式时的9±3减少到心房超速起搏模式时的3±3(P<0.01);呼吸暂停/低通气指数从自身节律模式时的28±21减少到心房超速起搏模式时的10±13(P<0.01)。结论:心房超速起搏可明显降低中枢性与阻塞性老年SAS患者睡眠呼吸暂停事件的发生,而不减少总的睡眠时间。     

Experience on application of transveneous implantable MINI Ⅱ cardioverterdefibrillator for ventricular tachycardia due to right ventricular dysplasia:a report of a case

Theimplantablecardioverterdefibrillator(ICD)therapyhasbecomeanimportantmethodfortreatingmalignantventrlculartachyarrhythmiasatpresent.ThisreportdealswithourPrimaryexperienceinclinicalapplicationoftransveneousimplantablecardioverterdeflbrlllator.CLINICALMATERIALSA43--year--oldmalepatientadmittedtohospitalonoctober10.1997becauseofparoxymalventrlculartachycardla(VT).HecomplainedofsufferingVTasmanyas6timesduring2years.TherateofVTwas110to180bpm.In:3times.V'YcouldnotbeterminatedbyInject…     

静注胺碘酮后电复律转复预激综合征合并房颤1例报道

某男,23岁,持续性心悸伴大汗2 h。心电图：心室率280次/min,窦性P波消失,QRS波群呈宽大畸形,形态不一,宽QRS波群之间出现窄的QRS波,且起始部粗钝,最短R-R间隔200 ms。静注胺碘酮300 mg后心室率减慢至180次/min左右,为房颤心律。胺碘酮静滴维持8 h,心律、心率无变化,行150 J体外直流电复律,转为窦性心律。     

房颤患者环肺静脉电隔离术后快速性房性心律失常的再消融治疗效果分析

目的:观察心房颤动患者环肺静脉电隔离术(CPVI)后快速性房性心律失常(ATa)的再消融治疗效果,并探讨其可能的发生机制。方法:64例阵发性房颤患者在初次行CPVI后(3.7±2.4)个月再次行电解剖标测系统指导下ATa标测和消融。结果:共标测到78种ATa,其中48种(61.5%)为局灶性机制,30种(38.5%)折返机制。在折返机制中,12例为普通房扑,18例为左房内折返,其折返环与二尖瓣峡部、左房前壁及原环肺静脉消融线上的传导间隙有关。2例患者因ATa不稳定而无法标测。64例患者中,56例(87.5%)消融即刻成功,8例需要电复律成窦性心律。术后随访13~21个月,平均(16.5±2.9)个月,60例(93.8%)患者不再发生ATa。结论:CPVI术后ATa的机制可为折返性和局灶性,可通过CARTO系统激动顺序标测成功消融治疗。     

不同类型心房颤动导管消融治疗的对比研究

目的探讨三维标测系统指导下对阵发性、持续性和长程持久性心房颤动(房颤)行导管消融治疗的有效性和安全性。方法选择2008年1月—2010年12月在我院行导管消融治疗的持续性及长程持久性房颤患者55例为组1,选取同期住院的阵发性房颤患者55例为组2。在CARTO或ENSITE 3000系统标测下行射频消融治疗,术中采用CARTO-Merge或Ensite Fusion图像融合技术,持续性和长程持久性房颤采用步进式消融策略,在进行环肺静脉电隔离的基础上,进一步行复杂心房碎裂电位(CFAE)或高频电位消融、对规律的房性心动过速或心房扑动(房扑)进行标测和消融,主要是线性消融,包括左房顶部线、二尖瓣环峡部线、左房间隔线和(或)三尖瓣环峡部线等其中之一或不同组合,消融至实现窦性心律,对于呈持续性房扑者经静脉推注伊布利特或直流电转复窦性心律;阵发性房颤仅行环肺静脉电隔离术。所有患者术后继续服用华法林抗凝,停服抗心律失常药物,采用门诊随访,于术后3个月、6个月随访采用动态心电图监测评价心律失常情况,术后6个月复查超声心动图评价左房直径。结果 (1)组1中17例(30.9%)消融过程中直接转复窦性心律;29例(52.7%)消融过程中房颤转变为房扑,经三维激动标测及拖带标测证实其中22例(22/29)为左房大折返房扑,余7例(7/29)为右房三尖瓣峡部依赖的典型房扑,左房房扑经静脉推注心律平或胺碘酮或伊布利特转复5例,直流电转复窦性心律15例,快速起搏拖带转复2例,7例右房房扑行三尖瓣峡部线性消融均转复窦性心律;9例(16.4%)至消融结束仍为房颤律经直流电复律。组2中18例术中发生房颤,其中13例完成环肺静脉消融后恢复窦性心律,2例采用高频刺激转复窦性心律,3例静脉推注心律平转复。(2)组1术后3个月内随访发生房性心动过速29例,不典型房扑9例,房颤13例;术后6个月房颤复发19例,一次消融成功率为65.5%。3个月内组2发生房性心动过速16例,不典型房扑8例,房颤8例;术后6个月时房颤复发7例,一次消融成功率为87.3%。两组一次消融成功率比较差异有统计学意义(P<0.01)。结论对持续性和长程持久性房颤行三维标测系统指导下射频导管消融治疗较为安全,但与阵发性房颤比较,手术时间和X线曝光时间较长,消融步骤较复杂,一次消融成功率较阵发性房颤低;消融术后发生大折返房速或不典型房扑较为常见,部分可在术后3个月减少或消失,往往需再次导管消融治疗。持续性房颤和慢性房颤射频消融治疗转复窦性心律后,左房容积减小,提示有利于心房重构的减轻或逆转。     

慢性心房颤动射频消融术后应用氯沙坦联合胺碘酮治疗的疗效观察

目的观察慢性心房颤动射频消融术后应用氯沙坦联合胺碘酮治疗对心房颤动复发的影响。方法选择拟行射频消融治疗的慢性心房颤动患者60例,随机分为射频消融组30例和射频消融+药物组(氯沙坦联合胺碘酮)30例,术后评价患者症状改善情况,术后6、12个月分别行动态心电图检查确定房颤复发情况,超声心动图复查心脏结构和功能。结果 60例均完成治疗及随访。射频消融组、射频消融+药物组完成环肺静脉电学隔离后各有3例和4例患者直接转为窦性心律,通过消融三尖瓣峡部各有2例患者转为窦性心律,进一步消融及电复律各有25例和24例转为窦性心律。随访中2组心脏结构和功能指标均有所变化,但差异无统计学意义(P>0.05)。随访12个月,射频消融组房颤复发率60.0%(18/30),而射频消融+药物治疗组房颤复发率33.3%(10/30),2组比较差异有统计学意义(P<0.05)。结论慢性心房颤动射频消融术后口服氯沙坦联合胺碘酮可以更有效地维持窦性心律。