导管消融心脏病术后心房内大折返性心动过速

目的:报道应用常规和三维电生理标测方法经导管消融心脏病术后心房内折返性心动过速(IART)的疗效和安全性。方法:选择2002年1月～2006年2月在我院因心脏病术后心房内折返性心动过速行射频消融的44例患者,早期采用常规电生理标测方法,之后随机采用Carto和Ensite三维标测方法指导导管消融。结果:44例患者共诱发出54种心房内折返性心动过速,其中37种(37/54,68.5%)心房内折返性心动过速心电图表现为典型心房扑动(AFL)锯齿形F波,31种心房扑动(31/54,57.4%;31/37,83.8%)成功靶点在下腔静脉和三尖瓣环(IVC-TA)峡部,4种心房扑动成功靶点在疤痕和下腔静脉峡部,2种心房内折返性心动过速成功靶点在疤痕和三尖环之间。另外17种(17/54,31.5%)心房内折返性心动过速临床心电图表现与典型房扑不同,表现为P’波,其中15种(15/ 54,27.8%)成功靶点在右心房游离壁疤痕—下腔静脉或疤痕—上腔静脉或疤痕与疤痕之间;房间隔补片和上腔静脉之间、房间隔补片和三尖瓣环之间各消融成功1种。随访1例复发,行2次消融成功。1例出现持续性心房颤动伴RR长间歇,植入永久性起搏器。结论:导管消融心脏病术后心房内折返性心动过速具有较高的疗效和安全性,应当作为首选的治疗方法。     

下腔静脉三尖瓣环峡部消融中心房扑动从逆钟向急转顺钟向——机制如何？

下腔静脉三尖瓣环峡部依赖的心房扑动导管消融已成为一种经常实施的手术,成功率高,是巨折返心律失常的原型。虽然导管消融峡部依赖的心房扑动已成为常规手术,但电生理实验中的不寻常表现并非少见。我们提供这一病例以揭示折返性心律失常和心房扑动的某些电生理原理。     

下腔静脉-三尖瓣环连线射频消融治疗Ⅰ型心房扑动

目的 观察连线射频消融对治疗心房扑动的效果。方法 对4例Ⅰ型心房扑动(房扑)患者用解剖标志法从下腔静脉口(IVC)～三尖瓣环(TA)进行多次连线消融、结果4例均成功终止房扑,平均放电6.5±2.8次,每靶点平均消融1.86min,无手术相关井发症发生。随访2～5个月无复发。结论 采用IVC～TA连线射频消融可有效地阻断房扑,其远期效果有待观察。     

下腔静脉至三尖瓣环连线射频消融治疗心房扑动

报道所完成下腔静脉至三尖瓣环射频消蚀治疗心房扑动7例。均经电生理检查证实为典型房扑，发作时心房率240～320次／分。7例中6树成功；1例失败，为Ebstein畸形伴有巨大右心房者。7例均采用消蚀下腔静脉至三尖瓣环连线的方法，消蚀中用Swartz鞘作支撑，导管在鞘内拖拉，直至消蚀线完成。本研究提示下腔静脉至三尖瓣环线性射频消蚀术是心房扑动治疗的安全有效手段。     

先天性心脏病术后心房内折返性心动过速的射频消融

先天性心脏病术后常常发生心房内折返性心动过速(IART)而且治疗困难。本研究的目的是观察疤痕下方2下腔静脉开口或/和下腔静脉2三尖瓣环峡部消融的疗效。11例患者12种房性心动过速进行电生理检查和射频消融。在双电位区域仔细寻找碎裂电位和A波最早处为消融开始的靶点,并向自身解剖形成的传导障碍区延伸。结果:10例11种房性心动过速射频消融成功,成功率为11/12(91.7%),8种心动过速的成功靶点位于右心房外侧壁疤痕下方,3例为典型心房扑动的峡部。平均放电次数为5±4次。随访17±6个月,10例无心动过速发作。结论:疤痕2下腔静脉之间或/和下腔静脉2三尖瓣峡部消融可以有效的消除先天性心脏病术后的IART。     

Carto标测指导导管消融心脏病术后心房内折返性心动过速

目的：心脏外科术后的心房折返性心动过速（IART）折返环涉及无传导的或各向异性的传导障碍区，本研究的目的是利用三维电解剖标测系统（Carto）标测这些障碍区并确定与折返环的关系，指导导管消融。方法：22例患者共26种IART进行了Carto标测，首先确定形成IART的基质以及与折返环的关系，并在其峡部消融。结果：22例患者诱发出27种心动过速，对其中26种进行标测，12种IART中心障碍区为三尖瓣环，其消融靶点在下腔静脉一三尖瓣环峡部；12种IART中心障碍区在右心房游离壁，其消融靶点在其周围；2种IART中心障碍区在房间隔，并在此障碍区下方消融成功。即刻成功21例，其中峡部消融成功者12例、游离壁消融成功者7例、间隔部消融成功者2例。平均随访（22±7）个月，20例无心律失常发生而不需用药。结论：可以利用三维电解剖标测方法标测IART基质，这些基质构成IART的中心传导障碍区，消融靶点常常位于其周围。     

对比观察射频消融右房后位峡部和间隔峡部治疗典型心房扑动的疗效

对比观察射频消融右房后位峡部和间隔峡部治疗心房扑动 (简称房扑 )两种方法的疗效。 41例房扑患者随机分为后位峡部组 ( 18例 )和间隔峡部组 ( 2 3例 ) ,消融线径分别为三尖瓣环—下腔静脉和三尖瓣环—欧氏嵴。成功消融终点为房扑不能诱发和峡部呈完全性双向阻滞。结果 :40例消融成功 ( 97.6 % ) ,无并发症。后位峡部组 3例和间隔峡部组 2例在首选消融方法失败后 ,改用另一种消融方法获得成功。两组患者的放电次数和手术时间均无显著性差异。平均随访 12 .4± 6 .8个月 ,在后位峡部消融成功者中 ,有 2例房扑复发。结论 :射频消融右房后位峡部和间隔峡部治疗房扑均安全有效 ,两种方法互补可以提高消融的成功率     

射频导管消融典型心房扑动和手术疤痕折返性房性心动过速共存一例

典型心房扑动(房扑)的成功消融部位是右心房的先天性峡部(三尖瓣环-下腔静脉峡部)，而对于手术疤痕折返性房性心动过速(疤痕折返性房速)，消融部位则是与手术疤痕相关的后天性峡部。本文报道1例共存有上述两种心动过速患者的成功消融过程。     

典型心房扑动峡部冷冻消融的短期疗效

目的观察冷冻消融治疗峡部依赖性心房扑动(简称房扑)的可行性和短期疗效。方法选择阵发性和持续性房扑患者5例,采用8mm冷冻消融导管,设定输出温度-85℃,每点消融4min,从三尖瓣环至下腔静脉行线性消融,以峡部双向阻滞并保持30min为消融成功。结果5例均峡部双向阻滞,达到有效消融的平均次数5.2±1.9次,出现冷冻有效的时间56.0±11.4s,1例双向阻滞4min后恢复,再消融3次后成功,每例平均消融次数6.0±2.9次。4例未完成完整的线性消融便已达到消融终点。手术总时间为102±26.8min,X线曝光时间为14.42±7.74min。患者均无疼痛等不适主诉。随访76±11.4天,未见房扑复发。结论经导管冷冻可以有效,快速的行典型房扑峡部消融,短期疗效好。     

三尖瓣峡部消融对心房颤动导管消融术后复发的影响

目的:评估三尖瓣峡部消融对伴有典型心房扑动(房扑)和不伴典型房扑发作的心房颤动(房颤)患者术后复发的影响.方法:连续入选房颤射频消融治疗患者113例,根据有无典型房扑分为三尖瓣峡部消融组(CTI组)和未行三尖瓣峡部消融组(Non-CTI组),比较临床特征及手术特点,并随访术后典型房扑和房颤发生率.结果:Non-CTI组左房内径更大,持续性和永久性房颤的比例、左房线性消融的比例更高.而CTI组射频消融时间较Non-CTI组更长.术后典型房扑和房颤发生率2组无显著区别.结论:无典型房扑发作的房颤患者,不行三尖瓣峡部消融,不会升高术后典型房扑发生率和房颤复发率,同时射频消融时间缩短.     

Radiofrequency Catheter Ablation of Atrial Flutter After Orthotopic Heart Transplantation

Ablation of Atrial Flutter After Heart Transplantation. Introduction : Antiarrhythmic drug refractory recurrent atrial flutter occurred in a 39-year-old man who had undergone successful orthotopic heart transplantation 3 months ago.
Methods and Results : At electrophysiologic study, the transplanted right atrium showed type I atrial flutter. The recipient right atrium was in sinus rhythm with complete atrioatrial dissociation of electrical activity. Mapping demonstrated double-spike electrograms in the low posterior region of the donor right atrium. During radiofrequency current application near this site, the double potentials were dissociated progressively and atrial flutter was terminated immediately. Thereafter, both the recipient and the transplanted atria were in sinus rhythm of different cycle lengths with continued electrical dissociation.
Conclusion : This is the first report of successful radiofrequency catheter ablation of atrial flutter in a transplanted heart. Although mapping of the arrhythmia is more difficult due to the large circumference of the right atrium, which consists of parts of the recipient right atrium and the transplanted atrium, ablation should be considered in those patients with drug refractory supraventricular tachyarrhythmias.     

Electrophysiologic Characteristics and Radiofrequency Catheter Ablation in Patients with Clockwise Atrial Flutter

RF Catheter Ablation of Clockwise Atrial Flutter. introduction: Although the mechanism and radiofrequency catheter ablation of counterclockwise (typical) atrial flutter have been studied extensively, information about the electrocardiographic and electropbysiologic characteristics and effects of radiofrequency ablation in patients with clockwise atrial flutter is limited. Methods and Results: Thirty consecutive patients with clinically documented paroxysmal clockwise atrial flutter were studied. Endocardial recordings and entrainment study using a “halo” catheter with 10 electrode pairs in the right atrium were performed. Radiofrequency energy was applied to the inferior vena cava-tricuspid annulus (IVC-TA) and/or coronary sinus ostium-tricuspid annulus (CSO-TA) isthmus to evaluate the effects of linear catheter ablation. Eighteen patients had both counterclockwise and clockwise atrial flutters, and 12 patients had only clockwise atrial flutter. Both forms of atrial flutter had similar flutter cycle lengths (232 ± 30 vs 226 ± 25 msec, P = 0.526) but reverse activation sequences. Right atrial pacing at a cycle length 20 msec shorter than the flutter cycle length from the CSO-TA isthmus, IVC-TA isthmus, and the area between the two isthmuses revealed concealed entrainment with stimulus-to-P wave intervals of 32 ± 19, 95 ± 14, and 50 ± 17 msec (P = 0.022) in the counterclockwise form, and 110 ± 12, 40 ± 20, and 60 ± 15 msec (P = 0.018) in the clockwise form. In clockwise atrial flutter, 20 patients with biphasic P waves in the inferior leads had the presumed exit site of slow conduction area located at the low posterolateral right atrium; 10 patients with positive P waves in the inferior leads had the presumed exit site located at the mid-high posterolateral right atrium. Among the 18 patients with both forms of atrial flutter, linear ablation lesions directed at the IVC-TA isthmus eliminated both forms of atrial flutter in 14 patients; in the remaining 4 patients. CSO-TA linear lesions eliminated the counterclockwise form and IVC-TA lesions eliminated the clockwise form. Among the 12 patients with the clockwise form only, CSO-TA linear lesions eliminated flutter in 2 and IVC-TA linear lesions eliminated flutter in 10 patients. Successful ablation was confirmed by creation of bidirectional conduction block in the IVC-TA and/or CSO-TA isthmus during pacing from the proximal coronary sinus and right posterolateral atrium sandwiching the linear lesions. During the follow-up period of 17 ± 8 months, 2 patients had recurrence of clockwise atrial flutter, 1 patient had new onset of atypical atrial flutter, and 2 patients had new onset of atrial fibrillation. Conclusions: Counterclockwise and clockwise atrial flutters may have overlapping slow conduction areas with different exit sites. Radiofrequency catheter ablation using the linear method directed at the IVC-TA and CSO-TA isthmuses was feasible and effective in treating both forms of atrial flutter.     

射频导管消融术治疗老年人心房扑动的临床研究

目的：分析采用从下腔静脉至三尖瓣环线性消融方法治疗老年人心房扑动的临床价值。　　方法：对１８例老年人心房扑动（男１２例,女６例,平均年龄６４ 岁）患者采用多电极记录心房激动,分析激动顺序的方法及隐匿拖带的方法确定折返环部位。采用从下腔静脉至三尖瓣环线性消融的方法治疗心房扑动。　　结果：１８ 例均为典型心房扑动。１７ 例（９４．４％ ）消融成功。１例伴有病态窦房结综合征者消融成功后安置永久起搏器。随访１～２５个月,１ 例复发,再次导管消融成功。　　结论：射频导管消融术是治疗老年人心房扑动的安全有效的方法。     

射频消融源于三尖瓣环的房性心动过速

目的:报道起源于三尖瓣环上的房性心动过速(房速)的电生理特点和射频消融结果。方法:根据成功靶点影像位置和靶点图A:V比值,5例房速起源于三尖瓣环。结果:5例房速心动过速平均周长(340.2±30.5)ms,心房刺激可以诱发和终止心动过速,3例心室刺激可以诱发, 三磷酸腺苷可以终止所有心动过速。成功靶点图的A:V之比为0.7±0.9,3例位于右侧游离壁,2例为右后游离壁,5 例均消融成功。结论:部分房速可以起源于三尖瓣环并可以被成功地消融。     

Electrophysiologic Study and Radiofrequency Catheter Ablation of Isthmus-Independent Atrial Flutter

INTRODUCTION: We report the electrophysiologic study and radiofrequency catheter ablation of isthmus-independent atrial flutter in 2 patients. The isthmus-independent atrial flutter in these 2 patients had similar ECG and electrophysiologic findings. Both were reproducibly induced by rapid atrial pacing. The atrial activation sequence and entrainment study proved that these atrial flutters were not isthmus-dependent. A high-right atrial site was identified as the critical site of the slow conduction zone of the tachycardia in both. This site showed double potentials and mid-diastolic potentials. Radiofrequency catheter ablation at this site successfully eliminated the isthmus-independent atrial flutter in both patients.     

CARTO标测指导射频消融治疗非峡部依赖性心房扑动的初步研究

初步探讨非峡部依赖性心房扑动 (简称房扑 )———非典型房扑CARTO标测的方法学和射频消融效果。 4例经电生理标测证实的非典型房扑患者 ,男、女各 2例 ,年龄 2 4～ 5 7岁。 1例为先天性心脏病 (简称先心病 )三房心外科术后 ,1例为慢 快综合征。房扑发作时在右房或左房CARTO标测 ,三维重建右房或左房 ,寻找房扑折返径路的关键峡部区域行线性消融。结果 :3例为右房非峡部依赖性房扑 ,1例消融径线为 2条 ,即三尖瓣环至下腔静脉(IVC)口和右房后外侧至IVC ,1例消融径线为右房前中外侧 ,1例为右房下外侧。 1例左房房扑 ,消融径线位于右上肺静脉口下方至卵园窝。 4例均即时消融成功。随访 8～ 2 4个月 ,有 1例先心病术后房扑复发 ,再次行CARTO标测发现房扑折返环位于左房 ,划线消融未成功。结论 :CARTO标测非峡部依赖性房扑有一定的优势 ,能显示房扑折返环和关键峡部 ,并能指导线性消融     

导管消融治疗合并器质性心脏病的心房颤动的临床评价

目的评价经导管消融治疗合并器质性心脏病的心房颤动(房颤)患者临床效果。方法35例合并器质性心脏病的房颤患者(器质性心脏病组),合并的器质性心脏病类型包括肥厚型心肌病4例;合并左心室肥厚的高血压12例;甲状腺机能亢进性心脏病1例;心动过速性心肌病1例;扩张型心肌病3例;心脏瓣膜病5例;冠心病9例。同期78例无器质性心脏病的房颤患者作为对照(非器质性心脏病组)。消融方法为三维电解剖标测系统(CARTO)指导下的环肺静脉线性消融术,消融终点为同侧肺静脉电隔离。结果器质性心脏病组的平均左心房内径大于非器质性心脏病组[(42±5.7)mmvs(36±5.3)mm,P<0.05]。所有患者均成功实现消融终点。器质性心脏病组平均随访(8.7±5.6)个月后,77.1%(27例)的患者为稳定的窦性心律;非器质性心脏病组平均随访(7.2±3.7)个月后,84.6%(66例)的患者为稳定的窦性心律,两组差异无显著性。并发症无症状性肺静脉狭窄3例,其中器质性心脏病组出现1例,非器质性心脏病组出现2例;非器质性心脏病组发生1例心脏压塞,经紧急行心包穿刺引流后恢复。结论CARTO指导下的环肺静脉线性消融对于合并器质性心脏病的房颤具有较好的临床效果和安全性。     

典型心房扑动的经导管射频消融治疗

回顾分析 35例典型心房扑动 (简称房扑 )患者电生理检查和射频消融治疗的临床结果。心内激动标测显示沿三尖瓣环 (TA)逆钟向折返性房扑 2 7例 ,顺钟向折返 2例 ,同时存在二种折返 6例。 8例行TA峡部拖带起搏者均呈隐匿性拖带 ,起搏后间期与房扑周长差值为 1± 4(- 3～ 5 )ms。采用TA峡部双线性消融、后峡部或 /和间隔峡部消融的方法治疗所有患者均成功。 15例以房扑不能再诱发为手术终点 ,随访 10例 ,3例复发 ,复发率 30 % ;2 0例达到TA峡部双向阻滞 ,随访 19例 ,1例复发 ,复发率 5 % ,两组比较P <0 .0 5。随访的 2 9例中 ,7例发生心房颤动 (简称房颤 ) ,发生率 2 4%。与无房颤发作者相比 ,合并器质性心脏病、心房扩大和有房颤病史者的比例明显增加 (6 / 7比 9/ 2 2 ,6 / 7比 4/ 2 2和 7/ 7比 2 / 2 2 ,均P <0 .0 5 )。结果表明 ,心内激动标测结合拖带起搏技术可确定典型房扑的诊断 ,后峡部或间隔峡部消融是治疗房扑的有效方法 ,以TA峡部双向阻滞为手术终点较房扑不能被再诱发为终点可明显降低复发率。房扑消融术后发生房颤与合并器质性心脏病、心房扩大和术前存在房颤有关