肺静脉电隔离对阵发性心房颤动患者P向量环的影响

目的探讨成功的肺静脉电隔离对心房除极的影响。方法记录接受环肺静脉电隔离术的18例阵发性心房颤动(PAF)患者术前及术后第1天窦性心律时的心向量图。测量P环的运行时间、P向量环在正交导联额面(F)、水平面(H)、左侧面(LS)的最大振幅及方向。同时记录P环从运行开始后每10ms的除极振幅。结果肺静脉隔离术后P环F最大振幅较术前降低(0.109±0.038mVvs0.128±0.040mV,P0.05)。P环运行时间,H及LS的最大振幅,F、H、LS的最大振幅方向,术前术后无差异(P0.05)。消融成功组(n=12)术后P环H最大振幅较术前降低(0.092±0.019mVvs0.122±0.030mV,P0.05),而术后复发组(n=6)则无明显变化。肺静脉隔离术后P环振幅降低发生在P环运行至40～80ms的部分,即P向量环的中部。结论PAF病人在肺静脉电隔离成功后P环最大振幅发生改变。     

左心耳电学隔离术

<正>导管消融是当前心房颤动(atrial fibrillation, AF)节律控制的首选治疗方案~([1-2])。在众多针对AF不同病理生理机制的消融术式中,于前庭部位行环肺静脉隔离术(pulmonary vein isolation, PVI)已成为AF消融治疗的基石~([3])。但是,PVI针对以肺静脉触发机制为主的阵发性AF(paroxysmal AF, PAF)疗效较好,而对肺静脉外触发灶及包含更复杂心房基质的持续     

心电向量图在预激综合征诊断中的优势

一.心电向量图与心电图在一个心动周期中循序出现的瞬间综合心电向量的顶端连线所构成的环形轨迹称空间心电向量环(P-QRS-T环)。心电向量环在额面、横面和侧面上的投影形成心电     

左房后壁双盒式消融策略治疗阵发心房颤动合并左房前后径扩大患者的疗效观察

目的评价左房后壁双盒式消融(PWDB)术式对合并左房前后径(LAD)扩大阵发性心房颤动(简称房颤)患者的疗效。方法连续入选在本院行射频消融治疗的阵发性房颤合并LAD扩大患者65例,随机分为PWDB组(n=34)和肺静脉隔离(PVI)组(n=31)。PWDB组在右侧环肺静脉消融隔离后,自右侧消融环顶点行心房顶部线、左肺静脉嵴部和后壁线消融至右侧消融环底部,形成囊括右肺静脉和左房后壁大部的两个区域。PVI组沿双侧肺静脉前庭行电学隔离。对比观察两组临床一般情况、手术总时间、X线曝光时间、消融时间、围术期并发症例数。随访12个月,对比观察消融成功率、LAD变化和不良事件。结果两组临床一般情况对比无差异。与PVI组相比,PWDB组手术总时间[(168.8±20.8)min vs(140.3±22.5)min,P0.001]和消融时间延长[(39.0±6.1)min vs(33.1±6.5)min,P0.001)]。两组X线曝光时间[(21.6±4.3)min vs(20.1±3.5)min,P=0.132)]和围术期并发症事件(1例vs 0例,P=1.000)无差异。12个月随访期内,PWDB组26例(76.5%)维持窦性心律,PVI组17例(54.8%)维持窦性心律,差异有显著性(P=0.043)。两组间不良事件发生例数(2例vs 3例,P=0.663)无差异。对随访期内无复发患者进行亚组分析,LAD在PWDB组有减小趋势(P=0.001),PVI组未见明显变化(P=0.583)。结论对于合并LAD扩大的阵发房颤,PWDB术后12个月成功率显著高于PVI术式,值得临床推广应用。     

无人区心电轴

心电图诊断中 ,心电轴是一个重要的参考指标。而无人区心电轴 (noman’sland)是近几年在阵发性心动过速鉴别诊断中出现的一个新概念、新指标 ,有重要的临床应用价值 ,同时也提高了临床医师和心电图医师对心电轴应用的重视。一、电轴的相关概念㈠电轴的基本概念心房、心室在除极和复极的过程中 ,每一瞬间都会形成和产生电流方向及电压大小瞬时变化的电动力或称瞬时心电向量 ,代表瞬间电动力或心电向量的轴心线称为瞬间心电轴。将无数个瞬时电动力或心电向量连接起来则分别形成心房除极的P向量环 ,心室除极的QRS向量环 ,心室复极的T向量环。…     

环肺静脉电隔离术对阵发性心房颤动患者肺静脉电生理特性的影响

目的探讨环肺静脉电隔离术(CPVI)对肺静脉电生理特性的影响。方法纳入抗心律失常药物治疗无效的阵发性心房颤动(房颤)且初次行CPVI治疗的患者26例,CPVI前、后分别测量肺静脉和左心房的有效不应期(ERP)、相对不应期(RRP),比较CPVI前、后肺静脉和左心房ERP、RRP的变化。结果 26例阵发性房颤患者共隔离104根肺静脉,术后即刻均为窦性心律。CPVI前、后肺静脉舒张期起搏阈值分别为(3.2±0.6)V vs.(3.3±0.5)V,P0.05。CPVI前肺静脉的ERP(n=82)、RRP(n=35)时间短于左心房,分别为(187±60)ms vs.(229±31)ms(P0.001);(223±45)ms vs.(261±34)ms(P0.05)。CPVI后肺静脉ERP(n=47)、RRP(n=26)时间和左心房均无统计学差异,分别是(245±38)ms vs.(234±43)ms(P0.05),(268±44)ms vs.(245±41)ms(P0.05)。CPVI后肺静脉ERP(n=47)、RRP(n=21)较CPVI前显著延长,分别是(245±38)ms vs.(187±76)ms(P0.05);(259±44)ms vs.(230±47)ms(P0.05)。结论 CPVI隔离肺静脉和左心房之间的电传导,同时也改变了肺静脉的电生理特性,降低了其致心律失常特性。     

正常青年人心房除（复）极立体心电向量图分析

目的观测正常青年人心房除（复）极立体心电向量图特点,为立体心电向量图临床应用提供依据。方法对200例正常青年人（男、女各100例）,按性别分两组,行心电图、向量图、立体心电图检查,并对立体心电向量图和平面向量图心房除极最大向量振幅、心房复极Ta向量振幅指标对比分析。结果①青年人立体P环最大向量振幅正常范围男性0.045~0.15mV、女性0.041~0.119mV,立体Ta向量振幅正常范围男性0.006~0.049mV、女性0.004mV~0.044mV,性别间均有显著差异（男性〉女性,p〈0.05）;②立体P环最大向量和Ta向量均大于各平面值,其中与H面差异有显著性（立体〉H面,p〈0.05）。结论立体P环最大向量较平面向量图准确、简便,对心房肥大诊断优于向量图,在应用时应注意性别差异。     

EnSite NavX指导下无肺静脉造影的阵发性心房颤动导管消融术

目的探讨不作肺静脉造影行阵发性心房颤动(房颤)环肺静脉电隔离术的有效性和可行性。方法 34例阵发性房颤患者分为无肺静脉造影组(n=18)和肺静脉造影组(n=16),无肺静脉造影组不作肺静脉造影,余步骤与肺静脉造影组相同,两组均在EnSiteNavX三维标测系统指导下重建左心房及肺静脉,再分别行左、右环肺静脉电隔离术,消融终点为肺静脉与心房完全电隔离。结果无肺静脉造影组消融术时间[(92.78±19.46)minvs.(106.44±20.18)min,P0.05]及X-线曝光时间[(11.47±4.32)minvs.(16.06±8.72)min,P0.05]少于肺静脉造影组,差异有统计学意义。两组左心房三维重建时间[(6.22±2.65)minvs.(6.31±3.00)min,P0.05]、左、右侧环肺静脉消融时间[(21.61±7.66)minvs.(20.50±8.09)min,P0.05;(17.33±10.22)minvs.(17.48±7.86)min,P0.05]及即刻消融成功率[100%(18/18)vs.100%(16/16),P0.05]比较,差异无统计学意义。结论不作肺静脉造影,仅在三维标测系统指导下行房颤消融治疗,可达到相同消融效果,可节省消融术及X-线曝光时间,减少手术步骤、耗材和费用。     

心电轴新视野

<正>心电图中的心电轴(cardiac electrical axis,CEA)系指某部位心肌(如心房肌、心室肌)除极或复极时总体综合向量和/或最大向量的所在方位。在日常心电图检查时,QRS波的额面心电轴是一项重要的常规分析指标之一,该指标由Einthoven于1912年创立双极肢体导联和艾氏三角时期提出。近年来,如何拓宽心电轴的临床应用受到关注。额面窦P电轴的正常值及临床应用     

新型Achieve环状标测导管在心房颤动冷冻消融术中的应用

目的探讨应用新型Achieve环状标测导管在心房颤动(AF)冷冻球囊消融(CBA)过程中,实时监测肺静脉隔离(PVI)的作用。方法回顾分析2014年5月至2014年11月,在瑞金医院使用28mm冷冻球囊(CB)进行消融的61例阵发性AF患者。房间隔穿刺后,将带有Achieve环状标测导管的CB置于左房(LA)内,进行肺静脉电位(PVP)的标测和消融。结果 61例患者的244根肺静脉中有240根(98.4%)达到成功PVI,其中196根肺静脉(80.3%)可于消融中实时监测PVI(91.8%LSPV,82.0%LIPV,86.9%RSPV,60.7%RIPV)。在可实时监测PVI的196根静脉中,按照术中LA-PV传导恢复情况分为早期传导恢复(LAPVR)组和传导未恢复(nLAPVR)组。LAPVR组的平均PVI时间为(89±39.3)s,显著长于nLAPVR组(41±17.9)s,P0.01。且LAPVR组最低冷冻温度为(-42±4.3)℃,显著高于nLAPVR组(-48±13.3)℃,P0.05。预测术中持续PVI最佳界值为53s(灵敏度83%,特异度75%,曲线下面积0.894,P0.05)。结论新型Achieve环状标测导管不仅可用于判断PVI;还可以通过实时记录PVI时间,预测术中LA-PV早期传导是否容易恢复。     

Electrophysiologic Characteristics of a Dilated Atrium in Patients with Paroxysmal Atrial Fibrillation and Atrial Flutter

This study investigated the difference of atrial electrophysiologic characteristics between a normal and dilated atrium and compared them among patients with paroxysmal atrial fibrillation and flutter. Twenty-seven patients with paroxysmal atrial fibrillation and 28 patients with paroxysmal atrial flutter were divided into four subgroups, according to the presence of a normal atrium or bilateral atrial enlargement. Thirty patients without atrial arrhythmia (20 patients with normal atrium and 10 patients with bilateral atrial enlargement) were included in control group. The atrial refractoriness in patients with a dilated atrium was longer than those with normal atrial size. In patients with paroxysmal atrial fibrillation and patients of control group, the P-wave duration and interatrial conduction velocity with or without atrial enlargement were similar. However, in patients with paroxysmal atrial flutter, P-A_PCS (86 ± 10 ms vs. 73 ± 9 ms, p < 0.05) and P-A_DCS (109 ± 9 ms vs. 95 ± 9 ms, p < 0.05) in patients with a dilated atrium were longer than in patients with a normal atrium. The patients with paroxysmal atrial fibrillation or atrial flutter all demonstrated longer P-wave duration and interatrial conduction time than control group. Among the groups with a normal atrium or a dilated atrium, atrial refractoriness in patients with paroxysmal atrial flutter was shorter than that in control group. Moreover, in the patients with a normal atrium, the potential minimal wavelength in control group (6.6 ± 1.7) was longer than that of paroxysmal atrial fibrillation (5.3 ± 1.1), or atrial flutter (5.0 ± 1.2). These findings suggest that atrial electrophysiologic characteristics of a dilated atrium were different from those of normal atrium, and these changes were different between paroxysmal atrial fibrillation and flutter. Multiple factors are considered to be related to the genesis of atrial tachyarrhythmias.     

阵发性心房颤动患者心房及肺静脉不应期离散度的变化

目的探讨阵发性房颤患者房颤相关组织的电生理特性改变情况。方法选取阵发性房颤患者10例(房颤组)和无房颤病史的左侧旁路有显性预激波患者15例(对照组)。将大头电极分别放置在两组患者左上肺静脉、左下肺静脉、右上肺静脉、右下肺静脉开口及左心房顶壁、前壁、后壁、高位右心房,分别测定各部位有效不应期(EPR)。结果①房颤组心房及肺静脉EPR离散度指数(DI)为0.117±0.028,对照组为0.074±0.029,两组比较,P<0.05。②房颤组左心房ERP为(234.00±28.72)ms,肺静脉ERP为(230.75±32.69)ms;对照组左心房ERP为(248.00±25.99)ms,肺静脉ERP为(244.33±26.78)ms,两组比较,P均<0.05。结论阵发性房颤患者DI明显增大,左心房、肺静脉ERP显著缩短。     

肺静脉电隔离术联合碎裂电位消融治疗持续性房颤疗效观察

目的：观察肺静脉电隔离术（ pulmonary vein isolation , PVI ）联合碎裂电位（ complex fractionated atrial electrograms , CFAE）消融对持续性房颤的疗效。方法对比观察23名于本院行房颤射频消融术的持续性房颤患者,所有患者均行PVI及左房顶部线性消融,其中12例联合CFAE消融,术后随访1年;观察两组手术时间、X线曝光时间、消融时间、手术并发症、左房大小、左房血栓、一次手术成功率等指标。结果联合CFAE消融组总手术时间（252±35） min、X线曝光时间（42±9．1）min、消融时间（94±11）min,单纯行PVI 组分别为（176±22）min、（34±7．6）min、（63±8）min,联合CFAE消融组手术各时间均明显延长（P＜0．01）;两组手术并发症、对左房大小及左房血栓的影响比较差异均无统计学意义;联合CFAE消融组一次手术成功率（75％）明显高于单纯行PVI组（64％）（ P＜0．05）。结论 PVI联合CFAE消融治疗持续性房颤虽增加手术、消融及X线曝光时间,但并不会提高并发症发生率,可提高房颤消融的一次手术成功率。     

Atrial flutter. Electrocardiographic,vectorcardiographic and echocardiographic correlation

The duration, contour, and amplitude of atrial flutter wave (f) was studied by electrocardiogram (ECG) and vectorcardiogram (VCG) in 32 patients and was related to the size of the left atrium (LA) measured by the echocardiogram (E). The following ECG parameters were analyzed: (1) the duration of left atrial depolarization, i.e., LA wave; (2) the amplitude of LA wave; (3) the surface area of LA wave; (4) maximum amplitude (A) of f in Leads 2 and V₁. There was good correlation between LA size and the duration of depolarization and surface area (p < 0.01), but the maximum amplitude of the f wave in Leads 2 and V₁ failed to predict LA size.The post-conversion sinus P wave showed abnormal LA depolarization time (P > 0.12 sec.) in 62 per cent of patients with enlarged left atrium (ELA) and in 43 per cent of patients with normal size LA (NLA).The VCG of the flutter wave revealed two patterns, (1) an eliptical smooth fsÊ loop in 63 per cent of patients with NLA, and (2) distorted fsÊ loop in 67 per cent of patients with ELA.Both VCG patterns were subdivided in two subgroups according to the number and location of conduction delays. The VCG of post-conversion P wave confirmed conduction delays in both groups.We conclude that both the size of the left atrium and conduction delays play a basic role in the duration and contour of left atrial wave.     

心房血清TNF-α及IL-6水平与非结构性心脏病房颤的相关性

目的 通过对心房颤动(房颤)患者左心房或右心房中血清肿瘤坏死因子(TNF)-α与白细胞介素(IL)-6的水平检测,探讨两种炎症因子与无结构性心脏病的患者房颤发生的关系。方法 59例首选射频消融术治疗方案的心律失常患者,59例患者心脏皆无结构性病变,其中包括房颤患者42例（阵发性房颤24例、持续性房颤18例）、预激综合征或阵发性室上性心动过速患者共17例,分别纳入房颤组及非房颤组。术前分别采集两组患者左房和右房中血液,并通过ELISA方法对血清样本的TNF-α、IL-6水平进行检测,应用心脏超声测量左心房内径（LAD）、左心室舒张末期内径（LVEDD）及左室射血分数（LVEF）等。结果 在两组比较中,房颤组LAD（36±7）mm显著高于非房颤组（31±4）mm（P<0.01）;TNF-α水平及IL-6L水平在房颤组的左、右心房的血清中含量均显著高于非房颤组,依次为P<0.01及P<0.05。在对房颤组中持续性房颤与阵发性房颤的组内亚组比较中:持续性房颤血清IL-6（17±9）pg/ml显著高于阵发性房颤组（12±5）pg/ml（P<0.05）,而持续性房颤及阵发性房颤的血清TNF-α水平均无显著差异。结论 心房血清TNF-α、IL-6水平与无结构性心脏病的房颤有相关性,持续性房颤患者心房血清IL-6 水平较阵发性房颤患者有升高趋势,可以作为房颤持续的预测因子。     

阵发性房颤患者心电图P波变化分析

目的分析阵发性心房颤动（PAF）患者心电图P波的变化。方法选择100例无器质性心脏病阵发性房颤患者（PAF组）,100例无房颤患者作为对照组（无PAF组）,采用体表心电图和超声心动图分别测量两组的V1导联P波时限（Pt）、V1导联P波终末负电势（Ptfv1）和左心房内径（LAD）、舒张末期左心室内径（LVD）、左心室射血分数（LVEF）等指标。结果 PAF组、无PAF组的Pt分别为（120±10）ms、（99±11）ms,Ptfv1分别为（0.051±0.023）mm·s、（0.026±0.010）mm·s,两组比较差异有统计学意义（P均〈0.01）;PAF组、无PAF组LAD分别为（33.6±3.9）mm、（32.7±4.2）mm,LVD分别为（44.6±4.1）mm、（42.7±4.3mm）,LVEF分别为（56.6±4.9）、（59.7±5.2）,两组比较差异无统计学意义（P均〉0.05）。结论阵发性房颤可引起心电图Pt及Ptfv1值增加,与左心房内径大小无相关。     

Percutaneous ablation of atrial fibrillation: for whom and how?

Recent developments in our understanding of atrial fibrillation (AF) have focused on the key role of pulmonary vein initiators of multiple wavelet reentry in the atria. Percutaneous catheter ablation of atrial fibrillation is commonly performed by electrical disconnection of pulmonary vein myocardium from the left atrium. As a result, pulmonary vein foci can no longer drive the atria into fibrillation. At present, the procedure is offered to patients with paroxysmal atrial fibrillation refractory to multiple antiarrhythmic agents. For patients with persistent atrial fibrillation, supplementary linear lesions in the left atrium may be necessary. Success rates (AF elimination) are 90% without drugs in case of paroxysmal atrial fibrillation and 80% for persistent atrial fibrillation. Complications including pulmonary vein stenosis are uncommon.     

What have we learned of ablation procedures for atrial fibrillation?

Atrial fibrillation is a widespread disease of growing clinical, economic and social importance. Interventional therapy for atrial fibrillation offers encouraging results, with pulmonary vein isolation (PVI) as the established cornerstone. Yet, the challenge to create durable transmural lesions remains, leading to recurrence of atrial fibrillation in long‐term follow‐up even after multiple ablation procedures in 20% of patients with paroxysmal atrial fibrillation and approximately 50% with persistent atrial fibrillation. To overcome these limitations, innovative tools such as the cryoballoon and contact force catheters have been introduced and have demonstrated their potential for safe and effective PVI. Furthermore, advanced pharmacological and pacing manoeuvres enhance evaluation of conduction block in PVI.     

Outcomes and predictors of difficulty with coronary sinus lead removal

Objective  

The purpose of this study is to evaluate the relationship between plasma high-sensitivity C-reactive protein (hs-CRP), atrial natriuretic peptides (ANP), N-terminal-pro-brain natriuretic peptide (NT-proBNP) levels, and the risk and recurrence of atrial fibrillation (AF) after pulmonary vein isolation (PVI) in patients with paroxysmal atrial fibrillation (PAF).     

P波离散度与阵发性心房颤动的关系研究

目的 探讨体表心电图P波离散度（P-wave dispersion,Pdis）对阵发性心房颤动的预测价值。方法 对86例阵发性心房颤动病人（观察组）和同期54例健康成人（对照组）窦性心律时体表心电图的Pdis、P波最大时限（maximum P-wave duration，Pmax）进行测量分析。结果 观察组Pdis和Pmax与对照组比较,差异有统计学意义（P＜0.01）,Pdis或Pdis加Pmax对阵发性心房颤动有较高的特异度（81.5%,92.6%）和阳性预测价值（88.2%,94.6%）。结论 Pdis可作为预测阵发性心房颤动的一个可靠的体表心电图指标。