12通道生理记录仪在射频导管消融治疗心房纤颤中的作用

目的 研究12通道心电生理记录仪在左房环状线性(线)消融、肺静脉口节段性(段)电隔离术加局灶性(点)消融法(简称线-段-点法)治疗心房纤颤(房颤)中的作用.方法 使用12通道心电生理记录仪,在双Lasso电极标测下分别在左房环状线性消融左右侧上下肺静脉口周围,肺静脉口壶腹部节段性消融丛状电位,最后标测和点状消融提前的单相电位(在肺静脉内或心房内和腔静脉口).结果 26例患者均行肺静脉开口外环状线性消融.电隔离肺静脉共89条.行点状消融共25例.26例中20例所有异常电位消失,6例肺静脉内仍有高耸的异常电位,但已达到传出阻滞.手术即刻成功率100%.随访4～8个月,24例(92%)未发作房颤;2例(8%)术后仍有房颤发作,服用抗心律失常药物后房颤发作明显减少.所有病例未发生并发症.结论 采用12通道心电生理记录仪能够达到"线-段-点联合消融法"治疗房颤的要求,方法简单,成功率高,是目前我国大多数医院所具备的常规电生理检测仪.     

在心房颤动发作时行肺静脉隔离治疗

目的　探讨在心房颤动 (房颤 )发作时 (包括部分持续性房颤 )进行肺静脉节段性电隔离的方法 ,评价其安全性及有效性。方法　选择 5例持续半年以内的房颤病例及 4例发作频繁的房颤病例 ,在房颤发作时行肺静脉电隔离。通过一次性房间隔穿刺送入标测及消融导管 ,行左房或肺静脉选择性造影 ,显示肺静脉后 ,标测肺静脉电位活动 ,并行节段性隔离。结果　 9例患者共 2 9条肺静脉 ,肺静脉电位特征明确 ,在肺静脉环状电极标测到较左房电位振幅高尖 ,频率更快的肺静脉电位。选择最高尖处或频率最快处电位开始节段性消融。肺静脉电位 10 0 %消失 ,无并发症发生。 7例手术中或术后转为窦性心律。 2例电复律恢复窦性心律。结论　房颤发作时行肺静脉节段性电隔离方法安全、有效     

射频导管消融肺静脉电隔离过程中残存静脉电位的鉴别诊断

心房颤动(房颤)的非药物治疗是近年来的研究热点，国内外许多临床研究证明应用射频导管消融技术成功电隔离肺静脉可以有效预防房颤的复发。环状标测导管指导下的节段性消融肺静脉电隔离成功的指标为，窦性心律或心房内不同部位起搏时肺静脉电位消失、静脉与心房之间的电活动分离。在肺静脉电隔离过程中常碰到较明显的静脉电位被成功消融后，     

肺静脉间嵴消融在环肺静脉线性隔离术中的作用

目的研究肺静脉间嵴消融在环肺静脉线性隔离术中所起的作用。方法共124例阵发性心房颤动(简称房颤)患者在电解剖标测和CT图像整合技术的指导下行环肺静脉线性消融术。手术的终点为肺静脉隔离。环肺静脉消融线完成后,在原消融线径上寻找可能存在的传导"gap"进行补充消融,如反复消融依然无法达到肺静脉隔离者,根据环状标测电极显示的最早肺静脉电位,在消融环线以内肺静脉口处进行节段性消融以实现肺静脉隔离。结果共41.1%的左侧肺静脉和11.3%的右侧肺静脉需在消融环线以内行节段性消融才达到电学隔离,其中左肺静脉节段隔离部位多见于左侧肺静脉间嵴前部;右侧肺静脉节段隔离部位多见于右侧肺静脉间嵴中后部。结论行环肺静脉线性消融的患者中,一部分需要在肺静脉间嵴处消融以提高肺静脉隔离的成功率。     

阵发性心房颤动患者肺静脉与心房电连接特征的临床研究

目的 总结阵发性心房颤动(房颤)患者肺静脉的电生理标测和导管射频消融电隔离的结果，评估中国人肺静脉与心房的电连接类型和特点。方法 顽固性阵发性房颤患者43例，在环状标测电极指导下行肺静脉电位(PVP)记录和分析，并对能标测到PVP的肺静脉进行开口部的点或段的消融电隔离治疗。根据窦性心律和心房起搏下的肺静脉内环形标测电报导管标测到的PVP的激动顺序，以及有效放电对PVP的影响，分析和总结肺静脉与心房之间的电连接特点。结果 共标调和域电隔离肺静脉100根，其中呈单束状电连接35根(35％)，双束状电连接48根(48％)，多束状电连接11根(11％)，环状电连接3根，无电连接3根。结论 根据环状电报标测到的PVP激动顺序和对放电的反应，提示肺静脉与心房之间电连接的类型多为单束状和双束状(83％)，说明对于大多数肺静脉不必进行环状消融，而只需在肺静脉与心房连接处进行点状或节段性消融即可达到完全电隔离的效果。     

Carto系统指导下左房电解剖隔离治疗心房颤动

对 3例阵发性和 2例持续性心房颤动 (简称房颤 )进行左房线性消融。采用Carto标测构建左房三维电解剖图 ,并标识出肺静脉和二尖瓣环 ,在距肺静脉口外 1～ 2cm处进行绕左右肺静脉和左房峡部的环状线性隔离消融 ,后 2例增加一条左房后壁的消融线 ,消融的终点为 :①环状隔离区内的双极电压≤ 0 .1mV ,②跨消融线相邻两点的传导时间延迟 30ms以上。结果 :整个手术时间为 2 2 9± 18min ,X线曝光时间为 2 5± 3min。消融线环绕的左房面积占整个被标测左房面积的 36 %± 3.2 % ,消融线环绕的左房区域内的电压较消融前明显降低 ,绕消融线以外的部分心房组织的电压亦降低。 3例阵发性房颤有 2例在术后 1～ 2天有房颤发作 ,1例持续性房颤于术后 1周转为持续性心房扑动 ,3周时电复律为窦性心律 ,术中和术后随访期内无并发症发生 ,5例在 5 .3± 1.85个月的随访中无有症状的房颤发作。结论 :左房线性电隔离治疗房颤是安全有效的方法。     

阵发性心房颤动的射频导管消融大静脉电隔离治疗

目的报道阵发性心房颤动(房颤)的射频导管消融电隔离肺静脉和腔静脉的疗效。方法阵发性房颤患者36例,年龄(42.5±13.2)岁。经1次房间隔穿刺放置环状标测电极导管(Lasso导管)和冷盐水灌注消融导管,在Lasso导管的指导下,采用全肺静脉或上腔静脉与靶静脉节段性电隔离相结合的方法对肺静脉和腔静脉行标测和电隔离治疗。窦性心律时最早激动的肺静脉和腔静脉电位处和/或心房起搏时最短的心房和静脉电位间期处为靶点行消融。结果36例阵发性房颤患者均接受一次电隔离治疗,共电隔离大静脉115根,其中左上肺静脉34根,左下肺静脉22根,右上肺静脉30根,右下肺静脉17根,上腔静脉12根,即刻电隔离成功率为95.6%,术中并发症发生率2.78%。随访3~22个月,成功率(无房颤发作或房颤发作明显减少)为75.0%。结论射频导管消融电隔离肺静脉或腔静脉与心房间的电活动连接,可有效预防房颤的复发。治疗的关键是消融靶点的标测和确定。     

盐水灌注导管电隔离心房-肺(或上腔)静脉治疗阵发性心房颤动的评价

目的评价盐水灌注导管电隔离心房-肺(或上腔)静脉的效果及安全性。方法69例阵发性心房颤动(房颤)患者,男48例,女21例,平均年龄(55±10)岁,平均病史(4.2±1.1)年。所有患者均采用盐水灌注电极进行肺静脉口部节段性消融,电隔离终点为环状标测电极标测的肺静脉电位全部消失。术后随访症状,心电图及24h动态心电图,以无临床症状及无房颤的心电图证据判定为成功。结果69例共电隔离肺静脉206根,上腔静脉11根,右上肺静脉口外点消融1例。即刻电隔离成功率100%,放电时间(2902.0±1326.3)s。随访时间(118.1±69.7)天,成功率71%。结论应用盐水灌注导管电隔离心房-肺(或上腔)静脉消融安全有效,未见严重并发症发生。     

节段性肺静脉电隔离治疗阵发性心房颤动的方法学

目的 对阵发性心房颤动(房颤)经药物治疗无效并接受射频导管消融治疗的患者，采用经改良的节段性电隔离方法隔离肺静脉进行治疗，并研究该方法的有效性及安全性。方法 61例阵发房颤患者采用一次房间隔穿刺技术，分别送入标测及消融电极导管。应用猪尾造影导管用高压注射器非选择性左心房造影显示肺静脉开口及左心耳位置，指导导管行进方向以减少心脏压塞风险。标测中常规探查、标测右下肺静脉，避免遗漏可能触发房颤的肺静脉电位。在肺静脉与左心房之间肺静脉电位优势传导部位用温控导管或冷盐水灌注导管做多点消融形成节段性隔离。结果 单个节段或多个节段消融可使肺静脉与左心房之间形成完全性电隔离，使肺静脉电位消失。节段性隔离靶肺静脉173根，即刻成功168根，成功率97．1％。术中2例发生心脏压塞，1例左上肺静脉狭窄60％。结论 节段性电隔离肺静脉法可有效隔离肺静脉，可替代点状隔离和环状隔离方法。与其他传统方法比较，手术时间短、成功率高，可明显减少肺静脉的损伤和避免肺静脉狭窄的发生。     

阵发性心房颤动患者肺静脉与心房电连接特征的临床研究

顽固性阵发性房颤患者43例,在环状标测电极指导下行肺静脉电位(PVP)记录和分析,并对能标测到PVP的肺静脉进行开口部的点或段的消融电隔离治疗。根据窦性心律和心房起搏下的肺静脉内环形标测电极导管标测到的PVP的激动顺序,以及有效放电对PVP的影响,分析和总结肺静脉与心房之间的电连接特点。     

阵发性心房颤动节段性肺静脉电隔离方法学评价

目的评价经改良的节段性电隔离肺静脉方法治疗阵发性心房颤动的有效性及安全性.方法 39例阵发心房颤动患者,男性28例,女性11例,采用一次房间隔穿刺技术,送入标测及消融电极,并选用猪尾造影导管用高压非选择性造影显示肺静脉开口及左心耳位置,指导导管行进方向以减少心脏压塞风险.标测中常规探查、标测右下肺静脉,避免遗漏可能触发心房颤动的肺静脉电位.在肺静脉电位优势传导部位消融并轻微移动形成节段性电隔离.结果单个节段或多个节段消融可使肺静脉与左心房之间形成完全性电隔离.节段性隔离靶肺静脉85根,即刻成功81根,成功率95%,无并发症发生.结论节段性电隔离肺静脉法可有效隔离肺静脉,与其他传统方法比较,手术时间短、成功率高,可减少肺静脉的损伤和避免肺静脉狭窄的发生.     

阵发性心房颤动大静脉电隔离后肌袖内自发电活动的特点

目的　总结阵发性心房颤动 (房颤 )患者大静脉 (肺静脉和 /或上腔静脉 )电隔离治疗后肌袖内自发电活动的特点 ,探讨其临床意义。方法　顽固性特发性房颤患者 ,在环状标测电极导管指导下行心内电生理标测以及肺静脉和 /或上腔静脉肌袖的射频导管消融电隔离治疗 ,电隔离后继续留置环状标测导管 10～ 2 0min ,观察自发电位发生情况。结果　电隔离前心内标测显示 32例患者的 36根大静脉肌袖有自发电活动。以心房 大静脉传入阻滞为终点行大静脉口部消融后 ,16根 (4 4 % )记录到大静脉内自发电活动 ,其中 2根呈偶发的单一电活动 ,11根呈平均频率 (38± 12 )次 /min的缓慢节律 ,3根呈偶发的由 3～ 6个电位组成的短阵快速节律。 15根示大静脉内电活动与心房完全分离 (93 8% ) ,1根左上肺静脉存在大静脉 心房单向传导。结论　射频导管消融电隔离大静脉后 ,出现心房 大静脉传入阻滞时多同时伴有大静脉 心房传出阻断 ,心房 大静脉传入阻滞后大静脉内的电活动频率明显变慢、减少或消失 ,说明窦性心律时的心房 大静脉传导是引起大静脉内电活动不稳定的重要原因 ,射频导管消融技术即使只阻断心房 大静脉单向传导也可通过稳定大静脉内电活动而减少或控制房颤的发作。     

环状标测电极指导下射频消融治疗阵发性房颤的临床分析

目的探讨环状标测电极指导下射频消融治疗阵发性心房颤动的疗效。方法对23例阵发性房颤患者在环状电极指示下行经验性肺静脉和（或）上腔静脉电隔离。结果23例阵发性房颤患者中共隔离肺加上腔静脉87条，左上肺静脉22条，左下肺静脉18条，右上肺静脉22条，右下肺静脉12条，上腔静脉13条，平均每例3．78条。平均操作时间和X线透视时间分别为（148±34）min和（52±9）min。1例发生术中心包填塞，2例行2次手术。平均随访（3．8±1．6）个月，20例无房颤复发，2例有房早发作，成功22例。结论阵发性心房颤动采用环状标测电极指导下射频消融电隔离术对绝大多数患者是有效的，并能改善患者的心功能情况。     

阵发性心房颤动复杂病例的射频消融

目的　对阵发性心房颤动 (房颤 )复杂病例的射频消融进行方法学探讨。方法　 130例患者中 ,男性 87例 ,女性 4 3例 ,平均年龄 5 6岁 ;均经 2 4小时动态心电图和普通心电图证实为阵发性房颤。常规穿刺放置导管后 ,根据每个肺静脉造影所显示的解剖形态 ,在环状电极的引导下 ,依次对4根肺静脉进行电隔离。结果　 (1) 130例房颤患者中造影发现 2 1例患者的 2 1根肺静脉开口巨大 ,发生率为 16 2 % ,5根为左侧肺静脉共干 ,发生率为 3 8% ,3根为右侧肺静脉共干 ,发生率为 2 3% ;6例患者右肺静脉呈分支状多个开口 ,发生率为 4 7%。 (2 )共对 130例患者 341根肺静脉进行了电隔离 ,2 9根肺静脉未达到完全电隔离 ,包括上述 2 1例患者中的 11例 ,发生率为 8 3% ,其中 14根发生在左上肺静脉 ,8根发生在左下肺静脉 ,5根发生在右下肺静脉 ,2根发生在右上肺静脉。结论　肺静脉自身的解剖变异是导致射频消融中病例复杂的主要因素     

Anatomic location of pulmonary vein electrical disconnection with balloon-based catheter ablation

Introduction:  Balloon-based catheters are an emerging technology in catheter ablation for atrial fibrillation, which aim to achieve consistent and rapid ablation encirclement of pulmonary veins (PVs). Recent emphasis has been placed on achieving more proximal electrical isolation within the PV–left atrial (LA) junction. We sought to evaluate the precise anatomic level of PV electrical disconnection with current design balloon-based catheters.
Methods and Results:  Thirteen patients with drug-refractory paroxysmal atrial fibrillation undergoing balloon catheter ablation with the endoscopic laser system (CardioFocus) or the high frequency-focused ultrasound system (ProRhythm) underwent electroanatomic mapping (EAM) of the left atrium. Intracardiac echocardiographic (ICE) imaging was used for visualization of the position of the balloon catheter during energy delivery. Detailed point analysis of the location of electrical disconnection was then documented on EAM and with ICE.
Successful electrical isolation was achieved in all 52 PVs. Despite ICE imaging confirming balloon catheter position at the antrum of the PVs, the location of electrical disconnection was demonstrated to be at or near the tubular ostium of the PVs on EAM and on ICE in all patients.
Conclusion:  Current generation balloon-based catheter ablation achieves electrical isolation distal in the LA–PV junction. This may limit the results of such systems in treating nonparoxysmal forms of atrial fibrillation.     

Catheter ablation of atrial fibrillation: Radiofrequency catheter ablation for redo procedures after cryoablation

AIM: To evaluate the effectiveness of two different strategies using radiofrequency catheter ablation for redo procedures after cryoablation of atrial fibrillation.METHODS: Thirty patients(paroxysmal atrial fibrillation: 22 patients,persistent atrial fibrillation: 8 patients) had to undergo a redo procedure after initially successful circumferential pulmonary vein(PV) isolation with the cryoballoon technique(Arctic Front Balloon,CryoCath Technologies/Medtronic).The redo ablation procedures were performed using a segmental approach or a circumferential ablation strategy(CARTO;Biosense Webster) depending on the intra-procedural findings.After discharge,patients were scheduled for repeated visits at the arrhythmia clinic.A 7-day Holter monitoring was performed at 3,12 and 24 mo after the ablation procedure.RESULTS: During the redo procedure,a mean number of 2.9 re-conducting pulmonary veins(SD ± 1.0 PVs) were detected(using a circular mapping catheter).In 20 patients,a segmental approach was sufficient to eliminate the residual pulmonary vein conduction because there were only a few recovered pulmonary vein fibres.In the remaining 10 patients,a circumferential ablation strategy was used because of a complete recovery of the PV-LA conduction.All recovered pulmonary veins could be isolated successfully again.At 2-year follow-up,73.3% of all patients were free from an arrhythmia recurrence(22/30).There were no major complications.CONCLUSION: In patients with an initial circumferential pulmonary vein isolation using the cryoballoon technique,a repeat ablation procedure can be performed safely and effectively using radiofrequency catheter ablation.     

Anatomy of the pulmonary veins in patients with atrial fibrillation and effects of segmental ostial ablation analyzed by computed tomography

INTRODUCTION: The anatomic arrangement of pulmonary veins (PVs) is variable. No prior studies have quantitatively analyzed the effects of segmental ostial ablation on the PVs. The aim of this study was to determine the effect of segmental ostial radiofrequency ablation on PV anatomy in patients with atrial fibrillation (AF). METHODS AND RESULTS: Three-dimensional models of the PVs were constructed from computed tomographic (CT) scans in 58 patients with AF undergoing segmental ostial ablation to isolate the PVs and in 10 control subjects without a history of AF. CT scans were repeated approximately 4 months later. PV and left atrial dimensions were measured with digital calipers. Four separate PV ostia were present in 47 subjects; 3 ostia were present in 2 subjects; and 5 ostia were present in 9 subjects. The superior PVs had a larger ostium than the inferior PVs. Patients with AF had a larger left atrial area between the PV ostia and larger ostial diameters than the controls. Segmental ostial ablation resulted in a 1.5 +/- 3.2 mm narrowing of the ostial diameter. A 28% to 61% focal stenosis was present 7.6 +/- 2.2 mm from the ostium in 3% of 128 isolated PVs. There were no instances of symptomatic PV stenosis during a mean follow-up of 245 +/- 105 days. CONCLUSION: CT of the PVs allows identification of anatomic variants prior to catheter ablation procedures. Segmental ostial ablation results in a significant but small reduction in ostial diameter. Focal stenosis occurs infrequently and is attributable to delivery of radiofrequency energy within the PV.     

Randomized comparison of bipolar versus unipolar plus bipolar recordings during segmental ostial ablation of pulmonary veins

INTRODUCTION: Segmental ostial ablation to isolate pulmonary veins is guided by pulmonary vein potentials. The aim of this prospective randomized study was to compare the utility of unipolar plus bipolar electrograms versus only bipolar electrograms as a guide for segmental ablation to isolate the pulmonary veins in patients with atrial fibrillation. METHODS AND RESULTS: Isolation of the left superior, right superior, and left inferior pulmonary veins was attempted in 44 patients (35 men and 9 women; mean age 54 +/- 10 years) with paroxysmal atrial fibrillation. A decapolar Lasso catheter was positioned in the pulmonary veins, near the ostium, and a conventional ablation catheter was used for segmental ablation aimed at elimination of all pulmonary vein potentials. One hundred fourteen pulmonary veins were randomly assigned for ostial ablation guided by either bipolar or unipolar plus bipolar recordings. Electrical isolation was achieved in 51 (96%) of 53 pulmonary veins randomized to the bipolar approach, and 57 (93%) of 61 pulmonary veins randomized to the unipolar plus bipolar approach (P = 0.7). In the unipolar plus bipolar group, the total duration of radiofrequency energy needed to achieve isolation, 5.5 +/- 2.8 minutes/vein, was significant shorter than in the bipolar group, 7.6 +/- 4.1 minutes/vein (P < 0.01). Mean procedure and fluoroscopy durations per vein were 19% to 28% shorter in the unipolar plus bipolar group. CONCLUSION: Segmental ostial ablation to isolate the pulmonary veins can be achieved more efficiently and with less radiofrequency energy when guided by both unipolar and bipolar recordings than by bipolar recordings alone.