非右房入路二尖瓣置换术后房性心律失常电解剖机制及射频消融

目的 评价导管消融非右房入路二尖瓣置换术后房性心动过速(简称房速)的电解剖基质及射频消融.方法 分析非右房入路二尖瓣置换术后房速消融病例,应用三维电解剖标测心房,结合拖带标测,明确房速机制后进行线性及基质消融.结果 共入选17例患者,其中间隔入路11例,左房入路6例.共诱发25种房速,其中间隔入路组诱发15种房速,大折...     

射频消融治疗风湿性心脏病二尖瓣置换术后房性心动过速

目的报道一组风湿性心脏病二尖瓣置换术后房性心动过速（房速）的机制及射频消融效果。方法共入选22例（男8例）二尖瓣置换术后持续性房速患者,在心动过速状态下采用三维电解剖系统建立右心房或左心房激动标测图和电压图,标出瘢痕区、低电压区及双电位区,并揭示心动过速的机制。根据标测结果选择心动过速的关键峡部或起源点进行消融。结果22例患者共标测33种心动过速,17例次房速起源于右心房（51．5％）,16例次房速起源于左心房（48．5％）。符合大折返机制的31例次（93．9％）,符合局灶起源机制的2例次（6．1％）。消融术中即时成功率90．9％（20／22）。随访过程中5例患者仍有房速发作,3例再次消融成功。结论二尖瓣置换术后房速机制复杂且个体化,在三维电解剖标测指导下射频消融治疗效果满意。     

“特发性”瘢痕相关性左心房房性心动过速—电解剖标测和消融结果

目的 报道1组无明显器质性心脏病,无外科手术或导管消融史的左心房折返性房性心动过速(房速)的电解剖标测特点及消融结果.方法 共10例[男3例,女7例,年龄37 ～72(57.4±14.6)岁]符合上述特征的左心房房速患者接受电解剖标测和导管消融.结果 所有房速的折返环均位于大面积低电压(双极电压≤0.5 mV)区域内,低电压区域内可标测到1～5(2.6±1.2)个双电位线和/或电静止瘢痕区,这些传导障碍区和左心房固定的解剖屏障(如二尖瓣环)构成各个折返环必经的关键峡部.8例在折返环峡部内可记录到低幅,长时限碎裂电位,平均振幅(0.21±0.05)mV,平均时限(123±14) ms,占心动过速周长43％±5％.选择折返环峡部特别是长时限碎裂电位为消融靶点,10例均通过1～3(平均2次)次局部放电即终止房速,首次消融后2例复发房速,再次消融成功,随访共(14±10)个月,所有患者无房速复发.结论“自发”的左心房广泛瘢痕形成构成本组房速的“致心律失常基质”,折返环内存在的狭窄且传导缓慢的峡部对维持房速非常重要,并易于消融成功.     

单导管实施三维电解剖标测与消融治疗流出道室性心律失常

目的探讨使用单导管技术实施三维电解剖标测和消融治疗流出道室性心律失常。方法78例住院患者（男34例,女44例）,平均年龄（41±11）岁。采用Carto及单一专用导管行电解剖重建、激动顺序标测、起搏与拖带或基质标测,实施射频消融。部分病例与多排CT心脏影像融合显示,观察即刻成功率、消融成功靶点的分布、并发症,随访复发情况。结果共75例完成消融,73例采用单导管技术,即刻成功71例。成功消融部位：右心室流出道间隔部33例,游离壁18例,肺动脉瓣上5例,左心室流出道4例,左冠窦7例,右冠窦4例。操作时间（62±25）min,X线曝光时间（12±8）min。3例消融术中出现右束支阻滞,2例术后恢复,未见其他并发症。随访复发2例,1例再次消融成功,1例症状减轻未再消融。结论用单导管实施三维电解剖标测与消融治疗流出道室性心律失常,安全、有效、操作简单。     

三维电解剖标测指导疑难右侧游离壁旁路的导管消融

目的应用三维电解剖标测技术详述常规消融无效的右侧游离壁旁路电解剖特征。方法本组共入选17例常规消融无效的右侧游离壁旁路患者,消融失败1～3（1．8±0．6）次。3例在顺向型心动过速下构建右心房电激动模型,14例在右心室心尖部起搏下构建右心房电激动模型。逆向传导的心房最早激动点代表旁路的心房插入端,冷盐水消融最早心房激动点。结果17例患者中,最早激动点距离对应部位三尖瓣环的宽度为9—20（13．6±3．4）mm,较相对部位三尖瓣环的局部激动时间提前18～80（31．5±16．3）ms。共14例患者记录到独立的旁路电位。1例患者在导管标测时阻断旁路逆传,冷盐水局部巩固消融;16例患者冷盐水消融均成功阻断所有旁路的传导,其中1例患者的旁路心房插入端呈广泛分布而行片状消融。无消融术相关并发症。随访了3～41（18．6±12．7）个月,无旁路传导恢复及心动过速发作。结论常规方法消融失败的右侧游离壁旁路可能具有特殊的解剖特征,如旁路在三尖瓣环水平沿心外膜走行,旁路的心房插入部位远离瓣环。三维电解剖标测有助于精确定位旁路的心房插入端并指导消融。     

三维电解剖标测指导疑难右侧游离壁旁路的导管消融

Objective To demonstrate the electroanatomic substrates of right-sided free wall (RFW)accessory pathways (APs) which were refractory to conventional catheter ablation utilizing three-dimensional (3D) mapping. Methods Seventeen patients with RFW APs that failed initial conventional catheter ablation(s)by a mean of 1～3(1.8±0.6) attempts were enrolled in the study. Electroanatomic mapping of the right atrium was performed during right ventricular pacing in 14 patients and orthodromic reciprocating tachycardia in 3patients. Radiofrequency energy was delivered via irrigation catheter to the earliest atrial activation site. Results The earliest atrial activation site, which represented the atrial insertion of the APs, was separated from the tricuspid annulus by an average of 9 ～ 20 ( 13.6 ± 3.4 ) mm, and the local activation time was 18 ～ 80(31.5±16.3) ms earlier than that of the corresponding annular point. The target electrogram demonstrated AP potential in fourteen patients and ventriculoatrial fusion in the rest three. Accessory pathway was blocked in one case during moving the catheter and RF ablation delivery on the areas. One patient exhibited an AP with wide branching on the atrial side during mapping. RF ablation with an irrigated catheter successfully interrupted AP conduction in remaining 16 patients without complications. After a mean follow-up of 3 ～ 41 (18.6±12.7) months, there were no recurrences of ventricular preexcitation or episodes of tachycardia. Conclusion RFW APs refractory to conventional catheter ablation might be due to unique anatomic AP features such as more epicardial course at the annulus level with atrial insertion distance from the tricuspid annulus. Electroanatomic mapping is helpful to accurately localize the atrial insertion sites of these APs and facilitates catheter ablation.     

三维电解剖标测指导器质性心脏病室性心动过速导管射频消融的初步经验

器质性心脏病室性心动过速（室速）是一临床顽疾，也是导管射频消融治疗的难题。在上世纪九十年代，心肌梗死后室速和致心律失常性右室心肌病（ARVC）室速的成功标测与消融充分揭示了此类室速的电生理机制。目前认为，绝大多数器质性心脏病室速是瘢痕相关性的折返性心动过速，其缓慢传导区常位于瘢痕内部，入口和出口位于瘢痕边缘。     

非外科手术瘢痕相关性右心房房性心动过速：电解剖标测与消融

目的探讨非外科手术后的瘢痕相关性右心房房性心动过速（房速）的心内电生理和Carto三维电解剖标测特点及消融方法。方法2008年9月至2009年4月我中心诊治的14例无器质性心脏病基础的右心房房速患者,在Carto三维标测系统指导下行心内电生理检查、标测和射频消融。结果14例患者中有4例心内电生理检查和Carto电解剖标测符合右心房大折返性房速且在Carto电解剖电压标测中显示出“自发性瘢痕”,瘢痕分布于右心房游离壁。这4例患者年龄32～48岁,病史（23．40±15．43）个月,曾使用2种以上抗心律失常药物治疗无效。2例患者右心房轻至中度扩大,左心室射血分数均在正常范围,无明显器质性心脏病依据和心外科手术史及导管消融史。3例患者在瘢痕区内标测到缓慢传导的峡部,2例可诱发出三尖瓣峡部依赖性逆时针心房扑动（房扑）。在三尖瓣峡部、上腔静脉与瘢痕之间、下腔静脉与瘢痕之间、瘢痕与三尖瓣环之问,瘢痕与瘢痕之问或瘢痕区内缓慢传导的“峡部”进行线性消融。4例患者均即刻消融成功。随访（4．2±1．8）个月,3例未再发作心动过速,1例偶尔发作非持续性房速,服药控制良好。结论“自发性瘢痕”相关性右心房大折返性房速临床少见,三维电解剖电压标测可提高消融成功率。     

特发性室性心动过速12例的电磁解剖标测系统标测和消融

目的评价电磁解剖标测系统(Carto)标测和指导射频消融在治疗特发性室性心动过速的临床应用价值。方法入选12例特发性室性心动过速患者,年龄(33±12)岁。心动过速周期(370±95)ms。室性心动过速持续发作时,7FNavi-Star在相关心室标测,实时重建心腔三维电解剖图,右心室室性心动过速在右心室流出道详细标测,根据激动图上最红色区域为较早激动部位,结合大头导管记录心室波最早、且起搏时体表12导联图形与心动过速一致处,作为消融靶点。左心室室性心动过速在间隔部细标,标识较体表QRS波及His束电位提前的P电位处,作为靶点。温控60℃放电消融。以基础态及静脉滴注异丙肾上腺素反复电生理检查.不可诱发室性心动过速作为成功消融终点。结果12例均成功消融,其中右心室室性心动过速7例,均位于右心室流出道前中间隔部,左心室室性心动过速5例,起源于左心室后中间隔4例、中下间隔近心尖部1例。1例左心室室性心动过速于心动过速在左心室后中间隔处标测时,室性心动过速终止,后标志此处作为靶点,放电消融成功。手术时间为(102±25)分钟,曝光时间为(11±7)分钟。随访6～18个月,无复发病例。结论Carto系统通过磁场标测定位,结合心内电图重建室性心动过速时心室电激动图,可有效快速寻找最早激动点或P电位处作为消融靶点,进行电解剖标测,并可在标测导管机械损伤终止室性心动过速处标志,结合起搏标测,作消融参考点指导消融,治疗特发性室性心动过速安全有效。     

高密度标测指导下射频导管消融房性心动过速

目的 探讨EnSite NavX系统高密度标测对房性心动过速（房速）射频导管消融的指导作用.方法 17例房速患者,平均年龄（45.9±16.9）岁,男性15例,女性2例.心动过速均呈持续性发作,应用EnSite NavX系统于心房进行高密度标测,建立激动图.对于折返性房速,线性消融关键峡部或传导通道（channel）,对于局灶性房速,点消融局部最早心房激动区域.结果 17例患者中,共标测到19种房速,周长为（254±49）ms,平均取点（316±90）个,标测时间为（8.4±2.6）min,建立19种激动图 激动图显示大折返性房速10种,局灶性房速9种 19种房速中,18种即时消融成功 无标测与消融相关并发症发生.随访（3.0±1.6）个月,2例服用胺碘酮可预防发作（1例患者房速复发,1例患者术中有1种房速未消融成功）.结论 EnSite NavX系统高密度标测对心动过速机制可作出快速、准确的判断,有助于确定消融靶点,提高消融成功率.     

Factors affecting error in integration of electroanatomic mapping with CT and MR imaging during catheter ablation of atrial fibrillation

Objective Integration of 3-D electroanatomic mapping with Computed Tomographic (CT) and Magnetic Resonance (MR) imaging is gaining acceptance to facilitate catheter ablation of atrial fibrillation. This is critically dependent on accurate integration of electroanatomic maps with CT or MR images. We sought to examine the effect of patient- and technique-related factors on integration accuracy of electroanatomic mapping with CT and MR imaging of the left atrium. Materials and methods Sixty-one patients undergoing catheter-based atrial fibrillation (AF) ablation procedures were included. All patients underwent cardiac CT (n = 11) or MR (n = 50) imaging, and image integration with real-time electroanatomic mapping of the aorta and left atrium (LA). CARTO-Merge software (Biosense-Webster) was used to calculate the overall average accuracy of integration of electroanatomic points with the CT and MR-derived reconstructions of the LA and aorta. Results There was a significant correlation between LA size assessed by electroanatomic mapping (112 ± 31 ml) and average integration error (1.9 ± 0.6 mm) (r = 0.46, p = 0.0003). There was also greater integration error for patients with LA volume ≥ 110 ml (n = 31) versus < 110 ml (n = 30) (p = 0.004). In contrast, there was no significant association between average integration error and paroxysmal versus persistent AF, left ventricular ejection fraction, days from imaging to electroanatomic mapping, or images derived from CT versus MR. Conclusions Patients with larger LA volume may be prone to greater error during integration of electroanatomic mapping with CT and MR imaging. Strategies to reduce integration error may therefore be especially useful in patients with large LA volume.     

心脏病外科术后右房房性心动过速的标测及射频消融

目的总结分析心脏病外科术后右房起源房性心动过速(简称房速)的标测及射频消融结果。方法共入选27例心脏外科术后持续性右房房速患者,在心动过速状态下采用三维电解剖标测系统建立右房激动标测图和电压图,标示出疤痕区及双电位区,并揭示心动过速的机制。根据标测结果选择心动过速的关键峡部或起源点进行消融。结果心动过速机制分为以下几种类型:单环折返包括右房峡部依赖性心房扑动(15例)和切口折返性房速(5例);双环折返性房速(3例);两种以上机制(包括局灶性)的复杂房速(4例)。术中即时手术成功率100%。随访过程中5例复发房速,3例再次消融成功。结论心脏外科术后右房房速多数与外科手术切口疤痕相关,在三维电解剖标测系统指导下射频消融治疗效果满意。     

应用电解剖标测系统引导经盐水灌注导管消融法洛四联症术后的室性心动过速

目的报道6例应用电解剖标测系统（Carto系统）引导经盐水灌注射频导管消融法洛四联症术后室性心动过速（VT）。方法6例患者均为男性，年龄6～38岁，法洛四联症术后出现阵发性心悸，体表心电图均表现为持续性VT，3例有晕厥史，6例患者均不同意放置植入型心律转复除颤器（ICD）。应用Carto系统标测和消融VT方法如下：心室程序电刺激诱发VT，如血流动力学稳定则在VT时行激动标测和电压标测，结合标测舒张期电位和拖带标测等方法确定并消融VT关键峡部；如血流动力学不稳定或不能诱发持续性VT，则在窦性心律时行右心室电压标测、起搏标测，在局部起搏时和VT有相同或相近的体表心电图并伴较长的刺激到QRS波时间的部位消融，并消融晚电位或碎裂电位及消融连接可能的电屏障区。结果6例患者可诱发出8种形态VT，VT周长230～310ms，7种为持续性VT，其中2种血流动力学不稳定；另1种为非持续性VT。4例患者在VT时标测和消融，2例患者在窦性心律下标测后消融。6例8种形态VT均为瘢痕折返机制，均消融成功。随访6～19个月，仅1例VT复发，经再次消融成功。结论应用Carto系统引导盐水灌注射频导管消融法洛四联症术后VT有较高的成功率和较低的复发率，尤其对引导血流动力学不稳定、多形或非持续性VT的消融可能有较好的效果。     

电解剖系统引导下环肺静脉线性消融隔离肺静脉治疗心房颤动

目的采用双Lasso导管标测技术行环肺静脉及其周围组织隔离预防心房颤动复发。方法13例心房颤动(房颤)患者,男性8例,女性5例,平均年龄为(56±8)岁,行电生理检查和射频导管消融。其中,8例为频发的阵发性房颤(1~20年),5例为持续性房颤(1~4年)。窦性心律下起搏远端冠状静脉窦或房颤发生时,利用电解剖系统进行左心房重建。然后,将两根Lasso多极导管同时置于右(左)上、下肺静脉之内。在距肺静脉口1cm左右处行环肺静脉及其周围组织电隔离。消融终点为左心房-肺静脉/周围组织完全性阻滞,表现为放电时肺静脉电位消失。结果7例阵发性房颤患者在窦性心律下电隔离成功,5例持续性房颤和1例阵发性房颤患者在窦性心律和房颤发生时电隔离成功。3例患者放电时房颤终止:左肺静脉隔离时房颤终止1例,右肺静脉隔离时房颤终止1例,左肺静脉隔离完成后54s自行终止1例。其余3例需体外电转复。消融术时间为(256±56)min,X线曝光时间为(39±11)min。无并发症发生。在术后平均随访(104±50)d,只有1例患者在第71d时出现不典型心房扑动,自行终止。其余12例患者均无房性快速性心律失常复发。结论有明确心电学隔离指标的环肺静脉及其周围组织电隔离是一种安全有效的方法。肺静脉既可为房颤的诱发机制,亦有可能参与房颤的维持机制。     

Efficacy of electroanatomic mapping in the catheter ablation of premature ventricular contractions originating from the right ventricular outflow tract

Background Mapping of premature ventricular contractions (PVCs) originating from the right ventricular outflow tract (RVOT) sometimes is not easy because of an unstable incidence and multiple foci of the PVCs. The aim of this study was to evaluate the effectiveness of electroanatomic mapping in catheter ablation of those PVCs. Methods and results One hundred patients with 134 RVOT origin PVCs were randomly allotted to undergo either conventional (group I; 50 patients with 65 PVCs) or electroanatomic mapping (group II; 50 patients with 69 PVCs). In group II, electroanatomic mapping of the RVOT was performed using auto-freeze maps in patients with frequent PVCs, and pace mapping was performed marking the pacing sites on the remap which was made by extracting the anatomic frame out of the baseline map during sinus rhythm in patients with infrequent PVCs. Successful ablation was achieved in 44 (88%) group I patients and 48 (96%) group II patients (p = 0.14). The fluoroscopy and procedure times and those per PVC morphology were all significantly shorter in group II than group I overall (p < 0.0001 for all comparisons), and in each patient group with infrequent PVCs, frequent PVCs or unstable PVCs (p < 0.05–0.0001). The number of RF applications and that per PVC was significantly smaller in group II than group I (5.3 ± 1.8 vs 6.2 ± 2.4, and 4.4 ± 1.2 vs 5.2 ± 2.1; p < 0.05). Conclusions The use of electroanatomic mapping may reduce the fluoroscopy and procedure times in the ablation of RVOT PVCs, but there is no evidence that it improves the overall efficacy of the procedure.     

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。