持续性心房颤动递进式消融术中房性心动过速的标测和消融

目的 阐明持续性心房颤动(房颤)递进式消融术中产生的房性心动过速(房速)的电生理机制.方法 持续性房颤行递进式消融术中房颤转化为房速的92位患者入选.通过三维标测系统指导下的电激动标测和拖带标测方法确定房速的机制,并针对心动过速的关键峡部或最早激动点进行消融.结果 共标测124例房速,6例(4.8％)为局灶性房速,118例(95.2％)为折返性房速,其中99例(83.9％)为大折返(折返环直径≥3 cm),19例(16.1％)为局部小折返(折返环直径＜3 cm),17例存在双环或多环折返.术中即刻114例房速(91.9％)消融成功,首次消融术后22位患者复发房速,18位接受多次消融治疗,平均随访(14±8)个月,共79位(85.9％)患者维持窦性心律.结论 对持续性房颤递进式消融术中出现的房速准确标测其机制是可行的,对指导成功消融有重要意义.     

经导管点状射频消融反复短阵"心房颤动"

目的　报道反复短阵快速房性心律失常的电生理特性、射频导管消融方法和结果。方法　对 32例自发的反复短阵快速房性心律失常患者进行射频导管消融。观察房性心律失常的心内激动顺序和周长。单极和双极标测快速房性心律失常的起源病灶 ,并进行消融。结果　 32例患者的快速房性心律失常的心电图表现酷似心房颤动。AA间期绝对不齐 16 0～ 4 5 0ms,平均 (2 87± 93)ms ,而心房激动顺序则绝对规整有序。局部点状消融成功治疗所有患者的房性心律失常。平均随访 (14± 8)个月 ,1例复发。结论　反复短阵快速房性心律失常是一种局灶性房性心动过速 ,而非心房颤动。点状消融可达到根治的目的。     

心房颤动消融术中合并室上性心动过速的相关性研究

目的对心房颤动(房颤)消融术中合并阵发性室上性心动过速(室上速)的患者进行特征性分析。方法回顾性选取2016年1月至2018年6月浙江大学医学院附属邵逸夫医院庆春院区心内科所有接受房颤消融术的患者(1484例),依据术中是否合并室上速分为合并室上速组和未合并室上速组,分析性别、年龄、房颤类型是否与房颤消融术中合并室上速的关系。同时,以年龄50岁和65岁为界点,再次进行分层分析。术中合并室上速组患者明确机制后同时行慢径改良或旁路消融,进行长期随访。结果房颤消融术中合并室上速共41例(41/1484,2.76%)。其中,合并房室结折返性心动过速(AVNRT)29例,合并房室折返性心动过速(AVRT)12例。女性房颤组合并室上速(25/505)明显高于男性组(16/979,4.95%对1.63%,P<0.001);≤50岁房颤组合并室上速(8/133)的患者明显高于>50岁组(33/1351,6.02%对2.44%,P=0.016);阵发性房颤组合并室上速(29/741)的患者明显高于持续性房颤组(12/743,3.91%对62%,P=0.007)。Logistic回归分析显示女性、≤50岁、阵发性房颤是房颤消融术中合并室上速患者的高危因素(女性:OR=0.292,95%CI 0.151~0.565,P<0.050;≤50岁:OR=0.301,95%CI 0.131~0.689,P=0.004;阵发性房颤:OR=0.456,95%CI 0.230~0.906,P=0.025)。结论房颤消融术中患者应同时行电生理检查排除室上速,尤其是年龄较轻的女性阵发性房颤患者。     

持续性心房颤动递进式消融术后复发双环折返性房性心动过速的电生理诊断

目的 阐明递进式消融术治疗持续性心房颤动(房颤)术后复发双环折返性房性心动过速(房速)的电生理特点.方法 入选2007年7月至2012年12月持续性房颤递进式消融术后复发房速的19例患者.结果 19例患者均通过详细的三维激动标测(＞200个采集点)和在每个折返环内拖带的方法确定了双环折返的机制,其中大折返环和大折返环组成的双环折返13例,大折返环和局部小折返环组成的双环折返6例.大多数病例消融策略采取分别消融两折返环各自的峡部,先将双环折返变为单环折返(由再次拖带结果确定),最后消融单折返环峡部终止房速.结论 双环折返性房速并非是持续性房颤递进式消融术后少见的一种心律失常,详细的三维激动标测联合拖带标测是确诊的最佳方案.     

经导管射频消融治疗肥厚性心肌病合并心房颤动的初步经验

目的报道经导管射频消融治疗肥厚性心肌病（HCM）伴心房颤动（房颤）,并对其可行性、安全性、有效性进行评价。方法回顾性分析2006年8月至2008年10月期间因HCM伴房颤且药物治疗效果较差至南京医科大学第一附属医院行经导管射频消融治疗的患者临床资料。患者均接受三维标测系统（Carto或EnSite—NavX）导航下环肺静脉消融术达到同侧肺静脉隔离,对持续性房颤再行左心房碎裂电位消融以及线性消融。消融术后3个月内继续服用抗心律失常药物,并于消融术后1、3、6个月行动态心电图检查,出现症状后立即行常规心电图,随访治疗效果。结果共11例HCM患者行射频消融术,年龄（52±17）岁,女性2例。其中6例为阵发性房颤,5例为持续性房颤。经导管射频消融后4周有1例因急性左心功能不良死亡,其余10例有4例复发,其中2例再次接受消融术。随访（14±10）个月,共有7例维持窦性心律,总成功率64％,未发生消融术相关的严重并发症。维持窦性心律者左心房内径及射血分数变化差异无统计学意义[（46±4）mmVS（46±4）mm,0．64±0．05VS0．66±0．04,P〉0．05],心功能改善（2．0±0．7VS1．2±0．4,P〈0．05,NYHA分级）。结论本文结果提示射频消融治疗HCM伴房颤安全且有效,术后维持窦性心律者心功能得到显著改善。     

Recurrent supraventricular tachycardias prevalence and pathophysiology after RF ablation: A 5-year registry

Background

The introduction of technique of radiofrequency (RF) catheter ablation in 1990, has revolutionized management of different types of paroxysmal supraventricular tachycardia (PSVT). In spite of higher success rate, there were reported recurrences among different types of SVT. The aim of this study was to report the efficacy of RF ablation, its complications, recurrence rate and its predictors.

Methods

The material of this study (our 3rd registry) included patients who underwent electrophysiological study (EPS) and radiofrequency ablation of their supraventricular tachycardia in the past 5 years, starting from January 2002 to January 2007 at The Critical Care Medicine Department, Cairo University.

Results

Out of 400 pts studied, 381 (95%) had been subjected to radiofrequency ablation (RF) ablation while the remaining 19 pts (4.7%) refused ablation for fear of possible complications. Out of the 381 pts, 366 (96%) had their target tachycardia successfully terminated, from them 26 pts (7%) experienced recurrence after having successful RF ablation. Nine pts (34.6%) of total recurrence was reported in pts with AVNRT, 7 pts (26.9%) of total recurrence was reported in pts with AVRT utilizing septal accessory pathway (Rt AS and /or Rt PS AP), 4 pts (15.4%) was reported in pts with double AP, 2 pts (7.7%) of total recurrence was reported in pts with AFl, one pt (3.8%) of total recurrence was reported in cases of AT. Redo ablation have been carried out successfully in 25 pts (96.2%), and one pt (3.8%) refused ablation for fear of possible complications.

Conclusions

Although electrophysiological study and RF ablation eliminated different types of SVT. However, there may be increased incidence of recurrence among pts with AVNRT and AVRT utilizing concealed septal AP and multiple APs secondary to the complexity of AVN physiology, the critical location of septal AP, the clinical expertise, and poor electrophysiological criteria for good procedural success.     

Cardiac injury after percutaneous catheter ablation for atrial fibrillation

Aims: Small elevations in troponin T levels have been shown with limitedradiofrequency (RF) ablation procedures for supraventriculartachycardia, usually to levels below the threshold for ischaemiaor infarction. Left atrial catheter ablation for atrial fibrillation(AF) requires far more RF energy, therefore could be expectedto have greater elevation in troponin T. We determined troponinT levels before and after ablation in these patients to evaluatethe amount of rise with this ablation. Methods: All patients undergoing pulmonary vein isolation (PVI) fromMay 2004 to October 2004 had troponin T levels measured 4 hfollowing completion of the procedure. The first 30 patientsalso had a troponin T level measured 1 h prior to PVI to establisha baseline reference. Results: Sixty patients were studied, with 81.7% males and a mean ageof 54.6 ± 9.9 years. No patient had underlying structuralheart disease. The baseline troponin T level was normal (<0.01µg/L) in all 30 patients. Post-procedure troponin T levelswere elevated in all 60 patients compared with baseline (P <0.05), with a mean level of 0.85 µg/L and a range of 0.26–1.57µg/L after an average RF ablation time of 56 ±15 min. All levels were above the reference range for diagnosisof acute myocardial infarction (>0.15 µg/L). TroponinT level was not related to the number of RF lesions, RF time,procedure time, or associated external cardioversion. Conclusions: Troponin T elevations occurred in all patients undergoing PVI,to levels at least 20 times the normal concentration, into therange for diagnosis of acute myocardial infarction. Therefore,troponin T would not be specific for ischaemia in the settingof chest pain post-catheter ablation for AF.     

室上速并发心房颤动的电生理研究

目的探讨室上速并发心房颤动(房颤)的电生理特性及其发生机制。方法对38例室上速患者,根据有无房颤史分为两组,即房颤组18例,无房颤组20例。分别测量两组室上速周长、心房内压、心房各部位有效不应期、心房不应期离散度、心房最大不应期与室上速周长的比值,所有对象均行射频消融术治疗室上速,并行为期半年的随访,观察两组病人房颤的发生情况。结果房颤组与无房颤组的室上速周长分别为（326±9）ms,（331±11）ms,P>0.05。在窦性心律与室上速发作时,房颤组的心房不应期离散度均较无房颤组增加,房颤组的心房最大不应期与室上速周长的比值比无房颤组明显增加（P<0.05）。房颤组的心房最大不应期比无房颤组增加（P<0.05）,但却发生在心房的不同部位。结论(1)室上速合并房颤与室上速周长无明显关系。(2)心房不应期离散度是室上速合并房颤发生和维持的一个重要机制。(3)心房最大不应期与室上速周长的比值可能是室上速诱发房颤的另一个机制。     

One-puncture, double-transseptal catheterization manoeuvre in the catheter ablation of atrial fibrillation.

Pulmonary vein isolation (PVI) guided by circumferential mapping has been established as a curative treatment of atrial fibrillation. In the PVI technique, two transseptal catheters are necessary for mapping and catheter ablation. The one-puncture, double-transseptal catheterization manoeuvre is generally used in the PVI technique. However, to the best of our knowledge, there have been no reports describing transseptal manoeuvre in detail. In this article, the manoeuvre to achieve double-transseptal catheterization easily and safely is described.     

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。     

个体化的心房消融终止心房颤动

目的心房颤动(房颤,AF)的发生和维持可能存在多种机制,对所有的AF都以一种固定的术式进行消融治疗缺乏针对性。为此,我们采用心内非接触式标测,探索个体化消融的可行性。方法52例患者(男性44例,女性8例),年龄22～70(51.1±10.9)岁,左心房内径22～54(36.1±6.5)mm,其中12例为持续性AF(1～22年)。均经房间隔穿刺在左心房内对AF进行非接触式等电位标测,并在等电位标测下逐步进行个体化消融,消融术式不固定,以AF被终止且不被诱发、消融线形成双向阻滞为消融终点。结果AF被分为3种类型,而肺静脉(pulmonaryvein,PV)口周围、左心房顶部是波阵面的主要传导区。消融方式根据标测结果决定,包括在以上任一部位的线性消融、环PV口外的线性消融等,其中持续性AF多形成绕PV口周的环形消融加左心房顶部消融线。82.7%(43/52)的AF被消融所终止且不能再诱发,其中4例需在右心房消融方成功;另有5例的AF被转变为左心房扑动(房扑)。首次消融的即时成功率为90.4%(47/52)。消融中1例有心脏压塞。6例首次消融后有左心房房扑的患者再次接受了消融,标测发现既往消融线存在缝隙,针对缝隙消融后心动过速均被终止且不能被诱发。平均随访(11.0±6.2)个月,术后3个月82.7%(43/52)的患者不服药物亦无AF发生,其中阵发性AF成功率为87.5%(35/40);持续性AF为66.7%(8/12),其余患者均转为左心房房扑。结论本组结果初步提示,在非接触式等电位标测的基础上进行个体化的心房电学改良消融可有效地终止AF并有较好的中期疗效。其远期的效果有待观察。     

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.     

儿童房性心动过速的电生理标测和射频导管消融

目的报道儿童房性心动过速（房速）的电生理标测及射频导管消融的疗效。方法43例患儿（男性23例,女性20例）,年龄2～14（7．1±3．1）岁,其中33例为无休止房速,17例伴有明显的左心室扩大及慢性心力衰竭。所有患儿均进行电生理标测,在最早激动点进行导管射频消融。结果39例自发或诱发房速,局灶起源36例（右心房26例,左心房10例）,先天性心脏病后大折返房速3例。35例（89．7％）患儿消融术即刻成功,消融术中及术后无严重并发症发生。平均随访（25．2＋-13．5）个月,34例（87．2％）患儿不服药亦无房速发作,其余均获得明显改善。14例左心室重度扩大及射血分数减低患儿心脏大小及功能恢复正常。结论儿童房速可经导管消融消除或获得明显改善。     

心房颤动导管消融术后复发嵴部依赖折返的电生理特点和成因分析

目的阐明心房颤动(房颤)导管消融术后复发二尖瓣环峡部线(MI)嵴部缝隙依赖折返的电生理特点和产生原因。方法选取82例曾于房颤导管消融术中行MI消融并因术后复发规则房性心动过速(OAT)而行二次消融的患者,行电生理检查和二次导管消融,一旦判定为MI嵴部传导缝隙依赖的OAT,则在三维电磁导管定位系统(CARTO)引导下在MI消融线上和嵴部取点,计算左心房内膜周长占心动过速周长(TCL)比例,术后至少随访6个月。另外选择2012年10月至2012年12月间于房颤导管消融术中行MI消融且已达阻滞标准者36例。将消融导管置于嵴部,重复鉴别性起搏过程,观察嵴部是否存在传导缝隙。结果 82例因房颤导管消融术后复发OAT行二次消融的患者有7例(8.5%)为MI嵴部缝隙依赖折返,心动过速周长(TCL)为(247.9±19.2)ms,左心房内膜面激动时间为(145.4±17.7)ms,占TCL(58.5±3.2)%。体表F波形态和激动标测符合围绕二尖瓣环大折返特点,但MI消融线上拖带起搏后间期(PPI)较长[PPI-TCL(34.3±6.6)ms],且存在较宽双电位[间距(99.7±7.4)ms],而嵴部拖带PPI-TCL明显较短[(11.4±3.9)ms,P0.001];6例于嵴部消融终止,1例于冠状窦远端对应位置消融终止,随访(11.1±4.5)个月无复发。另外,36例行MI消融且满足双向阻滞标准的患者,于嵴部重新行鉴别性起搏,发现5例(13.9%)存在嵴部传导缝隙。结论 MI嵴部缝隙依赖折返是一类以嵴部缝隙为关键峡部、而既往MI消融线在折返路径之外的独特OAT,其成因可能与嵴部尚存传导缝隙却符合MI阻滞判定标准的MI假性阻滞现象有关。     

射频导管消融治疗青年人群心房颤动的临床分析

目的 对青年心房颤动（房颤）患者（≤45岁）接受三维标测系统指导下房颤射频导管消融治疗的临床疗效和安全性予以研究.方法 回顾分析兰州军区兰州总医院自2011年1月至2012年5月在EnSite 3000指导下接受房颤射频消融治疗的152例患者,按年龄分为青年房颤患者（≤45岁）和中老年房颤患者（＞45岁）,对比分析其在临床基线资料、消融术时间、X线曝光时间、住院天数、术后复发率、术后6个月服药率和并发症发生率等临床指标上的差异.结果 与中老年房颤患者（n=125）相比,青年房颤患者（n=27）多以阵发性房颤为主（P＜0.05）,且术前左心房内径较小（P＜0.01）,消融术时间明显缩短（P＜0.01）,术后住院天数减少（P＜0.01）,复发率和术后6个月服药率均明显减少（P＜0.05）.结论 青年房颤患者多以阵发性房颤为主且较少伴有高血压、糖尿病等疾病,接受房颤消融术后恢复较快且房颤复发率低.     

Cost analysis of radiofrequency catheter ablation for atrial fibrillation

Atrial fibrillation is the most common arrhythmia associated with increased mortality and morbidity. Its management requires high healthcare expenditures; 52%–70% of expenses for AF care are constituted by hospitalization costs. The current management strategies of pharmacological rhythm control and pharmacological or invasive rate control show no difference in impact on major outcomes in patients with AF. Radiofrequency catheter ablation (RFA) has been shown to reduce the risk of AF recurrence, improve quality of life and reduce hospitalization rate as compared to pharmacological rhythm control and rate control strategies. This review summarizes current knowledge on cost and cost-effectiveness analysis of RFA for patients with atrial fibrillation.     

阵发性心房颤动的电生理机制及导管射频消融的初步研究

目的　探讨阵发性心房颤动 (房颤 )的电生理机制和右房峡部消融对房颤的影响。方法　1 995年 6月～ 1 999年 6月 ,1 5例药物治疗无效的阵发性房颤 ,男性 8例 ,女性 7例 ,年龄 (5 6± 9)岁 ,病程 (7± 4)年 ,消融前 3个月平均每月发作 6次至每日数十次不等 ,发作时均有明显症状 ;对照组 1 5例房室结折返性室上性心动过速 ,男性 5例 ,女性 1 0例 ,年龄 (5 7± 6 )岁。电生理检查及消融 ,房颤组和对照组均测量房室结正向和逆向传导文氏点 (Wenckebach point)。程序电刺激诱发房颤 ;在右房峡部线性消融。结果　房颤组房室结正、逆向文氏点分别为 (34 0± 38) m s和 (6 1 8± 75 ) ms,两者差异具有显著性 (P<0 .0 0 1 ) ;对照组正、逆向文氏点分别为 (34 5± 5 2 ) ms和 (338± 48) m s,两者之间差异无显著性 (P>0 .0 5 ) ;两组间正、逆向文氏点离散度差异 (正、逆向文氏点之差 )具有显著性 (P<0 .0 0 1 )。房颤组可用短阵快速刺激 (burst)诱发房颤 ,9例房颤由心房扑动 (房扑 )蜕变而成 ,7例消融后即刻成功 ,随防 3个月～4年 ,3例无房颤复发 ,1例随访时间最长达 3年 6个月 ;其余病例房颤发作频度较术前减少 70 %～95 %。结论　部分阵发性房颤患者在右房内与房扑一样存在大折返环 ,这些患者房颤由房扑蜕变而来     

Visualization of catheter ablation for atrial fibrillation: Impact of devices and anatomy

Endocardial access to the left atrium is commonly achieved to treat patients with atrial fibrillation, using different device delivery systems for cardiac ablation. But the large variation in human anatomy presses the limits of existing medical devices. In this unique study, we directly visualized the device-tissue interface in fresh reanimated human hearts using Visible Heart^® methodologies. Our goal was to better understand any opportunities to improve therapeutic approaches. The visual images obtained in this study (also featured in this article) allow a more intimate grasp of the key steps required in various ablation procedures, as well as some limitations of current device designs. These images show the potential risks of conducting transseptal punctures and the difficulties of placing catheter tips in certain scenarios (e.g., when creating circumferential lesions); they also demonstrate potential problems that could occur while attempting to place catheter tips on such anatomies like the mitral isthmus. In our analysis of these images, we focus on where enhancements are needed to refine device functionality.     

射频消融术治疗室上性心动过速的现状与进展

评价射频消融术(RFCA)治疗室上性心动过速的现状与进展。综合国内外近10年RFCA治疗室上性心动过速的资料。RFCA是近年应用于临床与国际接轨较好的引进技术。RFCA是一种安全、有效的根治室上性心动过速的方法,成功率高,并发症低。正逐步用于治疗室上性心动过速、心房颤动等,发展前景广阔。