采用心内非接触式标测的右心室流出道室性心动过速的射频消融

目的 右心室流出道(right ventricular outflow tract,RVOT)的解剖结构使得对该部位的室性心动过速(ventricular tachyeardia,VT,室速)标测定位的难度较大,远期成功率也较低,为此,采用心内非接触式标测指导导管消融。方法 20例患者(男性12例,女性8例),年龄14～59(35.1±12.3)岁。其中6例有晕厥或黑矇史,7例既往曾接受射频消融未获成功。全部患者均在RVOT内放置EnSite3000标测导管,在窦性心律下进行疤痕标测和心动过速时进行最早激动标测,并根据标测结果使用EnSite 3000导管的导航功能指导消融定位。消融前并进行起搏标测。结果 20例患者共诱发出22种RVOT室速,其中3例还伴其它起源的室性早搏(室早)。疤痕标测提示,13例患者有电学意义上的疤痕区域,且有11例室速起源于该疤痕区域。25个室速或室早起源点中1例起源于近肺动脉瓣口部,10个位于间隔侧,其余均偏游离壁,其中7个偏RVOT后壁中、下部,4个偏前壁中、下部,3个位于游离壁侧;病变基质的直径为6～42 mm,平均(16.8±9.2)mm。非接触式标测所确定的最早激动处电位平均领先体表20～62(41.0±13.8)ms;与自发的室性心动过速相比,起搏标测下14例的12个导联QRS形态完全一致,11/12个导联一致的为10例,1例有10/12导联一致。全部室速和室早均消融成功。在标测确定的     

非接触心内膜球囊标测系统指导瘢痕相关性室性心动过速标测和消融

目的 运用非接触心力膜球囊标测系统（EnSite3000系统）对瘢痕相关性室性心动过速（室速）进行心内膜标测，探讨瘢痕相关性室速电生理机制。标测和消融。方法 运用非开胸法建立心肌梗死后持续性单形性室速猎模型4只；同时选取致心律失常性右室心肌病（ARVC）合并室速患者2例，于左心室或左，右心室内各置入-EnSite3000球囊，分别构建左和（或）右心室的三维几何模型。确定心内膜瘢痕组织的部位，范围和边界，分析单形性室速的激动顺序，关键部位和折返环路及与瘢痕组织的关系，并制定消融策略指导消融。结果 （1）EnSite3000系统准确标测出4只猪左心室心梗后瘢痕组织，其部位，大小及边缘等均与病理一致。4只猪共诱发出8种形态的单形性室速，系统标测出2种室速为左心室典型的“8”字形折返途径，1种室速最早激动点位于左心室前侧壁瘢痕边缘。通过双心室球囊放置准确标测到2只猪5种形态室速在双心室内的激动路径，所有室速的关键位点均在瘢痕组织边缘或其中，6种室速位于左室，2种室速位于右室，可成功释放电流的3种室速消融有效，1种室速线性消融失败；4种室速因放电仅几秒钟即出现凡室颤动，且反复出现，使消融难以完成因而未获成功。（2）2例ARVC患者的右心室流出道处均可标测到类似瘢痕组织的低电压区，1例患者诱发出2种类型的折返性室速，均消融成功，随访4个月无室速发作；另1例患者2种室速，消融失败后置入心脏复律除颤器。结论 EnSite3000系统能准确标测到常规方法无法标测的室速相关性低电压区或瘢痕区域，确定瘢痕相关性室速的机制和关键位点，并精确导航，有助于提高瘢痕相关性室速的消融成功率，为此类室速的消融提供了较好的标测手段。如能结合消融方法和能源的改善，可望进一步提高这类室速的消融成功率。     

非接触式标测指导特发性左心室室性心动过速的射频消融

目的　虽然采用传统标测技术指导特发性左心室室性心动过速 (idiopathicleftventriculartachycardia ,ILVT)射频消融的效果较满意 ,但临床上仍存在一些疑难或复发病例。为此 ,我们使用非接触式标测技术指导ILVT的射频消融。方法　共 13例患者 ,均为男性 ,平均年龄 (31 0± 14 3)岁 ,其中8例既往共接受 15次射频消融术。将EnSite电极导管置于左心室心尖部以获取心内膜等电位图 ,并使用其导航功能指导消融。结果　 13例患者均诱发并标测到ILVT ,其中 5例起源于室间隔中下部 ;3例起源于心尖部 ;3例起源于室间隔中上部 ,2例起源于主动脉根部。全部ILVT均在EnSite标测到的最早激动处消融成功 ,其中 ,有 9例ILVT在EnSite滤波设置为 8Hz时 ,在心内膜等电位图上最早激动部位可见峡部状狭窄区 ,此处消融均一次成功。仅 3例VT于消融靶点处有浦肯野电位。平均X线暴露时间 (2 6± 12 )min。随访 (13 0± 6 2 )个月 ,1例患者有VT复发 ,但心电图和EnSite标测显示为另一起源 ,再次消融成功。结论　心内非接触式标测技术有望提高ILVT尤其是复杂和疑难病例导管消融治疗的成功率。建议使用 8Hz做为目前版本下ILVT标测的标准滤波参数。     

非接触式球囊标测系统指导阵发性心房颤动个体化消融

目的探讨应用非接触式球囊三维标测系统(EnSite Array)指导下心房颤动(简称房颤)个体化射频消融的临床效果。方法18例阵发性房颤患者,应用EnSite Array三维标测房颤优势电传导部位指导个体化消融,并结合大头电极心房内描记到或虚拟电位显示为碎裂电位区进行消融,消融终点为房颤终止转窦性心律或消融线形成双向阻滞。重复术前电刺激或用异丙上腺素静脉滴注后不能诱发或诱发<30s的房颤。结果首次消融的即时成功率为94.4%(17/18),消融中1例出现心包压塞。15例行左右上肺静脉之间靠顶部心房电学改良消融,11例加左上肺静脉与左心耳之间等部位消融,6例加消融左或/和右房峡部或冠状窦口等部位消融。随访15.3±11.3个月,14例术后不服用抗心律失常药物均无房颤发生,3例房颤复发,1例出现心房扑动发作,中期成功率77.8%(14/18)。结论EnSite Array指导下实时根据房颤优势传导区个体化射频消融,消融靶点灵活、针对性强,消融创伤小,中期效果良好。     

“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.     

特发性左室室性心动过速非接触球囊导管系统的标测与消融

介绍非接触球囊导管标测系统 (EnSite 30 0 0系统 )指导难治性特发性左室室性心动过速的标测与射频消融的初步经验。 5例男性病人 ,年龄 33± 17(17～ 6 2 )岁 ,常规方法标测和导管消融失败 2 .4± 1.1(1～ 4)次。常规放置高位右房和右室电生理导管 ,运用置入左室的 6 4极球囊导管和大头电极 ,系统重建三维心内膜几何模型和等电势 ,经右室导管诱发VT ,心动过速周期为 32 3.8± 48.1ms。EnSite 30 0 0系统标测到VT的最早激动点分别位于左后间隔中下部、左侧间隔后下部左束支下方、后下间隔近心尖部、左室后壁近基底部和左后间隔中部。在最早激动点和关键峡部分别行点状、环状和线性消融。 2例患者在心动过速时放电、3例患者在窦性心律时消融 ,均获成功。成功消融靶点处的单极电图均为QS型。X线曝光时间为 2 5± 12min。随访 7.8± 4.6 (1～ 11)个月所有患者均未发作心动过速。结果表明 ,与常规方法比较 ,EnSite 30 0 0系统所建立的心腔三维模拟等电势图可直观地显示心动过速的起源点、传导途径和关键峡部 ,系统模拟的单极腔内电图的形态也有助于判断病灶起源部位及提高消融成功率 ,尤其适用于常规方法消融失败的室性心律失常的标测 ,其独特的导航系统可引导消融导管到达靶点部位指导射频消融 ,并可减少X?     

特发性右心室流出道室性心律失常心内接触式标测与非接触式标测指导导管射频消融

目的 研究心内接触式标测与心内非接触式标测对特发性右心室流出道室性心律失常射频导管消融术及术后有效性的影响.方法 23例特发性右心室流出道室性心律失常患者(室性早搏14例,室性心动过速9例),平均年龄(38.4±7.7)岁,男性8例,女性15例,采用心内接触式标测指导导管射频消融治疗.12例特发性右心室流出道室性心律失常患者(室性早搏7例,室性心动过速5例),平均年龄(39.2±8.5)岁,男性5例,女性7例,采用EnSite心内非接触式标测指导导管射频消融术治疗.比较心内接触式标测组与心内非接触式标测组心律失常靶点标测时间、X线曝光时间、操作总时间.消融术前、后1、3个月动态心电图检查两组患者24 h室性早搏次数,随访观察右心室流出道室性心律失常复发情况.结果 与心内接触式标测比较,心内非接触式标测指导下,特发性右心室流出道室性心律失常靶点标测时间[(21.8±7.6)min vs(42.4±14.4)min]、X线曝光时间[(17.6±2.9)min vs(36.4±7.5)min]、操作总时间[(88.1±8.8)min vs(108.5±16.9)min]均明显缩短(P《0.01),两组均无并发症发生.术后1个月随访时,心内接触式标测组2例心律失常复发;心内非接触式标测组无复发病例.术后3个月随访时,心内接触式标测组与心内非接触式标测组均无复发病例.结论 与心内接触式标测比较,心内非接触式标测指导下的特发性右心室流出道室性心律失常导管射频消融治疗,心律失常靶点标测时间、X线曝光时间及消融术总时间缩短.并且,EnSite心内非接触式标测深化了特发性右心室流出道室性心律失常的电生理机制研究,制定合理准确的消融策略、降低术后复发率提供了更可靠的指导.     

非接触心内膜激动标测系统指导房间隔缺损修补术后H型心房扑动的射频消融（附一例报道）

评价非接触球囊导管标测系统(EnSite 3000)在指导房间隔缺损(ASD)修补术后心房扑动(简称房扑)的射频消融中的临床应用。1例女性患者，41岁，ASD修补术后22年开始频繁发作心动过速，体表心电图示H型房扑。应用EnSite 3000构建右房三维几何模型，标测心动过速的折返激动顺序，发现手术疤痕与三尖瓣环之间、下腔静脉与三尖瓣环之间为折返环路的关键峡部，应用导航系统指导峡部消融，成功阻断心动过速；消融后通过起搏标测判定峡部已达完全双向阻滞。随访20个月，无心动过速复发。结论：在ASD修补术后房扑的标测和消融中应用EnSite 3000系统是安全有效的，不仅能确定折返环路的关键峡部，而且能准确判断线性损伤的连续性。     

窦性心律下非接触式标测指导线性消融治疗特发性左心室室性心动过速

目的 大多数特发性左心室室性心动过速(ILVT)是起源于左后分支(LPF)浦肯野纤维网的折返性心动过速,因而利用非接触式标测系统在窦性心律下标测LPF并经其导航系统指导线性消融治疗ILVT是可行的,现介绍此方法的安全性和有效性。方法 6例患者,1例既往接受3次射频导管消融术,临床呈无休止发作;1例为常规消融术后1个月复发;4例为常规首次接受射频导管消融术患者。其中男性5例,女性1例,平均年龄15～58(34.00±16.26)岁。常规电生理检查明确ILVT诊断后,将球囊电极导管经股动脉逆行送入至左心室心尖部,构建几何构形后建立窦性心律的等电位图。结果 窦性冲动沿希氏束向下传导,在间隔中部不到心尖处激动局部间隔心肌并很快激动整个左心室。局部虚拟电图显示,在间隔部激动的每个QRS波前均有高频、低幅的电位,该电位与QRS波之间的距离随激动的推移而逐渐缩短;心室激动爆发点处的局部电图呈QS型。在心室激动爆发点上方1 cm处于LPF区域作垂直于LPF激动方向的线性消融,消融后所有患者均出现不同程度的左后分支阻滞图形,线性消融的平均放电次数为4～8(5.66±1.50)次,消融完毕后心动过速均不能诱发。平均随访7～13(10.00±2.76)个月,所有患者均无心动过速复发。结论 窦性心律下标测LPF并指导线性消融治疗ILVT不仅安全有效     

三维标测系统指导行希氏束区永久起搏器植入术的可行性探讨

目的:探讨三维标测系统(EnSite)指导行希氏束区永久起搏器植入术的可行性。方法:对66例有常规心脏起搏适应证的患者,在EnSite指导下行希氏束区永久起搏器植入术,并进行门诊随访3个月。观察患者术中及术后体表心电图QRS波群时限、心室起搏阈值、R波振幅及阻抗情况。结果:66例患者均植入永久起搏器,其中44例(66.7%)成功希氏束区起搏。术后即刻体表心电图QRS波群时限(119.41±5.99) ms,术后3个月体表心电图QRS波群时限(120.35±6.38) ms。术中(急性期)心室起搏阈值(0.89±0.16)V,R波振幅(8.23±3.06) mV,阻抗(702.73±103.12)Ω;术后3个月(慢性期)心室起搏阈值(0.95±0.11) V,R波振幅(8.13±2.26) mV,阻抗(679.77±103.12)Ω,术中各参数与术后3个月相比,差异均无统计学意义(P均0.05)。结论:EnSite指导行希氏束区永久起搏器植入术可行、有效。     

Open-window mapping of accessory pathways utilizing high-density mapping

Journal of Interventional Cardiac Electrophysiology - Accessory pathway (AP) mapping is currently based on point-by-point mapping and identifying if a local electrogram’s origin is atrial,...     

非接触球囊导管标测系统指导心律失常的心内膜标测和导航消融

目的:观察非接触球囊导管标测系统指导疑难心律失常的标测与射频消融的有效性与优越性。方法:6例患者,男5例,女1例,年龄28~50(36.2±12.3)岁。电生理检查为右室特发性室性期前收缩1例,左房房性心动过速1例,右房房性心动过速2例,左房心房颤动2例。其中3例常规电生理标测消融未获成功。经股静脉置入64极球囊电极和射频消融导管至同一心腔,计算机标测系统首先构建心腔几何构型,然后建立心动过速的腔内等电势图,分析心动过速的起源点及关键峡部,利用计算机导航系统指导消融导管至拟定靶点处进行消融。结果:1例起源于右室流出道偏间隔的室性期前收缩患者行片状消融获得成功,1例左房房性心动过速标测其心动过速起源于右肺下静脉间隔部,并指引消融导管行右肺下静脉至二尖瓣之间线性消融获得成功,2例右房房性心动过速中1例标测其最早激动点位于下腔静脉口,此处行环状消融获得成功,另1例位于上腔静脉后方穿过界嵴中部线性消融获得成功。2例左房心房颤动患者,1例在窦性心律下其致心房颤动房性期前收缩起源于左右上肺静脉之间,行线性消融成功;另1例在心房颤动持续发作下行左上下肺静脉环状消融及左右上肺静脉间线性消融成功。6例患者术中、术后均无并发症发生,随访4~13个月,无一例复发。结论:非接触球囊导管标测指导心律失常的心内膜标测与消融是安全有效的,对复杂、难治性心律失常的电生理机制的阐明和指导消融具有较好的临床应用价值。     

Endocardial mapping of right ventricular outflow tract tachycardia using noncontact activation mapping

INTRODUCTION: Activation mapping and pace mapping identify successful ablation sites for catheter ablation of right ventricular outflow tract (RVOT) tachycardia. These methods are limited in patients with nonsustained tachycardia or isolated ventricular ectopic beats. We investigated the feasibility of using noncontact mapping to guide the ablation of RVOT arrhythmias. METHODS AND RESULTS: Nine patients with RVOT tachycardia and three patients with ectopic beats were studied using noncontact mapping. A multielectrode array catheter was introduced into the RVOT and tachycardia was analyzed using a virtual geometry. The earliest endocardial activation estimated by virtual electrograms was displayed on an isopotential color map and measured 33 +/- 13 msec before onset of QRS. Virtual unipolar electrograms at this site demonstrated QS morphology. Guided by a locator signal, ablation was performed with a mean of 6.9 +/- 2.2 radiofrequency deliveries. Acute success was achieved in all patients. During follow-up, one patient had a recurrence of RVOT tachycardia. Compared with patients (n = 21) who underwent catheter ablation using a conventional approach, a higher success rate was achieved by noncontact mapping. Procedure time was significantly longer in the noncontact mapping group. Fluoroscopy time was not significantly different in the two groups. CONCLUSION: Noncontact mapping can be used as a reliable tool to identify the site of earliest endocardial activation and to guide the ablation procedure in patients with RVOT tachycardia and in patients with ectopic beats originating from the RVOT.     

Body surface potential mapping for mapping and treatment of persistent atrial fibrillation

Techniques facilitating individual mapping and ablation of arrhythmogenic substrates are desired to enhance our understanding of persistent atrial fibrillation (persAF) mechanisms as a prerequisite to increasing the success rates of single procedure persAF catheter ablation. The technique of body surface potential mapping (BSM) involves the use of multiple electrodes to collect the potentials over a large body surface area and, with the use of a computed tomography scan, it facilitates their correlation to a 3D model of the atrial structures. During AF,the visualization and localization of AF driver activity, both reentrant and focal wavefronts, is possible with this technique. The ECVUE system from CardioInsight was examined for this indication in clinical studies and showed a termination rate of persAF of 63?% in a large multicenter trial (AFACART) with a promising low recurrence rate during follow-up. From our initial experience, the system appears to be effective in persAF patients who have continuous AF for less than ?1 year. However, the utility of the system for highly challenging cases like long-standing persistent AF and patients with very short AF cycle length remains to be explored. Further studies are needed to confirm these data and answer the multitude of open questions in this field.     

Phylogenetic fate mapping

Cell fate maps describe how the sequence of cell division, migration, and apoptosis transform a zygote into an adult. Yet, it is only in Caenorhabditis elegans where microscopic observation of each cell division has allowed for construction of a complete fate map. More complex, and opaque, animals prove less yielding. DNA replication, however, generates somatic mutations. Consequently, multicellular organisms comprise mosaics where most cells acquire unique genomes that are potentially capable of delineating their ancestry. Here we take a phylogenetic approach to passively retrace embryonic relationships by deducing the order in which mutations have arisen during development. We show that polyguanine repeat DNA sequences are particularly useful genetic markers, because they frequently change length during mitosis. To demonstrate feasibility, we phylogenetically reconstruct the lineage of cultured mouse NIH 3T3 cells based on mutations affecting the length of polyguanine markers. We then employ whole genome amplification to genotype polyguanine markers in single cells taken from a mouse and use phylogenetics to infer the developmental relationships of the sampled tissues. The result is consistent with the present understanding of embryogenesis and demonstrates the large scale potential of this method for producing a complete mammalian cell fate at the resolution of a single cell.     

Degree of mapping for nonlinear mappings of monotone type: Densely defined mapping

The classical degree function constructed earlier for pseudomonotone mappings has been used to develop a broader degree theory of classical type for the sum of a maximal monotone map from a reflexive Banach space to its dual together with a bounded pseudomonotone map. The proof uses the generalized Yosida approximation of the maximal monotone mapping.     

Degree of mapping for nonlinear mappings of monotone type: Strongly nonlinear mapping

The classical degree function constructed earlier for pseudomonotone mappings has been used to develop a broader degree theory of classical type for the sum of a maximal monotone map from a reflexive Banach space to its dual together with a bounded pseudomonotone map. The proof uses the generalized Yosida approximation of the maximal monotone mapping.     

Epicardial isopotential mapping from body surface isopotential mapping in myocardial infarction

It is useful to construct the epicardial isopotential mapping (the Ep Map) from the body surface isopotential mapping (the Body Map) for clinical diagnosis of cardiac disease, even though there are many unsolved problems in using the inverse solution. Yamashita et al. carried out this solution by using the finite element technique. In the present study, the clinical value of that method has been investigated in cases of myocardial infarction. The Ep Maps at 20, 25 and 30 msec. from the beginning of the QRS complex were obtained from the Body Map at the same time by using that method; the infarcted areas on the Ep Map were determined by using Toyama's method which was reported in a previous study. The infarcted area at 30 msec. on the Ep Map was located at the anterior wall along the ventricular septum in anterior infarction and at the posterior wall of the left ventricle in inferoposterior infarction. Patients were independently examined with the scintigram with thallium-201 and the infarcted area was coincident to the location of the abnormal findings of the scintigram. Moreover, the size of the infarcted area on the Ep Map and the size of the abnormal findings of the scintigram were parallel in most cases except one.