左心室流出道持续性室性心动过速伴多个出口1例

心室流出道起源的室性心律失常是比较常见的特发性室性心律失常类型,其中右心室流出道(RVOT)起源最常见(约占特发性室性心律失常的60%~70%),其次是左心室流出道(LVOT,约占10%),射频导管消融(下称消融)治疗安全有效。近期我院收治1例起源于LVOT的持续性室性心动过速伴多个出口现象,并经消融成功治疗,现报道如下。患者男性,59岁,有糖尿病病史3年。患者因心     

心大静脉远端室性心律失常射频消融术的护理

特发性室性心律失常（VAs ）,包括特发性室性期前收缩（PVCs ）和特发性室性心动过速（IVT ）,是最常见的心律失常,大多数为无结构性心脏病。经导管射频消融（RFCA ）是治疗室性心律失常的有效方法,近年来,经心内膜途径导管射频消融治疗PVCs／IVT逐年增加。然而,左心室心外膜VAs起源者经左心室心内膜消融无效而需经心外膜消融才能成功。Daniels等报道心外膜起源IVT的发生率可达9％。     

右室流出道室性心律失常导管消融标测方法

导管消融右室流出道起源的特发性室性心律失常是一种安全有效的治疗方法。右室流出道室性心律失常起源点的标测方法有起搏标测、激动标测、单极电极激动标测、心室局部电压电位标测、双极电极极性反转标测等,综合使用上述方法可提高确定有效消融靶点的精确性,提高导管消融成功率。     

特发性室性心动过速及室性早搏的射频导管消融治疗

特发性室性心动过速(IVT)临床多发生于未发现器质性心脏病的青壮年。主要有右心室流出道室性心动过速(RVOT—VT)和特发性左心室室性心动过速(ILVT)。射频导管消融已成为治疗这类室性心动过速的一种安全、有效的方法。现将1999年5月至2003年1月进行的IVT、室性早搏(室早)的射频导管消融13例报道如下。     

特殊部位特发性室性心动过速的射频消融

对 8例起源于特殊部位的特发性室性心动过速 (简称室速 )的心电图特征及其导管射频消融的方法学进行了分析。 8例患者中男 5例、女 3例 ,心动过速史 3～ 2 0年。室速形态呈右束支阻滞者 4例、呈左束支阻滞者 4例 ;电轴右偏 6例、左偏 2例。结果 :8例患者均射频消融成功 ,消融靶点 2例位于左室流出道左冠窦内 ,距左冠状动脉主干开口约 1cm ,2例位于左室游离壁 ,2例位于左前分支近心尖部 ,2例位于右室流入道游离壁。结果提示导管射频消融对起源于特殊部位的室速也具有较高的成功率 ;左室流出道室速 (LVOT VT)的心电图具有一定的特殊性 ,对LVOT VT进行射频消融时应避免累及冠状动脉左主干     

特发性室性心动过速及室性期前收缩的射频消融治疗

目的探讨射频导管消融(radiofrequency catheter ablation,RFCA)治疗特发性室性心动过速(idiopathic ventricular tachycardia,IVT)和室性期前收缩(premature ventricualr contraction,PVC)可行性、必要性和疗效。方法回顾性分析16例IVT、PVC患者采用激动顺序标测和起搏标测法确定室性心动过速(ventricular tachycardia,VT)、PVC的起源部位并行RFCA治疗的资料。结果 3例IVT中2例起源于左室间隔部左后分支的蒲肯野系统,1例起源于右心室流出道(right ventricular outflow tract,RVOT)游离壁,同时合并另一种游离壁起源的PVC,3例消融均成功,1例复发。13例PVC中7例起源RVOT间隔部,3例起源于RVOT游离壁,1例同时存在两种形态PVC(分别起源于ROVT间隔部和游离壁),2例起源于左心室流出道,13例消融成功,1例复发。结论 RFCA治疗IVT及特定部位的PVC是安全、有效且成功率高的一种方法。     

体表QRS电轴与特发性室性心律失常射频导管消融关系的探讨

目的探讨体表QRS电轴与特发性室性心律失常射频导管消融的关系。方法对65例特发性室性心律失常患者采用激动顺序标测和起搏标测法确定室性搏动起源部位并测量其QRS电轴,分析与消融成功的关系。结果65例中室性心动过速24例(左心室源性18例、右心室源性6例),室性期前收缩41例(右心室流出道起源)。其中18例左心室源性室性心动过速,电轴左偏13例,12例(平均-80°)均一次消融成功,另1例出现两种形态室性心动过速,电轴分别为-55°、-30°,为消融失败;电轴右偏5例(平均227°),只有2例(265°、261°)消融成功。电轴左偏者消融成功率(92.3%)与电轴右偏者(40.0%)比较,差异有显著性意义(P<0.05)。6例右心室源性室性心动过速电轴正常(平均84°),且均消融成功。而41例右心室室性期前收缩中,电轴正常37例(64°～90°)消融成功。4例电轴轻度右偏者2例(97°)消融成功,2例(99°、100°)消融失败。电轴正常消融成功率(100%)与右偏者(50.0%)比较,差异有显著性意义(P<0.05)。结论体表室性QRS电轴对术前判断室性心律失常的起源部位、指导标测和缩短标测时间及推断射频导管消融成功的可能性均具有一定的价值。     

R波移行导联和V2转换率对流出道起源室性心律失常的定位价值

目的 通过回顾性研究对R波移行导联及V2转换率定位流出道起源的室性心律失常(VA)的流程进行准确性验证,旨在寻找一个简洁准确的方法区分右心室流出道(RVOT)和左心室流出道(LVOT)起源的VA.方法 回顾性分析接受射频导管消融治疗的起源于流出道的VA患者心电图资料,计算R波移行导联及V2转换率,并与射频消融结果相比,验证心电图流程的准确性.结果 52例患者中有24例VA时R波移行≥V4导联,均在RVOT消融成功.10例R波移行≤V2导联患者中,9例在LVOT消融成功.18例R波移行在V3导联的患者中,5例VA时胸前导联移行晚于窦性心律时的患者全部在RVOT消融成功,6例V2转换率＜0.6的患者均在RVOT消融成功,而V2转换率≥0.6的7例患者中,5例在LVOT消融成功,2例在RVOT消融成功.该心电图流程定位结果与射频消融定位结果一致性程度高,Kappa值为0.8627,区分RVOT和LVOT起源的VA的正确指数为0.9211.结论 利用R波移行导联及V2转换率相结合的方法能准确区分RVOT和LVOT起源的VA,R波移行≥V4导联和VA时胸前导联移行晚于窦性心律时能100％除外VA起源于LVOT.     

瓣环部起源的特发性室性期前收缩射频导管消融治疗研究

目的探讨瓣环部起源的特发性室性期前收缩患者的体表心电图特点及射频导管消融（下称消融）治疗的疗效与安全性。方法对8例瓣环起源的特发性室性期前收缩患者行消融治疗,并分析其心电图的QRS波群特征。结果所有患者均消融成功。无并发症发生。根据X线影像定位,起源于三尖瓣环侧（游离）壁6例、三尖瓣环前间隔1例、二尖瓣环前侧壁1例。结论消融治疗瓣环部起源的特发性室性期前收缩安全有效,掌握体表心电图特点有助于消融前初步判定其起源部位。     

磁导航指导特发性室性心律失常消融手术的学习曲线分析

目的:评估磁导航指导特发性室性心律失常(idiopathic ventricular arrhythmia,IVA)消融手术的学习曲线及其对手术参数的影响.方法:纳入249例应用磁导航指导IVA消融的患者,比较起始标测右心室(右室组)和起始标测左心室(左室组)的并发症发生率和手术相关参数.按时间顺序将右室组患者的手术时...     

Radiofrequency catheter ablation of idiopathic left ventricular outflow tract tachycardia: utility of intracardiac echocardiography

INTRODUCTION: The site of origin of idiopathic ventricular tachycardia (VT) arising from the left ventricular outflow tract (LVOT) may be closely related to the aortic valve leaflets, and radiofrequency (RF) delivery potentially can damage them. Intracardiac echocardiography (ICE) can identify accurately the ablation electrode and anatomic landmarks, and contact with the endocardium can be easily assessed. The aim of this study was to define the utility and the accuracy of ICE in guiding RF ablation of idiopathic VT of the LVOT. METHODS AND RESULTS: Five consecutive patients (all men; mean age 20.4 years, range 16 to 25) symptomatic for idiopathic VT underwent RF ablation. A 9-French, in-sheath catheter with a 9-MHz ultrasound transducer was inserted through the femoral vein and positioned in the His-bundle region or right ventricular outflow tract to provide a clear view of the aortic root. Local earliest ventricular activation during tachycardia and pace mapping were used to identify the ablation site. Idiopathic VT was ablated successfully in all patients using a median of two RF pulses, delivered during tachycardia. High-resolution images of the aortic valve and ablation electrode were achievable in all cases. Direct vision of ablation electrode-endocardial contact in the outflow tract was assessed easily in all patients. CONCLUSION: Idiopathic VT of the LVOT can be treated successfully with RF ablation. ICE can accurately guide catheter ablation and identify anatomic landmarks, endocardial contact, and ablation electrode movement.     

起源于左右心室流出道心动过速和早搏的射频导管消融治疗

目的 探讨射频导管消融（RFCA）治疗心室流出道特发性室性心动过速（室速）和室性早搏（室早）的临床效果、心电图及电生理特征。方法 58例患者中室速10例,室早48例。起源于右室流出道（RVOT）43例,左室流出道（LVOT）15例,其中起源于主动脉瓣上Valsalva左冠窦（LSV）12例。5例RVOT室速是在非接触标测系统Ensite3000指导下进行消融的。结果 （1）58例患者中55例成功,3例失败,9例复发。（2）其中1例患者术中出现急性心包压塞。（3）起源心室流出道的室速和室早具有典型的心电图特征,其中Ⅱ、Ⅲ、aVF导联单向R波是流出道室性心律失常的共同特点。（4）V1或V2导联的R波时限指数与R／S波幅指数可作为区别LSV与RVOT室速和室早的有效指标。结论 射频导管消融治疗心室流出道特发性室性心律失常是一种安全、有效的方法。非接触标测系统对于血流动力学不稳定的复杂性室性心律失常的标测与治疗具有重要的意义。     

导管射频消融治疗特发性室性心动过速的临床应用

目的评价射频消融治疗特发性室速的有效性和安全性.方法收集2002年1月至2005年1月期间在我院进行射频消融的特发性室性心动过速(IVT)患者34例,右室流出道特发性室速(IRVT)采用起搏标测确定消融耙点,左室特发性室速(ILVT)采用激动顺序标测和起搏标测相结合确定消融靶点.结果其中20例起源于左室间隔部和流出道,14例起源于右室流出道;31例即刻成功,3例失败,成功率91.2%.结论射频消融治疗特发性室性心动过速是安全和有效的.     

Clinical characteristics and catheter ablation of left ventricular outflow tract tachycardia

Left ventricular outflow tract (LVOT) tachycardia is an uncommon form of idiopathic ventricular tachycardia (IVT). The underlying mechanism of this arrhythmia appears to be cyclic AMP-medicated triggered activity. The tachycardia occurs in the absence of structural heart disease and is generally benign, presenting commonly as palpitations and presyncope. It can manifest either a right or left bundle branch block morphology with an inferior axis. Subtle variations in the QRS morphology in leads I, V1, and V2 can help in localizing the anatomic site of origin (SOO). The arrhythmia is typically responsive to a variety of pharmacologic agents (β-blockers, calcium channel blockers, Class I and II agents). Radiofrequency catheter ablation of LVOT tachycardia SOO as determined by pace mapping is quite efficacious (success rates of 90%). Magnetic electroanatomic mapping augments this by permitting three-dimensional catheter mapping and reproducible localization of the SOO. Catheter ablation should be considered relatively early in patients who experience severe symptoms with their arrhythmia and have failed, or are reluctant to take medications for the disorder.     

Earliest activation time is a good predictor of successful ablation of idiopathic outflow tract ventricular arrhythmias

BackgroundIn idiopathic outflow tract ventricular arrhythmias (OT‐VAs), identifying the site with the earliest activation time (EAT) using activation mapping is critical to eliminating the arrhythmogenic focus. However, the optimal EAT for predicting successful radiofrequency catheter ablation (RFCA) has not been established.HypothesisTo evaluate the association between EAT and successful RFCA in idiopathic OT‐VAs and to determine the optimal cut‐off value of EAT for successful ablation.MethodsWe retrospectively analyzed patients undergoing RFCA for idiopathic OT‐VAs at a single center from January 2015 to December 2019.ResultsAcute procedural success was achieved in 168 patients (87.0%). Among these patients, 158 patients (81.9%) were classified in the clinical success group according to the recurrence of clinical VAs during median (Q1, Q3) follow‐up (330 days [182, 808]). EAT was significantly earlier in the clinical success group compared with the recurrence (p = .006) and initial failure (p < .0001) groups. The optimal EAT cut‐off value predicting clinical success was −30 ms in the right ventricular outflow tract (RVOT) with 77.4% sensitivity and 96.4% specificity. In all cases of successful ablation in the left ventricular outflow tract (LVOT), EAT in the RVOT was not earlier than −29 ms.ConclusionsEAT in patients with successful catheter ablation was significantly earlier than that in patients with recurrence and initial failure. EAT earlier than −30 ms could be used as a key predictor of successful catheter ablation as well as an indicator of the need to shift focus from the RVOT to the LVOT.     

Cooled tip ablation of left ventricular outflow tract tachycardia through the aortic sinus of valsalva

BACKGROUND: Monomorphic tachycardia with an epicardial site of the arrhythmic focus in the left ventricular outflow tract (LVOT) usually cannot be ablated by an endocardial approach. We describe the use of cooled tip catheter ablation through the aortic sinus of valsalva to treat LVOT tachycardia. METHODS: In seven patients (four males, one with valvular cardiomyopathy, six patients without heart disease) with sustained and non-sustained ventricular tachycardia (VT) an epicardial focus of LVOT tachycardia could be identified by pace-mapping and earliest local activation within the aortic sinus of valsalva. Coronary angiography served to define the position of the coronary arteries with respect to the ablation catheter. High frequency current was delivered using a closed-loop cooled tip catheter system (Chilli Cool(R), Boston Scientific). ECG, Holter-ECG, echocardiography and transesophageal echocardiography were performed after the procedure and 3 months later. RESULTS: Foci were located in the left (two patients), in the right (three) and in the a coronary aortic sinus (two). Successful ablation could be achieved in six patients. No procedure-related complications could be observed during a mean follow-up of 4.2 months. CONCLUSION: Monomorphic VT with epicardial origin in the LVOT can be successfully treated by cooled tip ablation through the aortic sinus of valsalva. The use of a cooled tip ablation system may be favourable in several ways: 1) it allows the creation of deep lesions necessary to reach remote foci; 2) due to lower temperatures at the catheter/tissue interface surface tissue damage may be reduced; 3) lower catheter temperature may additionally reduce the risk of local clot formation which is crucial for all left-sided procedures and especially for ablation in the sinus of valsalva.     

射频消融治疗室性早搏触发特发性室性心动过速／心室颤动的病例分析

目的探讨射频消融治疗在室性早搏（室早）触发特发性室性心动过速／心室颤动（室速／室颤）中的作用。方法总结3例由室早触发室速／室颤的治疗经验,1例对室早进行射频消融（RF—CA）并植入心律转复除颤器（ICD）,另1例经射频消融未完全消除室早而选择植入ICD,第3例经射频消融成功消除室早,未再发室颤。结果随访2年,3例患者均存活,ICD未再记录到室速／室颤。结论在室早触发室速／室颤病例中,应分析室早与室速／室颤的相关性,给予个体化治疗,射频消融室早可以消除／减少晕厥和室颤的发作。     

Special considerations in mapping and ablation of focal ventricular arrhythmias originating from the left ventricular outflow tract in patients with a transcatheter aortic valve replacement

Transcatheter aortic valve replacements (TAVRs) have been increasingly performed in high‐risk patients with severe aortic stenosis. Focal ventricular arrhythmias (VAs) originating from the left ventricular outflow tract (LVOT) can occur after a TAVR, and radiofrequency catheter ablation (RFCA) should be considered as a treatment option when those VAs are drug‐refractory. There are specific challenges in the RFCA of LVOT VAs after a TAVR because the tubular structure of the TAVR device sits in the LVOT. However, if the anatomical background of the TAVR and LVOT VAs are well understood and the anatomical relationship between the TAVR device and LVOT is sufficiently evaluated, RFCA of LVOT VAs in patients with a TAVR should be safe and highly successful.     

Substrate in the interventricular septum for left ventricular and right ventricular outflow tract tachycardia: ablation from the right side of the septum

Simultaneous epicardial and endocardial mapping demonstrated that in a substantial number of ventricular tachycardias (VTs) endocardial, intramural, and epicardial structures are involved in the substrate of the reentrant circuits. Both right and left ventricular breakthrough has also been described during VT originating in the interventricular septum. We report the case of a patient with a nonischemic left ventricular aneurysm presenting with a left ventricular outflow tract (LVOT) tachycardia and a right ventricular outflow tract (RVOT) tachycardia. Mapping from the anterior interventricular vein and the endocardium of the RVOT revealed mid-diastolic potentials at the epicardium of the LVOT and the endocardium of RVOT, where the criteria of central isthmus sites could be demonstrated. Ablation targeting an isolated late potential during sinus rhythm in RVOT eliminated both the LVOT tachycardia and the RVOT tachycardia. In this patient with a nonischemic left ventricular aneurysm, the substrate of a LVOT tachycardia and RVOT tachycardia is described, and successful catheter ablation of the right and left ventricular tachycardia from the septal wall of RVOT is reported.     

Successful radiofrequency catheter ablation of epicardial left ventricular outflow tract tachycardia from the anterior interventricular coronary vein

We report a case of idiopathic left ventricular outflow tract (LVOT) tachycardia that was eliminated by a radiofrequency application from the anterior interventricular coronary vein (AIV). The ECG exhibited QRS complexes with an inferior axis and atypical left bundle branch block pattern with an early transition of the precordial R waves at V3. Several radiofrequency applications from the coronary cusps and endocardial LVOT were not effective. Radiofrequency applications in the AIV, where the activation preceded the onset of the QRS by 30 msec, successfully eliminated the tachycardia. The AIV may be an optional site for radiofrequency ablation of idiopathic epicardial LVOT tachycardia.