经主动脉窦途径射频消融心动过速临床研究

目的:探讨经主动脉窦途径导管射频消融治愈的快速性心律失常患者的心电图特点及射频消融情况.方法:回顾性分析17例室性心动过速/室性期前收缩、前间隔房性心动过速及前间隔旁路等该类患者的体表心电图、及消融成功时靶点电图等心电生理学特征.结果:经主动脉窦途径导管射频消融治愈室性心动过速/室性期前收缩12例,其中起源于左冠状动脉窦(左冠窦)10例、右冠状动脉窦(右冠窦)2例;源于无冠状动脉窦(无冠窦)的局灶性前间隔房性心动过速3例及前间隔旁路2例.室性心动过速/室性期前收缩心电图特点:Ⅱ、Ⅲ和aVF导联为高大R波,胸导联R波移行较早,V1导联r/S波振幅比≥30%,r波时限(82.2±16.4)ms,V1导联中r/QRS波时限比≥50%,V5、V6导联为高振幅R波、无s波.有效消融靶点心内电图示心室波明显比体表心电图QRS波提前(35.2±21.6)ms.前间隔房性心动过速均能被心房刺激反复诱发和终止,其心电图特点:房性心动过速时P波间期明显窄于窦律时P波间期,Ⅰ、aVL导联P波正向,Ⅱ、Ⅲ和aVF导联P呈负正双向.在心房标测中提示最早的心房激动在希氏(His)束区,但在主动脉无冠窦内标测的心房激动较His束区的心房波提前,其解剖定位于His束上后方,消融靶点无His束电位.前间隔旁路心电图示:窦性心律时呈窄QRS波形,未见预激波,心动过速呈窄QRS形,在无冠窦内记录到最早心房激动点,且无His束电位.17例均消融成功.结论:源于主动脉窦内的室性心动过速/室性期前收缩、前间隔房性心动过速和前间隔旁路具有相对的心内电生理学特征,常规心内膜途径消融困难时应该考虑从主动脉窦途径标测消融策略,把握消融导管与冠状动脉的关系,导管消融治疗安全而有效.     

经主动脉窦消融成功的室性心律失常体表心电图特点

目的分析经主动脉窦消融成功的室性心律失常体表心电图特点。方法 36例频发室性早搏/非持续性室性心动过速(PVCs/NSVT)的患者经主动脉逆行途径,在CARTO三维电解剖标测指导下,在主动脉根部-左室流出道衔接部进行三维解剖重建、激动顺序标测和指导消融,且消融成功(1例部分成功),并分析其体表心电图特点。结果 36例患者,经左冠窦消融成功30例(83.3%),右冠窦6例(16.7%)。PVCs在体表心电图均表现心电轴下偏的反复单一形态的QRS波形。经左冠窦消融成功的PVCs/NSVT,Ⅰ导联为R、Rs、rS、r、q或rsr波,Ⅱ、Ⅲ、aVF导联均为高振幅R波,胸前导联PVCs R波移行区位于V_1~V_3导联,且PVCs移行区均早于窦性心律移行区,V_1导联表现为R、Rs、RS、rS或qr波,V_1或V_2导联R/S波幅指数2.64±2.03,R波时限指数0.62±0.12,Ⅲ导联与Ⅱ导联R波振幅比(RⅢ/RⅡ)1.09±0.18,aVL导联与aVR导联QS波振幅比(QSaVL/QSaVR)1.32±0.46。经右冠窦消融成功的PVCs/NSVT,Ⅰ导联为R、Rs、r波,Ⅱ、Ⅲ、aVF导联均为高振幅R波,胸前导联PVCs R波移行区位于V_1~V_3导联,V_1导联表现为R、Rs、rS波,V_1或V_2导联R/S波幅指数0.51±0.38,R波时限指数0.55±0.26,RⅢ/RⅡ0.95±0.23,QSaVL/QSaVR1.12±0.39。PVCs经左冠窦消融成功的V_1或V_2导联R/S波幅指数要高于右冠窦(P<0.05)。结论经左冠窦消融成功的室性心律失常多于右冠窦。体表心电图的相关特征有助于决策主动脉窦内的室性心律失常的具体消融部位。     

主动脉无冠状动脉窦内射频消融治疗频发室性早搏和(或)短阵室性心动过速三例

报道3例无冠状动脉窦内射频消融频发室性早搏和短阵室性心动过速的心电图特点和射频消融结果。室性早搏或室性心动过速均呈左束支传导阻滞图形,胸导联V3R/S>1,1例Ⅰ导联呈现R波,2例Ⅰ导联呈顿挫r波,Ⅱ、Ⅲ、aVF均为高大R波,标测消融确定成功靶点在无冠状动脉窦,术中无并发症,随访20~29个月,1例偶发室性早搏。结论:在主动脉无冠状动脉窦内射频消融是可行的。     

起源于主动脉窦与二尖瓣环交界处的室性心律失常心电图特征及射频消融

目的研究起源于主动脉窦与二尖瓣环交界处(AMC)室性心律失常的心电图特点及射频消融。方法观察6例起源于AMC的室性心律失常患者心电图特征及射频消融。结果 41例室性心律失常患者成功完成射频消融并且证实其起源部位,其中6例起源于AMC。仅有起源于AMC的室性心律失常心电图表现为右束支传导阻滞,QRS波电轴右偏,V1～V6导联中见到R或Rs波形,下壁导联振幅较高,Ⅰ导联呈Rs或rs形,RⅡ/RⅢ<1。三维激动扩布图可见始于AMC的波阵扩布,随后沿AMC传导至主动脉根部及左室,成功靶点消融时间短于左、右室流出道室性心律失常。结论室性心律失常时V1～V6出现R或Rs波形提示其起源于AMC,射频消融治疗安全、有效。     

特发性左室流出道室性心律失常的心电图特点

探讨特发性左室流出道室性心律失常患者的心电图特点。对 7例特发性左室流出道室性早搏 (简称室早 )、室性心动过速 (简称室速 )患者进行心电图分析 ,并行心内电生理检查及射频消融治疗 ,同时对 10例预激综合征患者成功消融房室旁道后行主动脉瓣上及瓣下起搏 ,记录同步 12导联起搏心电图。对比分析两组病例体表心电图QRS波图形特点。结果 :7例左室流出道室早、室速患者经心内电生理检查证实 6例起源于冠状动脉窦内 ,1例起源于左室流出道主动脉瓣右瓣下方 ,所有患者经射频消融成功治疗室性心律失常。对照组 10例在主动脉瓣下起搏(其中 6例同时在主动脉瓣上起搏 )获得同步 12导联起搏心电图。两组病例体表心电图共同特点为 :QRS波额面电轴向下 ,Ⅱ、Ⅲ、aVF导联主波向上 ,QRS波在V2 或V3 前移行为Rs或R型。结论 :左室流出道为特发性室早、室速发生部位之一 ,体表心电图有其独特性 ,导管射频消融治疗安全有效。     

EnSiteNavX三维标测系统指导主动脉窦起源的室性心律失常的消融

目的对主动脉窦起源的室性心律失常进行标测和消融需要准确和安全。本研究尝试采用EnSiteNavX标测技术对起源于主动脉窦的室性心动过速（室速）和／或室性早搏（室早）进行消融。方法运用NavX标测系统构建主动脉窦、升主动脉及冠状动脉开口的三维电解剖及激动顺序图,同时进行冠状动脉造影,以确认NavX导航的准确性。结合传统的电生理标测,射频消融治疗24例主动脉窦起源的室早和／或室速。结果24例均射频消融成功,其中,左冠窦内起源16例,右冠窦内起源4例,左、右冠窦问起源4例,术中和术后无并发症。消融时间及x线曝光时间（包括冠状动脉造影时间）分别为（56．1±18．3）min、（11．2±6．8）min。1例患者消融前发现合并左旋支中段狭窄,消融术后成功行支架术。平均随访（16_＋12）个月,1例室速患者有室早复发,再次消融成功。结论NavX标测技术可以代替冠状动脉造影,指导主动脉窦起源的室早和／或室速的标测和消融。     

起源于主动脉左冠窦室性早搏的射频消融治疗

目的探讨导管射频消融治疗起源于主动脉左冠窦室性早搏的方法和疗效。方法对11例起源于主动脉左冠窦的室早患者行射频消融治疗。采用激动顺序标测,靶点V波较体表心电图QRS波群提前20～45 ms,温控大头导管温度65℃～70℃,功率30～50 W,放电120～240 S。分别在左冠窦内或主动脉瓣下近左冠窦底标测消融,术中同时做左冠状动脉造影。结果靶点位于主动脉左冠窦内左冠状动脉开口下方1～2 cm者8例,消融室早消失,即刻成功率为100%。3例标测未见V波较体表心电图QRS波群明显提前,消融未见室早减少,在主动脉瓣下近左冠窦底标测到提前20～35 ms,消融室早消失,即刻成功率为100%。术中及术后无并发症发生。术后1个月内,11例患者复查动态心电图,室早消失,2例患者见偶发室旱(分别是26次/d和10次/d),但形态非左冠窦起源室早。随访6～36个月无复发。结论射频消融治疗起源于主动脉左冠窦的室早安全有效,如窦内标测消融不佳,应在主动脉瓣下近窦底处标测消融可提高成功率,同时行左冠状动脉造影可有效的避免严重并发症的发生和指导标测。     

起源于主动脉窦内的房性心动过速、频发室性早搏的射频消融治疗

目的报道4例局灶性房性心动过速（房速）,3例频发室性早搏（室早）经主动脉途径在左冠窦和无冠窦内标测和射频消融的结果。方法对4例房速、3例频发室早进行常规心电图、心内电生理检查和射频消融治疗。结果4例阵发性房速患者的标测靶点位于主动脉窦内,在无冠窦成功消融;3例频发室早在左冠窦内标测及消融成功。术中无并发症,随访3～31个月,无1例复发。结论在主动脉无冠窦、左冠窦内射频消融是可行的且能达到安全、有效的治疗目的。尤其适用于在常规、经典部位消融失败的患者。     

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。     

主动脉左冠状窦内消融室性早搏导致严重心绞痛及心电图缺血改变一例

起源于主动脉左冠状窦附近的室性心动过速(室速)、室性早搏(室早)是新近发现的一种特发性室性心律失常，在主动脉左冠状窦附近消融可以获得成功。在此部位消融出现冠状动脉损伤少见报告，现报告在左冠状窦内消融频发室早导致严重心绞痛及心电图缺血改变1例。     

心室流出道频发室性早搏、室性心动过速的心电图特征及射频消融治疗

目的探讨心室流出道频发室性早搏和/或室性心动过速的心电图特征及射频消融治疗的有效性及安全性。方法对14例(13例右心室流出道频发室性早搏和/或室性心动过速,1例左心室流出道频发室性早搏)的心电图特征进行分析并行射频消融治疗。结果右心室流出道室性早搏及室性心动过速体表12导联心电图QRS波特征:Ⅰ导联呈rs、m、QS及R型,aVRa、VL均呈QS型,Ⅱ、Ⅲ、aVF、V5-6导联均呈单向R波型,胸前导联R波移行区常在V3、V3导联之后,V1、V2导联R高度/S高度比值常<0.3。左心室流出道频发室性早搏和/或室性心动过速的QRS波特征与右心室流出道频发室性早搏和/或室性心动过速类似,但其胸前导联R波移行区常在V2导联之前,V1、V2导联(尤其V2导联)R高度/S高度比值常≥0.8。13例消融成功,手术操作时间45~156min,X线曝光时间8~28min。术后随访2~36个月,无复发病例。结论起源于心室流出道的频发室性早搏和/或室性心动过速有其独特的心电图表现,射频消融治疗能安全、有效地根治此类心律失常。     

右心室间隔部希氏束附近室性期前收缩心电图与射频消融

目的 报道右心室流入道间隔部希氏束附近起源室性期前收缩体表心电图特征及射频消融效果。方法 无器质性心脏病频发性室性期前收缩5例,分析其12导联体表心电图室性期前收缩特点;病人接受心内电生理检查,于右心室流入道行激动与起搏标测,以心室激动较体表QRS波提早、消融导管远端起搏图形与体表心电图室性期前收缩相似部位为消融靶点。结果 室性期前收缩QRS波形态：5例病人Ⅰ导联和Ⅱ导联QRS波均呈R型,Ⅲ导联、aVF导联以低振幅波为主,V1导联均呈QS型,胸导联较早转变成qR或R型（发生于V2或V3）,V5、V6均呈高R型;室性期前收缩QRS波时限为110～120ms。5例病人分别于前间隔（2例）、中间隔（1例）、后间隔（2例）标测到消融靶点,放电后前间隔部、后间隔部病人室性期前收缩均消失,中间隔病人消融失败。无房室传导阻滞并发症。随访8～30个月,成功病例未应用抗心律失常药物,无室性期前收缩发作。结论 右心室流入道间隔部希氏束附近起源室性期前收缩体表心电图具有明显的特征,认识这些特征有助于导管标测与射频消融,消融此部位室性期前收缩安全、有效。     

右室流出道室性心律失常的射频导管消融体会

目的报道右室流出道(RVOT)室性心律失常的射频导管消融(RFCA)体会。方法43例RVOT室性心律失常患者男18例、女25例,年龄39.2±15.1(13～67)岁。经血液生化、胸片、心脏彩超等检查证实无器质性心脏病证据。其中室性心动过速(VT)8例,室性早搏(PVC)35例。38例采用传统的起搏与激动标测。5例VT是在非接触标测系统EnSite3000指导下进行消融治疗的。结果①间隔部起源40例,游离壁起源3例。42例成功,1例失败,成功率97.7%,9例复发,再次标测消融后成功。②RVOT起源的VT和PVC具有典型的心电图特征,表现为典型的左束支传导阻滞型伴电轴右偏。RVOT的起源点不同,其12导联心电图特征不同,Ⅰ、Ⅱ、Ⅲ和aVF导联呈RR′型,V1～V3具有深S波是游离壁起源的特征。③1例术中出现急性心包压塞,其心电图虽具有RVOT起源的特征,但Ⅱ、Ⅲ和aVF导联R波振幅异常增高。结论RVOT室性心律失常具有典型的心电图和电生理特征,RFCA是一种安全、有效的治疗方法。EnSite3000非接触标测系统定位快速准确,适用于血流动力学不稳定的复杂性心律失常的标测。     

Electrocardiographic characteristics of repetitive monomorphic right ventricular tachycardia originating near the His-bundle

INTRODUCTION: Most idiopathic nonreentrant ventricular tachycardia (VT) and ventricular premature contractions (VPCs) arise from the right or left ventricular outflow tract (OT). However, some right ventricular (RV) VT/VPCs originate near the His-bundle region. The aim of this study was to investigate ECG characteristics of VT/VPCs originating near the His-bundle in comparison with right ventricular outflow tract (RVOT)-VT/VPCs. METHODS AND RESULTS: Ninety RV-VT/VPC patients underwent catheter mapping and radiofrequency ablation. ECG variables were compared between VT/VPCs originating from the RVOT and near the His-bundle. Ten patients had foci near the His-bundle (HIS group), with the His-bundle local ventricular electrogram preceding the QRS onset by 15-35 msec (mean: 22 msec) and His-bundle pacing produced a nearly identical ECG to clinical VT/VPCs. The HIS group R wave amplitude in the inferior leads (lead III: 1.0 +/- 0.6 mV) was significantly lower than that of the RVOT group (1.7 +/- 0.4 mV, P < 0.05). An R wave in aVL was present in 6 of 10 HIS group patients, while almost all RVOT group patients had a QS pattern in aVL. Lead I in HIS group exhibited significantly taller R wave amplitudes than RVOT group. HIS group QRS duration in the inferior leads was shorter than that of the RVOT group. Eight of 10 HIS group patients exhibited a QS pattern in lead V1 compared to 14 of 81 RVOT group patients. HIS group had larger R wave amplitudes in leads V5 and V6 than RVOT group. CONCLUSION: VT/VPCs originating near the His-bundle have distinctive ECG characteristics. Knowledge of the characteristic QRS morphology may facilitate catheter mapping and successful ablation.     

Electrocardiographic and electrophysiologic characteristics of ventricular tachycardia originating within the pulmonary artery

OBJECTIVES: We investigated the electrocardiographic (ECG) and electrophysiologic characteristics of ventricular tachycardia (VT) originating within the pulmonary artery (PA). BACKGROUND: Radiofrequency catheter ablation (RFCA) is routinely applied to the endocardial surface of the right ventricular outflow tract (RVOT) in patients with idiopathic VT of left bundle branch block morphology. It was recently reported that this arrhythmia may originate within the PA. METHODS: Activation mapping and ECG analysis were performed in 24 patients whose VTs or ventricular premature contractions (VPCs) were successfully ablated within the PA (PA group) and in 48 patients whose VTs or VPCs were successfully ablated from the endocardial surface of the RVOT (RV-end-OT group). RESULTS: R-wave amplitudes on inferior ECG leads, aVL/aVR ratio of Q-wave amplitude, and R/S ratio on lead V(2) were significantly larger in the PA group than in the RV-end-OT group. On intracardiac electrograms, atrial potentials were more frequently recorded in the PA group than in the RV-end-OT group (58% vs. 12%; p < 0.01). The amplitude of local ventricular potentials recorded during sinus rhythm within the PA was significantly lower than that recorded from the RV-end-OT (0.62 +/- 0.56 mV vs. 1.55 +/- 0.88 mV; p < 0.01). CONCLUSIONS: Ventricular tachycardia originating within the PA has different electrocardiographic and electrophysiologic characteristics from that originating from the RV-end-OT. When mapping the RVOT area, the catheter may be located within the PA if a low-voltage atrial or local ventricular potential of <1-mV amplitude is recorded. Heightened attention must be paid if RFCA is required within the PA.     

起源于左主动脉窦的室性心律失常的心电生理特点和消融治疗

目的报道21例起源于左主动脉窦的室性心律失常的心电生理特征和射频消融疗效。方法分析术前体表心电图(ECG)和Holter心电图室性早搏(VPB)或室性心动过速(VT)的形态特点,测量V1导联r波振幅和时限,计算r与QRS波的振幅和时限比值。术中在自发VPB或VT时标测主动脉窦,以局部室波最早部位放电消融,并进行冠状动脉造影,测量消融靶点距左冠状动脉口的距离。结果21例均有频发VPB,8例有反复短阵VT。VPB或VT在Ⅱ、Ⅲ、aVF导联为高大R波,V1导联r波振幅为QRS波的1/3或以上,r波时限87.5±9.5 m s,为QRS波时限的1/2以上。V3导联多为R s形,V5、V6导联无S波。有效消融靶点局部电图室波明显超前ECG的QRS波(36.2±12.2 m s),距左冠状动脉口部1 cm左右。有效靶点放电2~8 s VPB消失或VT终止。结论起源于左主动脉窦的VPB或VT其Ⅱ、Ⅲ、aVF导联为高大R波,V1导联r波振幅高(≥1/3QRS波),时限宽(≥1/2QRS波);主动脉窦激动顺序标测可安全有效地指导消融治疗。     

Ventricular tachycardias mimicking those arising from the right ventricular outflow tract

INTRODUCTION: Ablation of ventricular tachycardia (VT) arising from the right ventricular outflow tract (RVOT) has proven highly successful, yet VTs with similar ECG features may originate outside the RVOT. METHODS AND RESULTS: We reviewed the clinical, echocardiographic, and ECG findings of 29 consecutive patients referred for ablation of monomorphic VT having a left bundle branch block pattern in lead V1 and tall monophasic R waves inferiorly. Nineteen patients (group A) had VTs ablated from the RVOT, and 10 patients (group B) had VTs that could not be ablated from the RVOT. The QRS morphology during VT or frequent ventricular premature complexes was the only variable that distinguished the two groups. During the target arrhythmia, ECGs of group B patients displayed earlier precordial transition zones (median V3 vs V5; P < 0.001), more rightward axes (90 +/- 4 vs 83 +/- 5; P = 0.002), taller R waves inferiorly (aVF: 1.9 +/- 1.0 vs 2.4 +/- 0.5; P = 0.020) and small R waves in lead V1 (10/10 vs 9/19; P = 0.011). Radiofrequency catheter ablation from the RVOT failed to eliminate VT in any group B patient, but ablation from the left ventricular outflow tract (LVOT) eliminated VT in 2 of 6 patients in whom left ventricular ablation was attempted. CONCLUSION: The absence of an R wave in lead V1 and a late precordial transition zone suggest an RVOT origin of VT, whereas an early precordial transition zone characterizes VTs that mimic an RVOT origin. The latter VTs occasionally can be ablated from the LVOT. Recognition of these ECG features may help the physician advise patients and direct one's approach to ablation.     

体表心电图特征对特发性右心室流出道室性心动过速和室性早搏起源点的定位价值

目的 起源于右心室流出道(RVOT)不同位点的室性心动过速(VT)具有相应的心电图表现,本研究旨在摸索一种相对简单的根据体表心电图进行定位的方法 .方法 将RVOT分为游离壁和间隔而两大区,其中间隔面又分为9个区域.共320例RVOT-VT患者中,对213例既往消融成功患者的靶点与体表12导联心电图中QRS波形态之间的关系进行分析,并在消融前前瞻性地对另外107例患者的消融靶点进行预测,以检验其定位价值.结果 I导联对RVOT起源的VT有特殊的定位价值.在间隔面前部起源时,I导联以负向波为主,多为QS、Qr及rS型,随着起源点从前向后、从上向下,R波逐渐升高,其中起源于间隔侧中带(2、5、8区)时,以"M"型居多,在后壁时则表现为R波且有切迹.游离壁起源者的QRS时限明显延长,I和aVL导联的R波较间隔起源者高,而下壁导联的R波均较间隔的低(P<0.05).在前瞻性分析中,这些参数的敏感度、特异度、阳性和阴性预测值均较高.结论 RV-OT不同部位起源的VT有相应的心电图特征,其中I导联形态尤其具有定位价值,为RVOT心律失常起源提供了简便的定位标准.     

How to diagnose,locate, and ablate coronary cusp ventricular tachycardia

INTRODUCTION: Although radiofrequency energy usually is applied to the most favorable endocardial site in patients with outflow tract ventricular tachycardia, there are still some patients in whom the tachycardia can be ablated only from an epicardial site. We established the characteristics and technique of catheter ablation from both the left and right coronary cusps to cure left ventricular outflow tract ventricular tachycardia. METHODS AND RESULTS: We studied 15 patients in whom VT was thought to originate from the coronary cusp by both activation and pace mapping after precise mapping of the right ventricle, left ventricle, pulmonary artery, coronary cusps, and anterior interventricular vein. Twelve-lead ECG analysis revealed an S wave on lead I, tall R wave on leads II, III, and aVF, and no S wave on either lead V5 or V6. Precordial R wave transition occurred on leads V1 and V2. The earliest ventricular electrogram at a successful ablation site was recorded 35+/-12 msec before QRS onset and 19+/-15 msec earlier than the earliest ventricular electrogram recorded from the anterior interventricular vein. Almost identical pace mappings were obtained from the coronary cusp. Catheter tip temperature was maintained at 55 degrees C during energy delivery, and the distance from the tip to the ostium of each left and right coronary artery was > 1.0 cm by coronary angiography. CONCLUSION: Left ventricular outflow tract VT that could not be ablated from an endocardial site could be safely eliminated by radiofrequency application to the left and right coronary cusps.