室性早搏性心肌病的相关危险因素分析

目的:分析室性早搏性心肌病的相关危险因素以及射频导管消融治疗的可行性。方法:功能性频发单源室性早搏成功进行射频消融治疗的患者192例,其中单纯室性早搏组141例、室性早搏性心肌病组51例,分析2组患者性别、年龄、病程、体重指数、室性早搏数量及来源、是否合并室性心动过速等特点并进行比较。结果:与单纯室性早搏组比较,室性早搏性心肌病组男性更为多见(P0.01),体重指数更高(P0.01),室性早搏总负荷量更大(P0.05),合并室性心动过速的比例更高(P0.01)。结论:无其它器质性心脏病的频发室性早搏患者中,男性、室性早搏总负荷量较大、体重指数较高、合并室性心动过速可能是室性早搏性心肌病的高危因素。室性早搏性心肌病行室性早搏射频导管消融术安全、有效。     

射频消融室性早搏逆转心动过速性心肌病七例

目的总结室性早搏(简称室早)导致的心动过速性心肌病的临床特点及射频消融疗效。方法频发单源性室早导致的心动过速性心肌病7例,长程心电图示24 h总早搏个数为33 117±11 173个,均行射频消融治疗室早。分析其临床特点并观察术前术后超声及长程心电图各项指标的变化。结果射频消融室早后6个月,心功能(NYHA分级)明显改善(1.0±0.12级vs 2.2±1.1级,P<0.01);左室舒张末期内径变小(45±9 mm vs 59±15mm,P<0.01);左室射血分数增高(0.55±0.09 vs 0.40±0.08,P<0.01)。结论频发室早可引起心动过速心肌病,射频消融室早可逆转心肌病。     

室性早搏消融对扩张型心肌病患者心功能的影响

[摘 要 ] 目的：观察对于扩张型心肌病伴有频繁室性早搏患者,相比药物治疗,导管消融治疗室性早搏能否改善患者心功能。方法：入选从2014年3月-2016年5月入选于河北医科大学第二医院住院治疗的伴有频发单形性室性早搏（大于1万/24h）的扩张型心肌病患者。所有患者随机分为两组：一组为导管消融组,一组为药物治疗组。导管消融组在传统的药物治疗基础上接受三维标测系统指导下的室性早搏导管消融术;药物组只接受传统的药物治疗,包括改善心衰症状和改善心室重构的药物。药物治疗组的室性早搏的治疗首选β-受体阻滞剂,若效果不佳,加用胺碘酮。所有患者术前接受24小时动态心电图、心脏超声检查,心功能分级采用纽约心功能分级(NYHA)方法。所有患者出院后第一个月门诊随访一次,随后第3个月及第6个月各随访一次,随访时接受心脏超声、24小时动态心电图检查和心功能分级评估。结果：共入选102例患者,其中导管消融组50例,药物治疗组52例。平均随访16±5.6个月,导管消融组手术成功率94%（包含二次手术患者）,室性早搏数量（15672±4567个/24h vs 1001±234个/24h）明显减少,心功能状态明显好转（2.6±1.1 VS 1.4±0.5 p=0.001）,左室射血分数明显提高（0.33±0.07 vs 0.43±0.03）。药物治疗组随访结束时早搏数量（15373±3556个/24h vs 14980±3789个/24h）,心功能分级（2.7±1.0 VS 2.9±0.8 p=0.12）,和左室射血分数（0.34±0.06vs 0.30±0.05）无明显改变。导管消融组的心功能（1.4±0.5 vs 2.9±0.8 p=0.001） 、左室舒张末内径（57±4mm vs 67±9mm p=0.001）左室射血分数（0.43±0.03 vs 0.30±0.05 p=0.001）明显优于药物治疗组。结论：对于扩张型心肌病患者,相比药物治疗,通过导管消融治疗室性早搏可明显改善患者心功能。 [关键词]：室性早搏 导管消融 扩张型心肌病     

左室扩大合并室性心律失常的诊断与治疗

左室扩大合并频发室性心律失常在临床中比较常见，可见于各种心肌病和冠心病心肌梗死后，多认为该室性心律失常为继发性，通常以药物治疗为主，必要时植入埋藏式心脏除颤器（ICD），但疗效欠佳。近年来，提出频发室性早搏/室性心动过速可导致室早性心肌病的概念[1-3]，因此，任何左室扩大合并频发室性心律失常的患者都不能轻易否定室早性心肌病。我们近期遇到1例年轻的女性患者，多年来一直诊断为“扩张型心肌病 频发室早 短阵室速”，药物疗效欠佳，后成功进行室性早搏的射频导管消融术而短期内治愈，最后诊断为“室早性心肌病。”     

频发室性早搏射频消融治疗前后左室功能和结构的变化

探讨频发室性早搏(简称室早)射频消融治疗前后左室功能和结构的变化。按有一定功能和结构变化的标准收集成功行射频消融治疗的频发室早56例。比较手术前、后NYHA心功能分级、超声心动图有关参数的变化。与术前比较,消融治疗后,24h室早总数由术前23 662±12 559个减少为125±113个;患者胸闷、心悸症状缓解;NYHA心功能分级较前改善(P<0.05);超声心动图腔室结构参数明显缩小;左室射血分数显著提高(P<0.05)。结论射频消融可改善频发室早引起的心脏结构重构和功能减退。     

射频消融治疗起源于左室流出道的非持续性室性心动过速和频发性室性早搏

目的观察左室流出道非持续性室性心动过速（室速）和频发性室性早搏患者的射频消融治疗结果,探讨此类患者的射频消融指证。方法５例患者因非持续性室速和频发性室性早搏而引起明显临床症状,药物治疗无效。采用起搏标测法确定室速和室性早搏的起源部位,并射频消融治疗。结果在升主动脉瓣左窦下方的左室流出道记录到提前（３１±４）ｍｓ的心室激动,起搏心电图１２导联ＱＲＳ波形与室速和室性早搏形态完全相同者４例,１１导联相同者１例,该部位消融后５例患者的室速和室性早搏不被诱发。随访１３±６个月,除１例患者复发,另４例的临床症状明显改善。结论射频消融治疗左室流出道非持续性室速和室性早搏安全有效,但应严格掌握适应证。     

射频导管消融治疗非器质性心脏病患者的顽固性频发室性早搏

目的 :报道顽固性频发室性早搏的射频导管消融治疗结果。　　方法 :采用起搏标测法 ,射频导管消融治疗 12例非器质性心脏病患者的顽固性频发室性早搏。　　结果 :12例患者均消融成功 ,平均放电 3.2± 2 .3次。术后室性早搏总数由术前的 2 86 17± 42 88个 /天减至0～ 2个 /天 ,患者症状基本消失。随访 12个月 ,室性早搏≤ 5个 /天。　　结论 :射频导管消融可用于药物治疗无效而症状明显的频发单形性室性早搏。     

室性早搏性心肌病

长期频发室性早搏(尤其是>10 000次/24 h)可引起心肌病,其临床特征类似于扩张型心肌病,消除室性早搏后心肌病变可以逆转,称为室性早搏性心肌病。这类心肌病的发病机制尚不清楚,可能与室性早搏导致心脏机械性收缩、电激动不同步,心室负荷过大,激活神经体液机制,心脏有效泵血量减少及舒张功能减退等有关。室性早搏的负荷是心肌病的重要影响因素。目前诊断室性早搏性心肌病,多是回顾性诊断。如消除室性早搏后心肌病变可逆转,即可确诊。恰当的药物或导管射频消融治疗能清除或减少室性早搏,改善心功能。     

起源于左室流出道的频发性室性早搏射频消融治疗

目的:观察左室流出道频发室性早搏的射频消融治疗效果。方法:8例频发室性早搏患者,药物治疗无效,采用激动标测和起搏标测法确定室性早搏的起源部位,并行射频消融治疗。结果:8例患者7例射频消融成功。7例中6例在主动脉瓣下方的左室流出道记录到提前(31±8)ms的心室激动,室性早搏形态与起搏心电图12导联QRS波形完全相同者5例,11导联相同者1例;1例在左冠窦内记录到提前33ms的心室激动,属左室流出道室性早搏特殊类型,消融成功。随访3～21个月未复发。1例左室流出道早搏因多处标测未找到理想的靶点,消融失败。结论:射频消融治疗左室流出道室性早搏安全有效。     

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。     

Comparison of the results of programmed ventricular stimulation from the right ventricular apex and outflow tract: a randomized, prospective study

Objective: The aim of this prospective study was to analysethe yield of programmed ventricular stimulation at the rightventricular apex compared with the outflow tract. Methods: A stepwise randomized cross-over protocol of programmedventricular stimulation with alternating stimulation at bothsites was used in 66 patients who were studied because of sustainedventricular tachycardia (n = 30), ventricular fibrillation (n= 7), or non-sustained ventricular tachycardia and/or syncope(n = 29). Results: There were no significant differences between the resultsof stimulation from either right ventricular site with regardto the presence or absence of structural heart disease, spontaneousarrhythmia, ejection fraction or effective refractory periods.Overall, monomorphic ventricular tachycardia was inducible in33 patients (50%); in 25 patients (75.8%), this arrhythmia wasinduced from both sites. However, in only 17 of these 25 patients(68%) did the induced monomorphic ventricular tachycardias havethe same morphologies and similar (± 50 ms) cycle lengths.Ventricular fibrillation was inducible in 11 patients (17%),mostly by three extrastimuli (n=8; 73%). Conclusions: (1) stimulation from at least two right ventricularsites is desirable because of their independent contributionto the induction of ventricular tachyarrythmias, (2) the non-inducibilityor inducibility at one ventricular site does not predict theeffect at another stimulation site, (3) the effective refractoryperiod at the right ventricular apex and outflow tract do notdiffer, (4) the inducibility of multiple ventricular tachycardiamorphologies emphasizes the importance of documenting the causeof spontaneous arrhythmias with multiple electrocardiographicleads to ensure the correct interpretation of arrhythmias inducedby programmed stimulation, (5) clinical or haemodynamic featurescannot predict whether one or more stimulation sites will berequired for induction of ventricular tachycardia. These resultsare important for the diagnostic evaluation and assessment ofpharmacological or non-pharmacological interventions.     

特发性右心室流出道室性心动过速/室性早搏的性别、年龄和临床特点

Objective The aim of this study was to clarify gender,age and clinical feature of idiopathic right ventricular outflow tract ventricular tachycardia/premature ventricular complexes(ROVT/PVC). Methods We studied 478 patients[mean age(39. 8 ± 13. 8)years]with idiopathic ROVT/PVC who were admitted to our center consecutively in past 15 years. All of them underwent catheter mapping and radiofrequency catheter ablation (RFCA), and the original sites of ventricular tachycardia/premature ventricular complexes were confirmed by catheter mapping and radiofrequency catheter ablation. Results Of 478 patients, 288 patients (60. 3% )were female, 190 patients(39. 7% )were male, female/male ratio was 1.52. The early onset of symptom was at (41.2 ± 12. 7 ) years for female, and ( 37.6 ± 15. 0) years for male ( P ＜ 0. 05 ). Almost all patients had palpitation in varying degrees. Sixty-seven of 478 patients( 14.2% ) had history of near-syncope,and 13 of 478 patients(2. 7% )had history of syncope. Two hundred and sixty-three patients( 55% )underwent unsuccessful treatment with antiarrhythmic drugs before the radiofrequency ablation. Of them, 110 patients (23%)had received one kind of antiarrhythmic drug, 104 patients (21.8%)had received two types of antiarrhythmic drugs,49 patients( 10. 3% )had received three types of antiarrhythmic drugs. Conclusion ROVT/VPC occur more in female than in male,the early onset of symptom is older for female than for male. Almost all patients have symptom in varying degrees, some of them have near-syncope or syncope.     

特发性右心室流出道室性心动过速/室性早搏的性别、年龄和临床特点

Objective The aim of this study was to clarify gender,age and clinical feature of idiopathic right ventricular outflow tract ventricular tachycardia/premature ventricular complexes(ROVT/PVC). Methods We studied 478 patients[mean age(39. 8 ± 13. 8)years]with idiopathic ROVT/PVC who were admitted to our center consecutively in past 15 years. All of them underwent catheter mapping and radiofrequency catheter ablation (RFCA), and the original sites of ventricular tachycardia/premature ventricular complexes were confirmed by catheter mapping and radiofrequency catheter ablation. Results Of 478 patients, 288 patients (60. 3% )were female, 190 patients(39. 7% )were male, female/male ratio was 1.52. The early onset of symptom was at (41.2 ± 12. 7 ) years for female, and ( 37.6 ± 15. 0) years for male ( P ＜ 0. 05 ). Almost all patients had palpitation in varying degrees. Sixty-seven of 478 patients( 14.2% ) had history of near-syncope,and 13 of 478 patients(2. 7% )had history of syncope. Two hundred and sixty-three patients( 55% )underwent unsuccessful treatment with antiarrhythmic drugs before the radiofrequency ablation. Of them, 110 patients (23%)had received one kind of antiarrhythmic drug, 104 patients (21.8%)had received two types of antiarrhythmic drugs,49 patients( 10. 3% )had received three types of antiarrhythmic drugs. Conclusion ROVT/VPC occur more in female than in male,the early onset of symptom is older for female than for male. Almost all patients have symptom in varying degrees, some of them have near-syncope or syncope.     

Idiopathic Left Ventricular Aneurysm: An Unusual Substrate of Ventricular Fibrillation and Ventricular Tachycardia

Idiopathic left ventricular aneurysm (LVA) is a very rare clinical condition. This article describes a patient with idiopathic LVA associated with episodes of ventricular tachycardia and ventricular fibrillation. Clinical and instrumental examinations did not reveal the pathogenesis of the aneurysm. The malignant clinical course suggests that an aggressive antiarrhythmic treatment, including ICD implantation, may be warranted.     

Effect of Basic Drive Train Cycle Length on Induction of Ventricular Tachycardia by a Single Extrastimulus

This study determined the effects of a wide range of basic drive cycle lengths on the induction of ventricular tachycardia (VT) by a single extrastimulus (S₂). Seventy-one patients with coronary artery disease and inducible sustained monomorphic VT underwent 121 electrophysiology tests either in the control state or during treatment with an antiarrhythmic drug. Ventricular basic drive trains were eight beats in duration and the intertrain interval was three seconds. Programmed ventricular stimulation was performed with S₂ using the longest possible basic drive cycle length rounded off to the nearest multiple of 100 msec, then using basic drive train cycle lengths that decreased in 100 msec steps to 400 msec, and finally using a basic drive cycle length of 350 msec. At each drive cycle length, an interval of > 50 msec beyond the effective refractory period (ERP) was scanned with S₂. Monomorphic VT was induced by S₂ in 52/121 studies (43%). The drive cycle length had a significant linear effect on the log odds of inducing VT (P < 0.0001). The highest yield of VT occurred with a drive cycle length of 350 msec (42/121, 34%), and with each increment in drive cycle length, the expected odds of inducing VT decreased by a factor of 1.7. In 88% of cases in which VT was induced at a particular drive cycle length but not at longer drive cycle lengths, the coupling intervals that induced VT exceeded the ERP measured at one or more of the longer basic drive cycle lengths. In conclusion, there is an inverse relationship between the basic drive cycle length and the yield of monomorphic VT induced by S₂. The use of shorter basic drive cycle lengths often facilitates the induction of VT by some effect other than critical shortening of the S₂ coupling interval.     

左心室质量及几何模式对左心室功能的影响

目的 探讨左心室质量(LVM)及几何模式对左心室功能的影响。方法 根据相对室壁厚度(RWT)>0.43和≤0.43将170例高血压患者分为向心性模式组和离心性模式组,分别作超声心动图检测。结果 向心性模式组的EF明显高于离心性模式组,而前者E、E/A明显低于后者。单变量及多变量回归分析均显示EF与LVM及RWT相关,E/A在单变量分析时与RWT呈非常显著负相关,但在多变量分析时被剔出。结论 LVM及几何模式的改变均对左心室收缩功能产生明显的损害,几何模式的变化可能对左心室舒张功能也会产生不利影响。     

The mechanisms of ventricular tachycardia in humans determined by intraoperative recording of the electrical activation sequence

We recorded ventricular activation sequence during ventricular tachycardia in 76 patients who underwent surgical therapy of refractory ventricular tachycardia. Ventricular tachycardia arose from a discrete site (focal origination) in 28 patients (37%) or resulted from reentry around scar (macroreentry) in 22 patients (29%). The mechanism responsible for ventricular tachycardia was not discernable in the remaining 26 patients (34%), usually because of inadequacy of activation data. We conclude: (1) although focal originating of ventricular tachycardia is common, more frequently the mechanism is either macroreentry or uncertain, as assessed by conventional recording techniques; thus, a search for the "site of earliest activation" during ventricular tachycardia frequently may fail to direct rationally the operative procedure; (2) conventional techniques for intraoperative study of electrical activation during ventricular tachycardia are inadequate.     

Vulnerability of the right ventricle to cathodal,anodal, and bipolar stimulation at double diastolic threshold strength

Summary The repetitive ventricular response (RVR) to three stimulation techniques (bipolar, cathodal and anodal) was investigated in 35 patients. 26 patients suffered from coronary heart disease and 9 patients from dilative cardiomyopathy. The stimulation study was performed at a ventricular driving rate of 120/min with one and two premature ventricular extrastimuli. We used rectangular impulses of 1.8 ms duration at duable diastolic threshold strength. RVR was scored as follows: 0: no RVR, 1: one nonstimulated RVR, 2: two nonstimulated RVR, 3: three nonstimulated RVR, 4: four to ten nonstimulated RVR, 5: more than ten nonstimulated RVR lasting less than 2 minutes, 6: sustained ventricular tachycardia or ventricular fibrillation. We found that with unipolar anodal stimulation the diastolic threshold was significantly greater and the effective refractory period of the right ventricle was significantly shorter as compared to the other stimulation techniques. Between the three different electrode configurations there were no significant differences concerning the number of consecutive ventricular depolarizations following premature stimulation. Conclusion: the phenomenon of RVR is not influenced by the stimulation technique (bipolar, cathodal and anodal) at double diastolic threshold.Supported by the Robert-Müller-Stiftung