左室特发性室性心动过速的射频消融治疗

对 19例 IL VT患者进行射频消融治疗 ,在心动过速时标测最早出现的 P电位 ,并以此处为靶点进行消融。 19例中 ,心动过速起源于左室间隔面者 18例 ,左室流出道 1例 ;有 17例标测到 P电位 ,较体表心电图 QRS波群平均提前 2 4.7± 9.0 ms,均为起源于间隔部位者 ;另 2例标测到提前出现的 V波 ,分别提前 10 m s和 2 0 ms。射频消融治疗的总成功率为 95 .2 % ,复发率 5 %。采用激动标测寻找最早 P电位处为消融靶点是提高消融成功率的关键。     

起源于左后分支的室性早搏临床心电图特点和射频消融治疗

目的报道起源于左后分支的室胜早搏（PVC）的临床心电图特点及射频消融经验。方法8例无器质性心脏病且频发PVC的患者（男5例,女3例）,其中5例伴有阵发性左心室室性心动过速（室速）,年龄19—54（42．7±10．6）岁。其中3例患者行常规射频导管消融治疗,5例在三维电解剖标测系统（Carto系统）指导下行射频消融治疗。在左后分支标测到最早心室激动点处给予温度控制下射频导管消融。结果8例患者术前均以体表心电图定位起源于左后分支处区域,其PVC或左心室室速的体表心电图均为典型特发性左心室室速（ILVT）表现（QRS波呈右束支阻滞图形,心电轴左偏,QRS时限≤160ms）。其中,QRS波I导联6例呈rS,2例呈Rs;aVL导联呈qR;II、Ⅲ、aVF导联呈rs。胸前导联多在V,～V,处移形,由R转为Rs或rs。在消融成功部位（最早激动点）消融导管均记录到融合有浦肯野电位（PP）的V波,V波提前于体表心电图QRS波时限20—48（33．0±10．2）ms,8例患者行射频消融即时成功。术后3～15（8．1±4．2）个月复查,8例患者动态心电图的PVC均小于10000／24h。所有患者术中、术后无并发症发生。结论起源于左后分支处的PVC,在消融导管标测到PVC最早激动点并融合有PP时可成功消融PVC。     

射频消融起源于三尖瓣环游离壁的室性早搏的靶点电位和疗效

目的 探讨三尖瓣环游离壁起源的室性早搏(简称室早)射频消融治疗的靶点电位特征和消融效果。方法 回顾性分析2018年1月至2021年7月行射频消融治疗室早547例患者，其中21例证实三尖瓣环游离壁起源，分析其消融靶点电位的特征及消融疗效。结果 21例即刻消融成功率100%,长期手术成功率95.2%。18例患者室早时最早激动点单双极电图起始均为负向，消融靶点领先QRS波起始(30±4.1)ms,首次射频能量(30W)释放，早搏即刻消失。3例室早时最早激动点双极电图起始非负向，首次射频能量释放，1例早搏即刻消失，2例重新标测多次消融，1例术后复发。结论 起源于三尖瓣环游离壁的室早，采用单双极电图起始同为负向能够精确的识别早搏起源点，有助于精准的射频消融治疗。     

起源于右室流出道小憩室的室性早搏消融一例

患者男,55岁,因频发性室性早搏(简称室早)行射频消融,心电图室早呈完全性左束支阻滞,胸前移行在V4导联,Ⅱ、Ⅲ和aVF导联QRS波主波向上,上升支轻度顿挫、Ⅰ导联呈"Qr"形。影像和三维标测显示最早激动点在右室流出道(RVOT)前间隔,在该处消融室早消失,但停止放电,室早重现。经造影和三维重建发现RVOT一小憩室,在憩室内标测到提前28ms电位,且在此处起搏获得与室早一致的图形,在该点消融成功。     

左前分支近端室性早搏射频消融的新靶点

目的 完全性右束支阻滞图形合并电轴右偏的窄QRS波室性早搏(简称室早),通常被认为起源于左前分支(LAF)近端。探讨这类LAF近端室早的确切来源和电生理特征。方法 本研究纳入22例完全性右束支阻滞图形合并电轴右偏的窄QRS波室早患者。在窦性心律和室早期间对束支电位(FP)进行详细三维标测。同时使用心腔内超声重建主动脉窦、左室和乳头肌详细三维图形。结果 在窦性心律下,在主动脉窦下方可发现一簇FPs,这些FPs代表了左束支系统的一个独立分支,该分支向主动脉根部逆行延伸。将这个分支命名为主动脉根部盲端束(RARB)。LAF近端与RARB末端之间的最短距离为(13.5±4.2)mm。在所有患者中,室早的最早激动点(EAS)均在RARB末端,室早的FP-V间期为(35.1±4.3)ms。从右冠窦(RCC)到EAS的最短距离为(5.3±3.5)mm。在45.5%(10/22)的病例中,RCC处消融可成功消除室早。在其余病例中,左室心内膜面EAS消融可成功消除室早。结论 RARB末端是完全性右束支阻滞图形合并电轴右偏的窄QRS波室早的真正起源点。RARB与左室传导系统主干有足够的安全距离。因此在RC...     

射频导管消融治疗起源于左心室游离壁的频发室性早搏

目的报道1组起源于左心室游离壁的无器质心脏病基础的频发室性早搏（室早）射频消融结果。方法共11例特发性室早患者,男性7例,女性4例,平均年龄（47．2±14．4）岁。均接受常规电生理检查及射频消融治疗,所有病例室早体表心电图均呈右束支阻滞图型。消融术中采用激动标测和起搏标测相结合的方法。结果11例室早均消融成功（2例复发经再消融成功）,所有室早被证实均起源于左心室游离壁,6例起源于前外侧游离壁中、高段,4例起源于后下侧游离壁中段,1例起源于游离壁低段近心尖部。术中成功消融部位局部V波较体表心电图QRS波起点提前24～41（27±9）ms。其中9例成功消融部位起搏心电图与室早图形基本相同。结论起源于左心室游离壁的室早是特发性室早的一个亚组,射频消融治疗可取得良好效果。     

三维心腔内超声引导下应用压力监测导管消融左心室乳头肌室性心律失常

目的介绍在三维心腔内超声引导下应用压力监测导管标测和消融左心室乳头肌起源室性心律失常(VAs)的初步经验。方法 2017年6月至2018年4月于北京安贞医院心内科施行经CartoSound指导射频消融治疗左心室乳头肌起源VAs的患者10例,均采用压力监测导管进行激动标测,并行射频消融治疗,同时分析其体表12导联心电图的QRS波群特征。结果 10例患者VAs的QRS波时限为(149.0±17.8)ms,其中6例VAs起源于左后乳头肌,4例VAs起源于左前乳头肌。左后乳头肌起源VAs表现为右束支阻滞,电轴左偏,Ⅲ导联主波向下,aVL导联主波向上;左前乳头肌起源VAs表现为右束支阻滞,电轴右偏,Ⅲ导联主波向上,aVL导联主波向下。除1例起源于左后乳头肌VAs患者消融失败外,其余9例患者均即刻消融成功,对10例患者随访6个月,1例起源于左后乳头肌的VAs复发。消融靶点至体表QRS波起始时限为(25.8±3.8)ms。所有患者双极电图靶点处窦性心律下无领先于QRS波的P电位,其中9例患者VAs时可记录到提前QRS波的高频电位。即刻消融成功患者的平均放电(2.4±1.3)次。结论左室前乳头肌和后乳头肌起源的VAs在心电图上有明显差别,CartoSound指导下应用压力导管进行左室乳头肌标测和消融可提高成功率,减少复发。     

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。     

射频消融左前分支起源的室性早搏

目的 探讨左前分支起源的室性早搏(PVC)的心电生理特点及射频导管消融结果.方法 6例排除器质性心脏病的左前分支起源的PVC患者,均在三维电解剖(Carto)标测系统指导下消融.结果6例患者标准12导联心电图PVC均表现为:右束支阻滞(RBBB)+左后分支阻滞(LPFB);V1～V6呈Rs型,Ⅰ、aVL呈rS或QS型,Ⅱ、Ⅲ、aVF呈qR或qRs型,aVR呈Qr或QS型;电轴右偏;QRS时限为(118±17)ms;PVC的移行区指数(transitional zoneindex)平均为(-2.08±0.49).在成功消融靶点(最早或提前激动点)附近均记录到浦肯野电位(purkinje potential,PP),位于左心室前外侧间隔或左心室中间隔高位,Ⅴ波提前于体表心电图QRS波20 ～48(33.0±9.9)ms.6例患者采用冷盐水灌注消融或普通Carto导管消融,即刻成功,无并发症.术后随访(11±5)个月,5例患者PVC完全消失,1例患者24 h动态心电图的PVC ＜1000次.结论 起源于左前分支处的PVC可在消融导管标测到PVC最早或提前激动点并伴有PP处成功消融.     

经导管射频消融室性早搏或室性心动过速治疗心肌梗死后室性心律失常电风暴

目的报道射频消融治疗心肌梗死(MI)后抗心律失常药物治疗无效的室性心律失常电风暴4例,探讨其标测方法和消融效果。方法 4例病人均为男性,64岁、75岁、73岁和60岁。分别于前壁心肌梗死后19天、45天、3天和10天出现反复发作室性心动过速(室速)或室性颤动(室颤),经血运重建、抗心律失常药物治疗室速、室颤仍反复发作。病例1、3、4的单形或多形室速、室颤均有频发室性早搏诱发,病例2植入ICD后服用胺碘酮和β-受体阻滞剂使反复发作的室速暂时得到了控制,但ICD植入一月后室速再次频繁发作。室速均呈右束支阻滞(RBBB)图形伴心电轴左偏。标测和消融方法为在左心室内标测到室早或持续室速时最早激动处后进行射频消融。结果病例1、3、4均可记录到呈右束支阻滞(RBBB)伴电轴左偏和/或右偏形态的室早,在这3例患者中室早均可诱发室速。在频发室早下行标测和消融,激动标测显示3例患者的室早最早激动处在左心室中下部位,室早时浦肯野纤维电位提前体表心电图QRS波40-50ms,且窦性心律时在同一部位可记录到清晰的提前QRS波群的浦肯野纤维电位。3例分别于最早激动处且标测到浦肯野纤维处放电6次、8次和16次,均成功消融室早。病例3因为出现了另一形态的室早,于左室前内侧反复消融5次,另一形态室早亦消融成功。病例2中没有记录到室早,心室程序刺激诱发2种形态室速,呈右束支阻滞(RBBB)图形伴有电轴左偏。在左心室内标测到浦肯野纤维提前室速起始最早60ms处进行消融,成功消融室速。4例分别随访7年、6年、4年和6个月,病例1和病例3无室速和室颤复发,病例2有1次ICD放电,病例4复发室早诱发短阵室速,但无持续性室速、室颤和晕厥发生。结论 MI后频繁快速室性心律失常可能由起源于左室浦肯野纤维网的室早或室速所诱发,经导管射频消融室早或室速对?     

Cure of Interfascicular Reentrant Ventricular Tachycardia by Ablation of the Anterior Fascicle of the Left Bundle Branch

Ablation of Interfascicular Reentrant Tachycardia. Introduction: Fascicular reentrant ventricular tachycardia (VT) using the anterior fascicle of the left bundle anterogradely is rare and may produce identical QRS morphology during sinus rhythm and VT. Catheter ablation of this type of VT has not been described in detail.
Methods and Results: In a postinfarct patient with dilated left ventricle and recurrent VT (showing a QRS configuration of right bundle branch, left posterior fascicular block), endocardial recordings from the His-Purkinje system showed that VT was due to interfascicular reentry. Induction of VT occurred after progressive retrograde conduction delay on increasing the prematurity of the extrastimulus. Anterograde conduction occurred exclusively over the left anterior fascicle, which caused identical QRS morphology during sinus rhythm and VT. During VT, the left posterior fascicle was used retrogradely. The usual target for bundle branch reentry ablation, the right bundle, did not participate in the reentrant circuit. While performing left ventricular endocardial mapping, VT was interrupted when positioning the catheter on the left anterior fascicle, and "reversed" nonsustained bundle branch reentry occurred with anterograde conduction over the posterior fascicle and retrograde conduction over the anterior fascicle. Ablation of conduction in the anterior fascicle led to cure of the VT.
Conclusion: Interfascicular reentrant VT with right bundle branch block, right-axis QRS configuration can be cured by catheter ablation of anterior fascicle conduction.     

Paroxysmal fascicular tachycardia and ventricular tachycardia due to mechanical stimulation by a mitral valve prosthesis

Electrophysiologic studies were performed in a woman who had two varieties of paroxysmal wide QRS tachycardia after mitral valve replacement with a Starr-Edwards prosthesis. One tachycardia originated in the left anterior fascicle; QRS complexes were 100 ms wide and resembled right bundle branch block with left posterior fascicular block, and a His bundle potential preceded each QRS by an interval of 20 ms (compared with 50 ms during sinus rhythm). The other tachycardia originated in the left ventricle. Clinical and echocardiographic observations suggested that the tachycardias were caused by mechanical stimulation of the interventricular septum by the mitral prosthesis.     

起源于乳头肌特发性室性心律失常的电生理特点及射频导管消融

目的 报道特发性左心室乳头肌起源室性心律失常(VA)的电生理特点及射频导管消融结果.方法 连续8例接受射频消融治疗、术中经电生理检查及心室造影证实起源于左/右心室乳头肌的VA患者,包括室性心动过速(VT)6例、频发室性早搏(PVCs)2例,男7例,女1例,年龄4～66岁,均无器质性心脏病.结果 8例患者中,6例VA起...     

射频导管消融治疗的特发性室性心律失常心电图特征分析

目的：探讨不同起源的特发性室性期前收缩（PVCs）和（或）室性心动过速（VT）的心电图特征,提出鉴别流程。方法根据射频导管消融PVCs/VT有效靶点或心室最早激动点的X线胸片进行定位,分析不同起源PVCs/VT的12导联心电图QRS波群。结果828例接受导管消融,580例起源于右心室,248例起源于左心室,左、右心室起源者胸导联移行指数＜0的分别占97.58%及7.24%;左和右心室流出道起源者下壁导联多数呈R型,V1上,多数右心室流出道起源者呈rS型,右室间隔起源呈QS型,主动脉瓣上起源者常呈rS或RS型;下壁导联上,左前分支起源者常呈qR型,左后分支起源者常呈rS型。结论结合体表心电图胸导联移行指数、下壁导联和V1上的QRS波群特征可初步判断特发性PVCs/VT的起源部位。     

Diagnosis and Ablation of Multiform Fascicular Tachycardia

Ablation Multiform Fascicular Tachycardia . Introduction: Fascicular tachycardia (FT) is an uncommon cause of monomorphic sustained ventricular tachycardia (VT). We describe 6 cases of FT with multiform QRS morphologies. Methods and Results : Six of 823 consecutive VT cases were retrospectively analyzed and found attributable to FT with multiform QRS patterns, with 3 cases exhibiting narrow QRS VT as well. All underwent electrophysiology study including fascicular potential mapping, entrainment pacing, and electroanatomic mapping. The first 3 cases describe similar multiform VT patterns with successful ablation in the upper mid septum. Initially, a right bundle branch block (RBBB) VT with superior axis was induced. Radiofrequency catheter ablation (RFCA) targeting the left posterior fascicle (LPF) resulted in a second VT with RBBB inferior axis. RFCA in the upper septum just apical to the LBB potential abolished VT in all cases. Cases 4 and 5 showed RBBB VT with alternating fascicular block compatible with upper septal dependent VT, resulting in bundle branch reentrant VT (BBRT) after ablation of LPF and left anterior fascicle (LAF). Finally, Cases 5 and 6 demonstrated spontaneous shift in QRS morphology during VT, implicating participation of a third fascicle. In Case 6, successful ablation was achieved over the proximal LAF, likely representing insertion of the auxiliary fascicle near the proximal LAF. Conclusions : Multiform FTs show a reentrant mechanism using multiple fascicular branches. We hypothesize that retrograde conduction over the septal fascicle produces alternate fascicular patterns as well as narrow VT forms. Ablation of the respective fascicle was successful in abolishing FT but does not preclude development of BBRT unless septal fascicle is targeted and ablated. (J Cardiovasc Electrophysiol, Vol. 24, pp. 297‐304, March 2013)     

Radiofrequency Catheter Ablation of Idiopathic Ventricular Tachycardia Originating in the Anterior Fascicle of the Left Bundle Branch

Ablation of an Anterior Fascicular Idiopathic VT. Introduction : Idiopathic ventricular tachycardia (VT) originating in or close to the anterior fascicle of the left bundle is rare. A patient with no structural heart disease and VT with a right bundle branch block configuration and right-axis deviation underwent an electrophysiologic examination.
Methods and Results : Both endocardial activation mapping during VT and pacemapping were performed via a transseptal approach to localize the site of origin of the VT. Endocardial recordings of the His bundle and the posterior and anterior fascicles of the left bundle branch revealed an origin of the VT in or close to the anterior fascicle. The Purkinje potential at that site preceded the QRS complex by 20 msec, with pacemapping showing an optimal match between the paced rhythm and the clinical VT. RF energy delivered at this site terminated the VT. A left anterior nemiblock appeared after RF ablation. Ten months later, the patient is free from recurrences of VT.
Conclusions : Idiopathic VT originating in or close to the anterior fascicle was cured by RF ablation. A Purkinje potential preceding the QRS during tachycardia and an optimal pacemap were used to guide RF ablation.     

射频消融治疗summit附近起源室性心律失常的临床分析

目的:分析summit附近起源室性心律失常(VA)心电图(ECG)特征,射频消融术治疗的疗效及安全性,探讨解剖消融的可行性.方法:入选summit附近起源VA射频消融患者60例,通过同步12导联ECG,分析其特征及进行初步定位;利用激动标测、起搏标测结合ENSITE Velocity Nav标测系统标测summit附近...     

Ventricular tachycardia with participation of the left bundle-Purkinje system in patients with structural heart disease: identification of slow conduction during sinus rhythm

Introduction: Idiopathic left ventricular tachycardia (VT) originating from the left posterior fascicle can be eliminated by ablation at sites with abnormal diastolic potentials (DPs) during sinus rhythm. We investigated whether such DPs can also be recorded in patients with structural heart disease and VT involving the left bundle-Purkinje system.
Methods and Results: Eight patients (mean age 67 ± 11 years) with nonischemic cardiomyopathy (n = 5) or prior myocardial infarction (n = 3) presented with VT involving the left bundle-Purkinje system (cycle length 376 ± 45 ms). Three types of VT were observed: macroreentrant VT with participation of both left bundle fascicles in three patients, fascicular VT involving the left posterior fascicle in two patients, and scar-related VT with Purkinje fibers as part of the reentrant circuit in three patients. In all patients, abnormal isolated DPs of low amplitude with a QRS—earliest DP interval of 374 ± 86 ms were found during sinus rhythm in the mid- or inferior left ventricular septum in areas with Purkinje potentials. The abnormal DPs during sinus rhythm coincided or were in proximity to DPs during the VT in six patients. VT ablation targeting the sites with the earliest abnormal DPs during sinus eliminated the VT in 7 of 8 patients with freedom from VT recurrence in six patients during the follow-up of 11 ± 5 months.
Conclusions: Isolated DPs during sinus rhythm were found in proximity to the posterior Purkinje network in patients with VT involving the left bundle-Purkinje system associated with heart disease and can be used to guide successful catheter ablation.     

Experience with radiofrequency catheter ablation of fascicular tachycardia.

OBJECTIVE: To report experience with radiofrequency catheter ablation of fascicular tachycardia including two cases of the rare type of this arrhythmia which arises from the anterior fascicle of the left bundle branch. DESIGN: Review of results of radiofrequency ablation in nine consecutive patients presenting with fascicular tachycardia. SETTING: Regional cardiac centre. INTERVENTION: Percutaneous radiofrequency catheter ablation, performed between 1993 and 1996. RESULTS: Radiofrequency ablation was successful in both patients with tachycardia arising from the anterior fascicle and in six of the seven patients with tachycardia arising from the anterior fascicle and in six of the seven patients with tachycardias arising from the posterior fascicle. Notable differences in the "right bundle branch block" configuration of lead V1 during tachycardia between patients were observed. One patient with incessant tachycardia had marked impairment of ventricular function which returned to normal after ablation. CONCLUSIONS: Radiofrequency ablation is effective in both anterior and posterior fascicular tachycardias. The arrhythmia can cause reversible impairment of ventricular function.