高精密度标测技术在导管消融治疗心律失常中的应用

高精密度标测技术是近年来随着三维电解剖标测技术和导管制造技术的进步而产生的概念。目前高精密度标测技术已经应用于各种心律失常的导管消融,因其更高的标测效率和更高的分辨率,有望缩短手术时间、提高手术成功率。本文就高精密度标测技术在心律失常的导管消融中的应用作一综述。     

使用海星状电极快速解剖建模联合压力导管在心房颤动肺静脉隔离术中的优势

目的探讨海星状电极(Pentaray)导管对左房进行高密度标测快速解剖建模(FAM),联合使用压力导管在心房颤动(简称房颤)肺静脉电隔离术中的优势。方法序贯入组2015年7月1日到2016年5月30日在华山医院心内科确诊房颤、拟行环肺静脉电隔离术的患者,在Carto3系统下用环状电极(Lasso)或者Pentaray,以FAM法建立左房三维模型,根据使用的建模导管将患者分为Lasso组(L组)和Pentaray组(P组),两组患者均使用SmarttouchTM压力监测导管进行环肺静脉消融,术后在窦性心律下通过肺静脉与左房的双向起搏,以传导阻滞为手术终点。记录患者的一般情况,手术时间以及消融点的平均压力等参数,术后3个月、6个月随访24h动态心电图,并记录患者用药情况,分析消融效果。结果共纳入符合要求的患者52例,其中L组30例,P组22例。所有患者中,阵发性房颤43例,男性占73%。手术均能达到肺静脉电隔离的终点。两组建模时间为:L组(18.3±2.43)min,P组(13.3±3.63)min(P<0.001);L组和P组总消融时间分别为:(157.1±13.55)min和(138.9±11.30)min(P<0.001),两组患者肺静脉隔离使用时间分别为L组(98.6±12.26)min和P组(95.9±11.56)min,(P=0.427)。术后6个月房颤复发率L组为22.7%,P组为23.3%(P=0.752)。结论使用Pentaray进行心房高密度标测快速建模联合压力导管,可以在保证安全性的前提下,缩短房颤肺静脉电隔离的时间,提高手术成功率。     

Initial experiences with the Impella device in patients with cardiogenic shock - Impella support for cardiogenic shock

BACKGROUND: We planned a study to assess the safety, feasibility, and efficacy of the Impella micro-axial blood pump in patients with cardiogenic shock. METHODS: From January 2001 to September 2002 inclusive, 16 patients in cardiogenic shock (maximal inotropic support and with IABP in 11 cases) underwent left ventricle unloading with the Impella pump. 6 were placed via the femoral artery (patients in the coronary care unit) and 10 directly through the aorta (postcardiotomy heart failure). In three patients, the device was used in combination with ECMO. Mean age was 60 years (range 43 - 75), 11 were male. RESULTS: A stable pump flow of 4.24 +/- 0.28 l/min was reached (3.3 +/- 1.9 l/min in patients with ECMO and Impella). Mean blood pressure before Impella) support was 57.4 +/- 13 mmHg, which increased to 74.9 +/- 13 mmHg after 6 hours and 80.6 +/- 17 mmHg (p = 0.003) after 24 hours. Cardiac output increased from 4.1 +/- 1.3 l/min to 5.5 +/- 1.3 (p = 0.003) and 5.9 +/-1.9 l/min (p = 0.01) at 6 and 24 hours. Mean pulmonary wedge pressure decreased from 29 +/- 10 mmHg to 17 +/- 5 mmHg and 18 +/- 7 mmHg at 6 (p = 0.04) and 24 hours. Blood lactate levels decreased significantly after 6 hours of support (from 2.7 +/- 1 to 1.3 +/- 0.5 mmol/l, p = 0.004). Device-related complications included three sensor failures (no clinical action), one pump displacement (replacement) and six incidences of haemolysis (peak free plasma haemoglobin > 100 mg/dl, no clinical action). Eleven patients (68 %) were weaned, six (37 %) survived. CONCLUSIONS: Left ventricular unloading with the Impella pump via the transthoracic or femoral approach is feasible and safe. Support led to a decrease in pulmonary capillary wedge pressure, increase in cardiac output and mean blood pressure, and improved organ perfusion in patients with severe cardiogenic shock.     

Use of ventricular synchronized triggered atrial pacing to facilitate hemodynamic support during mapping and catheter ablation of ventricular vachycardia

Use of VSTAP to Facilitate Hemodynamic Support. The ablation of hemodynamically unstable ventricular tachycardia (VT) is challenging and frequently requires alternative mapping techniques or the use of percutaneous mechanical support devices. Loss of atrioventricular synchrony contributes to hemodynamic compromise during VT. In order to facilitate successful mapping and ablation of unstable VT, we employed ventricular synchronized triggered atrial pacing (VSTAP) at 50% of the RR interval. In this case, triggered atrial pacing permitted activation mapping and, subsequently, successful ablation of the patient's unstable VT. Thus, VSTAP is a readily available and noninvasive technique that may provide adequate hemodynamic support during catheter ablation of unstable VT.     

Value of high-density endocardial and epicardial mapping for catheter ablation of hemodynamically unstable ventricular tachycardia

BACKGROUND: Percutaneous epicardial mapping has been used for ablation of recurrent ventricular tachycardia (VT). OBJECTIVES: The purpose of this study was to use a combined epicardial and endocardial mapping strategy to delineate the myocardial substrate for recurrent VT in both ischemic (n = 12) and nonischemic cardiomyopathy (n = 8), and to define the role of epicardial ablation. METHODS: Electroanatomic mapping was performed in 20 patients. High-density voltage maps were obtained by acquiring both endocardial and epicardial electrograms. Electrograms derived from six patients with structurally normal hearts were used as controls. A total of 26 VTs were targeted in the 20 patients. RESULTS: Most VTs (23/26 [88.5%]) were hemodynamically unstable. In patients with ischemic cardiomyopathy, the extent of endocardial scar was greater than epicardial scar. A definable pattern of scar could not be demonstrated in nonischemic cardiomyopathy. Pathologic examination of explanted hearts in two patients with nonischemic cardiomyopathy demonstrated that low-voltage areas were not always predictive of scarred myocardium. A substrate-based approach was used for catheter ablation. Catheter ablation was performed on the endocardium in all patients; additional epicardial delivery of radiofrequency energy was required in 8 (40%) of 20 patients for successful ablation. During follow-up (12 +/- 4 months), 15 (75%) of 20 patients have been arrhythmia-free. CONCLUSION: Patients with ischemic cardiomyopathy tend to have a larger endocardial than epicardial scar. Use of epicardial and endocardial electroanatomic mapping to define the full extent of myocardial scars allows successful catheter ablation in patients with hemodynamically unstable VTs.     

Impact of a high-density grid catheter on long-term outcomes for structural heart disease ventricular tachycardia ablation

Journal of Interventional Cardiac Electrophysiology - Substrate mapping has highlighted the importance of targeting diastolic conduction channels and late potentials during ventricular tachycardia...     

The use of hemodynamic support in massive pulmonary embolism

Massive pulmonary embolism is life threatening and can present as cardiogenic shock and cardiac arrest. We report a case of a 47‐year‐old male who arrested during his postoperative hospitalization and was found to have a massive pulmonary embolism with bilateral involvement of the pulmonary arteries. Given his profound shock and right ventricular failure, an Impella RP was used to stabilize his acute right ventricular failure while percutaneous embolectomy and thrombolysis was used to treat the pulmonary embolism. The patient underwent the procedure successfully with reduction in vasopressors and thrombus burden and recovery of right ventricular function. © 2017 Wiley Periodicals, Inc.     

房间隔缺损封堵术后合并心房颤动的房间隔穿刺及导管消融

目的先天性房间隔缺损（简称房缺）患者介入封堵术后合并的心房颤动（简称房颤）导管消融存在一定挑战,本研究拟评价这类患者房间隔穿刺及导管消融的安全性及疗效。方法共入选16例[年龄（56±12）岁,10例男性]房缺封堵术后接受导管消融的房颤患者,其中阵发性房颤10例,持续性房颤6例。房间隔封堵器之外无穿刺空间者直接穿刺封堵器,在球囊扩张辅助下建立左房入路后单导管完成所有操作。阵发性房颤消融策略为环肺静脉电隔离;持续性房颤消融策略为环肺静脉电隔离联合心房线性消融并实现传导阻滞。结果 16例患者中,房间隔穿刺成功率100%,11例（A组）直接穿刺房间隔成功,5例（B组）穿刺封堵器并经球囊扩张后长鞘可顺利通过。与A组比较,B组房间隔穿刺操作时间[（38±8）min vs（5±3）min]、总透视时间[（54±15）min vs（31±11）min）]以及总手术时间[（224±36）min vs（165±35）min）]显著延长,P均〈0.05。除B组中1例持续性房颤患者未实现二尖瓣峡部传导阻滞之外,所有患者实现既定手术终点,无严重围术期并发症发生,术后3个月复查经胸超声未见房间隔水平左向右分流。平均随访（16±6）个月,12例（75%）患者维持稳定窦性心律。结论房缺封堵术后合并的房颤经导管消融安全,有效。球囊扩张辅助下可直接穿刺房间隔封堵器获得左房入路。     

An expandable percutaneous catheter pump for left ventricular support: proof of concept

OBJECTIVES: We sought to evaluate the performance of a newly designed percutaneous catheter with expandable pump. BACKGROUND: The device was designed as a percutaneously insertable temporary support system for patients with acute left ventricular failure. METHODS: The pump catheter (introduction diameter 9-F) is positioned in the left ventricle. The rotor is driven by an external motor through a flexible drive shaft. A model circuit was used to assess pump performance, hemolysis tests, and particle image velocimetry. The feasibility of the catheter placement and pump operation were examined in 12 anesthetized sheep. Cardiogenic shock was induced in seven of the animals. Cardiac output (CO) and mean aortic blood pressure (MAP) were recorded before and during shock, and during catheter pump action. RESULTS: The catheter pump delivered a flow of 4.1 l/min at a differential pressure of 60 mm Hg. The average modified index of hemolysis was 11.6 (optimum, 1.8). Fluoroscopically and echocardiographically guided in vivo placement and deployment of the device were quick and uncomplicated. Under simulation of acute left ventricular failure (CO 43 +/- 22% and MAP 55 +/- 16% of the baseline value), the catheter pump significantly improved CO to 67 +/- 12% and MAP to 74 +/- 18%. Maximum in vivo duration of operation was 6 h (average, 3.1 +/- 1.4 h). These animal studies revealed: 1) no significant hemolysis (average plasma-free hemoglobin 26 +/- 4 mg/l after 3 h); 2) no thrombotic deposits at rotor or pump housing; and 3) no damage to the endocardium or aortic valve. CONCLUSIONS: A percutaneously insertable, expandable catheter pump is technically and clinically feasible. Our first experimental results are encouraging.     

Transseptal catheterization in the catheter ablation of atrial fibrillation in a patient with cor triatriatum sinister

A 66-year-old man with cor triatriatum sinister underwent pulmonary vein (PV) isolation (PVI) for atrial fibrillation (AF) twice because of AF recurrence. Different transseptal approaches into the anterior chamber receiving the left atrial appendage and posterior chamber receiving the PVs, were achieved in two sessions. PVI of the left PVs and right superior PV was challenging via the anterior chamber, whereas PVI of the right inferior PV was challenging via the posterior chamber because of the disturbance of the membrane. Therefore, an intentional transseptal catheterization into the more appropriate chamber may be necessary for PVI in a cor triatriatum sinister. There was no financial support for this study.     

Acute and long-term results of PVI at antrum using a novel high-density mapping catheter without help of 3D electro-anatomic mapping in patients with paroxysmal and chronic atrial fibrillation

Purpose  

Multi-electrode circumferential mapping catheters have been developed by several manufacturers to facilitate catheter ablation procedures for atrial fibrillation (AF). We tested the effectiveness and safety of a conventional, fully endocardial electrogram-guided circumferential antrum isolation (PVI) with a novel mapping device.     

Transseptal and retrograde left ventricular catheterization in patients with the stent-mounted porcine xenograft valve prosthesis in the aortic position

Cardiac catheterization techniques for measuring the systolic pressure gradient across the stent-mounted porcine xenograft in the aortic position and accomplishing left ventriculography are described. The transseptal technique is a rapid and predictable means of entering the left ventricle but requires a highly skilled operator. Retrograde left ventricular catheterization via the femoral artery is a technique familiar to all invasive cardiologists. Usually a pitfall catheter is used. In patients with the stent-mounted procine xenograft in the aortic position, we have found the A2 Multipurpose catheter to be the fastest and most predictable means of entering the left ventricle from the groin. Potential complications of retrograde left ventricular catheterization in patients with aortic valve prostheses are discussed.     

Real-world use of the Impella 2.5 circulatory support system in complex high-risk percutaneous coronary intervention: The USpella Registry

Objectives: We report on the real-world, multicenter experience of the Impella 2.5 circulatory support system during high-risk PCI, a subset of the larger USpella Registry. Background: Standard of care for most patients with compromised ventricular function with multivessel or high-risk coronary lesions has been coronary artery bypass grafting. In poor operative candidates, high-risk PCI is increasingly considered, despite an increased risk for periprocedural hemodynamic compromise. Methods: 175 consecutive patients who underwent high-risk PCI with prophylactic support of the Impella 2.5 were evaluated. The primary safety endpoint was the incidence of major adverse cardiac events (MACE) at 30 days. Secondary endpoints included safety and efficacy related to the device and patient outcomes, including survival at 12 months. Results: Overall angiographic revascularization was successful in 99% of patients and in 90% of those with multivessel revascularization, resulting in a reduction of the mean SYNTAX score post-PCI from 36 ± 15 to 18 ± 15 (P < 0.0001) and an improvement of the ejection fraction (from 31 ± 15% to 36 ± 14%, P < 0.0001). In 51% of patients, the functional status improved by one or more NYHA class (P < 0.001). At 30-day follow-up, the rate of MACE was 8%, and survival was 96%, 91%, and 88% at 30 days, 6 months, and 12 months, respectively. Conclusions: The use of Impella 2.5 in high-risk PCI appeared feasible and safe in the real-world setting. The utilization of the Impella 2.5 was successful, resulting in favorable short- and midterm angiographic, procedural and clinical outcomes. ? 2012 Wiley Periodicals, Inc.     

Successful use of the Impella device in giant cell myocarditis as a bridge to permanent left ventricular mechanical support

Idiopathic giant cell myocarditis is a rare condition with a poor prognosis. Patients with giant cell myocarditis typically die of refractory ventricular arrhythmias or progressive congestive heart failure in about 3 months. The benefit of immunosuppressive therapy varies among patients with giant cell myocarditis, and no factors that would predict which patients will respond to therapy have been identified. Mechanical circulatory support devices, from intra-aortic balloon pumps to more permanent systems, have been used for ventricular support in cases of acute heart failure.Herein, we describe a case of giant cell myocarditis in a previously healthy 44-year-old woman who presented with cardiogenic shock. She was supported hemodynamically with the Impella Recover LP 2.5 left ventricular assist device until a permanent device could be surgically implanted. To our knowledge, this is the 1st reported case of the successful use of the Impella device for hemodynamic support in a patient with giant cell myocarditis until more definitive treatment could be instituted.     

Emergent use of retrograde left ventricular support in patients after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is currently a therapeutic alternative to open aortic valve replacement for high‐risk patients with severe symptomatic aortic valve stenosis. The procedure is associated with some life‐threatening complications including circulatory collapse which may require temporary hemodynamic support. We describe our experience with the use of the Impella 2.5 system to provide emergent left ventricular support in cases of hemodynamic collapse after TAVR with the Edwards SAPIEN prosthesis.© 2012 Wiley Periodicals, Inc.