立体定向放射治疗听神经瘤的疗效分析

目的评价立体定向放射治疗听神经瘤的局部控制率及不良反应。方法对82例听神经瘤患者进行立体定向放射治疗，所有患者均有患侧听力的进行性下降或肿瘤进行性增大，或两者兼有，MRI测量肿瘤的最大径平均为3．2cm（1．8-4．0cm）。有牙齿的患者采用分次治疗，接受剂量为20-24Gy／5-6次（80％等剂量曲线），无牙齿的患者采用单次治疗，剂量为11～13Gy（80％等剂量曲线），所有患者均设一个等中心。结果随访12～62个月。平均26个月，5年局部控制率为91．5％，听力保留率为75．8％，三叉神经功能保护率为91．4％．无面瘫、脑积水及其它并发症发生。结论立体定向放射治疗能有效的控制肿瘤的生长，听力保留率高。其它不良反应小。     

心外膜消融少见部位的特发性室性早搏

目的报道1组起源于心外膜远离crux区和summlt区城的特发性室性早搏(PVC)的心电图、标测特征, 以及经皮心包穿刺心外膜消融结果。方法回顾性分析2015年8月至2020年11月在南京医科大学附属第一医院和武汉亚洲心脏医院共收集9例在经皮心包穿刺心外膜消融的特发性PVC患者资料, 通过心外膜标测和消融确定PVC的起源部位, 分析不同起源部位的体表心电图和标测特征。如GRS波宽度, 相应导联GRS波呈GS型, 心内膜标测提前量。如体表起始有无"r"波, GRS波宽度以及心内膜最早激动总相比于GRS波起点的提前量。结果入选9例患者, 年龄(32±13)岁。其中男6例, 所有患者PVC均起源于心外膜, 其中有4例位于下壁, 1例位于前壁, 1例位于心尖部, 其余3例位于侧壁。体表心电图的对应导联组QRS波为无"r"波的QS型。在心内膜和心外膜都进行标测, 两者激动提前QRS时限分别为(-11±4)ms和(-25±8)ms。所有患者心内膜单极电图均呈rS型, 外膜起源处标测单极电图为QS型。所有患者均消融成功且无相关并发症发生, 中位随访11个月无复发。结论部分特发PVC可起源于远离cru...     

三维电解剖标测指导疑难右侧游离壁旁路的导管消融

Objective To demonstrate the electroanatomic substrates of right-sided free wall (RFW)accessory pathways (APs) which were refractory to conventional catheter ablation utilizing three-dimensional (3D) mapping. Methods Seventeen patients with RFW APs that failed initial conventional catheter ablation(s)by a mean of 1～3(1.8±0.6) attempts were enrolled in the study. Electroanatomic mapping of the right atrium was performed during right ventricular pacing in 14 patients and orthodromic reciprocating tachycardia in 3patients. Radiofrequency energy was delivered via irrigation catheter to the earliest atrial activation site. Results The earliest atrial activation site, which represented the atrial insertion of the APs, was separated from the tricuspid annulus by an average of 9 ～ 20 ( 13.6 ± 3.4 ) mm, and the local activation time was 18 ～ 80(31.5±16.3) ms earlier than that of the corresponding annular point. The target electrogram demonstrated AP potential in fourteen patients and ventriculoatrial fusion in the rest three. Accessory pathway was blocked in one case during moving the catheter and RF ablation delivery on the areas. One patient exhibited an AP with wide branching on the atrial side during mapping. RF ablation with an irrigated catheter successfully interrupted AP conduction in remaining 16 patients without complications. After a mean follow-up of 3 ～ 41 (18.6±12.7) months, there were no recurrences of ventricular preexcitation or episodes of tachycardia. Conclusion RFW APs refractory to conventional catheter ablation might be due to unique anatomic AP features such as more epicardial course at the annulus level with atrial insertion distance from the tricuspid annulus. Electroanatomic mapping is helpful to accurately localize the atrial insertion sites of these APs and facilitates catheter ablation.     

碎裂QRS波在致心律失常性右心室心肌病诊断中的价值

Objective To evaluate diagnostic value of fragmented QRS complex (fQRS)in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). Methods Forty-three patients [33 men, aged (40. 4 ± 13.9)years]meet the ISFC/ESC diagnostic criteria for ARVC were enrolled in this study. A standard twelve-lead electrocardiogram was obtained during the resting status. Characteristics of fQRS were detailedly studied by three doctors independently. A comparison of the prevalence among fQRS, epsilon wave and T wave inversion( TWI )in the right precordial leads exceeding V3 was done. Results Most fQRS could be found in the inferior leads (44. 3% ) and the right precordial leads (24. 2% ). Within the QRS complex, the prevalence of fQRS in the R wave was significantly higher than it in the S wave(58. 4% vs 32. 9% ,Z =4. 30,P ＜0. 01 ).fQRS could be found in a total of 31 of 43 cases( mean 4. 6 ± 1.7 ( range 2 to 9) per patient). The prevalence of fQRS was significantly higher than that of epsilon wave ( 73.8% vs 30. 2%, Z = 3.67, P ＜ 0. 01 ) and TWI (73.8% vs41.9% ,Z =2. 61 ,P＜0. 01 ). Conclusion fQRS was a common electrocardiographic abnormality,and most was found in the inferior and right precardial leads in patients with ARVC. It may be used as an important noninvasive preliminary screening electrocardiographic criteria.     

磁导航遥控射频导管消融治疗房室结折返性心动过速的初步体会

Objective To evaluate the safety and feasibility of remote radiofrequency catheter ablation of atrioventricular nodal reciprocating tachycardia (AVNRT) using the magnetic navigation system (MNS). Methods A total of 37 patients[female 29, mean age (44 ± 15 )years]with documented AVNRT were enrolled in this study from March 2007 to June 2009. A 4 mm tip magnetic mapping and ablation catheter ( Helios Ⅱ ,Stereotaxis, USA),which was remotely controlled by the MNS (Niobe Ⅱ , Stereotaxis, USA), was used for both mapping and ablation. Conventional slow pathway modification with focal ablation at the fight posterior septum was first performed in all patients. If it was failed, linear lesions at the base of Koch' s triangle was then done. Results After ablation, AVNRT was non-inducible in all 37 patients without any complication except one case experienced transient first degree AV block. Focal ablation was performed in 34 patients, and linear ablation strategy was used in the remaining three cases to achieve the end point. Among all the 37 patients, slow pathway ablation was achieved in 14, whereas slow pathway modification was reached in the remaining 23 cases.The mean procedural time, the RF deliveries, the duration of RF application were ( 120 ± 32) min, (2. 9 ± 1.6)times, ( 130 ± 33 )s,respectively. The total fluoroscopy time and the physician X-ray exposure time were(5.3 ±2. 7)min and(2.9 ± 1.1 ) min,respectively. There was no significant change of the AH interval,the HV interval,and the atrioventricular nodal conduction refractory period after ablation. Compared with the first 18 patients, the mean procedural time, the total fluoroscopy time and the X-ray fluoroscopy time during magnetic navigation were significantly decreased in the later 19 patients (P ＜0. 001 ). It indicated that the learning curve of remote catheter ablation using the MNS is short. Conclusion Remote catheter ablation using the MNS to cure AVNRT is safe and effective with short learning curve and decreasing X-ray exposure time for interventional physicians.     

起源于左侧希氏-浦肯野系统的特发性加速性室性自主心律

目的 介绍起源于左侧希氏-浦肯野系统的特发性加速性室性自主心律,揭示其临床特征并探讨可能的电生理机制.方法 回顾分析4例特发性加速性室性自主心律患者的心电图形态特征、临床表现、治疗方法及预后.结果 4例患者,男性2例,平均年龄48(40～54)岁,均无器质性心脏病.室性自主心律均呈右束支阻滞型,其QRS时限0.11～0.13 s,符合左侧希氏-浦肯野系统起源,其中3例电轴右偏,1例电轴左偏.自主心律RR间期不规则,平均频率为87(55～110)次/min,与窦性心律交替出现.所有患者临床均表现为发作性心悸.1例患者室性自主心律在短期服用普罗帕酮后消失,另1例短期服用维拉帕米后消失,余2例未予以特殊处理后自然消退.平均随访4.5(2～8)年,临床无心律失常发作,亦无其他心血管事件发生.结论 起源于左侧希氏-浦肯野系统的加速性室性自主心律是左侧希氏-浦肯野系统特发性室性心律失常的一种表现形式,多数为自限性,临床呈良性经过.     

直肠癌术前放疗的效果观察

目的探讨术前放疗对直肠癌的临床疗效。方法31例直肠癌患者为试验组,予以术前放疗,放疗结束后3～4周行根治性手术;以31例同期直接给予根治性手术的患者为对照组,随访2年,比较两组患者的淋巴结转移率、复发率及生存时间。结果试验组患者的复发率为29.0%、淋巴结转移率25.8%,均显著低于对照组51.6%和54.8%(P值均<0.05),试验组患者术后2年生存率为69.9%显著高于对照组39.8%(P<0.05)。结论术前放疗对直肠癌患者疗效肯定,可缩小肿瘤体积,降低术后复发率及淋巴结转移率,延长患者的术后生存时间。     

射频消融治疗阵发性心房颤动伴长间歇患者的长期随访研究

目的 随访射频消融治疗阵发性心房颤动（房颤）伴长间歇的临床转归.方法 2006年5月至2008年9月共入选18例（男12例,女6例）阵发性房颤伴发作终止时窦性停搏≥3 s的患者,年龄37～72（56.8±11.7）岁,病程2～276（69.6±71.3）个月.所有患者均有房颤终止时窦性停搏≥3 s的临床资料,平均长RR间期3.1～8.0（4.5±1.6）s,部分患者伴有黑矇、晕厥先兆或者晕厥症状.首次消融患者,在三维标测系统指导下行肺静脉前庭隔离术达到肺静脉-左心房电学隔离;术后常规程序刺激诱发,若合并室上性心律失常或者非肺静脉触发灶,同时消融.术前,术后3d,1、3、6个月分别常规检查动态心电图,检测心率变异性（HRV）指标.结果 18例患者共进行了27次消融,8例1次手术成功,5例行2次手术,2例行3次手术,3例复发未再行手术治疗.首次消融术中,3例诱发典型心房扑动,同时行后位峡部消融,达到双向阻滞;3例术中出现显性去迷走[血压＜ 90/60 mm Hg（1 mm Hg=0.133 kPa）,心率＜60次/min].10例复发患者中,1例合并左心房后壁的局灶房颤,第3次消融时成功.平均随访（34.1±7.5）个月,术后2例发生窦性心动过速;3例房颤复发,其中1例为起搏器植入术后,1例房颤复发患者终止后有10.4 s的长间歇,植入单腔起搏器,另外1例房颤复发但无症状,未作特殊处理,临床密切随访.共12例完成6个月动态心电图随访的患者符合分析要求.术前反应迷走神经功能的HRV指标相邻RR间期差的均方根（rMSSD）,RR间期平均值的标准差（SDNN）,高频（HF）,低频（LF）/HF分别为（42.0±11.1）ms,（136.0±24.9）ms,12.5±3.9,1.32±0.26.术后随访发现其指标均下降并持续至少3个月,但在6个月时恢复.结论 房颤发作时能够抑制窦房结功能,导致长间歇;射频消融治疗祛除房颤这一原始因素后,窦房结功能常有一定程度的恢复.