单纯碎裂电位指导心房颤动消融的初步临床观察

Objective To evaluate the feasibility of mdiofrequency catheter ablation of atrial fibrilla-tion (AF) guided by complex fractionated atrial electrograms (CFAEs). Methods Twenty-two patients with drug refractory and symptomatic AF(16 paroxysmal, 6 persisten) were enrolled. Using Carto, the left atrial or biatrial replica was created during spontaneous or induced AF, and areas associated with CFAEs were identi-fied. Radiofrequency ablation at the site with CFAEs was performed and the end points were to eliminate CFAEs or convert to sinus rhythm. Results Thirteen patients(59%)were converted to sinus rhythm, (7 cases conver-ted directly to sinus rhythm, and 6 via the intermediate atrial tachycardia(AT) or atrial flutter (AFL). The re-maining nine patients required cardioversion with D. C. shock or drug. Repeat ablation was performed in 6 pa-tients (5 AT/AFL, 1 paroxysmal AF). During(10.9 ±4.8) months follow-up, 16 patients (73%) were free of arrhythmia and symptoms. CFAEs were most commonly found along the left interatrial septum, pulmonary veins, left atrial roof. CFAEs ablation prolonged AFCL[(157 ± 18) ms vs (211 ± 32) ms, P < 0.05]. Only one patient had pericardial tamponade that required pericardiocentesis. Conclusion Radiofrequeney catheter abla-tion of atrial fibrillation (AF) guided by CFAEs is safe and effective.     

78例特发性右室流出道室速的射频导管消融和随访

目的 研究特发性右室室速射频导管消融的安全性和有效性。方法 78例发作时呈左束支阻滞图形伴电轴下偏的特发性右室流出道室速进行射频导管消融和随访,采用起搏标侧法,最佳起搏标测点（起搏时12导联心电图与自然发作室速的12导联心电图相同）为消融靶点。结果 78例中73例（93.5%)消融成功,消融靶点位于前,中和后间隔分别为33%、41%和26%。临床和电生理研究发现,特发性右室室速有两种类型,即室早室速型和单纯室速型;室早室速型43例,单纯室速型35例。随访0.5-7年,3例复发,除1例右束支传导阻滞外,无手术相关并发症。结论 射频消融治疗右室特发性室性心律失常安全有效。     

血清N-末端脑钠肽与心脏再同步化治疗慢性心衰患者预后的相关研究

目的:探讨术前血清N-末端脑钠肽(N-terminal pro-brain natriuretic peptide,NT-proBNP)浓度与心脏再同步化治疗(cardiac resynchronization therapy,CRT)术后慢性心衰(chronic heart failure,CHF)患者心功能以及预后的关系?方法:选择2012年3月—2014年10月在本院植入CRT或CRT-D的CHF患者60例,术前测定血浆NT-proBNP水平;术前以及术后6个月测定超声心动图测定左心室射血分数(left ventricular ejection fraction,LVEF)?依据CRT植入后6个月随访时LVEF绝对值较基线增加≥5%为标准,分为有反应组和无反应组?随访期间观察CHF患者主要不良心血管事件(major adverse cardiovascular events,MACE)?结果:CRT术后有反应组术前NT-proBNP?随访MACE发生率明显小于CRT无反应组(P < 0.01)?以NT-proBNP 2 354.5 pg/mL为最佳分界点,预测CRT术后无反应的敏感度为95.0%,特异度为92.5%?以NT-proBNP 2 254.5 pg/mL为最佳分界点,预测发生心血管事件的敏感度95.2%,特异度92.3 %?Kaplan-Meier生存曲线显示NT-proBNP≤2 254.5 pg/mL患者生存时间高于NT-proBNP≥2 254.5 pg/mL者(P < 0.01)?结论:术前血清NT-proBNP水平与CHF患者CRT术后反应程度以及心血管不良事件相关?     

健康人微伏级T波电交替渐量修正平均法检测分析

目的探讨渐量修正平均法检测健康人微伏级T波电交替(microvolt T wave alternans,MTWA)的正常范围。方法平板运动提升心率,渐量修正平均法检测120例健康志愿者各胸前导联T波交替电压(alternans voltage,Valt),分析其大小分布范围及与性别、年龄的关系。结果(1)各胸前导联T波交替电压数据均呈偏态分布;胸前导联Valt大小与年龄无关;V4、V5导联Valt男女性别间差异有统计学意义,女性高于男性。(2)各胸前导联T波交替电压有较大差别,第75百分位数分别为V1导联8.0μV;V2导联5.0μV;V3导联2.0μV;V4导联男性2.0μV,女性6.0μV;V5导联男性4.5μV,女性6.5μV;V6导联7.0μV;胸前导联T波交替电压最大值(Vmax)第75百分位数11.0μV。结论:渐量修正平均法检测健康人微伏级T波电交替不同胸前导联之间有较大差别;确定正常标准需要因导联而异。     

左束支起搏的临床应用及其并发症

左束支起搏(LBBP)是继His束起搏后兴起的一种新型的生理性起搏方式,其临床应用的有效性及安全性逐步得以证实。LBBP适应证包括心动过缓,慢性心力衰竭伴左束支传导阻滞,持续性心房颤动伴心力衰竭行房室结消融及起搏诱导性心肌病患者升级。LBBP相关并发症发生率与右室起搏类似,严重并发症极为罕见。具体包括右束支损伤、导线脱位和间隔穿孔、间隔动脉损伤及间隔内血肿、导线微移位和阈值升高、三尖瓣返流加重、室性心律失常等。     

肺毛细血管楔压与心脏再同步化治疗慢性心衰疗效的相关性分析

目的 :探讨右心导管肺毛细血管楔压(pulmonary capillary wedge pressure,PCWP)与心脏再同步化治疗(cardiac resynchronization therapy,CRT)慢性心衰疗效的相关性。方法:入选拟行心脏再同步化治疗的慢性心衰患者,术前1周内进行右心导管检查,测定肺毛细血管楔压;根据CRT术后患者心功能变化分成CRT有反应组与无反应组。术后6个月内左室射血分数(LVEF)提高超过5%,纽约心功能分级(NYHA)降低1级或1级以上者定义为CRT有反应;通过受试者工作曲线分析PCWP对CRT反应性的预测价值。应用Kaplan-Meier生存曲线分析不同水平PCWP患者主要心血管不良事件的差异。结果:35例CRT患者中有反应24例,无反应11例;有反应组PCWP(11.9±7.0)mm Hg,无反应组PCWP(21.7±9.1)mm Hg,两组间差异有统计学意义(P=0.006)。以PCWP 12.0 mm Hg为最佳分界点时,Youden指数最大,预测CRT反应性的敏感度为90.9%,特异度为58.3%。相对于PCWP>12.0 mm Hg组,PCWP≤12.0 mm Hg组CRT术后心功能、左室内径和PCWP更佳。Kaplan-Meier生存曲线表明PCWP≤12.0 mm Hg组患者比PCWP>12.0 mm Hg组患者无主要心血管不良事件的生存时间长,但未达到统计学差异(P=0.079)。结论:术前右心导管检测PCWP对CRT反应性有较好的预测价值。术前PCWP低的患者无主要心血管不良事件的生存时间长。     

致心律失常性右室心肌病患者Epsilon波的检出率

Objective To investigate the prevalence of Epsilon wave in patients with arrhythmogenic right ventrieular cardiomyopathy (ARVC). Methods The Epsilon wave was detected in 32 patients [24 men, mean age (42.3±13.3) years] with ARVC using three different electrocardiography (ECG) recording methods: standard twelve leads ECG (S-ECG), right precordial leads ECG (R-ECG) and Fontaine bipolar precordiai leads ECG (F-ECG). The Epsilon wave was defined as wiggle, small spike wave and smooth potential between the end of the QRS complex and the beginning of the ST segment. Results Epsilon wave was detected in 37.5%, 37.5% and 50.0% patients with ARVC by S-ECG, R-ECG and F-ECG respectively. The detection rates derived from the three recording methods were similar(P ＞ 0.05). The Epsilon wave was only detectable by S-ECG in one case, by R-ECG in three cases, and by F-ECG in five cases. The detection rate of Epsilon wave was 50.0% by combined use of S-ECG and R-ECG (SR-ECG), 56.3% by combined use of S-ECG and F-ECG (SF-ECG), and 65.6% by combined use of the three recording methods (SRF-ECG). The detection rate was significantly higher by SF-ECG (56.3%) and SRF-ECG (65.6%) than by S-ECG alone (37.5%, all P ＜0.05). Most Epsilon waves detected by the S-ECG, R-ECG and F-ECG were small spiked waves. Conclusion Combined use of S-ECG, F-ECG and R-ECG could increase the detection rate of Epsilon wave in patients with ARVC.     

希浦传导系统的解剖及其临床意义

希氏束为房室结的延续,其在室间隔肌部的顶端开始分为左右束支。希氏束主干穿透中心纤维体延伸为左束支,走行于无冠窦和右冠窦交界的下方,其分支呈带状外观分布于心内膜下。右束支较为细长,走行于节制索上。临床研究发现,希浦系统起搏对于房颤伴心衰、心肌病伴左束支传导阻滞等患者具有很好的疗效,对心室起搏依赖的患者进行希浦系统起搏也能保持良好的心室同步性。文章从希浦系统的解剖学特征及其对临床应用的指导意义进行综述。     

致心律失常性右室心肌病患者Epsilon波的检出率

Objective To investigate the prevalence of Epsilon wave in patients with arrhythmogenic right ventrieular cardiomyopathy (ARVC). Methods The Epsilon wave was detected in 32 patients [24 men, mean age (42.3±13.3) years] with ARVC using three different electrocardiography (ECG) recording methods: standard twelve leads ECG (S-ECG), right precordial leads ECG (R-ECG) and Fontaine bipolar precordiai leads ECG (F-ECG). The Epsilon wave was defined as wiggle, small spike wave and smooth potential between the end of the QRS complex and the beginning of the ST segment. Results Epsilon wave was detected in 37.5%, 37.5% and 50.0% patients with ARVC by S-ECG, R-ECG and F-ECG respectively. The detection rates derived from the three recording methods were similar(P ＞ 0.05). The Epsilon wave was only detectable by S-ECG in one case, by R-ECG in three cases, and by F-ECG in five cases. The detection rate of Epsilon wave was 50.0% by combined use of S-ECG and R-ECG (SR-ECG), 56.3% by combined use of S-ECG and F-ECG (SF-ECG), and 65.6% by combined use of the three recording methods (SRF-ECG). The detection rate was significantly higher by SF-ECG (56.3%) and SRF-ECG (65.6%) than by S-ECG alone (37.5%, all P ＜0.05). Most Epsilon waves detected by the S-ECG, R-ECG and F-ECG were small spiked waves. Conclusion Combined use of S-ECG, F-ECG and R-ECG could increase the detection rate of Epsilon wave in patients with ARVC.     

慢性心力衰竭患者左束支起搏后植入全皮下心脏转复除颤器的可行性筛查

目的 探究慢性心力衰竭患者行左束支起搏(LBBP)后植入全皮下心脏转复除颤器(S-ICD)的可行性。方法 纳入慢性心力衰竭合并左束支传导阻滞患者，分别在LBBP术后2天内和术后6个月左右使用自动筛查工具进行S-ICD的植入前合格性筛查，每次筛查分别在自身完全性左束支阻滞非起搏模式、单纯LBBP模式、自身右束支下传与LBBP融合三种模式下进行；对于经冠状静脉窦植入左室导线的患者，增加左束支与左室同步起搏模式筛查。每种模式均在坐位和卧位两种体位下进行筛查，至少有一个感知向量在两种体位下通过筛查认为该模式通过筛查。统计不同模式下的通过向量个数和筛查通过率。结果 共纳入31例患者，年龄(68.0±8.3)岁，其中男性18例(56.1%)。14例植入带有除颤功能的起搏器(CRT-D),17例植入不带除颤功能的起搏器(包括13例植入DDD,4例植入CRT-P)。在术后的第一次筛查中，31名患者四种模式下筛查通过率分别为45.5%、87.1%、90.9%和100.0%(P<0.001);平均通过的向量个数为0.64±0.90、1.52±0.85、1.45±0.80、1.00±0.00(P=0....