三维标测指导致心律失常性右心室心肌病室性心动过速的射频消融

目的介绍致心律失常性右心室心肌病（ARVC）室性心动过速（室速）的三维标测方法及其消融策略。方法21例ARVC室速患者，因1—4种抗心律失常药物治疗无效，临床上呈反复发作、无休止发作或植入型心律转复除颤器（ICD）植入后频繁放电治疗，接受导管消融治疗。其中，男性19例，女性2例，平均年龄（32±12）岁。9例患者接受电解剖（Carto）标测，12例患者接受非接触标测（EnSite—Array）。在首先明确病变基质的基础上，通过激动标测、拖带标测及起搏标测，分析心动过速的起源、可能的传导径路及其出口以及它们与病变基质的关系。通常于心动过速的出口处及其周边行局灶消融，术中病变基质周边的延迟激动电位应一并消融。结果21例患者，2例呈无休止发作，1例患者表现为频繁室性早搏及加速性室性自主心律，余18例患者消融中共诱发出34种心动过速。所有心动过速均呈左束支阻滞形，平均心动过速周长为（289±68）ms。16例患者（28种室速）消融治疗即刻成功，3例患者（7种室速）部分成功，2例患者（2种室速）消融失败，即刻消融成功率76．2％。所有患者消融术后继续服用抗心律失常药物。平均随访6～30（1d±7）个月，成功患者中2例复发，其中1例再次消融成功；未达即刻成功的5例患者，经抗心律失常药物治疗后，均无室性心律失常事件发生，其中包括1例消融后植入ICD者。结论三维标测系统可首先明确ARVC患者的病变基质，在此基础上结合激动标测和心内各种电刺激技术，可直观显示心动过速的起源、缓慢传导区出口及折返环路，以此制定消融策略可成功治疗ARVC室速。心动过速起源于心肌深部或ARVC病变进展，是消融失败和复发的常见原因。

Catheter ablation of ventricular tachycardia with arrhythmogenic right ventricular cardiomyopathy under the guidance of 3-dimentional mapping

Objective To evaluate the application of 3-dimensional mapping and the ablation strate-gies in the treatment of ventricular tachycardia (VT) with arrhythmogenic right ventricular cardiomyopathy (ARVC). Methods Twenty-one ARVC patients [19 male,mean age (32±12)years]with recurrent or inces-sant VT attack which were refractory to 1～4 antiarrhythmic drug therapy were investigated in the study. The low voltage sites (sear area) were identified by using noncontact mapping (12 cases) and electroanatomic mapping (9 cases). Activation mapping, pace mapping and entrainment mapping were then performed and the reentrant circuit, critical isthmus, slow conduction and exit sites were localized. Catheter ablation was carried out accord-ing to the mapping information using saline-irrigated catheter (35～40 W,45℃, 17～30 ml/min). Sites with delayed potentials during sinus rhythm at the edge of scar tissue were also selected for ablation. Results Among 21 patients,2 had incessant VT, 1 had frequent ventricular premature contractions ,and in the rest 18,34 VTs in LBBB morphology were induced during the procedure and the mean cycle length was (289±68) ms. Catheter ablation successfully eliminated all the VTs in 16 patients (28 VTs). The strategy failed in 2 pa-tients (2 VTs) and partial successed in 3 patients. All the patients took antiarrhythmic drug after ablation pro-cedure regardless of the ablation results. During follow-up of 6～30 (14±7) months, 19 patients were free of VT attack. Two patients had recurred VT, with one patient regained ablation success in the second proce-dure. Conclusions Three-dimentional mapping, combined with activation mapping and pacing maneuvers can help to discover the origin,reentrant circuit, slow conduction zone of ARVC-VT. Epicardial VT-origin or newly developed VT may be the common reasons responsible for ablation failure and VT recurrence.