零射线下应用倒U法联合普通弯法行射频消融治疗特发性右心室流出道室性期前收缩的效果分析

目的探讨零射线环境下应用倒U法联合普通弯法行射频消融治疗特发性右心室流出道(RVOT)室性期前收缩(PVC)的有效性及安全性。方法入选2017年6月至2017年12月在首都医科大学附属北京安贞医院行导管射频消融的36例PVC患者,术前行体表心电图监测。术中借助三维标测系统和压力监测导管,在零射线下采用普通弯法激动标测RVOT,再采用倒U法激动标测肺动脉瓣上,并于最早激动点处行射频消融。结果 36例PVC患者于RVOT零射线消融成功,其中31例首先通过倒U法于肺动脉瓣上行射频消融(30例消融成功;1例消融无效,最终通过普通弯法于RVOT前间隔消融成功),其余5例首先通过普通弯法于RVOT消融(3例消融成功;2例无效,最终通过倒U法于肺动脉瓣上消融成功)。术后患者均无手术相关并发症发生,除1例患者外所有患者停用抗心律失常药物且无再次PVC发作。结论借助三维标测系统和压力监测导管,在零射线下应用倒U法联合普通弯法行射频消融治疗RVOT PVC是安全可行的。     

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。     

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附近解剖的电位,并进行比较,分析最早点电图特征,测量外膜最早点至内膜最早点的距离及靶点至冠状动脉(冠脉)的距离,采用冷盐水模式下消融。结果:Summit附近起源VA的ECG有一定的特征性。所有患者中,手术成功率为90%,复发率为6.9%,并发症发生率为3.3%;最早点分布如下:左冠窦(LCC)20例、主动脉瓣与二尖瓣连接处(AMC)10例、心大静脉(GCV)28例及右室流出道间隔部2例;所有患者中,GCV的局部电位(35±11)ms;最早点电图的特征:有尖峰电位33例,局部电位较VA的QRS波提前(37±7)ms;靶点电图的特征:有尖峰电位23例,局部电位较VA的QRS波提前(25±13)ms。靶点至冠脉距离(15±5)mm,GCV最早点与LCC、AMC最早点的距离较近。其中有23例患者消融成功的靶点并不在标测到的最早点。结论:Summit附近起源VA的ECG具有一定的特征,射频消融术治疗具有有效性及安全性;在部分患者中,经心内膜途径结合解剖消融是可行的,对提高消融成功率及减低风险可能有一定的帮助。     

房室折返性心动过速射频消融术后复发原因分析

目的探讨房室折返性心动过速(AVRT)患者射频消融(RFCA)术后复发率、复发原因。方法回顾分析2017年1月至2019年10月间收治的323例AVRT患者的临床资料、首次射频消融术资料、随访结果和复发患者二次射频消融术资料。结果 323例患者中男性196(60.9%)例,年龄(40.2±14.3)岁,术中即刻成功率99.7%,随访(20.0±12.7)个月,复发21(6.5%)例。复发患者的旁道分布:左侧游离壁10例、右侧游离壁7例、前间隔2例、后间隔2例。术中使用三维标测的复发率低于传统标测复发率(2.8%vs 9.5%,P=0.015),与复发组相比未复发组V/A融合时限短[(74.3±3.6)ms vs (80.7±3.1)ms,P0.05],逆传A波更提前[(24.2±2.8)ms vs (17.3±3.9)ms,P0.05],靶点心室电位提前QRS波时间更长[(25.4±2.3)ms vs (22.2±1.4)ms,P0.05],消融反应时间更短[(4.4±1.8)s vs (8.9±3.5)s,P0.05]。左侧旁道患者术中采用主动脉逆行途径的复发率低于穿间隔途径(1.8%vs 7.1%,P0.05)。多因素回归分析显示,术中是否使用三维标测、消融反应时间、逆传A波提前程度是复发的影响因素。复发患者中有20例接受了二次消融手术均消融成功,随访(12.2±8.0)个月未见复发。结论导管消融术治疗AVRT成功率高,复发率较低。术中是否使用三维标测、消融反应时间、逆传A波提前程度是复发的影响因素。     

左束支电位结合三维标测射频消融犬左束支实验研究

目的：探讨左束支电位（LBP）结合三维标测系统指导下射频消融左束支的可行性。
　　方法：对13只犬行左束支射频消融术,常规放置右房电极记录希氏束电位作为X线影像定位右侧希氏束,经右股动脉途径跨主动脉瓣逆行标测并消融左束支电位。同时应用NavX三维标测系统定位右侧希氏束（R-His）、左侧希氏束（L-His）及LBP电位。观察消融成功犬电位特点,记录消融前后的PR间期、QRS形态和时限、AH间期、HV间期和消融导管心内电图A/V值。对比LBP结合X线影像指导左束支消融和LBP结合三维标测指导左束支消融手术时间及X线曝光时间。
　　结果：13只犬中9只成功消融左束支,3只犬消融失败,1只犬发生完全性房室阻滞。成功消融靶点LBP到最早心室电图平均时限（LBP-V）为（17.8±2.6）ms（13~21 ms）。成功消融靶点A/V值<1/10。LBP结合三维标测手术时间及X线曝光时间较LBP结合X线影像手术时间及X线曝光时间明显降低[分别为（1.7±0.3）h vs （2.4±0.3）h,P=0.007,（10.8±1.5）min vs（30.5±4.0）min,P<0.001]。
　　结论：LBP结合三维标测系统可以成功消融左束支,与传统LBP和X线影像指导下左束支消融方法相比,LBP结合三维标测系统可以明显缩短手术时间和X线辐射量。     

PaSO起搏标测软件在右心室流出道室性期前收缩射频消融中的应用

目的探讨PaSO起搏标测软件(CARTO3,美国强生公司)在右心室流出道(RVOT)室性期前收缩(PVC)射频消融治疗中的应用价值。方法回顾性分析2016年1月至2016年8月于北京协和医院接受射频消融治疗的RVOT PVC患者共21例,入选患者同时行激动标测和PaSO起搏标测。将激动标测最早点定义为A点,PaSO起搏标测相似度软件评分最优点定义为B点,消融有效点定义为C点。比较两种标测方法指导RVOT PVC射频消融治疗的准确度。结果患者术中激动标测取点数为(11.0±5.0)个,激动顺序标测显示最早激动部位电位提前体表QRS时限15～36 ms(27.3±5.6)ms。PaSO起搏标测取点数为(10.0±5.0)个,起搏标测最优点与自发PVC QRS相似度为94.3%～99.2%[(97.4±1.5)%]。激动标测和PaSO起搏标测在判断PVC内膜靶点上比较,差异无统计学意义[AC间距(5.9±3.1)mm比BC间距(5.1±2.7)mm,P=0.320]。激动标测最早点与PaSO起搏标测最优点之间的中位距离为7.7(2.6,16.7)mm。结论 PaSO自动匹配起搏标测软件指导RVOT PVC射频消融靶点的准确度不劣于激动标测。基于自动匹配运算的PaSO起搏标测软件不受术中PVC负荷的限制,可以客观、准确、快速地定位PVC起源点,从而实现PVC精准消融。     

峰电位及起搏标测对主动脉窦起源室性期前收缩射频消融的意义

目的:对主动脉窦起源室性期前收缩患者应用三维电解剖标测系统(Carto系统)进行激动顺序标测及起搏标测,探讨锋电位和起搏标测对主动脉窦起源期前收缩射频消融的指导意义。方法:本研究病例为我院2013-07-2017-07于主动脉窦内消融成功的室性期前收缩病例,运用Carto三维标测系统对右室流出道及主动脉窦行三维重建,行激动标测及起搏标测,观察锋电位与起搏标测心室夺获情况与消融靶点的关系。结果:23例患者最终于主动脉窦消融成功,其中左冠窦18例,右冠窦5例,无冠窦0例。左冠窦起源的室性期前收缩右室流出道(RVOT)心室最早激动点(EVA)提前体表心电图V波20~38(25.56±5.20)ms,左冠窦靶点处EVA提前体表心电图V波18~37(27.33±6.07)ms。18例左冠窦起源室性期前收缩患者中,16例(88.9%)记录到锋电位。14例(77.8%)于左冠窦靶点处起搏可成功夺获心室,消融成功后于靶点处再次起搏均无法夺获心室。右冠窦起源的室性期前收缩RVOT处EVA提前体表心电图V波18~37(26.6±5.41)ms,右冠窦靶点处EVA提前体表心电图V波21~38(30.20±6.83)ms。5例右冠窦起源的室性期前收缩患者全部记录到锋电位,其中3例(60%)可于右冠窦靶点处成功夺获心室,消融成功后于靶点处再次起搏均无法夺获心室。结论:锋电位与起搏标测成功夺获心室对主动脉窦起源室性期前收缩的射频消融有指导意义。     

心电图Ⅰ导联m型QRS波形态在流出道室性心律失常中的诊断价值

目的探讨心电图Ⅰ导联QRS波形态呈m型在流出道室性心律失常(PVC)中的定位诊断价值。方法回顾性分析成功行射频消融的流出道PVC患者357例,根据消融成功的心腔分为两组:左室流出道(LVOT)消融成功者(A组,n=139),右室流出道(RVOT)消融成功者(B组,n=218),比较两组患者心电图Ⅰ导联QRS波呈m型的例数、Ⅰ导联QRS波的振幅、靶点位置及靶点图电位特点。结果 (1)A组患者9例Ⅰ导联QRS波形态呈m型,B组患者30例Ⅰ导联QRS波形态呈m型,发生率有显著差异(6.5%vs 13.8%,P0.05)。(2)两组患者Ⅰ导联QRS波振幅有显著差异[(0.38±0.13)mV vs(0.21±0.13)mV,P0.01];两组患者Ⅰ导联QRS波时程差异无显著性[(129.0±29.4)ms vs(145.6±26.0)ms,P0.05]。(3)A组消融成功靶点位置位于RCC前部,B组消融成功靶点位置位于RVOT左侧肺动脉瓣附近游离壁、间隔交界处的间隔侧,两者靶点解剖位置相距较近。(4)两组靶点图V波提前QRS波程度有显著差异[(31±12.3)ms vs(21±5.7)ms,P0.05]。结论流出道PVC的Ⅰ导联QRS波形态呈m型提示消融成功靶点位置在RCC前部,或RVOT左侧肺动脉瓣附近游离壁、间隔交界处的间隔侧,RVOT起源多于LVOT起源,且两者靶点解剖位置相距较近。     

肺动脉窦起源的室性心律失常的电生理特点及射频消融治疗

目的研究肺动脉窦(PSC)标测与消融在射频消融治疗形似右室流出道(RVOT)起源的室性心律失常(VAs)中的价值。方法入选70例体表心电图表现为左束支传导阻滞、电轴向下的频发室性早搏/室性心动过速患者,经右股静脉进RVOT行电激动标测和起搏标测,证实为PSC或RVOT起源并进行射频消融治疗。分析其体表心电图特点、电生理检查特征及导管射频消融治疗结果。结果 PSC起源VAs在体表心电图形态表现上与RVOT起源者无明显差异,均表现为QRS形态呈左束支阻滞图形,下壁导联R波直立。各PSC起源VAs体表心电图表现略有差异。60例(86%)患者激动标测最早激动点在PSC内,且成功在PSC内消融。约93%的患者于PSC内获得较好的起搏标测结果。其余10例患者最终消融成功靶点位于肺动脉瓣下RVOT后间隔部6例,前间隔4例。PSC内靶点电位领先体表QRS波(26.2±2.5)ms,远大于RVOT处标测结果(20.2±2.4)ms。结论 PSC起源室性心律失常临床较常见。确定PSC内起源VAs约90%可在窦内消融成功。     

左侧隐匿性房室旁路靶点局部慢电位的临床意义

目的 在射频消融左侧隐匿性房室旁路部分病例的靶点图中发现存在提前于常规心电图QRS波的局部低振幅慢电位,本文旨在探讨该电位在隐匿性旁路消融靶点中出现的可能原因、隐匿性旁路隐匿性前传的可能机制及临床意义。方法2000年1月～6月经二尖瓣瓣下成功射频消融的46例左侧隐匿性旁路,以 200mm/s描记速度分析射频消融术前、术后窦性心律和术前成功靶点的心室起搏与心动过速时心内电图,尤其注意分析窦性心律时成功靶点心内电图在射频消融术前与术后的区别与特点,以及心室起搏、心动过速时靶点电图与窦性心律时靶点电图的区别,并测量术前常规心电图QRS波最早起点至成功靶点V波起点之间的距离（QV间期）。结果46例患者中有16例（3.78％）术前存在提前于常规心电图QRS波的局部低振幅慢电位;QV间期为-5～-58ms,平均（-14.94±-13.40）ms。所有16例患者的这些局部低振幅慢电位在心室起搏和心动过速时不能显露,并在射频消融术后全部消失。结论 左侧隐匿性旁路部分病例的瓣下消融靶点存在提前于体表QRS波的低振幅慢电位,推测该电位可能为隐匿性房室旁路隐匿性前传所致;存在局部慢电位的靶点提示为有效的消融靶点。     

Left ventricular function in right ventricular overload: asymmetry of the left ventricular ejection

This study clarified regional and global functions of the distorted left ventricle due to right ventricular overload by means of gated radionuclide ventriculography (RNV). Cardiac catheterization and RNV were performed in 13 cases of atrial septal defect (ASD), 13 of pure mitral stenosis (MS), 10 of primary pulmonary hypertension (PPH), and 10 of normal subjects (NL). Right ventricular systolic pressure (RVSP) was 32.9 +/- 13.9, 45.0 +/- 12.2, 88.3 +/- 17.1, and 21.2 +/- 4.5 mmHg, respectively. RNV was performed with a 99mTc-red blood cell in a vivo labeling technique. The end-systolic LAO view of the left ventricle was halved into septal and free-wall sides. The end-diastolic halves were determined in the same plane. Ejection fractions of the global left ventricle (LVEF), global right ventricle (RVEF), the septal half of the left ventricle (SEPEF), and the free-wall half of the left ventricle (FWEF) were obtained. LVEF was 56.8 +/- 9.8% in NL, 52.8 +/- 10.5% in ASD, and 49.5 +/- 12.9% in PPH. In MS, LVEF (47.0 +/- 13.0%) was smaller than those in the other groups. RVEF was 37.0 +/- 5.2% in NL, 43.7 +/- 15.5% in ASD, and 32.8 +/- 11.5% in MS. In PPH, RVEF (25.0 +/- 10.6%) was smaller than those in the other groups. SEPEF was smaller in AS D (42.5 +/- 13.2%), MS (40.4 +/- 13.1%), PPH (40.5 +/- 12.5%) than in NL (53.5 +/- 8.5%). Systolic function of the septal half of the left ventricle was disturbed by right ventricular overload. RVEF (r = -0.35, p less than 0.05) and SEPEF (r = -0.51, p less than 0.01) had negative correlations with RVSP. As RVSP rose, systolic function of the septal half of the left ventricle was more severely disturbed. FWEF was the same among the four groups; NL (57.0 +/- 12.6%), ASD (48.6 +/- 15.2%), MS (50.5 +/- 12.0%), and PPH (51.1 +/- 12.3%). Right ventricular overload does not affect systolic function of FWLV. There was a good correlation between SEPEF and LVEF in NL (r = 0.81), though in PPH this correlation was poor (r = 0.64). In patients with PPH the septal side of the left ventricle does not act as a part of the global left ventricle. Systolic function of the septal side of the left ventricle is disturbed due to the distortion of the ventricular septum, but systolic function of the free-wall side is maintained within a normal range, when the left ventricular myocardium is kept normal.(ABSTRACT TRUNCATED AT 400 WORDS)     

Right ventricular performance during left ventricular unloading conditions: the contribution of the right ventricular free wall

AIM: Right ventricular (RV) dysfunction is a significant complication following implantation of left ventricular assist device (LVAD). However, RV performance after LVAD implantation remains unclear. We have studied the effects of preload and afterload on RV performance under left ventricular (LV) unloading. METHODS: Six adult mongrel dogs were subjected to cardiopulmonary bypass. RV preload and afterload were independently regulated. Dynamic pressure-length analysis of RV free walls was performed using micromanometer catheter and sonomicrometric dimension transducers. Global RV systolic function was evaluated by the relationship between stroke volume vs. end-diastolic length (EDL) or end-diastolic pressure (EDP). We also examined the afterload dependency of RV performance at constant stroke volume. RESULTS: Stroke volume vs. EDP and stroke volume vs. EDL demonstrated a linear relationship (r(2) = 0.849 +/- 0.147 and 0.776 +/- 0.121, respectively). At constant stroke volume, RV systolic peak pressure vs. EDL or EDP were shown to have a linear relationship (r(2) = 0.906 +/- 0.050 vs. 0.909 +/- 0.047, respectively). CONCLUSION: The Frank-Starling relationship for RV performance was shown in this animal model. Without interventricular interaction, RV preload is dependent on RV afterload.     

Value of ventricular geometry in the evaluation of direct ventricular pressure

OBJECTIVE: To determine the echocardiographic end-systolic ventricular geometry value in evaluating right ventricular systolic pressure (RVSP). MATERIAL AND METHODS: We studied prospectively 68 patients (mean age = 6.0 +/- 5.0 years), submitted to cardiac catheterization for cardiac disorders not involving left ventricular (LV) outflow tract obstruction, within 24 hours after two-dimensional echocardiographic (2D echo) examination. 2D echo evaluation of RVSP was performed using end-systolic LV transverse orthogonal diameters (TDR). The LV transverse orthogonal diameters (antero-posterior and supero-inferior) were measured on a parasternal short-axis image, at the tips of papillary muscles. 2D echo semi-quantitative evaluation of RVSP was tested correlating TDR with hemodynamic RVSP/LV systolic pressure (LVSP) ratio--group 1. We also used regression equation derived from the first 35 patients to quantify RVSP in the last 33 patients--group 2. In these cases, systolic systemic arterial pressure measured by sphygmomanometry was taken as LVSP. RESULTS: The TDR ranged from 1.0 to 2.1 (mean = 1.5 +/- 0.3) and the RVSP/LVSP ratio from 0.3 to 1.7 (mean = 0.7 +/- 0.4). All patients with RVSP/LVSP greater than or equal to 65% have TDR greater than or equal to 1.3 and when RVSP less than or equal to 35 mmHg we always obtained TDR less than or equal to 1.2. The correlation between 2D echo estimated and catheter measured RVSP shows, for group 1, r = 0.88 and y = 1.1X-0.88 and, for group 2'. r = 0.88. CONCLUSION: In the absence of LV systolic obstruction, TDR is a reliable non invasive method in evaluating the RVSP.     

Characterization of the right ventricular substrate participating in postinfarction ventricular tachycardia

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Roles of the right ventricular free wall and ventricular septum in right ventricular performance and influence of the parietal pericardium during right ventricular failure in dogs

The roles of the right ventricular (RV) free wall and ventricular septum in RV performance were studied in the canine heart. The parietal pericardium was kept intact. Acute ischemia of the RV free wall from right coronary ligation decreased the RV stroke work index more than did that of the ventricular septum from the septal branch of the left coronary artery ligation (41 and 23%, respectively, p < 0.01). The response of the RV stroke work index to acute volume loading was also decreased. Left ventricular dysfunction was detected only with ventricular septal ischemia. Combined RV free wall and ventricular septal ischemia produced more severe and predominant RV dysfunction with disproportionate elevation of RV end-diastolic pressure. After combined ischemia, pericardiotomy improved the RV stroke work index as well as the left ventricular stroke work index (40 and 27%, respectively, p < 0.05), although the increase in RV stroke work index was greater than in left ventricular stroke work index (p < 0.05).The results of this study suggest that (1) the RV free wall has a more important role than the ventricular septum in RV performance, (2) predominant RV failure can be induced experimentally after combined RV free wall and ventricular septal ischemia, and (3) the pericardium has a restrictive effect on the damaged and dilated right ventricle.     

射频消融触发心室颤动的室性早搏治疗心室颤动

目的 探讨导管射频消融触发心室颤动(室颤)的室性早搏(室早)对室颤作预防性治疗的可行性、安全性、和有效性。方法 4例有晕厥多次发作史的患者，经心电图和域动态心电图证实晕厥发作因室颤所致。其中1例的家族中有猝死者；另1例有先天性室间隔缺损修补术史，室颤发作是否与此有关难以定论。4例患者经各种临床检查均无异常，3例可诊断为特发性室颤。常规进行电生理检查后，在S1S1心室起搏时引进S2、S3、和S4心室期前刺激以及短阵快速刺激，还加用异丙肾上腺素静脉滴注，诱发了室颤以及室早、多形室早、和短阵室性心动过速(室速)。用激动顺序方法标测最期前的室早的起源处。对4例患者分别用大头电极导管进行消融，消融靶点是期前程度最大的室早前的浦肯野电位。结果 经心内膜标测发现4例患者的室早起源处分别在右束支远端乳头肌周围(1例)和室间隔左侧面(3例)。经多次放电消融后，室早和域短阵室速消失，用与消融术前同样的刺激方案，未再诱发室颤。4例患者消融过程中，放电时间分别为240s、2600s、720s、和1900s；X线投照时间20至35min，消融过程总共历时3h20min，4h，2h30min、和3h50min。术后随访11个月至3年(其中3例停用抗心律失常药物)，无室颤或晕厥复发。结论 在浦肯野电位指引下导管射频消融室早和域短阵室速，在较长的随访期内可以成功地防止特发性室颤复发。     

Left ventricular thrombi in the presence of normal left ventricular function

We report two cases of left ventricular thrombi identified by routine echocardiography in the presence of normal ventricular function to highlight the rarity and clinical significance of this condition. A 14-year-old boy, positive for anticardiolipin and antinuclear antibodies, was found to have a left ventricular thrombus. A 30-year-old male, who presented with a transient ischemic attack, was found to have hypereosinophilic syndrome and a mobile left ventricular thrombus. The thrombi disappeared in both patients after a few days of anticoagulant therapy without symptoms of embolization.