致心律失常性右室心肌病的CARTO系统电生理基质标测和射频导管消融

目的应用CARTO系统对致心律失常性右室心肌病(ARVC)患者进行电解剖标测并指导射频消融治疗其室性心动过速(简称室速)。方法入选伴有室速反复发作的25例ARVC患者,年龄36±12岁,男性17例,有家族成员35岁以下早发猝死史3例。术前行常规心电图、心室晚电位、心脏B超检查。在窦性心律或/和心动过速时,电解剖标测三维重建右室。术中6例同时行右室造影检查。根据双极电图电压高低确定疤痕区、正常心肌和临界边缘区。对于折返性室速,线性消融关键峡部或疤痕区与三尖瓣环之间或两疤痕区间;对于局灶性室速,点消融局部最早激动区域。结果 20%(5/25)体表心电图发现前壁或下壁导联Epsilon波,心室晚电位阳性占88%(21/25),心脏B超发现右室不同程度的局部或整体扩张,56%(14/25)可见局部囊袋状向外膨出。所有患者均出现1～5(2±1)种左束支阻滞型室速,其中5例合并频发室性早搏,1例伴心房扑动,1例伴左后间隔旁道。即时消融成功率为72%(18/25)。随访14±10(4～36)个月,原消融成功的5例室速复发。1例消融失败伴晕厥史的患者植入ICD治疗。无手术相关并发症和死亡发生。结论应用CARTO系统电解剖标测可安全有效指导射频消融治疗ARVC患者的室速,有相对较高的失败和复发率。CARTO系统标测的电压图,参考术前心电图、心脏B超及右室造影可了解病变心肌的分布范围,对初步确定室速的病理基质有帮助。

Electroanatomic mapping and radiofrequency catheter ablation for ventricular tachycardia with arrhythmogenic right ventricular cardiomyopathy using CARTO system

Objective To assess the efficacy of electroanatomic mapping and radiofrequency catheter ablation （RFCA） for ventricular tachycardia （VT） with arrhythmogenic right ventricular cardiomyopathy （ARVC） under the guide of CARTO system. Methods Twenty-five patients （36 ± 12 years old, 17 male） with ARVC were studied. Implantable cardiac defibrillator （ICD） was implanted in 1 patient before ablation procedure and experienced frequent defibrillation episodes. One had incessant VT which lasts 2 days. Right ventricle was reconstructed electroanatomically in three dimensions during the sinus rhythm or/and tachycardia, the scar, normal myocardium and the border zone were defined according to their bipolar voltage. Linear ablation was applied in the critical isthmus or to connect the scar to the tricuspid annulus or to another scar in reentrant VT pattern. In focal VT pattern, RFCA was performed at the earliest activation area. Results Totally 49 VTs were induced in the 25 patients. One to five VTs were recorded in each patient. Among 23 hemodynamically stable VT,reentrant pattern was found in 19 VTs,in other 4 patients VT pattern was focal. Acute success was achieved in 18/25 （72%）. During a follow-up of 14 ± 10 months, VT recurred in 5 patients initially successfully ablated. ICD was implanted in one patient with failed ablation and syncope. No complication and death was found. Conclusions RFCA is a safe and effective treatment for VT in patients with ARVC using electroanatomic mapping. It has relatively higher unsuccessful rate and recurrence rate. Pathological substrate of VT can be defined by voltage mapping of abnormal myocardium. Chinese Journal of Cardiac Pacing and Electrophysiology, 2010,24 （2） ：116- 121]