射频导管消融术阻滞二尖瓣峡部的研究进展

目前,射频导管消融术阻滞二尖瓣峡部已成为心脏电生理领域的研究热点。然而,实现二尖瓣峡部双向传导阻滞仍存在巨大的挑战。现就二尖瓣峡部消融的一般介绍、应用难点、应对策略和展望四个方面做一综述。     

射频导管消融阻断二尖瓣环-左下肺静脉峡部导致左心房激动顺序改变一例

报道 1例在经房间隔途径消融左侧房室旁路过程中 ,位于二尖瓣环与左下肺静脉 (ＭＶ ＬＩＰＶ)之间的峡部被消融阻断 ,导致左心房激动顺序变化。患者女性 ,32岁。预激综合征病史 6年。入院体格检查、Ｘ线胸片和超声心动图未发现器质性心脏病。根据心电图上δ波和ＱＲＳ波向量 ,判断为左侧游离壁显性旁路。穿刺股静脉后 ,将 3根 4极导管放置于高位右心房、希氏束部位、右心室心尖部。经右颈内静脉将 10极导管送入冠状静脉窦 ,双极法 (按近端至远端的次序 ,5对电极依次为ＣＳ5、ＣＳ4 、ＣＳ3、ＣＳ2 、ＣＳ1,图 1)标测和记录左心房后壁的激动…     

心房颤动消融术后二尖瓣峡部房性心动过速的发生机制及消融治疗

目的探讨心房颤动(简称房颤)患者环肺静脉左房线性消融术后二尖瓣峡部房性心动过速(简称房速)的发生机制及其消融策略。方法122例房颤患者采用EnSite-NavX和环状电极行环肺静脉左房线性消融,术后32例复发房颤或房速,8例经EnSite-NavX激动标测及拖带标测证实存在二尖瓣峡部房速,在三维导航下于左下肺静脉口部下缘至二尖瓣环之间行线性消融,对不能成功阻断二尖瓣峡部传导者予以冠状静脉窦内消融。术中同时探查双侧肺静脉电位,如传导恢复予以再次隔离。结果8例中2例呈无休止性发作,6例为阵发性,可被程序刺激诱发。房速的周长217.5±20.6ms,其中顺钟向折返5例,逆钟向折返3例。二尖瓣峡部线性消融至完全性双向传导阻滞5例,3例心内膜途径失败者经冠状静脉窦内消融,其中1例获得成功。术后随访5.5±4.3个月,6例无房颤及房速发作,1例仍有阵发性房速发作。另1例术后房速呈无休止发作,予以胺碘酮及美托洛尔控制心室率治疗。结论环肺静脉线性消融术后发生的二尖瓣峡部房速与左房线性消融治疗房颤的致心律失常作用有关,其主要的机制是消融线相关的大折返性心动过速,阻断峡部传导可以治疗此类房速。     

阵发性心房颤动的射频导管消融大静脉电隔离治疗

目的报道阵发性心房颤动(房颤)的射频导管消融电隔离肺静脉和腔静脉的疗效。方法阵发性房颤患者36例,年龄(42.5±13.2)岁。经1次房间隔穿刺放置环状标测电极导管(Lasso导管)和冷盐水灌注消融导管,在Lasso导管的指导下,采用全肺静脉或上腔静脉与靶静脉节段性电隔离相结合的方法对肺静脉和腔静脉行标测和电隔离治疗。窦性心律时最早激动的肺静脉和腔静脉电位处和/或心房起搏时最短的心房和静脉电位间期处为靶点行消融。结果36例阵发性房颤患者均接受一次电隔离治疗,共电隔离大静脉115根,其中左上肺静脉34根,左下肺静脉22根,右上肺静脉30根,右下肺静脉17根,上腔静脉12根,即刻电隔离成功率为95.6%,术中并发症发生率2.78%。随访3~22个月,成功率(无房颤发作或房颤发作明显减少)为75.0%。结论射频导管消融电隔离肺静脉或腔静脉与心房间的电活动连接,可有效预防房颤的复发。治疗的关键是消融靶点的标测和确定。     

对心房颤动射频导管消融治疗的再认识

自1998年起,心房颤动(房颤)的导管消融治疗就成为临床心电生理学研究的持续热点,目前在国外部分医疗中心,单中心房颤导管消融的治疗例数已逾千例。近2年多来,随着治疗主要技术的日臻完善,不仅其成功率再创新高,适应证扩展至几乎整个房颤临床谱,而且临床研究的结果还对房颤机制的研究产生了重要影响(即所谓“learningbyburning”)。因此可以说,晚近有关房颤导管消融的临床实践已经从一定程度上更新了对这项治疗本身乃至房颤机制的若干认识,并很可能成为未来房颤治疗的主要方法。肺静脉电隔离术　　肺静脉电隔离术是现阶段房颤导管消融治疗的…     

经导管射频消融治疗乙灶性心房颤动

报道１９例局灶性心房颤动（简称房颤）射频消融治疗的结果,其中药物治疗无效且发作频繁（〉１次／日）的阵发性房颤１７例、慢性房颤２例。１７例患者尚同时合并有频发房性早搏（简称房早）（动态心电图显示〉７００个／日）。同步记录高位右房、冠状静脉窦及左、右上肺静脉电图。根据房早或房颤开始发作时的心房激动顺序确定异位兴奋灶部位,以局部双极科较体表心电图Ｐ波起点最提前处为消融靶点。成功标准为消融后６０ｍｉｎ内房     

阵发性心房颤动射频导管消融进行心房-肺静脉电隔离术的方法学

~~阵发性心房颤动射频导管消融进行心房肺静脉电隔离术的方法学@杨延宗!116001$大连医科大学附属第一医院心内科 @刘少稳!116001$大连医科大学附属第一医院心内科 @高连君!116001$大连医科大学附属第一医院心内科 @林治湖!116001$大连医科大学附属第一医院心内科~~     

经导管射频消融治疗起源于肺静脉的心房颤动（？…

报道２例经射频消融治疗成功的起源点位于肺静脉的心房颤动（简称房颤）均伴有频发房性早搏（简称房早）的阵发性房颤,电生理检查时行两次房间隔穿刺,将两根１０极标测导管通过长鞘送入左,右上肺静脉,选择性肺静脉造影证实肺静脉开口部位,静脉滴注异丙肾上腺素后１例诱发出频发房早,另１例诱发出频发房早及房颤,且房早及房颤开始发作时的心内电图无间显示最早心房激动点位于右上肺静脉内,其局部电位分别产体表心电图异位Ｐ波     

不同性别行导管射频消融治疗心房颤动的有效性和安全性差异

目的：探讨不同性别的阵发性心房颤动（房颤）患者行导管射频消融有效性与安全性的差异。方法纳入我院自2009年3月~2013年1月阵发性房颤并接受射频消融患者116例，按照患者性别分为男性组（n=71）和女性组（n=45）。随访时间为（6～51）个月，随访期间根据患者症状、心电图及Holter明确房颤是否复发，复发者则再次行消融术治疗，并明确房颤复发原因。比较两组手术成功率及并发症（包括：穿刺部位血肿、心包填塞、脑栓塞、脑出血、肺静脉狭窄及左房食管瘘）发生率，并分析手术复发率与其临床特点[包括：年龄、体质量指数（BMI）、左室射血分值（LVEF）、病史及合并疾病等]的相关性。结果男性组首次手术成功率显著高于女性组（83.1%vs.66.67%，P=0.046）。女性组平均年龄较男性组更高，两组手术并发症无统计学差异。Logistic回归分析女性组复发率高（OR=3.3， P=0.049），复发原因以存在非肺静脉起源驱动灶为主，男性复发还与糖尿病相关（OR=1.99， P=0.037）。结论女性房颤患者接受射频消融治疗更晚，单次治疗成功率较低，但安全性与男性患者无差异。     

普通射频消融导管电隔离肺静脉治疗局灶性心房颤动

导管射频消融治疗起源于肺静脉的局灶性心房颤动(房颤 ) ,是近年来心律失常介入治疗领域的热点 ,我们应用普通射频消融导管 ,通过消融肺静脉口 ,对 6例局灶性房颤患者成功地实施了肺静脉与左心房之间的电隔离。一、资料与方法6例患者均为男性 ,年龄 4 1～ 6 3岁 ,有阵发性房颤病史3～ 10年 ,心电图示频发“ＰｏｎＴ”房性早搏 (房早 ) ,房早诱发短阵房颤 ,持续数分钟和数小时不等。房颤发作频繁 ,3～ 4种抗心律失常药物治疗无效 ,行心内电生理检查及导管射频消融术。主肺动脉造影显示肺静脉解剖位置后 ,两次房间隔穿刺放置 7Ｆ 10极Ｌａｓｓ…     

Left atrial isthmus: anatomic aspects relevant for linear catheter ablation procedures in humans

INTRODUCTION: The success rate of catheter maze ablation procedures for atrial fibrillation depends upon adequate electrical isolation by performing linear ablation lesions. However, recurrence of atrial arrhythmias is not uncommon, particularly in the so-called left atrial isthmus, between the orifice of the left inferior pulmonary vein and the mitral valve annulus. The focus of the present study is the anatomy of this area. METHODS AND RESULTS: Twenty human hearts were studied. The distance between the left inferior pulmonary vein and the mitral valve, the thickness of the left atrial myocardium, and the extent of left atrial myocardium toward the mitral valve were measured. The AV groove contained a fat pad harboring the great cardiac vein. The distance between the vein and the valve varied considerably (range 17-51 mm). The great cardiac vein coursed along the inferior left atrial wall, approximately 1 cm above the level of the mitral valve. Myocardial thickness also varied considerably (distal: range 1.4-7.7 mm, midway: range 1.2-4.4 mm, proximal: range 0-3.2 mm). Left atrial myocardium extended onto the mitral valve in two hearts, and the left atrial myocardium ended above the level of the mitral valve (range 1.8-5.1 mm) in six hearts. An important variable because it raises the question of how much energy should be used--and at which point--to achieve an adequate transmural ablation line. CONCLUSION: The great cardiac vein is not an adequate marker for the level of the mitral valve, left atrial myocardium may continue onto the mitral valve, the distance between the left inferior pulmonary vein and mitral valve varies considerably, and left atrial myocardial thickness is highly variable and not uniform.     

Left atrial flutter after radiofrequency catheter ablation of focal atrial fibrillation

We report an arrhythmic complication in two patients in whom a procedure directed at isolating one or two pulmonary veins had been performed. The complication was related to pulmonary vein disconnection scars after ablation. Both patients developed new clinical tachycardia (atypical atrial flutter) secondary to a reentrant phenomena in the vicinity of a previously ablated pulmonary vein.     

Left atrial-esophageal fistula following radiofrequency catheter ablation of atrial fibrillation

This report describes a fatal case of left atrial-esophageal fistula occurring in a 72-year-old man after a radiofrequency catheter ablation of paroxysmal atrial fibrillation. Catheter ablation was performed around the pulmonary vein using an 8-mm-tip electrode (60 W or 55 degrees C) guided by a 25-mm circular catheter. On day 22 of follow-up, the patient presented with seizures followed by hematemesis due to left atrial-esophageal fistula. His clinical condition deteriorated, and he died of speticemia. Thus, left atrial-esophageal fistula is a sever complication of radiofrequency catheter ablation of the left atrial posterior wall.     

单导管标测在心房扑动射频消融中的意义

目的:探讨单导管标测法在心房扑动(房扑)射频消融中的应用方法和效果。方法:阵发性心房颤动并发房扑患者行肺静脉电隔离术时采用单导管标测法消融房扑30例。所有患者行肺静脉电隔离术后,将10极冠状静脉窦(CS)导管远端2对电极放置于CS内,余位于CS外,并使之有一定的张力,使导管贴靠于三尖瓣环和低右房。用冷盐水灌注消融导管线性消融三尖瓣峡部,房扑发作患者在房扑下消融,窦律患者在CS远端电极起搏下消融,可在术中随时把大头消融导管置于希氏束部位,用于评价是否已完全达双向阻滞,即:起搏CS远端电极,刺激信号至CS近端电极A波的距离大于至希氏束A波的距离,则CS口至低右房单向阻滞;CS近端电极起搏,刺激信号至CS远端电极A波的距离大于至希氏束A波的距离,则低右房至CS口单向阻滞,从而达双向阻滞,CS近端电极起搏所需电压较高,有的患者可达24mA。结果:所用阵发性心房颤动并发房扑患者均成功行三尖瓣峡部线性射频消融,达到双向阻滞,无手术相关并发症,随访4个月～2年,无房扑复发。结论:单导管标测法对房扑患者行三尖瓣峡部线性射频消融操作简单、快速,可完全用于评价消融结果,成功率高,并且节省手术费用。     

阵发性心房颤动射频消融术后左房大小和机械功能变化

目的探讨经导管射频消融术对阵发性心房颤动（房颤）患者左房功能的影响,并比较肺静脉口节段性电隔离（SPVI）和环肺静脉消融（CPVA）两种术式在此方面的异同。方法66例阵发性房颤患者接受射频消融手术治疗。应用经胸心脏超声检查测量患者术前、术后1天、1个月和3个月时的左房前后径、左房面积、舒张晚期跨二尖瓣血流峰速（A峰）和舒张晚期心肌组织运动峰速（A’峰）。结果66例患者中,30例接受SPVI术,36例接受CPVA术。两组患者一般临床情况及术前超声参数相似。术后随访（315±153）d,SPVI组和CPVA组无房性心律失常复发率相似（70％与75％,P=0．650）。两组在手术后左房面积均较术前缩小,SPVI组发生于术后1个月,而CPVA组于术后3个月。SPVI组左房直径也显示出明显缩小（P〈0．05）,而CPVA组术前和术后则差异无统计学意义。左房机械功能方面,CPVA组于术后1天A峰和A’峰明显降低（P〈0．05）,两者均于3个月后较术后1天明显回升,A峰恢复至术前水平,A’峰较术前有明显升高。SPVI组术后1天没有出现A峰和A’峰明显降低;其A峰于术后1个月升高,并保持至3个月;A’峰于术后3个月时升高。结论阵发性房颤经导管SPVI术和CPVA术治疗后3个月,可以出现左房面积缩小和收缩功能改善。CPVA术比SPVI术造成了更多的左房损伤,表现为术后1天左房功能的下降以及术后左房大小、功能参数改善的延迟。     

房颤治疗:外科射频消融术与内科导管射频消融术孰优?

诸学时:2006年10月13日,中国第一家房颤研究治疗中心——北京安贞医院房颤中心,在北京召开的第四届五洲国际心血管病研讨会上正式宣告成立。该中心集医疗、科研、教学、培训和咨询五位一体,整合了安贞医院心脏内科和外科两支房颤研究治疗团队的力量,优势互补。其学科带头人均是我国著名心脏病学专家。心脏内科马长生教授于1998年率先在国内开展房颤的经导管射频消融治疗,截至目前已累计完成近千例,为国内最大系列。在心脏外科孟旭教授带领下,2002年安贞医院开始外科直视下的房颤射频消融术,至今累计完成420例,为国内最大系列,也是亚洲范围内…     

Mapping-guided ablation of the cavotricuspid isthmus: A novel simplified approach to radiofrequency catheter ablation of isthmus-dependent atrial flutter

BACKGROUND: Because the anatomic features of the cavotricuspid isthmus (CTI) are complex, radiofrequency (RF) energy requirements for CTI ablation may vary at each point within the CTI. Conventionally, multiple-site mapping has been required for determining CTI conduction block. OBJECTIVES: The purpose of this study was to develop a more efficacious method for ablation of isthmus-dependent atrial flutter. METHODS: Forty consecutive patients underwent CTI ablation using a CTI mapping-guided approach (20 patients) or a conventional approach (20 patients). In the CTI mapping-guided approach, an octapolar catheter was positioned on the CTI parallel to, and downstream from, the intended ablation line in order to map and ablate the breakthrough point. RESULTS: Complete CTI block was achieved in all study patients. CTI mapping of incomplete ablation lines revealed that the site with the shortest interval between double potentials did not always coincide with the conduction gap. Disappearance of a breakthrough pattern on the CTI electrograms corresponded to creation of complete CTI block. During ablation, CTI mapping exhibited pseudo-CTI block in 8% of patients in the clockwise direction and 63% of patients in the counterclockwise direction. The number and total time of RF applications were significantly lower with the CTI mapping-guided approach than with the conventional approach (7.7 +/- 3.9 applications vs 13.8 +/- 8.9 applications and 8.9 +/- 4.4 minutes vs 16.3 +/- 11.9 minutes, respectively, P <.05). In the CTI mapping-guided approach, RF applications were not required along the entire CTI in 7 patients (35%). CONCLUSION: This simplified technique was feasible for creating and determining complete CTI block, with fewer RF applications required.     

Phased-array intracardiac echocardiography for defining cavotricuspid isthmus anatomy during radiofrequency ablation of typical atrial flutter

INTRODUCTION: Cavotricuspid isthmus (CTI) topography includes ridges, pouches, recesses, and trabeculations. These features may limit the success of radiofrequency ablation (RFA) of typical atrial flutter (AFL). The aim of this study was to assess the utility of phased-array intracardiac echocardiography (ICE) for imaging the CTI and monitoring RFA of AFL. METHODS AND RESULTS: Fifteen patients (mean age 64 +/- 9 years) underwent ICE assessment (imaging frequency 7.5-10 MHz) before and after RFA of AFL. The ICE catheter was positioned at the inferior vena cava-right atrial junction and the following parameters were measured: (1) CTI length from the tricuspid valve to the eustachian ridge; (2) extent of CTI pouching; and (3) thickness pre/post RFA of the anterior, mid, and posterior CTI. CTI length was 35 +/- 6 mm at end-ventricular systole but shorter (30 +/- 6 mm) and more pouched at end-ventricular diastole (P = 0.02). A pouch or recess was seen in 11 of 15 patients (mean depth 6 +/- 2 mm). The septal CTI was more pouched than the lateral CTI, but the latter had more prominent trabeculations. Trabeculations were seen in 10 of 15 patients, and at these locations the CTI was 4.6 +/- 1 mm thick. Anterior, mid, and posterior CTI thickness pre-RFA was 4.1 +/- 0.8, 3.3 +/- 0.5, and 2.7 +/- 0.9 mm, respectively (P < 0.001 by analysis of variance). ICE guided RFA away from unfavorable CTI features (recesses/thick trabeculations). RFA applications created discrete CTI lesions that coalesced, forming diffuse CTI swelling. Post-RFA thickness was as follows: anterior 4.8 +/- 0.8 mm (P = NS vs pre); mid 3.8 +/- 0.8 mm (P = 0.05 vs pre); and posterior 3.8 +/- 0.8 mm (P = 0.02 vs pre). CONCLUSION: Phased-array ICE permits novel real-time CTI imaging with excellent endocardial resolution and may facilitate RFA of AFL.