阵发性心房颤动患者肺静脉与心房电连接特征的临床研究

顽固性阵发性房颤患者43例,在环状标测电极指导下行肺静脉电位(PVP)记录和分析,并对能标测到PVP的肺静脉进行开口部的点或段的消融电隔离治疗。根据窦性心律和心房起搏下的肺静脉内环形标测电极导管标测到的PVP的激动顺序,以及有效放电对PVP的影响,分析和总结肺静脉与心房之间的电连接特点。     

阵发性心房颤动患者上腔静脉肌袖与心房的电学连接特征

总结 16例阵发性心房颤动患者上腔静脉 (SVC)肌袖的电生理标测和导管射频消融电隔离的结果 ,评价SVC肌袖和心房电连接的类型和特点。在环状标测电极指导下 ,对 16根SVC肌袖进行电位的记录、分析以及开口部的点或段的消融电隔离治疗。根据窦性心律和心房起搏下的肌袖内环形电极标测的袖电位激动顺序 ,即电突破点的数目和位置 ,以及有效放电对袖电位及其电突破点的影响 ,总结和分析袖房之间的电连接类型和特点。结果 :共标测和电隔离SVC肌袖 16根。其中呈单束状电连接 8根 (5 0 % ) ,双束状电连接 7根 (43.7% ) ,多束状电连接 1根 (6 .3% )。 16根SVC平均每根电连接束为 1.6± 0 .6根 ,共消融 2 .1± 0 .6个节段和部位 ,每个部位进行了2 .3± 0 .7次的放电。所有病例均达到完全电隔离的标准。结论 :SVC袖房之间电连接的类型多为单束状和双束状 ,在袖房连接处行点或节段性消融即可达到完全袖房电隔离的结果。     

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。     

起源于肺静脉的阵发性房颤的电生理特点及射频消融治疗

目的探讨环状电极(Lasso电极)标测诱发阵发性房颤的肺静脉电位的电生理特点并对射频消融靶点进行评介。方法16例阵发性房颤者在Lasso电极标测寻找优势肺静脉电位(PVP),温控消融放电。结果起源于肺静脉的局灶性房颤其电生理特征包括:①异位激动灶主要分布于两上肺静脉。②肺静脉内可观察到从肺静脉内至心房传导阻滞。消融成功的靶点与体表心电图P′波提前(74±33)ms。成功隔离38条肺静脉:其中左上肺静脉16条,右上肺静脉12条。术程(186.7±63.8)min,X线曝光时间(51.5±15.0)min。术后随访1～12个月,11例(68.7%)无需药物而维持窦性心律。结论阵发性房颤异位起源点大多数位于左房肺静脉,起源于肺静脉的局灶性房颤有其特殊的电生理表现。     

在心房颤动持续过程中行肺静脉电学隔离术的可行性

探讨在心房颤动 (简称房颤 )持续过程中行肺静脉电学隔离术的可行性。 9例在导管消融术中房颤持续发作的房颤患者 ,根据肺静脉环状标测电极导管记录的肺静脉激动特征采用 2种方法进行肺静脉开口部的消融 :①肺静脉激动有序且有一种或多种固定的激动顺序 ,采用射频导管消融环状电极记录的最早的激动部位 ;②肺静脉激动无序或无明确的激动顺序 ,首先使用超声球囊导管消融 ,如未达终点再加用射频导管消融。 2种方法的消融终点均为肺静脉电学隔离。总计对 31根肺静脉进行了消融 ,其中 2 8根在房颤心律下消融。房颤心律下电隔离肺静脉的成功率为 92 .9% (2 6根 )。总操作时间和X线透视时间分别为 1 38± 2 1min和 38± 9min。本组无肺静脉狭窄及其他并发症。随访 6 .3± 2 .9(3～ 1 1 )个月后 ,4例 (44.4% )患者无房颤发作 (无需药物 )。结论 :在房颤持续过程中行肺静脉电学隔离术方法可行 ,且较为安全 ;联用超声球囊消融和射频消融对于房颤发作过程中无序或无明确激动顺序的肺静脉具有较好的电学隔离效果。     

阵发性心房颤动大静脉电隔离后肌袖内自发电活动的特点

目的　总结阵发性心房颤动 (房颤 )患者大静脉 (肺静脉和 /或上腔静脉 )电隔离治疗后肌袖内自发电活动的特点 ,探讨其临床意义。方法　顽固性特发性房颤患者 ,在环状标测电极导管指导下行心内电生理标测以及肺静脉和 /或上腔静脉肌袖的射频导管消融电隔离治疗 ,电隔离后继续留置环状标测导管 10～ 2 0min ,观察自发电位发生情况。结果　电隔离前心内标测显示 32例患者的 36根大静脉肌袖有自发电活动。以心房 大静脉传入阻滞为终点行大静脉口部消融后 ,16根 (4 4 % )记录到大静脉内自发电活动 ,其中 2根呈偶发的单一电活动 ,11根呈平均频率 (38± 12 )次 /min的缓慢节律 ,3根呈偶发的由 3～ 6个电位组成的短阵快速节律。 15根示大静脉内电活动与心房完全分离 (93 8% ) ,1根左上肺静脉存在大静脉 心房单向传导。结论　射频导管消融电隔离大静脉后 ,出现心房 大静脉传入阻滞时多同时伴有大静脉 心房传出阻断 ,心房 大静脉传入阻滞后大静脉内的电活动频率明显变慢、减少或消失 ,说明窦性心律时的心房 大静脉传导是引起大静脉内电活动不稳定的重要原因 ,射频导管消融技术即使只阻断心房 大静脉单向传导也可通过稳定大静脉内电活动而减少或控制房颤的发作。     

肺静脉电隔离治疗持续性心房颤动方法学及效果评价

目的对肺静脉电隔离治疗持续性心房颤动(房颤)的方法学及效果进行评价。方法14例持续性房颤患者,房颤病史6个月～20年,房颤持续时间1周～4个月,左心房直径37～47 mm平均(40．8±26．0)mm,左心室射血分数0．26-0．68平均0．55±0．11。术前抗凝治疗2～3周。术中常规放置冠状静脉窦导管及右心室起搏导管。房间隔穿刺成功后送入肺静脉环状标测电极导管(Lasso电极导管)及盐水灌注消融导管,预设功率30 W,温度50℃,于肺静脉口依次对4根肺静脉进行隔离。电复律恢复窦性心律后,再将Lasso电极导管依次送入各肺静脉口部标测,在残存肺静脉电位(PVP)的部位继续消融至心房与肺静脉完全电隔离。结果共对54根肺静脉进行电隔离,左上肺静脉14根,左下肺静脉13根,右上肺静脉14根,右下肺静脉13根,电隔离成功后PVP均完全消失,即刻成功率100％,平均放电时间(2 972±843)s。1例出现心脏压塞。随访12-18个月,无房颤复发5例(36％);症状明显减轻、房颤发作频率及持续时间明显减少4例(28％);症状无改善,房颤仍持续发作5例(36％),总有效率64％。结论肺静脉电隔离对持续性房颤治疗有效,其方法学可行但存在一定局限性。     

射频导管消融进行心房-肺(或上腔)静脉电隔离治疗阵发性心房颤动的并发症分析

目的总结射频导管消融进行心房 肺静脉和 /或上腔静脉 (合称大静脉 )电隔离治疗阵发性心房颤动 (房颤 )的并发症。方法顽固性阵发性房颤患者 89例 ,在环状标测电极导管指导下行大静脉的射频导管消融电隔离治疗 ,分析出现的各种并发症。结果 89例病人共接受电隔离治疗 10 3次 ,隔离大静脉 2 30根 ,其中肺静脉 2 0 7根 ,上腔静脉 2 3根。出现并发症 10例 ,其中严重迷走神经反射导致的一过性三度房室阻滞引起的晕厥发作 2例 ,脑卒中 2例 ,肺静脉狭窄 4例 (狭窄程度 >5 0 % ) ,术后少量心包积血 2例 ,并发症的总发生率为 11%。结论射频导管消融进行心房 肺和 /或上腔静脉电隔离治疗阵发性房颤可出现各种并发症 ,多数并发症可通过采取相应的措施使之减少或避免 ,其中肺静脉狭窄和脑卒中为最棘手的并发症 ,应予以高度重视。     

起源于肺静脉的房性心律失常体表心电图和心内电生理特点

目的:分析起源于肺静脉的房性心律失常体表心电图和心内电生理特点,识别触发心房纤颤(房颤)的房性期前收缩(房早)和房性心动过速(房速)。方法:回顾性分析房性心律失常并阵发性房颤84例体表心电图(房颤组),非房颤组84例体表心电图为频发房早(800次/24 h)。房颤组结合心内电生理检查及Lasso环状电极标测,行导管射频消融(RFCA)肺静脉隔离(PVI)。结果:房颤组电隔离肺静脉286支,均达即刻成功标准,无并发症发生。房颤组体表心电图呈房早、房速、心房扑动(房扑)和阵发性房颤(房颤)频繁发作和交替转换,并常伴长间歇,房早联律间期470～280(420±57)ms明显短于非房颤组的房早联律间期660～350(610±86)ms,P0.05,房颤多由短联律间期房早触发。心内电生理改变为Lasso环状电极标测到起源于肺静脉的连续、快速、有序或无序的较P波提前,时限短、峰锐利的尖峰电位(Spike电位),同步心电图显示该Spike电位常是阵发性房颤的触发因素。经导管射频消融消除肺静脉内电位或隔离肺静脉与心房间的电或组织连接,可终止房性心律失常,维持窦性心律。结论:起源于肺静脉的房性心律失常的特点是短联律间期房早,也是阵发性房颤的触发因素。     

射频导管消融肺静脉电隔离过程中残存静脉电位的鉴别诊断

心房颤动(房颤)的非药物治疗是近年来的研究热点，国内外许多临床研究证明应用射频导管消融技术成功电隔离肺静脉可以有效预防房颤的复发。环状标测导管指导下的节段性消融肺静脉电隔离成功的指标为，窦性心律或心房内不同部位起搏时肺静脉电位消失、静脉与心房之间的电活动分离。在肺静脉电隔离过程中常碰到较明显的静脉电位被成功消融后，     

阵发性心房颤动复杂病例的射频消融

目的　对阵发性心房颤动 (房颤 )复杂病例的射频消融进行方法学探讨。方法　 130例患者中 ,男性 87例 ,女性 4 3例 ,平均年龄 5 6岁 ;均经 2 4小时动态心电图和普通心电图证实为阵发性房颤。常规穿刺放置导管后 ,根据每个肺静脉造影所显示的解剖形态 ,在环状电极的引导下 ,依次对4根肺静脉进行电隔离。结果　 (1) 130例房颤患者中造影发现 2 1例患者的 2 1根肺静脉开口巨大 ,发生率为 16 2 % ,5根为左侧肺静脉共干 ,发生率为 3 8% ,3根为右侧肺静脉共干 ,发生率为 2 3% ;6例患者右肺静脉呈分支状多个开口 ,发生率为 4 7%。 (2 )共对 130例患者 341根肺静脉进行了电隔离 ,2 9根肺静脉未达到完全电隔离 ,包括上述 2 1例患者中的 11例 ,发生率为 8 3% ,其中 14根发生在左上肺静脉 ,8根发生在左下肺静脉 ,5根发生在右下肺静脉 ,2根发生在右上肺静脉。结论　肺静脉自身的解剖变异是导致射频消融中病例复杂的主要因素     

Lasso环形标测电极导管指导阵发性心房颤动肺静脉电隔离

探讨在Lasso环形标测电极导管指导下对阵发性心房颤动 (PAF)患者行肺静脉电隔离术的安全性、有效性。顽固性PAF患者 30例 ,男 19例 ,年龄 5 3± 15 (41～ 70 )岁 ,在肺静脉口用Lasso环形电极导管对肺静脉逐一进行标测 ,于肺静脉最早的心房 肺静脉电位处消融 ,电学隔离肺静脉。消融温度控制在 5 0℃ ,功率 2 5～ 35W。结果 :电学隔离肺静脉 6 9根 ,其中左上肺静脉 2 8根、左下肺静脉 2 0根、右上肺静脉 15根、右下肺静脉 6根 ,电隔离成功6 5根 ;电隔离上腔静脉 6根 ,左房后游离壁异位兴奋灶消融 8个 ,无手术相关并发症。即刻成功率 94 %。随访10 .1± 5 .1(5～ 2 2 )个月 ,成功率 (无心房颤动发作 ) 6 1%。结论 :在Lasso环形标测电极导管指导下对PAF患者行肺静脉电隔离术安全有效 ,是一种很有前途的治疗PAF的消融方法。     

Electrophysiological pulmonary vein antrum isolation with a multielectrode basket catheter is feasible and effective for curing paroxysmal atrial fibrillation: efficacy of minimally extensive pulmonary vein isolation.

BACKGROUND: How extensive should an appropriate pulmonary vein (PV) ablation be is a matter of controversy. OBJECTIVE: The study's aim was to investigate the efficacy of minimally extensive PV ablation for isolating the PV antrum (PVA) with the guidance of electrophysiological parameters. METHODS: Fifty-five consecutive symptomatic paroxysmal atrial fibrillation (PAF) patients underwent PV mapping with a multielectrode basket catheter (MBC). A 31-mm MBC was deployed in 3-4 PVs as proximally as possible without dislodgement, and the longitudinal PV mapping enabled us to recognize single sharp potentials formed by the total fusion of the PV and left atrial potentials around the PV ostium or the transverse activation patterns that were observed. Those potentials were defined as PVA potentials. Radiofrequency ablation was performed circumferentially targeting PVA potentials with the end point being their elimination. RESULTS: After circumferential PVA ablation, electrical disconnection was achieved in 77% and residual PVA conduction gaps were observed in 23% of all targeted PVs. Those residual conduction gaps were mainly located at the border between ipsilateral PVs (42%) and between the left PVs and left atrial appendage (33%) and were eliminated by a mean of 3 +/- 2 minutes of local radiofrequency deliveries. During the follow-up period (11 +/- 5 months), 46 (84%) patients were free of symptomatic PAF without any anti-arrhythmic drugs. No PV stenosis or spontaneous left atrial flutter occurred. CONCLUSIONS: Electrophysiological PVA ablation with an MBC is feasible and effective for curing PAF because this minimally extensive PVA isolation technique targets the optimal sites, achieving both high efficacy and safety.     

阵发性心房颤动节段性肺静脉电隔离方法学评价

目的评价经改良的节段性电隔离肺静脉方法治疗阵发性心房颤动的有效性及安全性.方法 39例阵发心房颤动患者,男性28例,女性11例,采用一次房间隔穿刺技术,送入标测及消融电极,并选用猪尾造影导管用高压非选择性造影显示肺静脉开口及左心耳位置,指导导管行进方向以减少心脏压塞风险.标测中常规探查、标测右下肺静脉,避免遗漏可能触发心房颤动的肺静脉电位.在肺静脉电位优势传导部位消融并轻微移动形成节段性电隔离.结果单个节段或多个节段消融可使肺静脉与左心房之间形成完全性电隔离.节段性隔离靶肺静脉85根,即刻成功81根,成功率95%,无并发症发生.结论节段性电隔离肺静脉法可有效隔离肺静脉,与其他传统方法比较,手术时间短、成功率高,可减少肺静脉的损伤和避免肺静脉狭窄的发生.     

环状标测电极指导下射频消融治疗阵发性房颤的临床分析

目的探讨环状标测电极指导下射频消融治疗阵发性心房颤动的疗效。方法对23例阵发性房颤患者在环状电极指示下行经验性肺静脉和（或）上腔静脉电隔离。结果23例阵发性房颤患者中共隔离肺加上腔静脉87条，左上肺静脉22条，左下肺静脉18条，右上肺静脉22条，右下肺静脉12条，上腔静脉13条，平均每例3．78条。平均操作时间和X线透视时间分别为（148±34）min和（52±9）min。1例发生术中心包填塞，2例行2次手术。平均随访（3．8±1．6）个月，20例无房颤复发，2例有房早发作，成功22例。结论阵发性心房颤动采用环状标测电极指导下射频消融电隔离术对绝大多数患者是有效的，并能改善患者的心功能情况。     

Prevalence of pulmonary vein disconnection after anatomical ablation for atrial fibrillation: consequences of wide atrial encircling of the pulmonary veins.

AIMS: Anatomical and wide atrial encircling of the pulmonary veins (PVs) has been proposed as a cure of atrial fibrillation (AF). We evaluated the acute achievement of electrical PV isolation using this approach. In addition, the consequences of wide encircling of the PVs with isolation were assessed. METHODS AND RESULTS: Twenty patients with paroxysmal AF were studied. Anatomically guided ablation was performed utilizing the CARTO system to deliver coalescent lesions circumferentially around each PV to produce a voltage reduction to <0.1 mV, with the operator blinded to recordings of circumferential PV mapping. After achieving the anatomical endpoint, the incidence of residual conduction and the amplitude and conduction delay of residual PV potentials were determined. Electrical isolation of the PV was then performed and the residual far-field potentials evaluated. Individual PV ablation was performed in all PVs. Anatomically guided PV ablation was performed for 47.3+/-11 min, after which 44 (55%) PVs were electrically isolated. In the remaining 45%, despite abolition of the local potential at the ablation site, PV potentials [amplitude 0.2 mV (range 0.09-0.75) and delay of 50.3+/-12.6 ms] were identified by circumferential mapping. After electrical isolation (12.2+/-11.7 min ablation), 55 (69%) PVs demonstrated far-field potentials; with a greater incidence (P=0.015) and amplitude (P=0.021) on the left compared with the right PVs. At 13.2+/-8.3 months follow-up, 13 patients (65%) remained arrhythmia-free without anti-arrhythmics. In four patients (20%), spontaneous sustained left atrial macrore-entry required re-mapping and ablation. Macrore-entry was observed to utilize regions around or bordering the previous ablation as its substrate. CONCLUSION: Anatomically guided circumferential PV ablation results in apparently coalescent but electrically incomplete lesions with residual conduction in 45% of PVs. Wide encircling of the PVs was associated with left atrial macrore-entry in 20% of patients.     

三维标测系统指导下环肺静脉消融治疗心房颤动

目的 探讨三维标测系统指导下环肺静脉消融治疗心房颤动的安全性和有效性.方法 阵发性心房颤动92例和持续性或永久性心房颤动36例,接受环肺静脉消融术.采用Carto电解剖标测系统,进行环肺静脉左心房线性消融,消融终点为肺静脉电隔离.手术结束时对心律仍为心房颤动者行同步直流电心脏复律.结果 完成"解剖学"环形消融线256条,其中58.6%达到电隔离肺静脉的终点,经寻找缝隙补充消融后最终248条(96.9%)消融线达到终点.手术时间(231±45)min、X线曝光时间(42±13)min和放电时间(66±17)min.术后随访平均10个月,无复发101例(78.9%).接受了再次手术15例,心内电生理检查证实14例有左心房-肺静脉传导,射频消融成功并随访30～270 d,两次射频消融术后总成功率为87.5%,其中阵发性心房颤动成功率为93.0%,持续性或永久性心房颤动为76.7%.并发症发生率为6.2%,包括心包填塞2例、小脑梗死2例、股静脉穿刺部位血肿1例和左侧大量血胸1例,经治疗后均痊愈.结论 以肺静脉电隔离为目标的环肺静脉消融术治疗心房颤动有效和安全.     

Is circumferential pulmonary vein isolation preferable to stepwise segmental pulmonary vein isolation for patients with paroxysmal atrial fibrillation?

BACKGROUND: Stepwise segmental pulmonary vein isolation (SPVI) and circumferential pulmonary vein isolation (CPVI) have been developed to treat patients with atrial fibrillation (AF), but the preferable approach for paroxysmal AF (PAF) has not been established. METHODS AND RESULTS: One hundred and ten patients with symptomatic PAF were randomized into a stepwise SPVI group (n=55) or CPVI group (n=55). Systemic SPVI combined with left atrial linear ablation tailored by inducibility of AF was performed in the stepwise SPVI group. Circumferential linear ablation around the left and right-sided pulmonary veins (PVs) guided by 3-dimensional electroanatomic mapping was performed in the CPVI group. The endpoints of ablation are non-induciblity of AF in the stepwise SPVI group and continuity of circular lesions combined with PV isolation in the CPVI group. After the initial procedures, atrial tachyarrhythmis (ATa) recurred within the first 3 months in 23 of the 55 patients (41.8%) who underwent stepwise SPVI and in 20 of the 55 patients (36.4%) who had CPVI (p=0.69). Repeat procedures were performed in 7 patients from the stepwise SPVI group and 5 from the CPVI group (p=0.76). During the 3-9 months after the last procedure, 46 patients (83.6%) from the CPVI group and 43 (78.2%) from the stepwise SPVI group did not have symptomatic ATa while not taking anti-arrhythmic drugs (p=0.63). Severe subcutaneous hematoma or PV stenosis occurred in 3 patients. CONCLUSIONS: The efficacy of stepwise SPVI is comparable to that of CPVI for patients with PAF.     

Effects of left atrial ablation of atrial fibrillation on size of the left atrium and pulmonary veins

OBJECTIVES: The purpose of this study was to determine the effect of left atrial circumferential ablation on the size of the left atrium and pulmonary veins (PVs). BACKGROUND: The long-term effects of left atrial circumferential ablation on left atrial and PV size and anatomy have not been analyzed in quantitative fashion. METHODS: PV and left atrial sizes were analyzed in 41 consecutive patients (mean age 54 +/- 12 years) with paroxysmal (n = 25) or chronic (n = 16) atrial fibrillation. Computed tomography of the chest with three-dimensional reconstruction was performed before and 4 +/- 2 months after left atrial circumferential ablation. Left atrial circumferential ablation was performed to encircle the PVs 1 to 2 cm from the ostia, using a power output of 70 W. Additional ablation lines were created in the posterior left atrium and mitral isthmus. Radiofrequency energy also was delivered within the circles and at the PV ostia in 51% of patients at a reduced power output of 35 W. RESULTS: At 6 months, 36 patients (88%) were in sinus rhythm without antiarrhythmic drug therapy, including 3 patients (7%) who developed persistent left atrial flutter and underwent subsequent successful ablation of atrial flutter. There was a 15 +/- 16% decrease in left atrial volume (P < .01) and 10 +/- 35% decrease in PV ostial area (P < .01), without focal narrowing, in patients with a successful outcome. Focal PV stenosis did not occur in any of the 41 patients. CONCLUSIONS: Maintenance of sinus rhythm after left atrial circumferential ablation is associated with reduced left atrial and PV ostial size. Left atrial circumferential ablation for atrial fibrillation does not cause PV stenosis.