心房颤动肺静脉电隔离后肺静脉自发电位分析

目的探讨心房颤动(简称房颤)患者肺静脉电隔离后发生肺静脉自发电位的相关因素。方法153例患者,其中阵发性房颤114例,持续性或永久性房颤39例,术前行肺静脉CT血管造影并测量肺静脉最大直径,行环肺静脉消融肺静脉电隔离术,并进行肺静脉自发电位标测及其相关因素评价。结果术中,69例(45.1%)共125根肺静脉(20.1%,125/621)标测到自发电位。左上肺静脉最大径(LSPV,18.5±4.0mm)及右上肺静脉最大径(RSPV,18.7±4.2mm)均大于左下肺静脉(LIPV,15.2±3.0mm)及右下肺静脉(RIPV,16.3±3.8mm)(P均<0.001),右侧肺静脉大于左侧肺静脉(17.5±4.2mmvs16.8±3.9mm,P=0.012);有自发电位的RSPV最大径大于无自发电位的RSPV(20.0±3.8mmvs18.3±4.3mm,P=0.027)。右侧肺静脉自发电位发生率高于左侧肺静脉(25.5%vs15.1%,P=0.002),RSPV和RIPV自发电位发生率均高于LIPV(27.2%,23.8%vs11.4%,P<0.001与P=0.005)。RSPV自发电位发生率与RSPV最大径正相关(β=0.097,P<0.05)。结论肺静脉最大径越大则自发电位的发生率越高,而RSPV有无自发电位与RSPV最大径明显相关。     

选择性上肺静脉造影显示下肺静脉开口位置的研究

目的探讨心房颤动(简称房颤)射频消融治疗中通过选择性上肺静脉造影显示下肺静脉开口位置的可行性与效果。方法97例房颤患者,取左前斜位(LAO)50°和右前斜位(RAO)50°两个体位进行左上肺静脉造影。取LAO50°及RAO30°两个体位进行右上肺静脉造影。结果97例(100%)均可通过选择性左上肺静脉造影清晰显示左下肺静脉开口的下缘,其中78例(80.4%)可以清晰显示左下肺静脉的开口前缘。79例(81.4%)患者可以清晰显示左下肺静脉开口的后缘。选择性右上肺静脉造影时,86例(88.7%)能够清晰识别右下肺静脉开口下缘,76例(78.4%)能清晰显示右下肺静脉开口前缘,81例(83.5%)能清晰显示右下肺静脉开口后缘。结论选择性上肺静脉造影不仅能够显示上肺静脉的开口位置,而且在大部分患者中亦能较清晰显示下肺静脉的开口解剖。     

肺静脉电隔离对环肺静脉线性消融术效果的影响

目的:探讨肺静脉完全隔离与否对环肺静脉线性消融术治疗阵发性心房颤动(Af)效果的影响。方法:63例阵发性Af患者随机分为隔离肺静脉组(30例)和不隔离肺静脉组(33例)。所有患者均在三维电解剖系统指导下完成环左右肺静脉线性消融。在术前和术后均放置10极环状导管(Lasso)以标测各肺静脉电位情况,对隔离肺静脉组,如环肺静脉消融完成后仍残存肺静脉电位则补充进行节段性肺静脉隔离,而对不隔离肺静脉组环肺静脉消融完成后不作进一步处理。结果:环肺静脉消融完成后,不隔离肺静脉组33例患者中30例(90.9%)未达完全肺静脉隔离。隔离肺静脉组30例患者中26例(86.7%)未达完全肺静脉隔离,在行补充性节段消融后,隔离肺静脉组完全肺静脉电隔离率达96.7%(29/30)。平均随访(11±3)个月后,不隔离肺静脉组81.8%(27/33)的患者和隔离肺静脉组83.3%(25/30)的患者停用抗心律失常药物后无Af发作,2组间差异无统计学意义。结论:环肺静脉线性消融术用于治疗阵发性Af时,术中完全的肺静脉电隔离对于提高长期疗效并非必需。     

肺静脉前庭重构与环肺静脉前庭电隔离术后肺静脉-左房电传导恢复的关系

目的分析肺静脉前庭重构与环肺静脉前庭电隔离术(CPVI)后肺静脉-左房电传导恢复之间的关系。方法入选2007年1月至2009年9月因房颤行导管射频消融术后复发,再次消融患者359例(阵发性房颤180例,持续性房颤179例)。LASSO环状电极标测肺静脉-左房电传导恢复情况,在Carto系统引导下行补点消融。利用CARTO系统自带软件测量左右肺静脉前庭面积。结果 359例患者均顺利完成导管射频消融。阵发性房颤患者中有144例(80%)电传导恢复,其中单支肺静脉电传导恢复占45例(31.25%),2支占58例(40.28%),3支占24例(16.67%),4支恢复占17例(11.81%)。持续性房颤患者中有155例(86.59%)电传导恢复,其中单支肺静脉电传导恢复占24例(15.48%),2支占72例(46.45%),3支占17例(10.97%),4支占42例(27.1%)。阵发性房颤左肺静脉前庭面积(6.15±0.65)cm2,右肺静脉前庭面积(7.95±2.24)cm2。持续性房颤左肺静脉前庭面积(10.48±1.00)cm2,右肺静脉前庭面积(11.4±2.16)cm2。统计学分析提示阵发性房颤CPVI术后单支肺静脉电传导恢复比例高于持续性房颤(P=0.001),而持续性房颤4支肺静脉电传导恢复比例高于阵发性房颤(P=0.001)。阵发性房颤左、右肺静脉前庭面积均小于持续性房颤(P0.001,P=0.022)。结论持续性房颤肺静脉前庭重构程度高于阵发性房颤,因此持续性房颤电隔离术后肺静脉-左房电传导恢复比例高于阵发性房颤。     

核磁共振肺静脉造影与经导管选择性肺静脉造影对肺静脉解剖特征评价的对比研究

目的准确了解肺静脉开口解剖特征对心房颤动(简称房颤)肺静脉电隔离术有重要意义.本研究对比磁共振肺静脉造影(MRA)与经导管选择性肺静脉造影对肺静脉解剖特征的评价结果,以阐明MRA在指导房颤肺静脉电隔离术的价值.     

起源于肺静脉的阵发性心房颤动患者肺静脉开口直径的测量

目的　测量肺静脉起源的阵发性心房颤动 (房颤 )患者肺静脉的开口直径。方法　连续5 1例肺静脉起源的阵发性房颤患者 ,根据选择性肺静脉造影测定双上肺静脉开口直径和致心律失常的肺静脉开口直径。结果　共发现 76根致心律失常性肺静脉 ,其中左上肺静脉 31根、右上肺静脉 2 9根、左下肺静脉 13根、右下肺静脉 3根。致心律失常的左上和右上肺静脉开口直径分别为 (13 7±0 9)mm和 (13 9± 1 1)mm ,显著粗于非致心律失常的左上和右上肺静脉开口直径 [分别为 (12 8± 1 3)mm和 (13 0± 1 1)mm ,P <0 0 1]。结论　肺静脉起源的阵发性房颤患者致心律失常的肺静脉存在开口部扩张。     

完全性肺静脉异位引流术后肺静脉狭窄的外科治疗

目的:回顾总结完全性肺静脉异位引流(TAPVC)术后肺静脉狭窄(PPVS)的外科治疗经验,探讨PPVS的发病机制及手术方式。方法:2013年1月至2016年12月,5例PPVS患儿行手术治疗。男性2例,女性3例。心下型3例,心上型2例。初次手术年龄1~26d,平均(12.2±5.3)d;体质量3.1~4.0kg,平均(3.4±1.2)kg。再次手术年龄2月~3岁,两次手术间隔65d~3年。手术采用中度低温体外循环4例,深低温停循环1例。吻合口纤维瘢痕切除4例,无缝线缝合技术1例。手术采用中度低温体外循环4例,深低温体外循环1例。体外循环时间102~150min,平均(127.5±15.8)min;主动脉阻断47~75min,平均(62.3±9.5)min;1例停循环时间42min。结果:术后早期死亡1例;分支肺静脉梗阻1例,术后7个月死亡;余3例患儿发育良好。结论:肺静脉异位引流手术后肺静脉狭窄是一种进展性疾病,预后不良。发病机制与肺静脉异位引流的类型、肺静脉发育情况及外科操作等因素有关。一经诊断应积极手术治疗,根据不同的病理类型选择适当的手术方法。     

环肺静脉电隔离术对阵发性心房颤动患者肺静脉电生理特性的影响

目的探讨环肺静脉电隔离术(CPVI)对肺静脉电生理特性的影响。方法纳入抗心律失常药物治疗无效的阵发性心房颤动(房颤)且初次行CPVI治疗的患者26例,CPVI前、后分别测量肺静脉和左心房的有效不应期(ERP)、相对不应期(RRP),比较CPVI前、后肺静脉和左心房ERP、RRP的变化。结果 26例阵发性房颤患者共隔离104根肺静脉,术后即刻均为窦性心律。CPVI前、后肺静脉舒张期起搏阈值分别为(3.2±0.6)V vs.(3.3±0.5)V,P0.05。CPVI前肺静脉的ERP(n=82)、RRP(n=35)时间短于左心房,分别为(187±60)ms vs.(229±31)ms(P0.001);(223±45)ms vs.(261±34)ms(P0.05)。CPVI后肺静脉ERP(n=47)、RRP(n=26)时间和左心房均无统计学差异,分别是(245±38)ms vs.(234±43)ms(P0.05),(268±44)ms vs.(245±41)ms(P0.05)。CPVI后肺静脉ERP(n=47)、RRP(n=21)较CPVI前显著延长,分别是(245±38)ms vs.(187±76)ms(P0.05);(259±44)ms vs.(230±47)ms(P0.05)。结论 CPVI隔离肺静脉和左心房之间的电传导,同时也改变了肺静脉的电生理特性,降低了其致心律失常特性。     

国人肺静脉组织学研究

目的大量研究表明心房颤动(简称房颤)与肺静脉内异位兴奋点的"局灶性触发或驱动"有关,肺静脉有产生异位兴奋并传导冲动的解剖电生理特征.本研究对肺静脉的组织学特性进行研究,以探讨其参与肺静脉触发阵发性房颤(PAF)的组织学基础.     

环肺静脉线性消融电学隔离肺静脉治疗100例心房颤动临床评价

目的探讨三维标测系统和单环状标测电极指导下行环肺静脉线性消融电学隔离肺静脉治疗心房颤动(房颤)的可行性和有效性。方法自2004年4月至2005年1月共对连续100例症状明显、发作频繁、抗心律失常药物治疗无效的房颤患者进行了在CARTO系统(76例)或EnSite-NavX系统(24例)指导下的环肺静脉线性消融术,消融终点为双侧肺静脉的彻底电学隔离。结果100例患者共完成200个环形消融环,肺静脉电学隔离率为95.0%。操作时间150～365(240±65)min,X线时间为23～61(37±12)min。其中8例(8.0%)复发患者接受了再次导管消融。随访5.5～12(10.2±5.7)个月,累计无房性快速心律失常率为85.0%。术后1、2、3、4、5、6个月时无房性快速心律失常率分别为66.0%、82.0%、87.0%、85.0%、85.0%、88.6%。并发症包括1例心脏压塞,经保守治疗后康复,1例患者出现无症状性肺静脉狭窄。结论在三维标测系统指导下,环肺静脉线性消融电学隔离肺静脉治疗房颤安全有效。     

Bigeminal pulmonary vein ectopy suppressed by pulmonary vein isolation

A 58-year-old man with atrial fibrillation underwent pulmonary vein (PV) isolation (PVI). Bigeminal atrial premature beats persisted from the beginning of the PVI. The cardiac recordings from a basket catheter (BC) revealed the PV ectopic origin in the distal right superior PV. Successful PVI with the guidance of BC was confirmed by the appearance of concealed ectopy. Surprisingly, the PV ectopy completely disappeared immediately after the successful PVI. The findings suggest that the generation of PV trigger is sometimes dependent on left atrial input and that the underlying mechanism of the PV trigger may have been triggered activity or reentry.     

Spontaneous and induced pulmonary vein tachycardia after pulmonary vein isolation.

A case is reported of recurrence of paroxysmal atrial fibrillation after pulmonary vein ablation. A second procedure achieved isolation of three pulmonary veins and showed persistence of pulmonary vein tachycardia in one with implications concerning the electrophysiology of atrial fibrillation.     

Primary pulmonary vein stenosis

Primary pulmonary vein stenosis (PVS) is a rare entity with a high mortality rate. Relatively little is known regarding predictors of outcome or the appropriate timing of intervention. The Pediatric Cardiac Care Consortium database (n = 98,126) was searched for patients who had undergone cardiac catheterization or surgical procedures with primary diagnoses of PVS or atresia from 1982 to 2002. Patients with total or partial anomalous pulmonary venous return, cor triatriatum, previous atrial switch, or previous lung transplantation were excluded. Additional data were obtained through questionnaires sent to each Pediatric Cardiac Care Consortium institution. A total of 31 patients were identified with primary PVS. Excluding lung transplantation, 16 of 31 patients underwent intervention to relieve PVS. Univariate predictors of lung death, defined as death or lung transplantation, included younger age at diagnosis (16.2 vs 52.5 months, p = 0.0221), higher initial mean pulmonary arterial pressure (46.4 vs 26.8 mm Hg, p = 0.0003), and bilateral vessel involvement (lung death in 17 of 19 vs 0 of 9 patients, p <0.0001). Patients diagnosed at 18 months of age and those with initial mean pulmonary arterial pressures >33 mm Hg had incidences of lung death of 76% and 88%, respectively. In conclusion, primary PVS carries a high mortality rate despite attempts at palliation. Patients diagnosed at 18 months of age, having initial mean pulmonary arterial pressures >33 mm Hg, or with bilateral vessel involvement are at significantly increased risk for death or lung transplantation. In these high-risk groups, death occurs rapidly despite intervention, and lung transplantation should be an early consideration.     

Congenital pulmonary vein stenosis

Congenital pulmonary vein stenosis is a rare and serious form of congenital heart disease. Between 1969 and 1982 10 patients with this lesion were studied. In 2 patients the condition was diagnosed at autopsy; these patients died before the presence of congenital heart disease was suspected. Of the 8 in whom the condition was diagnosed during life, it was suspected clinically in 6 and found unexpectedly at cardiac catheterization in 2. All underwent operation, and 5 were hospital survivors. In all survivors rapid and progressive restenosis of the pulmonary veins occurred over the next several months. Three of the 5 underwent reoperation, but progressive restenosis recurred and all eventually died of this condition. Thus, despite partial surgical relief of pulmonary vein stenosis, the lesion is apparently one of relentless progression. No surgical repair has been successful in the cure or long-term palliation of this lethal lesion.     

Unilateral pulmonary vein stenosis

Unilateral pulmonary vein stenosis is a rare congenital anomaly. A case is described in a girl who first presented at the age of four years with recurring haemoptysis but in whom diagnosis was not established until she was 16 years old. Pulmonary angiography demonstrated a minimally hypoplastic right pulmonary artery, and the laevophase showed normal pulmonary venous return from the left lung, but none from the right. Surgical treatment was necessary because of life threatening haemoptysis, and pneumonectomy was required in the light of the findings at operation.     

Isolated pulmonary vein atresia

Two patients with isolated atresia of the pulmonary veins are described. One patient presented with haemoptysis and the other with recurrent unilateral chest infections. The diagnosis was confirmed in both instances by cardiac catheterisation and pulmonary angiography. One patient died one year after the diagnosis was made and the second child has been stable during a follow up period of three years.