Carto指引下环肺静脉导管消融术的达终点靶点分析及临床评价

目的:探讨环肺静脉导管消融术(CPVI)达终点部位及其分布规律,更有效地指导其达到肺静脉电隔离。方法:96例药物治疗无效的有临床症状的心房颤动患者。通过Carto电解剖标测系统三维标测指引下行CPVI。消融终点为完成环状消融线并实现肺静脉电位消失即肺静脉电隔离。结果:96例患者CPVI时记录到的消融靶点达终点部位203处,包括左侧肺静脉114处,位于左前上(45处,39.5%),左前下(26处,22.8%)和左前中(16处,14.0%);环右侧肺静脉89处,分别位于右后上(40处,44.9%)和右中下(27处,30.3%)。9例再次行CPVI的电隔离者与上述部位一致。手术并发症包括:1例少量心包积液,1例顽固性呃逆,血气胸1例,迷走反射2例,2例颈部血肿。结论:CPVI达终点部位有一定规律,多见于左侧肺静脉消融线前壁和右侧肺静脉消融线后壁,可为再次消融有效提示消融达终点部位的大体位置。     

同一肺静脉内缓慢性和快速性肺静脉电位共存现象

目的观察心房颤动(简称房颤)导管消融过程中同一肺静脉发生缓慢性和快速性肺静脉电位共存的现象并分析其可能的机制。方法分析5例持续性房颤患者单Lasso电极标测的心内电图,以及记录消融导致肺静脉电位分层和隔离的部位。结果在房颤消融过程中,1例在右下肺静脉内记录到两种不同的肺静脉电位节律,电位分层以及隔离靶点分别为环肺静脉消融线径的右后下壁和右后上壁近房顶处;4例在左上肺静脉内记录到两种不同的肺静脉电位节律,电位分层以及隔离靶点分别为环肺静脉消融线径的左前下壁和左前上壁。结论同一肺静脉发生缓慢性和快速性肺静脉电位共存现象的原因可能系邻近肺静脉间存在电学连接,亦可能与邻近肺静脉远场电位有关。     

肺静脉间嵴消融在环肺静脉线性隔离术中的作用

目的研究肺静脉间嵴消融在环肺静脉线性隔离术中所起的作用。方法共124例阵发性心房颤动(简称房颤)患者在电解剖标测和CT图像整合技术的指导下行环肺静脉线性消融术。手术的终点为肺静脉隔离。环肺静脉消融线完成后,在原消融线径上寻找可能存在的传导"gap"进行补充消融,如反复消融依然无法达到肺静脉隔离者,根据环状标测电极显示的最早肺静脉电位,在消融环线以内肺静脉口处进行节段性消融以实现肺静脉隔离。结果共41.1%的左侧肺静脉和11.3%的右侧肺静脉需在消融环线以内行节段性消融才达到电学隔离,其中左肺静脉节段隔离部位多见于左侧肺静脉间嵴前部;右侧肺静脉节段隔离部位多见于右侧肺静脉间嵴中后部。结论行环肺静脉线性消融的患者中,一部分需要在肺静脉间嵴处消融以提高肺静脉隔离的成功率。     

同一肺静脉内缓慢性和快速性肺静脉电位共存现象

目的观察心房颤动（简称房颤）导管消融过程中同一肺静脉发生缓慢性和快速性肺静脉电位共存的现象并分析其可能的机制。方法分析5例持续性房颤患者单Lasso电极标测的心内电图，以及记录消融导致肺静脉电位分层和隔离的部位。结果在房颤消融过程中，1例在右下肺静脉内记录到两种不同的肺静脉电位节律，电位分层以及隔离靶点分别为环肺静脉消融线径的右后下壁和右后上壁近房顶处；4例在左上肺静脉内记录到两种不同的肺静脉电位节律，电位分层以及隔离靶点分别为环肺静脉消融线径的左前下壁和左前上壁。结论同一肺静脉发生缓慢性和快速性肺静脉电位共存现象的原因可能系邻近肺静脉间存在电学连接，亦可能与邻近肺静脉远场电位有关。     

盐水灌注导管电隔离心房-肺(或上腔)静脉治疗阵发性心房颤动的评价

目的评价盐水灌注导管电隔离心房-肺(或上腔)静脉的效果及安全性。方法69例阵发性心房颤动(房颤)患者,男48例,女21例,平均年龄(55±10)岁,平均病史(4.2±1.1)年。所有患者均采用盐水灌注电极进行肺静脉口部节段性消融,电隔离终点为环状标测电极标测的肺静脉电位全部消失。术后随访症状,心电图及24h动态心电图,以无临床症状及无房颤的心电图证据判定为成功。结果69例共电隔离肺静脉206根,上腔静脉11根,右上肺静脉口外点消融1例。即刻电隔离成功率100%,放电时间(2902.0±1326.3)s。随访时间(118.1±69.7)天,成功率71%。结论应用盐水灌注导管电隔离心房-肺(或上腔)静脉消融安全有效,未见严重并发症发生。     

环状电极在Ensite/NavX指导下的心房颤动环肺静脉消融术中的应用

目的评价环肺静脉消融术联合应用环状电极标测对心房颤动(房颤)消融成功率的影响。方法连续入选61例房颤患者,其中男40例,女21例,阵发性房颤50例,慢性房颤11例。在EnsiteNavX三维电解剖标测系统指导下行环肺静脉消融术。应用环状电极标测肺静脉电位,以肺静脉电隔离为消融终点。结果61例均顺利完成手术。环左肺静脉消融使左肺静脉电隔离34例(55.7%),环右肺静脉消融使右肺静脉电隔离35例(57.4%),环左、右肺静脉消融使所有肺静脉电隔离23例(37.7%)。16例阵发性房颤和5例慢性房颤放电时终止房颤,终止房颤部位为左、右上肺静脉外近房顶前、后壁19例,右上肺静脉外后壁中部1例,完成左肺静脉消融时房颤终止1例。平均随访6±2个月,50例阵发性房颤中42例(84.0%)以及11例慢性房颤中5例(45.4%)无房颤发作,总成功率为77%。并发症:少量心包积液1例,经心包穿刺引流后积液消失;左侧血胸1例,经胸腔穿刺引流痊愈。结论EnsiteNavX系统指导下的环肺静脉消融术中联合应用环状电极标测可使房颤消融成功率进一步提高。     

超声导管电学隔离犬心脏静脉的实验研究

目的评价采用新设计超声导管电学隔离犬心脏静脉的有效性及安全性. 方法采用新设计超声导管(IBI,头端直径9F,弯度可控)对5只犬的5根心脏静脉进行电学隔离,其中包括采用穿刺股静脉与房间隔经心内膜途径消融隔离永存左上腔静脉的1个分支、经心外膜途径直视下消融隔离4只犬的4根肺静脉.采用15mm直径的环状标测电极经心内膜放置于1只犬的永存左上腔静脉、或经心外膜将环状标测电极套于肺静脉外,以环状标测电极记录的最早静脉电位或极性反转处为消融靶点,均采用30W×45S消融,消融终点为静脉电学隔离.消融过程中超声导管盐水灌注速度999ml/h,消融间歇时盐水灌注速度为120ml/h.     

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。     

肺静脉内缓慢性与快速性自律电位共存1例

患者男性,55岁。因阵发性心房颤动在三维电解剖标测系统指引下行环肺静脉射频导管消融术（CPVA）,术中以环状电极（LASSO）标测肺静脉电位。左肺静脉电隔离后（图1A）,环状电极在左上肺静脉内记录到缓慢性与猝发的快速性肺静脉电位共存（图1B）,肺静脉电位与左心房电位无传导关系,继续消融至右肺静脉达到电学隔离。随访3个月无房性心律失常发作。     

关于心房颤动导管消融治疗方法学的思考

现阶段心房颤动导管消融治疗的方法学主要包括以下四种:⑴肺静脉节段性电学隔离;⑵环肺静脉左心房线性消融;⑶超声引导下的近肺静脉开口部心房环状消融;⑷三维标测 双肺静脉环状标测电极导管指导下的环肺静脉射频消融电隔离。现对这4种消融方法的有效性、存在问题及理论意义等进行了论述。     

Circumferential pulmonary vein isolation: the role of key target sites.

AIMS: Circumferential pulmonary vein isolation (CPVI) had been proved effective for treating atrial fibrillation (AF). However, the achievement of pulmonary vein (PV) isolation was sometimes challenging. PVs could not be isolated until some key target sites (KTSs) were ablated thoroughly. The aim of our study was to explore the distribution of KTSs. METHODS AND RESULTS: Four hundred and fifty-two cases (271 males, mean age 62.5 +/- 12.6 years) with drug-refractory AF were enrolled for catheter ablation. CARTO-guided CPVI was performed in all cases with one circular catheter for verification of PVs isolation. Target sites where PV potentials delayed, conduction sequence changed, slowed down, or isolated were defined as KTSs. From 452 CPVI procedures, 1520 KTSs were identified; 813 of which were located at left PV antrums and 707 were at right PV antrums. KTSs at left PV antrums were most commonly situated at anterior wall (63%), while KTSs at right PV antrums were most commonly situated at posterior wall (66.2%). Additional gaps ablation was performed for left PVs in 344 cases and for right PVs in 248 cases owing to incomplete PVs isolation by a single attempt of CPVI. One thousand one hundred and fifty-eight KTSs were identified, 662 of which were located at left PV antrums and 496 were at right PV antrums. At the anterior wall, 66.1% of left PV KTSs were located, and 67.9% of right PV KTSs were located at the posterior wall. Out of 1158, 961 (82.99%) KTSs were predicted correctly by circular mapping. PV isolation could not be achieved until some KTSs were ablated by higher power, longer duration, and higher irrigation rate than usual. CONCLUSION: KTSs during CPVI were most commonly situated at the anterior wall of left PVs and at the posterior wall of right PVs. Circular mapping within ipsilateral PVs' ostia could accurately predict the location of KTSs. Some KTSs must be ablated thoroughly by applying higher power, longer duration, and higher irrigation rate than usual to achieve PV isolation.     

环肺静脉电隔离术后心房-肺静脉电位恢复情况的随访

目的明确环肺静脉电隔离术的长期效果以及心房-肺静脉电位传导恢复的具体部位,以提高手术成功率,预防复发。方法 232例再次行心房颤动(简称房颤)射频消融的患者,采用Lasso环状电极标测,明确其心房-肺静脉电位恢复部位,并在CARTOTM系统指导下予以消融。结果 232例第2次手术病例术中标测示44例(19.0%)无心房-肺静脉电位传导恢复,且术中心房-肺静脉电位传导恢复的部位多存在于左肺静脉前上部65例(28%)、前下部49例(21.1%)、右肺静脉后上部59例(25.4%)及后下部61例(26.3%)。28例行第3次手术,术中标测示无心房-肺静脉电位传导恢复的有16例(57.1%)。5例第4次手术术中标测仅有1例左下肺静脉电位恢复。结论环肺静脉隔离术后,随着随访时间延长肺静脉电位传导有恢复的趋势,并且心房-肺静脉电位传导存在易恢复区,多集中于左肺静脉前上部、前下部、右肺静脉后上部及后下部。部分心房-肺静脉电位传导经多次手术可达完全隔离。     

心房颤动初次环肺静脉隔离与再次消融的关键部位分析

目的评价心房颤动（房颤）初次环肺静脉隔离与再次消融的关键部位分布特点。方法入选48例房颤复发患者,其中男性30例,女性18例;平均年龄54.3±10.2岁;阵发性房颤24例,慢性房颤24例。初次消融采用环肺静脉隔离。再次消融距初次消融时间平均37.2±7.4d。环肺静脉隔离的关键部位为消融时引起肺静脉电位延迟、激动顺序变化或肺静脉电位频率减慢和肺静脉电隔离的部位。将环肺静脉消融线划均分为8个区域,统计初次消融和再次消融关键部位的分布异同。结果48例患者初次消融共有关键部位145个,平均每例患者3.02±1.08个;再次消融共有关键部位76个,平均每例患者1.58±1.09个（P〈0.001）。阵发性房颤7例（29.2%）左肺静脉传导未恢复,7例（29.2%）右肺静脉传导未恢复;12例（50%）左肺静脉中再次消融关键部位与初次消融相同者6例,位于初次消融关键部位的相邻节段者6例;8例（33.3%）右肺静脉中再次消融关键部位与初次消融相同者3例,位于初次消融关键部位的相邻节段者5例。慢性房颤9例（37.5%）左肺静脉传导未恢复,11例（45.8%）右肺静脉传导未恢复;10例（41.7%）左肺静脉中再次消融关键部位与初次消融相同者3例,位于初次消融关键部位的相邻节段者7例;5例（20.8%）右肺静脉中再次消融关键部位与初次消融相同者2例,位于初次消融关键部位的相邻节段者3例。结论房颤复发患者再次消融关键部位显著少于初次消融。约30%~40%一侧肺静脉传导未恢复,约20%~50%再次消融关键部位位于初次消融关键部位或其邻近节段。提示对于关键部位及其附近应巩固消融。     

两种三维电解剖标测系统结合CT影像融合技术指导阵发性心房颤动环肺静脉电隔离的随机对照研究

目的比较三维电解剖标测系统EnSitcNavX与CARTOxP结合计算机断层扫描（computed tomography,cT）影像融合技术EnSite—Fusion与CARTO—Merge指导阵发性心房颤动（paroxysmal atrial fibrillation,PAF）环肺静脉电隔离（circumferential pulmonary vein isolation,CPVI）的有效性及临床疗效。方法随机（电脑随机数字表法）抽取药物无法治疗未能控制症状的PAF患者24例,分别在三维电解剖标测系统EnSiteNavX与CARTOXP指导环肺静脉标测电极完成肺静脉与左心房建模,分别结合CT影像融合技术分为EnSite．Fusion组（n=12）与CARTO—Merge组（n=12）．指导完成CPVI,终点为消除所有肺静脉电位。术后每个月至少经受1次体表心电图或24h动态心电图检查明确维持窦性心律情况。结果两组临床基线水平、总x线曝光量及建模所需X线曝光时间、总手术时间及消融位点至cT模型平均距离比较,差异无统计学意义（P〉0．05）。EnSite—Fusion组建模时间、消融位点至cT模型最大距离多于CARTO-Merge组,差异有统计学意义（P〈0．05）;CPVI时间及其所需x线曝光时间少于CARTO—Merge组,差异有统计学意义（P〈0．05）。术中及随访（9．6±3．8）个月内均无严重并发症发生,EnSite-Fusion组、CARTO-Merge组各有10例（83％）与9例（75％）维持窦性心律,两组比较差异无统计学意义（P〉0．05）。结论EnSite-Fusion与CARTO-Merge指导PAF患者行CPVI安全、有效,两者对指导手术操作存在一定差异,但手术成功率相近。     

Utility of exit block for identifying electrical isolation of the pulmonary veins

INTRODUCTION: Electrical isolation of the pulmonary veins (PVs) to treat paroxysmal atrial fibrillation (AF) has been described using "entry block" as an endpoint for PV isolation. We describe a new technique for guiding PV isolation, using "exit block" out of the PV after ablation as a criterion for successful isolation. METHODS AND RESULTS: A circular mapping catheter was positioned at the os of arrhythmogenic PVs and ablation was performed proximal to the mapping catheter until entry block into the vein was achieved. Pacing was performed from the mapping catheter and from the ablator inside the PV to document exit block out of the PV. In patients in whom cardioversion did not restore sinus rhythm, PV isolation was performed in AF. Entry and exit block were reassessed in ablated veins after a 20-minute waiting period. Ninety-five PVs were ablated in 41 patients. A total of 66 PVs in 34 patients were ablated in sinus rhythm. After entry block was achieved, exit block was present in only 38 (58%) of 66 PVs. A total of 29 PVs in 21 patients were ablated in AF. After cardioversion to sinus rhythm, there was evidence of entry block into the PV in 20 (69%) of 29 PVs and exit block in only 14 (48%) of 29 PVs. There was no significant difference between the total number of lesions applied per vein in sinus rhythm compared with AF (11.6 +/- 8.6 vs 10.3 +/- 6.2; P = NS). There was recovery of conduction after a 20-minute waiting period in 9 (11%) of 84 PVs. CONCLUSION: Identification of exit block after ostial PV ablation provides a clear endpoint for electrical isolation of the PVs. Isolation of the PVs can be performed during sustained AF without the need to apply excess RF lesions. Applying a 20-minute waiting period after electrical isolation will identify reconnection in approximately 10% of PVs.     

心房颤动消融术后心房-肺静脉电位传导恢复的随访结果与影响因素

目的 环肺静脉电隔离术已成为治疗心房颤动（房颤）的一种有效手段,但是心房-肺静脉电位传导恢复是环肺静脉电隔离术需要克服的一个难关.本研究的目的 是明确环肺静脉电隔离术的效果以及影响心房-肺静脉电位传导恢复的因素,以提高消融术成功率,预防复发.方法 232例两次行房颤射频消融的阵发性房颤和持续性房颤患者,采用Lasso环状电极导管标测,明确其心房-肺静脉电位恢复部位,并在CartoTM系统指导下予以消融.并分析患者年龄、性别、房颤病史、体重指数、左心房内径、左心房舒张末内径、左心室射血分数（LVEF）及各合并症与心房-肺静脉电位传导恢复的关系.结果 232例第2次消融术病例术中标测示44例次（19.0%）无心房-肺静脉电位传导恢复,且术中心房-肺静脉电位传导恢复部位（Gap）多存在于左肺静脉前上部65例次（28%）、前下部49例次（21.1%）、右肺静脉后上部59例次（25.4%）及后下部61例次（26.3%）.年龄是房颤消融术后心房-肺静脉电位传导恢复的独立危险因素（P=0.012）,且性别、房颤病史、体重指数、左心房内径、左心房舒张末期内径、LVEF恢复组与未恢复组差异无统计学意义.结论 环肺静脉隔离术后,经长时间随访有约80%的患者心房-肺静脉电位传导恢复,并且心房-肺静脉电位传导存在易恢复区,多集中于左肺静脉前上部、前下部、右肺静脉后上部及后下部.年龄是房颤消融术后心房-肺静脉电位传导恢复的独立危险因素.     

Pulmonary vein isolation to treat paroxysmal atrial fibrillation: conventional versus multi-electrode radiofrequency ablation

Purpose

For patients with symptomatic atrial fibrillation (AF), a curvilinear multi-electrode ablation (MEA) catheter has been reported to be successful to achieve pulmonary vein (PV) isolation. However, this approach has not been compared prospectively with conventional PV isolation (CPVI) using a standard circular mapping catheter and 3D electro-anatomic mapping. In this prospective non-randomized study, we compared the efficacy of these two techniques.

Methods

Of 185 consecutive patients, age 54.6?±?10.1?years, with symptomatic paroxysmal AF (PAF), 96 patients underwent PV isolation by CPVI and 89 patients underwent MEA to isolate the PVs. CPVI was performed by encircling the left- and right-sided PVs. During MEA, the PV ablation catheter (Medtronic, USA) was used to isolate PVs with duty-cycled radiofrequency energy.

Results

The mean procedure time was 171.73?±?52.87?min for CPVI and 133.25?±?37.99?min for MEA, respectively (P?P?=?0.651). At 12?months, 80% of patients who underwent CPVI and 82% of patients who underwent MEA were free of symptomatic PAF off antiarrhythmic drug therapy (P?=?0.989). Among the variables of age, gender, duration and frequency of PAF, left ventricular ejection fraction, left atrial size, structural heart disease, and the ablation technique, only an increased left atrial size was an independent predictor of recurrent PAF. Left atrial flutter occurred after CPVI in two patients and after MEA ablation in three patients.

Conclusion

In patients undergoing catheter ablation for PAF, MEA and CPVI proved equally efficacious.     

Balloon catheter ablation to treat paroxysmal atrial fibrillation: What is the level of pulmonary venous isolation?

BACKGROUND: Unlike the initial balloon ablation catheters that were designed to deliver ablation lesions within the pulmonary veins (PVs), the current balloon prototypes are fashioned to deliver lesions at the PV ostia. OBJECTIVE: Using electroanatomical mapping, this study evaluates the actual location of ablation lesions generated by cryo-based, laser-based, or ultrasound-based balloon catheters. METHODS: In a total of 14 patients with paroxysmal atrial fibrillation, PV isolation was performed using either a cryoballoon catheter (8 patients), laser catheter (4 patients) or ultrasound balloon catheter (2 patients). Patients underwent preprocedural computed tomographic/magnetic resonance imaging. An intracardiac ultrasound catheter was used to aid in positioning the balloon catheter at the PV ostium/antrum. In all patients, sinus rhythm bipolar voltage amplitude maps (using either CARTO with computed tomographic/magnetic resonance image integration or NavX mapping) were generated at baseline and after electrical PV isolation as confirmed by use of a circular mapping catheter. RESULTS: Electrical isolation was achieved in 100% of the PVs. Electroanatomical mapping revealed that after ablation with any of the 3 balloon catheters, the extent of isolation included the tubular portions of each PV to the level of the PV ostia. However, the PV antral portions were left largely unablated with all 3 balloon technologies. CONCLUSION: Using the current generation of balloon ablation catheters, electrical isolation occurs at the level of the PV ostia, but the antral regions are largely unablated.     

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.