环静脉导管消融术的消融达终点部位分析及相应的策略

目的分析以电隔离为终点的环肺静脉导管消融过程中,消融达终点部位的分布规律,并探讨相应的标测策略和消融技巧。方法入选症状明显、药物治疗无效的心房颤动患者452例。在三维电解剖标测系统(CAR-TO)指导下行导管射频消融,均采用环肺静脉电隔离术为基本术式,使用单个环状电极标测肺静脉电位,消融终点为肺静脉电隔离。在环肺静脉消融过程中,用CARTO标记出消融达终点部位,即肺静脉心房肌束连接部位,通常表现为消融后肺静脉电位明显延迟、频率明显减慢或消失。结果在452例的消融过程中共记录到消融达终点部位1520处,包括环左侧肺静脉813处,最常见于左前上(201处,24.7%)、左前中(180处,22.1%)和左前下(132处,16.2%);环右侧肺静脉707处,最常见于右后中(207处,29.3%)和右后上(162处,22.9%)。所有单圈未隔离而在环肺静脉消融线上补点消融的病例中,961个消融达终点部位(82.99%)与环状电极指示区域一致,通过在消融线上大头仔细标测进一步确定消融达终点部位,并根据不同的部位分别采用增加消融时间、冷盐水灌注的流速以及改变导管贴靠方式等方法可有效地达到肺静脉电隔离的消融终点。结论环静脉导管消融术达到电隔离终点的常见消融达终点部位分布有一定规律,最多见于左侧消融线前壁和右侧后壁,环状电极可有效提示消融达终点部位的大体位置,采用改变导管贴靠方式以及增加消融时间、冷盐水流速等方法可以有效阻断消融达终点部位,达到电隔离终点。

The distribution of dominant target sites in circumferential pulmonary vein isolation

Objective To analyze and summarize the distribution of dominant target sites of circumferential PV isolation （CPVI） and to explore the mapping and ablation skills. Methods 452 cases with drug-refractory atrial fibrillation （AF） were enrolled for catheter ablation. Guided by CARTO system, CPVI was performed in all cases with single circular mapping catheter for verification of PV isolation. In cases with persistent AF, Complex fractionated atrial electrograms （CFAEs） were mapped and ablated additionally. Target sites where PV potentials delayed, slowed down or isolated were defined as dominant target sites （DTS） and were tagged on the CARTO map. Results 1520 DTS were identified during 452 CPVI procedures , 813 of which were located at left PV antrnms, and 707 were at right PV antrums. For the most common DTS at left PV antrums, 201 DTS （24.7%） were situated at antero-superior wall, 180 DTS （22.1%） at mid-anterior wall, and 132 DTS at antero-inferior wall; For the most common DTS at right PV antrums, 207 DTS （29.3%） were situated at mid-posterior wall, 162 DTS （22.9%） at postero-superior wall. PV isolation was not achieved for left-sided PVs in 344 cases and for right-sided PVs in 248 cases by single attempt of CPVI. Additional gap ablation revealed 1 158 DTS, 961 （82.99%） of which were situated in accordance with the sites predicted by circular mapping. PV isolation could be successfully achieved by intensive DTS mapping and the application of longer energy delivery, higher irrigating flow rate and better tip-tissue proximity than usual. Conclusions The distribution of DTS obeyed specific pattern during CPVI procedure. DTS were most commonly situated at anterior wall of left PV lesion line and at posterior wall of right PV lesion line. Circular mapping within ipsilateral PV ostia could effectively predict the location of DTS. DTS could be ablated effectively by applying longer energy delivery, higher irrigating flow rate, and better tip-tissue contact than usual to achieve PV is