三维心腔内超声引导下应用压力监测导管消融左心室乳头肌室性心律失常
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摘要
目的介绍在三维心腔内超声引导下应用压力监测导管标测和消融左心室乳头肌起源室性心律失常(VAs)的初步经验。方法 2017年6月至2018年4月于北京安贞医院心内科施行经CartoSound指导射频消融治疗左心室乳头肌起源VAs的患者10例,均采用压力监测导管进行激动标测,并行射频消融治疗,同时分析其体表12导联心电图的QRS波群特征。结果 10例患者VAs的QRS波时限为(149.0±17.8)ms,其中6例VAs起源于左后乳头肌,4例VAs起源于左前乳头肌。左后乳头肌起源VAs表现为右束支阻滞,电轴左偏,Ⅲ导联主波向下,aVL导联主波向上;左前乳头肌起源VAs表现为右束支阻滞,电轴右偏,Ⅲ导联主波向上,aVL导联主波向下。除1例起源于左后乳头肌VAs患者消融失败外,其余9例患者均即刻消融成功,对10例患者随访6个月,1例起源于左后乳头肌的VAs复发。消融靶点至体表QRS波起始时限为(25.8±3.8)ms。所有患者双极电图靶点处窦性心律下无领先于QRS波的P电位,其中9例患者VAs时可记录到提前QRS波的高频电位。即刻消融成功患者的平均放电(2.4±1.3)次。结论左室前乳头肌和后乳头肌起源的VAs在心电图上有明显差别,CartoSound指导下应用压力导管进行左室乳头肌标测和消融可提高成功率,减少复发。
Objective To introduce catheter ablation of ventricular arrhythmias(VAs) originating from left ventricular papillary muscle guided by three-dimensional intracardiac echocardiography(ICE). Methods From June 2017 to April 2018, 10 patients in the Department of Cardiology of Beijing Anzhen Hospital who underwent Carto Sound-guided radiofrequency ablation for the treatment of left ventricular papillary muscle VAs were performed with pressure monitoring catheters and radiofrequency ablation. The QRS complex characteristics of the 12-lead ECG were analyzed. Results Among 10 patients, QRS wave time were 149.0±17.8 ms and the target sites were located at the left anterior papillary muscle(APM) in 4 patients and the left posterior papillary muscle(PPM) in 6 patients.VAs arising from the APM typically demonstrate a right bundle branch block(RBBB) morphology, right axis, negative in a VL, positive in III. VAs from the PPM show a RBBB morphology, left superior axis positive in aVL, negative in III.Except one cases originating from the left PPM, the other 9 patients were successfully ablated and followed up for 6 months.One patient originating from the left PPM had recurrence during follow-up. The earliest bipolar electrograms of the targets preceded the onset of the QRS complex during VAs by 25.8±3.8 ms, and the targets of 9 patients presented sharp potential before QRS during VAs. The average number of discharges in patients with immediate ablation was(2.4±1.3) times. Conclusions ECG characteristics of VAs originating from left APM muscles is different from which originating from left PPM.Catheter ablation of VAs originating from left ventricular papillary muscle guided by threedimensional ICE was feasible and effective with a high success rate and low recurrence rate.
Objective To introduce catheter ablation of ventricular arrhythmias(VAs) originating from left ventricular papillary muscle guided by three-dimensional intracardiac echocardiography(ICE). Methods From June 2017 to April 2018, 10 patients in the Department of Cardiology of Beijing Anzhen Hospital who underwent Carto Sound-guided radiofrequency ablation for the treatment of left ventricular papillary muscle VAs were performed with pressure monitoring catheters and radiofrequency ablation. The QRS complex characteristics of the 12-lead ECG were analyzed. Results Among 10 patients, QRS wave time were 149.0±17.8 ms and the target sites were located at the left anterior papillary muscle(APM) in 4 patients and the left posterior papillary muscle(PPM) in 6 patients.VAs arising from the APM typically demonstrate a right bundle branch block(RBBB) morphology, right axis, negative in a VL, positive in III. VAs from the PPM show a RBBB morphology, left superior axis positive in aVL, negative in III.Except one cases originating from the left PPM, the other 9 patients were successfully ablated and followed up for 6 months.One patient originating from the left PPM had recurrence during follow-up. The earliest bipolar electrograms of the targets preceded the onset of the QRS complex during VAs by 25.8±3.8 ms, and the targets of 9 patients presented sharp potential before QRS during VAs. The average number of discharges in patients with immediate ablation was(2.4±1.3) times. Conclusions ECG characteristics of VAs originating from left APM muscles is different from which originating from left PPM.Catheter ablation of VAs originating from left ventricular papillary muscle guided by threedimensional ICE was feasible and effective with a high success rate and low recurrence rate.
引文
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[5]Rivera S,Ricapito ML,Tomas L,et al.Results of Cryoenergy and Radiofrequency-Based Catheter Ablation for Treating Ventricular Arrhythmias Arising From the Papillary Muscles of the Left Ventricle,Guided by Intracardiac Echocardiography and Image Integration[J].Circ Arrhythm Electrophysiol,2016,9(4):e003874.
[6]Yue-Chun L,Wen-Wu Z,Na-Dan Z,et al.Idiopathic premature ventricular contractions and ventricular tachycardias originating from the vicinity of tricuspid annulus:results of radiofrequency catheter ablation in thirty-five patients[J].BMC Cardiovasc Disord,2012,12(1):32.
[7]Latchamsetty R,Yokokawa M,Morady F,et al.Multicenter Outcomes for Catheter Ablation of Idiopathic Premature Ventricular Complexes[J].JACC Clin Electrophysiol,2015,1(3):116-23.
[8]Yamada T,Doppalapudi H,McElderry HT,et al.Electrocardiographic and electrophysiological characteristics in idiopathic ventricular arrhythmias originating from the papillary muscles in the left ventricle:relevance for catheter ablation[J].Circ Arrhythm Electrophysiol,2010,3(4):324-31.
[9]龙德勇,孙莉萍,王琎,等.三维超声引导下经房间隔穿刺消融左心室前乳头肌室性早搏[J].中国介入心脏病学杂志,2017,25(6):321-5.
[10]Yokokawa M,Kim HM,Baser K,et al.Predictive value of programmed ventricular stimulation after catheter ablation of post-infarction ventricular tachycardia[J].J Am Coll Cardiol,2015,65(18):1954-9.
[11]Al'Aref SJ,Ip JE,Markowitz SM,et al.Differentiation of papillary muscle from fascicular and mitral annular ventricular arrhythmias in patients with and without structural heart disease[J].Circ Arrhythm Electrophysiol,2015,8(3):616-24.
[2]Ouyang F,Fotuhi P,Ho SY,et al.Repetitive monomorphic ventricular tachycardia originating from the aortic sinus cusp:electrocardiographic characterization for guiding catheter ablation[J].J Am Coll Cardiol,2002,39(3):500-8.
[3]Kanagaratnam L,Tomassoni G,Schweikert R,et al.Ventricular tachycardias arising from the aortic sinus of valsalva:an underrecognized variant of left outflow tract ventricular tachycardia[J].J Am Coll Cardiol,2001,37(5):1408-14.
[4]Yamada T,McElderry HT,Okada T,et al.Idiopathic focal ventricular arrhythmias originating from the anterior papillary muscle in the left ventricle[J].J Cardiovasc Electrophysiol,2009,20(8):866-72.
[5]Rivera S,Ricapito ML,Tomas L,et al.Results of Cryoenergy and Radiofrequency-Based Catheter Ablation for Treating Ventricular Arrhythmias Arising From the Papillary Muscles of the Left Ventricle,Guided by Intracardiac Echocardiography and Image Integration[J].Circ Arrhythm Electrophysiol,2016,9(4):e003874.
[6]Yue-Chun L,Wen-Wu Z,Na-Dan Z,et al.Idiopathic premature ventricular contractions and ventricular tachycardias originating from the vicinity of tricuspid annulus:results of radiofrequency catheter ablation in thirty-five patients[J].BMC Cardiovasc Disord,2012,12(1):32.
[7]Latchamsetty R,Yokokawa M,Morady F,et al.Multicenter Outcomes for Catheter Ablation of Idiopathic Premature Ventricular Complexes[J].JACC Clin Electrophysiol,2015,1(3):116-23.
[8]Yamada T,Doppalapudi H,McElderry HT,et al.Electrocardiographic and electrophysiological characteristics in idiopathic ventricular arrhythmias originating from the papillary muscles in the left ventricle:relevance for catheter ablation[J].Circ Arrhythm Electrophysiol,2010,3(4):324-31.
[9]龙德勇,孙莉萍,王琎,等.三维超声引导下经房间隔穿刺消融左心室前乳头肌室性早搏[J].中国介入心脏病学杂志,2017,25(6):321-5.
[10]Yokokawa M,Kim HM,Baser K,et al.Predictive value of programmed ventricular stimulation after catheter ablation of post-infarction ventricular tachycardia[J].J Am Coll Cardiol,2015,65(18):1954-9.
[11]Al'Aref SJ,Ip JE,Markowitz SM,et al.Differentiation of papillary muscle from fascicular and mitral annular ventricular arrhythmias in patients with and without structural heart disease[J].Circ Arrhythm Electrophysiol,2015,8(3):616-24.