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非接触标测系统对右心室特发性心律失常的临床应用研究
摘要
第一部分特发性右心室流出道室性心律失常的 非接触标测及导管消融策略
目的:本研究的目的是探讨右心室流出道起源特发性室性心律失常 非接触标测方法和射频消融策略。
方法:共有33名患者(17名男性患者,16名女性患者),平均年龄40.7±13.2岁。3月内未服用抗心律失常药物和/或停药至少5个半衰期后进行心内电生理检查,并进行射频消融治疗。 非接触标测最早激动起源点(EA)、激动爆发点(EX)、优势传导径路,结合常规激动标测和起搏标测确定消融靶点。消融成功位置即可确定为有效靶点。通过动态基质标测(DSM)限定功能性和器质性低电压区,观察低电压区与EA/EX关系。术中使用温控消融导管消融。
结果:在右心室流出道三维模型中,33例中8个靶点位于上部,25个靶点位于下部;21个靶点位于前部,12个靶点位于后部;12个靶点位于游离面,21个靶点位于间隔部。33例中17个消融靶点在激动爆发点,16个消融靶点在最早激动起源点消融成功。动态基质标测下33例右心室流出道器质性低电压区全部分布右心室流出道上部,并与最早激动起源点密切相关。
结论: 非接触标测系统可直观地揭示特发性右心室流出道室性心律失常电生理现象,并成功指导消融。
第二部分 非接触标测系统在肺动脉主干起源特发性室性心律失常的研究
目的:本研究的目的是探讨肺动脉主干起源特发性室性心律失常电生理特点,体表心电图特征和射频消融策略。
方法:46名体表心电图疑似右心室流出道室性心律失常患者(23名男性患者,23名女性患者),平均年龄40.1±14.3岁,其中13例术中右心室心尖部或流出道造影证实消融靶点在肺动脉主干,占总例数28%。 非接触标测最早激动起源点(EA)、激动爆发点(EX)、优势传导径路,结合常规激动标测和起搏标测确定消融靶点。46例患者的体表心电图被离线分析,比较右心室流出道起源与肺动脉主干起源室性心律失常心电图异同。术中使用温控消融导管消融。
结果:所有肺动脉主干起源特发性室性心律失常患者均排外器质性心脏病,13例患者均有心悸症状,其中1例患者有晕厥症状。肺动脉主干起源和右心室流出道起源的体表心电图无明显差异。 非接触标测显示最早激动起源点位于球囊上方较远距离,激动面积大,最早激动起源点距激动爆发点距离远。成功消融靶点处激动较体表QRS波起始提前20.84±7.88ms,8例记录到A波和V波,8例记录到融合的尖峰或碎裂电位,5例在有效靶点起搏成功且获得良好的起搏标测图形。11例肺动脉主干起源特发性室性心律失常消融成功,2例失败。
结论:肺动脉主干起源特发性室性心律失常并非少见, 非接触标测可快速揭示诊断,并成功指导消融。
第三部分消融靶点的三维分布和右心室流出道室性心律失常心电图特征间关系的研究
目的:研究的目的是探讨在 非接触标测下,右心室流出道室性心律失常消融靶点三维分布及相关体表心电图图形特征。
方法:共有33名患者(17名男性患者,16名女性患者),平均年龄40.7±13.2岁。3月内未服用抗心律失常药物和/或停药至少5个半衰期后进行心内电生理检查,并进行射频消融治疗。 非接触标测系统通过激动顺序标测初步判断的消融靶点的三维位置,在该位置消融成功后即可确定为有效靶点。有效靶点在右心室流出道三维模型中分布首先被分割为四个部分:右心室流出道前部区域和后部区域,游离壁区域和间隔部区域,每个区域可再被分隔为上部和下部区域。统计有效消融靶点在以上划分区域内的分布,并且离线分析有效消融靶点所对应的体表心电图相关信息,体表心电图所分析参数包括:下壁导联的QRS间期、振幅和R波形态;V1胸前导联r波宽度;aVR和aVL导联QS波振幅;V1和V2胸前导联r波振幅。
结果:在研究中总结以下12导联体表心电图特征可以初步确定消融靶点位置,33例中8个靶点位于上部,25个靶点位于下部;21个靶点位于前部,12个靶点位于后部;12个靶点位于游离面,21个靶点位于间隔部。心电图特征:(1)如果下壁导联的QRS间期≥150 ms,消融靶点多在右心室流出道游离壁,如QRS间期<150 ms,消融靶点多在间隔部(诊断准确率70%,p<0.05);下壁导联R波有明显的切迹(RR’波或者Rr’波),消融靶点多在右心室流出道游离壁,如果R波无切迹(R波),消融靶点多在间隔部(诊断准确率73%,p<0.05);右心室流出道间隔部下壁导联R波振幅高于游离壁R波振幅1.54±0.46对1.21±0.38mv; p<0.05;游离壁V1胸前导联r波宽度大于间隔部r波宽度39.17±25.51对19.19±23.92ms; p<0.05。(2)QS波振幅aVR 结论:体表心电图图形特征与非接触标测系统确定并消融成功的靶点有明确的关系,可根据心电图特征初步确定有效消融靶点位置。
PartⅠNon-contact mapping and ablation of idiopathic ventricular arrhythmia originating in the right ventricular outflow tract
Objective: The aim of this study is to discuss the electrophysiologic characteristics, non-contact mapping methods, and catheter ablation strategy of premature ventricular contractions or tachycardias (PVCs/VT) originating in right ventricular outflow tract (RVOT).
Methods: 33 consecutive patients (17 men and 16 women; mean age, 40.7±13.2 years) were included in the study. The target site was identified by non-contact mapping and confirmed by successful ablation. Non-contact mapping were used in 33 cases, and identified the earliest activation (EA), the exit (EX) point and preferential conduction. Routine activation mapping and pace mapping were also used in these cases. Dynamic substrate mapping (DSM) identified low-voltage zone in RVOT, and revealed the relationship between EA/EX and low-voltage zone. Radiofrequency energy was delivered through temperature controlled ablation catheter in patients.
Results: Catheter ablation was successful in 33 patients. The target sites were located in the superior area in eight patients, the inferior area in 25 patients, the anterior area in 21 patients, the posterior area in 12 patients, the free wall in 12 patients and the septum in 21 patients. 17 target sites were located on EA, and 16 target sites on EX. The low-voltage zone were mostly located in the superior area of RVOT. There is a close relation between EA and low-voltage zone.
Conclusion: Non-contact mapping can reveal the electrophysiologic characteristics of right ventricular outflow tract idiopathic ventricular arrhythmia, and guide the successful catheter ablation.
PartⅡNon-contact mapping and ablation of idiopathic ventricular arrhythmia originating in the main stem of the pulmonary artery
Objective: The aim of this study is to discuss the electrophysiologic characteristics, electrocardiogram features, non-contact mapping methods and catheter ablation strategy of premature ventricular contractions or tachycardias (PVCs/VT) originating in the main stem of the pulmonary artery (MSPA).
Methods: fourty-six consecutive patients with ECG documentation of idiopathic ventricular arrhythmia with the feature of right ventricular outflow tract origin were referred for catheter ablation, 13 ( 23 men and 23 women; mean age, 40.1±14.3 years ) of which (28%) were found to be main stem of the pulmonary artery origin by pulmonary artery or right ventricular angiogram. Non-contact mapping were used in 46 cases, and identified the earliest activation (EA), the exit (EX) point and preferential conduction. Routine activation mapping and pace mapping were also used in these cases. ECG data obtained from 46 patient with RVOT-PVCs/VT were analyzed, and compared between RVOT group and MSPA group. Radiofrequency energy was delivered through temperature controlled ablation catheter in patients.
Results: All the patients originating from main stem of the pulmonary artery did not have any sign to suggest structural heart disease. All 13 patients had the symptom of palpitation during idiopathic ventricular arrhythmia, but only one had syncope. There were not distinctive differential in ECG characteristics between RVOT group and MSPA group. Non-contact mapping suggested the earliest activation (EA) point was far from the above of the center of EnSite Array with a longer distance between the EA point and the exit (EX) point. Endocardial recording of the target site showed a mean of (20.84±7.88) ms proceding the onset of QRS complex, with atrial and ventricular electrogram in 8 patients, and a fusion of spike or fractionated potential and the ventricular elctrogram in 8 patients. Perfect pace mapping could be done with higher output in 5 patients. Catheter ablation was successful in 11 patients, and failed in 2 patient.
Conclusion: idiopathic ventricular arrhythmia originating from main stem of the pulmonary artery is not uncommon. Its diagnosis can be rapidly made by non-contact mapping but need to be confirmed by pulmonary artery or right ventricular angiogram. Detailed activation mapping and routine pace mapping should be done above the pulmonary valve to guide the successful catheter ablation.
PartⅢThree Dimensional Distribution of the Target Sites and The Electrocardiographic Characteristics of idiopathic ventricular arrhythmia Originating from Right Ventricular Outflow Tract
Objective: The purpose of the study was to explore the relationship between electrocardiogram (ECG) patterns of right ventricular outflow tract idiopathic ventricular arrhythmia and three dimensional distribution of the target sites which were identified by non-contact mapping.
Methods: 33 consecutive patients (17 men and 16 women; mean age,40.7±13.2 years) were included in the study. The target site was identified by non-contact mapping and confirmed by successful ablation. The distribution of the target site in three dimentional geometry of RVOT was classified into 4 subdivisions: anterior area (A)–posterior area (P), free wall (F)–septum (Se); each subdivision was further divided into two areas: superior (Su)–inferior (I). The ECG characteristics were analyzed according to their ablation sites with the following characteristics: the QRS duration, amplitude, the r wave pattern in the inferior leads, and the initial r wave width in lead V1; the QS-wave amplitude in aVR and aVL; and the initial r wave amplitude in lead V1 and V2.
Results: The target sites were located in the superior area in eight patients, the inferior area in 25 patients, the anterior area in 21 patients, the posterior area in 12 patients, the free wall in 12 patients and the septum in 21 patients. On the 12-lead ECG, the following indexes were helpful to identify the position of the target site: (1) the QRS duration (≥150 ms, F; <150 ms, Se; diagnostic accuracy: 70%) (p<0.05) and the r wave pattern in the inferior leads (RR’or Rr’, F; R, Se; diagnostic accuracy: 73%) (p<0.05), the R wave amplitude in the inferior leads (high, Se; low, F) (1.54±0.46 vs 1.21±0.38mv; p<0.05), the initial r wave width in lead V1 (wide, F; narrow, Se) (39.17±25.51 vs 19.19±23.92ms; p<0.05), (2) the QS-wave amplitude in aVR and aVL (aVR Conclusion: The ECG characteristics of RVOT-PVCs/VT had distinctive relationship with the target sites localized with the use of non-contact mapping.
引文
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1.Coggins DL, Lee RJ, Sweeney J, Chein WW, Van Hare G, Epstein L, Gonzalez R, Griffin JC, Lesh MD, Scheinman MM. Radiofrequency catheter ablation as a cure for idiopathic tachycardia of both left and right ventricular origin. J Am Coll Cardiol, 1994, 23:1333–1341.
2.Shiro Kamakura, Wataru Shimizu, Kiyotaka Matsuo, et al. Localization of Optimal Ablation Site of Idiopathic Ventricular Tachycardia from Right and Left Ventricular Outflow Tract by Body Surface ECG. Circulation, 1998, 98:1525-33.
3 . Hiroshi Tada, Sachiko Ito, Shigeto Naito, et al. Prevalence and Electrocardiographic Characteristics of Idiopathic Ventricular Arrhythmia Originating in the Free Wall of the Right Ventricular Outflow Tract. Circ J, 2004, 68: 909–919.
4.Yukio Sekiguchi, Kazutaka Aonuma, Atsushi Takahashi, Yasuteru Yamauchi, Hitoshi Hachiya, Yasuhiro Yokoyama, Yoshito Iesaka, Mitsuaki Isobe. Electrocardiographic and electrophysiologic characteristics of ventricular tachycardia originating within the pulmonary artery. J Am Coll Cardiol, 2005, 45: 887-895.
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