经冠状动脉化学消融术的实验研究及初步临床应用
摘要
一．经冠状动脉化学消融术(TCA)消除实验性梗塞后室性心动过速(VT)
按Harris氏二期结扎法建立犬心肌梗塞模型26只，4～16天后再次开胸以标准心脏程序刺激法诱发VT。26只犬中诱发VT22只(86％)，共41例次，其中持续性VT33例次，非持续性VT8例次。采用心外膜低温(0～2℃)方法标测定位持续性VT起源灶，确定起源灶20例次(61％)，未确定13例次。于VT起源灶心肌供血的小冠状动脉内注射95％乙醇0.3～1.2ml(平均0.6ml)14例，10例(71％)未再诱发出VT。心肌内注射95％乙醇1～3ml9例(包括血管内注射无效4例)，6例未再诱发出VT。
观察TCA对18只正常犬心脏病理生理学影响。组Ⅰ9只犬，小冠状动脉内注射95％乙醇0.4～0.6ml，组Ⅱ9只注射1.0～1.2ml。TCA后CK—MB活性平均峰值组Ⅰ78±63U／L，组Ⅱ155±82 U／L；组Ⅰ室性早搏9例，非持续性VT4例，组Ⅱ室性早搏9例，非持续性VT6例，持续性VT4例；心电图ST段抬高组Ⅰ平均1.2±0.6mm，组Ⅱ4.8±1.9mm(p＜0.01)；透壁性心肌坏死两组各9例。TCA后8小时内组Ⅰ心脏功能指标无明显改变，组Ⅱ左室功能明显低下。心肌坏死面积比值平均组Ⅰ4.5±4.0％，组Ⅱ12.0±4.0％(p＜0.01)。本文实验结果表明TCA消除折返机制的实验性梗塞后VT效果肯定，
A study was done on chemical ablation with ethanol in the treatment of ventricular tachycardia (VT) in experimental animals and two patients. Epicardial ice mapping was performed with a probe to localize the site of origin of VT induced by programmed stimulation in 26 dogs 4 ～ 16 days after experimental acute myocardial infarction.In 20 of 33 episodes, a specific area where cooling with the ice probe terminated the VT could be found.Late diastolic activity was recorded from 3 of 6 such sites. The data presented suggested that the mechanism responsible for VT was reentry. After 0.3 ～ 1.2m1 of 95% ethanol was injected into a small coronary artery supplying the arrhythmogenic area, VT was no longer inducible in 10 of 14 dogs. Intramyocardial ethanol (1 ～ 3ml) was injected into the site of origin of VT in 9 dogs. In six of these, VT could not be reinduced. After injection of 0.4～ 1.2ml of 95% ethanol into a small normal coronary artery in 18 dogs, the changes in ECG, CK-MB and pathology werefound to be related to the dose of
按Harris氏二期结扎法建立犬心肌梗塞模型26只，4～16天后再次开胸以标准心脏程序刺激法诱发VT。26只犬中诱发VT22只(86％)，共41例次，其中持续性VT33例次，非持续性VT8例次。采用心外膜低温(0～2℃)方法标测定位持续性VT起源灶，确定起源灶20例次(61％)，未确定13例次。于VT起源灶心肌供血的小冠状动脉内注射95％乙醇0.3～1.2ml(平均0.6ml)14例，10例(71％)未再诱发出VT。心肌内注射95％乙醇1～3ml9例(包括血管内注射无效4例)，6例未再诱发出VT。
观察TCA对18只正常犬心脏病理生理学影响。组Ⅰ9只犬，小冠状动脉内注射95％乙醇0.4～0.6ml，组Ⅱ9只注射1.0～1.2ml。TCA后CK—MB活性平均峰值组Ⅰ78±63U／L，组Ⅱ155±82 U／L；组Ⅰ室性早搏9例，非持续性VT4例，组Ⅱ室性早搏9例，非持续性VT6例，持续性VT4例；心电图ST段抬高组Ⅰ平均1.2±0.6mm，组Ⅱ4.8±1.9mm(p＜0.01)；透壁性心肌坏死两组各9例。TCA后8小时内组Ⅰ心脏功能指标无明显改变，组Ⅱ左室功能明显低下。心肌坏死面积比值平均组Ⅰ4.5±4.0％，组Ⅱ12.0±4.0％(p＜0.01)。本文实验结果表明TCA消除折返机制的实验性梗塞后VT效果肯定，
A study was done on chemical ablation with ethanol in the treatment of ventricular tachycardia (VT) in experimental animals and two patients. Epicardial ice mapping was performed with a probe to localize the site of origin of VT induced by programmed stimulation in 26 dogs 4 ～ 16 days after experimental acute myocardial infarction.In 20 of 33 episodes, a specific area where cooling with the ice probe terminated the VT could be found.Late diastolic activity was recorded from 3 of 6 such sites. The data presented suggested that the mechanism responsible for VT was reentry. After 0.3 ～ 1.2m1 of 95% ethanol was injected into a small coronary artery supplying the arrhythmogenic area, VT was no longer inducible in 10 of 14 dogs. Intramyocardial ethanol (1 ～ 3ml) was injected into the site of origin of VT in 9 dogs. In six of these, VT could not be reinduced. After injection of 0.4～ 1.2ml of 95% ethanol into a small normal coronary artery in 18 dogs, the changes in ECG, CK-MB and pathology werefound to be related to the dose of
引文
1. Evens JT, et al. The percutaneous cardiac capping and ablation registry: Summary of results. PACE 19 87:10:1395.
2. Chilson DA,et al.Chemical ablation of ventricular tachycardia in the dog. Am Heart J 1986; 111: 1113.
3. Guse P, et al. Effects of methylprednisolone on ventricular arrhy-thmias, mortality and infarct size following experimental coronary artery occlusion. Am J Cardiol 1979; 43: 372(abst) .
4. Qi Xiang-qian, et al. Transcoronary ethanol ablation of experimental ventricular tachycardia after epicardial ice mapping and localizing. Chin Med J 1991;104:639.
5. Anderson KP, et al. Conduction velocity depression and drug-induced ventricular tachyarrhythmia. Effects of lidocaine in the intact caine heart. Circulation 1990;81: 1024.
6. Gressman LJ, et al. Localization and mechanism of ventricular tachycardia by ice mapping 1 week after the onset of myocardial infarction in dogs.??circulation 1983; 68: 657.
7. Cassidy DM, et al. The value of catheter mapping during sinus rhythm to localize site of origin of ventricular tachycardia. Circulation 1984; 69: 1103.
8. Klein H, et al. Intraoperative electrophysiologic mapping of the ventricles during sinus rhythm in patients with a previous myocardial infarction. Circulation 1956; 66: 847.
9. Gallagher JJ, et al. Cryoablation of drug resistant ventricular tachycardia in a patient with variant of scleroderma. Circulation 1977; 55: 471.
10. Brugada P, et al. Termination of tachycardias by interruping blood flow to the arrhythmogenic areas. Am J Cardial 1988; 62: 387.
11. Wellens HJJ, Brugada P. Treatment of cardiac arrhythmias: When, how and where? J Am Coll Cardiol 1989; 14: 1417.
12. Evans JT, Scheinman MM, and the members of the percutaneous cardiac mapping ablation registry. The percutaneous cardiac mapping and ablation registry: Final Summary of results. PACE 1987; 11: 1621.
13. Brugada P, de Swart H, Smeets JL, et al. Trans-??coronary chemical ablation of ventricular tachycardia. Circulation 1989; 79:475.
14. Inoue H, Waller BF, Zipes DP, et al. Intracoro-nary ethyl alcohol or phenol injection ablates aconitine-induced ventricular tachycardia in dogs. J Am Coll Cardiol 1987; 10:1342.
15. Schelag BJ, Harrison LA, Kabell G, et al. Lidocaine unmasks ventricular arrhythmias in chronic myocardialinfarction. Circulation 1980; 62 (Suppl III): III-173 (abst).
16. Qi Xiang-qian, Gao Run-lin, Wang Fang-zheng, et al. Tanscoronary chemical ablation of ventricular tachycardia: A case report Chin Med J 1992; 105:247
17.Boor PJ and Reynolds ES. A simple planimetric method for determination of left ventricular mass and necrotic myocardial mass in postmortem hearts. Am J Clin Pathol 1977;68:387
18.Brugada P, de Swart H, Smeets JL, et al. Trans-coronary chemical ablation of atrioventricular conduction. Circulation 1990 ; 81 : 757.
19.DeMaio SJ, Walter PF and Douglas JS .Treatment of ventricular tachycardia induced cardiogenic shock??by percoronary chemical ablation. Cathet Cardiovasc Diagn 1990; 21: 170.
20.Ellman BA, Parkhill BJ, Marcus PB, et al. Renal ablation with absolute ethanol. Invest Radiol 1984 ; 19 ; 416.
21,Ellman BA, Parkhill BJ, Curry TS, et al. Ablation of renal tumors with absolute ethanol: A new technique.Radiologg 1981 : 141 : 619
22.Stricklerger SA, Okishige K, Friedmen PL, et al. Intracoronary chemical ablation of rentriclar tachycardia: selecting the target artery using iced saline versus antiarrhythmic drugs. PACE;14: 685.
23,Qi Xiang-qian, et al. Transcoronary chemical ablation of areas in the ventricule in dogs: CK-MB, ECG, hemodynamic and pathologic observations. Chin Med J (in press).
2. Chilson DA,et al.Chemical ablation of ventricular tachycardia in the dog. Am Heart J 1986; 111: 1113.
3. Guse P, et al. Effects of methylprednisolone on ventricular arrhy-thmias, mortality and infarct size following experimental coronary artery occlusion. Am J Cardiol 1979; 43: 372(abst) .
4. Qi Xiang-qian, et al. Transcoronary ethanol ablation of experimental ventricular tachycardia after epicardial ice mapping and localizing. Chin Med J 1991;104:639.
5. Anderson KP, et al. Conduction velocity depression and drug-induced ventricular tachyarrhythmia. Effects of lidocaine in the intact caine heart. Circulation 1990;81: 1024.
6. Gressman LJ, et al. Localization and mechanism of ventricular tachycardia by ice mapping 1 week after the onset of myocardial infarction in dogs.??circulation 1983; 68: 657.
7. Cassidy DM, et al. The value of catheter mapping during sinus rhythm to localize site of origin of ventricular tachycardia. Circulation 1984; 69: 1103.
8. Klein H, et al. Intraoperative electrophysiologic mapping of the ventricles during sinus rhythm in patients with a previous myocardial infarction. Circulation 1956; 66: 847.
9. Gallagher JJ, et al. Cryoablation of drug resistant ventricular tachycardia in a patient with variant of scleroderma. Circulation 1977; 55: 471.
10. Brugada P, et al. Termination of tachycardias by interruping blood flow to the arrhythmogenic areas. Am J Cardial 1988; 62: 387.
11. Wellens HJJ, Brugada P. Treatment of cardiac arrhythmias: When, how and where? J Am Coll Cardiol 1989; 14: 1417.
12. Evans JT, Scheinman MM, and the members of the percutaneous cardiac mapping ablation registry. The percutaneous cardiac mapping and ablation registry: Final Summary of results. PACE 1987; 11: 1621.
13. Brugada P, de Swart H, Smeets JL, et al. Trans-??coronary chemical ablation of ventricular tachycardia. Circulation 1989; 79:475.
14. Inoue H, Waller BF, Zipes DP, et al. Intracoro-nary ethyl alcohol or phenol injection ablates aconitine-induced ventricular tachycardia in dogs. J Am Coll Cardiol 1987; 10:1342.
15. Schelag BJ, Harrison LA, Kabell G, et al. Lidocaine unmasks ventricular arrhythmias in chronic myocardialinfarction. Circulation 1980; 62 (Suppl III): III-173 (abst).
16. Qi Xiang-qian, Gao Run-lin, Wang Fang-zheng, et al. Tanscoronary chemical ablation of ventricular tachycardia: A case report Chin Med J 1992; 105:247
17.Boor PJ and Reynolds ES. A simple planimetric method for determination of left ventricular mass and necrotic myocardial mass in postmortem hearts. Am J Clin Pathol 1977;68:387
18.Brugada P, de Swart H, Smeets JL, et al. Trans-coronary chemical ablation of atrioventricular conduction. Circulation 1990 ; 81 : 757.
19.DeMaio SJ, Walter PF and Douglas JS .Treatment of ventricular tachycardia induced cardiogenic shock??by percoronary chemical ablation. Cathet Cardiovasc Diagn 1990; 21: 170.
20.Ellman BA, Parkhill BJ, Marcus PB, et al. Renal ablation with absolute ethanol. Invest Radiol 1984 ; 19 ; 416.
21,Ellman BA, Parkhill BJ, Curry TS, et al. Ablation of renal tumors with absolute ethanol: A new technique.Radiologg 1981 : 141 : 619
22.Stricklerger SA, Okishige K, Friedmen PL, et al. Intracoronary chemical ablation of rentriclar tachycardia: selecting the target artery using iced saline versus antiarrhythmic drugs. PACE;14: 685.
23,Qi Xiang-qian, et al. Transcoronary chemical ablation of areas in the ventricule in dogs: CK-MB, ECG, hemodynamic and pathologic observations. Chin Med J (in press).