疑难快速性心律失常的非接触标测及导管射频消融
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摘要
第一章 起源于界嵴房性心动过速的非接触标测与导管射频消融
目的:非接触标测是一新型三维标测系统,本研究利用该系统对界嵴房性心动过速(CT-AT)进行标测并指导导管射频消融。
方法:9例反复发作性心悸患者,心动过速体表心电图提示右心房房性心动过速。腔内电生理检查显示心动过速的最早激动位于高位右心房处。置入多极矩阵电极于右心房后,构建右心房的几何构型,并于窦性节律和心房起搏时分析右心房的传导阻滞区域。心房起搏周长为250ms,部位位于冠状静脉窦口附近和右心房前侧壁近心耳处。自动聚焦标测分析窦性节律和心动过速的最早起源及其传导方向。系统导航消融导管至心动过速的最早激动点处消融。
结果:所有9例患者在高位右心房行程序电刺激均可诱发出持续性AT,心动过速平均周长为344±55ms。心动过速均可被心房超速刺激和三磷酸腺苷(ATP)静脉弹丸注射终止。于冠状静脉窦口附近和右心房前侧壁近心耳处以周长250ms起搏时,可见右心房前外侧壁有一纵向传导阻滞带,其上端延续至上腔静脉前壁,该传导阻滞带被拟定为CT的解剖部位。非接触标测发现,AT的最早激动点位于CT上端,平均距窦性激动爆发点1.8±0.6 cm。系统导航消融导管至最早激动点处,平均放电4.2±3.5次,心动过速不再被诱发。消融过程中无一例发生窦性静止及窦房阻滞。平均随访23.3±4.7月,所有患者无心动过速复发。
结论:非接触标测能快速确定CT的解剖部位,标测心动过速的最早激动点;系统导航消融可避免损伤窦房结及其周围组织。另外全心腔标测还可揭示CT-AT的电生理机制。
Part Ⅰ Noncontact Mapping and Catheter Ablation ofAtrial Tachycardias Arising from Crista TerminalisPurpose: Noncontact mapping is a novel, three dimensional mapping system. We used it in the present study to identify the anatomic region of the crista terminalis (CT), to trace the origin of the atrial tachycardias (AT) and to guide catheter ablation of ATs from the CT.Methods: Nine consecutive patients with recurrent palpitations were included in the study. ATs with the earliest activation in the high right atrium were induced during electrophysiological study. The geometry of the right atrium was then created and the conduction block area was analyzed both in sinus rhythm and during right atrial pacing at the drive length of 250ms at sites of posterior wall near CSo and anterior wall. Autofocus mapping was used to find the earliest activation point and the wave front propagation mode of both sinus rhythm and the ATs. Guiding ablation of ATs was made thereafter.Results: Sustained AT could be induced in all 9 patients by high right atrium programmed electrical stimulation, and the mean cycle length was 344 ± 55ms. All ATs could be terminated by burst stimuli and intravenous adenosine triphosphate bolus injection. CT was identified as a short perpendicular conduction block
line near superior vene cava in the lateral wall of the right atrium during pacing at a cycle length of 250ms both at the posterior septal area and the anterior wall. The earliest activation point of all ATs was found to be in the CT with a mean distance of 1.8 ±0.6 cm from sinus breakout point. After a mean of 4. 2 ± 3. 5 RF deliveries, all ATs became non-inducible. No sinus arrest and sino-atrial block happened during RF delivery and no tachycardia recurred after a mean follow-up of 23. 3 + 4. 7 months.Conclusions: The noncontact mapping system can help you to easily identify the anatomic region of CT and to quickly trace the origin of AT, and the guiding ablation can reduce the risk of inadvertent damage to sinus node and sino-atrial conduction. The whole chamber mapping makes it easier to disclose the mechanism of CT-AT.Part II Noncontact Mapping and Radiofrequency Catheter Ablation of Intraatrial Dual-loop ReentrantTachycardiasPurpose: To illustrate the mechanisms of intra-atrial dual-loop tachycardia and its catheter ablation methods. Methods: 3 cases, all female, age from 41 to 66 years old, had the history of tachycardia for 6 months to 10 years. Case 1 had atrial septal defect repairment 22 years before, case 2 had no structural heart disease and case 3 had idiopathic dilated
cardiomyopathy. 9 French baloon catheter was advanced via left femoral vein to the right atrium and deployed at the level between His bundle and coronary sinus. Heparin was used to keep ACT (activative coagulation time) level around 250ms during the procedure.8 French deflectable catheter was inserted through right femoral vein to make geometry of right atrium. Complete tachycardia mapping was performed in the right atrium with noncontact mapping system (EnSite 3000), followed by linear radiofrequency ablation of the narrowest part of each complete loop.Results: 2 different tachycardias could be induced in each of 3 cases. All cases had clockwise cavotricuspid isthmus dependent atrial flutter. In addition to that, case 1 had atrial tachycardia going around atriotomy scar counter-clockwisely, case 2 around the upper part of crista terminalis clockwisely and case 3 around scar tissue clockwisely. Linear ablation was done both in cavotricuspid isthmus and critical isthmus of atrial tachycardia under the guidance of EnSite 3000 guiding system. No tachycardia could be induced after the procedure. There were no recurrences after follow-up of 27-36 months. Conclusions: Dual-loop atrial reentrant tachycardia can occur both in diseased atrium and nondiseased atrium. Noncontact mapping is a good way for such tachycardias not only for its mapping property but also for its guiding system. Linear ablation should be done in two isthmuses in these cases.
Part III Further Insight i
目的:非接触标测是一新型三维标测系统,本研究利用该系统对界嵴房性心动过速(CT-AT)进行标测并指导导管射频消融。
方法:9例反复发作性心悸患者,心动过速体表心电图提示右心房房性心动过速。腔内电生理检查显示心动过速的最早激动位于高位右心房处。置入多极矩阵电极于右心房后,构建右心房的几何构型,并于窦性节律和心房起搏时分析右心房的传导阻滞区域。心房起搏周长为250ms,部位位于冠状静脉窦口附近和右心房前侧壁近心耳处。自动聚焦标测分析窦性节律和心动过速的最早起源及其传导方向。系统导航消融导管至心动过速的最早激动点处消融。
结果:所有9例患者在高位右心房行程序电刺激均可诱发出持续性AT,心动过速平均周长为344±55ms。心动过速均可被心房超速刺激和三磷酸腺苷(ATP)静脉弹丸注射终止。于冠状静脉窦口附近和右心房前侧壁近心耳处以周长250ms起搏时,可见右心房前外侧壁有一纵向传导阻滞带,其上端延续至上腔静脉前壁,该传导阻滞带被拟定为CT的解剖部位。非接触标测发现,AT的最早激动点位于CT上端,平均距窦性激动爆发点1.8±0.6 cm。系统导航消融导管至最早激动点处,平均放电4.2±3.5次,心动过速不再被诱发。消融过程中无一例发生窦性静止及窦房阻滞。平均随访23.3±4.7月,所有患者无心动过速复发。
结论:非接触标测能快速确定CT的解剖部位,标测心动过速的最早激动点;系统导航消融可避免损伤窦房结及其周围组织。另外全心腔标测还可揭示CT-AT的电生理机制。
Part Ⅰ Noncontact Mapping and Catheter Ablation ofAtrial Tachycardias Arising from Crista TerminalisPurpose: Noncontact mapping is a novel, three dimensional mapping system. We used it in the present study to identify the anatomic region of the crista terminalis (CT), to trace the origin of the atrial tachycardias (AT) and to guide catheter ablation of ATs from the CT.Methods: Nine consecutive patients with recurrent palpitations were included in the study. ATs with the earliest activation in the high right atrium were induced during electrophysiological study. The geometry of the right atrium was then created and the conduction block area was analyzed both in sinus rhythm and during right atrial pacing at the drive length of 250ms at sites of posterior wall near CSo and anterior wall. Autofocus mapping was used to find the earliest activation point and the wave front propagation mode of both sinus rhythm and the ATs. Guiding ablation of ATs was made thereafter.Results: Sustained AT could be induced in all 9 patients by high right atrium programmed electrical stimulation, and the mean cycle length was 344 ± 55ms. All ATs could be terminated by burst stimuli and intravenous adenosine triphosphate bolus injection. CT was identified as a short perpendicular conduction block
line near superior vene cava in the lateral wall of the right atrium during pacing at a cycle length of 250ms both at the posterior septal area and the anterior wall. The earliest activation point of all ATs was found to be in the CT with a mean distance of 1.8 ±0.6 cm from sinus breakout point. After a mean of 4. 2 ± 3. 5 RF deliveries, all ATs became non-inducible. No sinus arrest and sino-atrial block happened during RF delivery and no tachycardia recurred after a mean follow-up of 23. 3 + 4. 7 months.Conclusions: The noncontact mapping system can help you to easily identify the anatomic region of CT and to quickly trace the origin of AT, and the guiding ablation can reduce the risk of inadvertent damage to sinus node and sino-atrial conduction. The whole chamber mapping makes it easier to disclose the mechanism of CT-AT.Part II Noncontact Mapping and Radiofrequency Catheter Ablation of Intraatrial Dual-loop ReentrantTachycardiasPurpose: To illustrate the mechanisms of intra-atrial dual-loop tachycardia and its catheter ablation methods. Methods: 3 cases, all female, age from 41 to 66 years old, had the history of tachycardia for 6 months to 10 years. Case 1 had atrial septal defect repairment 22 years before, case 2 had no structural heart disease and case 3 had idiopathic dilated
cardiomyopathy. 9 French baloon catheter was advanced via left femoral vein to the right atrium and deployed at the level between His bundle and coronary sinus. Heparin was used to keep ACT (activative coagulation time) level around 250ms during the procedure.8 French deflectable catheter was inserted through right femoral vein to make geometry of right atrium. Complete tachycardia mapping was performed in the right atrium with noncontact mapping system (EnSite 3000), followed by linear radiofrequency ablation of the narrowest part of each complete loop.Results: 2 different tachycardias could be induced in each of 3 cases. All cases had clockwise cavotricuspid isthmus dependent atrial flutter. In addition to that, case 1 had atrial tachycardia going around atriotomy scar counter-clockwisely, case 2 around the upper part of crista terminalis clockwisely and case 3 around scar tissue clockwisely. Linear ablation was done both in cavotricuspid isthmus and critical isthmus of atrial tachycardia under the guidance of EnSite 3000 guiding system. No tachycardia could be induced after the procedure. There were no recurrences after follow-up of 27-36 months. Conclusions: Dual-loop atrial reentrant tachycardia can occur both in diseased atrium and nondiseased atrium. Noncontact mapping is a good way for such tachycardias not only for its mapping property but also for its guiding system. Linear ablation should be done in two isthmuses in these cases.
Part III Further Insight i
引文
1. Sra J, Bhatia A, Krum D, et al. Endocardial noncontact activation, mapping of idiopathic left ventricular tachycardia. J Cardiovasc Electrophysiol. 2000; 11(12): 1409-1412
2. Gasparini M, Coltorti F, Mantica M et al. Noncontact system-guided simplified right atrial linear lesions using radiofrequency transcatheter ablation for treatment of refractory atrial fibrillation. PACE 2000; 23(11 Pt 2): 1843-1847
3. Betts TR, Roberts PR, Allen SA, et al. Radiofrequency ablation of idiopathic left ventricular tachycardia at the site of earliest activation as determined by noncontact mapping. J Cardiovasc Electrophysiol 2000; 11(10): 1094-1101
4. Schmitt e, Ndrepepa G, Deisenhofer I, et al. Recent advances in cardiac mapping techniques. Curr Cardiol Rep 1999; 1(2): 149-156
5. Friedman PA, Beinborn DA, Schneider M, et al. Ablation of noninducible idiopathic left ventricular tachycardia using a noncontact map acquired from a premature complex with tachycardia morphology. PACE 2000; 23 (8): 1311-1314
6. Friedman PA, Stanton MS. Spot welding the gap in atrial flutter ablation. Circulation 1999; 99: 3206-3208
7. Betts TR, Roberts PR, Allen SA, et al. Electrophysiological mapping and ablation of intra-atrial reentry tachycardia after Fontan surgery with the use of a noncontact mapping system. Circulation 2000; 102 (4): 419-425
8. Schneider MA, Ndrepepa G, Zrenner B, et al. Noncontact mapping-guided catheter ablation of atrial fibrillation associate with left atrial ectory. J Cardiovasc Electrophysiol 2002; 11 (4):475-479
9. Strickberger SA, Knight BP, Michaud GF, et al. Mapping and ablation of ventricular tachycardia guided by virtual electrograms using a noncontact, computerized mapping system. J Am Coll Cardiol 2000; 35(2): 414-421
10. Schumacher B, Jung W, Lewalter T, et al. Verification of linear lesions using a noncontact multielectrode array catheter versus conventional contact mapping techniques. J Cardiovasc Electrophysiol 1999; 10(6): 791-798
11. Schilling RJ, Peters NS, Davies DW. Feasibility of a noncontact catheter for endocardial mapping of human ventricular tachycardia. Circulation 1999; 99(19): 2543-2552
12. Kadish A, Hauck J, Pederson B, Beatty G, Gornick C. Mapping of atrial activation with a noncontact, multielectrode catheter in dogs. Circulation 1999; 99 (14): 1906-1913
13. Gornick CC, Adler SW, Pederson B, et al. Validation of a new noncontact catheter system for electroanatomic mapping of left ventricular endocardium. Circulation 1999; 99(6): 829-835
14. Schilling RJ, Davies DW, Peters NS. Characteristics of sinus rhythm electrograms at sites of ablation of ventricular tachycardia relative to all other sites: a noncontact mapping study of the entire left ventricle. J Cardiovasc Electrophysiol 1998; 9(9): 921-933
15. Schilling RJ, peters NS, Davies DW. Simultaneous endocardial mapping in the human left ventricle using a noncontact catheter: comparison of contact and reconstructed electrograms during sinus rhythm. Circulation 1998; 98(9): 887-898
16. Peters NS, Jackman WM, Schilling RJ, et al. Images in cardiovascular medicine. Human left ventricular endocardial activation mapping using a novel noncontact catheter. Circulation 1997; 95 (6): 1658-1660
2. Gasparini M, Coltorti F, Mantica M et al. Noncontact system-guided simplified right atrial linear lesions using radiofrequency transcatheter ablation for treatment of refractory atrial fibrillation. PACE 2000; 23(11 Pt 2): 1843-1847
3. Betts TR, Roberts PR, Allen SA, et al. Radiofrequency ablation of idiopathic left ventricular tachycardia at the site of earliest activation as determined by noncontact mapping. J Cardiovasc Electrophysiol 2000; 11(10): 1094-1101
4. Schmitt e, Ndrepepa G, Deisenhofer I, et al. Recent advances in cardiac mapping techniques. Curr Cardiol Rep 1999; 1(2): 149-156
5. Friedman PA, Beinborn DA, Schneider M, et al. Ablation of noninducible idiopathic left ventricular tachycardia using a noncontact map acquired from a premature complex with tachycardia morphology. PACE 2000; 23 (8): 1311-1314
6. Friedman PA, Stanton MS. Spot welding the gap in atrial flutter ablation. Circulation 1999; 99: 3206-3208
7. Betts TR, Roberts PR, Allen SA, et al. Electrophysiological mapping and ablation of intra-atrial reentry tachycardia after Fontan surgery with the use of a noncontact mapping system. Circulation 2000; 102 (4): 419-425
8. Schneider MA, Ndrepepa G, Zrenner B, et al. Noncontact mapping-guided catheter ablation of atrial fibrillation associate with left atrial ectory. J Cardiovasc Electrophysiol 2002; 11 (4):475-479
9. Strickberger SA, Knight BP, Michaud GF, et al. Mapping and ablation of ventricular tachycardia guided by virtual electrograms using a noncontact, computerized mapping system. J Am Coll Cardiol 2000; 35(2): 414-421
10. Schumacher B, Jung W, Lewalter T, et al. Verification of linear lesions using a noncontact multielectrode array catheter versus conventional contact mapping techniques. J Cardiovasc Electrophysiol 1999; 10(6): 791-798
11. Schilling RJ, Peters NS, Davies DW. Feasibility of a noncontact catheter for endocardial mapping of human ventricular tachycardia. Circulation 1999; 99(19): 2543-2552
12. Kadish A, Hauck J, Pederson B, Beatty G, Gornick C. Mapping of atrial activation with a noncontact, multielectrode catheter in dogs. Circulation 1999; 99 (14): 1906-1913
13. Gornick CC, Adler SW, Pederson B, et al. Validation of a new noncontact catheter system for electroanatomic mapping of left ventricular endocardium. Circulation 1999; 99(6): 829-835
14. Schilling RJ, Davies DW, Peters NS. Characteristics of sinus rhythm electrograms at sites of ablation of ventricular tachycardia relative to all other sites: a noncontact mapping study of the entire left ventricle. J Cardiovasc Electrophysiol 1998; 9(9): 921-933
15. Schilling RJ, peters NS, Davies DW. Simultaneous endocardial mapping in the human left ventricle using a noncontact catheter: comparison of contact and reconstructed electrograms during sinus rhythm. Circulation 1998; 98(9): 887-898
16. Peters NS, Jackman WM, Schilling RJ, et al. Images in cardiovascular medicine. Human left ventricular endocardial activation mapping using a novel noncontact catheter. Circulation 1997; 95 (6): 1658-1660
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