心房扑动的电生理机制、体表心电图F波的形成机理及射频消融方法
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摘要
目的 (1) 探讨典型心房扑动(Atrial Flutter,AFL)的电生理机制及其体表心电图F波形态与心房传导顺序的关系;(2) 心房扑动的峡部消融对心房除极顺序的影响;(3) 不典型右房和左房心房扑动的发生机制、心电图特征及射频消融的方法。
方法 (1) 典型AFL患者55例(包括63个AFL事件),男47例,女8例,平均年龄61.2±19.5岁。其中逆钟向传导(CCW)AFL 38例,顺钟向传导(CW)AFL 9例,逆钟向与顺钟向传导共存AFL 8例。对63个AFL事件,进行了心脏电生理检查、非接触性的三维标测系统标测、同步体表心电图(ECG)分析,并对其成功地实施了射频消融治疗。
(2) 对52例典型AFL患者,行射频消融术前、后分别起搏低右房侧壁(LLRA)和冠状静脉窦口(PCS)。测量指标为:1) LLRA起搏时,冠状静脉窦近端和远端的间期(PCS—DCS)及其射频消融术前、后的差值(△(PCS—DCS)),LLRA与PCS之间的间期(LLRA-PCS)和差值(△(LLRA-PCS)),希氏束(His)到PCS的间期(His-PCS);2) PCS起搏时,PCS到LLRA的间期(PCS-LLRA),及其射频消融术前、后的差值(A(PCS-LLRA))。3) LLRA和PCS起搏时,体表心电图12导联P波形态、P波间期的改变和P波终末正向波振幅与整个P波振幅的比值(P波比值)。其中20例患者射频消融术前、后使用非接触性的三维
Objective (1) To study the relationship between morphology of flutter wave in the surface electrocardiogram and endocardiial atrial transmission sequence in patients with typical counterclockwise conduction (CCW AFL) and clockwise conduction atrial flutter (CW AFL). (2) To investigate the impact of trans-cavo-tricuspid isthmus(CTI) linear ablation of typical atrial flutter on activation sequence of atria. (3) To study the mechanism, surface electrocardiographic characteristics and catheter ablation of atypical right and left atrial flutter.Methods (1) We performed conventional, noncontract three-dimensional mapping, surface ECG analysis and ablation for 55 patients with typical atrial flutter with 63 episodes (47 males, 8 females; mean age 61.2 ±19.5 years). There were 38 patients with counter clockwise conduction, 9 with clockwise conduction and 8 with both counter clockwise and clockwise conduction. (2) 52 patient with typical atrial flutter were investigated during proximal coronary sinus (PCS) and lower lateral right atrium (LLRA) pacing before and after ablation. The measurement includes 1) activation time from proximal to distal coronary sinus(PCS-DCS) and difference of PCS-DCS ( A(PCS-DCS)), from LLRA to PCS(LLRA-PCS) and A(LLRA-PCS) ,from His bundle to PCS(His-PCS) before and after ablation during LLRA pacing; 2) activation time from PCS to LLRA (PCS-LLRA) and the difference of PCS-LLRA ( A(PCS-LLRA) during PCS pacing, and 3) morphology, duration and ratio of a positive terminal P
wave part and whole P wave amplitude changes of the paced P wave. Right atrial activation in 20 patients was visualized using a noncontract mapping system (EnSite-3000) for a three dimensional reconstruction of the endocardial depolarization. (3) We performed conventional, noncontract three-dimensional mapping, surface ECG analysis and ablation for 18 patients with 34 episodes of atypical right atrial flutter and 10 patients with 12 episodes of left atrial flutter.Results (1) Of the 63 episodes evaluated, 46 were CCW AFL, 17 were CW AFL. Four groups of CCW AFL were observed: Group 1 had purely negative F wave inferiorly with a proximal-to-distal pattern (PD) in coronary sinus recording (CS). Group 2 had small positive terminal deflections with PD pattern. Group 3 had broad positive terminal deflections or purely positive F wave with a distal-to-proximal pattern (DP) or fused pattern (F). Group 4 had almost flat-line recording with PD pattern. All groups of CCW AFL had a positive F wave in Vi lead. Three groups of CW AFL were observed: Group 1 had positive or notched positive F wave inferiorly with a PD or F pattern in CS. Group 2 had negative with PD pattern. Group 3 had almost flat-line recording with fused pattern. All group of CW AFL had negative F wave in Vj leads. (2) Banchmann's bundle and CSos can develop varying degrees of conduction delay and block, which can make connection between right and left atrium change consequentially. (3) The AVF/I flutter wave amplitude ratio was >2 .0 in CCW AFL but <2.0 in all CW AFL (4) The duration of the plateau in lead III correlated with strongly Cavo-tricuspid isthmus conduction time (r=0.96). (5) The decreased amplitude of F wave in inferior leads seems to relate to heart disease and left atrium enlargement. (6) Complete CTI block was achieved in 52 patients. During LLRA pacing, linear ablation at CTI results in a significant delay of activation in all coronary sinus recording sites with great extent at the ostium area. The A (PCS-DCS) was well correlated with results of CTI block and significantly longer in patient with complete than incomplete CTI block (30±17 vs. 10±ll ms p<0.001), thereby allowing a
value of 20 ms as a discriminative parameter to differentiate incomplete (<20ms) from complete (>20ms) CTI counterclockwise conduction block with a sensitive of 92% and a specificity of 85%. (7) PCS advanced His before ablation and then His advanced PCS after ablation, His-PCS was well-correlated counter clockwise block, allowing a value 35ms as a discriminative parameter to differentiate incomplete (<35 ms) from complete (>35ms) CTI block with a sensitive of 94% and a specificity of 90%. (8) A change of the terminal portion of the P wave towards a positive morphology in 48(92%) of 52 patients during PCS and LLRA pacing. These changes were predominantly observed in the inferior leads. Positive morphology changes of the terminal P wave portion and larger increment of ratio of P wave ratio (40±12ms) in the inferior leads indicating conduction block with a sensitive of 92% and a specificity of 90% were observed. An increment of 20ms or more in P wave duration during PCS and 15 ms or more during LLRA pacing indicates conduction block with a sensitivity of 90% and a specificity of 90%. (9) There were 18 episodes with low loop reentry atrial flutter(LLR) involved the low right atrium(RA), as early breakthrough in the low RA, wave-front collision in the high lateral RA or septum, and conduction through the CTI. Surface-ECG showed negative F wave in inferior leads as same as typical flutter with counter clockwise conduction. There were 4 episodes with upper loop reentry flutter (ULR) involved upper atrium and no conduction through CTI, positive F wave in inferior leads. (10) 12 episodes originating in right atrial free wall (RAFW), the surface ECG does not distinguish RAFW atypical atrial flutter from typical atrial flutter, but they can be differentiated by entrainment (or electroanatomic) mapping. (11) 10 patients with 12 episodes of left atrial(LA)flutter involved LA septal, LA posterior wall and mitral annulus. Surface ECG showed positive F wave in Vj lead and flat or isoelectric F wave in inferior leads.Conclusion (1) Polarity of the F wave in surface ECG inferior lead is determined by connection between two atria and activation sequence in
方法 (1) 典型AFL患者55例(包括63个AFL事件),男47例,女8例,平均年龄61.2±19.5岁。其中逆钟向传导(CCW)AFL 38例,顺钟向传导(CW)AFL 9例,逆钟向与顺钟向传导共存AFL 8例。对63个AFL事件,进行了心脏电生理检查、非接触性的三维标测系统标测、同步体表心电图(ECG)分析,并对其成功地实施了射频消融治疗。
(2) 对52例典型AFL患者,行射频消融术前、后分别起搏低右房侧壁(LLRA)和冠状静脉窦口(PCS)。测量指标为:1) LLRA起搏时,冠状静脉窦近端和远端的间期(PCS—DCS)及其射频消融术前、后的差值(△(PCS—DCS)),LLRA与PCS之间的间期(LLRA-PCS)和差值(△(LLRA-PCS)),希氏束(His)到PCS的间期(His-PCS);2) PCS起搏时,PCS到LLRA的间期(PCS-LLRA),及其射频消融术前、后的差值(A(PCS-LLRA))。3) LLRA和PCS起搏时,体表心电图12导联P波形态、P波间期的改变和P波终末正向波振幅与整个P波振幅的比值(P波比值)。其中20例患者射频消融术前、后使用非接触性的三维
Objective (1) To study the relationship between morphology of flutter wave in the surface electrocardiogram and endocardiial atrial transmission sequence in patients with typical counterclockwise conduction (CCW AFL) and clockwise conduction atrial flutter (CW AFL). (2) To investigate the impact of trans-cavo-tricuspid isthmus(CTI) linear ablation of typical atrial flutter on activation sequence of atria. (3) To study the mechanism, surface electrocardiographic characteristics and catheter ablation of atypical right and left atrial flutter.Methods (1) We performed conventional, noncontract three-dimensional mapping, surface ECG analysis and ablation for 55 patients with typical atrial flutter with 63 episodes (47 males, 8 females; mean age 61.2 ±19.5 years). There were 38 patients with counter clockwise conduction, 9 with clockwise conduction and 8 with both counter clockwise and clockwise conduction. (2) 52 patient with typical atrial flutter were investigated during proximal coronary sinus (PCS) and lower lateral right atrium (LLRA) pacing before and after ablation. The measurement includes 1) activation time from proximal to distal coronary sinus(PCS-DCS) and difference of PCS-DCS ( A(PCS-DCS)), from LLRA to PCS(LLRA-PCS) and A(LLRA-PCS) ,from His bundle to PCS(His-PCS) before and after ablation during LLRA pacing; 2) activation time from PCS to LLRA (PCS-LLRA) and the difference of PCS-LLRA ( A(PCS-LLRA) during PCS pacing, and 3) morphology, duration and ratio of a positive terminal P
wave part and whole P wave amplitude changes of the paced P wave. Right atrial activation in 20 patients was visualized using a noncontract mapping system (EnSite-3000) for a three dimensional reconstruction of the endocardial depolarization. (3) We performed conventional, noncontract three-dimensional mapping, surface ECG analysis and ablation for 18 patients with 34 episodes of atypical right atrial flutter and 10 patients with 12 episodes of left atrial flutter.Results (1) Of the 63 episodes evaluated, 46 were CCW AFL, 17 were CW AFL. Four groups of CCW AFL were observed: Group 1 had purely negative F wave inferiorly with a proximal-to-distal pattern (PD) in coronary sinus recording (CS). Group 2 had small positive terminal deflections with PD pattern. Group 3 had broad positive terminal deflections or purely positive F wave with a distal-to-proximal pattern (DP) or fused pattern (F). Group 4 had almost flat-line recording with PD pattern. All groups of CCW AFL had a positive F wave in Vi lead. Three groups of CW AFL were observed: Group 1 had positive or notched positive F wave inferiorly with a PD or F pattern in CS. Group 2 had negative with PD pattern. Group 3 had almost flat-line recording with fused pattern. All group of CW AFL had negative F wave in Vj leads. (2) Banchmann's bundle and CSos can develop varying degrees of conduction delay and block, which can make connection between right and left atrium change consequentially. (3) The AVF/I flutter wave amplitude ratio was >2 .0 in CCW AFL but <2.0 in all CW AFL (4) The duration of the plateau in lead III correlated with strongly Cavo-tricuspid isthmus conduction time (r=0.96). (5) The decreased amplitude of F wave in inferior leads seems to relate to heart disease and left atrium enlargement. (6) Complete CTI block was achieved in 52 patients. During LLRA pacing, linear ablation at CTI results in a significant delay of activation in all coronary sinus recording sites with great extent at the ostium area. The A (PCS-DCS) was well correlated with results of CTI block and significantly longer in patient with complete than incomplete CTI block (30±17 vs. 10±ll ms p<0.001), thereby allowing a
value of 20 ms as a discriminative parameter to differentiate incomplete (<20ms) from complete (>20ms) CTI counterclockwise conduction block with a sensitive of 92% and a specificity of 85%. (7) PCS advanced His before ablation and then His advanced PCS after ablation, His-PCS was well-correlated counter clockwise block, allowing a value 35ms as a discriminative parameter to differentiate incomplete (<35 ms) from complete (>35ms) CTI block with a sensitive of 94% and a specificity of 90%. (8) A change of the terminal portion of the P wave towards a positive morphology in 48(92%) of 52 patients during PCS and LLRA pacing. These changes were predominantly observed in the inferior leads. Positive morphology changes of the terminal P wave portion and larger increment of ratio of P wave ratio (40±12ms) in the inferior leads indicating conduction block with a sensitive of 92% and a specificity of 90% were observed. An increment of 20ms or more in P wave duration during PCS and 15 ms or more during LLRA pacing indicates conduction block with a sensitivity of 90% and a specificity of 90%. (9) There were 18 episodes with low loop reentry atrial flutter(LLR) involved the low right atrium(RA), as early breakthrough in the low RA, wave-front collision in the high lateral RA or septum, and conduction through the CTI. Surface-ECG showed negative F wave in inferior leads as same as typical flutter with counter clockwise conduction. There were 4 episodes with upper loop reentry flutter (ULR) involved upper atrium and no conduction through CTI, positive F wave in inferior leads. (10) 12 episodes originating in right atrial free wall (RAFW), the surface ECG does not distinguish RAFW atypical atrial flutter from typical atrial flutter, but they can be differentiated by entrainment (or electroanatomic) mapping. (11) 10 patients with 12 episodes of left atrial(LA)flutter involved LA septal, LA posterior wall and mitral annulus. Surface ECG showed positive F wave in Vj lead and flat or isoelectric F wave in inferior leads.Conclusion (1) Polarity of the F wave in surface ECG inferior lead is determined by connection between two atria and activation sequence in
引文
1. Olshansky B, Okumura K, Hess PG, Waldo AL. Demonstration of an area of slow conduction in humans atrial flutter. J Am Coll Cardiol. 1990;16:1639-1648.
2. Feld GK, Fleck RP, Chen PS, Boyce K, Bahuson TD, Stein JB, Calisi CM, Ibassa M. Radiofrequency catheter ablation for the treatment of human type I atrial flutter: identification of a critical zone in the reentrant circuit by endocardial mapping techniques. Circulation. 1992; 86: 1233-1240.
3. Cosio FG, Lopez-Gil M, Giocolea A, Arribas F, Barroso JL. Radiofrequency ablation of the inferior vena cava-tricuspid valve isthmus in common atrial flutter. Am J Cardiol. 1993;71:705-709.
4. Saoudi N, Atallah G; Kirkorian G, Touboul P. Catheter ablation of the atrial myocardium in human type I atrial flutter. Circulation. 1990;81:762-771.
5. Klein GJ, Guiraudon GM, Sharma AD, Milstein S. Demonstration of macroreentry and feasibility of operative therapy in the common type of atrial flutter. Am J Cardiol. 1986;57:587-591.
6. FC. Schmitt, G. Ndrepepa, B. Zrenner et al. Relationship between surface electrocardiogram characteristics and endocardial activation sequence in patient with typical atrial flutter. Z. Kardiol 89: 527-537.
7. Saoudi N, Nair M, Abdelazziz A, et al. Electrocardiographic patterns and results of radiofregency catheter ablation of clockwise type I flutter. J Cardiovasc Electrophysiol 1996; 7:931-42.
8. Wagner ML, Lazzara R, Weiss RM, et al. Specialized conducting fibers in the interatrial band. Circ Res. 1966; 18:502-518
9. Childers RW, Merideth J, Moe GK. Supernormality in Bachmann's bundle: an in vitro and in vivo study in the dog. Circ Res. 1968; 22: 363-370.
10. Zipes DP, DeJoseph RL. Dissimilar atrial rhythms in man and dog. Am J Cardiol. 1973; 32: 618-628.
11. Leier CV, Schaal SF. Dissimilar atrial rhythms: a patient with interatrial block. Br Heart J. 1977; 39: 680-684.
12. Boineau JP, Canavan TE, Schuessler RB, et al. Demonstration of a widely distributed atrial pacemarker complex in the human heart. Circulation 1988; 6: 121-37.
13. Bachmann G. The inter-auricular time interval. Am J Physiol. 1916; 41: 309-320.
14. Antz M, Otomo K, Arruda M, et al. Electrical conduction between the right atrium and the left atrium via the musculature of the coronary sinus. Circulation. 1998; 98: 1790-1795.
15. Sun H, Velipasaoglu EO, Wu DE, et al. Simultaneous multisite mapping of the right and the left atrial septum in the canine intact beating heart. Circulation. 1999; 100: 312-319.
16. Rodriguez,Luz-Maria MD; Timmermans, Carl MD; Nabar, Ashish MD et al. Biatrial Activation in Isthmus-Dependent Atrial Flutter. Circulation. 2001; 104: 2545-2550.
17. Schols W, Offiner B, Brachmann J, et al. Circus movement atrial flutter in canine sterile'pericarditis modle. Relation of characteristics of the surface electrocardiogram and conduction properties of the reentrant pathway. JAM Coll Cardiol 1994; 23:799-808.
18. Wells JL, Maclean WA, James TN et al. Characterization of atrial flutter: studies in man after open heart surgery using fixed atrial electrodes. Circulation 1979; 60; 665-3.
19. Olshansky B, Okumura K, Hess PG, Waldo AL. Demonstration of an area of slow conduction in human atrial flutter. J AM Coll Cardiol 1990; 16: 1639-48.
20. Kalman JM, Olgin JE, Saxon LA et al. Activation and entrainment mapping defines the tricuspid annulus as the anterior barrier in typical
2. Feld GK, Fleck RP, Chen PS, Boyce K, Bahuson TD, Stein JB, Calisi CM, Ibassa M. Radiofrequency catheter ablation for the treatment of human type I atrial flutter: identification of a critical zone in the reentrant circuit by endocardial mapping techniques. Circulation. 1992; 86: 1233-1240.
3. Cosio FG, Lopez-Gil M, Giocolea A, Arribas F, Barroso JL. Radiofrequency ablation of the inferior vena cava-tricuspid valve isthmus in common atrial flutter. Am J Cardiol. 1993;71:705-709.
4. Saoudi N, Atallah G; Kirkorian G, Touboul P. Catheter ablation of the atrial myocardium in human type I atrial flutter. Circulation. 1990;81:762-771.
5. Klein GJ, Guiraudon GM, Sharma AD, Milstein S. Demonstration of macroreentry and feasibility of operative therapy in the common type of atrial flutter. Am J Cardiol. 1986;57:587-591.
6. FC. Schmitt, G. Ndrepepa, B. Zrenner et al. Relationship between surface electrocardiogram characteristics and endocardial activation sequence in patient with typical atrial flutter. Z. Kardiol 89: 527-537.
7. Saoudi N, Nair M, Abdelazziz A, et al. Electrocardiographic patterns and results of radiofregency catheter ablation of clockwise type I flutter. J Cardiovasc Electrophysiol 1996; 7:931-42.
8. Wagner ML, Lazzara R, Weiss RM, et al. Specialized conducting fibers in the interatrial band. Circ Res. 1966; 18:502-518
9. Childers RW, Merideth J, Moe GK. Supernormality in Bachmann's bundle: an in vitro and in vivo study in the dog. Circ Res. 1968; 22: 363-370.
10. Zipes DP, DeJoseph RL. Dissimilar atrial rhythms in man and dog. Am J Cardiol. 1973; 32: 618-628.
11. Leier CV, Schaal SF. Dissimilar atrial rhythms: a patient with interatrial block. Br Heart J. 1977; 39: 680-684.
12. Boineau JP, Canavan TE, Schuessler RB, et al. Demonstration of a widely distributed atrial pacemarker complex in the human heart. Circulation 1988; 6: 121-37.
13. Bachmann G. The inter-auricular time interval. Am J Physiol. 1916; 41: 309-320.
14. Antz M, Otomo K, Arruda M, et al. Electrical conduction between the right atrium and the left atrium via the musculature of the coronary sinus. Circulation. 1998; 98: 1790-1795.
15. Sun H, Velipasaoglu EO, Wu DE, et al. Simultaneous multisite mapping of the right and the left atrial septum in the canine intact beating heart. Circulation. 1999; 100: 312-319.
16. Rodriguez,Luz-Maria MD; Timmermans, Carl MD; Nabar, Ashish MD et al. Biatrial Activation in Isthmus-Dependent Atrial Flutter. Circulation. 2001; 104: 2545-2550.
17. Schols W, Offiner B, Brachmann J, et al. Circus movement atrial flutter in canine sterile'pericarditis modle. Relation of characteristics of the surface electrocardiogram and conduction properties of the reentrant pathway. JAM Coll Cardiol 1994; 23:799-808.
18. Wells JL, Maclean WA, James TN et al. Characterization of atrial flutter: studies in man after open heart surgery using fixed atrial electrodes. Circulation 1979; 60; 665-3.
19. Olshansky B, Okumura K, Hess PG, Waldo AL. Demonstration of an area of slow conduction in human atrial flutter. J AM Coll Cardiol 1990; 16: 1639-48.
20. Kalman JM, Olgin JE, Saxon LA et al. Activation and entrainment mapping defines the tricuspid annulus as the anterior barrier in typical