个体化的心房消融终止心房颤动  

The initial study of left atrial electrical modification catheter ablation for atrial fibrillation using noncontact isopotential mapping

作　　者：姚焰[1] 张澍[1] 唐闽[1] 张奎俊[1] 王方正[1] 陈新[1] 

机构地区：[1]中国医学科学院中国协和医科大学心血管病研究所阜外心血管病医院心律失常诊治中心,北京100037

出　　处：《中华心律失常学杂志》2005年第2期93-99,共7页Chinese Journal of Cardiac Arrhythmias

基　　金：国家"十五"科技攻关资助项目(2003BA712A1108);国家自然科学基金资助项目(30240046)

摘　　要：目的心房颤动(房颤,AF)的发生和维持可能存在多种机制,对所有的AF都以一种固定的术式进行消融治疗缺乏针对性。为此,我们采用心内非接触式标测,探索个体化消融的可行性。方法52例患者(男性44例,女性8例),年龄22～70(51.1±10.9)岁,左心房内径22～54(36.1±6.5)mm,其中12例为持续性AF(1～22年)。均经房间隔穿刺在左心房内对AF进行非接触式等电位标测,并在等电位标测下逐步进行个体化消融,消融术式不固定,以AF被终止且不被诱发、消融线形成双向阻滞为消融终点。结果AF被分为3种类型,而肺静脉(pulmonaryvein,PV)口周围、左心房顶部是波阵面的主要传导区。消融方式根据标测结果决定,包括在以上任一部位的线性消融、环PV口外的线性消融等,其中持续性AF多形成绕PV口周的环形消融加左心房顶部消融线。82.7%(43/52)的AF被消融所终止且不能再诱发,其中4例需在右心房消融方成功;另有5例的AF被转变为左心房扑动(房扑)。首次消融的即时成功率为90.4%(47/52)。消融中1例有心脏压塞。6例首次消融后有左心房房扑的患者再次接受了消融,标测发现既往消融线存在缝隙,针对缝隙消融后心动过速均被终止且不能被诱发。平均随访(11.0±6.2)个月,术后3个月82.7%(43/52)的患者不服药物亦无AF发生,其中阵发性AF成功率为87.5%(35/40);持续性AF为66.7%(8/12),其余患者均转为左心房房扑。结论本组结果初步提示,在非接触式等电位标测的基础上进行个体化的心房电学改良消融可有效地终止AF并有较好的中期疗效。其远期的效果有待观察。Objective Current dominant ablation strategies for aftrial fibrillation (AF) are fixed empirical protocols regardless of the variety of AF.This study was aimed to observe the effect of the individualized ablation strategy of AF using the noncontact isopotential mapping.Methods Fifty-two patients [mean age (51.1±10.9) years]were enrolled,of which,12 patients were persistent AF(1~22 years).The mean diameter of left atrium was (36.1±6.5) mm.A multiple electrode array was placed in the middle of left atrium(LA) through septum puncture approach.The burst stimulation (250~600 bpm) was applied to induce AF if there was no spontaneous AF.Individualized ablation varied from segmental to circumferential,was completed step by step under the guidance of isopotential mapping.Results The isopotential mapping showed that the AF in 52 cases were classified as 3 types.The roof of left atrium and PV ostia were the main substrate of the wavefront.The AF was converted to sinus rhythm by ablation in 82.7%(43/52) and was converted to atypical atrial flutter (AAFL) in 5 patients,4 proxysmal AF cases were hot judged due to short AF duration.The success rate of primary ablation was 90.4% (47/52).Cardiac tamponade occurred in 1 patients.Six patients with AAFL underwent electrophysiological study again and gap was found in all cases.The AAFLs were terminated after ablation on gaps.Three months post the ablation(average follow-up was 11.0±6.2 months),82.7% (43/52) were AF free without medication.The success rate was 87.5% (35/40) in paroxysmal and 66.7% (8/12) in persistent AF group.The rest were converted to AAFL.Conclusions This study suggests that the individualized ablation protocol based on the isopotential mapping of atrial fibrillation mechanism is feasible and effective in sinus rhythm restoration.

关 键 词：心房颤动 个体化 心内非接触式标测 左心房顶部 电位标测 线性消融 左心房内径 持续性 消融治疗 消融终点 vein 心房扑动 心脏压塞 心动过速 中期疗效 AF 患者 针对性 诱发 肺静脉 波阵面 右心房 阵发性 术式 PV 功率 缝隙 

分 类 号：R541.7[医药卫生—心血管疾病]