低能量放电下标测无室性早搏的流出道室性心动过速  

Low energy stimuli mapping for ablation of ventricular tachycardia originating from the right ventricular outflow tract

作　　者：贾玉和[1] 王靖[1] 毛克修[1] 韦伟[1] 赵英杰[1] 方丕华[1] 楚建民[1] 张澍[1] 

机构地区：[1]中国医学科学院心血管病研究所北京协和医学院阜外心血管病医院心律失常中心,100037

出　　处：《中华心律失常学杂志》2010年第3期192-196,共5页Chinese Journal of Cardiac Arrhythmias

摘　　要：目的本文报道11例非频发室性早搏（室早）的流出道室性心动过速（室速）伴反复晕厥病例经导管射频消融成功的体会，并由此介绍一种新的针对这类患者的标测方法。方法11例患者，全部为女性，年龄（39．9±13．7）岁，全部曾使用2种以上抗心律失常药物治疗，治疗期间均有晕厥或黑噱病史1～3年。结果（1）所有11例患者在术中经过各种方法均可记录到至少1次室早、室速发作心电图，其中6例经程序刺激不能诱发的通过静脉滴注异丙肾上腺素能诱发室早、室速。（2）所有患者先在右心室流出道预测起源区以15—20W低能量放电下微调消融电极导管位置和方向，在诱发出与所记录、冻结的室早完全一致的位点时，加大能量至35～50w，反复巩固2—3次，直至室早、室速不再出现。然后以此点为中心，向周围微移动电极导管约5mm，最终消融出大约1am。的面积。所有11例患者，采用这种方法全部都诱发出与记录室早12／12导联完全一致的室速。（3）11例患者中有10例达到消融终点，其中9例在右心室流出道间隔部及后壁，1例在右冠窦基底部。另1例未达到消融终点的患者，在消融开始时用异丙。肾上腺素仅可诱发极少的室早，但在低能量消融后诱发频发的短阵室速，激动标测提示最早激动点位于左冠窦中下部，该处放电诱发出与自发室早一致的图，但反复放电室早、室速不能完全消除，考虑为靠外膜区室早而放弃。（4）术后所有患者经电话、预约门诊随访3～14个月，没有1例主诉再发黑嚎和晕厥者。结论低能量放电标测完全可作为一种新的标测手段在实际工作中配合使用，尤其对那些反复黑噱、晕厥但室早、室速发作较少的患者，常规标测方法几乎无用，此时低能量放电标测就显得更加实用。Objective This study reported initial experience of a new mapping method for ablation of syncope-caused ventricular tachycardia （VT） without combining frequent premature ventricular contraction （ PVC ）. Methods All 11 recruited patients were female, mean age （ 39. 9 _＋ 13.7 ） years. They had experienced at least 1 syncope episode and were refractory to 2 or more antiarryhthmic agents in the past 1 to 3 years. Results （ 1 ） Clinical arrhythmia characteristics ： In 5 patients, PVC or VT was induced by programmed stimuli without intravenous isoproterenol in right ventricular outflow tract（RVOT）. In these patients, Holter mo- nitoring recorded more PVCs （mean 3678 beats/24 hours）with ventricular bigeminy or trigeminy, but less VT （mean 5.8 episodes/24 hours）. These patients suffered more transient amaurosis than syncope except one older woman combining hypertension. While in other 6 patients, VT could not be induced with programmed stimuli unless isoproterenol was administrated. These patients all suffered syncope in their medical history, their Holter monitoring recorded more VT （ mean 15.5 episodes/24 hours） less PVC （ mean 1208 beats/24 hours ） with few ventricular bigeminy or trigeminy. （2）Electrophysiologic mapping and catheter ablation：Induced PVC or VT were frozen on monitor screen as reference, ablation catheter was posited on expected area of RVOT, pace map- ping was performed firstly and Low Radio Frequency（LRF） energy（ 15 -20 W）was delivered at sites that paced VT morphology identical to reference VT in all 12 leads of ECG. Once the sites was found that VT morphology induced by LRF was identical to reference VT in all 12 leads of ECG, the radiofrequency energy would be in- creased to 35 ~ 50 W（50 - 55~C ） on same site until VT was eliminated. Then enlarge ablation area to about 1 cm2 around this site. All 11 patients were induced identical VT during low radiofrequency energy. （3）No VT! PVC was induced through program stimuli or intravenous isopr

关 键 词：室性心动过速 晕厥 射频消融 低能量标测 

分 类 号：R541.7[医药卫生—心血管疾病]