窦性心律下通过三维电压标测心肌梗死后瘢痕性室性心动过速  

Three dimensional voltage map scar-related ventricular tachycardias due to myocardial infarction under sinus rhythm

作　　者：贾玉和[1] 任岚[1] 方丕华[1] 唐闽[1] 毛克修[1] 赵允梓[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》2012年第2期134-139,共6页Chinese Journal of Cardiac Arrhythmias

摘　　要：目的介绍一种不需行拖带标测，而在窦性心律下可标测和消融心肌梗死后瘢痕性室性心动过速（室速）的方法。方法两例男性患者，均在心肌梗死和冠状动脉再通治疗后出现室速。经胺碘酮治疗后出现甲状腺功能异常而停药。其中例1为前壁心肌梗死合并心尖部室壁瘤，在发作室速时心功能恶化伴顽固咳嗽；例2为下后壁心肌梗死，其临床室速有两种形态，室性早搏（室早）有多种形态。该两种情况占心肌梗死后室速的大部分，均不太适合常规的拖带标测。首先在窦性心律时在Carto系统指导下建立左心室的三维电解剖图，通过调整瘢痕区电压标准，使梗死边缘区三层结构清楚显示后，沿边缘区行起搏标测，通过特征电位和测量刺激至QRS间距来判定峡部区，然后以峡部区为中心，以垂直于边缘区的方向行连续线性消融，直至室速不能被诱发视为消融终点。结果两例在消融前均可反复诱发室速，在经过几条垂直线消融后室速均不能被诱发，随访3个月室速也未复发。心功能和生活质量明显改善。但例1出现室壁瘤附壁血栓。结论对大多数心肌梗死后瘢痕性室速患者，均可在窦性心律下标测到其关键峡部区，并以此为中心点沿着垂直于边缘区方向行线性消融，以室速不能被诱发做为急性期终点同样能得到较好的远期成功率，但术后1个月需保持华法林抗凝。Objective To introduce an initial experience of mapping scar-related ventricular tachycar- dias （VTs）after myocardial infarction using three dimensional voltage mapping under sinus rhythm without in- duction of ventricular tachycardia. Methods Two males with ventricular tachycardias （VTs） due to myocardial infarction received percutaneous catheter intervention（PCI） and stent implantation. Both of them had abnormal thyroid function due to amiodarone administration and finally quitted it. Case one with remote anterior wall myo- cardial infarction and apex ventricular aneurysm complicated with stubborn cough due to exacerbated cardiac function once ventricular tachycardia occurred. Case two with remote inferio-posterior wall myocardial infarction had more than two morphologies of VTs and these VTs showed short runs of frequent episodes. Therefore, neither of the two cases was suited to be mapped by conventional entrainment. Then their three dimensional electroanat- omy maps were reconstructed using voltage mapping（ Carto system）under sinus rhythm. Three layers anatomy of boundaries were displayed with continuous color gradient through voltage adjustment, in the two cases 0. 2 mV was adjusted as scar criteria. Pacing along border zones was performed, once paced QRS morphologies which were identical to clinical VTs were obtained, further local potentials were analyzed to confirm whether double potentials or late potentials were recorded, and/or measure the interval between stimuli to onset of QRS （ S- QRS）. The sites that display these characteristic potentials or have the longest S-QRS interval can be regarded as isthmus sites and radiofrequency energy will be delivered and about 3 -5 cm line lesion perpendicular toborder zone were created. When VTs could not be induced anymore procedure endpoint was being considered. Results Three and five lesion lines were created in case one and two, respectively. Both cases could not induce VTs anymore at the end of procedure. VTs didn＇ t reoccur during thre

关 键 词：心肌梗死 瘢痕性室性心动过速 三维电压标测 

分 类 号：R542.22[医药卫生—心血管疾病]