经皮心包穿刺途径标测和消融室性心律失常的安全性和有效性  

Percutaneous pericardial puncture for mapping and ablation of ventricular arrhythmias:safety and efficacy

作　　者：张春瑜[1] 聂振宁[1] 代世摩[1] 齐保振[1] 林瑾仪[1] 林佳雄[1] 葛均波[1] 

机构地区：[1]复旦大学附属中山医院心内科,上海市心血管病研究所,上海200032

出　　处：《上海医学》2017年第4期201-205,共5页Shanghai Medical Journal

基　　金：国家自然科学基金资助项目(81521001)

摘　　要：目的评价剑突下经皮心包穿刺途径标测和消融室性心律失常(VA)的安全性和有效性。方法回顾性分析2014年6月—2015年12月在复旦大学附属中山医院心内科于剑突下经皮心包穿刺途径进行标测和消融的10例VA患者的临床资料,男8例、女2例,年龄16~69岁;其中特发性VA 1例,器质性心脏病合并室性心动过速(VT)9例(非缺血性心肌病8例,缺血性心肌病1例)。9例器质性心脏病患者中,6例术前已植入器械[植入式心脏复律除颤器(ICD)、心脏再同步治疗联合ICD各3例]。4例患者既往有1次心内膜消融失败史。分析所有患者心包穿刺并发症的发生情况,以及导管消融的策略和效果。结果所有患者剑突下经皮心包穿刺均获成功。术后仅1例患者发生心包出血,考虑由穿刺刺破心室壁所致,经引流后好转;无1例患者发生急性心包填塞、冠状动脉损伤、邻近脏器损伤、膈神经损伤等并发症。1例特发性VA患者经联合心内膜-心外膜标测提示VA起源心肌壁内,最后于心内膜侧大功率(45 W)延长消融时间(90s,2次)后急性消融成功。9例器质性心脏病合并VT患者行基质改良消融,其中7例急性消融成功(均为非缺血性心肌病患者),2例急性消融失败。这2例患者经心内膜-心外膜联合标测后提示VA起源心肌壁内深处,尝试将消融导管送入冠状静脉窦分支亦均失败。4例既往行消融但失败的患者,本次行心内膜-心外膜联合标测后,3例经心外膜消融成功,1例心内膜消融成功。8例消融成功的患者术后随访3~12个月,2例VA复发,其中1例患者于消融术后3个月因顽固性心力衰竭死亡。结论剑突下经皮心包穿刺途径标测和消融VA安全、有效,联合心内膜-心外膜标测和消融能提高器质性心脏病合并VT患者的导管消融成功率。Objective To evaluate the safety and efficacy of-percutaneous subxiphoid pericardial puncture for mapping and ablation of ventricular arrhythmias. Methods Clinical data of 10 patients with ventricular arrhythmias who underwent pericardial puncture for epicardial mapping and ablation from June 2014 to December 2015 were retrospectively analyzed in this study, There were 8 males and 2 females aged from 16 to 69 years, One suffered from idiopathic ventricular arrhythmias and nine had structural heart disease combined with ventricular tachycerdia （8 with non-ischemic cardiomyopathy and 1 with ischemic cardiomyopathy）. Six patients with structural heart disease received cardic-resynchronization therapy with a defibrillator （CRT-D） or implantable cardioerter defibrillator （ICD） before the procedure. Four patients had a history of failed endocardial ablation. The complications of pericardial puncture were evaluated. The efficacy of pericardial mapping and ablation was analyzed. Results The pericardial punctures were done successfully in all the patients. Pericardial bleeding occurred in one patient, which might be caused by right ventricular injury and was cured by drainage. No pericardial tamponade, coronary vessel damage, injury to subdiaphragmatic vessels and abdominal viscera or phrenic nerve injury occurred. Acute endocardial ablation was achieved （45 W, 90 s, 2 times） in the patient withdiopathic ventricular arrhythmia after endo-epicardial mapping. For the patients with structural heart disease, targeted the successfully ablation achieved ocal abnormal ventricular activities （LAVAs）. Of them, acute epicardial ablation was n 7 patients after endo-epicardial mapping, but it failed in 2 patients because of intramura ventricular arrhythmia. Ablation catheter was tried to reach the branches of the coronary sinus in the 2 failed patients; however, it still failed mapping, epicardial ablation was In the 4 patients with previous failed endocardial ablations, after endo-epicardia achieved successfully

关 键 词：经皮心包穿刺 心外膜 室性心律失常 基质消融 

分 类 号：R541.7[医药卫生—心血管疾病]