左心室乳头肌起源室性心律失常的电生理特征及导管消融  

Ventricular arrhythmias originating from left ventricular papillary muscles

作　　者：桑才华[1] 李梦梦[1] 龙德勇[1] 蒋晨曦[1] 李松南[1] 郭雪原[1] 王伟[1] 董建增[1] 马长生[1] SANG Cai-hua;LI Meng-meng;LONG De-yong;JIANG Chen-xi;LI Song-nan;GUO Xue-yuan;WANG Wei;DONG Jianzeng;MA Chang-sheng(Department of Cardiology,Capital Medical University Affiliated Beijing Anzhen Hospital,Beijing 100029,China)

机构地区：[1]首都医科大学附属北京安贞医院心内科,北京市心肺血管疾病研究所,北京100029

出　　处：《中国介入心脏病学杂志》2020年第3期126-131,共6页Chinese Journal of Interventional Cardiology

基　　金：国家重点研发计划资助(2017YFC1307800);国家自然科学基金(81770326)。

摘　　要：目的探讨左心室乳头肌起源的室性心律失常电生理特征和导管消融。方法连续纳入2015年1月至2017年3月首都医科大学附属北京安贞医院收治的31例左心室乳头肌起源的室性早搏/室性心动过速患者,术中采用三维电解剖标测系统联合三维心腔内超声技术,经三维心腔内超声证实有效靶点位于左前或者左后乳头肌,完成三维解剖重建、起搏标测和激动标测。分析乳头肌的解剖结构、室性早搏/室性心动过速的心电图特征、腔内靶点图特点和消融技巧等。结果心腔内超声提示22例(71.0%)患者最早起源点位于乳头肌中段,6例(19.4%)起源于基底部,3例(9.7%)起源于近腱索处。标测到的最早激动点平均领先体表QRS波(28±11)ms,15例(48.4%)患者可记录到高频或碎裂电位。起搏信号到心室波距离SV间期在腱索段最长(52.0±8.5)ms,中段其次(32.5±5.7)ms,基底部最短(13.1±4.1)ms。31例(100%)患者均成功消融,贴靠压力5~15 g。随访15(14,17)个月,3例(9.7%)患者出现复发,无手术相关并发症发生。结论左心室各组乳头肌之间的传导相互绝缘,起博标测初步定位,激动标测精确定位心律失常的起源部位,心腔内超声指导下贴靠稳定,有助于达到消融终点。Objective To investigate the electrophysiological and ablation characteristics of ventricular arrhythmias(VA)originating from left ventricular papillary muscles(LVPM).Methods Thirty-one patients with LVPM-related VA were consecutively included from Beijing Anzhen Hospital from Jan,2015 to Mar,2017.Three-dimensional electroanatomic mapping system and intracardiac echocardiography(ICE)were used to facilitate the mapping and ablation.During the procedure,we collected the electrophysiological characteristics from pace mapping and activation mapping,as well as the anatomical details from ICE.Results ICE revealed 22 cases(71.0%)with earliest ventricular activation(EVA)was localized within mid LVPM,6 cases(19.4%)within basal LVPM and 3 cases(9.7%)within distal LVPM.When pacing from these three sites,the stimuli-to-QRS was diff erent but with similar QRS morphologies,suggesting the unidirectional conduction property within one isolated papillary muscle.The EVA preceding the QRS averaged(28±11)ms with fractioned or high frequency potentials recorded in 15(48.4%)patients.All patients underwent successful ablation without perioperative complications,and the contact force was controlled in 5 to 15 g under ICE monitoring.After a median of 15(14,17)months follow-up,there were 3 cases(9.7%)with recurrence and without complications.Conclusions The isolated conduction property could be observed within one LVPM.The accurate identifi cation was mainly relied on activation mapping,while pace mapping was helpful to identify the general localization of LVPM.Under ICE monitoring,a desirable contact force could be achieved with acceptable effi cacy.

关 键 词：乳头肌 室性心律失常 导管消融 

分 类 号：R541.7[医药卫生—心血管疾病]