左前分支近端室性早搏射频消融的新靶点  

An unrecognized origin for"proximal left anterior fascicle"premature ventricular complexes with narrow QRS duration

作　　者：陈耽 郭再雄[1] 张劲林[1] 李康[2] 丁燕生[2] 唐成 CHEN Dan;GUO Zai-xiong;ZHANG Jin-lin;LI Kang;DIN Yan-sheng;TANG Cheng(Department of Cardiology,Wuhan Asia Heart Hospital,Wuhan 435000,Hubei,China;Department of Cardiology,Peking University First Hospital,Beijing 100000,China;Department of Cardiology,Wuhan YaxinDunkou Hospital,Wuhan 435000,Hubei,China)

机构地区：[1]武汉亚洲心脏病医院心内科,湖北武汉市435000 [2]北京大学第一医院心内科,北京100000 [3]武汉亚心总医院心内科,湖北武汉435000

出　　处：《中国心脏起搏与心电生理杂志》2023年第6期485-492,共8页Chinese Journal of Cardiac Pacing and Electrophysiology

摘　　要：目的完全性右束支阻滞图形合并电轴右偏的窄QRS波室性早搏(简称室早),通常被认为起源于左前分支(LAF)近端。探讨这类LAF近端室早的确切来源和电生理特征。方法本研究纳入22例完全性右束支阻滞图形合并电轴右偏的窄QRS波室早患者。在窦性心律和室早期间对束支电位(FP)进行详细三维标测。同时使用心腔内超声重建主动脉窦、左室和乳头肌详细三维图形。结果在窦性心律下,在主动脉窦下方可发现一簇FPs,这些FPs代表了左束支系统的一个独立分支,该分支向主动脉根部逆行延伸。将这个分支命名为主动脉根部盲端束(RARB)。LAF近端与RARB末端之间的最短距离为(13.5±4.2)mm。在所有患者中,室早的最早激动点(EAS)均在RARB末端,室早的FP-V间期为(35.1±4.3)ms。从右冠窦(RCC)到EAS的最短距离为(5.3±3.5)mm。在45.5%(10/22)的病例中,RCC处消融可成功消除室早。在其余病例中,左室心内膜面EAS消融可成功消除室早。结论RARB末端是完全性右束支阻滞图形合并电轴右偏的窄QRS波室早的真正起源点。RARB与左室传导系统主干有足够的安全距离。因此在RCC或左室心内膜面EAS消融成功率高且损伤传导束的风险极低。Objective Premature ventricular complexes(PVCs)with narrow QRS duration,inferior frontal plane QRS axis and right bundle branch block(RBBB)pattern generally originate from the proximal segment of the left anterior fascicle(LAF).This study aimed to investigate the exact origin and electrophysiological characteristics of this category of PVCs.Methods In this study,22 patients with PVCs combined with narrow QRS duration,inferior frontal plane QRS axis and RBBB were enrolled.Detailed mapping of fascicular potentials(FPs)was performed during sinus rhythm and PVCs.Intracardiac echocardiography(ICE)were used during the procedure to create a detailed 3D geometry of the aortic coronary cusps,left ventricular(LV)and papillary muscles.Results During sinus rhythm,a cluster of FPs could be found at the most superior portion of the LV just below the aortic cusps.These FPs represented the terminal end of a discrete branch of the left fascicular system which ran retrogradely towards the aortic root.We named the“retro-aortic root branch”(RARB).The shortest distance between the proximal LAF and the terminal end of RARB was(13.5±4.2)mm.The earliest activation site of PVCs in all patients were confirmed at the terminal end of RARB,where the FP-V interval was(35.1±4.3)ms during PVCs.The shortest distance from the right coronary cusp(RCC)to the EAS was(5.3±3.5)mm.PVCs could be eliminated by ablation from the RCC in 45.5%(10/22)cases,in the remaining cases,ablation at the EAS in the LV endocardium successfully abolished PVCs.Conclusions The terminal end of the RARB is the actual origin site for PVCs with narrow QRS duration,inferior frontal plane QRS axis and RBBB.The adequate distance from the left His and the LBB provids enough safety for eliminating these PVCs regardless of ablation in the right coronary cusp or at the earliest activation site in the LV could both eliminate PVCs safely with high efficacy.

关 键 词：心血管病学 导管消融 主动脉根部盲端束 左前分支近端 室性早搏 

分 类 号：R541.7[医药卫生—心血管疾病] R454.1[医药卫生—内科学]