右室流出道室性心动过速的发生机制研究进展

右心室流出道室性心律失常是临床上常见的特发性心律失常,占特发性室速的60%~70%,绝大多数右心室流出道室速为腺苷敏感性,其发病机制为儿茶酚胺介导的延迟后除极和触发活动。其发生机制一直是电生理领域研究的热点问题,新近研究表明,L型钙通道的改变与特发性右心室流出道室性心动过速的发生密切相关,提示L型钙通道可能会成为特发性右心室流出道室性心动过速治疗的新靶点。     

导管射频消融治疗特发性室性心动过速的体会

目的探讨应用导管射频消融（ＲＦＣＡ）治疗特发性室性心动过速的疗效。方法经皮穿刺左右侧股静脉右侧股动脉（起源于左室时）,将多根６Ｆ或７Ｆ４极导管送至高位右房（ＨＲＡ）、房束（ＨＢＥ）、右室心尖（ＲＶＡ）、右室流出道（ＲＶＯＴ）或左室（ＬＶ）,作短阵快速和程序刺激心室诱发ＶＴ,同步记录１２导联及心腔内各部位电图。结果除１例不能坚持ＲＦＣＡ外,成功１１例（９１．７％）,另１例因疗效不满意改用导管心内膜直流电消融而获成功。结论术前诊断及靶点标测的准确性是ＲＦＣＡ治疗成功的关键。     

影响心房颤动射频消融术后复发率的相关因素

近年来,随着方法学的不断改进,导管射频消融治疗心房颤动(房颤AF)有了一定程度的提高,但因其随访观察AF再发率较高,为20%左右,限制了此项技术在临床上的应用.如何降低一次消融后的房颤复发率以及房颤复发的原因是目前亟待解决和探讨的焦点问题之一.本文主要对影响房颤消融术后复发的相关因素进行综述.     

P波离散度对房颤消融术后复发的预测价值

目的:探讨P波离散度对心房颤动(房颤)导管消融术后复发的预测价值。方法:连续收集经导管消融的房颤患者120例,根据是否复发分为复发组与对照组,分别测定和比较两组术后心电图最大P波时限(Pmax)及最小P波时限(Pmin)并计算P波离散度(Pd)。结果:房颤消融术后,53例病人复发,复发组最大P波时限(132±23mm VS 102±25mm)及P波离散度(33±9mm VS 29±10mm)均显著高于非复发组,差异有统计学意义(P0.05)。结论:P波离散度可用于辅助预测房颤导管消融术后是否复发。     

Tp-e间期、P波离散度对室性心律失常病情的预测价值

摘要 目的：探讨Tp-e间期、P波离散度(Pd)对室性心律失常病情的预测价值。方法：2016年6月到2018年6月选择在本院诊治的心绞痛患者110例,所有患者都给予动态心电图检查,记录Tp-e间期、Pd值与室性心律失常发生情况。随访患者的心绞痛复发情况,并判定预测价值。结果：在110例患者中,发生室性心律失常48例(失常组),发生率为43.6 %,其中偶发室早21例、频发室早19例、室早4例、心室颤动3例、室性心动过速1例。失常组的Tp-e间期、Pd值都显著高于非失常组(P<0.05)。随访至今,失常组的心绞痛复发率为45.8 %,显著低于对照组的8.1 %(P<0.05)。在失常组中,单因素与多因素logistics回归分析显示Tp-e间期、Pd都为影响患者心绞痛复发的重要因素(P<0.05)。ROC曲线分析显示Tp-e间期、Pd预测心绞痛复发的敏感性与特异性都在85.0 %以上。结论：心绞痛合并室性心律失常患者多伴随有Tp-e间期、Pd增加,也会增加患者的复发率,Tp-e间期、Pd对预测室性心律失常复发情况具有重要价值。     

个体化快速心律失常虚拟介入手术体系的建立与临床应用价值研究

目的:建立个体化快速心律失常虚拟介入手术体系定位手术靶点并分析其临床应用价值。方法:收集2011年1月-2013年1月在我院进行射频消融手术治疗的室性早搏和房室折返性心动过速患者共120例,(其中室性早搏40例,房室折返性心动过速80例),平均年龄40.6±9.7岁,获取数字新电机记录18导体表心电图(ECG)、数字食道调搏图、心脏CT成像原始数据,并记录手术靶点。所有采集心电图和CT数据进行多模式序列识别系统的计算机辅助诊断(CAD)处理,然后再对处理后的数据进行分析。两名心内科医生人工对心电图进行分析定位,并不告知患者的临床资料及射频消融手术最终靶点定位结果,按照室性早搏和房室旁路的诊断定位标准进行诊断,随后两名医师对处理后的心电图进行诊断,再次得出诊断结果,以术中成功消融靶点定位诊断为金标准,分析,个体化快速心律失常虚拟介入手术体系定位手术靶点的特异性、敏感性、阳性预测值,阴性预测值等指标。结果:ECG+CAD组诊断准确度高于单独ECG组,ECG组ROC曲线下面积(Az)=0.742,95%可信区间[0.652-0.832];ECG+CAD组:Az=0.934,95%可信区间[0.882-0.985];ECG+CAD组:精确度0.908;敏感性:0.905;特异性:0.923;阳性预测值:0.818;阴性预测值:0.934,较单独ECG组明显提高。结论:与单独体表心电图定位诊断相比,虚拟介入手术体系显著提高快速心律失常诊靶点定位的准确度,临床应用价值更高。     

P波离散度对房颤消融术后复发的预测价值

目的：探讨P波离散度对心房颤动（房颤）导管消融术后复发的预测价值。方法：连续收集经导管消融的房颤患者120例,根据是否复发分为复发组与对照组,分别测定和比较两组术后心电图最大P波时限（Pmax）及最小P波时限（Pmin）并计算P波离散度（Pd）。结果：房颤消融术后,53例病人复发,复发组最大P波时限（132±23mm VS 102±25mm）及P波离散度（33±9mm VS 29±10mm）均显著高于非复发组,差异有统计学意义（P〈0.05）。结论：P波离散度可用于辅助预测房颤导管消融术后是否复发。     

微波灭活与射频消融术中联合应用于治疗四肢骨肉瘤的疗效分析

目的:探讨微波灭活与射频消融技术联合应用治疗骨肉瘤的临床疗效。方法:回顾性分析我院自2007年至2012年间手术治疗的具有完整临床资料的骨肉瘤患者29例,其中发生于肱骨上端9例,股骨远端12例,胫骨上段5例,盆腔3例,并经TNM分期。术前采取动脉植入式化疗泵化疗2疗程,并于术中给以微波灭活与射频消融方法联合灭火肿瘤瘤体,刮除肿瘤后行骨水泥填充。术后随访8-60个月,平均50±2月。结果:29例患者中死亡1例,局部复发3例,远端转移2例。结论:微波灭活与射频消融术中联合应用于恶性骨肿瘤术中瘤体灭活,可以达到良好的肿瘤灭活效果,减少术中出血,大大提高患者生存率及降低复发率。     

瓣膜置换术同期射频消融术后房颤复发和BNP关系

目的:研究瓣膜置换术同期实施射频消融术后房颤复发和脑钠肽(BNP)的关系.方法:对60例心脏瓣膜病合并心房颤动的患者行瓣膜置换手术和射频消融手术,根据患者术后6个月内房颤是否复发将患者分为房颤复发组(AF组)和房颤未复发组(SR组).两组患者在性别、体外循环时间、阻断时间和射血分数等方面无明显差异(P0.05).两组患者分别于术前和术后第七天抽血测定血浆中BNP,分析患者术后BNP水平与房颤复发的关系.结果:60例患者均进入结果分析.房颤复发组患者术后的BNP水平明显高于房颤未复发组,差异比较有显著性意义(P<0.05).结论:BNP在消融术后房颤复发的预测上具有良好的临床应用价值,可以为临床干预和制定合理的治疗方案提供理论依据.     

肺静脉口弧形指数与房颤消融术后复发的关系

目的:探讨肺静脉口弧形指数与心房颤动(房颤)导管消融术后复发的关系。方法:选取2008年2月至2011年3月在我院接受导管消融术的房颤患者120例,所有患者于术前3日内利用多排CT行左心房及肺静脉造影,并进行图像的三维重建。测量每条肺静脉前后径及上下径,并计算弧形指数(肺静脉前后径/肺静脉上下径)以描述肺静脉口形态。行射频消融治疗的房颤病人全部达消融终点,术后随访超过3个月,根据患者房性快速性心律失常(房颤、房扑或房速)的发生情况,将其分为治愈组和复发组,进行统计分析。结果:由弧形指数分析,四支肺静脉开口形态存在统计学差异(P0.05);房颤消融术后,53例病人复发。房颤消融术后复发患者的LIPV弧形指数与治愈者不同,差异有显著性(P0.05);两组患者的左上肺静脉(Left Superior Pulmonary Vein,LSPV),右上肺静脉(Right Superior Pulmonary Vein,RSPV),右肺下静脉(Right Inferior Pulmonary Vein,RIPV),的弧形指数比较差异不明显(P0.05)。结论:左下肺静脉形态的不一致性与房颤导管消融术复发有关。     

Role of catheter ablation in arrhythmogenic right ventricular dysplasia

Arrhythmogenic right ventricular dysplasia/cardiomyopathy is a disorder characterized by frequent ventricular tachycardia originating from the right ventricle and fibro-fatty replacement of right ventricular myocardium. Though the disorder was originally described during surgical ablation of refractory ventricular tachycardia, catheter ablation of tachycardia is one of the options for patients not responding to anti arrhythmic agents. Direct current fulguration was used in the initial phase followed by radiofrequency catheter ablation. In the present day scenario, all patients with risk for sudden cardiac death should receive an implantable cardioverter defibrillator. Radiofrequency catheter ablation remarkably reduces the frequency of defibrillator therapies. Direct current fulguration can still be considered in cases when radiofrequency ablation fails, though it requires higher expertise, general anesthesia and carries a higher morbidity. Newer mapping techniques have helped in identification of the site of ablation. In general, the success rate of ablation in arrhythmogenic right ventricular dysplasia is less than in other forms of right ventricular tachycardias like right ventricular outflow tract tachycardia.     

What Next After Failed Septal Ventricular Tachycardia Ablation?

Ablation of ventricular tachycardia (VT) by conventional radiofrequency ablation can be impossible if the ventricular wall at the targeted ablation site is very thick, as for example the ventricular septum. We present a case of a patient with incessant, non-sustained slow VT originating from the septal part of the lower outflow tracts. Radiofrequency catheter ablation from both ventricles as well as from the anterior cardiac vein were not successful. Both high power radiofrequency ablation and bipolar radiofrequency ablation neither were successfull. Finally, ethanol ablation of the first septal perforator successfully terminated arrhythmia. We discuss the possibilities to overcome failed conventional radiofrequency VT ablation of a septal focus.     

Premature Ventricular Contractions and Non-sustained Ventricular Tachycardia: Association with Sudden Cardiac Death,Risk Stratification,and Management Strategies

Premature ventricular contractions (PVCs) and non-sustained ventricular tachycardia (NSVT) are frequently encountered and a marker of electrocardiomyopathy. In some instances, they increase the risk for sustained ventricular tachycardia, ventricular fibrillation, and sudden cardiac death. While often associated with a primary cardiomyopathy, they have also been known to cause tachycardia-induced cardiomyopathy in patients without preceding structural heart disease. Medical therapy including beta-blockers and class III anti-arrhythmic agents can be effective while implantable cardiac defibrillators (ICD) are indicated in certain patients. Radiofrequency ablation (RFA) is the preferred, definitive treatment in those patients that improve with anti-arrhythmic therapy, have tachycardia-induced cardiomyopathy, or have certain subtypes of PVCs/NSVT. We present a review of PVCs and NSVT coupled with case presentations on RFA of fascicular ventricular tachycardia, left-ventricular outflow tract ventricular tachycardia, and Purkinje arrhythmia leading to polymorphic ventricular tachycardia.     

Normal Heart Ventricular Tachycardia Associated with Pregnancy: Successful Treatment with Catheter Ablation

Background

Normal heart ventricular arrhythmia occurring during pregnancy has been previously described. Whilst there are established reports of catheter ablation to treat supraventricular arrhythmia during pregnancy, there are no reports of ablation to treat ventricular tachycardia.

Case

We present the case of a 36 year old women, 31 weeks into an otherwise uncomplicated pregnancy, experiencing significant, troublesome and drug refractory tachycardia emanating from the right ventricular outflow tract.

Conclusion

We describe a successful radio frequency ablation in the third trimester of pregnancy.     

Coexistence of atrioventricular nodal reentrant tachycardia and idiopathic left ventricular outflow-tract tachycardia

Double tachycardia is a relatively rare condition. We describe a 21 year old woman with history of frequent palpitations. In one of these episodes, she had wide complex tachycardia with right bundle branch and inferior axis morphology. A typical atrioventricular nodal tachycardia was induced during electrophysiologic study, aimed at induction of clinically documented tachycardia. Initially no ventricular tachycardia was inducible. After successful ablation of slow pathway, a wide complex tachycardia was induced by programmed stimulation from right ventricular outflow tract. Mapping localized the focus of tachycardia in left ventricular outflow tract and successfully ablated via retrograde aortic approach. During 7 month's follow-up, she has been symptom free with no recurrence. This work describes successful ablation of rare combination of typical atrioventricular nodal tachycardia and left ventricular outflow tract tachycardia in the same patient during one session.     

Usefulness of remote magnetic navigation for ablation of ventricular arrhythmias originating from outflow regions

Monomorphic ventricular tachycardia (VT) and symptomatic monomorphic PVCs originating from the region of the right and left outflow tracts are increasingly treated by radiofrequency (RF) catheter ablation. Technical difficulties in catheter manipulation to access these outflow tract areas, very accurate mapping and reliable catheter stability are key issues for a successful treatment in this vulnerable region. VT ablation from the aortic sinus cusp (ASC) in particular carries a significant risk of perforation, of creating left coronary artery injury and of damage to the aorta and the aortic valve. This case series describes RF ablation of VT originating in the outflow region using the remote magnetic navigation system (MNS). Potential advantages of the MNS are catheter flexibility, steering accuracy and reproducibility to navigate to a desired location with a low probability of perforating the myocardium. This report supports the idea of using advanced MNS technology during RF ablation in regions which are difficult to reach and thin walled, such as parts of the outflow tract and the ASC. (Neth Heart J 2009;17:245–9.)     

Radiofrequency Catheter Ablation of Idiopathic Right Ventricular Outflow Tract Arrhythmias

Idiopathic ventricular arrhythmias (VA) consist of various subtypes of VA that occur in the absence of clinically apparent structural heart disease. Affected patients account for approximately 10% of all patients referred for evaluation of ventricular tachycardia (VT). Arrhythmias arising from the outflow tract (OT) are the most common subtype of idiopathic VA and more than 70–80% of idiopathic VTs or premature ventricular contractions (PVCs) originate from the right ventricular (RV) OT. Idiopathic OT arrhythmias are thought to be caused by adenosine-sensitive, cyclic adenosine monophosphate (cAMP) mediated triggered activity and, in general, manifest at a relatively early age. Usually they present as salvos of paroxysmal ventricular ectopic beats and are rarely life-threatening. When highly symptomatic and refractory to antiarrhythmic therapy or causative for ventricular dysfunction, ablation is a recommended treatment with a high success rate and a low risk of complications.     

Idiopathic fascicular ventricular tachycardia

Idiopathic fascicular ventricular tachycardia is an important cardiac arrhythmia with specific electrocardiographic features and therapeutic options. It is characterized by relatively narrow QRS complex and right bundle branch block pattern. The QRS axis depends on which fascicle is involved in the re-entry. Left axis deviation is noted with left posterior fascicular tachycardia and right axis deviation with left anterior fascicular tachycardia. A left septal fascicular tachycardia with normal axis has also been described. Fascicular tachycardia is usually seen in individuals without structural heart disease. Response to verapamil is an important feature of fascicular tachycardia. Rare instances of termination with intravenous adenosine have also been noted. A presystolic or diastolic potential preceding the QRS, presumed to originate from the Purkinje fibers can be recorded during sinus rhythm and ventricular tachycardia in many patients with fascicular tachycardia. This potential (P potential) has been used as a guide to catheter ablation. Prompt recognition of fascicular tachycardia especially in the emergency department is very important. It is one of the eminently ablatable ventricular tachycardias. Primary ablation has been reported to have a higher success, lesser procedure time and fluoroscopy time.     

超敏C反应蛋白与阵发性房颤射频消融术后早期复发的关系

目的：前瞻性研究超敏C反应蛋白（hsCRP）与阵发性心房颤动射频消融术后早期复发的关系。方法：接受CARTO指导房颤射频消融术的非瓣膜性阵发性房颤患者57例,平均年龄（53.32±9.98）岁,其中男42例,女15例。术前及术后5 d连续测定外周血hsCRP和高敏肌钙蛋白T （hs-cTnT）水平,记录体表心电图,行24 h动态心电图检查。术后5 d内,32名患者（56.14%）为窦性心律,为未复发组,25名（43.86%）复发房颤,为复发组。结果：未复发组与复发组患者的hsCRP与hs-cTnT日均升高量显著正相关,P=0.044,r=0.268。而两组间基线临床特征、手术前后血浆hsCRP、hs-cTnT水平、血浆hsCRP及hs-cTnT的总升高量（峰值水平-术前水平）、日均升高量（总升高量/达到峰值所用天数）无明显统计学差异（P均>0.05）。结论：房颤射频消融术后hsCRP升高变化与心肌损伤程度相关,与早期复发无直接关系,尚不能作为预测房颤术后早期复发的高危因子。     

Tissue tracking imaging for identifying the origin of idiopathic ventricular arrhythmias: a new role of cardiac ultrasound in electrophysiology

Several strategies for mapping ventricular outflow tract tachycardia have been reported as useful indices for differentiating between those originating from the right and the left side. Recently, tissue tracking imaging (TTI) has been demonstrated as a novel non-invasive modality for identifying the origin of outflow tract tachycardias. Tissue tracking imaging is an ultrasonographic technique that measures the myocardial motion amplitude towards the transducer in each region during systole, identifying regional myocardial displacement on the basis of myocardial velocities using color Doppler myocardial imaging principles. In this technique, the origin of the arrhythmia could be recognized as the site where the earliest color-coded signal (ECCS) appeared on the myocardium at the onset of the systole. In preliminary studies this modality was found to be useful in differentiating outflow tract ventricular tachycardias. ECCS was always found below or at the level of the pulmonary valve in all arrhythmias which could be ablated from the right ventricular outflow tract, while in those where the ECCS was above and close to the pulmonary valve it could be ablated from the left sinus of valsalva. These results indicate that TTI can provide detailed and accurate information on the arrhythmia origin of outflow tract tachycardia and may be useful for differentiating between an outflow tract tachycardia originating from the LV epicardium remote from the LSV and that from the LSV. Newer advances in echocardiographic technologies like high resolution, high frame rate real time three dimensional echocardiography with speckle tracking may further improve the precise localization of arrhythmias in the future.