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三维电解剖标测指导缺血性心肌病室性心动过速的射频消融

Catheter ablation of ventricular tachycardia in patients with ischemic cardiomyopathy under the guidance of three-dimensional electroanatomic mapping

摘要:

目的 介绍缺血性心肌病伴室性心动过速(室速)的三维标测方法及消融策略.方法 7例缺血性心肌病室速患者(男6例,女1例),年龄46~70(57±8)岁.经多种抗心律失常药物治疗效果不佳,室速反复或无休止发作,包括1例植入心律转复除颤器(ICD)后频繁放电而接受导管射频消融治疗.所有患者均接受三维电解剖(Carto)标测.首先进行心室基质标测,继而结合激动时间、起搏、拖带等标测方法,分析室速的起源点、折返路径和出口,了解病变基质与其关系.对室速出口部位及病变周边的晚电位给予局灶消融.结果 7例患者共诱发出13种心动过速,均起源于左心室,平均心动周期(309±65)ms.5例(8种室速)消融治疗即刻成功,1例(2种室速)部分成功,1例(3种室速)消融失败.随访6 ~36(21±11)个月,成功患者中1例复发,再次消融成功;部分成功和消融失败的2例患者,植入ICD(其中1例原已植入)并经抗心律失常药物治疗后,室速发作减少.结论 通过三维电解剖标测系统明确缺血性心肌病室速患者的心室病变基质,在此基础上进行激动标测和心内各种电刺激技术,明确室速的起源、折返环路及关键峡部、缓慢传导区出口,据此制定消融策略可以成功治疗缺血性心肌病室速.部分患者消融失败和复发,可能是由于室速起源于心肌深部、心外膜或乳头肌等部位而消融困难.

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abstracts:

Objective To introduce the initial experience of electroanatomic mapping and catheter ablation of ventricular tachycardia(VT) in patients with ischemic cardiomyopathy(ICM).Methods Seven ICM patients [6 male,1 female,mean age (57±8) years] with recurrent or incessant VT attack who were refractory to antiarrhythmic drug therapy were referred for catheter ablation,one of which was the case of frequent discharges after the implantation of implantable cardioverter defibrillator(ICD).All patients underwent 3-dimensional electroanatomic (Carto) mapping.The low voltage sites(scar area) were identified by voltage map.Activation mapping,pace mapping and entrainment mapping were then performed to localize the reentrant circuit,critical isthmus,slow conduction zone and exit sites.Catheter ablation was carried out at exit area of tachycardia circuits.Sites with delayed potentials during sinus rhythm at the edge of scar tissue were also selected for ablation.Results Among seven patients,13 VTs which were originated from left ventricle were induced during the procedure and the mean cycle length was (309±65) ms.Catheter ablation successfully eliminated all 8 VTs in 5 patients.The ablation strategy failed in 1 patient with 3 VTs,and partially succeeded in 1 patient with 2 VTs.During the follow-up of 6 ~ 36(21 ± 11) months,one patient had recurred VT,and regained ablation success in the second procedure.In the remaining two patients,ICD implantation was recommended post ablation,even though the VT was suppressed with antiarrhythmic drugs thereafter.Condusions Three-dimensional electroanatomic mapping,combined with activation mapping and pacing maneuvers can help to discover the origin,reentrant circuit,slow conduction zone and theexit of ICM-VT.Irrigated catheter ablation is a safe and effective way to eliminate such VTs.Deep,epicardial,orpapillary muscle origin may be the common reasons responsible for ablation failure and VT recurrence.

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