本文關(guān)鍵詞：分支性室速的機(jī)制、導(dǎo)管消融治療的長期有效性及復(fù)發(fā)影響因素　出處：《北京協(xié)和醫(yī)學(xué)院》2017年博士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 導(dǎo)管消融 復(fù)發(fā) 室性心動過速 標(biāo)測 分支性室性心動過速 微折返 導(dǎo)管消融 電生理 復(fù)發(fā) 分支性室性心動過速 左后分支室速 導(dǎo)管消融 左后分支阻滯 標(biāo)測

【摘要】：第一部分導(dǎo)管消融治療分支性室速的長期有效性及復(fù)發(fā)的預(yù)測因素[研究背景]分支性室性心動過速(Fascicular ventricular tachycardia,FVT)是左室特發(fā)性室性心動過速(室速)中最常見的類型。關(guān)于導(dǎo)管消融治療的長期有效性的研究仍較少。本研究通過分析接受導(dǎo)管消融治療的FVT患者數(shù)據(jù),探討導(dǎo)管消融治療FVT的長期有效性及復(fù)發(fā)的預(yù)測因素。[研究方法]連續(xù)入選我中心2005年3月至2016年12月期間收治的因FVT接受電生理檢查及導(dǎo)管消融的患者。進(jìn)行激動順序標(biāo)測,在心動過速時(shí)標(biāo)測到最早的浦肯野電位(P電位)處為靶點(diǎn)。如果FVT不能誘發(fā)或心動過速不持續(xù)而難以進(jìn)行詳細(xì)的激動順序標(biāo)測時(shí)則結(jié)合起搏標(biāo)測結(jié)果確定靶點(diǎn)。術(shù)后規(guī)律對患者進(jìn)行隨訪。[研究結(jié)果]共入選234例FVT患者,平均年齡30±13歲,其中男性占82%。在183例(78.2%)患者中完成了詳細(xì)的激動順序標(biāo)測,其余51例因心動不能誘發(fā)或不持續(xù)而難以進(jìn)行詳細(xì)的激動順序標(biāo)測,需要結(jié)合起搏標(biāo)測結(jié)果確定靶點(diǎn)。231例(98.7%)達(dá)到了即刻消融成功。在術(shù)后平均隨訪58±42(1-135)月期間,有35例(15.2%)室速復(fù)發(fā),其中絕大部(85.7%)的室速復(fù)發(fā)發(fā)生在術(shù)后1年內(nèi)。不能進(jìn)行詳細(xì)的激動順序標(biāo)測是術(shù)后室速復(fù)發(fā)的獨(dú)立預(yù)測因素(OR:4.9,95%CI:2.3-10.7,P0.001)。[結(jié)論]在平均隨訪5年期間,導(dǎo)管消融治療FVT有效性達(dá)84.8%。絕大多數(shù)的室速復(fù)發(fā)發(fā)生在術(shù)后的1年內(nèi)。未能進(jìn)行詳細(xì)的激動順序標(biāo)測是術(shù)后室速復(fù)發(fā)的獨(dú)立危險(xiǎn)因素。第二部分分支性室速的機(jī)制及消融后復(fù)發(fā)的原因分析[研究背景]雖然越來越多的研究表明分支性室性心動過速(Fascicular ventricular tachycardia,FVT)的機(jī)制是折返,但仍尚未完全明確。應(yīng)用EnSite Array(EA)三維電解剖標(biāo)測系統(tǒng)進(jìn)行標(biāo)測FVT,能夠地顯示每一次心跳虛擬激動傳導(dǎo)。本研究的目的通過EA探索FVT的機(jī)制,同時(shí)分析FVT消融失敗的原因。[研究方法]本研究入選21例(平均年齡33±15歲,男性17例)因左后分支室性心動過速首次接受電生理檢查及射頻消融患者,所有患者均在EA指導(dǎo)下完成標(biāo)測及消融。同時(shí)入選57例(平均年齡28±12歲,男性45例)既往外院消融失敗或復(fù)發(fā)的患者。分析所有患者的標(biāo)測及消融數(shù)據(jù)。[研究結(jié)果]EA激動順序標(biāo)測顯示FVT為微折返機(jī)制,未見大折返表現(xiàn),心動過速時(shí)最早激動位于左室間隔面中段區(qū)域,而后經(jīng)左后分支及左前分支向整個(gè)左室擴(kuò)布,其中左后分支遠(yuǎn)端心肌最早激動。在既往消融失敗或復(fù)發(fā)的病例中,標(biāo)測未見大折返表現(xiàn),8.8%的患者中診斷錯(cuò)誤是消融失敗的原因。[結(jié)論]應(yīng)用EA激動順序標(biāo)測提示FVT的機(jī)制是微折返,支持采用激動順序標(biāo)測尋找心動過速時(shí)最早的浦肯野電位作為有效的消融靶點(diǎn)的標(biāo)測和消融策略,而未標(biāo)測到心動過速時(shí)真正的最早浦肯野電位是FVT消融失敗或術(shù)后復(fù)發(fā)的主要原因。第三部分左后分支室速導(dǎo)管消融術(shù)后的特殊復(fù)發(fā)類型:發(fā)生率、機(jī)制及最佳消融策略[研究背景]左后分支室性心動過速(Left posterior fascicular ventricular tachycardia,LPF-VT)應(yīng)用導(dǎo)管消融術(shù)治療后復(fù)發(fā)病例中常有形態(tài)改變,如何標(biāo)測和消融這種“新發(fā)的”室性心動過速(室速)尚未達(dá)成共識。本研究通過分析大樣本的LPF-VT導(dǎo)管消融資料,探討這種“新發(fā)的”室速的發(fā)生率、機(jī)制及最佳的消融策略。[研究方法]通過分析我中心2005年3月至2016年12月期間因分支性室速首次接受電生理檢查及導(dǎo)管消融治療的病例資料,探討LPF-VT消融術(shù)后“新發(fā)的”右束支阻滯+電軸右偏形態(tài)室速的發(fā)生率、機(jī)制及其最佳消融策略。[研究結(jié)果]在175例首次接受導(dǎo)管消融治療的分支性室速患者中,共有11例(平均年齡31 ± 10歲,均為男性)在消融LPF-VT術(shù)中或術(shù)后隨訪期間出現(xiàn)了右束支阻滯+電軸右偏形態(tài)的室速,其中9例發(fā)生左后分支阻滯�！靶掳l(fā)的”室速與原有的LPF-VT室速的周長無顯著差異(403±48 ms vs.399±44 ms,P=0.06)。標(biāo)測顯示“新發(fā)的”右束支阻滯+電軸右偏形態(tài)的室速最早心肌激動位于前間隔區(qū)域,但是最早的浦肯野電位仍在間隔中段偏后區(qū)域,心動過速時(shí)最早的P電位領(lǐng)先體表心電圖V1導(dǎo)聯(lián)QRS起始處44±9 ms。在此處放電消融可成功消融“新發(fā)的”室速,在術(shù)后中位隨訪72個(gè)月期間未見心動過速復(fù)發(fā)。[結(jié)論]左后分支阻滯可導(dǎo)致LPF-VT的折返環(huán)向心肌傳導(dǎo)的出口發(fā)生改變,使其通過遠(yuǎn)離折返環(huán)的左前分支向左室心肌傳導(dǎo),而這種“新發(fā)的”室速的最佳消融靶點(diǎn)仍在左后分支分布區(qū)域。
[Abstract]:The first part of catheter ablation of tachycardia in long-term efficacy and predictors of recurrence [background] branch ventricular tachycardia (Fascicular ventricular, tachycardia, FVT) is an idiopathic left ventricular tachycardia (VT). The most common type of research on the long-term effectiveness of catheter ablation therapy is still limited. In this study, patients receiving FVT data for catheter ablation through analysis, predictive factors.] research methods to explore the treatment of FVT catheter ablation of the long-term effectiveness and recurrence in selected for our center in March 2005 to December 2016 from FVT for patients undergoing electrophysiological study and catheter ablation were excited sequentially. In the test, the tachycardia mapping to the earliest Purkinje potential (P potential) as the target. If the FVT can not induce tachycardia or not to continue the detailed activation mapping at Combined with the pacing mapping results to determine the target. Regular postoperative patients were followed. Results: a total of 234 patients with FVT patients, mean age 30 + 13 years, males accounted for 82%. in 183 cases (78.2%) patients completed a detailed activation mapping, the remaining 51 patients with heart can not induce or not continue to detailed activation mapping and pacing mapping need to combine the results to determine the targets of.231 cases (98.7%) achieved immediate ablation. In the mean follow-up time was 58 + 42 (1-135) months, 35 cases of recurrent ventricular tachycardia (15.2%), most of them (85.7%). Rate of recurrence occurred in 1 years after operation. No detailed activation sequence mapping is an independent predictor of ventricular tachycardia recurrence (OR:4.9,95%CI:2.3-10.7, P0.001). Conclusion: the average follow-up period of 5 years, the effectiveness of catheter ablation in treatment of FVT 84.8%. most of the ventricular tachycardia recurrence occurred in 1 after operation Years. Failed to carry out the detailed activation sequence mapping is an independent risk factor of recurrent ventricular tachycardia after operation. The mechanism of second part branch ventricular tachycardia after ablation and recurrence analysis [background] although more and more studies show that the branch ventricular tachycardia (Fascicular ventricular, tachycardia, FVT) mechanism back, but has not yet been completely clear. The application of EnSite Array (EA) three-dimensional electroanatomical system for mapping FVT, can display every beat of the virtual excited conduction. The purpose of this study is to explore the mechanism of FVT by EA. At the same time, reason research methods analysis of FVT ablation failed this study selected 21 cases (mean age 33 + 15 years old, male 17 cases) with left posterior fascicular ventricular tachycardia undergoing electrophysiological examination and radiofrequency ablation patients, all patients completed under the guidance of EA mapping and ablation. At the same time, 57 patients (mean age 28 + 1 At the age of 2, 45 males) of previous failed ablation or recurrent patients. All patients analyzed the mapping and ablation of data. The research results of]EA activation sequence mapping showed that the FVT for micro reentry mechanism, no reentrant tachycardia, the earliest activation in the left ventricular septal surface middle region, and then through the left after the branch and left anterior branch of the left ventricle to the left after the spreading branches distal to the earliest activation. In previous myocardial ablation failure or relapse cases, there were no reentrant mapping performance, 8.8% of the patients in the diagnosis of errors are the reasons for the failure of the ablation by EA. Conclusion excited sequence mapping mechanism FVT is microreentry, support the activation mapping for Purkinje potentials during tachycardia as the earliest ablation target mapping and ablation strategy effectively, without mapping to tachycardia when real is the earliest Purkinje potential failure or FVT ablation surgery The main reason of recurrence after recurrence. A special type of branch ventricular tachycardia after catheter ablation of left posterior part third: incidence, mechanism and the best ablation strategy [background] left posterior fascicular ventricular tachycardia (Left posterior fascicular ventricular tachycardia, LPF-VT) by application of recurrent cases after tube ablation in the treatment of common morphological changes. How to mapping and ablation of this "new" ventricular tachycardia (VT) has not yet reached a consensus. Through the analysis of LPF-VT catheter ablation of large sample data, this "new" incidence of ventricular tachycardia, mechanism and ablation method research] the best strategy. Through the analysis of our center from March 2005 to December 2016 due to tachycardia undergoing electrophysiological study and catheter ablation for the treatment of the clinical data of LPF-VT after ablation of "new" right bundle branch block + right axis deviation form of ventricular tachycardia 鐨勫彂鐢熺巼,鏈哄埗鍙?qiáng)鍏舵湥?

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