本文選題：二尖瓣環(huán)心房撲動(dòng)　切入點(diǎn)：基質(zhì)　出處：《南京醫(yī)科大學(xué)》2017年博士論文　論文類型：學(xué)位論文

【摘要】：研究背景及目的經(jīng)驗(yàn)性消融二尖瓣峽部(mitral isthmus,MI)是治療二尖瓣環(huán)心房撲動(dòng)(peri-mitral atrial flutter,PMFL)的主要方法,但盲目消融MI其本身有致心律失常的作用,且PMFL的具體電生理機(jī)制尚未完全明確。本研究的目的是探討房顫消融中或消融后出現(xiàn)的無基質(zhì)的PMFL的臨床和電生理機(jī)制特征,制定個(gè)體化的治療策略。方法本研究應(yīng)用三維標(biāo)測系統(tǒng)(EnSite-NavXTM Velocity3.0,美國圣猶達(dá)公司或Carto 3TM,美國強(qiáng)生公司)對39例房顫消融術(shù)中或術(shù)后發(fā)生的PMFL患者,分析其臨床特征及電生理特征,應(yīng)用環(huán)狀電極或消融導(dǎo)管對左心房進(jìn)行高密度標(biāo)測,分析左心房環(huán)二尖瓣環(huán)三個(gè)不同區(qū)域的電壓、低電壓區(qū)域或復(fù)雜電位分布情況,并比較不同區(qū)域的電壓、傳導(dǎo)時(shí)間及傳導(dǎo)速度。根據(jù)三維重建左房模型沿二尖瓣環(huán)將左房體部分為三個(gè)部分:分別為間隔前壁(SAW:自冠狀靜脈竇竇口至左心耳正下口處)、后下壁區(qū)域(PIW:冠狀靜脈竇竇口至二尖瓣瓣環(huán)4點(diǎn)處)及MI區(qū)域(左心耳正下口處至二尖瓣環(huán)4點(diǎn)區(qū)域)。根據(jù)激動(dòng)標(biāo)測和電壓標(biāo)測的結(jié)果制定治療策略。結(jié)果39例PMFL患者12例納入本研究,其中陣發(fā)性房顫10例,持續(xù)性房顫2例,房顫持續(xù)性時(shí)間分別為6、12個(gè)月。平均年齡57.6± 10.2歲,11例(92%)為男性,房顫病史中位數(shù)為36個(gè)月(6-120個(gè)月)。左心房內(nèi)徑平均為41.1 ±4.2mm,左心室射血分?jǐn)?shù)平均為63.8±3.9%。心動(dòng)過速周長平均為197.8± 15.4ms,所有患者環(huán)二尖瓣環(huán)各個(gè)區(qū)域均未標(biāo)測到低電壓區(qū)域和復(fù)雜電位區(qū)域。各區(qū)域電壓分別為 MI:1.55±0.53mV,SAW:1.58±0.45mV,PIW:1.44±0.48mV,三個(gè)區(qū)域間電壓無顯著性差異(P= 0.63)。傳導(dǎo)速度在MI,SAW及PIW區(qū)域分別為(0.75±0.14m/s,0.74±0.14m/s,0.83±0.19m/s,P=0.34)。所有患者在行環(huán)肺靜脈消融,隔離肺靜脈電位后直接電復(fù)律后轉(zhuǎn)復(fù)為竇性心律。平均隨訪18個(gè)月,無患者復(fù)發(fā)PMFL,1例陣發(fā)性房顫患者復(fù)發(fā)房顫,予以重新補(bǔ)點(diǎn)消融隔離肺靜脈電位后隨訪無房顫復(fù)發(fā)。結(jié)論對于心臟結(jié)構(gòu)正常的陣發(fā)性房顫或短程持續(xù)性房顫術(shù)中發(fā)生的短周長、無基質(zhì)的PMFL患者,其發(fā)生機(jī)制可能由于電重構(gòu)引起的,此類心律失常無需進(jìn)一步消融,直接電復(fù)律恢復(fù)竇性心律即可。
[Abstract]:Background and objective empirical ablation of mitral isthmus is the main method for the treatment of peri-mitral annular atrial flutter (atrial flutterus), but blind ablation of MI can cause arrhythmia. The purpose of this study was to investigate the clinical and electrophysiological characteristics of stromal free PMFL during or after ablation of atrial fibrillation. Methods the clinical and electrophysiological characteristics of 39 patients with PMFL during or after atrial fibrillation ablation were analyzed using the three-dimensional mapping system EnSite-NavXTM Velocity3.0, St. Jude Inc. Or Carto 3TM3, Johnson Inc. The high density mapping of left atrium was performed with annular electrode or ablation catheter. The voltage distribution of three different regions of left atrial annular mitral annulus, low voltage region or complex potential were analyzed, and the voltages of different regions were compared. Conduction time and velocity. The left atrial body is divided into three parts according to the three-dimensional reconstruction of left atrial annulus along the mitral annulus: SAW from the sinus orifice of coronary vein to the inferior part of left atrial appendage, and PIW: coronal from the sinus orifice of coronary vein to the inferior left atrial appendage. Venous sinus orifice to mitral annulus 4 points) and MI region (left atrial appendage right inferior orifice to mitral annulus 4 points). According to the results of activation mapping and voltage mapping, treatment strategies were formulated. Results 12 patients with PMFL were included in this study. There were 10 cases of paroxysmal atrial fibrillation and 2 cases of persistent atrial fibrillation. The duration of atrial fibrillation was 6 months and 12 months respectively. The mean age was 57.6 鹵10.2 years old. The median history of atrial fibrillation was 36 months, 6-120 months, the mean diameter of left atrium was 41.1 鹵4.2 mm, the mean ejection fraction of left ventricle was 63.8 鹵3.9 mm, the average circumference of tachycardia was 197.8 鹵15.4ms. all the regions of annular mitral annulus were not detected in low-voltage area. And complex potential regions. The voltage of each region was MI:1.55 鹵0.53mV SAW: 1.58 鹵0.45mV PIW: 1.44 鹵0.48mV. there was no significant difference in voltage between the three regions (P = 0.63). The conduction velocity in the Misaw and PIW regions was 0.75 鹵0.14mrs0.74 鹵0.14m/ s 0.83 鹵0.19msP 0.34 respectively. All patients underwent annular pulmonary vein ablation. After isolating the pulmonary vein potential, the patients changed to sinus rhythm after direct electrocardiogram. The average follow-up period was 18 months. No recurrent PMFLF was found in 1 patient with paroxysmal atrial fibrillation. There was no recurrence of atrial fibrillation in patients with paroxysmal atrial fibrillation with normal cardiac structure or short duration atrial fibrillation with short circumference and without matrix. The mechanism may be caused by electrical remodeling, such arrhythmias do not need to further ablation, the direct electrocardiogram can restore sinus rhythm.
【學(xué)位授予單位】：南京醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R541.7

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