【摘要】：目的主動(dòng)脈根部起源的特發(fā)室性早搏、室性心動(dòng)過速可通過射頻消融的方法得到安全有效的治愈。目前為止,還沒有系統(tǒng)研究對(duì)消融靶點(diǎn)的電生理特征進(jìn)行細(xì)致闡述。本研究主要分析,局部雙電位對(duì)于確定消融成功靶點(diǎn)的意義。方法本研究采用回顧性分析方法,納入2008年10月至2016年2月期間在阜外醫(yī)院心律失常中心接受射頻消融治療的起源于主動(dòng)脈根部的特發(fā)性室性早搏、室性心動(dòng)過速患者132例。通過電生理檢查及腔內(nèi)標(biāo)測(cè)證實(shí)起源位置。根據(jù)消融成功靶點(diǎn)有無雙電位,將132例患者分為兩組:雙電位組和非雙電位組。通過比較兩組的電生理特點(diǎn)、放電次數(shù)和術(shù)后復(fù)發(fā)情況,分析局部雙電位對(duì)于確定消融靶點(diǎn)的意義。結(jié)果主動(dòng)脈根部起源的特發(fā)性室性早搏、室性心動(dòng)過速的起源包括:主動(dòng)脈左冠竇(56例),主動(dòng)脈右冠竇(39例),主動(dòng)脈左右冠竇交界(33例)和主動(dòng)脈無冠竇(4例)。97例(73.5%)的消融成功靶點(diǎn)具有局部雙電位特征,其中主動(dòng)脈左冠竇44/56(78.6%)例,主動(dòng)脈右冠竇29/39(74.4%)例,主動(dòng)脈左右冠竇交界21/33(63.6%)例,主動(dòng)脈無冠竇3/4(75.0%)例。雙電位特征組較非雙電位特征組相比,局部電位領(lǐng)先QRS起始時(shí)間更長(zhǎng)(31±2ms vs.26±3ms,P=0.007),消融放電次數(shù)更少(3.6±1.2 vs.4.5±2.3,P0.001)。在術(shù)后隨訪期間,有7例室性早搏、室性心動(dòng)過速復(fù)發(fā)(雙電位組2例vs.非雙電位組5例,P0.001)。結(jié)論絕大多數(shù)(97/132例)起源于主動(dòng)脈根部的特發(fā)性室性早搏、室性心動(dòng)過速,其消融成功靶點(diǎn)具有局部雙電位特征。局部雙電位對(duì)于確定消融靶點(diǎn)有輔助判斷的臨床意義。同時(shí)消融靶點(diǎn)有雙電位組其消融長(zhǎng)期成功率,顯著高于非雙電位組。目的盡管主動(dòng)脈右冠竇起源的特發(fā)性室性早搏、室性心動(dòng)過速可以通過激動(dòng)標(biāo)測(cè)的方法確定成功消融靶點(diǎn)位置。但目前還沒有相關(guān)研究——通過心電圖判斷主動(dòng)脈右冠竇起源特發(fā)性室性早搏、室性心動(dòng)過速的導(dǎo)管消融靶點(diǎn)位置。本試驗(yàn)旨在通過研究術(shù)前心電圖特征與主動(dòng)脈右冠竇起源室性早搏、室性心動(dòng)過速的消融靶點(diǎn)的關(guān)系,探討心電圖預(yù)判消融靶點(diǎn)位置的可行性。方法回顧分析從2008年10月至2016年2月期間于阜外醫(yī)院心律失常中心接受射頻消融治療起源于主動(dòng)脈右冠竇的特發(fā)性室性早搏、室性心動(dòng)過速的39例患者。通過二維影像及三維電解剖標(biāo)測(cè)系統(tǒng)確定其消融靶點(diǎn)位置,根據(jù)消融靶點(diǎn)是否位于主動(dòng)脈右冠竇竇底,將其分為竇底組和非竇底組。分析兩組術(shù)前心電圖特點(diǎn),通過統(tǒng)計(jì)學(xué)計(jì)算并結(jié)合臨床找出與確定消融靶點(diǎn)位置相關(guān)的心電圖特征。結(jié)果6例消融成功靶點(diǎn)位于主動(dòng)脈右冠竇竇底,而其余33例消融成功靶點(diǎn)位置高于主動(dòng)脈右冠竇竇底。通過分析術(shù)前12導(dǎo)聯(lián)心電圖,發(fā)現(xiàn)竇底組較非竇底組:下壁導(dǎo)聯(lián)平均 R 波振幅(1.4±0.2mVvs.1.8±0.2mV,P0.05)、Ⅲ/Ⅱ 導(dǎo)聯(lián) R 波振幅比值(0.68±0.02 vs.0.64±0.04,P0.05)、avL導(dǎo)聯(lián)出現(xiàn)r波或是R波比例[6/6(100%)vs.5/33(15.2%),P0.001]、Ⅰ 導(dǎo)聯(lián) R 波振幅(0.44±0.03mV vs.0.36±0.06mV,P0.05)和 Ⅲ 導(dǎo)聯(lián)出現(xiàn) S 波比例[3/6(50%)vs.1/33(3.03%),P=0.008]有顯著統(tǒng)計(jì)學(xué)差異。通過ROC曲線得出,Ⅰ導(dǎo)聯(lián)R波振幅0.44mV,平均下壁導(dǎo)聯(lián)R波振幅1.3mV和Ⅲ/Ⅱ?qū)?lián)R波振幅比值0.65,可有效區(qū)分主動(dòng)脈右冠竇起源室性早搏、室性心動(dòng)過速的消融靶點(diǎn)位置。結(jié)論由于主動(dòng)脈右冠竇的復(fù)雜解剖和相關(guān)毗鄰結(jié)構(gòu),主動(dòng)脈右冠竇起源的室性早搏、室性心動(dòng)過速可有兩種不同心電圖表現(xiàn)。根據(jù)本文確定的心電圖指標(biāo),可以有效的判斷主動(dòng)脈右冠竇起源室性早搏、室性心動(dòng)過速的成功消融靶點(diǎn)位置。目的起源于主動(dòng)脈根部的特發(fā)性室性早搏、室性心動(dòng)過速,可通過導(dǎo)管消融的方法得到有效的治愈。但是左右冠狀動(dòng)脈分別起源于主動(dòng)脈左右冠竇,為避免消融損傷冠狀動(dòng)脈,在消融之前均需采用冠脈造影的方法確認(rèn)導(dǎo)管頭端位置與冠狀動(dòng)脈開口的相對(duì)關(guān)系。常規(guī)冠脈造影方法增加了血管損傷和冠脈夾層的風(fēng)險(xiǎn)。本研究主要探討一種替代常規(guī)冠脈造影的新方法---即通過鹽水灌注導(dǎo)管進(jìn)行造影,并評(píng)價(jià)其安全性和有效性。方法回顧性分析2008年10月至2016年2月期間接受射頻消融治療的起源于主動(dòng)脈根部的室性早搏、室性心動(dòng)過速的132例患者資料。術(shù)中運(yùn)用常規(guī)豬尾造影或是鹽水灌注導(dǎo)管造影的方法,確認(rèn)導(dǎo)管頭端與冠狀動(dòng)脈開口的相對(duì)位置關(guān)系。根據(jù)造影方法將132例研究對(duì)象分為兩組:常規(guī)造影組和鹽水灌注導(dǎo)管造影組。結(jié)果室性早搏、室性心動(dòng)過速起源于主動(dòng)脈左冠竇56例,主動(dòng)脈右冠竇39例,主動(dòng)脈左右冠竇交界33例,主動(dòng)脈無冠竇4例。與20例通過常規(guī)豬尾導(dǎo)管造影方法相比,運(yùn)用鹽水灌注導(dǎo)管造影降低了術(shù)中造影劑的用量(8.6±2.7mlvs.21.6±7.7ml,P0.001)。在常規(guī)造影組,2例因額外血管穿刺,在橈動(dòng)脈穿刺部位發(fā)生血腫。通過40.4±28.8個(gè)月的長(zhǎng)期隨訪,沒有因消融損傷冠狀動(dòng)脈而需要行冠脈介入治療的病例。同時(shí)兩種造影方法消融復(fù)發(fā)率無顯著統(tǒng)計(jì)學(xué)差異[1 vs.6,P=1.0]。112例通過鹽水灌注導(dǎo)管注射造影劑,沒有技術(shù)性難題,未發(fā)生造影劑堵塞管腔的情況。結(jié)論為明確消融導(dǎo)管與冠狀動(dòng)脈開口的相對(duì)位置關(guān)系,需要對(duì)主動(dòng)脈根部進(jìn)行造影,鹽水灌注導(dǎo)管造影方法相較于常規(guī)豬尾造影方法在安全性、有效性上無顯著統(tǒng)計(jì)學(xué)差異。因?yàn)辂}水灌注導(dǎo)管造影不需要額外血管穿刺,從而降低了穿刺并發(fā)癥的發(fā)生。同時(shí)鹽水灌注導(dǎo)管造影方法減少了造影劑的用量。
[Abstract]:Objective Idiopathic ventricular premature beats originating from the aortic root can be safely and effectively cured by radiofrequency ablation. So far, there is no systematic study on the electrophysiological characteristics of ablation targets. From October 2008 to February 2016, 132 patients with idiopathic ventricular premature beats originating from aortic root and ventricular tachycardia underwent radiofrequency ablation in the Arrhythmia Center of Fuwai Hospital. The origin was confirmed by electrophysiological examination and intraluminal mapping. 132 patients were divided into two groups: double potential group and non-double potential group. By comparing the electrophysiological characteristics, discharge times and postoperative recurrence of the two groups, the significance of local double potential in determining ablation target was analyzed. 97 (73.5%) of the successful ablation targets had local dual potential characteristics, including 44/56 (78.6%) of the left coronary sinus, 29/39 (74.4%) of the right coronary sinus, 21/33 (63.6%) of the left and right coronary sinus, and 3/4 (75.6%) of the aorta without coronary sinus. Compared with the non-double potential group, the local potential of the double potential group had a longer onset time of QRS than the non-double potential group (31 65507 Most of them (97/132) originated from idiopathic ventricular premature beats (IVP) and ventricular tachycardia (VT) at the root of the aorta. The successful ablation targets were characterized by local double potentials. Local double potentials were helpful to determine the ablation targets. Although ventricular tachycardia (VT) can be successfully ablated by excitation mapping in patients with idiopathic ventricular premature beats originating from the right aortic sinus, no studies have been conducted to determine the location of catheter ablation targets for the right aortic sinus-originated idiopathic ventricular premature beats and ventricular tachycardia. To study the relationship between preoperative ECG characteristics and ablation targets of ventricular premature beats and ventricular tachycardia originating from right coronary sinus, and to explore the feasibility of predicting ablation targets by ECG. 39 patients with idiopathic ventricular premature beats and ventricular tachycardia in the right coronary sinus were divided into sinus floor group and non-sinus floor group. Results The successful ablation target was located at the right sinus floor of the aorta in 6 cases, and the other 33 cases were higher than the right sinus floor of the aorta. 2 mVvs. 1.8 +0.2 mV, P 0.05, P 0.05, R-wave amplituderatio (0.68 +0.02 vs. 0.02 vs. 0.64 +0.04, P 0.05), ratio of R wave or R wave in avL lead [6/6 (100%) vs. 5/33 (15.2%) (15.5/33 (15.2%), P 0.001], R-wave amplitudein I lead (0.44 +0.03 mV vs. 0.36 +0.06mV, P 0.05) and S-wave ratio in III lead [3/6 (3/6%) (1/6/6 (100%)vs.5/33 (15.5/33%) (15.5/33 (15.2%), P 0.0.001 0.008] Significant statistics The results of ROC curves showed that the R wave amplitude in lead I was 0.44 mV, the R wave amplitude ratio in lead III/II was 0.65, which could effectively distinguish the ablation target location of ventricular premature beat and ventricular tachycardia originating from right coronary sinus. There are two different electrocardiographic manifestations of ventricular premature beats and ventricular tachycardia originating from the sinus. According to the electrocardiographic indexes determined in this paper, the target location of successful ablation of ventricular premature beats and ventricular tachycardia originating from the right coronary sinus can be effectively judged. However, the left and right coronary arteries originate from the left and right coronary sinuses of the aorta. In order to avoid coronary artery injury, coronary angiography is necessary to confirm the relationship between the catheter tip position and the coronary artery opening before ablation. Risk of coronary dissection. A new alternative to conventional coronary angiography, saline perfusion catheterization, was investigated to evaluate its safety and efficacy. Methods Radiofrequency ablation of ventricular premature beats (VPB) originating from the aortic root and ventricular tachycardia (VT) during the period from October 2008 to February 2016 were retrospectively analyzed. 132 patients with tachycardia underwent routine pigtail angiography or saline perfusion catheterization to confirm the relationship between the head of the catheter and the opening of the coronary artery. There were 56 cases of left coronary sinus, 39 cases of right coronary sinus, 33 cases of junction of left and right coronary sinus and 4 cases of absence of coronary sinus. After a long-term follow-up of 40.4 [28.8] months, there were no cases requiring percutaneous coronary intervention because of coronary artery ablation injury. ConclusionIn order to determine the relationship between the ablation catheter and the coronary artery orifice, the aortic root needs to be examined. There is no significant difference in safety and effectiveness between saline perfusion catheterization and conventional pigtail angiography because saline perfusion catheterization does not require a forehead. External blood vessel puncture reduces the incidence of puncture complications, and saline perfusion catheterization reduces the amount of contrast agent used.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R541.7

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