阵发性心房颤动患者肺静脉前庭电生理现象及分析

Electrophysiological characteristics of pulmonary vein antrum in patients with paroxysmal atrial fibrillation

目的采用EnSite／NavX系统指导下，结合单Lasso进行环肺静脉电隔离术治疗阵发性心房颤动（简称房颤），分析消融过程中肺静脉前庭电生理现象。方法入选2004年10月～2005年12月症状性阵发性房颤患者143例，男85例、女58例，年龄60．7±10．3（35～80）岁，房颤病程5．5±6．7年（21天～50年），左房内径36．9±6．4（24～54）mm。在EnSite-NavX系统引导下行环肺静脉消融达到肺静脉电隔离。结果143例完成环肺静脉隔离术，手术时间157±30（90～240）min，放射线时间25．8±8．8（9．8～60．1）min。环单侧左、右肺静脉前庭消融电隔离率分别为81．2％、78．3％，其余病例结合节段性消融（SOA）达到肺静脉电隔离。房颤终止的比例为69．7％（23／33例），第一次消融63．6％（91／143）可记录到肺静脉内自发电位，2．1％（3／143）可记录到肺静脉内快速的自主节律，而体表心电图为稳定的窦性心律。房颤复发患者第二次消融时，所有21例均有肺静脉电位（PVP）恢复，其中第一次消融时结合SOA达到肺静脉隔离的患者：57．1％左侧PVP恢复，55．6％右侧PVP恢复。第二次消融时，85．7％（18／21）例存在肺静脉内自发电位。术后房性心动过速／心房扑动15例（10．5％），12例再次行射频消融治疗，11例消融成功。术后随访10．7±4．9（4～18）个月，包括第二次消融术后患者在内，共90．2％（129／143）在无抗心律失常药物治疗下无房颤发作。心包积液2例，Ensite／NavX电极贴片故障1例。结论心房一肺静脉传导存在优势传导径路，且传导方式并非“全或无”；结合SOA的消融方法复发率较高；多数患者肺静脉隔离后可记录到自发肺静脉电位，复发患者的肺静脉通常具有较高的兴奋性。

Objective To analyze the electrophysiological characteristics of pulmonary antrum by circumferential pulmonary vein（PV） isolation in cases with paroxysmal atrial fibrillation （AF） guided by the EnSite-NavX system. Methods 143 cases （85 males, mean age 60.7 ± 10.3 years ） with paroxysmal AF were enrolled from October 2004 to December 2005. The mean duration of AF was 5.5 ± 6.7 years （ 21days N 50years） , and the mean left atrium diameter was 36.9 ± 6.4 （24 -54）mm. Circumferential PV isolation was performed guided by the EnSite-NavX system, combined with single Lasso technique. Results 143 cases underwent the procedure successfully, with the mean procedure time 157 ± 30（90 -240） min and the mean fluoroscopic time 25.8 ± 8.8 （9.8 - 60.1 ） min. The pulmonary vein isolation rate for the left ipsilateral PVs was 81.2% and 78.3% for the right PVs. Segmental ostial ablation was applied for the rest cases. AF terminated in 69.7% （23/33）cases by radiofrequency energy delivery. In the previous procedure, the automatic activities of PVs were documented in 91 cases, and pulmonary automatic tachyarrhythmias with stable sinus rhythm in surface ECG were observed in 3 cases. In the repeat procedure of recurrent AF, pulmonary vein potentials （PVPs） were observed in all 21 cases. Among them, a higher recovered PVP rate was observed in patients with pulmonary vein isolation combined with SOA in initiated procedure： PVP recovered in 57.1% in the left side and 55.6% in the right side. In the repeat procedure, automatic activeties of PVs were documented in 85.7% （18/21） cases. Post-ablation atrial tachyarrhythmia （ATa） was documented in 15 cases （ 10.5% ） , and was abolished by re-ablation in 12 cases. After a mean of 10.7 ± 4.9 （4 - 18 ）months of followup, 90.2% （ 129/143 ） cases without antiarrhythmic drugs were free of AF （ including the repeat procedure）. Pericardial effusion was found in 2 cases and was cured after proper treatment. And fault of Ensite/NavX patch was found in 1 case. Conclusions The electrical connections of PV-atrium is not ＂all or none＂. A higher recurrent rate is associated with the strategy of ablation with SOA. Automatic activity of PVs is observed in the majority of patients after isolation, and usually the activation of PVPs is more active in recurrent cases. The recovered pulmonary vein conduction is the dominant factor for recurrent ATa associated with circumferential pulmonary vein isolation. [ Chinese Journal of Cardiac Pacing and Electrophysiology ,2006,20 （5） ：394 - 400]