Brugada综合征快速心律失常的发病机理与射频消融治疗

Clinical studies on the mechanisms and radiofrequency catheter ablation of the tachyarrhythmia in patients with Brugada syndrome.

目的探讨Brugada综合征ST-T抬高与快速心律失常的发病机理和射频消融治疗。方法选择体表心电图V1～V3相邻2个导联ST-T下斜或马鞍型抬高≥0．2mV，且有心律失常者按常规行心脏电生理检查和射频消融。结果38例患者，男31例，女7例，年龄38．27±13．91岁。17例有晕厥或黑噱，3例经历心肺复苏。23例为Ⅰ型Brugada图形，10例为Ⅱ型，5例为Ⅰ、Ⅱ、Ⅲ型交替，均合并不同类型的心脏传导异常。10例为单形（2例）或多形（8例）室性心动过速，1例为心室颤动电风暴，5例为室性与房性心律失常并存，5例为单纯室上性心动过速（4例为显性预激综合征），3例为室上性心动过速和心房扑动，14例为房性早搏、房性心动过速和心房颤动。射频消融即刻成功32例（成功率84％），失败6例，未发生并发症。消融成功者心律失常消失后即刻，ST-T抬高未见改变。而室性早搏、房性早搏伴差传、His束传导阻滞、间歇预激旁道、心室起搏与静脉滴注异丙肾上腺索可使ST-T抬高幅度改变或逆转。随访5．72±2．03年，1例失访，5例心律失常复发，1例猝死，3例安装心脏永久起搏器，1例安装心脏转复除颤器。结论Brugada综合征常见心脏传导异常，ST-T抬高继发于心脏传导系统疾病与除极顺序改变，而非原发心内、外膜复极离散与2相折返，射频消融可有效防治Brugada综合征的多种快速心律失常。

Objective To study the mechanism and the efficacy of catheter ablation of tachyarrhythmia in patients with Brugada syndrome. Methods Thirty-eight patients with coved and/or saddle-back ST-T elevation in precordial leads V1- V3 and with ventricular and/or supraventricular tachyarrhythmia undertook electrophysiological study and ablation. Resuits There were 31 man and 7 women, with mean ages of 38.27 ± 13.91 （12-66） years old. Seventeen cases had history of syncope or blackout. Three patients had history of cardiac arrest. Type Ⅰ Brugada electrocardiogram pattern was found in 23 patients, Type Ⅱ in 10 patients, alternation between type Ⅰ , Ⅱ and Ⅲ in 5 patients. Various degrees of conduction abnormalities were found in all the patients. Monomorphic （ 2 cases） and polymorphic （ 8 cases） ventricular tachycardia were documented in 10 patients. One patient had recurrent ventricular fibrillation. Five patients had both ventricular and supraventricar tachycardia, 3 patients had atrioventricular reentrant tachycardia and atrial arrhythmia and 5 patients had pure supraventricular tachycardia. Fourteen patients had atrial tachyarrhythmia, including atrial fibrillation. Ablation was successful in 32 （84%） patients without any major complication. Immediate after cessation of tachyarrhythmia, no change of ST-T elevation in precordial leads was founded in any patients, The polarity and degree of ST-T elevation was changed by atrial or ventricular premature beats, by delayed conduction in the His-Purkinje system, by right ventricular pacing at various sites, by intermediate accessory bypass way and by infusion of isoproterenol. During a follow-up of 5.72 ± 2.03 years, tachyarrhythmia reoccurred in 5 patients, one patient lost contact, one patient had sudden death, 3 patients had implanted pacemaker, one patient had an implantable cardioverter defibrillator. Conclusion in patients with Brugada syndrome,conduction abnormalities are common foundings. ST-T ele- vation may be caused by site-specific repolarization changes secondary to the changes of activation sequence by abnormal conduction in the His-Purkinje system, rather than by the transmural and subepicardial dispersion of repolariza tion and phase 2 reentry. Radiofrequeney ablation is highly effective in eliminating the various types of tachyarrhytbania in patients with Brugada syndrome.