不同起源部位局灶性房性心动过速的心电图P波形态分析及导管消融

P-wave Morphology and Impact on Catheter Ablation of Focal Atrial Tachycardia Originating from Different Anatomic Sites

目的:评价局灶性房性心动过速(房速)心房内不同起源部位的心电图房性P波形态特征及导管消融疗效。方法:通过三维电解剖标测系统的精确定位17例局灶性房速的起源部位,并回顾性分析体表心电图房性P波的形态特点,探讨二者的联系。结果:17例房速起源部位均获得精确定位并成功行导管消融。9例右心房起源房速包括上腔静脉房间隔侧1例,中上部界嵴1例,房间隔右侧3例,冠状静脉窦口内1例,希氏束旁2例,右心耳1例;8例左心房起源房速包括左上肺静脉2例,右上肺静脉1例,二尖瓣环2例,左心耳1例,房间隔左侧1例,无冠窦1例。V1导联P波负向者房速多起源于右心房;P波正向者,房速除起源于左心房外,尚可能起源于右心房上部、后部;P波等电位线者,房速多起源于Koch三角附近的相关解剖结构,如冠状静脉窦口、房间隔以及希氏束。结论局灶性房速常起源于肺静脉附近、瓣环、房间隔等心房内有特殊解剖结构的部位,心电图P波形态,尤其是V1导联可初步定位房速起源部位,而三维标测系统可快速对此作进一步精确定位,缩短导管消融及放射线透视时间。

Objective： To analyze the P-wave morphology（PWM） in fucal atrial tachycardia（AT） originating from different anatomic sites and efficacy of catheter ablation. Methods＇： To evaluate the relation between anatomic sites of origin by exact location with three dimensional electroanatomic mapping system（CARTO） and PWMs in atrial tachycardias. Results： All 17 patients underwent catheter ablation successfully. Exact anatomic locations were performed by CARTO. The distribution of ATs was right atrial in 9 patients and left atrial in 8 patients. Right atrial sites included superior vena cana（n=1）, crista（n=1）, right atrial septum（n=3）, coronary sinus ostium（n=1）, perinodaI（n=2）, right atrial appendage（n=1 ）. Left atrial sites included left superior pulmonary vein（n=2）,right superior pulmonary vein（n=1）, mitral annulus（n=2）,left atrial appendage（n=1）, left atrial septum（n-1）, non-coronary aortic sinus（n=1 ）. In electrocardiographic lead V1, a negative P-wave demonstrated a high specificity for a right atrial focus, and a positive P-wave demonstrated a high sensitivity for a left atrial focus besides superior or posterior right atrial, a isoelectric P-wave demonstrated a possibility of anatomic sites origin neighboring Koch triangle. Conclusions： Special anatomic sites within atrium, such as pulmonary vein, annulus, atrial septum and so on, were associated with AT loci. A characteristic PWM, especially lead V1 could locate tachycardia focus. What is more, further exact focus location, relatively shorter time of catheter ablation and X-ray exposure would achieved by CARTO.