经主动脉窦途径射频消融心动过速临床研究

The clinical analysis of radiofrequency catheter ablation tachycardia originating from the aortic sinus

目的:探讨经主动脉窦途径导管射频消融治愈的快速性心律失常患者的心电图特点及射频消融情况。方法:回顾性分析17例室性心动过速/室性期前收缩、前间隔房性心动过速及前间隔旁路等该类患者的体表心电图、及消融成功时靶点电图等心电生理学特征。结果:经主动脉窦途径导管射频消融治愈室性心动过速/室性期前收缩12例,其中起源于左冠状动脉窦(左冠窦)10例、右冠状动脉窦(右冠窦)2例;源于无冠状动脉窦(无冠窦)的局灶性前间隔房性心动过速3例及前间隔旁路2例。室性心动过速/室性期前收缩心电图特点:Ⅱ、Ⅲ和aVF导联为高大R波,胸导联R波移行较早,V1导联r/S波振幅比≥30%,r波时限(82.2±16.4)ms,V1导联中r/QRS波时限比≥50%,V5、V6导联为高振幅R波、无s波。有效消融靶点心内电图示心室波明显比体表心电图QRS波提前(35.2±21.6)ms。前间隔房性心动过速均能被心房刺激反复诱发和终止,其心电图特点:房性心动过速时P'波间期明显窄于窦律时P波间期,Ⅰ、aVL导联P'波正向,Ⅱ、Ⅲ和aVF导联P'呈负正双向。在心房标测中提示最早的心房激动在希氏(His)束区,但在主动脉无冠窦内标测的心房激动较His束区的心房波提前,其解剖定位于His束上后方,消融靶点无His束电位。前间隔旁路心电图示:窦性心律时呈窄QRS波形,未见预激波,心动过速呈窄QRS形,在无冠窦内记录到最早心房激动点,且无His束电位。17例均消融成功。结论:源于主动脉窦内的室性心动过速/室性期前收缩、前间隔房性心动过速和前间隔旁路具有相对的心内电生理学特征,常规心内膜途径消融困难时应该考虑从主动脉窦途径标测消融策略,把握消融导管与冠状动脉的关系,导管消融治疗安全而有效。

Objective： To discuss the electrocardiographic characteristics guiding catheter ablation tachycardia originating from the aortic sinus cusp in patients, and to describe the results of treatment with radiofrequency catheter ablation （ RFCA ）. Method ： Routine 1 2 - lead surface electrocardiography and electrophysiological characteristics, the ablation target sites review analysis were performed on 17 tachycardia patients which successfully eliminated from aortic sinus cusp with no organic heart disease, including 12 VT/PVCs, 3 ATs and 2 APs. Result： Among analyzed 17 cases,there were 12 cases of VT/PVCs （10 cases originating from the left aortic sinus, 2 cases from the right aortic sinus）. The surface ECG analysis revealed rs, rS or QS wave on lead Ⅰ and aVL, large R wave on lead Ⅱ ,Ⅲ and aVF, Precordial R wave transition occurred on lead V2 or V3, the indexes of R/S wave amplitude ≥30% in lead V1 , the average of R wave duration was （82.2±16.4） ms, the indexes of R/QRS wave duration≥50%, large R wave on lead V5 and V6 but no s wave either lead V5 or V6. The earliest ventricular electrogram at a successful ablation site was recorded 35.2±21.6 ms before QRS onset. 3 patients with focal anteroseptal AT were reproducibly induced and terminated by atrial pacing. Its surface ECG characteristics： the interphase of P＇wave during AT was obviously narrower than that of P wave during sinus rhythm, and the P＇wave was positive in lead Ⅰ and aVL,which was negative/positive in lead Ⅱ ,Ⅲ and aVF. Mapping in atria demonstrated that the earliest atrial activation was located at the His region, whereas mapping in the non-coronary aortic sinus demonstrated that an earliest atrial activation preceded the atrial activation at the His region by 12.3±7.8 ms and was anatomically located superoposterior to the His region in all 3 patients. Also the His potentials were not found at the successful site in the non-coronary aortic sinus in all 3 patients. The routine 12-lead surface ECG of 2 cases with anteroseptal AP revealed narrow QRS complex during sinus rhythm with no prexcitation wave and narrow QRS complex tachycardia, the earliest atrial activation were recorded in the non-coronary aortic sinus with no His potential. 17 patients were all successfully abolished. Conclusion：The specific surface ECG and electrophysiological characteristics of VT/PVCs, anteroseptal focal AT, anteroseptal AP originating from the aortic sinus cusp are helpful for guilding radiofrequency ablation when the tarchycardia was failed to ablate at the routine endocardium approach. A few tachycardia can be abolished successfully and safely.