Carto三维标测系统指导下心房颤动／扑动个体化消融原则的临床分析

Individualized ablation protocol for atrial fibrillation/flutter guided by Carto 3D mapping system:clinical analysis of 82 cases

目的探讨个体化消融原则的临床效果及右房的作用。方法房扑/房颤患者82例,男性42例,女性40例,年龄18～77(48.5±10.3)岁,左房内径26～52(35.4±5.3)mm。其中53例为阵发性房颤,14例为持续性房颤,15例为典型房扑。所有患者在Carto指导下进行个体化消融原则,以房扑/房颤被终止且不被诱发、肺静脉电位消失为消融终点。随访成功的定义为未服用抗心律失常药物、无任何症状性房性心律失常发作至少3个月。结果①随访时间3～28(13.4±3.3)个月,房扑和阵发性房颤消融随访成功率88.2%,持续性房颤仅为57.1%(P<0.05)。2例有心包压塞,1例合并假性动脉瘤。无肺静脉狭窄等血管严重并发症。②阵发性房颤53例,其中10例为局灶性房早、短阵房速诱发的房颤(4例病灶位于右房内),8例行靶静脉线性消融,这类亚组手术无任何心律失常发作。其余43例阵发性房颤患者均行环肺静脉线性消融术,合并典型(4例)和非典型(6例)房扑者外加三/二尖瓣峡部消融。③15例典型房扑(4例为持续性房扑)患者,均行三尖瓣峡部消融,4例合并房颤者外加双侧肺静脉线性消融。④14例持续性房颤均经历了消融由房颤转变为房扑的过程,6例被消融终止和8例电复律复为窦律,半数分别进行了三/二尖瓣峡部消融和冠状静脉窦内消融,2例合并了起源于右房的房扑和房速。结论Carto指导下房颤/房扑个体化消融可获得较好的临床疗效,右房的作用不能忽略。

Objective Fixed ablation strategies for atrial fibrillation （AF） are empirical protocols regardless of the variety of AF. This study was aimed to observe the efficiency of an individualized ablation strategy of AF/atrial flutter （AFL） under the guide of Carto 3D mapping system and the effects of the right atrium in the ablation. Methods Eighty-two patients [ 42 males and 40 females with a mean age （48.5±10.3）] admitted in our department from Feb. 2007 to Jun. 2009 were enrolled, of which, 53 patients were paroxysmal AF, 14 patients were persistent AF and 15 patients were typical AFL, and their mean diameter of left atrium was （ 35.4± 5.3 ） mm. Individualized ablation varied from segmental to circumferential was completed step by step under the guidance of Carto 3D mapping system. The burst stimulation （250 to 600 bpm） was applied to induce AF if there was no spontaneous AF, and the main procedure end point is electrical isolation of pulmonary veins （PVs） by circumferentia pulmonary veins ablation （CPVA） and complex fractional atrial electrogram （CFAE） ablation. Success was defined as symptomatic atrial tachyarrhythmias （ATa） free with no aid of any anti-arrhythmia drugs for at least 3 months. Results （ 1 ） After a mean follow-up of （ 13.4 ±3.3） months, the successful rate of ablation was 88.2% in patients with paroxysmal AF and AFL, but only 57.1% （P 〈 0. 05 ） in persistent AF. Complications included pericardial tamponade （2 cases） and pseudoaneurysm （1 case）, but no symptomatic pulmonary vein stenosis was observed. （2） Ten cases of paroxysmal AF were originated from rapid firing foci （4 cases from the right atrium）, and circumferential targeted vein ablation was performed in 8 cases with no recurrence of ATa. CPVA were performed on the other 43 cases of paroxysmal AF, and patients coexisted with typical （4 cases） and atypical （6 cases） AFL undergoing tricuspid/mitral isthmus ablation. （3） Fourteen typical AFL underwent tricuspid isthmus ablation, of which hipulmonary CPVA was operated in 4 patients complicated with AF. （4） All 14 cases of persistent AF was converted to typical or atypical AFL, sinus rhythm by ablation （6 cases ） and by defibrillator （ 8 cases）, and half of them received tricuspid or mitral isthmus ablation. Conclusion This study suggests that the individualized ablation protocol based on the mechanism of AF/AFL is feasible and effective in sinus rhythm restoration, and the right atrium may be involved in trigger and substrate of AF mechanism.