结合左心耳电位快速鉴别二尖瓣环折返性房性心动过速

A novel approach to quickly differential diagnose the macro-reentrant mitral annular atrial tachycardiawith left appendage potentials

目的探讨结合左心耳电位快速鉴别二尖瓣环折返性房性心动过速（房速）的临床应用价值。方法连续348例心房颤动（房颤）导管消融患者中发生大折返房速时，将环状标测电极置于左心耳内，消融导管置于左心房前壁，根据冠状静脉窦、左心耳和左心房前壁电位的激动模式初步判断大折返房速的机制，然后在Carto系统指导下进行激动标测和拖带标测明确折返机制，评价结合左心耳和冠状静脉窦电位快速鉴别诊断二尖瓣环折返的准确性和特异性。结果40例房颤患者消融过程中共发生经Carto系统激动标测及拖带验证明确诊断的53种大折返房速，其中24种二尖瓣折返、19种三尖瓣折返和10种房顶依赖的折返。24种二尖瓣折返中，8种为冠状静脉窦近端领先的逆钟向折返，均表现为冠状静脉窦近端．中间．远端一左心耳（CSP—CSM—CSD-LAA）的激动模式，16种是冠状静脉窦远端领先的顺钟向折返，均表现为左心耳一冠状静脉窦远端一中间一近端（LAA—CSD—CSM—CSP）的激动模式。与Car-to指导的激动标测和拖带标测出的折返环相比，用CSP·CSM-CSD—IJAA或LAA—CSD—CSM—CSP的激动模式判断二尖瓣折返性房速总体敏感性100％，特异性75％，结合左心房前壁电位可进一步提高诊断特异性。结论结合左心耳电位的快速标测是鉴别二尖瓣环折返性房速的有效方法。

Objective To investigate the feasibility and efficacy of quick mapping by analyzing the left atrial appendage （LAA）potentials to categorize two types of macro-reentrant mitral annular atrial tachycardia （MAAT）. Methods Three hundred forty-eight consecutive patients with atrial fibrillation （AF）underwent catheter ablation were enrolled. When macro-reentrant AT occurred, the circular electrodes were placed into LAA to record the changing of activation sequence during mapping and ablating. Simultaneously, the activation sequence mapping guided by Carto system and entrainment mapping were performed to reveal the mechanism of reentry, so as to estimate the accuracy and specificity of quick diagnosis of peri-mitral reentry by analyzing the LAA and coronary sinus （CS）potentials. Results There were 53 types of macro-reentrant AT verified by Carto guided activation mapping and entrainment mapping during catheter ablation in 40 cases. Among them, there were 24 types of peri-mitral AT, 19 types of peri-tricuspid AT and 10 types of roof dependent AT. Among 24 types of peri-mitral AT, there were 8 types of counter clockwise reentry with proximal CS ahead, which all mani- fested as CSP-CSM-CSD-LAA mode,and 16 types of clockwise reentry with distal CS ahead,which all shown as LAA-CSD-CSM-CSP mode. Compared with the results of Carto guided activation mapping and entrainment map- ping,the total sensitivity and specificity was 100% and 75% ,respectively by means of CSP-CSM-CSD-LAA or LAA-CSD-CSM-CSP mode to detect two types of MAAT. When combined with the potentials detected on left at- rial anterior wall, further improvements on specificity were made. Conclusion The quick mapping by analyzing the LAA notentials could imnrove the snecificitv in differential diagnose of MAAT.