经右锁骨下静脉途径导管射频消融三尖瓣环下的室性心律失常

Trans-subclavian approach for radiofrequency ablation of ventricular arrhythmias originating from subtricuspid annulus

目的探讨经右锁骨下静脉途径结合应用长鞘(SR0)导管射频消融三尖瓣环下起源的室性心律失常有效性及安全性。方法 8例患者,根据心电图和/或动态心电图诊断为三尖瓣环附近起源室性早搏(PVC)/室性心动过速(VT),均接受心脏电生理检查及射频消融治疗。术前曾经或术中采取常规下腔静脉途径消融失败后,改经右锁骨下静脉途径并辅用长鞘SR0进行标测与消融。消融成功后,结合靶点位置分析心电图及消融结果。结果 8例消融均获成功。根据消融导管的X线影像特征、电解剖证实其起源于三尖瓣环下6～9点。12导联体表心电图的PVC/VT的QRS波均呈左束支传导阻滞伴电轴左偏图形,Ⅰ、aVL导联主波向上,Ⅱ、Ⅲ、aVF导联主波向下,2例肢体导联见切迹,QRS波时限174.75±13.44 ms,消融靶点局部V波较体表心电图QRS波提早27.5±3.16 ms。8例成功消融靶点图只见V波,6例有峰电位。随访2～12个月,1例PVC复发。结论在长鞘辅助下,经右锁骨下静脉途径能够安全、有效地消融治疗三尖瓣环下PVC/VT,是经股静脉途径消融失败的有效补充。

Objective To determine the safety and efficacy of radiofrequency catheter ablation（RFCA） of ventricular arrhyth- mias originating from the vicinity of the tricuspid annulus via a trans-subclavian approach and a long sheath. Methods Eight patients, who were diagnosed as frequent premature ventrieular contractions （PVC） or ventricular tachycardia（VT） by electrocar- diogram or Holtor, underwent electrophysiological study and radiofrequency catheter ablation. Radiofrequency application at the earliest activation site could not abolish PVC/VT by the route femoral vein approch previous. Then, ablation catheter was intro- duced via the right subclavian vein by a long sheath. After a successful ablation was performed, the characteristics of electrocar- diogram and results of ablation were analyzed. Results The arrhythmias were ablated successfully in all patients by a long sheath. PVC/VT were demonstrated as originating from the 6-9 o＇clock of the tricuspid annulus by the appearances of X ray image and etectroanatomic mapping system. At baseline, PVC/VT were exhibited a left bundle branch block and left superior axis QRS morphology ,upright R-waves in leads I, aVL; negative complexes in leads Ⅱ, Ⅲ and aVF. QRS duration was 174.75 ± 13.44 ras, earliest activation preceding the onset of the QRS complex was 27.5 ±3.16 ms. Only V wave in successful ablation target and without A wave in all patients, and spike potential in 6 patiens . ＂Notching＂ of the QRS complex was observed in two patiens. One patient recurred during a follow-up period of 12 months. Conclusion RFCA could be effectively and safely treating PVC/VT originating from the subtricuspid annulus supported by a long sheath. Sometimes, trans-subclavian approach is an effec-tive alternative.