不同消融策略治疗三尖瓣峡部依赖房扑的疗效评价

Evaluation of efficacy of different ablation strategies on cavotricuspid isthmus-dependent atrial flutter

目的比较高电压(maximum voltage guided,MVG)及电位极性反转两种标测方法指导下的消融策略与传统线性消融策略对下腔静脉三尖瓣峡部(cavotricuspid isthmus,CTI)依赖房扑的疗效。方法 34例典型房扑患者随机分为3组:A组12例,于CTI行连续的线性消融;B组11例,采用首先消融CTI高电压区域的策略;C组11例,采用首先消融CTI区域电位极性反转位点的策略。各组中以相应消融方法未达到CTI双向阻滞者,均于CTI区域标测并消融残存传导束至峡部双向阻滞(消融终点)。比较各组手术即刻成功率、远期复发率、操作时间、X线曝光时间、消融点、总消融时间。结果①除C组1例患者外,其余所有患者均达到峡部的双向阻滞,且无严重并发症发生。②B组及C组较A组平均消融点(A组23.2±8.7,B组13.4±3.6,C组7.2±3.1,P<0.01)显著减少,消融时间[A组(15.4±6.8)min,B组(6.7±3.5)min,C组(5.4±2.6)min,P<0.01]显著缩短。③首先消融CTI高电压区域的策略(B组)较其余两种消融策略(A组及C组)显著缩短X线曝光时间[A组(15.2±7.2)min,B组(10.3±6.5)min,C组(16.3±8)min,P<0.05]及手术时间[A组(70.0±45.1)min,B组(50.8±30.5)min,C组(65±38.5)min,P<0.05]。结论高电压及电位极性反转两种标测方法指导下的CTI消融策略与传统线性消融策略治疗典型房扑的疗效相近,而需要的消融点更少,消融时间更短。高电压标测指导下的消融策略较电位极性反转标测进一步减少手术及X线曝光时间。

Objective To investigate the efficacy of different ablation strategies, maximum voltage-guided （MVG） ablation, polarity reversal-guided ablation and linear ablation, on patients with cavotricuspid isthmus （CTI）-dependent atrial flutter. Methods Thirty-four patients with typical atrial flutter were randomly divided into group A, group B and group C. In group A （n=12） continuous linear ablation was performed at CTI. In group B （n=11）, MVG ablation was performed at CTI. In group C （n=11） radiofrequency （RF） ablation guided by reversal of polarity was performed at CTI. In each group, when bidirectional isthmus block was not achieved after the ablation strategies, residual conduction gaps were mapped and eliminated by additional RF application. The following parameters were compared： acute success rate, recurrence rate in long-term follow-up, operation time, X-ray exposure time, number of RF applications, and total RF ablation duration. Results Bidirectional isthmus block was achieved in all patients except for 1 case in group C, without serious complication. There were lower mean number of RF applications （group A, 23.2±8.7; group B, 13.4±3.6; group C, 7.2±3.1; P〈0.01） and shorter total RF duration （group A, 15.4±6.8 min; group B, 6.7±3.5 min; group C, 5.4±2.6 min; P〈0.01） in group B and group C than in group A. Operation time （group A, 70.0±45.1 min; group B, 50.8±30.5 min; group C, 65±38.5 min; P〈0.05） and X-ray exposure time （group A, 15.2±7.2 min; group B, 10.3±6.5 min; group C, 16.3±8 min; P〈0.05） were shorter in group B than in other two groups. No difference was observed in respect of recurrence rate in long-term follow-up （2 in group A vs 1 in group B vs 1 in group C）. Conclusion MVG and polarity reversal-guided ablation strategies are associated with fewer RF applications and shorter ablation duration as compared to linear ablation strategy. Furthermore, MVG ablation strategy has shorter operation and X-ray exposure time than reversal-guided ablation strategy.