阵发性心房颤动患者非肺静脉触发灶的诱发及消融

Inducibility and ablation of atrial fibrillation from non-pulmonary vein foci in patients with paroxysmal atrial fibrillation

目的探讨环肺静脉电隔离（CPVI）术中静脉注射异丙肾上腺素（ISO）和三磷酸腺苷：ATP），在检出阵发性心房颤动（房颤）非肺静脉触发灶中的价值。方法回顾性分析2010年4～12月色浙江邵逸夫医院心内科所有患者接受三维标测系统指导下CPVI术136例患者，其中87例消融前后分别应用ISO＋ATP诱发房颤，Lasso导管置于右上肺静脉口、消融导管置于左上肺静脉中，结合冠状静冰窦导管判断房颤的触发灶，然后通过消融验证。结果87例首次接受导管消融的阵发性房颤患者，吏用ISO＋ATP后16例证实有非肺静脉房颤触发灶。其中，消融前诱发8例房颤、1例房性心动过速（房塞）、1例频发房性早搏（房早）。2例消融前诱发的患者CPVI术后房性快速性心律失常（ATa）仍存在，余8例及5例消融前未被诱发者CPVI后再次诱发时又检出非肺静脉触发灶。其中，9例为房颤（起源上腔静脉5例、冠状静脉窦内靠近口部1例、左心房后壁2例、不明1例），3例房性心动过速（均为冠状挣脉窦口起源）和1例频发房性早搏（上腔静脉起源）。14例患者在相应非肺静脉触发灶部位消融后心聿失常均终止，且不再被诱发。2例起源不明的房颤患者电复律后转为窦性心律。随访2年，单次手术或功率为87．5％（14／16）。结论静脉注射ISO＋ATP可简单有效地检出阵发性房颤非肺静脉触发灶。

Objective To evaluate the effectiveness of isoprel and adenosine triphosphate （ISO ＋ ATP） administration in induction of atrial fibrillation from non-pulmonary vein （PV） foci in patients with par- oxysmal atrial fibrillation （AF） during circumferential pulmonary vein isolation （CPVI） procedure. Methods Eighty-seven patients underwent CPVI with guidance of three dimensional navigation system.Mean- while ISO＋ATP iv bolus were administrated both before and post CPVI to induce AF.Lasso catheter in the an- trum of fight superior pulmonary vein, ablation catheter resting on the crina in the antrum of left superior pulmo- nary vein ,with coronary sinus catheter were used to identify the origin of extra-PV loci which was confirmed by further ablation.Results In a cohort of 87 patients who underwent initial catheter ablation therapy, using ISO＋ ATP infusion, non-PV AF was totally detected in 16 patients.AF was induced in 8 patients, atrial tachycardia in 1 patient,and frequent premature atrial contraction （PACs） in 1 patient before ablation.Except for 2 patients remained in atrial taehyarrhythmia after CPVI, the rest 8 patients and 5 patients who initially were in sinus rhythm after ISO＋ATP injection were induced atrial tachyarrhythmia after repeat administration of ISO＋ATP.Nine were in AF （origins were as following：superior vena cava in 5,coronary sinus in 1,1eft atrial posterior wall in 2,and unknown in 1 ）,3 in atrial tachycardia （all from coronary sinus）, and 1 PACs （from superior vena cava）.Fourteen patients converted to sinus rhythm after non-PV foci ablation without recurrence when ISO＋ATP iv infusion were repeated. The rest 2 patients with unknown origin underwent electrical cardioversion successfully. 87.5% （14/16） patients were recurrence-free during 2 years follow-up. Conclusion ISO＋ATP administration is a simple and effective method to reveal AF from non-PV foci in patients with paroxysmal AF during the CPVI pro- cedure.