下腔静脉造影——一种定位房间隔穿刺相关结构的有效方法

Inferior vena cava angiogram is a reliable way to visualize all structures related to transseptal puncture

目的描述一种用于定位房间隔穿刺关键解剖结构的简单可靠方法。方法在2012年3—11月心房颤动（简称房颤）消融术中，连续3次穿间隔失败的23例患者中应用下腔静脉（IVC）造影指导房间隔穿刺术（TP）。在右前斜45。透视下，将造影管远端置于IVC口下1cm处注射5—10ml造影剂。IVC、右房（RA）、右室流入道（RVIT）和右室流出道（RVOT）依次显影。RA，RVIT和RVOT之间围绕的无造影剂充盈的区域是主动脉根部及相邻组织。冠状窦（CS）电极经股静脉置入，其转弯处标志CS口上缘。右前斜45°投照下，合适的房间隔穿刺点（TPS）应在RA的中间、无冠窦的后下方、CS口的后上方。结果23例均成功完成IVC造影指导下的房间隔穿刺（20例1次穿刺成功，3例2次成功），并达到房颤消融的所有终点。91％（21／23）的患者所有结构清楚显示，能清楚看到所有患者RA下缘、后缘和无冠窦，在2例中RA上缘不能清楚显示。由IVC造影提示的最佳TPS在22例患者中是合适的。在IVC造影图像中，沿无冠窦后缘最头侧与CS口上缘之间连线的中点画一水平线（AE），AE线平分为4段。在87％（20／23）的患者，最佳TPS是在AE线上的左半段。结论IVC造影能提供关于TPS定位及其周围解剖结构的重要信息，IVC造影确定的TP很适合应用于房颤导管消融术。

Objective To describe a simple method, inferior vena cava （IVC） angiogram, to locate critical landmarks during transseptal puncture procedure. Methods In RAO 45 °, 10 ml contrast was injected 1 cm below the inferior vena cava（IVC） ostium. The IVC, right atrium （RA）, non-coronary aortic sinus （NCAS）, right ventricular inflow tract （RVIT） and right ventricular outflow tract （ RVOT） were visualized sequentially. The region between RA, RVIT and RVOT was the aortic root and its adjunctive structures. The curve of the coronary sinus catheter indicated the top of coronary sinus ostium （CSO）. The appropriate transseptal puncture site （TPS） should be determined as： inferoposterior to NCAS, superoposterior to CSO and in the middleof RA. The distance between TPS and surrounding landmarks were measured. From March 2012 to November 2012,23patients used this method after failed with conventional transseptal approach during atrial fibrillation （AF） ablation procedure. Results Transseptal puncture guided by IVC angiogram was successful in all patients （20 patients with one attempt and 3 patients with two attempts）. In 91% （21/23） patients, all structures mentioned above were visualized cleariy. The posterior and inferior wall of RA and NCAS were seen in 100% patients. The superior aspect of RA was not seen in 2 cases. The TPS determined by IVC angiogram was appropriate in 22 patients. Under RAO 45°, an imaginary horizontal line was drawn across the middle point between inferior part of NCAS and superior part of CSO. The line was divided into 4 equal parts by 3 points. In 87% （20/23） of the patients, the appropriate TPS was on the midline between point B and C. Conclusion IVC angiogram provides vital information about TPS localization and its anatomic relationship with surrounding landmarks. The TPS indicated by IVC angiogram is optimal for AF ablation procedure.