右心室流出道起源的室性心律失常消融靶点电生理特性分析及其判断标准的回顾性研究

Retrospective study of the electrophysiological characteristics and criteria of ablation target for ventricular arrhythmia originating from right ventricular outflow tract

目的分析右心室流出道(RVOT)起源室性心律失常(VA)的消融靶点分布特点、电压特点及单极电位的电生理特性,探讨并优化RVOT起源VA成功消融靶点的判断标准。方法对2016年6月至2017年8月146例在上海复旦大学附属中山医院行射频消融术且心电图提示RVOT起源的VA患者资料进行回顾性分析。术中共记录到室性早搏(室早)153种,室性心动过速(室速)6种;共记录成功消融靶点(ST)141个,失败消融靶点(FT)192个。消融术中通过行电压标测对RVOT进行分区,电压<0.5mV区域定义为低电压区;电压在0.5~1.5mV区域为电压移行区;电压>1.5mV区域为正常电压区。结果134例患者(141个靶点)消融成功,12例患者消融失败,其中消融靶点位于电压正常区23例,位于电压移行区95例,位于低电压区23例。ST组的单极电位下降支最大斜率(MSDL)与FT组相比差异无统计学意义,ST组单极电位激动提前时间(LAPT)高于FT组[(29.7±4.5)ms对(23.0±6.5)ms,P<0.001],ST组的MSDL间期(IMSDL)低于FT组[(11.80±10.39)ms对(21.64±11.83)ms,P=0.001]。IMSDL和LAPT对于成功靶点有预测价值[受试者工作特征曲线下面积(AUC)分别为70.7%和81.1%],但两者联合应用时对于成功消融靶点的预测价值更好(AUC89.3%,预测灵敏度为75.8%,特异度为90.4%)。结论肺动脉瓣下电压异常区域是RVOT心律失常好发部位,联合LAPT和IMSDL能更好地预测成功消融靶点。

Objective The purpose of this study was to analyze the target distribution characteristics, the voltage characteristics, and electrophysiological characteristics of unipolar potential in right ventricular outflow tract(RVOT)ventricular arrhythmias(VA). We expected to optimize the diagnostic criteria of the ablation targets for RVOT VA. Methods One hundred and forty-six consecutive patients with VA originating from RVOT underwent radiofrequency catheter ablation(RFCA)in Zhongshan Hospital from June 2016 to August 2017 were studied.One hundred and fifty-three types of premature ventricular complexes(PVC)and 6 types of ventricular tachycardia(VT)were recorded during the procedure.We recorded 141 successful targets(ST)and 192 failed targets(FT). RVOT was divided into three parts by the detailed three-dimensional voltage mapping using the Carto system prior to the RFCA.The voltage on bipolar electrogram was defined as follows: amplitude <0.5 mV as "low-voltage zone, " amplitude between 0.5 and 1.5 mV as "transitional-voltage zone, " and amplitude >1.5 mV as "normal-voltage zone" . Results One hundred and thirty-four patients with 141 targets were successfully ablated, and 12 patients failed.In the ST group, ablation target was located in normal-voltage zone in 23 patients, in transitional-voltage zone in 95 patients, and low-voltage zone in 23 patients.There was no significant difference of the max slope of the descending limb(MSDL)between ST group and FT group.The local activation preceding time(LAPT)was earlier in ST group than that in FT group [(29.7±4.5)ms vs.(23.0±6.5)ms, P<0.001]. The interval of MSDL(IMSDL)was shorter in ST group than that in FT group [(11.80±10.39)ms vs.(21.64±11.83)ms, P=0.001]. The IMSDL and LAPT were both valuable predictive indexes for ST, whose area under curve(AUC) were 70.7% and 81.1%, respectively.A better predictive value could acquire when IMSDL and LAPT were combined used(AUC 89.3%, sensibility 75.8%, specificity 90.4%). Conclusions Pulmonary subvalves are the sites of RVOT VA.A better predictive value can be acquired when IMSDL and LAPT are combined.