经皮心包穿刺术进行室性心律失常心外膜标测和消融的应用体会

Application of pericardial puncture for mapping and ablation of ventricular arrhythmias

目的：总结经皮心包穿刺技术应用于室性心律失常（ VA）心外膜标测和消融的有效性和安全性。方法回顾性分析2010年4月至2014年10月在广东省人民医院心内科经剑突下行心包穿刺术（ Sosa法）进行心外膜标测的40例VA患者,男28例,女12例,平均年龄（46±13）岁。合并非缺血性心肌病（NICM）16例,致心律失常性右心室心肌病（ARVC）11例,缺血性心肌病（ICM）3例,特发性VA 10例。分析患者穿刺术中、消融过程中及围术期出现的并发症、原因及处理策略,并总结穿刺、标测和消融过程如何避免潜在的并发症。结果所有患者均穿刺成功,其中25例患者1次穿刺成功,15例经过2次以上穿刺成功；右心室前壁路径15例,下壁路径25例。共35例（87．5%）患者消融成功,其中15例仅在心外膜消融成功；14例行心外膜-心内膜联合消融成功；另有6例经过心内膜-心外膜联合标测提示VA并非起源于心外膜,于心内膜消融成功。2例NICM合并的室性心动过速（室速）患者心内外膜联合消融失败,2例特发性室性早搏（室早）患者因靶点靠近冠状动脉而放弃消融；1例穿刺致冠状动脉损伤而放弃消融。共13例（32．5%）患者发生并发症,包括穿刺针进入右心室6例（15%）,退出后未造成后果；心包出血2例（5%）,经引流后痊愈；导丝进入胸膜腔2例（5%）,退出后未造成后果；迟发心脏压塞1例（2．5%）,经引流后治愈；冠状动脉损伤并急性心脏压塞1例,经外科手术修补成功；1例患者术后有发热,对症处理后好转。结论经皮心包穿刺行心外膜标测和消融有助于提高器质性心脏病VA消融成功率,虽然目前并发症发生率还较高,但及时发现和正确处理,多数可避免出现严重后果。

Objective To evaluate the effects and safety of pericardial puncture for epicardial mapping and ablation of ventricular arrhythmias（VA）. Methods We retrospectively studied 40 patients with VA who ac-cepted the subxyphoid pericardial puncture （ Sosa ’ s method ） for epicardial mappings. There were 28 men, 12 women,aged（46±13）years. Sixteen patients suffered from non-ischemic cardiomyopathies（NICM）,11 arrhythmo-genic right ventricular cardiomyopathies（ ARVC） ,3 ischemic cardiomyopathies（ ICM） ,10 idiopathic VA. We ana-lyzed how to minimize the occurrence of complications associated with this technique,and how to rapidly recognize and treat the complications that they encountered. Results The pericardial punctures were done successfully at the first attempt in 25 patients,while in 15 patients the pericardial puncture were done successfully at the second attempt or more. Fifteen pericardial punctures were directed to the anterior wall of the right ventricle,while 25 were directed to the inferior wall. Totally in 35 cases（87. 5%） the ablations were successful,including targets on the epicardium in 15 patients,targets on both the endocardium and the epicardium in 14 patients,targets on the endocardium in 6 patients demonstrated by the combined endocardial and epicardial mappings. The combined en-docardial and epicardial ablation failed in two patients with ventricular tachycardias due to NICM. The ablations in 2 cases with idiopathic premature ventricular contractions were abandoned due to vicinity of coronary arteries. In one patient,the ablation was given up due to coronary artery injured by puncture. Totally 13 patients（32. 5%）suf-fered from complications including a severe one（2. 5%）. There were 6 cases（15%）of right ventricular injuries＆amp;nbsp;without adverse results. There were 2 cases（5%）of bleeding in pericardial cavities,cured by drainage. The guide-wires entered the pleural cavities in 2 cases（5%）,without adverse results. There was one case（2. 5%） of late pericardial tamponade,cured by drainage of 80 ml effusion. There was one case of acute pericardial tamponade due to injury of coronary artery,cured by emergent surgery. Thirty-five（87. 5%） patients had a pigtail catheter placed in the pericardial cavity for drainage,including 1 suffered from fever and cured by medicine. Conclusions Although the incidence of complications of epicardial puncture was high, but only a few cases were se-vere. Timely recognition and treatment of complications can help to avoid severe results. Epicardial mapping and ablation of VA via pericardial puncture is effective and feasible,especially for structural heart diseases.