三维标测系统指导下采用射频消融基质改良治疗器质性室性心动过速7例

Treatment of ventricular tachycardia and structural heart disease by substrate modified ablation guided by 3-dimensional mapping system in 7 patients

目的 研究在接触式三维标测系统指导下,采用射频消融对器质性室性心动过速的患者进行基质改良治疗的方法、电生理特点及消融结果。方法 2013年5月至2014年3月,武汉亚洲心脏病医院对7例患有器质性心脏病（4例扩张型心肌病,2例缺血性心肌病,1例致心律失常性右心室心肌病）,同时有反复室性心动过速发作的患者（3例伴有晕厥）,在接触式三维标测系统指导下进行心脏电解剖重建,将心室双极电压〈0.5 m V的区域标记为致密瘢痕区,〉1.5 m V的为正常心肌,0.5~1.5 m V为低电压区。在致密瘢痕区、低电压区域内及其周围仔细寻找及标记窦性心律时的心室晚电位,以及室性心动过速时的舒张期电位。在所有能标记到这些特殊电位的区域,用冷盐水灌注消融导管以35~40 W、43℃、流速8~20 m L/min进行片状基质消融治疗,直至特殊电位基本消失,然后进行心室程序刺激及递增刺激确定不能诱发出临床类型的室性心动过速后结束手术。结果7例术中均可标测到瘢痕区,其中1例在心外膜面,2例在心外膜及心内膜面均有,其余4例位于心内膜面。瘢痕区域面积（31.0±17.7）cm2,占心室总面积14.5%±5.2%。瘢痕区域内及其周围在窦性心律时可记录到心室晚电位。7例患者共诱发出室性心动过速12种,其中2种起源于右心室,10种起源于左心室。室性心动过速发作时所有患者均可记录到心室舒张期电位。7例均成功完成手术,经过基质改良治疗后即刻消融成功率为100%,消融时采点数112.7±62.4,手术时间（159.3±37.6）min。7例患者中仅有3例植入了埋藏式心脏复律除颤器（implantable cardioverter defibrillator,ICD）。7例随访1~11个月,有1例植入了ICD的患者出现心力衰竭死亡,另有1例仍有室性心动过速发作,并出现心悸、黑及晕厥,其余5例无室性心动过速再发。结论 对于器质性心脏病所致的室性心动过速在接触式三维标测系统的指导下,采用射频消融进行基质改良治疗是有效的、可行的。

Objectives To investigate the methods,electrophysiological characteristics and treatment outcomes of substrate modified ablation under the guidance of 3-dimensional contact mapping system in patients with ventricular tachycardia（VT） and structural heart disease. Methods From May 2013 to March 2014, 7 patients with structural heart disease（4 with dilated cardiomyopathy,2 with ischemic cardiomyopathy and 1 suffering from arrhythmogenic right ventricular cardiomyopathy） and recurrent VT（3 with syncope） received EP study and ablation under the guidance of CARTO system in Wuhan Asia Heart Hospital. Accordingly, densely scarred area was arbitrarily defined as that of ventricular bipolar voltage〈0.5 m V, normal tissue was defined as that of 〉1.5 m V, and low voltage area was set to that of 0.5-1.5 m V. Late ventricular potential during sinus rhythm along with diastolic potential during VT in and around densely scarred and low voltage areas were observed and marked. These marked areas with special potentials were ablated until the special potentials disappeared. Before the end of ablation, programmed and increased ventricular stimulations were repeated to confirm no clinical VT could be induced. Results Scarred areas were found in all the 7cases（1 on the epicardial surface, 2 on the epicardial and endocardial surface, 4 on the endocardial surface）. The scarred areas [（31.0 ±17.7） cm2] occupied（14.5% ±5.2%） of the ventricular area. Late ventricular potentials were marked during sinus rhythm in and around the scarred areas. Of the 7 patients, 12 VTs were induced during the procedure（2 originating from right ventricle, 10 originating from left ventricle）. Ventricular diastolic potentials were recorded during VT. All the 7 patients received ablation successfully. The immediate success rate was 100% [ablation points ：112.7 ±62.4, ablation duration ：（159.3 ±37.6）min ]. Only 3 patients received implantable cardioverter defibrillators（ICD）. During the follow-up of 1 to 11 months,1 patient who received ICD implantation died of heart failure, 1 patient appeared VT as well as palpitation, amaurosis and syncope, and the others didn ＇t appear VT.Conclusions The substrate modified ablation under the guidance of 3-dimensional contact mapping system is effective and safe for VT ablation in patients with structural heart disease.