高密度标测在器质性心脏病室性心律失常电风暴导管消融中的应用

Radiofrequency catheter ablation of ventricular arrhythmia storm guided by high-density mapping in structural heart disease

目的评价单中心应用多极电极导管进行高密度标测指导器质性心脏病室性心动过速（室速）消融治疗的即刻和远期疗效。方法回顾性分析2014年8月至2015年11月在南京医科大学第一附属医院心血管内科进行消融治疗的14例器质性心脏病室速电风暴患者，平均年龄（49．1±16．1）岁，男12例，女2例。采用20极或10极可控标测导管于EnSite—Velocity（美国圣犹达公司）三维电解剖标测系统导航下行高密度采点标测（包括高密度激动及基质标测）并指导消融。结果14例共接受15次标测及消融，单纯行心内膜途径7次，联合心内膜及心外膜途径8次，术中共诱发或自发28种室速，平均周长为（358±107）ms，18％为血流动力学不稳定性室速或蜕变为心室颤动（室颤）。所有患者均行窦性心律（13例）或起搏下（1例）高密度基质标测，8例心内膜及心外膜联合途径消融者经高密度标测发现，其心外膜病变区域（包括瘢痕区、病变移行区及低电压区）显著大于心内膜（P值均〈O．05），术中平均x线曝光时间（37．6±7．6）min，手术总时间（227±34）min。消融治疗即刻完全成功率、部分成功率及失败率分别为53．3％、26．7％及20．0％，总体有效率为80．0％。所有患者均无严重手术并发症发生。于末次消融术后平均随访（8．2±3．6）个月，1例患者因严重心力衰竭于术后2周内死亡。远期完全成功率、部分成功率及失败率分别为84．6％、7．7％及7．7％，总体有效率92．3％。结论应用多极标测导管行高密度标测可较为准确地锁定器质性心脏病室速相关基质部位及关键传导通道，依此指导消融可有效控制电风暴平Ⅱ／或室速发作。

Objective To investigate the efficacy of high density mapping using muhielectrode cathe- ters and EnSite-Velocity system （ St. Jude Medical, US. ） for guiding radiofrequency ablation of ventricnlar ar- rhythmia storm（VAS） in structural heart disease.Methods Fourteen VAS patients [ 12 men ,mean age（ 49.1 ± 16.1 ）years ] with structural heart disease were retrospectively analyzed.Endoeardial and/or epicardial high den- sity mapping was performed with a steerable duodecapolar or decapolar catheter during the ventricular tachyear- dia（VT） and/or the baseline rhythm ,either sinus or paced ,with EnSite-Velocity system.Results A total of 15 mapping and ablation procedures were performed in 14 patients.Seven of them were performed only through en- docardial approach.Combined endocardial and epicardial approach were carried out in other 8 procedures.The abnormal substrate areas in epicardium were significantly larger than that in endocardium.Twenty-eight types of VT（ including 18% hemodynamically unstable VT or degenerated to ventrieular fibrillation）were induced or spontaneous during the procedures [ mean cycle length（ 358± 107 ） ms ] .The average X-ray fluoroscopy time and procedural time were （ 37.6± 7.6） rain and （ 227 ± 34） min, respectively. Complete success, partial success, and failure rates immediately post ablation were 53.3 %, 26.7 % and 20. 0%, respectively. During a mean follow-up of （8.2±3.6）months after the last ablation procedure,one patient died from severe heart failure after discharge in 2 weeks.The lang-term complete success,partial sueeess ,and failure rates were 84.6% ,7.7% and 7.7%, re- speetively.Conclusion The VT substrates and/or channels could be effectively deteeted and ablated by high density mapping via using multielectrede catheters and EnSite-Velocity system.