心大静脉远端移行区室性心律失常的消融治疗

The characteristics of catheter ablation of ventricular arrhythmia originating from the distal great cardiac vein

目的 探讨心大静脉远端（DGCV）移行区特发性室性心律失常（VAs）有效消融靶点腔内心电图特征及消融时注意事项.方法 研究纳入2006年10月至2016年3月于温州医科大学附属第二医院心内科成功行射频消融治疗的50例DGCV不同部位室性早搏（PVC）/室性心动过速（VT）患者,分析DGCV不同部位PVC/VT有效消融靶点腔内心电图特征及消融时注意事项.结果 根据标测及有效靶点消融结果分为4个亚组：心大静脉远端1组[DGCV1组,11例,男7例,年龄（52.18±15.81）岁]、心大静脉远端2组[DGCV2组,13例,男7例,年龄（51.01±15.22）岁]、前室间静脉近端组[PAIV组,17例,男9例,年龄（52.51±14.35）岁]和心大静脉远端延伸支组[EDGCV组,9例,男3例,年龄（52.91±14.11）岁].4组有相似的有效靶点腔内电图特征,双极标测呈多峰碎裂电位发生率高82.00%（41/50）,26.00%（13/50）伴电位翻转例;90.00%（45/50）可完成起搏标测,起搏的QRS波形态与自发PVC/VT 12导联形态完全相同22例（48.89%）,11个导联形态相同18例（40.00%）,10个导联形态相同5例（11.11%）.心大静脉区域较细,常需心脏静脉造影引导消融导管的放置,且与左冠状动脉毗邻,故消融前均应进行冠状动脉造影.结论 当心室流出道起源PVC/VT经右心室流出道、主动脉窦或窦下、二尖瓣环前侧壁消融无效时,经心脏静脉系统进行标测和消融安全有效.

Objective To investigate the radiofrequency catheter ablation（RFCA） of idiopathic ventricular arrhythmias（VAs） originating from the distal great cardiac veins（DGCV）.Methods The study included 50 patients underwent successful RFCA of premature ventricular contraction（PVC）/ventricular tachycardia（VT） originating from different portions of the DGCV in Department of Cardiology,Second Affiliated Hospital of Wenzhou Medical University from October 2006 to March 2016.The intracardiac electrogram feature,intraventricular ablation mapping features and announcements of ablating PVC/VT originating from different portions of DGCV were assessed.Results The patients were divided into four groups according to the mapping and ablation results,DGCV1（11 patients,man 7,age 52.18±15.81）,DGCV2（13 patients,man 7,age 51.01±15.22）,proximalanterior interventricular vein（PAIV）（17 patients,man 9,age 52.51±14.35）and extend DGCV（EDGCV）（9 patients,man 3,age 52.91±14.11）groups.All four groups shared similar intracardiac electrogram feature in efficient ablation site.Bipolar mapping showed multi-peak fractional potentials 82.00%（41/50）,26.00%（13/50）with reserve potentials.Pace-mapping can be achieved in 45 patients（90%）.The QRS complex morphology of pacing were perfect match（12/12）with spontaneous PVC/VT in 22 patients,near-perfect match（11/12）in 18 patients,（10/12）in 5 patients.The veins of this area were thin and near the left coronary artery,so both coronary arteriongraphy（CAG） and coronary venography（CVG） should be performed before the ablation to ensure the security.Conclusion RFCA via the coronary venous system was a relatively effective and safe approach for PVC/VTs when fail to achieve the successful ablation in and under the aortic sinus and RVOT.