心房内外膜联合消融治疗多次消融复发心房颤动的初步探索

Application of combined ablation procedures via percutaneous epi/endocardial access in patients with recurrent atrial fibrillation

目的初步评估多次导管消融复发的心房颤动（房颤）患者，同时经剑突下心包穿刺和房间隔穿刺途径行内外膜联合消融房颤的可行性、有效性和安全性。方法2016年9月至2017年1月连续入选在浙江大学附属邵逸夫医院i〉2次独立房颤消融后仍复发的12例患者，同时经剑突下心包穿刺和房间隔穿刺途径，在三维电解剖标测系统导航下，行心房内外膜联合标测和射频消融治疗，观察该术式可行性和围术期并发症情况，术后规律随访。结果12例患者中，11例完成心包穿刺和心外膜标测，10例进行了心外膜消融。内膜面标测提示7例患者仍保持4根肺静脉电隔离状态，内膜面消融终止心动过速4例，阻断消融线6例。外膜面消融终止心动过速（包括房性早搏）3例，阻断消融线4例。围术期未见心脏压塞、毗邻重要脏器组织结构损伤等并发症。术后随访（3．8±1．4）个月，未见心动过速复发事件。结论对于多次消融复发的难治性房颤患者，在常规心内膜消融基础上，联合经皮心包穿刺途径行外膜标测和消融是安全、可行的。

Objective We aimed to evaluate the feasibility, safety and efficacy of combined ablation procedures via percutaneous epi/endocardial access in patients with recurrent atrial fibrillation （AF）. Methods Twelve symptomatic patients with recurrent AF who received ablation at least twice before were enrolled in this study from September 2016 to January 2017. We did both epi/endocardial mapping and ablation via percutane- ous subxiphoid pericardial and transseptal access guided by Carto 3 system （Biosence Webster, USA）. The fea- sibility and perioperative complications were observed, and follow-up study was obtained. Results Totally 11 patients received both epicardial and endocardial mapping, and 10 of them underwent epicardial ablation. Endo- eardial mapping indicated that 7 patients still kept isolation of the 4 pulmonary veins （PVs） , and further endo procedures terminated 4 atrial taehycardia（ATs） and blocked 6 ablation lines. Epicardial procedures terminated 3 ATs including one premature atrial contraction （PAC） and blocked 4 refractory ablation lines. No tamponade or other perioperative complications were observed during a mean follow-up of 3.8±1.4 months. Conclusion For refractory AF patients with repeated ablation, it might be safe and feasible to undergo map-ping and ablation via both percutaneous epi/endocardial access.