心室乳头肌起源室性心律失常射频消融

Radiofrequency ablation of ventricular arrhythmias originating from ventricular papillary muscle

目的通过分析体表心电图特征及术中激动标测特点指导起源于乳头肌室性心律失常消融。方法自2015年12月~2017年3月于陆军总医院心血管内科共对6例起源于乳头肌室性心律失常患者进行射频消融术,术前常规12导联心电图、动态心电图,术中在CARTO3下行激动标测,同期根据年龄、病史选择右室流出道间隔部头肌起源12例患者进行对照。结果 6例起源于乳头肌室性心律失常患者均即刻消融成功,1例术后第2 d复发。与非乳头肌起源相比,心室乳头肌起源室性心律失常体表心电图QRS时限显著延长,且下降支存在切迹,术中标测4例均于V波前可见P电位或低幅乳头肌电位。4例为非ST导管,2例为ST导管,导管操作及标测均较非乳头肌起源困难,时间较长,但均未应用心腔内超声(ICE)。结论乳头肌起源室性心律失常体表心电图QRS时限延长,伴有降支切迹,导管操作较困难,但在掌握其标测技巧后并不一定需ICE指导,且成功率较高。

Objective To guide radiofrequency ablation of ventricular arrhythmias originating from ventricular papillary muscle by analysis of surface electrocardiogram and features of activation mapping. Methods From December of 2015 to March of 2016, six ventricular arrhythmias patients originating from ventricular papillary muscle received radiofrequency ablation. 12 leads electrocardiogram and dynamic electrocardiogram were accomplished before the procedure. Activation mapping was implemented with CARTO3 during the procedure. At the corresponding period, twelve ventricular arrhythmias patients originating from right ventricular outflow tract septum were chosen as controls according to age and medical history. Results Six ventricular arrhythmias patients originating from ventricular papillary muscle were ablated instantly. However, ventricular arrhythmias reappeared in one patient at the 2nd day after the procedure. Compared with ventricular arrhythmias from non-papillary muscle, QRS duration of surface electrocardiogram elongated significantly, and notches appeared in the descending branch of QRS. P potentials or papillary muscle potentials at low amplitude were found in four patients during activation mapping. Four non-Smartouch and two Smartouch catheters were used during the ablation. Catheter manipulation and activation mapping were more difficult in ventricular arrhythmias patients originating from ventricular papillary muscle than in ventricular arrhythmias patients from non-papillary muscle, and procedure time elongated apparently. However, none of the six patients employed intracardiac echocardiography. Conclusion QRS duration of surface electrocardiogram in ventricular arrhythmias patients originating from ventricular papillary muscle elongated significantly, accompanied with descending branch notches. Although catheter manipulation was difficult during the procedure, intracardiac echocardiography wasn＇t necessary after a grasp of mapping skill, and successful rate of ablation was relatively high.