倒U法消融右心室流出道室性心律失常的可行性

The feasibility of catheter ablation for ventricular arrhythmias originating from right ventricular outflow tracts with reversed U-curve approach

目的探讨倒U法消融右心室流出道(RVOT)室性心律失常(VA)的可行性及安全性。方法研究纳入2008年10月31日至2019年12月31日在温州医科大学附属第二医院经RVOT及其延伸(肺动脉窦、主动脉肺干)进行消融的1510例VA患者,年龄(48.10±16.31)岁,年龄范围6~85岁。根据纳入时间及消融方法将其分为常规组(981例,男342例)和倒U法组(529例,男179例),比较2组腔内电图特征、手术时间、手术成功率及术中并发症的差异。结果①倒U法组与常规组分别有经RVOT及其延伸消融成功率差异无统计学意义[86.20%(456/529)对87.56%(859/981),χ^(2)=0.539,P>0.05];②单因素分析显示倒U法组采用三维标测、冷盐水灌注导管、R0 Swartz鞘支撑、有效靶点单极标测呈QS型伴降支挫折、双极标测呈初始高幅尖峰电位或初始多峰碎裂电位,可记录到远场A波的比例更高,且腔内双极电图有效靶点的V波至体表心电图的QRS波时间(V-QRS时间)及X线曝光时间、手术时间更长(均P<0.001),而放电时间更短(P<0.001);多因素Logistics回归分析排除了有效靶点V-QRS时间存在的差异(P>0.05),其他因素2组间差异依然存在(均P<0.001)。③倒U法组消融时剧烈胸痛发病率[22.31%(118/529)对8.56%(84/981),P<0.001]及心率明显下降的发生率[21.17%(112/529)对12.13%(119/981),P<0.001]明显高于常规组;常规组放电时有爆裂音出现率明显高于倒U法组[7.75%(76/981)对2.08%(11/529),P<0.001];倒U法组未见心包积液或心脏压塞。结论倒U法消融RVOT-VA安全有效。

Objective To evaluate clinical effects and safety of catheter ablation for right ventricular outflow tracts(RVOT)ventricular arrhythmias(VA)with reversed U-curve methods.Methods The study enrolled 1510 consecutive patients with VA underwent radiofrequency ablation(RFCA)via the RVOT and its extension[pulmonary sinus cusp(PSC)and main stem of the pulmonary artery(MSPA)]in The Second Affiliated Hospital of Wenzhou Medical College from October 31th,2008 to December 31th,2019,to analyze the feasibility of RFCA with reversed U-curve approach.The mean age of patients was(48.10±16.31)years(6-85 years).The patients were divided into 2 groups according to the time and method of ablation.Results①Reversed U-curve approach and the routine approach groups had successful ablation of 86.20%(456/529)and 87.56%(859/981)via RVOT and its extension.The success rate of ablation was no statistical significance(χ^(2)=0.539,P>0.05).②In the reversed U-curve approach group,univariate analysis showed that with the three-dimensional mapping,cold saline perfusion catheter,and R0 Swartz sheath support,effective target unipolar potential demonstrated QS with descending branch depression,while bipolar potential recorded initial high spike potential or initial multi-peak fractional potential,and the proportion of far-field A-wave was higher in reversed U-curve approach group.The time between the V-wave of effective target in endocardial bipolar electrogram to the QRS wave of surface electrocardiogram(V-QRS time).X-ray exposure time and operation time were longer(all P<0.001),while the discharge time was shorter(all P<0.001).Multi-factor Logistics regression analysis showed that there was no difference of V-QRS time of effective target(P>0.05),while the other difference still existed difference between the 2 groups(all P<0.001).③During the ablation,the reversed U-curve approach group had a higher proportion of severe chest pain[22.31%(118/529)vs.8.56%(84/981),P<0.001]and a significant decrease in heart rate[21.17%(112/529)vs.12.13%(119/981),P<0.001],comparing with the routine approach group.Reversed U-curve approach group had crackle of 2.08%(11/529),and no patients had pericardial effusion or pericardial tamponade,while the routine approach group had crackle of 7.75%(76/981)and pericardial effusion or pericardial tamponade of 0.96%(9/981)(all P<0.001).Conclusion It is safe and effective to ablate RVOT-VA with reversed U-curve approach.