三尖瓣峡部的心腔内超声解剖学特征

Cavotricuspid isthmus:anatomical features of intracardiac ultrasound

目的本研究使用心腔内超声观察三尖瓣峡部实时解剖学形态特征。方法北京大学第一医院心内科连续收治的房性和室性心律失常行导管消融且使用了心腔内超声标测的患者共纳入79例,其中45例心房颤动/心房扑动(简称房颤/房扑),34例室性早搏/室性心动过速(简称室早/室速)。在导管消融术的标测过程中,使用心腔内超声留取右房三尖瓣峡部三个扇面的影像,分别为游离壁峡部、中心峡部和间隔峡部,并使用压力感应消融导管或多极标测电极进行右房三维模型重建。观察和记录三尖瓣峡部是否存在囊袋样凹陷及其形态与分布、有无粗大的梳状肌、有无欧氏嵴隆起、有无未退化的欧氏瓣或希阿里氏网,并测量右冠状动脉与三尖瓣峡部心内膜面的距离。结果房颤/房扑组的三尖瓣峡部存在囊袋样凹陷明显多于室早/室速组(80%vs 59%,P=0.028)。囊袋样凹陷多出现于间隔峡部、欧氏嵴前方靠近下腔静脉口,呈圆坑状或裂隙状。LogOR曲线分析提示三尖瓣峡部囊袋样凹陷的存在与年龄呈正相关。三尖瓣峡部存在粗大梳状肌、欧氏嵴隆起、以及未退化的欧氏瓣或希阿里氏网的比例在房颤/房扑组与室早/室速组无明显差异(22%vs 26%,27%vs 35%,9%vs 15%,P均>0.05)。走行在右房室沟内的右冠状动脉与游离壁峡部心内膜的距离最短(3.6±1.2)cm。结论三尖瓣峡部普遍存在囊袋样凹陷,尤其多见于房颤/房扑的患者,心腔内超声的实时影像有助于精准判断三尖瓣峡部的解剖学特征。

Objective To observe the real-time anatomical characteristics of the cavotricuspid isthmus.Methods Seventy-nine patients with tachyarrhythmias who underwent catheter ablation and used intracardiac ultrasound mapping were included in the Department of Cardiology of the Peking University First Hospital.The study population included 45 cases of atrial fibrillation/atrial flutter(AF/AFL)and 34 patients of ventricular premature beat/ventricular tachycardia(PVC/VT).Used the intracardiac ultrasound to retain the images of three sectors of the cavotricuspid isthmus of the right atrium,namely the free wall isthmus,the central isthmus,and the septal isthmus,to observe and record whether there was a pouch and its shape and distribution in the cavotricuspid isthmus.Moreover,used the pressure sensing ablation catheter or multipole mapping electrode to reconstruct the three-dimensional model of the right atrium.And confirmed the following:Whether there were thick pectinate muscles,prominent Eustachian ridge,non-degenerated Euclidean valve,or Chiari′s network,measured the distance between the right coronary artery and the endocardial surface of the annular isthmus of the tricuspid valve.Results The pouch of the cavotricuspid isthmus was more common in the AF/AFL group than in the PVC/VT group.Among them,36(80%)of 45 patients with AF/AFL and 20(59%)of 34 patients with PVC/VT had a pouch in the cavotricuspid isthmus(P=0.028).A sub-Eustachian pouch mainly occurs in the septal isthmus,close to the orifice of the inferior vena cava,in a round pit or fissure shape,which was related to age.There was no significant difference between the AF/AFL group and the PVC/VT group in the thick pectinate muscles,the proportion of prominent Euclidean ridge eminence,and the proportion of non-degenerated Euclidean valve or Chiari′s network(22%vs 26%,27%vs 35%,and 9%vs 15%,P>0.05).In addition,the distance between the right coronary artery running in the right atrioventricular sulcus and the endocardium of the isthmus of the free wall was the shortest(3.6±1.2)cm.Conclusion The sub-Eustachian pouch is common in the tricuspid isthmus,especially in patientswith AF/AFL.The real-time image of intracardiac ultrasound is helpful to accurately judge the anatomical characteristics.