心内膜消融失败难治性局灶性房性心动过速的心外膜高密度标测及导管消融

High density mapping and catheter ablation for refractory focal atrial tachycardia in epicardial approach after endocardial ablation failed

目的总结经心内膜消融失败的难治性局灶性房性心动过速(房速)在高密度标测下的电生理特点及经心外膜消融成功的经验。方法本研究为回顾性描述性研究, 选取2018年6月至2021年10月来自3家医疗机构共186例经术中电生理检查确诊为局灶性房速患者, 使用高密度标测系统常规进行心内膜导管消融。13例经心内膜消融失败患者中, 3例起源于心耳尖部接受外科微创手术行心耳结扎或切除, 10例经心外膜标测和消融成功。总结并分析10例经心外膜消融成功患者的临床特征、电生理检查、高密度标测相关指标、消融及随访结果。结果 10例经心外膜消融成功的局灶性房速患者中, 女7例、男3例, 年龄(38.4±11.5)岁, 术前左心室射血分数为51.2%±4.6%, 抗心律失常用药(包括Ⅰ类、Ⅲ类抗心律失常药物)共(1.5±0.7)种。内外膜联合的高密度标测结果:3例起源于右心耳与上腔静脉交界处、3例起源于Bachmann束在左心房的插入点、2例起源于右心房游离壁的心外膜侧、1例于右心耳心外膜侧、1例起源于左心房心外膜Marshall静脉区域。心外膜最早激动点(EAS)的激动时间提前心内膜(8.3±4.5) ms, 内、外膜EAS之间的距离为(8.6±2.7) mm, 心外膜消融靶点电位时限较窄[(37.1±13.9) ms], 振幅较高[(0.76±0.31) mV], 3例患者在成功消融的部位记录到双极电图碎裂电位。10例患者均在心外膜EAS消融成功。随访27.5(8.0, 40.0)个月, 10例患者均未使用抗心律失常药物, 均未发生房速。结论经心外膜标测和消融是治疗心内膜局灶性房速消融失败的一种安全有效的方法。

Objective To summarize the electrophysiological characteristics of refractory focal atrial tachycardia(AT)failed by endocardial ablation and successful by epicardial ablation under high density mapping,and experiences of successful epicardial ablation.Methods This study was a retrospective descriptive research.A total of 186 patients diagnosed with focal AT by intraoperative electrophysiological examination from three medical institutions from June 2018 to October 2021 were selected.High density mapping system was used for routine endocardial catheter ablation.Among the 13 patients who failed by endocardial ablation,3 underwent surgical minimally invasive procedures for left atrial appendage ligation or excision at the tip of the left atrium,and 10 underwent successful epicardial mapping and ablation.The clinical characteristics,electrophysiological examination,high density mapping,surgical ablation,and follow-up results of the 10 patients who underwent successful epicardial ablation were summarized and analyzed.Results Among the 10 patients with focal AT,there were 7 females and 3 males,with an average age of(38.4±11.5)years.The preoperative left ventricular ejection fraction was 51.2%±4.6%.The number of antiarrhythmic drugs used(including classⅠand classⅢantiarrhythmic drugs)was 1.5±0.7.High density mapping results combining endocardial and epicardial mapping showed that 3 cases originated from the junction of the right atrial appendage and superior vena cava,3 cases originated from the insertion point of the Bachmann bundle in the left atrium,2 cases originated from the epicardial side of the free wall of the right atrium,1 case originated from the epicardial side of the right atrial appendage,and 1 case originated from the Marshall vein area in the epicardium of the left atrium.The activation time of the earliest epicardial activation site(EAS)was earlier than the endocardium by(8.3±4.5)ms,and the distance between the endocardial and epicardial EAS was(8.6±2.7)mm.The epicardial ablation target potential had a narrow duration[(37.1±13.9)ms]and a high amplitude[(0.76±0.31)mV].Three patients had fragmented electrograms recorded at the successfully ablated sites.All 10 patients underwent successful epicardial EAS ablation.Following up for 27.5(8.0,40.0)months,all 10 patients did not use antiarrhythmic drugs and did not experience AT.Conclusion Epicardial mapping and ablation is a safe and effective method for treating failed endocardial focal AT ablation.