一种用于定位三尖瓣环不同方位起源的特发性室性心律失常的体表心电图方法的建立及验证

Establishing and validating a surface electrocardiographic method for locating idiopathic ventricular arrhythmias with different origins of tricuspid annulus

背景采用体表心电图对起源于三尖瓣环的室性心律失常(ventricular arrhythmias of the tricuspid annulus,TA-VAs)进行定位较为困难,尤其是对起源点的精确定位。目的总结TA-VAs的体表心电图特征,提出一种应用体表心电图定位TA-VAs的方法,并在临床病例中进行验证。方法选取2013年10月—2023年8月在解放军总医院第一医学中心经Carto 3三维标测系统引导下行射频导管消融的TA-VAs患者,以2021年8月为界,分为回顾组和验证组。收集回顾组患者心电图资料进行分析,开发一种识别不同方向起源TA-VAs的心电图算法:对于考虑TA起源的VAs,可根据联合应用下壁导联和V1导联的QRS波群形态定位起源位置。应用上述算法计算起源点位置,并与实际消融位置对比,计算所得方位与实际消融方位误差,评估方法准确性。对于验证组患者,前瞻性应用本心电图算法对起源点位置进行预测,优先在预测方位±1点钟方向标测消融,若在此区域内成功消融则认为心电图算法应用成功。结果共纳入88例患者,其中回顾组62例,男性31例,女性31例,中位年龄54.00(IQR:35.00~64.25)岁;验证组26例,男性17例,女性9例,中位年龄55.50(IQR:39.75~66.00)岁;两组年龄、性别差异无统计学意义(P>0.05)。回顾组和验证组应用此方法判断TA-VAs起源点方位的准确率分别为85%和88%,总准确率为86%。应用此方法指导射频消融手术的验证组患者消融时间[(216.68±99.08)s vs(136.81±68.89)s,P<0.001]和手术时间[(99.82±36.87)min vs(69.96±30.51)min,P<0.001]均短于回顾组,差异有统计学意义。结论TA-VAs具有特征性的心电图表现,通过利用联合应用下壁导联和V1导联QRS波形态的心电图算法,可实现TA-VAs的更准确定位。采取本研究心电图算法指导TA-VAs消融可缩短手术时间,减少无效消融,提高手术效率。

Background It is very difficult to locate ventricular arrhythmias of the tricuspid annulus(TA-VAs)by surface electrocardiogram(ECG),especially the accurate origin of TA-VAs.Objective To summarize the surface ECG characteristics of TA-VAs,propose a method for locating TA-VAs using surface ECG,and verify it in clinical cases.Methods Patients with TA-VAs who underwent RFCA guided by Carto 3 three-dimensional mapping system in the First Medical Center of Chinese PLA General Hospital from October 2013 to August 2023 were selected.With August 2021 as the boundary,they were divided into review group and validation group.The ECG data of patients were collected and analyzed,and an ECG algorithm was developed to identify TAVAs originating from different directions.For VAs considering the origin of TA,the origin position could be located according to the QRS complex morphology of inferior leads and lead V1.For the patients in the review group,the above algorithm was applied to calculate the position of the origin point and compared with the actual ablation position,and the error between the calculated position and the actual ablation position was assessed to evaluate the accuracy of the method;For the patients in the verification group,the ECG algorithm was prospectively applied to predict the position of the origin point,and the ablation was preferentially mapped in the predicted direction of 1 o'clock.If the ablation was successful in this area,the ECG algorithm was considered to be successful.Results A total of 88 patients were included and there were 62 cases in the review group,including 31 males and 31 females,with a median age of 54.00(IQR:35.00-64.25)years,and 26 cases in the validation group,including 17 males and 9 females,with a median age of 55.50(IQR:39.75-66.00)years.In this study,an ECG algorithm was developed to identify TA-VAs originating in different directions.For VAs considering TA origin,the location of origin could be located based on the combined application of QRS morphology in inferior leads and lead V1.The accuracy of this method in determining the orientation of the origin point of TA-VAs was 85%in the review group and 88%in the validation group,and the total accuracy was 86%in this study.The ablation time([216.68±99.08]s vs[136.81±68.89]s,P<0.001)and operation time([99.82±36.87]min vs[69.96±30.51]min,P<0.001)of the validation group were significantly shorter than those of the review group.Conclusion TA-VAs has typical ECG features.More accurate localization of TA-VAs can be achieved by combining the ECG algorithm of inferior leads and lead V1 QRS morphology.TA-VAs ablation guided by the ECG algorithm in this study can shorten the operation time,reduce ineffective ablation,and improve the efficiency of the operation.