CARTO指导下射频消融低位环右心房逆钟向折返不典型心房扑动

CARTO Guiding Radio Ablation for Counterclockwise Right Atrial Lower Loop Reentry Atypical Atrial Flutter

目的 分析逆钟向低位环折返不典型心房扑动的特点 ,评价CARTO标测系统对其鉴别诊断的意义。方法 一 5 7岁男性患者 ,因长期反复的心房扑动进行心脏电生理检查和导管射频消融治疗。常规放置右心房内导管、希氏束导管、冠状窦导管和标测消融导管。在心动过速中进行激动标测、电解剖标测及三尖瓣环至峡部的连续性线性消融。以宽分离的双电位为射频消融的终点。结果 体表心电图和心内激动顺序提示为典型心房扑动。多部位拖带标测发现右心房侧壁远离折返环 ,低位右心房后壁在折返环上 ,峡部隐匿性拖带。进一步CARTO标测提示折返环沿下腔静脉逆钟向折返 (尾头方向观 )。进行峡部至三尖瓣环的连续性线性消融终止心动过速 ,并出现宽分离的双电位。随访 6个月 ,未服用任何抗心律失常药物 ,无心房扑动复发。结论 逆钟向低位环折返不典型心房扑动可与典型心房扑动共用三尖瓣环与下腔静脉间的峡部作为缓慢传导区。峡部消融可以终止并消除心动过速。传统的标测方法容易漏诊 。

Objective To analysis the characteristics of counterclockwise lower loop reentry (LLR) atypical atrial flutter (AFL), and evaluate the value of 3D mapping system in the differential diagnosis of AFL.Methods A 57 years old man with frequently episodes of AFL was involved in the study. Surface ECG showed typical AFL. Atrial electrograms were recorded from the coronary sinus (CS), His postion and from a decapolar catheter in right atrium. A Biosense Navistar catheter was placed in the tricuspid annuluseustachican ridge(TAER) isthmus. Activation sequence mapping was performed during tachycardia and a 3D endocardial activation map of the RA was generated with the CARTO system. Entrainment pacing was performed with a pacing cycle length of 20 ms less than tachycardia cycle length at multiple sites in the RA (n = 67). Ablation was performed during tachycardia with the Navistar catheter with a drag lesion from the tricuspid annulus to the eustachican ridge in a continuous fashion widely separated double potential at isthmus was regarded as the endpoint. Results Entrainment pacing and detailed 3D mapping indicated the tachycardia was isthmus dependent with reentry circuit confined to the lower portion of the right atrium around inferior vena cava in a counterclockwise fashion when viewed in a caudaltocranial direction. Linear ablation between tricuspid annulus to the eustachican ridge led to termination of the tachycardia. A widely separated double potential was recorded after the linear ablation. There is no AFL during a 6 months followingup without any antiarrhythmia treatment.Conclusion LLR may coexist with mimic typical counterclockwise AFL and share the same isthmus (TAER isthmus) between the tricuspid annulus and the eustachian ridge. 3D mapping will be more helpful to find the exact reentry circuit.