分支性室速的机制、导管消融治疗的长期有效性及复发影响因素

发布时间：2018-01-02 19:16

  本文关键词：分支性室速的机制、导管消融治疗的长期有效性及复发影响因素　出处：《北京协和医学院》2017年博士论文　论文类型：学位论文

  更多相关文章： 导管消融 复发 室性心动过速 标测 分支性室性心动过速 微折返 导管消融 电生理 复发 分支性室性心动过速 左后分支室速 导管消融 左后分支阻滞 标测

【摘要】：第一部分导管消融治疗分支性室速的长期有效性及复发的预测因素[研究背景]分支性室性心动过速(Fascicular ventricular tachycardia,FVT)是左室特发性室性心动过速(室速)中最常见的类型。关于导管消融治疗的长期有效性的研究仍较少。本研究通过分析接受导管消融治疗的FVT患者数据,探讨导管消融治疗FVT的长期有效性及复发的预测因素。[研究方法]连续入选我中心2005年3月至2016年12月期间收治的因FVT接受电生理检查及导管消融的患者。进行激动顺序标测,在心动过速时标测到最早的浦肯野电位(P电位)处为靶点。如果FVT不能诱发或心动过速不持续而难以进行详细的激动顺序标测时则结合起搏标测结果确定靶点。术后规律对患者进行随访。[研究结果]共入选234例FVT患者,平均年龄30±13岁,其中男性占82%。在183例(78.2%)患者中完成了详细的激动顺序标测,其余51例因心动不能诱发或不持续而难以进行详细的激动顺序标测,需要结合起搏标测结果确定靶点。231例(98.7%)达到了即刻消融成功。在术后平均随访58±42(1-135)月期间,有35例(15.2%)室速复发,其中绝大部(85.7%)的室速复发发生在术后1年内。不能进行详细的激动顺序标测是术后室速复发的独立预测因素(OR:4.9,95%CI:2.3-10.7,P0.001)。[结论]在平均随访5年期间,导管消融治疗FVT有效性达84.8%。绝大多数的室速复发发生在术后的1年内。未能进行详细的激动顺序标测是术后室速复发的独立危险因素。第二部分分支性室速的机制及消融后复发的原因分析[研究背景]虽然越来越多的研究表明分支性室性心动过速(Fascicular ventricular tachycardia,FVT)的机制是折返,但仍尚未完全明确。应用EnSite Array(EA)三维电解剖标测系统进行标测FVT,能够地显示每一次心跳虚拟激动传导。本研究的目的通过EA探索FVT的机制,同时分析FVT消融失败的原因。[研究方法]本研究入选21例(平均年龄33±15岁,男性17例)因左后分支室性心动过速首次接受电生理检查及射频消融患者,所有患者均在EA指导下完成标测及消融。同时入选57例(平均年龄28±12岁,男性45例)既往外院消融失败或复发的患者。分析所有患者的标测及消融数据。[研究结果]EA激动顺序标测显示FVT为微折返机制,未见大折返表现,心动过速时最早激动位于左室间隔面中段区域,而后经左后分支及左前分支向整个左室扩布,其中左后分支远端心肌最早激动。在既往消融失败或复发的病例中,标测未见大折返表现,8.8%的患者中诊断错误是消融失败的原因。[结论]应用EA激动顺序标测提示FVT的机制是微折返,支持采用激动顺序标测寻找心动过速时最早的浦肯野电位作为有效的消融靶点的标测和消融策略,而未标测到心动过速时真正的最早浦肯野电位是FVT消融失败或术后复发的主要原因。第三部分左后分支室速导管消融术后的特殊复发类型:发生率、机制及最佳消融策略[研究背景]左后分支室性心动过速(Left posterior fascicular ventricular tachycardia,LPF-VT)应用导管消融术治疗后复发病例中常有形态改变,如何标测和消融这种“新发的”室性心动过速(室速)尚未达成共识。本研究通过分析大样本的LPF-VT导管消融资料,探讨这种“新发的”室速的发生率、机制及最佳的消融策略。[研究方法]通过分析我中心2005年3月至2016年12月期间因分支性室速首次接受电生理检查及导管消融治疗的病例资料,探讨LPF-VT消融术后“新发的”右束支阻滞+电轴右偏形态室速的发生率、机制及其最佳消融策略。[研究结果]在175例首次接受导管消融治疗的分支性室速患者中,共有11例(平均年龄31 ± 10岁,均为男性)在消融LPF-VT术中或术后随访期间出现了右束支阻滞+电轴右偏形态的室速,其中9例发生左后分支阻滞。“新发的”室速与原有的LPF-VT室速的周长无显著差异(403±48 ms vs.399±44 ms,P=0.06)。标测显示“新发的”右束支阻滞+电轴右偏形态的室速最早心肌激动位于前间隔区域,但是最早的浦肯野电位仍在间隔中段偏后区域,心动过速时最早的P电位领先体表心电图V1导联QRS起始处44±9 ms。在此处放电消融可成功消融“新发的”室速,在术后中位随访72个月期间未见心动过速复发。[结论]左后分支阻滞可导致LPF-VT的折返环向心肌传导的出口发生改变,使其通过远离折返环的左前分支向左室心肌传导,而这种“新发的”室速的最佳消融靶点仍在左后分支分布区域。
[Abstract]:The first part of catheter ablation of tachycardia in long-term efficacy and predictors of recurrence [background] branch ventricular tachycardia (Fascicular ventricular, tachycardia, FVT) is an idiopathic left ventricular tachycardia (VT). The most common type of research on the long-term effectiveness of catheter ablation therapy is still limited. In this study, patients receiving FVT data for catheter ablation through analysis, predictive factors.] research methods to explore the treatment of FVT catheter ablation of the long-term effectiveness and recurrence in selected for our center in March 2005 to December 2016 from FVT for patients undergoing electrophysiological study and catheter ablation were excited sequentially. In the test, the tachycardia mapping to the earliest Purkinje potential (P potential) as the target. If the FVT can not induce tachycardia or not to continue the detailed activation mapping at Combined with the pacing mapping results to determine the target. Regular postoperative patients were followed. Results: a total of 234 patients with FVT patients, mean age 30 + 13 years, males accounted for 82%. in 183 cases (78.2%) patients completed a detailed activation mapping, the remaining 51 patients with heart can not induce or not continue to detailed activation mapping and pacing mapping need to combine the results to determine the targets of.231 cases (98.7%) achieved immediate ablation. In the mean follow-up time was 58 + 42 (1-135) months, 35 cases of recurrent ventricular tachycardia (15.2%), most of them (85.7%). Rate of recurrence occurred in 1 years after operation. No detailed activation sequence mapping is an independent predictor of ventricular tachycardia recurrence (OR:4.9,95%CI:2.3-10.7, P0.001). Conclusion: the average follow-up period of 5 years, the effectiveness of catheter ablation in treatment of FVT 84.8%. most of the ventricular tachycardia recurrence occurred in 1 after operation Years. Failed to carry out the detailed activation sequence mapping is an independent risk factor of recurrent ventricular tachycardia after operation. The mechanism of second part branch ventricular tachycardia after ablation and recurrence analysis [background] although more and more studies show that the branch ventricular tachycardia (Fascicular ventricular, tachycardia, FVT) mechanism back, but has not yet been completely clear. The application of EnSite Array (EA) three-dimensional electroanatomical system for mapping FVT, can display every beat of the virtual excited conduction. The purpose of this study is to explore the mechanism of FVT by EA. At the same time, reason research methods analysis of FVT ablation failed this study selected 21 cases (mean age 33 + 15 years old, male 17 cases) with left posterior fascicular ventricular tachycardia undergoing electrophysiological examination and radiofrequency ablation patients, all patients completed under the guidance of EA mapping and ablation. At the same time, 57 patients (mean age 28 + 1 At the age of 2, 45 males) of previous failed ablation or recurrent patients. All patients analyzed the mapping and ablation of data. The research results of]EA activation sequence mapping showed that the FVT for micro reentry mechanism, no reentrant tachycardia, the earliest activation in the left ventricular septal surface middle region, and then through the left after the branch and left anterior branch of the left ventricle to the left after the spreading branches distal to the earliest activation. In previous myocardial ablation failure or relapse cases, there were no reentrant mapping performance, 8.8% of the patients in the diagnosis of errors are the reasons for the failure of the ablation by EA. Conclusion excited sequence mapping mechanism FVT is microreentry, support the activation mapping for Purkinje potentials during tachycardia as the earliest ablation target mapping and ablation strategy effectively, without mapping to tachycardia when real is the earliest Purkinje potential failure or FVT ablation surgery The main reason of recurrence after recurrence. A special type of branch ventricular tachycardia after catheter ablation of left posterior part third: incidence, mechanism and the best ablation strategy [background] left posterior fascicular ventricular tachycardia (Left posterior fascicular ventricular tachycardia, LPF-VT) by application of recurrent cases after tube ablation in the treatment of common morphological changes. How to mapping and ablation of this "new" ventricular tachycardia (VT) has not yet reached a consensus. Through the analysis of LPF-VT catheter ablation of large sample data, this "new" incidence of ventricular tachycardia, mechanism and ablation method research] the best strategy. Through the analysis of our center from March 2005 to December 2016 due to tachycardia undergoing electrophysiological study and catheter ablation for the treatment of the clinical data of LPF-VT after ablation of "new" right bundle branch block + right axis deviation form of ventricular tachycardia 鐨勫彂鐢熺巼,鏈哄埗鍙婂叾鏈，

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