无基质二尖瓣环心房扑动：电生理特征及治疗策略

发布时间：2018-03-10 18:33

本文选题：二尖瓣环心房扑动　切入点：基质　出处：《南京医科大学》2017年博士论文　论文类型：学位论文

【摘要】：研究背景及目的经验性消融二尖瓣峡部(mitral isthmus,MI)是治疗二尖瓣环心房扑动(peri-mitral atrial flutter,PMFL)的主要方法,但盲目消融MI其本身有致心律失常的作用,且PMFL的具体电生理机制尚未完全明确。本研究的目的是探讨房颤消融中或消融后出现的无基质的PMFL的临床和电生理机制特征,制定个体化的治疗策略。方法本研究应用三维标测系统(EnSite-NavXTM Velocity3.0,美国圣犹达公司或Carto 3TM,美国强生公司)对39例房颤消融术中或术后发生的PMFL患者,分析其临床特征及电生理特征,应用环状电极或消融导管对左心房进行高密度标测,分析左心房环二尖瓣环三个不同区域的电压、低电压区域或复杂电位分布情况,并比较不同区域的电压、传导时间及传导速度。根据三维重建左房模型沿二尖瓣环将左房体部分为三个部分:分别为间隔前壁(SAW:自冠状静脉窦窦口至左心耳正下口处)、后下壁区域(PIW:冠状静脉窦窦口至二尖瓣瓣环4点处)及MI区域(左心耳正下口处至二尖瓣环4点区域)。根据激动标测和电压标测的结果制定治疗策略。结果39例PMFL患者12例纳入本研究,其中阵发性房颤10例,持续性房颤2例,房颤持续性时间分别为6、12个月。平均年龄57.6± 10.2岁,11例(92%)为男性,房颤病史中位数为36个月(6-120个月)。左心房内径平均为41.1 ±4.2mm,左心室射血分数平均为63.8±3.9%。心动过速周长平均为197.8± 15.4ms,所有患者环二尖瓣环各个区域均未标测到低电压区域和复杂电位区域。各区域电压分别为 MI:1.55±0.53mV,SAW:1.58±0.45mV,PIW:1.44±0.48mV,三个区域间电压无显著性差异(P= 0.63)。传导速度在MI,SAW及PIW区域分别为(0.75±0.14m/s,0.74±0.14m/s,0.83±0.19m/s,P=0.34)。所有患者在行环肺静脉消融,隔离肺静脉电位后直接电复律后转复为窦性心律。平均随访18个月,无患者复发PMFL,1例阵发性房颤患者复发房颤,予以重新补点消融隔离肺静脉电位后随访无房颤复发。结论对于心脏结构正常的阵发性房颤或短程持续性房颤术中发生的短周长、无基质的PMFL患者,其发生机制可能由于电重构引起的,此类心律失常无需进一步消融,直接电复律恢复窦性心律即可。
[Abstract]:Background and objective empirical ablation of mitral isthmus is the main method for the treatment of peri-mitral annular atrial flutter (atrial flutterus), but blind ablation of MI can cause arrhythmia. The purpose of this study was to investigate the clinical and electrophysiological characteristics of stromal free PMFL during or after ablation of atrial fibrillation. Methods the clinical and electrophysiological characteristics of 39 patients with PMFL during or after atrial fibrillation ablation were analyzed using the three-dimensional mapping system EnSite-NavXTM Velocity3.0, St. Jude Inc. Or Carto 3TM3, Johnson Inc. The high density mapping of left atrium was performed with annular electrode or ablation catheter. The voltage distribution of three different regions of left atrial annular mitral annulus, low voltage region or complex potential were analyzed, and the voltages of different regions were compared. Conduction time and velocity. The left atrial body is divided into three parts according to the three-dimensional reconstruction of left atrial annulus along the mitral annulus: SAW from the sinus orifice of coronary vein to the inferior part of left atrial appendage, and PIW: coronal from the sinus orifice of coronary vein to the inferior left atrial appendage. Venous sinus orifice to mitral annulus 4 points) and MI region (left atrial appendage right inferior orifice to mitral annulus 4 points). According to the results of activation mapping and voltage mapping, treatment strategies were formulated. Results 12 patients with PMFL were included in this study. There were 10 cases of paroxysmal atrial fibrillation and 2 cases of persistent atrial fibrillation. The duration of atrial fibrillation was 6 months and 12 months respectively. The mean age was 57.6 卤10.2 years old. The median history of atrial fibrillation was 36 months, 6-120 months, the mean diameter of left atrium was 41.1 卤4.2 mm, the mean ejection fraction of left ventricle was 63.8 卤3.9 mm, the average circumference of tachycardia was 197.8 卤15.4ms. all the regions of annular mitral annulus were not detected in low-voltage area. And complex potential regions. The voltage of each region was MI:1.55 卤0.53mV SAW: 1.58 卤0.45mV PIW: 1.44 卤0.48mV. there was no significant difference in voltage between the three regions (P = 0.63). The conduction velocity in the Misaw and PIW regions was 0.75 卤0.14mrs0.74 卤0.14m/ s 0.83 卤0.19msP 0.34 respectively. All patients underwent annular pulmonary vein ablation. After isolating the pulmonary vein potential, the patients changed to sinus rhythm after direct electrocardiogram. The average follow-up period was 18 months. No recurrent PMFLF was found in 1 patient with paroxysmal atrial fibrillation. There was no recurrence of atrial fibrillation in patients with paroxysmal atrial fibrillation with normal cardiac structure or short duration atrial fibrillation with short circumference and without matrix. The mechanism may be caused by electrical remodeling, such arrhythmias do not need to further ablation, the direct electrocardiogram can restore sinus rhythm.
【学位授予单位】：南京医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R541.7

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