经皮心包穿刺途径标测和消融室性心律失常的安全性和有效性

发布时间：2018-03-28 10:23

本文选题：经皮心包穿刺　切入点：心外膜　出处：《上海医学》2017年04期

【摘要】：目的评价剑突下经皮心包穿刺途径标测和消融室性心律失常(VA)的安全性和有效性。方法回顾性分析2014年6月—2015年12月在复旦大学附属中山医院心内科于剑突下经皮心包穿刺途径进行标测和消融的10例VA患者的临床资料,男8例、女2例,年龄16~69岁;其中特发性VA 1例,器质性心脏病合并室性心动过速(VT)9例(非缺血性心肌病8例,缺血性心肌病1例)。9例器质性心脏病患者中,6例术前已植入器械[植入式心脏复律除颤器(ICD)、心脏再同步治疗联合ICD各3例]。4例患者既往有1次心内膜消融失败史。分析所有患者心包穿刺并发症的发生情况,以及导管消融的策略和效果。结果所有患者剑突下经皮心包穿刺均获成功。术后仅1例患者发生心包出血,考虑由穿刺刺破心室壁所致,经引流后好转;无1例患者发生急性心包填塞、冠状动脉损伤、邻近脏器损伤、膈神经损伤等并发症。1例特发性VA患者经联合心内膜-心外膜标测提示VA起源心肌壁内,最后于心内膜侧大功率(45 W)延长消融时间(90s,2次)后急性消融成功。9例器质性心脏病合并VT患者行基质改良消融,其中7例急性消融成功(均为非缺血性心肌病患者),2例急性消融失败。这2例患者经心内膜-心外膜联合标测后提示VA起源心肌壁内深处,尝试将消融导管送入冠状静脉窦分支亦均失败。4例既往行消融但失败的患者,本次行心内膜-心外膜联合标测后,3例经心外膜消融成功,1例心内膜消融成功。8例消融成功的患者术后随访3~12个月,2例VA复发,其中1例患者于消融术后3个月因顽固性心力衰竭死亡。结论剑突下经皮心包穿刺途径标测和消融VA安全、有效,联合心内膜-心外膜标测和消融能提高器质性心脏病合并VT患者的导管消融成功率。
[Abstract]:Objective to evaluate the safety and efficacy of percutaneous pericardial aspiration mapping and ablation of ventricular arrhythmias via subxiphoid pericardiocentesis. Methods from June 2014 to December 2015 at Zhongshan Hospital affiliated to Fudan University, we retrospectively analyzed the efficacy and safety of subxiphoid meridians in the Department of Cardiology of Zhongshan Hospital affiliated to Fudan University. Clinical data of 10 patients with VA by percutaneous pericardial puncture. There were 8 males and 2 females aged 1669 years, including 1 case of idiopathic VA and 9 cases of VT with ventricular tachycardia (8 cases of non-ischemic cardiomyopathy, 8 cases of non-ischemic cardiomyopathy). One patient with ischemic cardiomyopathy, one patient with organic heart disease, 6 patients who had implanted instruments before operation [implantable cardioverter defibrillator, 3 patients with cardiac resynchronization combined with ICD] .4 patients had a history of failure of endocardial ablation before operation. To analyze the incidence of pericardial puncture complications in all patients, Results Percutaneous pericardial puncture was successful in all patients. Only one patient had pericardial hemorrhage after operation, which was caused by puncture of ventricular wall and improved after drainage. No one patient developed acute pericardial tamponade, coronary artery injury, adjacent organ injury, phrenic nerve injury and other complications. At last, 9 patients with organic heart disease complicated with VT were treated with modified matrix ablation. Among them, 7 cases were successfully ablated (all of them were patients with non-ischemic cardiomyopathy) and 2 cases were failed in acute ablation. The results of endocardial and epicardial mapping showed that VA originated from the deep wall of myocardium. Attempts to transfer catheter into the coronary sinus branch also failed in 4 patients who had failed in previous ablation. In this study, 3 patients underwent endocardial and epicardial mapping and 1 patient was successfully ablated through epicardium. Two patients with VA recurrence were followed up for 3 to 12 months after successful endocardial ablation. One patient died of intractable heart failure 3 months after ablation. Conclusion it is safe and effective to map and ablate VA by percutaneous pericardial puncture under the xiphoid process. Combined endocardial-epicardial mapping and ablation can improve the success rate of catheter ablation in patients with organic heart disease complicated with VT.
【作者单位】：复旦大学附属中山医院心内科上海市心血管病研究所;
【基金】：国家自然科学基金资助项目(81521001)
【分类号】：R541.7

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