房顫消融術(shù)后房性心律失常的處理和二次消融選擇

中國醫(yī)學(xué)科學(xué)院阜外心血管病醫(yī)院心律失常中心ArrhythmiaCenter，F(xiàn)uwaiHeratHospitalChineseAcademyofMedicalSciences姚焰YanYao背景Background與房顫消融相關(guān)的左房房撲（LAFL）發(fā)生率介于2.6~31%[1]；ThemorbidityofAFablationrelatedleftatrialflutter(LAFL)are2.6~31%;包括局灶、大折返或小折返等多種機(jī)制且多與房顫消融線的“縫隙”有關(guān)；Focal、micro-¯o-reentrantmechanismsweredocumentedandthegaponthelesionslineisthestickingpointofthecircuit;1,GerstenfeldEP,HeartRhythm2007;4:S65-72

病例數(shù)Patients(n)80性別Gender:男性(M)/女性(F)60/20年齡Age(歲，years)57±9房顫持續(xù)時(shí)間DurationofAF(年,years)7±4陣發(fā)性Paroxysmal/持續(xù)性房顫PersistentAF62/18左房內(nèi)徑LAdiameter(mm)38±8左室射血分?jǐn)?shù)LVEF(%)52±6器質(zhì)性心臟病StructralHeartDisease16(20%)既往抗心律失常藥物AADs（n)2±1LAFL患者基本特點(diǎn)

BasicCharacteristicsofLAFLPatients結(jié)果ResultsLAFL可在消融中由AF轉(zhuǎn)化而成，或房顫消融成功之后快速刺激誘發(fā)；LAFLswereeitherconvertedfromAFbyablationorinducedbyCIS；34例有≥2(2~6)種的LAFL，共有146種，其中4種為局灶性，142種為大折返機(jī)制；Therewere34pts.with≥2(2~6)LAFLs，oftotal146LAFLs，142werereentrant&4werefocal；142種LAFL均與房顫消融線的縫隙有關(guān)，且均位于7字消融線上；ThereentrantcircuitswereallrelatedwiththegapsontheFigure“7”lesionsline.Case1：繞MVA的折返

ReentrantaroundtheMVA消融嵴部時(shí)AF轉(zhuǎn)為LAAFL

V1CS7.85678910111213141516180msLeadIISOCHRONES繞二尖瓣環(huán)的折返

(IsochronalmapoftheMVAcircuit)1.等時(shí)圖顯示為繞MVA的順鐘向折返；2.沿MVA激動(dòng)時(shí)間占心動(dòng)過速周長的100％；3.折返環(huán)路上全程虛擬單極電圖呈rS型且首尾相接；經(jīng)MVA－LIPV峽部的“縫隙”

ThegaponMVA-LIPVisthmus在峽部縫隙處消融轉(zhuǎn)為竇律

TerminationoftheLAFLCase2：7字型消融終止房顫后CSS1S1320bpm誘發(fā)LAFLLAFLinducedafterterminationofAFwithfigure“7”lesionsCase2：經(jīng)LAA-LSPV間嵴部縫隙的折返

ReentrantthroughthegapatLAA-LSPVridge左房房撲的動(dòng)態(tài)等電位圖等時(shí)圖Isochronalmap在嵴部消融終止了LAFL

LAFLterminatedduringablationattheLAA-LSPVridgeCase3:經(jīng)左房頂部縫隙折返的LAFL

ReentrantthoughthegapontheLAroof左房房撲的動(dòng)態(tài)等電位圖等時(shí)圖IsochronalMap在頂部縫隙處消融終止了LAFL

LAFLterminationduringablationonthegap與左房房撲折返環(huán)相關(guān)的縫隙分布

ThedistributionoftheLAFLrelatedgaps

LAA-LSPV嵴部（LAA-LSPVrigde）68(47%)二尖瓣環(huán)峽部（MVAisthmus）24(17%)左房頂部（LAroof）50(36%)7字消融線的多個(gè)縫隙

MultipleGapsontheFigure“7”lesionline頂部的縫隙GaponLARoof嵴部的縫隙GapatLAA-LSPVRidgeMVA的縫隙GapatLIPV-MVAIsthmus

最終消融成功部位FinalTarget消融效果AblationResults能量:功率60W，溫度58℃，每次60-90s；平均放電4±2.1次；即時(shí)成功率(消融終止+不再誘發(fā)):LSPV-LAA間嵴部：60/68(88.2%)；左房頂部：44/50(88%)；LIPV-MVA峽部：22/24(92%)；隨訪Followup平均(11±6.7)月：維持竇律(sinusrhythm):62/80(77.5%)；短陣房速(focalAT):12/80(15%)；左房房撲(LAFL):6/80(7.5)；新發(fā)現(xiàn)NewFindings縫隙的分布：既往研究中經(jīng)二尖瓣環(huán)峽部縫隙的折返多見，本研究中經(jīng)LAA－LSPV間嵴部及左房頂部縫隙的折返更多見；GapsonLAA-LSPVridge&roofweremorecommoninthisstudy；折返環(huán)類型：既往報(bào)告經(jīng)嵴部的折返環(huán)多為小折返，本研究中為經(jīng)嵴部及RIPV-MVA間峽部的大折返。Mostofthereentrantweremacrocircuitsacrossridge；AF的機(jī)制MechanismofAF

快速的異位節(jié)律（focal）; 單個(gè)折返環(huán)伴顫動(dòng)性傳導(dǎo)（singlerandomizedwavefrontwithfibrillatoryactivation；3)多個(gè)折返環(huán)?（multiplewavelets？）姚焰中華心律失常學(xué)雜志,2004;8;356消融線上縫隙的成因

TheformationofthegapsonthelesionslineLSPV-LAA間嵴部解剖特殊性[1]：（Anatomicfeatures）局部肌帶厚、狹窄；肌纖維走行復(fù)雜；鄰近神經(jīng)節(jié)及Marshall韌帶；LSPV-LAA間嵴部消融導(dǎo)管貼靠困難[2,3]；頂部正中有毗鄰組織結(jié)構(gòu)和心包折疊；現(xiàn)有消融能量的局限性；1.CabreraJA,EurHeartJ.2008;29:356-62.2.DeisenhoferI,Europace2006;8:573-82.3.MesasCE,JACC2004;44:1071-9.CabreraJA,etal.EurHeartJ.2008;29:356-62.D并發(fā)癥或消融成功的過渡階段？

ComplicationorTransformtotheSuccessofAFablation？步進(jìn)式線性消融的可行性已得到證實(shí)[1,2]；Thefeasibilityofstepwiselinearablationapproachwereconfirmed.當(dāng)前消融能量無法安全地形成透壁損傷；Completetransmuralityisnotguaranteedwithcurrentablationenergy;LAFL可能是當(dāng)前階段房顫消融