作者：王琎，公言伟，刘相飞

单位：

1.450052河南省郑州市，郑州大学第一附属医院心内科 2.257034山东省东营市，胜利油田中心医院心内科 通信作者：刘相飞，E-mail：zhaoyang20023903@126.com

Units：

1.Department of Cardiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China 2.Department of Cardiology, Shengli Oil Field Central Hospital, Dongying 257034, China Corresponding author: LIU Xiangfei, E-mail: zhaoyang20023903@126.com

关键词：

心律失常,心性; 节制束; 导管消融; 心腔内超声;

Keywords：

Arrhythmias, cardiac; Moderator band; Catheter ablation; Intracardiac echocardiography

CLC：

DOI：

10.12114/j.issn.1008-5971.2022.00.158

Funds：

山东省医药卫生科技发展计划项目（2019WS043）

摘要：

目的 探讨右心室节制束起源的室性心律失常患者电生理特征及三维心腔内超声引导下导管消融效果。方法 选取2016年1月至2021年1月于胜利油田中心医院心内科与郑州大学第一附属医院心内科住院的行射频消融的室性心律失常患者627例,选取其中10例起源于右心室节制束的室性心律失常患者为右心室节制束组,另选取12例起源于三尖瓣环后侧壁的室性心律失常患者为三尖瓣环后侧壁组。所有患者在三维心腔内超声引导下进行激动标测和消融,比较两组一般资料、影像学指标、心电图参数及其特点、标测和消融效果。结果 右心室节制束组QRS波时限、类本位曲折时间短于三尖瓣环后侧壁组,V1、V2、V3导联QRS波下降支斜率大于三尖瓣环后侧壁组(P<0.05)。起源于右心室节制束的室性心律失常患者心电图特点:(1)QRS波均呈左束支传导阻滞;(2)胸前导联移行均晚于V4导联;(3)Ⅰ、aVL导联QRS波主波均为直立,Ⅱ、Ⅲ、aVF导联主波方向则以负向为主。起源于三尖瓣环后侧壁的室性心律失常患者心电图特点:(1)QRS波呈左束支传导阻滞,V1、V2导联表现为rS型;(2)Ⅰ、aVL、V5、V6导联以正向波为主。右心室节制束组于消融有效靶点处记录到最早激动点的领先体表QRS波起点时限为(18.1±3.1)ms;在消融有效靶点中,有6例(6/10)于局部V波之前可见浦肯野电位;消融过程中有1例患者出现一过性右束支阻滞,术中及术后均未发生心包填塞。所有三尖瓣环后侧壁组患者消融成功且未出现并发症。右心室节制束组有1例患者出现与原发形态不同的室性期前收缩,且24 h动态心电图显示室性期前收缩<500次/24 h,未再给予干预治疗。此外,所有患者围术期及随访期间未发生心包压塞、房室传导阻滞及新发三尖瓣关闭不全等并发症。结论 右心室节制束起源的室性心律失常患者的QRS波时限、类本位曲折时间较短,V1、V2、V3导联QRS波下降支斜率大,且三维心腔内超声引导下导管消融的安全性及远期效果较好。

Abstract：

【Abstract】 Objective To investigate the electrophysiological characteristics of patients with ventricular arrhythmiaoriginating from right ventricular moderator band and effect of catheter ablation guided by three-dimensional intracardiacechocardiography. Methods A total of 627 patients with ventricular arrhythmia who underwent radiofrequency ablation in theDepartment of Cardiology of Shengli Oil Field Central Hospital and the Department of Cardiology of the First Affiliated Hospitalof Zhengzhou University from January 2016 to January 2021 were selected. Among them, 10 patients with ventricular arrhythmiaoriginating from the right ventricular moderator band were selected as the right ventricular moderator band group, and 12 patientswith ventricular arrhythmia originating from the posterior wall of the tricuspid annulus were selected as the posterior wall of thetricuspid valve annulus group. All patients underwent activation mapping and ablation under the guidance of three-dimensionalintracardiac ultrasound technology, and the general data, imaging indexes, ECG parameters and their characteristics, mapping andablation effects were compared between the two groups. Results The duration of QRS complex and the quasi-standard tortuositytime in the right ventricular moderator band group were shorter than those in the posterior wall of the tricuspid valve annulusgroup, the slope of the descending branch of the QRS complex in leads V1, V2, and V3 were bigger than those in the posteriorwall of the tricuspid valve annulus group (P < 0.05) . ECG characteristics of the patients with rentricular arrthythmia originatingfrom right ventricular moderator band: (1) QRS waves all showed left bundle branch block; (2) the prethoracic leads migrate laterthan lead V4; (3) the main waves of the QRS complex in leads Ⅰ and aVL were all upright, and the main waves in leads Ⅱ, Ⅲand aVF were mainly negative. ECG characteristics of patients with rentricular arrthythmia originating from the posterior wall ofthe tricuspid valve annulus: (1) the QRS complex showed left bundle branch block, and the leads V1 and V2 showed rS type; (2)leads Ⅰ, aVL, V5, and V6 were dominated by positive waves. In the right ventricular moderator band group, the onset time limitof the leading surface QRS complex at the earliest activation point recorded at the effective target of ablation was (18.1±3.1) ms.Among the effective targets for ablation, 6 cases (6/10) showed Purkinje potential before the local V wave. One patient developedtransient right bundle branch block during ablation, and neither intraoperative nor postoperative cardiac tamponade occurred. Allpatients in the posterior wall of the tricuspid valve annulus group were successfully ablated, and there was no complications. Inthe right ventricular moderator band group, 1 case had premature ventricular contractions different from the primary shape, andthe 24-hour dynamic electrocardiogram showed that the premature ventricular contractions were less than 500 times/24 h, and nofurther intervention was given. All patients had no complications such as pericardial tamponade, atrioventricular block and newtricuspid regurgitation during the perioperative period and follow-up period. Conclusion In patients with ventricular arrhythmiaoriginating from the right ventricular moderator band, the QRS complex duration and quasi-standard tortuosity are shorter, theslope of the descending branch of the QRS complex in leads V1, V2, and V3 are large, and the effect and safety of catheter ablationguided by three-dimensional intracardiac ultrasound are good.

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