李冬梅　陈芗茹　李忠娟　孟庆鑫

[關键词] 邻近左心室穹顶部起源;特发性室性早搏;标测;消融策略

[中图分类号] R541.4          [文献标识码] B          [文章编号] 1673-9701（2021）17-0112-04

Mapping and evaluation of ablation strategies for idiopathic premature ventricular contractions originating from the adjacent left ventricular dome

LI Dongmei   CHEN Xiangru   LI Zhongjuan   MENG Qingxin

Department of Ultrasound，the Second Affiliated Hospital of Mudanjiang Medical University， Mudanjiang    157011， China

[Abstract] Objective To evaluate the mapping and ablation strategies for idiopathic premature ventricular contractions originating from the adjacent left ventricular dome. Methods Thirty patients with ventricular arrhythmia originating from the left ventricular dome who planned to undergo radiofrequency ablation in our hospital from January 2019 to January 2021 were selected. According to the results of the mapping， they were divided into group A （the earliest activation point of single ventricular premature contraction， n=20） and group B（the earliest activation point of multiple premature ventricular contractions， n=10）. The mapping and ablation results of the two groups were statistically analyzed. The postoperative follow-up results of 30 patients were analyzed. Results Among the 20 patients in group A， the coronary sinus was mapped as the earliest activation point of premature ventricular contractions. There were 5 cases of the anterior interventricular vein mapped as the earliest activation point （25.0%）， and 15 cases of the distal great cardiac vein mapped as the earliest activation point （75.0%）. The advanced body surface QRS wave was 17-43 ms，with an average of （30.3±5.6） ms. Seventeen cases （85.0%） were satisfied with pacing mapping， and 3 cases （15.0%） were not satisfied. Other methods were preferred to try ablation， including successful ablation in 18 cases （90.0%） and failed ablation in 2 cases （10.0%）. Among the ten patients in group B，in terms of the location of the earliest activation point of premature ventricular contractions by mapping， there were 2 cases of the right ventricular outflow tract，1 case of the aortic left coronary sinus （successful ablation）， and 1 case between left and right coronary sinuses （successful ablation）， 3 cases at the aortic annulus-mitral annulus junction （all successfully ablated）， 3 cases under the aortic valve endocardial surface （2 successful ablations， one failed ablation）. The difference in the success rate of ablation between the two groups was not significant（P>0.05）. Among the 30 patients in the two groups， 27 were successful in ablation， and three failed in ablation. The ablation success rate was 90.0%. There was 1 case of hematoma at the puncture site， and the complication rate was 3.3%. There were 2 cases of recurrence， with a recurrence rate of 6.7%.Among them， there was no significant difference in ablation success rate， complication rate， and recurrence rate between group A and group B（P>0.05）. Conclusion The mapping results of idiopathic premature ventricular contractions originating from the adjacent left ventricular dome can provide an effective basis for clinical ablation strategies.

[Key words] The origin of the adjacent left ventricular dome; Idiopathic premature ventricular contractions; Mapping; Ablation strategy

大多数室性心律失常患者有心肌病变存在，由于缺乏一致的心肌病变程度，通常情况下有导状存活心肌存在于区域中，或有存活心肌存在于不同瘢痕间，将折返性或局灶室性心律失常形成的解剖基础构成。因此，手术终点不是心动过速的终止，由于心肌病变区域不规则，因此可能有多个局灶或这返环兴奋点存在[1]。传统观点认为[2]，起源于左室穹隆顶的室性心律失常类似于其他室性心律失常，在消融靶点的确定过程中，起搏标测、激动标测仍然占主导，但是大部分这一特殊类型的室性心律失常从心内膜面起源，而经心外膜相应途径向霸区接近又有显著的局限性存在，因此将和真正起源点最邻近最安全的解剖部位寻找出来是成功消融的关键。在心外膜特发性室性心律失常中，左室穹顶是最常见的发病部位，从理论上来说，需要接受心外膜途径导管消融治疗，但由于有重要的冠状动脉血管主干通过，同时有脂肪层分布于心外膜对应部位，因此治疗具有较低的有效性、较高的风险[3]。本课题预期可以解决非常规途径消融的新的导管操作方法，并提出进一步研究的线索，现报道如下。

1 资料与方法

1.1 一般资料

选取2019年1月至2021年1月我院拟行射频消融治疗的左室穹顶起源室性心率失常患者30例。术前对血液生化、胸部正侧位片、经胸超声心动图、常规心电图、24 h动态心电图、冠状动脉增强多排CT检查进行完善，排除冠心病。分析……