Radiofrequency catheter ablation of type 1 atrial flutter. Prediction of late success by electrophysiological criteria.
Radiofrequency catheter ablation of type 1 atrial flutter. Prediction of late success by electrophysiological criteria.
复制标题
射频导管消融术治疗 1 型心房扑动。
作者：
H. Poty;N. Saoudi;Ahmed Aziz;Mohan Nair;Brice Letac
背景
射频能量在心房扑动(AFL)的导管消融中已被证明是有效的。然而，AFL的长期复发在最初的消融后经常被报道，显然是成功的。到目前为止，缺乏预测晚期复发的标准。
方法和结果
12例患者(男性10例，平均年龄53.6岁，年龄26~69岁)行AFL消融术。使用双管和十管导管对三尖瓣环、下腔静脉瓣环(IVC-TA)峡部和冠状静脉窦口(CSOS)区域进行详细标测。另外使用多极导管记录冠状静脉窦和CSOS-TA峡部的活动。9例患者在基线状态下出现AFL，3例由近端冠状静脉窦(PCS)起搏诱发。所有患者均记录到逆时针右心房激动。消融的初步成功被定义为即使在异丙肾上腺素输注期间也不再能诱发AFL。所有12例患者均成功消融AFL，下腔静脉-TA峡部的平均脉冲数为4个。在3例诱发AFL的患者中，消融前以窦性心律进行PCS起搏时，可观察到右心房中外侧(LRA)降、升波阵面的碰撞。在射频应用失败后，LRA的这种激活模式也被注意到。射频治疗后AFL的不可诱导性与LRA激活模式的改变和9例患者从PCS起搏时下腔静脉-TA峡部的激活顺序颠倒(从顺时针到逆时针)有关。在3名患者中，有2名患者尽管无法诱发心房扑动，但仍进行了消融，以获得下腔静脉-TA峡部传导永久阻断的证据。最后，从PCS起搏时，除1例患者外，所有患者的LRA波前均完全下降。4例患者还进行了低位LRA起搏，发现峡部逆时针方向的起搏受阻。在9+/-3个月的随访中，有1例AFL复发，这是唯一一例术后峡部未见传导阻滞的患者。
结论
在PCS和低LRA起搏时，LRA的脉冲传播方向和下腔静脉-TA峡部的传播阻断似乎是预测AFL消融长期成功的有意义的指标。
BACKGROUND
Radiofrequency energy has demonstrated its efficacy in catheter ablation of atrial flutter (AFl). However, long-term recurrences of AFl have been reported frequently after initial, apparently successful ablation. To date, criteria for prediction of late recurrences are lacking.
METHODS AND RESULTS
Twelve patients (10 men; mean age, 53.6 years; range, 26 to 69 years) were referred for AFl ablation. Duodecapolar and decapolar catheters were used for detailed mapping of the tricuspid ring, the inferior vena cavatricuspid annulus (IVC-TA) isthmus, and the coronary sinus ostium (CSOs) area. Additional multipolar catheters were used for recording activation of the coronary sinus and the CSOs-TA isthmus. AFl was present at baseline in 9 patients and was induced by proximal coronary sinus (PCS) pacing in 3. Counterclockwise right atrial activation was recorded in all patients. Primary success of ablation was defined as when AFl was no longer inducible even during isoproterenol infusion. AFl was successfully ablated in all 12 patients, with a median of 4 pulses delivered at the IVC-TA isthmus. In the 3 patients in whom AFl was induced, during PCS pacing in sinus rhythm before ablation, a collision of descending and ascending wave fronts was observed at the middle lateral right atrium (LRA). This activation pattern of the LRA also was noted after unsuccessful radiofrequency applications. Noninducibility of AFl after radiofrequency applications was associated with a change of activation pattern at the LRA and with an inversion of the activation sequence of the IVC-TA isthmus (from clockwise to counterclockwise) in 9 patients when pacing from the PCS. In 2 of 3 patients, despite noninducibility of atrial flutter, ablation was pursued to obtain evidence of permanent block of conduction at the IVC-TA isthmus. Finally, a completely descending LRA wave front was observed when pacing from the PCS in all patients except one. Low LRA pacing was also performed in 4 patients and showed evidence for block in the counterclockwise direction at the isthmus. During a follow-up of 9 +/- 3 months, AFl recurred in 1 patient; this was the only patient who showed no conduction block at the isthmus after the procedure.
CONCLUSIONS
Direction of impulse propagation at LRA and block of propagation at the IVC-TA isthmus during PCS and low LRA pacing appear to be of interest in predicting long-term success of AFl ablation.