許環(huán)親　吳飛玉　郭照軍　陳武　劉先霞　何建桂

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·臨床研究論著·

房室交界區(qū)不應(yīng)期內(nèi)房性早搏刺激在預(yù)激綜合征消融術(shù)中的應(yīng)用

許環(huán)親吳飛玉郭照軍陳武劉先霞何建桂

目的探討房室交界區(qū)不應(yīng)期內(nèi)的房性早搏(房早)刺激在指導(dǎo)預(yù)激綜合征靶點(diǎn)定位及消融的臨床應(yīng)用價(jià)值。方法50例預(yù)激綜合征患者按是否使用房早刺激方法指導(dǎo)消融前傳旁路，分為對(duì)照組和房早干預(yù)組。對(duì)照組20例(A型預(yù)激12例，B型預(yù)激8例)，使用非房早刺激的常規(guī)術(shù)式消融前傳旁路。房早干預(yù)組30例(A型預(yù)激16例，B型預(yù)激14例)，使用房早刺激指導(dǎo)消融前傳旁路，首先在竇性心律下，通過(guò)測(cè)量其RR間期后，在此基礎(chǔ)上減去30 ms后作為房早的初始起搏間期，以5 ms逐步遞減，觀察體表QRS的預(yù)激成分，當(dāng)達(dá)到預(yù)激最明顯時(shí)，取此時(shí)的聯(lián)律間期作為固定刺激頻率，指導(dǎo)房早干預(yù)組前傳旁路消融。比較2組一次性消融成功率、累計(jì)消融時(shí)間及累計(jì)射線量。結(jié)果房早干預(yù)組一次性消融成功率達(dá)80%，高于對(duì)照組的55%，2組比較差異有統(tǒng)計(jì)學(xué)意義(P=0.03)。房早干預(yù)組累計(jì)消融時(shí)間為(301.3±61.1)s，低于對(duì)照組[(358.5±115.5)s,P=0.03]。房早干預(yù)組累計(jì)射線量為(49.3±31.8)mGray，低于對(duì)照組[(101.2±78.5)mGray，P<0.01]。結(jié)論房室交界區(qū)不應(yīng)期內(nèi)房早刺激指導(dǎo)預(yù)激綜合征導(dǎo)管消融具有一定臨床價(jià)值，能有效縮短手術(shù)時(shí)間、降低射線暴露率及提高手術(shù)的成功率。

房室交界區(qū)不應(yīng)期內(nèi)的房性早搏；預(yù)激綜合征；導(dǎo)管消融

Wolff-Parkinson-White syndrome; Catheter ablation

射頻消融旁道是根治預(yù)激綜合征并發(fā)嚴(yán)重心律失常的主要手段，影響消融成功率最重要因素是導(dǎo)管操作和旁道靶點(diǎn)圖指標(biāo)，尤其是右心室旁道消融成功率較低，因其竇律下AV融合性較差，靶點(diǎn)圖特異性偏低，常常導(dǎo)致過(guò)多消融及長(zhǎng)時(shí)間消融，甚至當(dāng)V1導(dǎo)聯(lián)預(yù)激不充分，臨床診斷A、B型預(yù)激綜合征亦經(jīng)常混淆，但目前旁道術(shù)前診斷和定位仍較多依賴于體表心電圖及術(shù)中導(dǎo)管操作比對(duì)，對(duì)預(yù)激充分性較差的旁道敏感性不高[1-2]。早搏刺激常用于心室起搏鑒別隱匿性房室旁路是否存在，但在房室交界區(qū)不應(yīng)期內(nèi)房早刺激較少用于預(yù)激不充分的房室旁路的臨床治療[3]。本研究旨在初步探討在房室交界區(qū)不應(yīng)期內(nèi)房早刺激能否提高預(yù)激綜合征靶點(diǎn)定位的準(zhǔn)確性，并提高一次消融的成功率，減少消融所帶來(lái)誤損傷[4]。

對(duì)象與方法

一、 研究對(duì)象

連續(xù)入選2011年6月至2015年9月入住海南省農(nóng)墾總醫(yī)院心血管內(nèi)科確診為預(yù)激綜合征且有射頻消融手術(shù)意向的患者50例，進(jìn)行前瞻性對(duì)照研究。按是否使用房早刺激方法指導(dǎo)消融預(yù)激綜合征前傳旁路，分為對(duì)照組和房早干預(yù)組。對(duì)照組使用非房早刺激的常規(guī)術(shù)式消融預(yù)激綜合征前傳旁路；房早干預(yù)組使用房室交界區(qū)不應(yīng)期內(nèi)房早刺激指導(dǎo)消融預(yù)激綜合征前傳旁路。首先根據(jù)體表心電圖初步篩選出A型預(yù)激綜合征和B型預(yù)激綜合征患者，然后根據(jù)就診順序按(對(duì)照組∶房早干預(yù)組1∶1.5比例)進(jìn)行分配。對(duì)照組20例，男女各10 例 ，年齡(32.5±8.3)歲；其中A型預(yù)激綜合征男8例，女4例；B型預(yù)激綜合征男4例，女4例。房早干預(yù)組30例，男16例，女14例， 年齡(39.1±10.9)歲；其中A型預(yù)激綜合征男11例，女5例；B型預(yù)激綜合征男5例，女9例。

每例患者均須簽署知情同意書，行體表12導(dǎo)聯(lián)同步心電圖及超聲心動(dòng)圖檢查，排除器質(zhì)性心臟病及室內(nèi)傳導(dǎo)阻滯，B型顯性預(yù)激綜合征患者體表心電圖V1導(dǎo)聯(lián)上均可見(jiàn)負(fù)向典型&波，A型顯性預(yù)激綜合征患者體表心電圖V1導(dǎo)聯(lián)上均可見(jiàn)正向典型&波。

二、 設(shè)備和方法

采用圣猶達(dá)多導(dǎo)電生理刺激儀EP-Maker。檢查方法：受檢者取仰臥位，平靜呼吸，連接心電圖，常規(guī)消毒鋪巾后，分別經(jīng)頸靜脈放置CS電極及經(jīng)股靜脈放置高右房電極。記錄刺激前V1導(dǎo)聯(lián)QRS間期、&波成分，CS電極的AV間期及RR間期后。使用高右房電極進(jìn)行房早電刺激，在初始RR間期基礎(chǔ)上減去30 ms后作為程序刺激的初始起搏間期，以5 ms逐步遞減，觀察體表V1導(dǎo)聯(lián)的QRS的預(yù)激成分，當(dāng)達(dá)到預(yù)激最明顯時(shí)的上閾時(shí)，取此時(shí)的聯(lián)律間期作為固定起搏頻率設(shè)定，此后每隔3次心跳，心房以此頻率給予早搏刺激，再用消融電極標(biāo)測(cè)預(yù)激成分充分前后靶位點(diǎn)的AV融合情況，同時(shí)與對(duì)照組對(duì)比其一次消融成功率、累計(jì)消融時(shí)間(至消融成功所用的時(shí)間)及累計(jì)射線的使用量(至消融成功所用的射線量)。如旁路不應(yīng)期較交界區(qū)不應(yīng)期短，則以旁路前傳中斷前一跳所給的房性早搏作為刺激條件。一次消融成功是指第一次標(biāo)到靶位點(diǎn)，并嘗試放電消融10 s后，驗(yàn)證旁路阻斷。

三、 統(tǒng)計(jì)學(xué)處理

結(jié)　　果

一、 房早干預(yù)組與對(duì)照組一次消融成功率比較

房早干預(yù)組一次性消融成功率高于對(duì)照組(P=0.03)；對(duì)B型預(yù)激指導(dǎo)消融方面，房早干預(yù)組一次性消融成功率高于對(duì)照組(P=0.03)，見(jiàn)表1。

二、 房早干預(yù)組與對(duì)照組累計(jì)消融時(shí)間比較

房早干預(yù)組累計(jì)消融時(shí)間短于對(duì)照組， 2組比較差異有統(tǒng)計(jì)學(xué)意義(P=0.03)。對(duì)于B型預(yù)激綜合征患者，房早干預(yù)組累計(jì)消融時(shí)間短于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P=0.01)。見(jiàn)表2。

三、 房早干預(yù)組與對(duì)照組累計(jì)射線量比較

房早干預(yù)組累計(jì)射線量為低于對(duì)照組，2組比較差異亦有統(tǒng)計(jì)學(xué)意義(P<0.01)。對(duì)于B型預(yù)激綜合征患者，房早干預(yù)組累計(jì)射線量使用低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P=0.01)。見(jiàn)表3。

表1 房早干預(yù)組與對(duì)照組一次消融成功率比較

表2 房早干預(yù)組與對(duì)照組累計(jì)消融時(shí)間±s)　s

表3 房早干預(yù)組與對(duì)照組累計(jì)射線量比較±s)　mGray

討　　論

Spotnitz等[5]報(bào)道腺苷誘導(dǎo)消融術(shù)后休眠房室旁路傳導(dǎo)的機(jī)制和臨床意義及Caetano等[6]的報(bào)道心房起搏可誘發(fā)潛在的預(yù)激綜合征等，提示適當(dāng)阻斷房室傳導(dǎo)或在房室傳導(dǎo)不應(yīng)期內(nèi)起搏，能充分引導(dǎo)旁路前傳，導(dǎo)致預(yù)激更充分，為本文提供了理論支持。

本文采用在房室交界區(qū)不應(yīng)期內(nèi)給予房早起搏指導(dǎo)預(yù)激綜合征消融，結(jié)果顯示，此方法對(duì)臨床消融成功率偏低的B型預(yù)激綜合征具有一定指導(dǎo)意義，能有效縮短手術(shù)時(shí)間、降低射線暴露及提高手術(shù)成功率，且能明顯降低術(shù)中對(duì)導(dǎo)管連續(xù)性標(biāo)測(cè)的干擾。

本方法簡(jiǎn)單易行，與Delelis等[7]報(bào)道的通過(guò)術(shù)前二維B超速度向量成像對(duì)預(yù)激綜合征旁道定位及Nishida等[8]報(bào)道的經(jīng)非接觸三維標(biāo)測(cè)系統(tǒng)指導(dǎo)消融B 型預(yù)激綜合征具有異曲同工之處，但本法準(zhǔn)確性高、無(wú)額外增加手術(shù)費(fèi)用，且可在術(shù)中指導(dǎo)精細(xì)定位，避免了術(shù)中嘗試性盲目消融導(dǎo)致的瓣膜損傷[9]。

本研究提示，心房起搏位點(diǎn)如離旁路越近，此法成功率越高，但對(duì)旁路不應(yīng)期明顯較交界區(qū)不應(yīng)期長(zhǎng)患者的消融指導(dǎo)意義，此法具有一定局限性。且本研究因目前入組的病例數(shù)較少，暫不能區(qū)分對(duì)不同部位的旁路其指導(dǎo)意義的區(qū)別，有待進(jìn)一步的跟蹤研究探討。

[1]王業(yè)松,孫愛(ài)嬌.心臟導(dǎo)管射頻消融術(shù). 新醫(yī)學(xué),2009,40(1):50-52.

[2]Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, Estes NA 3rd, Field ME, Goldberger ZD, Hammill SC, Indik JH, Lindsay BD, Olshansky B, Russo AM, Shen WK, Tracy CM, Al-Khatib SM. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol，2016，67(13):e27-e115.

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[5]Spotnitz MD, Markowitz SM，Liu CF, Thomas G, Ip JE, Liez J, Lerman BB, Cheung JW. Mechanisms and clinical significance of adenosine-induced dormant accessory pathway conduction after catheter ablation.Circ Arrhythm Electrophysiol，2014，7(6):1136-1143.

[6]Caetano F, Barra S, Cavaco D. Wolff-Parkinson-White syndrome unmasked by atrial pacing in a patient with cardiac sarcoidosis. Europace， 2014，16(12):1713.

[7]Delelis F, Lacroix D, Richardson M, Klug D, Kouakam C, Brigadeau F, Guyomar Y, Graux P, Kacet S, Gautier C, Ennezat PV, Marechaux S.Two-dimensional speckle-tracking echocardiography for atrioventricular accessory pathways persistent ventricular pre-excitation despite successful radiofrequency ablation. Eur He-art J Cardiovasc Imaging, 2012, 13(10):840-848.

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(本文編輯：楊江瑜)

Application of atrial premature of atrioventricular junction within refractory period in ablation for patients with Wolff-Parkinson-White syndrome

XuHuanqin,WuFeiyu,GuoZhaojun,ChenWu,LiuXianxia,HeJiangui.

DepartmentofCardiology，HainanProvincialNongkenGeneralHospital,Haikou570311,China

Correspondingauthor,HeJiangui,E-mail:hejiangui@163.com

ObjectiveTo assess the clinical efficacy of atrial premature stimulation of atrioventricular junction within refractory period on the target locating and ablation in patients with Wolff-Parkinson-White syndrome (W-P-W). MethodsFifty patients with overt pre-excitation syndrome were divided into the control (n=20) and the atrial premature groups (n=30) according to whether atrial premature stimulation was delivered to guide the ablation. In the control group, 20 patients (12 cases of type A, 8 cases of type B) underwent conventional ablation via anterior accessory pathway. In the atrial premature group, 30 patients (16 cases of type A, 14 cases of type B) received atrial premature stimulation-guided ablation via anterior accessory pathway. Under the condition of sinus rhythm, R-R interval minus 30 ms was regarded as the initial pacing interval of atrial premature stimulation. As initial pacing interval was reduced by 5 ms, the pre-excitation component of the surface QRS was observed. The interval with most significant overt pre-excitation component was considered as the fixed stimulus frequency to guide the ablation via anterior accessory pathway in W-P-W patients. The success rate of the first ablation, the accumulative ablation time and the accumulative radiation dose were statistically compared between two groups. ResultsThe success rate of the first ablation in the atrial premature group was 80%, significantly higher compared with 50% in the control group (P=0.03). The accumulative ablation time in the atrial premature group was (301.3±61.1)s, considerably shorter than (358.5±115.5) s in the control group (P=0.03). The cumulative radiation dose in the atrial premature group was (49.3±31.8) mGray, significantly lower compared with (101.2±78.5) mGray in the control group (P<0.01). ConclusionsCatheter ablation guided by atrial premature stimulation of atrioventricular junction within refractory period is of certain clinical significance, which shortens operation time, reduces radiation exposure rate and improves surgical success rate.

Atrial premature of atrioventricular junction within refractory period;

10.3969/j.issn.0253-9802.2016.09.013

570311 ?？冢Ｄ鲜∞r(nóng)墾總醫(yī)院心血管內(nèi)科(許環(huán)親，吳飛玉，郭照軍，陳武，劉先霞)；510080 廣州，中山大學(xué)附屬第一醫(yī)院心血管內(nèi)科(何建桂)

，何建桂，E-mail:hejiangui@163.com

2016-04-06)