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目的运用影像融合技术研究心脏外科手术后迟发性右房房性心动过速(AT)的机制并探讨在该技术指导下导管消融该类型AT的有效性。方法从2005年1月到2006年12月在影像融合系统(CartoMerge~(TM) system)指导下对连续40名患者的自发性或诱发的AT进行了完整的电生理标测。消融策略是在影像融合技术指导下在峡部最狭窄处消融,但避开可见的解剖异常处。术后3个月、6个月和每年进行一次临床和24小时动态心电图检查。结果总共发现三种主要的心动过速机制:单折返环大折返AT(MAT,n=36)、双折返环MAT(n=16)以及额外的局灶性AT(n=4)。最常见的关键峡部是三尖瓣峡部(CTI,n=35)和手术切口性峡部(n=36)。部分患者影像融合技术重建后右房可见到明显的瘢痕线、囊样物或瘤样物(n=12),上述解剖异常处都有瘢痕区特有的电生理表现。平均19.5±10.1次消融可阻断峡部。平均随访18±10个月后,80%的患者在不服药的情况下保持窦性心律。8例(20%)患者复发,分别在3～16个月进行了第2次消融;其中2例分别在3个月和5个月后再次复发,前者再次消融成功,后者未再消融。结论影像融合技术不仅能够确定AT的机制,还在精确定位和消融AT的致心律失常基质上具有优势。三维MR/CT影像能够成功重建和配准以用于右房的导管消融,这些真实和详细的解剖学信息有助于对手术导致解剖异常的右房AT进行导管消融。
Objective To study the mechanism of delayed right atrial tachycardia (AT) after cardiac surgery using image fusion technique and to explore the effectiveness of catheter ablation of this type of AT under the guidance of this technique. Methods From January 2005 to December 2006 under the guidance of the image fusion system (CartoMerge ™), spontaneous or induced AT in 40 consecutive patients were completely electrophysiologically mapped. The ablation strategy is to melt at the narrowest isthmus but avoid the visible anatomical abnormalities under the guidance of image fusion techniques. After 3 months, 6 months and annual clinical and 24-hour Holter examination. Overall, three major mechanisms of tachycardia were identified: single fold reentry AT (MAT, n = 36), double fold back MAT (n = 16), and additional focal AT (n = 4). The most common key isthmus is the tricuspid isthmus (CTI, n = 35) and surgical incision isthmus (n = 36). In some patients, obvious scar line, cyst sample or tumor sample (n = 12) were found in the right atrium after reconstructions of the fusion images. The anatomical abnormalities mentioned above all have the unique electrophysiological findings of scarring. An average of 19.5 ± 10.1 ablations blocked the isthmus. After a mean follow-up of 18 ± 10 months, 80% of patients remained sinus rhythm without medication. In 8 patients (20%), the patients recurred. The second ablation was carried out in 3 ~ 16 months respectively. Two of them relapsed again after 3 months and 5 months. The former was ablated again and the latter did not ablate again. Conclusion Image fusion technique not only can determine the mechanism of AT, but also has the advantage of accurately positioning and ablating AT-induced arrhythmia matrix. Three-dimensional MR / CT images can be successfully reconstructed and registered for catheter ablation of the right atrium, and these true and detailed anatomical information are helpful in catheter ablation of the right atrium AT, which results in anatomical abnormalities.