BACKGROUND:Electrocardiogram criteria for left bundle branch block (LBBB) inadequately predict left ventricular electrical dyssynchrony, complicating cardiac resynchronization therapy (CRT) candidate selection. OBJECTIVE:This study aimed to investigate the predictive value of the horizontal QRS axis for CRT response in heart failure (HF) patients with LBBB patterns. METHODS:The direction and magnitude of the horizontal QRS axis were calculated using the net amplitudes in leads V2 and V6. CRT response was defined as a ≥10% increase in left ventricular ejection fraction and at least 1 New York Heart Association class reduction 1 year after CRT implantation. The composite end point included HF hospitalization or all-cause mortality. RESULTS:Of 244 consecutive CRT recipients, 156 (63.9%) responded favorably; 88 (36.1%) were nonresponders. The horizontal QRS axis demonstrated significant backward deviation (-75.5° [-79.7° to -69.0°] vs -65.0° [-73.0° to -46.5°]; P < .001) and larger magnitude (35.5 ± 10.9 mm vs 25.5 ± 10.5 mm; P < .001) in CRT responders compared with nonresponders. The direction and magnitude independently predicted CRT response with an area under the curve of 0.778 (95% confidence interval [CI], 0.717-0.839) and 0.749 (95% CI, 0.685-0.814), respectively. Combining both parameters increased the area under the curve to 0.814 (95% CI, 0.760-0.868). Moreover, the direction and magnitude of the horizontal QRS axis, or their combination, predicted the composite end point of HF hospitalization or all-cause mortality, with hazard ratios of 0.36 (95% CI, 0.22-0.60), 0.41 (95% CI, 0.25-0.67), and 0.25 (95% CI, 0.15-0.41), respectively. CONCLUSION:Horizontal QRS axis accurately predicts CRT response and prognosis in HF patients with LBBB.

INTRODUCTION:The long-term efficacy of high-power (50 W) ablation guided by lesion size index (LSI-guided HP) for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) remains undetermined. Our study sought to assess the clinical efficacy of LSI-guided HP ablation for PVI in patients with AF and explore the potential predictors associated with clinical outcomes.METHODS:We consecutively included 186 patients with AF who underwent LSI-guided HP (50 W) ablation at Fuwai Hospital from June 2019 to October 2021. The target LSI values of 4.5-5.5 and 4.0-4.5 at the anterior and posterior walls, respectively, were used in our study. The baseline clinical characteristics, procedural and ablation data, and clinical outcomes were evaluated. The independent potential predictors associated with AF recurrence were further evaluated.RESULTS:The incidence rate of first-pass PVI was 83.9% (156/186). A total of 11 883 lesions were analyzed, and compared with posterior walls of pulmonary veins, anterior walls had significantly lower mean contact force (8.2 ± 3.0 vs. 8.3 ± 2.3 g, p = .015), longer mean radiofrequency duration (16.9 ± 7.2 vs. 12.9 ± 4.5 s, p < .001) and higher mean LSI (4.8 ± 0.2 vs. 4.4 ± 0.2, p < .001). The overall incidence of periprocedural complications was 3.7%, and steam pops without pericardial effusion occurred in three patients (1.6%). During a mean follow-up of 24.0 ± 8.4 months, the overall AF recurrence-free survival was 87.1% after a single procedure. Patients with paroxysmal AF had a higher incidence of freedom from AF recurrence than those with persistent AF (91.2% vs. 80.8%, log-rank p = .034). Higher LSI (HR 0.50, p < .001) and paroxysmal AF (HR 0.39, p = .029) were significantly associated with decreased AF recurrence. By receiver operating characteristic analysis, the LSI of 4.7 and 4.3 for the anterior and posterior walls of the PVs had the highest predictive value for AF recurrence, respectively.CONCLUSION:LSI-guided HP (50 W) ablation for PVI was an efficient and safe strategy and led to favorable single-procedure 2-year AF recurrence-free survival in patients with AF. Higher LSI and paroxysmal AF were independent predictors of decreased 2-year AF recurrence. The LSI of 4.7 for the anterior wall and 4.3 for the posterior wall of the PVs were the best cutoff values for predicting AF recurrence after LSI-guided HP ablation.

Background:Although both high-power (HP) ablation and lesion size index (LSI) are novel approaches to make effective lesions during pulmonary vein isolation (PVI) for atrial fibrillation (AF), the optimal LSI in HP ablation for PVI is still unclear. Our study sought to explore the association between LSI and acute conduction gap formation and investigate the optimal LSI in HP ablation for PVI.Methods:A total of 105 consecutive patients with AF who underwent HP ablation guided by LSI (LSI-guided HP) for PVI in our institute between June 2019 and July 2020 were retrospectively enrolled. Each ipsilateral PV circle was subdivided into four segments, and ablation power was set to 50 W with target LSI values at 5.0 and 4.0 for anterior and posterior walls, respectively. We compared the LSI values with and without acute conduction gaps after the initial first-pass PVI.Results:PVI was achieved in all patients, and the incidence of first-pass PVI was 78.1% (82/105). A total of 6,842 lesion sites were analyzed, and the acute conduction gaps were observed in 23 patients (21.9%) with 45 (0.7%) lesion points. The gap formation was significantly associated with lower LSI (3.9 ± 0.4 vs. 4.6 ± 0.4, p < 0.001), lower force-time integral (82.6 ± 24.6 vs. 120.9 ± 40.4 gs, p < 0.001), lower mean contact force (5.7 ± 2.4 vs. 8.5 ± 2.8 g, p < 0.001), shorter ablation duration (10.5 ± 3.6 vs. 15.4 ± 6.4 s, p < 0.001), lower mean temperature (34.4 ± 1.4 vs. 35.6 ± 2.6°C, p < 0.001), and longer interlesion distance (4.4 ± 0.3 vs. 4.3 ± 0.4 mm, p = 0.031). As per the receiver operating characteristic analysis, the LSI had the highest predictive value for gap formation in all PVs segments, with a cutoff of 4.35 for effective ablation (sensitivity 80.0%; specificity 75.4%, areas under the curve: 0.87). The LSI of 4.55 and 3.95 had the highest predictive value for gap formation for the anterior and posterior segments of PVs, respectively.Conclusion:Using LSI-guided HP ablation for PVI, more than 4.35 of LSI for all PVs segments showed the best predictive value to avoid gap formation for achieving effective first-pass PVI. The LSI of 4.55 for the anterior wall and 3.95 for the posterior wall were the best cutoff values for predicting gap formation, respectively.

Objective:To investigate the sleep quality and related factors among arrhythmia inpatients.Methods:Patients with arrhythmia who were hospitalized in Center of Arrhythmia in Fuwai Hospital, from October to December 2019 were selected.The sleep quality was assessed using the Pittsburgh sleep quality index (PSQI), and the total score of PSQI > 7 was defined as sleep disorder.Multivariate Logistic regression was used to identify potential influencing factors of sleep quality, and differences were considered statistically significant at the 5% level ( P<0.05). Results:Four hundred and ninety-two inpatients with arrhythmia were enrolled, including 278 males (278/492, 56.5%) with an average age of (55.49±14.93) years.The mean score of PSQI was 6.58±4.14, and 34.1% (168/492)had sleep disorders.Multivariable Logistic regression analysis showed that sleep quality was statistically significantly associated with gender ( OR=1.76, 95% CI 1.17-2.66, P=0.007), age ( OR=1.75, 95% CI 1.01-2.77, P=0.018), anxiety ( OR=3.72, 95% CI 2.24-6.19, P<0.001), and depression ( OR=1.82, 95% CI 1.15-2.88, P=0.010). The proportions of female patients with sleep disorders was significantly higher than that in male patients [41.6% (89/214) vs.28.4% (79/278), χ2=9.33, P=0.002]. The proportion of sleep disorders in patients younger than 65 years old was much lower than those older than 65 years old [31.3% (112/358) vs.41.8% (56/134), χ2=4.79, P=0.029]. The proportion of sleep disorders in patients with anxiety was much higher than those without anxiety [61.7% (71/115) vs.25.7% (97/377), χ2=50.82, P<0.001]. The proportion of sleep disorders in patients with depression was much higher than those without depression [50.0% (86/172) vs.25.6% (82/320), χ2=29.56, P<0.001]. Conclusion:The prevalence of sleep disorders in arrhythmia inpatients was higher than that in the general population, and was closely related to gender, age, anxiety, and depression .

目的:分析行射频导管消融治疗的青年(≤45岁)心房颤动(房颤)患者的临床特点,探讨射频导管消融治疗青年房颤患者的临床疗效.方法:回顾性收集于2017年1月至2019年1月在中国医学科学院阜外医院行射频导管消融治疗的358例房颤患者(≤60岁)的临床资料,按年龄分为青年组(≤45岁,n=94)及非青年组(45岁<年龄≤60岁,n=264),比较两组基线临床特点并对其进行随访.手术3个月后,经心电图或动态心电图证实的房颤、心房扑动和(或)房性心动过速发作且持续时间大于30 s定义为房颤复发.结果:青年组房颤患者平均年龄为(39.7±4.8)岁,男性76例(80.9％).青年组与非青年组相比房颤病程较短[(15.8±15.6)个月vs.(27.5±34.0)个月,P=0.001],CHA2DS2-VASc评分[(0.74±0.83)分vs.(1.19±1.07)分,P<0.001]和HAS-BLED评分[(0.40±0.54)分vs.(0.63±0.65)分,P=0.002]更低,左心房内径更小[(38.2±5.6)mm vs.(40.0±5.4)mm,P=0.006],合并心房扑动比例较高,而心脑血管疾病合并症较低(P<0.05).青年组患者行三尖瓣峡部线消融比例较高,而左心房后壁BOX线性消融比例较低(P<0.05).青年组与非青年组患者手术并发症发生率差异无统计学意义(1.1％vs.2.7％,P=0.513).平均随访(26.5±10.9)个月,青年组房颤单次射频导管消融术后成功率明显高于非青年组(87.2％vs.75.0％,P=0.030).青年组中阵发性房颤患者与持续性房颤患者射频导管消融成功率均较高,差异无统计学意义(88.1％vs.85.7％,P=0.754).结论:射频导管消融治疗青年房颤患者成功率较高,且青年阵发性房颤患者与持续性房颤患者射频导管消融成功率均较高.

BackgroundCatheter ablation (CA) effectively restores sinus rhythm in atrial fibrillation (AF) but causes a short-term fluctuation in the coagulation state. Potential risk factors and better management during this perioperative period remain understudied.MethodsWe consecutively included 940 patients with nonvalvular AF who received CA at Fuwai Hospital, Beijing, China. Patients were divided into two groups according to their bleeding status during 3 months' anticoagulation. Any adverse events related to bleeding in the 3 months were evaluated. The HAS-BLED score and ABC-bleeding score, as well as other potential factors, were explored to predict bleeding risk.ResultsIn this observational study, 8.0% and 0.9% of the whole population suffered from bleeding and thromboembolic events, respectively. After adjusting for known factors related to bleeding, mitral regurgitation (MR, p for trend <0.001) and body mass index (BMI, odds ratio (OR) = 0.920, 95% CI 0.852–0.993, p = 0.033) were the most significant ones. C-indexes of the HAS-BLED score and ABC-bleeding score for bleeding were 0.558 (0.492–0.624) and 0.585 (0.515–0.655), respectively. The incorporation of MR and BMI significantly improved the predictive value based on HAS-BLED score (C-index = 0.650, 95% CI 0.585–0.715, p = 0.004) and ABC-bleeding score (C-index = 0.671, 95% CI 0.611–0.731, p < 0.001). The relative risk of mild-moderate MR was 4.500 (95% CI 1.625–12.460) in patients with AF having HAS-BLED = 1 and 4.654 (95% CI 1.496–14.475) in HAS-BLED ≥ 2, while it was not observed in patients with HAS-BLED = 0 (p = 0.722).ConclusionMore severe MR and lower BMI are associated with a higher incidence of perioperative bleeding, which helps improve the predictability of increased individual bleeding risk of a patient with nonvalvular AF who has received CA therapy and oral anticoagulants.

Objectives: This study aimed to assess the depression and anxiety status and their association with sleep disturbance among one single center Chinese inpatients with arrhythmia and help cardiologists better identify patients who need psychological care.Methods: A cross-sectional survey was conducted among 495 inpatients with arrhythmia treated in Fuwai Hospital from October to December 2019. The psychological status and sleep quality were assessed using the Zung Self-Rating Anxiety Scale (SAS), the Zung Self-Rating Depression Scale (SDS) and the Pittsburgh Sleep Quality Index (PSQI). Multivariate logistic regression was used to identify the potential risk factors for anxiety and depression.Results: The mean age of the participants was 52.8 +/- 14.4 years, and 58.0% were male. Approximately 18.3% were in an anxious state, and 33.5% were in a depressive state. In multivariate logistic regression, age from 50 to 59 (p = 0.03), unemployment (p = 0.026) and sleep disturbance (p < 0.001) were the risk factors for anxiety status. Cardiac implanted electronic devices (CIEDs) (p = 0.004) and sleep disturbance (p < 0.001) were the risk factors for depression status. A total of 150 patients (30.3%) were categorized as having poor sleep quality (PSQI > 7). The adjusted odds ratio (OR) of having poor sleep quality was 4.30-fold higher in patients with both anxiety and depression (OR: 4.30; 95% confidence interval [CI]: 2.52-7.35); 2.67-fold higher in patients with depression (OR: 2.67; 95% CI: 1.78-4.00); and 3.94-fold higher in patients with anxiety (OR: 3.94; 95% CI: 2.41-6.44).Conclusions: Psychological intervention is critical for Chinese inpatients with arrhythmia, especially for patients aged 50-59, unemployed, or those using CIEDs. Poor sleep quality could be an important risk factor linked to psychological disturbances.

目的 对健康实验犬行左束支区域起搏(LBBAP),并与心室不同部位起搏的心电学及急性血流动力学参数进行比较.方法 本研究选取2020年10月至2021年10月由中国医学科学院阜外医院实验动物中心提供的5只犬,在X线影像指导下进行LBBAP及心室不同部位起搏(希氏束、右心室流出道、右心室间隔、右心室心尖部、左心室间隔及左心室心尖部),分析并比较LBBAP及心室不同部位起搏的QRS时限和左心室达峰时间(S-LVAT)以及左心室压力最大上升速率(dp/dt max).结果 本研究5只犬均成功行LBBAP,LBBAP与希氏束起搏在改善QRS时限[(108.0±3.2)ms比(109.7±1.6)ms,P>0.05]、S-LVAT[(61.0±2.6)ms比(61.0±3.3)ms,P>0.05]以及左心室dp/dt max[(1114.1±34.8)mmHg/s比(1107.4±34.8)mmHg/s,P>0.05]方面的差异无统计学意义.与心室其他部位起搏相比,LBBAP能够明显缩短QRS时限及S-LVAT,明显增加左心室dp/dt max(P均<0.001).结论 LBBAP与希氏束起搏对犬的心电学及急性血流动力学影响相似,均明显优于心室其他部位起搏.

Low-density lipoprotein receptor-related protein 6 (LRP6) plays a critical role in cardiovascular homeostasis. The deficiency of LRP6 is associated with a high risk of arrhythmias. However, the association between genetic variations of LRP6 and sudden cardiac death (SCD) remains unknown. This study aims to explore the association between common variants of LRP6 and the prognosis of chronic heart failure (CHF) patients. From July 2005 to December 2009, patients with CHF were enrolled from 10 hospitals in China. The single-nucleotide polymorphism (SNP) rs2302684 was selected for the evaluation of the effect of LRP6 polymorphisms on the survival in patients with CHF. A total of 1,437 patients with CHF were finally included for the analysis. During a median follow-up of 61 months (range 0.4–129 months), a total of 546 (38.0%) patients died, including 201 (36.8%) cases with SCD and 345 (63.2%) cases with non-SCD. Patients carrying A allele of rs2302684 had an increased risk of all-cause death (adjusted HR 1.452, 95% CI 1.189–1.706; P < 0.001) and SCD (adjusted HR 1.783, 95% CI 1.337–2.378; P < 0.001). Therefore, the SNP rs2302684 T>A in LRP6 indicated higher risks of all-cause death and SCD in patients with CHF. LRP6 could be added as a novel predictor of SCD and might be a potential therapeutic target in the prevention of SCD in the CHF population.

目的 探讨应用20极标测电极(DD电极)指导左室乳头肌起源室性期前收缩(室早)射频消融的可行性及有效性.方法 回顾性收集中国医学科学院阜外医院2019年5月至12月间11例左室乳头肌起源的频发室早患者,按照标测方法分为DD标测组(6例)和传统4极消融导管逐点(PBP)标测组(5例),确定理想的室早起源靶点后进行放电消融.收集两组患者临床资料、心电图资料以及术中参数,观察两种标测方法随访期的消融成功率.结果 本研究共纳入11例左室乳头肌频发室早患者,年龄(41±18)岁,男性5例(45.5％),平均24 h室早负荷(18.6±8.2)％.与PBP标测组相比,DD标测组总手术时间[(95.8±7.4)min比(141.2±12.3)min]、消融时间[(6.1±3.0)min比(15.8±4.7)min]、射线曝光时间[(14.2±1.5)min比(24.4±5.4)min]明显缩短,消融点数[(6.8±1.9)个比(14.8±3.6)个]明显减少,室早时靶点局部V波领先体表室早QRS间期[(37.8±7.2)ms比(25.4±2.8)ms].术中及术后随访期间,DD标测组未发生标测及消融相关并发症,而PBP标测组术中出现1例心包积液.随访(15.1±1.3)个月,DD标测组患者经射频消融后均无室早再发,成功率为100％,而PBP标测组3例消融成功,成功率为60％.结论 DD电极可易化左室乳头肌室早射频消融,缩短手术时间及减少X线曝光,随访期消融成功率均较高,具有良好的可行性及有效性.

患者女性,52岁,1年前因频发性室性早搏(简称室早)行射频消融术,3月前室早复发,为再次行射频消融入院.术中心内电生理检查证实室早起源于左右冠状动脉窦交界处,消融后频发室早消失.然而,术中消融导管在标测过程中误入冠状动脉左前降支致冠状动脉夹层,紧急植入2枚支架,术后恢复良好,平稳出院.术后随访3个月,患者为偶发室早,伴心功能减低,目前规范药物治疗,定期门诊随访.

目的 探讨透壁消融指数(LSI)指导下高功率(50W)射频消融对离体猪心的损伤效应.方法 应用光感应压力导管对离体猪心进行射频消融,消融功率分为低功率组(30W和40W)和高功率组(50W),通过调整导管压力(5g、10g和15g)达到相应的LSI目标值(5、6和7),分别测量消融灶的长度及深度,并分析LSI及消融功率与消融长度及深度的相关性.结果 本离体实验共完成75个消融灶,所有消融灶在射频消融过程中均未发生气爆现象.相关性分析显示,当消融功率介于30W～50W时,LSI与消融长度及深度呈正相关(r=0.49和r=0.51,P均＜0.0001).当达到不同的LSI目标值时,消融功率与消融长度呈正相关(产0.74,P＜0.0001),而与消融深度呈负相关(r=-0.55,P＜0.0001).当达到相同的LSI目标值(LSI=5、6和7)时,消融功率亦与消融长度呈正相关(r=0.75、0.81和0.89,P＜0.0001),而与消融深度均呈负相关(r=-0.73、-0.60和-0.75,P＜0.0001).与低功率组(30W和40W)相比,高功率组(50W)消融灶长度更长,消融灶深度更浅,形成宽而浅的消融灶.结论 当消融功率介于30W ～ 50W时,LSI与消融长度及深度呈正相关.无论达到不同/相同的LSI目标值,消融功率与消融长度呈正相关,而与消融深度呈负相关.

目的 探讨心内膜室间隔射频消融治疗肥厚型梗阻性心肌病(HOCM)的可行性及有效性.方法 回顾性收集阜外医院2019年9月至11月间经充分药物治疗后左室流出道压差(LVOTG)≥50 mmHg的HOCM患者,应用三维电解剖标测及心腔内超声行左室腔解剖建模并标记出二尖瓣前叶收缩期前向运动(SAM)-室间隔区及希浦系电位分布区域,经主动脉逆行途径应用冷盐水灌注消融导管于SAM-室间隔区肥厚心肌处进行放电消融.收集患者临床资料、超声资料以及术中参数,并随访术后LVOTG变化及心功能改善情况.结果 本研究共纳入5例HOCM患者,年龄(59±15)岁,男性2例(40.0％),室间隔厚度(23.4±1.7)mm,术前静息LVOTG(98.2±22.6)mmHg,运动激发LVOTG(130.0±25.6)mmHg.4例NYHA分级为Ⅲ级,余1例为Ⅳ级.术中标记平均SAM-室间隔区面积(5.2±1.6)cm2,消融面积(3.7±1.6)cm2,消融点数(18.2±4.7)个,消融时间(20.8±4.8)min.随访6个月,术后静息LVOTG(35.2±6.7)mmHg及运动激发LVOTG(47.6±5.6)mmHg,均较术前明显减低(P均=0.001).3例NYHA分级改善至Ⅰ级,2例改善至Ⅱ级.术中及术后随访期间,未发生射频消融相关并发症.结论 心内膜室间隔射频消融治疗可显著降低HOCM患者LVOTG并改善其临床症状,具有良好的可行性及有效性.

Objective:To analyze and investigate the efficacy and its predictive factors in patients upgraded from conventional pacing to cardiac resynchronization therapy (CRT) in the real world.Methods:The study included 56 consecutive patients who underwent CRT upgrading at Fuwai Hospital from May 2008 to February 2020. The patients were classified to right ventricular pacing -induced cardiomyopathy (PICM) group and no PICM group at baseline. The CRT response and its predictive factors were analyzed in patients who underwent CRT upgrading. Results:The mean age of patients was (58.8±11.6) years, and 42 patients (75.0%, 42/56) were male. Thirty -four patients (60.7%, 34/56) were PICM, and the remaining 22 patients (39.3%, 22/56) were no PICM. Compared with patients with PICM, patients with no PICM had larger left atrial dimension and left ventricular end -diastolic dimension, and lower left ventricular ejection fraction [ (12.0%±9.3%) vs. (5.4%±9.6%) , P=0.012] as well as higher proportion of pulmonary hypertension and renal malfunction. During a mean follow -up of 6 months, 40 patients (71.4%, 40/56) presented CRT response. The CRT response rate was significant higher in PICM group[85.3% (29/34) vs. 50.0% (11/22, P=0.007]. In a multivariable Logistic model, the CRT response was strongly associated with PICM. Conclusion:The clinical prognosis of patients who underwent CRT upgrading was favorable. The CRT response rate was significantly higher in PICM group and cardiac remodeling reversal of PICM following CRT upgrading was greater. The PICM patients could be considered initially to upgrade CRT as soon as possible.

心律失常是目前临床上最常见的心脏疾患之一,而快速型心律失常是导致心源性猝死的最主要原因之一.抗心律失常药物可改善临床症状,但不能使快速型心律失常患者长远获益,且无法降低患者远期死亡率,射频消融术已成为目前治疗快速型心律失常的主要手段.随着消融技术及相关器械的更新,使得射频消融的成功率得到明显的提高.双向可控弯鞘目前主要应用于房颤及其他心律失常的射频消融中,本文就双向可控弯鞘管在心律失常射频消融中应用的研究进展进行综述.

目的:分析心脏再同步化治疗(CRT)超反应患者的临床特点,探讨影响CRT超反应的预测因素.方法:回顾性收集中国医学科学院阜外医院2014年1月至2019年3月间CRT患者的临床资料并对其进行临床随访.CRT术后6个月NYHA心功能分级改善至Ⅰ级或Ⅱ级且左心室射血分数(LVEF)≥50％定义为CRT超反应.结果:本研究共纳入352例CRT患者,平均年龄为(58.8±11.6)岁,男性237例(67.3％).随访6个月,共有97例(27.6％)患者表现为CRT超反应.与CRT非超反应患者相比,CRT超反应患者的左心房内径(LAD)和左心室舒张末期内径(LVEDd)较小,LVEF更高,NYHA心功能分级更低,合并高血压比例较高,应用血管紧张素转换酶抑制剂(ACEI)/血管紧张素Ⅱ受体拮抗剂(ARB)及β受体阻滞剂比例较高.随访6个月,CRT超反应患者较CRT非超反应患者LAD、LVEDd、LVEF以及心功能改善更显著,且术后QRS波时限更窄,双心室起搏比更高.多因素Logistic回归分析显示合并高血压(OR=3.31,95％CI:1.83～5.97,P<0.001)、基线LVEDd(OR=0.94,95％CI:0.90～0.98,P=0.003)、LVEF(OR=1.05,95％CI:1.01～1.10,P=0.042)、NYHA心功能分级(OR=0.47,95％CI:0.28～0.79,P=0.005)、术后QRS波时限(OR=0.98,95％CI:0.96～0.99,P=0.008)以及双心室起搏比(OR=1.13,95％CI:1.05～1.22,P=0.001)均是CRT超反应的独立预测因素.结论:超过1/4的CRT患者表现为超反应,CRT超反应患者左心室机械重构及电重构指标显著改善.合并高血压、基线LVEDd、LVEF、NYHA心功能分级、术后QRS时限以及双心室起搏比均与CRT超反应相关.

目的:探讨在心内超声联合三维电解剖标测系统指导下经皮心内膜室间隔射频消融术治疗肥厚型梗阻性心肌病合并晕厥患者的安全性与有效性.方法:12例肥厚型梗阻性心肌病合并晕厥发作患者在局麻下完成在心内三维超声指导下的经皮左心室心内膜室间隔射频消融治疗.术中记录消融相关参数与病损参数.术前、术后住院期间与术后3个月随访期分别进行超声心动图和心电图检查.结果:患者平均年龄(57±15)岁,男性6例,5例合并高血压,4例合并糖尿病,4例合并心房颤动,1例曾行冠状动脉间隔支酒精消融.肥厚心室肌累及范围:6例单纯累及室间隔,1例累及室间隔和前壁,1例累及室间隔和后乳头肌肥大、4例累及室间隔+前壁+下壁.7例经主动脉逆行途径消融成功(其中2例经房间隔途径失败),5例经房间隔穿刺途径消融成功(其中3例经主动脉途径失败).平均消融功率(37±3)W,平均消融累计时间(916±728)s,平均消融表面积(1.14±1.16)cm2,平均消融深度(4.5±3.7)mm.1例患者消融术中发生心肌组织气爆现象,1例患者发生股动脉穿刺并发症.超声心动图检查显示,患者术后住院期间平均左心室流出道压差下降(中位数)23.5(第5和第95百分位数:1.0,84.0)mmHg(1 mmHg=0.133 kPa),术后3个月继续下降14(1,59)mmHg,较入院时总体下降37(2,78)mmHg,平均降幅36.4％(2.8％,80.4％).随访期间11例患者无晕厥发作,1例患者出现心力衰竭发作;所有患者均无心脏传导系统受损的心电图表现.结论:在心内超声联合三维电标测系统指导下进行经皮心内膜室间隔射频消融术治疗肥厚型梗阻性心肌病合并晕厥患者是安全、有效的.

肥厚型梗阻性心肌病(HOCM)是一类因编码肌小节或肌原纤维的基因突变引发的以室间隔或心尖部心肌非对称性肥厚为主要表现的常染色体显性遗传性疾病;其发病率约为 0.2％,实际发病率可能高于这个数值;室间隔肥厚可伴或不伴二尖瓣前叶收缩期前向运动(SAM), 使左心室射血受阻,从而在左心室流出道(主动脉瓣下)形成跨瓣压差,即左心室流出道压差(LVOTPG).一般将静息或诱发时经超声多普勒测算的LVOTPG ≥ 30 mmHg(1 mmHg=0.133 kPa)定义为梗阻 [1].大约只有 20％～30％ 的患者静息状态下 LVOTPG升高达标,70％ 的患者是在运动或药物诱发下才会出现 LVOTPG 升高 [2],其中蹲起的诱发敏感性高于硝酸酯类药物.

患者男性,30岁,10年前因三度房室传导阻滞植入心室单腔起搏器,5年前因心力衰竭植入心脏再同步化起搏器.此次因心房扑动(简称房扑)1个月、心功能减低入院,心内电生理检查诊断为右房峡部依赖型房扑,沿三尖瓣峡部行线性射频消融,房扑终止并转为窦性心律.射频消融术后随访5个月,患者未再发作房扑,心功能较术前改善.

Background: Previous studies on radiofrequency catheter ablation of premature ventricular complexes (PVCs) arising from the left ventricle (LV) papillary muscles (PM) show a modest procedural success rate with higher recurrence rate. Our study sought to explore the utility of using a multipolar mapping with a steerable linear duodecapolar catheter for ablating the PM PVCs. Methods： Detailed endocardial multipolar mapping was performed using a steerable linear duodecapolar catheter in 6 consecutive PM PVCs patients with structurally normal heart. The clinical features and procedural data as well as success rate were analysed. Results: LV endocardial electroanatomic mapping was performed in all patients via a retrograde aortic approach using a duodecapolar mapping catheter. All patients displayed a PVC burden with 16.2 ± 5.4%. Duodecapolar catheter mapping demonstrated highly efficiency with an average procedure time (95.8 ± 7.4 minutes) and fluoroscopy time (14.2 ± 1.5 minutes). The mean number of ablation applications points was 6.8 ± 1.9 with an average overall ablation duration of 6.1 ± 3.0 minutes. The values of earliest activation time during mapping using duodecapolar catheter were 37.8 ± 7.2 ms. All patients demonstrated acute successful ablation, and the PVC burden in all patients after an average follow-up of 8.5 ± 2.0 months was only 0.7%. There were no complications during the procedures and after follow-up. Conclusion: Mapping and ablation of PM PVCs using a duodecapolar catheter facilitated the identification of earliest activation potentials and pace mapping, and demonstrated a high success rate during follow-up.