Velázquez-Rodríguez Enrique
Servicio de Electrofisiología, Hospital de Cardiología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social.
Arch Cardiol Mex. 2009 Dec;79 Suppl 2:44-52.
To inform the efficacy and safety of the interventional treatment of typical atrial flutter (AFL). AFL is a common arrhythmia that has a characteristic pattern on 12-lead ECG. The unique endocardial anatomy of the right atrium, with its many orifices and distinct structures provides anatomic barriers around which reentry could occur, likely explains the consistency of AFL from patient to patient. Much of our current understanding of the role of barriers in AFL has been from animal models. Using multisite endocardial mapping in patients with AFL, activation in the right atrium spreads superiorly from the coronary sinus ostium, up the septum and down the lateral right atrial wall (counterclockwise rotation of typical flutter and clockwise in reverse typical AFL).
A critical area of slow conduction was identified between the coronary sinus ostium, tricuspid valve ring, and inferior vena cava (the cavotricuspid isthmus). Entrainment has also been used to interrogate the AFL circuit. Concealed entrainment demonstrates that typical AFL is a reentrant arrhythmia and it has been demonstrated in the area of cavotricuspid isthmus. AFL is an arrhythmia that can be cured by catheter ablation of the tricuspid valve-inferior vena cava isthmus. The aim of catheter ablation for typical AFL is to create a complete and stable bidirectional cavotricuspid isthmus block. Ablation is performed during AFL or sinus rhythm, using either an 8/10 mm tip catheter or an irrigated tip catheter.
After ablation, assessment of cavotricuspid isthmus conduction is performed periodically to confirm a complete and stable bidirectional block. With this primary end-point, the long-term efficacy has increased to >90% with low recurrence rate.
Ablation of AFL is safe and effective, improved quality of life and has a minimal risk of adverse effects. Catheter ablation is now considered as alternative first line therapy for all those with symptomatic sustained typical AFL.
了解典型心房扑动(AFL)介入治疗的疗效和安全性。AFL是一种常见的心律失常,在12导联心电图上具有特征性图形。右心房独特的心内膜解剖结构,有许多开口和不同的结构,形成了折返可能发生的解剖学屏障,这可能解释了AFL在患者之间的一致性。我们目前对屏障在AFL中作用的许多理解来自动物模型。在AFL患者中使用多部位心内膜标测,右心房的激动从冠状窦口向上传播,沿着间隔向上并沿着右心房外侧壁向下(典型扑动为逆时针旋转,反向典型AFL为顺时针旋转)。
在冠状窦口、三尖瓣环和下腔静脉之间(腔静脉-三尖瓣峡部)确定了一个缓慢传导的关键区域。拖带也被用于研究AFL环路。隐匿性拖带表明典型AFL是一种折返性心律失常,并且已在腔静脉-三尖瓣峡部区域得到证实。AFL是一种可通过导管消融三尖瓣-下腔静脉峡部治愈的心律失常。典型AFL导管消融的目的是创建一个完整且稳定的双向腔静脉-三尖瓣峡部阻滞。消融在AFL或窦性心律期间进行,使用8/10毫米尖端导管或灌注尖端导管。
消融后,定期评估腔静脉-三尖瓣峡部传导以确认完整且稳定的双向阻滞。以此为主要终点,长期疗效已提高到>90%,复发率低。
AFL消融安全有效,改善了生活质量,不良反应风险极小。导管消融现在被认为是所有有症状的持续性典型AFL患者的替代一线治疗方法。