慢传导电解剖峡部：法洛四联症 QRS 持续时间与室性心动过速之间的重要联系。
Slow Conducting Electroanatomic Isthmuses: An Important Link Between QRS Duration and Ventricular Tachycardia in Tetralogy of Fallot.
机构信息
Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands.
Electrophysiology and Heart Modeling Institute, Bordeaux University Hospital, Bordeaux, France; Department of Paediatric and Adult Congenital Cardiology, Bordeaux University Hospital, Bordeaux, France.
出版信息
JACC Clin Electrophysiol. 2018 Jun;4(6):781-793. doi: 10.1016/j.jacep.2018.02.002. Epub 2018 Mar 28.
OBJECTIVES
This study sought to evaluate the influence of slow conducting anatomic isthmuses (SCAI) as dominant ventricular tachycardia (VT) substrate on QRS duration.
BACKGROUND
QRS prolongation has been associated with VT in repaired tetralogy of Fallot.
METHODS
Seventy-eight repaired tetralogy of Fallot patients (age 37 ± 15 years, 52 male, QRS duration 153 ± 29 ms, 67 right bundle branch blocks [RBBB]) underwent programmed stimulation and electroanatomic activation mapping during sinus rhythm. Right ventricular (RV) surface, RV activation pattern, RV activation time, conduction velocity at AI, and remote RV sites were determined.
RESULTS
Twenty-four patients were inducible for VT (VT+); SCAI was present in 22 of 24 VT+ but only in 2 of 54 patients without inducible VT (VT-). Conduction velocity through AI was slower in VT+ patients (median of 0.3 [0.3 to 0.4] vs. 0.7 [0.6 to 0.9] m/s; p < 0.01) but conduction velocity in the remote RV did not differ between groups. In non-RBBB, QRS duration was similar in VT+ patients (n = 6) and VT- patients (n = 5), but RV activation within SCAI exceeded QRS offset in VT+ patients (37 ± 20 ms vs. -5 ± 9 ms, p < 0.01). In RBBB, both QRS duration and RV activation time were longer in VT+ patients (n = 18, 17 of 18 QRS > 150 ms) compared with VT- patients (n = 49, 27 of 49 QRS > 150 ms) (173 ± 22 ms vs. 156 ± 20 ms; p < 0.01; 141 ± 22 ms vs. 129 ± 21 ms; p = 0.04). In VT+ patients, QRS prolongation >150 ms (n = 17) was due to SCAI or blocked isthmus in 15 patients (88%) and 1 (6%). In contrast, in VT- patients, QRS prolongation >150 ms (n = 27) was due to enlarged RV or blocked isthmus in 10 patients (37%) and 8 (30%), but due to SCAI in only 1 (4%). After exclusion of a severely enlarged RV, a QRS duration >150 ms was highly predictive for SCAI/blocked AI (OR: 17; 95% CI: 3.3 to 84; p < 0.01).
CONCLUSIONS
A narrow QRS interval does not exclude VT-related SCAI. In the presence of RBBB, SCAI further prolongs QRS duration. QRS duration >150 ms is highly suspicious for SCAI or isthmus block distinguishable by electroanatomic mapping.
目的
本研究旨在评估慢传导解剖性峡部（SCAI）作为主要室性心动过速（VT）基质对 QRS 持续时间的影响。
背景
QRS 延长与修复性法洛四联症中的 VT 有关。
方法
78 例修复性法洛四联症患者（年龄 37±15 岁，52 例男性，QRS 持续时间 153±29ms，67 例右束支传导阻滞[RBBB]）在窦性心律下进行程序性刺激和电解剖激活映射。确定右心室（RV）表面、RV 激活模式、RV 激活时间、AI 中的传导速度和远程 RV 部位。
结果
24 例患者可诱发 VT（VT+）；24 例 VT+中有 22 例存在 SCAI，而 54 例无可诱发 VT（VT-）的患者中仅存在 2 例。VT+患者 AI 中的传导速度较慢（中位数 0.3[0.3 至 0.4]比 0.7[0.6 至 0.9]m/s；p<0.01），但两组之间远程 RV 的传导速度并无差异。在非 RBBB 中，VT+患者（n=6）和 VT-患者（n=5）的 QRS 持续时间相似，但 VT+患者 SCAI 内的 RV 激活超过了 QRS 终末（37±20ms 比-5±9ms，p<0.01）。在 RBBB 中，VT+患者（n=18，17 例 QRS>150ms）的 QRS 持续时间和 RV 激活时间均长于 VT-患者（n=49，27 例 QRS>150ms）（173±22ms 比 156±20ms；p<0.01；141±22ms 比 129±21ms；p=0.04）。在 VT+患者中，17 例 QRS 延长>150ms（n=17）是由于 SCAI 或峡部阻滞，其中 15 例（88%）和 1 例（6%）为 SCAI 所致。相比之下，在 VT-患者中，27 例 QRS 延长>150ms（n=27）是由于 RV 增大或峡部阻滞，其中 10 例（37%）和 8 例（30%）为 RV 增大所致，但仅有 1 例（4%）为 SCAI 所致。在排除 RV 严重增大后，QRS 持续时间>150ms 高度提示存在 SCAI/AI 阻滞（OR：17；95%CI：3.3 至 84；p<0.01）。
结论
窄 QRS 间隔不能排除与 VT 相关的 SCAI。在存在 RBBB 的情况下，SCAI 进一步延长了 QRS 持续时间。QRS 持续时间>150ms 高度怀疑存在 SCAI 或可通过电解剖映射来区分的峡部阻滞。
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