Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas; Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York.
Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York.
Heart Rhythm. 2019 May;16(5):724-732. doi: 10.1016/j.hrthm.2018.11.028. Epub 2018 Nov 30.
The optimal site of ablation of idiopathic left ventricular outflow tract (LVOT) ventricular arrhythmias (VAs) is challenging as activation mapping can reveal similar activation times in different anatomical sites, suggesting an intramural origin.
We sought to assess whether in patients with intramural VAs and with multiple early activation sites (EASs), sequential ablation of all the early EASs could improve acute and long-term clinical outcomes.
A total of 116 patients undergoing catheter ablation for symptomatic LVOT VAs were enrolled in this study. Thirty-nine patients (34%) were referred for a redo procedure, whereas the remaining presented for a first procedure. Mapping was performed manually in 86 cases (74%) and with a magnetic robotic system (Niobe, Stereotaxis, St. Louis, MO) in the remainder of the cases.
Of the 116 patients, 15 (13%) were found to have multiple sites of equally early activation. In patients with multiple EASs, the mean pre-QRS activation time was significantly less than in patients with a single EASs (-26 ± 3 ms vs -38 ± 6 ms; P < .005). Sequential ablation of all the EASs was possible in 14 patients (93%), resulting in complete arrhythmia suppression. After a mean follow-up of 21 ± 5 months, all patients with successful ablation of all multiple early EASs remained free from clinical VAs.
Intramural LVOT VAs manifesting with multiple EASs require ablation at all sites to achieve acute and long-term success, particularly if none of the EASs is > -30ms pre-QRS activation time.
特发性左心室流出道（LVOT）室性心律失常（VA）的消融最佳部位具有挑战性，因为激活图可以显示不同解剖部位具有相似的激活时间，提示起源于心室内膜下。
我们旨在评估在具有心室内膜下 VA 且具有多个早期激活部位（EAS）的患者中，是否可以通过消融所有早期 EAS 来改善急性和长期临床结局。
共有 116 名因有症状的 LVOT VA 而行导管消融的患者被纳入本研究。39 名患者（34%）为再次消融，而其余患者为首次消融。86 例患者（74%）采用手动标测，其余患者采用磁导航机器人系统（Niobe，Stereotaxis，密苏里州圣路易斯）进行标测。
在 116 名患者中，有 15 名（13%）患者存在多个同样早期激活的部位。在具有多个 EAS 的患者中，预 QRS 激活时间的平均值明显小于具有单个 EAS 的患者（-26±3ms 与 -38±6ms；P<.005）。在 14 名患者（93%）中可以进行所有 EAS 的顺序消融，从而实现完全抑制心律失常。平均随访 21±5 个月后，所有成功消融所有多个早期 EAS 的患者均未再出现临床 VA。
具有多个 EAS 的心室内膜下 LVOT VA 需要消融所有部位才能实现急性和长期成功，尤其是如果没有任何 EAS 的预 QRS 激活时间大于-30ms。
