三维电解剖标测指导希氏束起搏导线植入：技术、解剖与实际问题。
Direct Visualization of the His Bundle Pacing Lead Placement by 3-Dimensional Electroanatomic Mapping: Technique, Anatomy, and Practical Considerations.
机构信息
Department of Medicine, Division of Cardiology, Section of Electrophysiology, St. Elizabeth's Medical Center, Boston, MA (M.V.O., I.K. M.M., A.E., A.H., J.A., J.V.W.).
Department of Medicine, Tufts University School of Medicine, Boston, MA (M.V.O., I.K., J.A., J.V.W.).
出版信息
Circ Arrhythm Electrophysiol. 2019 Feb;12(2):e006801. doi: 10.1161/CIRCEP.118.006801.
BACKGROUND
His bundle pacing (HBP) remains technically challenging and is currently guided by electrograms and 2-dimensional fluoroscopy. Our objective was to describe a new technique for HBP directly guided by electroanatomic mapping (EAM).
METHODS
Twenty-eight patients were included. The atrioventricular septum was mapped via EAM, and His bundle (HB) electrograms, selective, and nonselective HB capture sites were tagged. Pacing leads were connected to EAM, navigated to tagged HB target sites and deployed. Intracardiac electrograms and pacing parameters were recorded. Lead location was tagged on the cloud of HB sites, which was divided into 3 arbitrary segments. In 5 patients, atrioventricular nodal ablation was performed with direct visualization of the HBP lead by EAM.
RESULTS
Reproducible navigation of the pacing lead to predetermined HBP locations guided by EAM was achieved in all patients. The lead was successfully deployed in 25 patients. HB cloud area was 360 (212) mm. There was no correlation between HBP threshold and lead location on the His cloud. The intracardiac electrograms atrial/ventricular ratio at the lead deployment site correlated with its EAM position on the His cloud ( P=0.045). Procedure, fluoroscopy, and mapping times were 116.0 (38.8), 8.6 (6.3), and 9.0 (11.4) minutes, respectively. HBP threshold at implant was 1.5 (2.3) V at 1.5 (1.0) ms. Distance between HB lead and ablation sites was 10.0 (1.3) mm in patients undergoing atrioventricular nodal ablation.
CONCLUSIONS
Direct guidance of HBP by EAM allows for direct visualization of the pacing lead on the HB cloud and reproducible navigation to predetermined HB capture sites. Intracardiac electrograms atrial/ventricular ratio at the lead deployment site correlates with His cloud location. EAM can be applied during standard HBP procedures or combined with atrioventricular nodal ablation.
背景
希氏束起搏（HBP）仍然具有技术挑战性，目前由电图和二维透视引导。我们的目标是描述一种新的直接通过电激动图（EAM）引导的 HBP 技术。
方法
共纳入 28 例患者。通过 EAM 对房室间隔进行标测，并标记希氏束（HB）电图、选择性和非选择性 HB 捕获部位。起搏导线与 EAM 连接，导航至标记的 HB 目标部位并展开。记录心内电图和起搏参数。将导丝位置标记在 HB 靶点云图上，将 HB 靶点云图分为 3 个任意段。在 5 例患者中，通过 EAM 直接观察 HBP 导线进行房室结消融。
结果
在所有患者中，均能通过 EAM 引导实现起搏导线对预定 HB 部位的可重复导航。在 25 例患者中成功植入了导线。HB 云图的面积为 360（212）mm。HB 阈值与 HB 云图上的导线位置之间无相关性。导线植入部位的心内电图心房/心室比值与 HB 云图上的 EAM 位置相关（P=0.045）。手术、透视和标测时间分别为 116.0（38.8）、8.6（6.3）和 9.0（11.4）分钟。植入时的 HB 阈值为 1.5（2.3）V，脉宽为 1.5（1.0）ms。在行房室结消融的患者中，HB 导线与消融部位之间的距离为 10.0（1.3）mm。
结论
EAM 直接引导 HBP 可直接观察 HB 云图上的起搏导线，并可重复导航至预定的 HB 捕获部位。导线植入部位的心内电图心房/心室比值与 HB 云图位置相关。EAM 可应用于标准的 HBP 手术中，也可与房室结消融联合应用。
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