Katritsis George, Luther Vishal, Cortez-Dias Nuno, Carpinteiro Luís, de Sousa João, Lim Phang Boon, Whinnett Zachary, Ng Fu Siong, Koa-Wing Michael, Qureshi Norman, Chow Anthony, Agarwal Sharad, Jamil-Copley Shahnaz, Peters Nicholas S, Linton Nick, Kanagaratnam Prapa
Imperial College Healthcare, London, United Kingdom.
Hospital de Santa Maria, Lisbon, Portugal.
JACC Clin Electrophysiol. 2021 May;7(5):578-590. doi: 10.1016/j.jacep.2020.10.017. Epub 2021 Jan 27.
The authors reviewed 3-dimensional electroanatomic maps of perimitral flutter to identify scar-related isthmuses and determine their effectiveness as ablation sites.
Perimitral flutter is usually treated by linear ablation between the left lower pulmonary vein and mitral annulus. Conduction block can be difficult to achieve, and recurrences are common.
Patients undergoing atrial tachycardia ablation using CARTO3 (Biosense Webster Inc., Irvine, California) were screened from 4 centers. Patients with confirmed perimitral flutter were reviewed for the presence of scar-related isthmuses by using CARTO3 with the ConfiDense and Ripple Mapping modules.
Confirmed perimitral flutter was identified in 28 patients (age 65.2 ± 8.1 years), of whom 26 patients had prior atrial fibrillation ablation. Scar-related isthmus ablation was performed in 12 of 28 patients. Perimitral flutter was terminated in all following correct identification of a scar-related isthmus using ripple mapping. The mean scar voltage threshold was 0.11 ± 0.05 mV. The mean width of scar-related isthmuses was 8.9 ± 3.5 mm with a conduction speed of 31.8 ± 5.5 cm/s compared to that of normal left atrium of 71.2 ± 21.5 cm/s (p < 0.0001). Empirical, anatomic ablation was performed in 16 of 28, with termination in 10 of 16 (63%; p = 0.027). Significantly less ablation was required for critical isthmus ablation compared to empirical linear lesions (11.4 ± 5.3 min vs. 26.2 ± 17.1 min; p = 0.0004). All 16 cases of anatomic ablation were reviewed with ripple mapping, and 63% had scar-related isthmus.
Perimitral flutter is usually easy to diagnose but can be difficult to ablate. Ripple mapping is highly effective at locating the critical isthmus maintaining the tachycardia and avoiding anatomic ablation lines. This approach has a higher termination rate with less radiofrequency ablation required.
作者回顾了二尖瓣环周围扑动的三维电解剖标测图，以识别与瘢痕相关的峡部，并确定其作为消融部位的有效性。
二尖瓣环周围扑动通常通过在左下肺静脉和二尖瓣环之间进行线性消融来治疗。传导阻滞可能难以实现，且复发很常见。
从4个中心筛选出使用CARTO3（Biosense Webster公司，加利福尼亚州欧文市）进行房性心动过速消融的患者。使用带有ConfiDense和Ripple Mapping模块的CARTO3对确诊为二尖瓣环周围扑动的患者进行与瘢痕相关峡部的检查。
在28例患者（年龄65.2±8.1岁）中确诊为二尖瓣环周围扑动，其中26例患者曾接受过房颤消融。28例患者中有12例进行了与瘢痕相关峡部的消融。在使用Ripple Mapping正确识别出与瘢痕相关的峡部后，所有患者的二尖瓣环周围扑动均终止。瘢痕电压阈值平均为0.11±0.05mV。与瘢痕相关峡部的平均宽度为8.9±3.5mm，传导速度为31.8±5.5cm/s，而正常左心房的传导速度为71.2±21.5cm/s（p<0.0001）。28例患者中有16例进行了经验性解剖消融，其中10例终止（63%；p=0.027）。与经验性线性消融相比，关键峡部消融所需的消融明显更少（11.4±5.3分钟对26.2±17.1分钟；p=0.0004）。对所有16例解剖消融病例进行了Ripple Mapping检查，63%有与瘢痕相关的峡部。
二尖瓣环周围扑动通常易于诊断，但可能难以消融。Ripple Mapping在定位维持心动过速的关键峡部和避免解剖消融线方面非常有效。这种方法终止率更高，所需射频消融更少。
