LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France.
Cardiology Department, Royal Papworth Hospital, Cambridge, UK.
Pacing Clin Electrophysiol. 2021 May;44(5):782-791. doi: 10.1111/pace.14208. Epub 2021 Apr 5.
Beyond pulmonary vein isolation, the two main additional strategies: Cox-Maze procedure or targeting of electrical signatures (focal bursts, rotational activities, meandering wavelets), remain controversial. High-density mapping of these arrhythmias has demonstrated firstly that a patchy lesion set is highly proarrhythmogenic, favoring macro-re-entry through conduction slowing and providing pivots for localized re-entry. Secondly, discrete anatomical structures such as the Vein or Ligament of Marshall (VOM/LOM) and the coronary sinus (CS) have epicardial muscular bundles that are more frequently involved in re-entry than previously thought. The Marshall Bundle can be ablated at any point along its course from the mid-to-distal coronary sinus to the left atrial appendage. If necessary, the VOM may be directly ablated using ethanol infusion to eliminate PV contributions and produce conduction block across the mistral isthmus. Ethanol ablation of the VOM, supplemented with RF ablation, may be more effective in producing conduction block at the mitral isthmus than repeat RF ablation alone.
除肺静脉隔离外，两种主要的附加策略：Cox-Maze 手术或针对电信号（局灶性爆发、旋转活动、蜿蜒小波），仍然存在争议。对这些心律失常的高密度映射首先表明，片状病变集高度致心律失常，通过传导减慢有利于大折返，为局部折返提供枢轴。其次，离散的解剖结构，如静脉或Marshall 韧带（VOM/LOM）和冠状窦（CS），在心外膜肌肉束中，比以前认为的更容易参与折返。Marshall 束可以在从中段到远端冠状窦到左心耳的整个过程中的任何位置消融。如果需要，VOM 可以直接用乙醇灌注消融，以消除 PV 贡献并在迷走峡部产生传导阻滞。VOM 的乙醇消融，辅以 RF 消融，可能比单独重复 RF 消融更有效地在二尖瓣峡部产生传导阻滞。
