Enriquez Andres, Yogasundaram Haran, Neira Victor, Guandalini Gustavo, Markman Timothy, Shivamurthy Poojita, Hyman Matthew, Hanumanthu Balaram, Lin David, Schaller Robert, Supple Gregory, Dixit Sanjay, Deo Rajat, Nazarian Saman, Kumareswaran Ramanan, Riley Michael, Epstein Andrew E, See Vincent, Zado Erica, Callans David, Frankel David, Marchlinski Francis, Garcia Fermin
Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PA (A.E., H.Y., G.G., T.M., P.S., M.H., B.H., D.L., R.S., G.S., S.D., R.D., S.N., R.K., M.R., A.E.E., V.S., E.Z., D.C., D.F., F.M., F.G.).
Department of Medicine, Division of Cardiology, Queen's University, Kingston, ON, Canada (V.N.).
Circulation. 2025 Jul 22;152(3):163-171. doi: 10.1161/CIRCULATIONAHA.125.074175. Epub 2025 Apr 26.
The intramural site of origin is a major cause of ablation failure of ventricular arrhythmias, and the optimal strategy is unclear. This study investigated the efficacy of a stepwise ablation approach for intramural outflow tract (OT) premature ventricular complexes (PVCs) guided by mapping of the septal coronary venous system.
Consecutive patients with OT PVCs were included, in whom an intramural origin was confirmed by demonstration of earliest activation in a septal coronary vein. Radiofrequency ablation was performed from the closest endocardial site in the left ventricular OT or right ventricular OT independent of the local activation time. If there was no suppression by endocardial ablation, then retrograde transvenous ethanol infusion with a single- or double-balloon technique was performed, targeting the earliest septal coronary vein. If venous anatomy was not suitable for ethanol ablation or if this failed, then bipolar ablation was performed.
Sixty patients (age 61±12 years; 78% men) were included. The mean QRS duration of the PVC was 150.8±17.6 ms with a maximum deflection index of 0.51±0.11, and the most common ECG pattern was a left bundle branch block with inferior axis and V3 transition (63%), followed by a right bundle branch block with inferior axis and no transition (27%). Earliest ventricular activation (28.6±11.2 ms before QRS) was recorded in the left ventricular annular vein in 15 cases and a septal perforator vein in 45 cases. Acute PVC suppression at the end of the procedure was achieved in all cases. In 87% of cases (n=52), endocardial ablation from the endocardial left ventricular OT, right ventricular OT, or both was successful in eliminating the PVC. In the remaining 8 patients, the PVC was eliminated with ethanol infusion (n=7) and bipolar ablation (n=1). Complications included one case of pericardial effusion related to venous mapping. During follow-up (17±24 months), the PVC burden was reduced from 28±12% to 2.3±4.7%, and long-term success (≥80% burden reduction) was 88%.
Most intramural OT PVCs can be successfully eliminated with endocardial ablation adjacent to the earliest intramural activation site. A high success rate is achieved when following a stepwise approach, with bailout ablation strategies required in a minority of cases.
起源于心肌内是室性心律失常消融失败的主要原因，而最佳策略尚不清楚。本研究探讨了在间隔冠状静脉系统标测引导下，逐步消融方法治疗心肌内流出道（OT）室性早搏（PVC）的疗效。
纳入连续的OT PVC患者，通过在间隔冠状静脉中显示最早激动来确认心肌内起源。在左心室OT或右心室OT中，从最接近的心内膜部位进行射频消融，与局部激动时间无关。如果心内膜消融未能抑制，则采用单球囊或双球囊技术经静脉逆行注入乙醇，靶向最早的间隔冠状静脉。如果静脉解剖结构不适合乙醇消融或消融失败，则进行双极消融。
纳入60例患者（年龄61±12岁；78%为男性）。PVC的平均QRS时限为150.8±17.6毫秒，最大偏转指数为0.51±0.11，最常见的心电图模式为下轴和V3移行的左束支传导阻滞（63%），其次是下轴且无移行的右束支传导阻滞（27%）。15例患者最早的心室激动（QRS前28.6±11.2毫秒）记录于左心室环形静脉，45例记录于间隔穿支静脉。所有病例在手术结束时均实现了急性PVC抑制。87%的病例（n=52），通过从左心室OT、右心室OT或两者的心内膜进行消融成功消除了PVC。其余8例患者中，7例通过乙醇注入、1例通过双极消融消除了PVC。并发症包括1例与静脉标测相关的心包积液。在随访期间（17±24个月），PVC负荷从28±12%降至2.3±4.7%，长期成功率（负荷降低≥80%）为88%。
大多数心肌内OT PVC可通过在最早的心肌内激动部位附近进行心内膜消融成功消除。采用逐步消融方法成功率较高，少数病例需要补救消融策略。
