希氏束旁起源的房性期前收缩或房性心动过速的无冠窦标测与消融

doi:10.3969/j.issn.1004-583X.2025.10.005

摘要/Abstract

摘要：

目的探讨在希氏束旁起源的房性期前收缩(房早)或房性心动过速(房速)通过无冠窦标测和消融的可行性、安全性与有效性。方法纳入2019年1月-2023年4月毕节市七星关区人民医院和贵州省人民医院收治的在CARTO3系统指导下接受射频消融手术,且在术中电生理证实最早局部心房激动位于希氏束旁或附近区域的房早或房速患者13例。分析其在无冠窦标测、消融的临床资料。结果希氏束房早或房速心电图有特异性,靶点图毗邻希氏束,小于5 mm,13例患者均在无冠窦标测,最早局部激动领先于体表P波(31.5±15.0) ms,局部电位双极为大A小V,单级为QS,无希氏束电位,均消融成功,无并发症发生。结论希氏束旁的房早或房速患者体表心电图有特异性,根据心电图的特征,采用CARTO3系统进行三维电解剖标测,无冠窦标测和消融安全有效。

关键词: 房性期前收缩, 房性心动过速, 无冠窦, 导管消融

Abstract:

Objective To evaluate the feasibility, safety, and effectiveness of a noncoronary cusp (NCC) approach to map and ablate premature atrial contractions (PACs) or atrial tachycardia (AT) arising from the para-Hisian region. Methods This retrospective study included 13 consecutive patients treated with radiofrequency ablation under CARTO 3 guidance at Qixingguan District People's Hospital and Guizhou Provincial People 's Hospital between January 2019 and April 2023. Intraoperative electrophysiologic study confirmed that the earliest atrial activation was located at or near the His bundle. Clinical characteristics and procedural data related to NCC mapping and ablation were analyzed. Results Para-Hisian PACs/AT displayed characteristic surface ECG findings. Target sites were within 5 mm of the His bundle. In all 13 patients, NCC mapping identified the earliest local atrial activation preceding the surface P-wave onset by (31.5±15.0) ms. Local electrograms were characterized by a bipolar signal with large A and small V, unipolar QS morphology, and absence of a His bundle potential. Ablation was successful in all cases with no complications observed. Conclusion Para-Hisian PACs/AT present with distinctive ECG features. Guided by these features, three-dimensional electroanatomical mapping with CARTO 3, combined with NCC mapping and ablation, is a safe and effective strategy.

Key words: premature atrial contractions, atrial tachycardia, noncoronary cusp, catheter ablation

中图分类号:

R541.7

刘振良, 周杨杰, 文伟, 李万能, 席斌武, 赵旭, 刘启方. 希氏束旁起源的房性期前收缩或房性心动过速的无冠窦标测与消融[J]. 临床荟萃, 2025, 40(10): 904-909.

Liu Zhenliang, Zhou Yangjie, Wen Wei, Li Wanneng, Xi Binwu, Zhao Xu, Liu Qifang. Mapping and ablation on the non-coronary cusp for treating para-Hisian premature atrial contractions and atrial tachycardia[J]. Clinical Focus, 2025, 40(10): 904-909.

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链接本文: https://www.lchc.cn/CN/10.3969/j.issn.1004-583X.2025.10.005

https://www.lchc.cn/CN/Y2025/V40/I10/904

图/表 4

表1 基线特征

Tab.1 Baseline characteristics

病例	性别	年龄(岁)	心电图诊断	电生理诊断
病例1	男	50	房早	房早
病例2	男	60	房早	房早
病例3	男	51	房早	房早
病例4	男	74	室上性心动过速	房速
病例5	女	53	室上性心动过速	房速
病例6	女	54	室上性心动过速	房速
病例7	女	49	室上性心动过速	房速
病例8	女	67	房速	房速
病例9	男	42	房速	房速
病例10	女	66	房速	房速
病例11	女	45	室上性心动过速	房速
病例12	男	67	房速	房速
病例13	女	37	室上性心动过速	房速

图1 希氏束旁房早在NCC消融成功 a.术前心电图:P波在V1导联、下壁导联多呈负或正双向,aVR导联直立,I导联多变:低平,aVL导联正向; b.消融术后心电图; c.右心房建模:左侧是LL,右侧是LAO,黄色点为希氏束,红色点最早领先体表P波56 ms;d.主动脉窦和右心房融合建模:左侧是LL, 右侧是LAO, 黄色点为希氏束, 红色点为NCC。注:LL:左侧位

Fig.1 Successful ablation of premature atrial contractions originating near the His bundle region in the NCC a. Preoperative electrocardiogram: P waves are mostly negative/positive biphasic in lead V1 and inferior leads; upright in lead aVR; variable in lead I: low and flat, positive in lead aVL; b. Postoperative electrocardiogram; c. Right atrial mapping, left side is LL (left lateral), right side is LAO (left anterior oblique), yellow points indicate the His bundle, red point shows the earliest activation preceding the surface P wave by 56 ms; d. Fusion image of the aortic sinus and RA:Left side is LL, right side is LAO, yellow points indicate the His bundle, red points indicate the NCC (non-coronary cusp).Note: LL: left lateral

图2 希氏束旁房速在NCC消融成功 a.房速发作:P波在V1导联、下壁导联呈负或正双向,aVR导联直立见,I导联负或正,aVL导联正向; b.消融后心电图; c.右心房建模:左侧是RAO, 右侧是LAO,黄色点是希氏束,在邻近希氏束间隔面标测出A波领先体表34 ms,消融不能终止房速; d.主动脉窦建模:左侧是RAO, 右侧是LAO, 房速发作时标测示局部激动在NCC最早领先体表P波47 ms,消融成功; e.右心房和主动脉窦融合:左侧是RAO,右侧是LAO,黄色点为希氏束,红色点最早领先体表P波在NCC。注:LCC:左冠窦;RCC:右冠窦;TA:三尖瓣;AO:主动脉

Fig.2 Successful ablation of atrial tachycardias originating near the His bundle region in the NCC a. ECG during atrial tachycardia: P waves appear negative or positive biphasic in lead V1 and inferior leads; upright in lead aVR; negative or positive in lead I, positive in lead aVL; b. ECG after ablation; c. Right atrial (RA) mapping: Left side is RAO (right anterior oblique), right side is LAO (left anterior oblique). Yellow points indicate the His bundle. Mapping near the His bundle septum showed an A wave preceding the surface P wave by 34 ms, but ablation did not terminate the atrial tachycardia; d. Aortic sinus mapping: Left side is RAO, right side is LAO. During atrial tachycardia, mapping showed the earliest local activation at the NCC (non-coronary cusp), preceding the surface P wave by 47 ms, and ablation was successful; e. Fusion image of the RA and aortic sinus: Left side is RAO, right side is LAO. Yellow points indicate the His bundle, red points indicate the earliest activation preceding the surface P wave at the NCC. Note: LCC: Left coronary cusp; RCC: Right coronary cusp; TA: Tricuspid annulus; AO: Aorta

图3 先后右房邻近希氏束旁间隔面、穿刺房间隔左房消融无效,在NCC消融成功 a.发作时心电图:P波在V2-V3、AVL直立,RP>PR; b.消融后心电图; c.右心房建模:左侧是RAO, 右侧是LAO,黄色是希氏束,在间隔面标测出A波领先体表P波51 ms,消融无效;d.左心房建模:左侧是RAO, 右侧是AP;穿刺房间隔,在前间隔左房前壁标测到领先体表P波26 ms局部电位(红色),放电无效;e.主动脉窦建模:穿刺股动脉,主动脉窦在发作时标测示局部激动在NCC最早领先体表P波21 ms,消融成功;左侧是RAO, 右侧是LAO,黄色点为希氏束,红色点最早领先体表P波21 ms, 放电,房速终止;f.主动脉窦、右心房和左心房融合建模:左侧是RAO,右侧是LAO,黄色点为希氏束,红色点最早领先体表P波在NCC。注:AP:前后位;AO:主动脉

Fig.3 Successful ablation of atrial tachycardias originating near the His bundle region in the NCCA, but ineffective in the right atrium near the His bundle and the left atrium through the interatrial septum a. ECG during arrhythmia: P wave upright in V2-V3, AVL, RP > PR; b. EC after ablation; c. Modeling map of the right atrium: RAO on the left, LAO on the right, yellow is the His bundle, A wave leads the P wave by 51 ms on the interspace surface, ablation ineffective; d. Modeling map of the left atrium: RAO on the left, AP on the; puncture the interatrial septum, local potentials (red) were recorded in the anterior wall of the left atrium in the anterior interspace, which led the P wave by 26 ms, ablation ineffective; e. Modeling map of the aortic sinus: puncture the femoral artery, the aortic sinus was during the arrhythmia, indicating that the local excitation was the earliest to lead the surface P wave by 21 ms, ablation was successful; on the left is RA, on the right is LAO, the yellow dot is the His bundle, the red dot is the earliest to lead the surface P wave by 21Mms, discharge, rial tachycardia terminated; f. Modeling map of the aortic sinus, RA, and LA fusion: RAO on the left, LAO on the, yellow dot is the His bundle, red dot is the earliest to lead the surface P wave in NCC. Note: AP: Anterior-posterior position; RA: Right atrium; LA: Left atrium; AO: aorta

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