1、中国医学科学院 阜外心血管病医院 心律失常中心Arrhythmia Center，Fuwai Herat Hospital Chinese Academy of Medical Sciences姚姚 焰焰 Yan Yao Yan Yao 与房颤消融相关的左房房扑（LAFL）发生率介于2.631%1；The morbidity of AF ablation related left atrial flutter(LAFL)are 2.631%;包括局灶、大折返或小折返等多种机制且多与房颤消融线的“缝隙”有关；Focal、micro-¯o-reentrant mechanisms were
2、 documented and the gap on the lesions line is the sticking point of the circuit;1,Gerstenfeld EP,Heart Rhythm 2019;4:S65-72病例数 Patients(n)8080性别 Gender:男性(M)/女性(F)60/2060/20年龄 Age(岁，years)57579 9房颤持续时间 Duration of AF(年,years)7 74 4阵发性 Paroxysmal/持续性房颤 Persistent AF62/1862/18左房内径 LA diameter(mm)3838
3、8 8左室射血分数 LVEF(%)52526 6器质性心脏病 Structral Heart Disease16(20%)16(20%)既往抗心律失常药物 AADs（n)2 21 1 LAFL可在消融中由AF转化而成，或房颤消融成功之后快速刺激诱发；LAFLs were either converted from AF by ablation or induced by CIS；34例有2(26)种的LAFL，共有146种，其中4种为局灶性，142种为大折返机制；There were 34 pts.with 2(26)LAFLs，of total 146 LAFLs，142 were reen
4、trant&4 were focal；142种LAFL均与房颤消融线的缝隙有关，且均位于7字消融线上；The reentrant circuits were all related with the gaps on the Figure“7”lesions line.消融嵴部时消融嵴部时AFAF转为转为LA AFLLA AFL V1CS7.85678910111213141516180msLead IISOCHRONES1.等时图显示为绕MVA的顺钟向折返；2.沿MVA激动时间占心动过速周长的100；3.折返环路上全程虚拟单极电图呈rS型且首尾相接；Case2：7字型消融终止房颤后CS S1S
5、1 320bpm诱发LAFLLAFL induced after termination of AF with figure“7”lesions左房房扑的动态等电位图左房房扑的动态等电位图左房房扑的动态等电位图左房房扑的动态等电位图LAA-LSPV LAA-LSPV 嵴部嵴部 （LAA-LSPV rigdeLAA-LSPV rigde）68(47%)68(47%)二尖瓣环峡部二尖瓣环峡部 （MVA isthmusMVA isthmus）24 (17%)24 (17%)左房顶部左房顶部（LA roofLA roof）50(36%)50(36%)能量:功率60W，温度58，每次60-90s；平均放
6、电 4 2.1 次；即时成功率(消融终止+不再诱发):LSPV-LAA间嵴部：60/68(88.2%)；左房顶部：44/50(88%)；LIPV-MVA峡部：22/24(92%)；平均(11 6.7)月：维持窦律(sinus rhythm):62/80(77.5%)；短阵房速(focal AT):12/80(15%)；左房房扑(LAFL):6/80(7.5)；缝隙的分布：既往研究中经二尖瓣环峡部缝隙的折返多见，本研究中经LAALSPV间嵴部及左房顶部缝隙的折返更多见；Gaps on LAA-LSPV ridge&roof were more common in this study；折返环类型
7、：既往报告经嵴部的折返环多为小折返，本研究中为经嵴部及RIPV-MVA间峡部的大折返。Most of the reentrant were macro circuits across ridge；1)快速的异位节律（focal）;2)单个折返环伴颤动性传导（single randomized wave front with fibrillatory activation；3)多个折返环?（multiple wavelets？）姚焰 中华心律失常学杂志,2019;8;356LSPV-LAA间嵴部解剖特殊性1：（Anatomic features）局部肌带厚、狭窄；肌纤维走行复杂；邻近神经节及Ma
8、rshall韧带；LSPV-LAA间嵴部消融导管贴靠困难2,3；顶部正中有毗邻组织结构和心包折叠；现有消融能量的局限性；1.Cabrera JA,Eur Heart J.2019;29:356-62.2.Deisenhofer I,Europace 2019;8:573-82.3.Mesas CE,JACC 2019;44:1071-9.Cabrera JA,et al.Eur Heart J.2019;29:356-62.D 步进式线性消融的可行性已得到证实1,2；The feasibility of stepwise linear ablation approach were confir
9、med.当前消融能量无法安全地形成透壁损伤；Complete transmurality is not guaranteed with current ablation energy;LAFL可能是当前阶段房颤消融难以避免的过渡阶段但有望在组织和电重构后消失；LAFL may possibly be the transform during the successful ablation process of AF;1,Yao Y,Heart Rhythm 20192,Bortone A,JCE 2019 19:338-341 步进式线性消融术中大折返机制的左房房扑多见且均与7字型消融线上（尤其嵴部和顶部）的缝隙有关；Macro reentrant LAFLs are common and mostly related with gaps on figure“7”lesion line（especially on LAA-LSPV ridge and LA roof）；非接触标测能够有效识别缝隙并指导消融；Array provides an accurate&fast mapping technique for the targeting of the gaps；
