2024 年第 11 期 第 19 卷

Marshall韧带介导心外膜相关二尖瓣峡部依赖心房扑动的电生理特点及消融策略

The electrophysiological characteristics and ablation strategies of epicardial mitral isthmus-dependent atrial flutter mediated by the Marshall ligament

作者：高明阳黄丽洪赖一炜郭琦黎旭董建增桑才华马长生

英文作者：Gao Mingyang Huang Lihong Lai Yiwei Guo Qi Li Xu Dong Jianzeng Sang Caihua Ma Changsheng

单位：首都医科大学附属北京安贞医院心律失常中心，北京100029

英文单位：Arrhythmia Center Beijing Anzhen Hospital Capital Medical University Beijing 100029 China

关键词：心房扑动；导管消融；二尖瓣峡部；Marshall静脉

英文关键词：Atrialflutter;Catheterablation;Mitralisthmus;Marshallvein

• 摘要：

• 目的 阐述Marshall韧带介导心外膜相关二尖瓣峡部依赖心房扑动的电生理特点及消融策略。方法 回顾性连续纳入2022年1月至2023年6月于首都医科大学附属北京安贞医院心律失常中心行心房颤动消融后心房扑动射频消融，且术中经高密度标测明确诊断为Marshall韧带介导心外膜相关二尖瓣峡部依赖心房扑动的38例患者，分析术中标测结果特征、消融方法及随访结果。结果 本研究38例患者包括围绕二尖瓣逆时针方向折返30例、顺时针方向折返5例及双房折返3例，激动标测均可见“假局灶样”激动模式，激动突破点往往位于左肺静脉与左心耳之间的嵴部或既往二尖瓣峡部心内膜面消融线后方。20例（52.6%）患者通过Marshall静脉无水酒精消融终止心房扑动。在(18±9)个月的随访期内，4例患者（10.5%）出现了空白期后心房颤动/房性心动过速复发。结论 Marshall韧带介导心外膜心房扑动多呈逆时针方向折返，具有特征性激动模式，Marshall静脉无水酒精消融可有效终止该类心房扑动，且远期复发率低。

• ObjectiveTo describe the electrophysiological characteristics and ablation strategies of epicardial mitral isthmus-dependent atrial flutter (AFL) mediated by the Marshall ligament. MethodsA retrospective study was conducted on 38 patients who underwent atrial fibrillation ablation and developed recurrent AFL radiofrequency ablation between January 2022 and June 2023 at the Arrhythmia Center, Beijing Anzhen Hospital, Capital Medical University. All patients were diagnosed intraoperatively with epicardial mitral isthmus-dependent AFL mediated by the Marshall ligament through high-density mapping. Intraoperative mapping characteristics, ablation method and follow-up results were analyzed. ResultsThe 38 patients in this study included 30 cases of counterclockwise reentry around the mitral valve, 5 cases of clockwise, and 3 cases of bi-atrial reentry. In all cases, activation mapping demonstrated a "pseudo-focal" activation pattern, with breakthrough points typically located at the ridge between the left pulmonary veins and the left atrial appendage or posterior to the previous endocardial mitral isthmus ablation line. Twenty patients (52.6%) had AFL terminated by ethanol infusion of the vein of Marshall. During a follow-up period of (18±9) months, 4 patients (10.5%) experienced recurrences of atrial fibrillation or atrial tachycardia post blanking period. ConclusionEpicardial mitral isthmus-dependent AFL mediated by the Marshall ligament often presents with counterclockwise rotation and has a characteristic activation pattern. ablation can effectively terminate this type of AFL, with a low long-term recurrence rate.