射频消融治疗快速心律失常300例回顾分析

目的 总结射频消融术（ＲＦＣＡ）治疗快速心律失常经验和教训,以利提高疗效。方法 回顾分析我院自１９９３年４月～１９９９年８月共治疗３００例ＲＦＣＡ。快速心律失常类别包括：房室结折返性心动过速（ＡＶＮＲＴ）７８例;房室折返性心动过速（ＡＶＲＴ）２０１例;特发性室性心动过速（ＩＶＴ）１３例;阵发性心房扑动（ＡＦ）７例;快心室率（≥１００次/分）心房颤动房室结改良１例。均先行心内电生理检查,寻找最佳靶点进行消融。结果 消融总成功率为９７．３％,总复发率为３．４％,并发症发生率１．７％,无死亡病例。结论 射频消融已成为快速心律失常简捷有效的治疗方法,但有目的地预测和降低并发症,识别和正确处理特殊病例,是提高成功率的关键。     

室上速并发心房颤动的电生理研究

目的探讨室上速并发心房颤动(房颤)的电生理特性及其发生机制。方法对38例室上速患者,根据有无房颤史分为两组,即房颤组18例,无房颤组20例。分别测量两组室上速周长、心房内压、心房各部位有效不应期、心房不应期离散度、心房最大不应期与室上速周长的比值,所有对象均行射频消融术治疗室上速,并行为期半年的随访,观察两组病人房颤的发生情况。结果房颤组与无房颤组的室上速周长分别为（326±9）ms,（331±11）ms,P>0.05。在窦性心律与室上速发作时,房颤组的心房不应期离散度均较无房颤组增加,房颤组的心房最大不应期与室上速周长的比值比无房颤组明显增加（P<0.05）。房颤组的心房最大不应期比无房颤组增加（P<0.05）,但却发生在心房的不同部位。结论(1)室上速合并房颤与室上速周长无明显关系。(2)心房不应期离散度是室上速合并房颤发生和维持的一个重要机制。(3)心房最大不应期与室上速周长的比值可能是室上速诱发房颤的另一个机制。     

食道心房调搏对窄QRS波室上性心动过速机制研究

目的：了解食道心房调搏（TEAP）对窄QRS波室上性心动过速机制的鉴别。方法：采用无创性TEAP技术,对145例有心动过速史但无器质性心脏病的患者进行检查,诱发窄QRS汉心动过速。结果：检出的窄QES波折返阵性发性室上性心动过速中,房室折返性心;动过速及房室结内折返性心动过速占约大多数,房性折返性心动过速极少。结论：TEAP是鉴别窄QRS波PSVT机制的一种安全,有效的方法。     

Effects of beta-adrenergic stimulation on atrial latency and atrial vulnerability in patients with paroxysmal supraventricular tachycardia

To assess the effects of beta-adrenergic stimulation on atrial latency and atrial vulnerability, the electrophysiologic properties of the atrium were studied before and during intravenous infusion of isoproterenol at 2 to 5 micrograms/min in 11 patients with paroxysmal supraventricular tachycardia exhibiting atrial latency during programmed atrial extrastimulation. In all patients, the isoproterenol infusion reduced the extent of maximum atrial latency (from 86 +/- 19 to 62 +/- 16 ms, p less than 0.001). This was accompanied by a significant shortening of both effective and functional refractory periods of the atrium (from 213 +/- 31 to 174 +/- 40 ms, p less than 0.005 and from 259 +/- 31 to 215 +/- 29 ms, p less than 0.001, respectively). The intra-atrial and interatrial conduction times were also significantly reduced (from 24 +/- 15 and 63 +/- 17 to 15 +/- 10 and 48 +/- 15 ms, p less than 0.005, respectively). In 3 patients with demonstrable atrial vulnerability, the isoproterenol infusion abolished the inducibility of repetitive atrial responses or atrial flutter, or both. Although the clinical significance of the suppressive action of beta-adrenergic stimulation on atrial vulnerability remains to be determined, the present study has demonstrated that beta-adrenergic stimulation significantly reduces atrial latency.     

Role of atrial electrophysiology and autonomic nervous system in patients with supraventricular tachycardia and paroxysmal atrial fibrillation

Objectives. The purposes of this study were to evaluate the atrial electrophysiology and autonomic nervous system in patients who had paroxysmal supraventricular tachycardia (PSVT) associated with paroxysmal atrial fibrillation (PAF).Background. PAF frequently appeared in patients with PSVT. However, the critical determinants for the occurrence of PAF were not clear.Methods. This study population consisted of 50 patients who had PSVT with (n = 23) and without (n = 27) PAF. Atrial pressure, atrial size, atrial effective refractory periods (AERPs), and AERP dispersion were evaluated during baseline and PSVT, respectively. Twenty-four hour heart rate variability and baroreflex sensitivity (BRS) were also examined.Results. There was greater baseline AERP dispersion in patients with PAF than in those without PAF. The atrial pressure, atrial size, AERPs in the right posterolateral atrium and distal coronary sinus, and AERP dispersion were increased during PSVT as compared with those during baseline. Patients with PAF had greater AERP dispersion than those without PAF during PSVT. The differences of atrial size, right posterolateral AERP, and AERP dispersion between baseline and PSVT were greater in patients with PAF than in those without PAF. BRS, but not heart rate variability, was higher in patients with PAF than in those without PAF. Univariate analysis showed that higher BRS (>4.5 ms/mm Hg, p = 0.0002, odds ratio = 16.1), AERP dispersion during PSVT (>40 ms, p = 0.0008, odds ratio = 9.7), and increase of right atrial area during PSVT (>2 cm², p = 0.016, odds ratio = 10.7) were significantly correlated with the occurrence of PAF in patients with PSVT.Conclusions. Disturbed atrial electrophysiology and higher vagal reflex could play important roles in the genesis of PAF in patients with PSVT.     

Comparative study of transesophageal atrial pacing and intracardiac electrophysiology in patients with supraventricular tachycardia

The diagnostic value of transesophageal atrial pacing in supraventricular tachycardia (SVT) has been discussed according to the comparison of the results of intracardiac and transesophageal electrophysiological study. Some quantitative criteria for the differential diagnosis of atrioventricular node reentrant tachycardia (RT-AVN) and atrioventricular reciprocating tachycardia (RT-AP) has been proposed. We found that RT-AVN and RT-AP could be separated by noninvasive transesophageal atrial pacing. We also suggested that induced SVT would be RT-AVN if (1) SR conductive curve was not continuous and SR jump greater than 70 ms, (2) AV interval less than 60 ms, and it would be RT-AP if (1) SR curve was continuous and there was no SR jump phenomenon, (2) VA interval greater than 100 ms. Thus, transesophageal atrial pacing was very helpful in distinguishing the mechanisms of SVT and could provide a simple clinical cardiac electrophysiological procedure in diagnosing SVTs.     

Electrophysiological characteristics and catheter ablation in patients with paroxysmal supraventricular tachycardia and paroxysmal atrial fibrillation

Introduction: Paroxysmal supraventricular tachycardia (PSVT) is often associated with paroxysmal atrial fibrillation (AF). However, the relationship between PSVT and AF is still unclear. The aim of this study was to investigate the clinical and electrophysiological characteristics in patients with PSVT and AF, and to demonstrate the origin of the AF before the radiofrequency (RF) ablation of AF.
Methods and Results: Four hundred and two consecutive patients with paroxysmal AF (338 had a pure PV foci and 64 had a non-PV foci) that underwent RF ablation were included. Twenty-one patients (10 females; mean age 47 ± 18 years) with both PSVT and AF were divided into two groups. Group 1 consisted of 14 patients with inducible atrioventricular nodal reentrant tachycardia (AVNRT) and AF. Group 2 consisted of seven patients with Wolff-Parkinson-White (WPW) syndrome and AF. Patients with non-PV foci of AF had a higher incidence of AVNRT than those with PV foci (11% vs. 2%, P = 0.003). Patients with AF and atypical AVNRT had a higher incidence of AF ectopy from the superior vena cava (SVC) than those with AF and typical AVNRT (86% vs. 14%, P = 0.03). Group 1 patients had smaller left atrial (LA) diameter (36 ± 3 vs. 41 ± 3 mm, P = 0.004) and higher incidence of an SVC origin of AF (50% vs. 0%, P = 0.047) than did those in Group 2.
Conclusion: The SVC AF has a close relationship with AVNRT. The effect of atrial vulnerability and remodeling may differ between AVNRT and WPW syndrome.     

Utility of atrial and ventricular cycle length variability in determining the mechanism of paroxysmal supraventricular tachycardia

Introduction: No prior studies have systematically investigated the diagnostic value of cycle length (CL) variability in differentiating the mechanism of paroxysmal supraventricular tachycardia (PSVT).
Methods and Results : We studied 173 consecutive patients with PSVT; 86 typical atrioventricular nodal reentrant tachycardia (AVNRT), 11 atypical AVNRT, 47 orthodromic reciprocating tachycardia (ORT), and 29 with atrial tachycardia (AT). Two consecutive atrial cycles that displayed the most CL variability were selected for analysis. One hundred and twenty-six patients (73%) had ≥15 msec variability in tachycardia CL. The change in atrial CL predicted the change in subsequent ventricular CL in six of eight patients (75%) with atypical AVNRT, 18 of 21 patients (86%) with AT, in none of 66 patients with typical AVNRT, and in 32 patients with ORT. The change in atrial CL was predicted by the change in preceding ventricular CL in 55 of 66 patients (83%) with typical AVNRT, no patient with atypical AVNRT, 27 of 31 patients (87%) with ORT, and one of 21 patients (5%) with AT. The sensitivity, specificity, and positive and negative predictive values of a change in atrial CL predicting the change in ventricular CL for AT or atypical AVNRT were 83%, 100%, 100%, and 95%, respectively. The corresponding values for the change in atrial CL being predicted by the change in the preceding ventricular CL for typical AVNRT or ORT were 85%, 97%, 99%, and 65%, respectively.
Conclusion: Tachycardia CL variability ≥15 msec is common in PSVT. A change in atrial CL that predicts the change in subsequent ventricular CL strongly favors AT or atypical AVNRT. A change in atrial CL that is predicted by the change in the preceding ventricular CL favors typical AVNRT or ORT.     

酷似阵发性室上性心动过速的心房扑动的心电图特点和诊断

目的：分析酷似阵发性室上性心动过速的心房扑动的心电图并探索其有效诊断方法。方法：选择我院1998~2010年门诊及住院酷似阵发性室上性心动过速的心房扑动病例资料26例,分析其特点及诊断方法价值。结果：（1）心电图特点：F波在Ⅱ、Ⅲ、aVF导联显现25例（96.2%）,在V1导联显现22例;F波在Ⅱ、Ⅲ、aVF导联呈负向22例（84.6%）,呈正向2例,难以辨别方向2例;F波在全部导联中的最大振幅≤0.2mV者5例;F波全部与QRS波和T波融合并使形态发生了变化;（2）诊断根据：①使用工具（分规,放大镜等）主动寻找F波,有25例（96.2%）发现可疑F波;②结合病史,均有器质性心脏病（100%）,9例（34.6%）有阵发性心房颤动史;③与发作前的心电图对照,15例（57.7%）发现有确切F波;④兴奋迷走神经（Valsalva动作等）：适合检查者20例,16例（61.5%,16/26）房室传导比例发生改变,得以确诊;⑤食道心电图：根据心电图诊断20例（76.9%）,余6例（23.1%）可疑者经食道心电图明确诊断。结论：上述方法联合使用,并综合判断可提高心房扑动诊断的准确性。     

Patients with paroxysmal atrial fibrillation but not paroxysmal supraventricular tachycardia display evidence of platelet activation during arrhythmia

It is well known that chronic atrial fibrillation (CAF) and paroxysmal atrial fibrillation (PAF) are associated with hypercoagulable state. However, pathological hemostatic changes during the paroxysmal supraventricular tachycardia (PSVT) have not yet been elucidated. To determine platelet activity in patients with PSVT, PAF and CAF, we examined the levels of beta-thromboglobulin (BTG) and platelet factor 4 (PF4) during tachyarrhythmia attacks. We measured the levels of BTG and PF4, as an index of platelet activation in 15 patients with PAF (9 men, mean age 45+/-11), and 14 patients with PSVT (8 men, mean age 40+/-10). Levels were compared to 22 age and sex matched healthy controls in sinus rhythm and with 25 patients with CAF (16 men, mean age 51+/-12). Blood samples were taken during arrhythmia and 24 hours after conversion to sinus rhythm. Patients taking medications or have clinical conditions that may affect the BTG and PF4 levels were excluded. In patients with PAF, BTG and PF4 levels were significantly higher than in controls (p<0.009, and p=0.002, respectively), and in patients with PSVT (p<0.004, and p=0.009, respectively), however, BTG and PF4 levels were significantly lower than CAF patients (p=0.002, and p=0.02, respectively). Moreover, BTG and PF4 levels were significantly decreased 24 hours after conversion to sinus rhythm (p<0.0001), and p=0.004, respectively). Although BTG and PF4 levels in patients with PSVT were significantly lower than in patients with PAF (p=0.04, and p=0.009, respectively) and CAF (p=0.0001, and p=0.0001, respectively), BTG and PF4 levels were similar to controls and did not change significantly after recovery to sinus rhythm (p=NS for all). These results indicate that there was no platelet activation in patients with PSVT during tachyarrhythmia but significantly increased platelet activity in PAF and CAF patients. There was a significant decrement of the platelet activity to a level of control subjects twenty-four hours after cardioversion of PAF.