Marked anterograde decremental conduction over a rapidly conducting accessory pathway after radiofrequency ablation

We report on a patient with the Wolff-Parkinson-White syndrome who temporarily exhibited a marked anterograde decremental conduction over a rapidly conducting accessory atrioventricular pathway after successful radiofrequency ablation. By recording the intracardiac electrogram via the ablation catheter placed at the successful ablation site, we were able to exclude the possibility of the occurrence of anterograde decremental conduction in the atrial or ventricular myocardium between the accessory pathway and the recording electrodes.     

右前隐匿性旁路的心电生理特点和射频消融治疗

目的 评价２８例右前隐匿性房社路（右前旁路）的电生理特点和射频消融治疗。方法 分析房室折返性心动过速（ａｔｒｉｏｖｅｎｔｒｉｃｕｌａｒ ｒｅｅｎｔｒａｎｔ ｔａｃｈｙｃａｒｄｉａ,ＡＶＲＴ）的体表心电图和经食管心电图逆行Ｐ波特点。比较消融前后的室房（ＶＡ）传导变化。结果 ２８例患者ＡＶＲＴ的Ⅱ、Ⅲ、ａＶＦ导联逆行Ｐ波均为直立正向,Ⅰ和ａＶＬ导联逆行Ｐ 可直立（１５例）或负向（１３例）,Ｖ１导联逆行Ｐ波均为负向,２０例Ｖ１的逆行Ｐ波与ＱＲＳ终末部相连而呈ｒＳｒ′型。心室程度刺激１４例显示ＶＡ传导恒定。１４例表现部分（１０例）或完全（４例）ＶＡ递减传导,其中１０例为未成年患者,２８例有效消融靶点位于三尖瓣环前上部（左前斜位的９～１１点）。１４例ＶＡ传导恒定者右心室起搏下标测和消融,旁路传导阻断后ＶＡ分离;１４例ＶＡ     

慢传导旁道的临床特征及射频消融治疗

目的 探讨慢传导旁道的临床、电生理检查特点及消融方法.方法 对5例心动过速时RP’>P’R的患者行电生理检查及射频消融治疗.结果5例患者电生理检查显示心室逆传文氏现象及递减传导,且消融靶点处VA不融合.取A波最早处做为消融靶点均获成功,随访2～13个月无复发.结论 慢传导旁道具有特殊的电生理特性,射频消融是有效的根治方法.     

多种类型房室结折返性心动过速的电生理特点

目的 探讨多种类型房室结折返性心动过速（AVNRT）的电生理特征及消融体会。方法 回顾性分析成功行射频导管消融的113例AVNRT病人的临床和心内电生理资料。结果 113例AVNRT患者中6例存在多种类型AVNRT,其中存在2种、3种和4种类型AVNRT者各占2例,共有8种类型AVNRT;2例存在MAVNP,其余4例DAVNP阳性;均在慢径路区域行射频消融,放电时出现交界性早搏和/或心律,放电次数,功率、时间和X线曝光时间与同期慢-快型AVNRT相似,术后应用阿托品或异丙基肾上腺素未再诱发室上性心动过速,亦无回波,术中和术后均无房室传导阻滞,随访2.0-25.5月,无1例复发。结论 多种类型AVNRT并不少见,中径路既有逆传功能,也具有前传功能,多种类型AVNRT的射频消融类似于慢-快型AVNRT,安全有效。     

长PR房室结双径路的电生理特点和射频消融慢径的安全性

目的　探讨窦律时PR已延长 ( >2 0 0ms)的房室结双径路的电生理特点和慢径消融的安全性。方法　观察 11例长PR组患者的电生理特点和射频消融慢径对PR和AH等心内参数的影响 ,并与 3 3例正常PR组对照。结果　长PR组患者无房室结双径路 ,即AH跳跃现象较正常PR组更常见 ,心室刺激较正常PR组更易诱发心动过速。射频消融对两组患者PR和AH无影响。长PR组射频消融后 1:1房室和室房传导的最大频率减慢 ,房室结有效不应期延长。结论　结果提示 ,长PR房室结双径路具有不同于正常PR者的电生理和射频消融特点 ,射频消融慢径对这些患者是安全、有效的。     

Minimally decremental atriofascicular accessory pathway with bidirectional conduction

Atriofacicular pathways of Mahaim type are typically decrementally conducting accessory pathways without retrograde conduction properties, located on the right ventricular free wall at the tricuspid annulus. We report a patient with an atriofascicular pathway with minimal anterograde decremental conduction. Both long and short V-H antidromic atriofascicular reentrant tachycardias were induced and mechanism confirmed with electrophysiologic testing. Additionally, orthodromic atriofascicular reentrant tachycardia with narrow and right bundle branch block morphologies were inducible. Mahaim pathway was successfully ablated with elimination of both antidromic and orthodromic tachycardias.     

直视下心外膜导管射频消融右侧房室旁路

目的对右侧房室旁路合并需要进行外科手术治疗的心脏病患者,或多次心内膜导管射频消融治疗失败者,探讨采用直视下心外膜导管射频消融法阻断房室旁路传导的可能性。方法３例右侧显性房室旁路,２例为男性慢性风湿性二尖瓣病变,术前经多家医院心内膜导管射频消融术治疗均未成功,旁路分别位于右房室环９点和７点处;１例为女性先天性心脏病室间隔缺损,术前未经导管射频消融治疗,体表心电图定位旁路位于右侧前壁。手术中于右房和右室外膜各缝扎一根２极导管用于双极记录和刺激,手执四极大头电极导管沿右侧房室沟从室间隔处经右游离壁到冠状静脉窦口或反向进行标测,在理想的标测靶点处放电消融。结果３例患者的３条旁路均一次消融成功,没有心房穿孔或右冠状动脉损伤等并发症,旁路阻断时间１～２ｓ,总操作时间１０～２０ｍｉｎ,术后随访６～１２个月无心动过速复发。结论对右侧房室旁路合并需要进行手术治疗的心脏病患者或多次心内膜导管射频消融治疗失败者,可考虑采用心外膜导管射频消融的方法进行治疗。     

Electrophysiologic characteristics and results of radiofrequency catheter ablation in elderly patients with atrioventricular nodal reentrant tachycardia

Background

As in the general population, atrioventricular nodal reentrant tachycardia (AVNRT) is the most common regular supraventricular tachycardia in the elderly patients. We tried to compare electrophysiologic characteristics, efficacy, and risks of the radiofrequency (RF) catheter ablation of the slow pathway in elderly and young patients with AVNRT.

Methods

Between April 2001 and March 2005, 268 consecutive patients (190 females; mean age, 49 ± 14 years) with AVNRT underwent RF catheter ablation at our institution. The patients were categorized into 2 groups: group 1 consists of patients younger than 65 years (n = 156), and group 2 consists of patients 65 years or older (n = 112).

Results

Compared with the younger subgroup, elderly patients more often had structural heart disease (11.6% vs 2.5%, P = .004), but there were no statistically significant differences in sex and symptoms during tachycardia (all P > .05). AVNRT cycle length was significantly longer in group 2 than in group 1 patients (P = .005). Among the conduction intervals of tachycardia, only atrio-his interval was significantly longer in group 2 patients (P = .007). The ablation fluoroscopy time, RF pulse duration, target temperature, applied energy, and number of RF applications were comparable in the 2 groups (All P > .05). Risk of atrioventricular block, pericardial effusion, and vascular thrombosis were similar in both groups (All P > .05). During follow-up with duration of 14 months, similar rate of recurrence was observed in the 2 groups (P = .94).

Conclusions

In elderly patients, slow pathway ablation is as effective and safe as in younger patients. Therefore, when considering different treatment options in elderly patients, an increased risk of complications or lower efficacy should not be a factor in determining the best therapeutic approach.     

右侧房室旁道导管射频消融治疗的体会

采用导管射频消融术（ＲＦＣＡ）阻断右侧房室旁道治疗房室折返性心动过速５０例，其中单旁道４５例，双旁道４例，三旁道１例，共５６条旁道。首次消融成功率９４％，二次消融成功率１００％。平均随访９个月，３例复发（６％），均经再次消融成功，其余病例未服用任何抗心律失常药物无心动过速复发，术后除１例右后间隔旁道消融后出现一过性Ⅲ°房室传导阻滞外无其它并发症发生。就右侧旁道消融的体会进行了讨论。     

Radiofrequency transcatheter ablation of a bidirectional decremental accessory atrioventricular pathway in the coronary sinus

We report the case of a 63-year-old patient who underwent radiofrequency catheter ablation of an atrioventricular accessory pathway with bidirectional decremental conduction properties. The successful ablation site was the distal end of a wedge-shaped dilation of the first tract of the coronary sinus. Atrioventricular accessory pathways with anterograde decremental conduction properties was thought to belong to fibers with Mahaim type electrophysiological properties. They rarely show decremental retrograde conduction properties. Most Mahaim type atrioventricular pathways are right-sided with atrial insertion points at various sites along the tricuspid ring. On the other hand, left-sided decrementally conducting accessory pathways are very rare. Mahaim type atrioventricular pathways were never found in the coronary sinus. The bidirectional decremental conduction properties and in particular the anatomic site of the atrioventricular accessory pathway we describe in the present report are both very interesting findings.     

射频消融后旁路传导复发的相关因素

射频消融房室旁路患者114例，成功地消融了125条旁路，经随访12个月，旁路复发10例（8％）。旁路复发11％～29％分布在前间隔、后间隔和右侧游离壁，左侧游离壁复发仅占4％。消融时未记录到旁路电位是很强的预示旁路复发的因素。25例未记录到旁路电位的有16％复发，而记录到旁路电位的89例仅6％复发（P＜0．01）。结论：旁路复发与消融时未记录到旁路电位以及旁路的部位有关。右侧游离壁、间隔以及隐匿性旁路复发相对较高，与旁路不能精确定位有关。     

射频导管消融左侧隐匿性房室旁路后裂隙现象:复发的表现之一

患者女性，43岁，6个月前因反复发牛心动过速，在本院接受电生理检查诊断为左侧隐匿性房室旁路，成功地进行了射频导管消融治疗，术后电生理检查以各种心房、心室起博和程序刺激方法证实心动过速不能被诱发。术后3个月，患者又发作类似于术前的心悸，发作时心率为160次／min以上，突发突止，临床考虑为室上性心动过速复发，再次入院接受电生理检查。     

预激综合征患者经射频导管消融阻断房室旁路术后房室旁路显性传导短暂恢复的处理思路

目的：探讨预激综合征（WPW）患者经射频导管消融（RFCA）阻断房室旁路（AP）术后,数小时内AP短暂恢复房室显性传导的处理策略。方法：回顾性分析连续1378例接受RFCA治疗成功的持续性WPW患者,剔除间歇性WPW和RFCA失败患者。记录分析所有患者的临床资料、电生理检查结果、病情转归及随访情况。结果：依据RFCA术后结果将1378例WPW患者分为3组。1356例直接取得成功（直接成功组）,8例患者术后WPW短暂恢复房室显性传导（WPW短暂恢复组）,14例RFCA术后WPW复发（WPW复发组）。WPW短暂恢复组与直接成功组的消融靶点局部心室电位提前体表ECG的QRS起始时间无统计学差异[（27±9）ms vs．（28±6）111S],但WPW复发组显著短于直接成功组[（23±9）ms vs．（28±6）ms,P〈0．05]。WPW复发组的消融放电开始至WPW消失时间显著长于另外两组[（12±6）SVS．（5±3）S,（6±3）S,P〈0．05]。WPW短暂恢复组8例患者的AP分别于右后间隔消融成功2例、右游离壁3例、左后间隔1例及左游离壁2例。WPW首次恢复均发生在术后24h内,并均于术后24h内WPW再次消失。WPW短暂恢复组的WPW首次复发和持续时间均显著短于WPW复发组[（9±5）hw．（56±38）d,P〈0．05]和[（12±6）h掷．≥72h,P〈0．05）。WPW短暂恢复组中的5例患者于术后72h以后接受了再次电生理检查,证实已消融的AP前向和逆向传导功能均已被成功阻断;另外3例患者选择了临床观察。经随访6个月以上,该8例患者WPW未再复发亦无室上性心动过速发生。结论：WPW患者经RFCA后出现WPW短暂恢复的患者,可继续观察,若WPW再次消失,可临床随访,无需再次行电生理检查及射频消融术。     

显性多旁道的电生理特点和射频消融治疗

目的报道显性多旁道的心电生理特点和射频消融治疗。方法回顾性分析70例显性多旁道患者的一般临床资料、旁道分布特点、心动过速类型及消融治疗的效果。结果①70例均有心动过速发作史,29例有2种、6例有3种心动过速;②70例共有158例显性旁道,18例为3条旁道,52例为2条旁道;③61例可诱发AVRT,其中13例为逆向型AVRT;④消融患者的成功率为97.1%(68/70例),消融的旁道成功率为98.7%(156/158条)。结论显性多旁道易发生多种心动过速,射频消融治疗成功率高。     

左侧房室慢旁路的电生理特征和射频消融靶点的定位

目的 :探讨左侧游离壁慢传导旁路的电生理特点和射频消融方法。方法 :5例患者诱发心动过速后用心室感知S2程序刺激中止心动过速确立心室为房室折返环的一部分。结果 :4例中止心动过速时无心房逆行 A波 ,1例有逆行 A波 ,旁路 1例有递减传导特点 ,均在心室侧消融成功。成功消融靶点 A波较冠状窦标测导管最早 A波提前 8～2 2 m s。结论 :心室感知 S2心室程序刺激终止心动过速是鉴别房性心动过速的可靠方法。     

Electrophysiological characteristics and radiofrequency ablation of accessory pathways with slow conductive properties.

BACKGROUND: Atrioventricular accessory pathways (AP) with unusually long ventriculo-atrial (VA) conduction times are present in a significant subset of patients with the Wolff-Parkinson-White (WPW) syndrome, not including patients with the permanent form of atrioventricular junctional reciprocating tachycardia. METHODS AND RESULTS: We compared the electrophysiological characteristics and outcomes after radiofrequency (RF) ablation in 34 patients with the WPW syndrome, a VA interval >80 ms, and paroxysmal tachycardia with an RP/PR ratio <1 (the slow group), vs 80 patients with WPW syndrome and a VA interval <80 ms (the fast group). AP were found in the posteroseptal region significantly more often in the slow than in the fast group. In addition, the decremental conductive properties of the AP were more common in the slow than in the fast group. Catheter ablation of AP was highly successful in both groups, although ablation required a greater number of RF applications and longer procedure times in the slow group, especially for AP with decremental conductive properties. CONCLUSIONS: A posteroseptal AP location was more common in AP associated with long conduction times than in AP with typical conductive properties. Both types of AP were successfully ablated, although the slow group required longer procedures and more RF energy deliveries.     

射频消融希氏束房室旁道的回顾性分析

目的 探讨射频消融希氏束房室旁道治疗房室折返性心动过速的方法.方法 根据电生理检查结果确定右侧房室折返性心动过速,左前斜位45°消融电极在三尖瓣环细标确定靶点图,即在希氏束附近AV融合或最短AV间期,可记录到小H波,其振幅明显小于希氏束电图H波振幅,在窦性心律或心动过速时低能量试放电,有效增加功率和延长放电时间.结果 15例患者射频消融术成功,无严重并发症发生.结论在准确标测和消融下,消融希氏束房室旁道是安全、有效的.     

Catheter ablation using radiofrequency current to cure symptomatic patients with tachyarrhythmias related to an accessory atrioventricular pathway

BACKGROUND. Recent investigations have shown that cure of patients with symptomatic tachyarrhythmias related to an accessory atrioventricular pathway may be achieved by closed-chest electrode catheter ablation of the accessory connection. Direct current shocks have primarily been used for this purpose, but its applicability is limited because of the lack of controlled titration of electrical energy, the infliction of barotrauma, and the need for general anesthesia. Radiofrequency current has been proposed as an alternate energy source. METHODS AND RESULTS. Seventy-three symptomatic patients with Wolff-Parkinson-White syndrome and 19 patients with only retrogradely conducting (concealed) pathways underwent ablative therapy with radiofrequency current. There were 71 accessory pathways located on the left side of the heart (57 free-wall and 14 posteroseptal pathways) and 25 on the right side (11 free-wall, seven posteroseptal, and seven midseptal or anteroseptal pathways). In patients with right-sided pathways, ablation was attempted via a catheter positioned at the atrial aspect of the tricuspid annulus. In patients with a left-sided free-wall accessory pathway, a novel approach was used in which the ablation catheter was positioned in the left ventricle directly below the mitral annulus. Accessory pathway conduction was permanently abolished in 79 patients (86%). Growing experience and improved catheter technology resulted in a 100% success rate after the 52nd consecutive patient. Failures were mainly the result of inadequate catheters used initially or an unfavorable approach to left posteroseptal pathways. CONCLUSIONS. Catheter ablation of accessory atrioventricular pathways by the use of radiofrequency current is an effective and safe therapeutic modality for patients with symptomatic tachyarrhythmias mediated by these pathways.     

Long-term results of radiofrequency catheter ablation in patients with multiple accessory pathways

Information on the long-term results of radiofrequency catheter ablation in a large group of patients with multiple accessory pathways (APs) was not available. This study included 858 patients with Wolff-Parkinson-White syndrome who underwent electrophysiologic study and radiofrequency catheter ablation: 73 patients (8.5%) had multiple APs. Sixty-six patients had 2 APs, 5 had 3 APs, 1 had 4 APs, and 1 had 5 APs. The most common combination pattern of these pathways were concealed APs (38 patients, 52%). Localization of accessory pathways showed a higher incidence of right free wall (22% vs 11%, p < 0.05), anteroseptal, and midseptal APs (9% vs 5%, p < 0.05) in patients with multiple APs than in patients with 1 AP. The most common anatomic sites for multiple APs were 2 APs in the left wall (21 patients, 28%). Although the success rate was similar (98% vs 99%, p > 0.05), procedure time (3.1 ± 1.2 vs 2.0 ± 1.1 hours, p < 0.05) and radiation exposure time (48 ± 26 vs 29 ± 19 minutes, p < 0.05) were longer in patients with multiple APs. The recurrence rate was higher in patients with multiple APs (9.5% vs 2.5%, p < 0.05), and the most common site of recurrent APs was in the left free wall (7.2%); in contrast, it was in the right free wall in patients with 1 AP. These findings demonstrated that a high success rate of radiofrequency catheter ablation was found in patients with multiple APs; however, the higher recurrence rate in patients with multiple APs should be considered.     

房室多旁道的电生理特征及其射频消融治疗

目的 探讨房室多旁道的电生理特点及射频消融方法。方法 23例患者经电生理检查确定房室多旁道,应用心房和心室刺激诱发室上速,确定每条旁道的电生理特征及与心动过速的关系,按照标测部位对相关旁道逐步消融,以射频消融成功确定旁道位置。结果 23例中检出旁道49条,其中三条旁道3例;左侧多旁道12例,右侧多旁道2例,双侧多旁道9例;左侧多旁道以隐匿性为主;右侧多旁道多为显性;未见心动过速时右侧旁道前传而同侧旁道逆传现象。结论 多旁道患者应首先确定和消融与心动过速相关旁道;左侧多旁道应以诱发心动过速或快速心室起搏方法标测;右侧多旁道应同步描记12导联体表心电图,旁道消融成功可能仅见于QRS波的变化,双侧多旁道应首先消融左侧旁道。