射频消蚀治疗预激综合征81例报告

以射频电流对81例预激综合征伴阵发性室上性心动过速患者的房室旁路进行消蚀。76例(93.8％)患者的83条旁路(94.3％)被阻断。平均放电12次,平均消蚀时程2.3小时,随访7个月,2例(2.5％)复发但成功地进行第二次消蚀,无严重并发症。     

预激综合征合并三尖瓣下移畸形的射频消蚀：附八例报告

对８例先天性三尖瓣下移畸形合并右侧房室旁路的患者行射频消蚀，结果显示：尽管该类患者有心脏结构的异常，但消蚀导管的选择、操作方法及过程无特殊之处，总操作时间、Ｘ线投照时间以及放电次数也与心脏结构正常的右侧房室旁路相似，成功率高。这一结果证实，射频消蚀为合并先天性心脏病的预激旁路的治疗提供了新的途径。     

561例快速心律失常射频消蚀经验

对５６１例快速心律失常患者进行射频导管消蚀治疗，其中房室旁路折返性心动过速（ＡＶＲＴ）４１３例（４２９条旁路），房室结折返性心动过速（ＡＶＮＲＴ）１４２例，房性心动过速３例，心房扑动２例，心脏正常的室性心动过速１例。显性旁路消蚀成功靶点心电图特征为：ＡＶ≤４０ｍｓ，Ｖ波较体表心电图最早的ｄｅｌｔａ波提前≥２０ｍｓ，Ａ／Ｖ＜１。隐匿旁路成功的靶点心电图特征为：心室起搏时ＶＡ≤４０ｍｓ，Ａ／Ｖ＜１。对左前旁路患者、合并主动脉瓣狭窄者、动脉迂曲的老年人或需同时行二尖瓣球囊扩张术者，导管经股动脉逆行放入左室不易到位，可采用房间隔穿刺法，本组６例均获成功。房室结改良患者采用下位法较后位法消蚀的平均放电次数、时间及操作时间均少（Ｐ值＜０．０５）。本组２例（０．４％）发生三度房室传导阻滞，置入永久性心脏起搏器。平均随访６．１±４．９个月，１４例（２．６％）复发，均再次消蚀成功。     

静息心电图对房室旁路定位的评价

自从外科手术、电烧灼术、射频消蚀术等先后被用于治疗预激综合征以来,应用体表心电图进行房室旁路定位的研究受到广泛的重视,迄今与此有关的诊断标准已有多种,其中有些是要求心电图有最大预激图形的,有些则只用窦性心律时的常规心电图进行诊断。赖以进行旁路定位的一些主要心电图指标,如预激波的极性、QRS主波的方向、额面平均电轴等,在静息窦律时与最大预激时是否相同?本文通过87例有前传功能的单一旁路患者进行观察和比较,希望体表心电图有助于对旁路定位价值的评估。     

多房室旁路的导管射频消蚀治疗

本研究旨在对多房室旁路的术前判断、电生理特点及射频消蚀方法进行探讨。预激综合征伴房室折返性心动过速的多房室旁路患者共１５例，其中平时心电图有预激波１０例，心电图正常５例。只有７例为术前判断或怀疑有多旁路存在。采用先逐条消蚀显性旁路，之后在心室刺激下逐条消蚀隐匿性旁路的方法进行射频消蚀治疗。结果证实，本组共３１条旁路，其中双旁路１４例，三旁路１例。旁路组合以同侧、同性（指显性或隐匿性）多见。射频消蚀均成功地阻断了全部旁路，成功率１００％。本研究表明，多数多房室旁路是在心内电生理检查及射频消蚀术中发现，但详细的术前资料分析亦能发现有某些线索存在。采用“剥笋法”逐条消蚀房室旁路是避免遗漏旁路的可靠方法。     

射频消融的延迟效应及其临床意义(附2例报道)

目的评价射频消融阵发性室上性心动过速的延迟作用及其临床意义.方法 2例顽固性阵发性室上性心动过速患者住院行射频消融术.例1女性,15岁,预激综合征,体表心电图及心内电生理检查示左侧旁路.例2男性,体表心电图正常,心内电生理检查证实为左侧房室旁路.结果在消融放电时,2例患者的房室旁路均可被阻断,但都因停止放电后旁路多次复发而致术中消融失败.例1术后一天预激消失,例2术后第七天重复心内电生理检查无旁路传导.平均随访7个月无心动过速复发.结论射频能量对心脏的作用,不仅发生在释放能量的当时,而且可延迟到术后一段时间.     

二维超声心动图位相分析:其在无创伤性确定预激综合征患者旁路部位的价值

在预激综合征的病人,准确判定旁路位置对手术或导管消蚀术消除旁路具有决定性的意义。由于旁路传导的存在改变了心室收缩的正常顺序,引起某一局部提前收缩。因此,本文作者探讨了二维超声心动图位相分析确定这些提前收缩部位的价值,并以此判定旁路的位置。材料与方法:作者前瞻性地研究了17例单条旁路病人,男性11例、女性6例,年龄11～35岁,分别于窦性心律(最轻预激)状态及右房调博(最大预激)状态下获得位相显象。另外,11例正常人(男性6例,女性5例;年龄26～37岁)作为正常对照组。比较了相位图显象,12导联心电图,肉眼直观正弦环图象及导管电极心内膜标测确定旁路部位的准确性。将正弦环状态下的数字化切面图象按一级和谐     

射频消蚀右侧房室旁路的体会

以导管射频消蚀右侧房室旁路患者２２例，占同期消蚀旁路总数的２２％；其中包括显性者１３例（５９％），隐性者９例（４１％）。２例合并有Ｍａｈａｉｍ氏束，１例合并有隐性左侧旁路。全部消蚀成功，随访１～１１个月，３例复发（１４％），均已再次消蚀成功。我们认为准确的旁路定位及消蚀导管与靶组织的接触是成功的关键。     

房室旁路射频消蚀后的T波改变

本文报告2例预激综合征患者旁路射频消蚀术后的T波改变．并对其临床意义做了讨论．病例和结果例1．男性46岁，主诉发作任心悸8年。心电图示领激综合征宽定上性心动过速干1992年1月入院行射频消融术。入院后体检，X线胸片及超声心动图检查未见器质性心脏病。常规12导联心电图示A型硕激，旁略位干左后间隔。入院后第10天行经导管射频消融水。术中标测旁略位于左后间隔。放电6次（每次10～30秒）后体表心电图delta波消失．心室起搏示室房分离，不能诱发室上速，表明分路阻断。术后每日查心肌酶（CPK、CK－MB）2次共3天，均在正常范围。24h…     

直流电和射频消蚀预激综合征游离壁房室旁路的比较

95例均为房室旁路引起的有症状的心动过速患者。年龄20～78(50±10)岁。5例伴扩张性心肌病,2例伴肺部疾患,2例有严重高血压,1例有爱勃斯坦畸型。将5～6根电极导管经由颈内静脉、左或右股静脉插入以对心房和心室行程序起搏以及旁路定位。旁路位于记到旁路电位处,或最早心室及心房激动点处。前29例以直流电消蚀,消蚀导管为6F四极导管。消蚀左侧旁路时,导管经房间隔穿刺送入左房,并将远端电极抵住二尖瓣环。消蚀右侧旁路时,导管的远端电     

Single-catheter approach to radiofrequency current ablation of left-sided accessory pathways in patients with Wolff-Parkinson-White syndrome

BACKGROUND. Catheter ablation with the use of radiofrequency current has been introduced as a therapeutic option for patients with tachyarrhythmias mediated by an accessory atrioventricular pathway. The technique conventionally implies the introduction of several catheters into the heart for assessment of electrophysiological parameters as well as for localization of the accessory pathway and may last for several hours. METHODS AND RESULTS. Thirty-four patients with Wolff-Parkinson-White syndrome and a delta wave pattern indicative of an overt (i.e., capable of consistent antegrade conduction) left-sided free-wall accessory pathway underwent attempts at radiofrequency current ablation of the pathway with the use of just one catheter. No patient had a previous electrophysiological study. The catheter was introduced into the left ventricle close to the mitral annulus and was used for pathway localization as well as for ablation. The approach was completely successful in 30 patients (88%). In the remaining four patients, ablation of the pathway was achieved by using the multiple-catheter approach. Overall procedure duration was 2.0 +/- 1.1 hours; radiation exposure time was 22.8 +/- 20.4 minutes (median, 17.3 minutes). There were no acute complications. CONCLUSIONS. The single-catheter approach to radiofrequency current ablation of overt left-sided free-wall accessory pathways is feasible, safe, and effective in the majority of patients. The approach requires considerable investigator experience but significantly reduces procedure duration and radiation exposure time.     

High frequency catheter ablation of accessory atrioventricular pathways

Radiofrequency catheter ablation has established as the first line therapy for the curative treatment of patients with accessory pathways. For left-sided accessory pathways, the retrograde approach over the aortic valve is commonly used for ablation of the ventricular insertion. For right-sided and septal accessory pathways, the atrial insertion is usually approached from the right atrium. Atrioventricular accessory pathways irrespective of the exact localization can be successfully ablated in more than 90-95% of all cases. Severe complications associated with the ablation procedure are rare and occur in approximately 2-3% of patients treated. The recurrence rate after successful ablation is approximately 5-10%. Recurrences of accessory pathway conduction occur almost exclusively within the first 3 months following successful ablation whereas late recurrences are rare. Because of the favorable efficacy--risk profile, radiofrequency catheter ablation can be recommended as the first line therapy to all symptomatic patients with accessory atrioventricular pathways.     

Electrocardiographic abnormalities after radiofrequency catheter ablation of accessory bypass tracts in the Wolff-Parkinson-White syndrome.

Repolarization abnormalities on surface electrocardiograms have been described after loss of ventricular preexcitation in some patients with the Wolff-Parkinson-White syndrome. Radiofrequency catheter ablation of overt accessory pathways provides a unique opportunity to study this phenomenon. In this study, serial electrocardiograms were obtained before and after radiofrequency ablation of manifest accessory pathways in 19 patients, of concealed accessory pathways in 6 and after radiofrequency atrioventricular nodal modification in 12. Seven patients undergoing manifest right-sided accessory pathway ablation had left superior frontal plane T-wave axis deviations after ablation (-42 +/- 13 degrees). No patient with a manifest left-sided or concealed accessory pathway, or atrioventricular nodal modification had T-wave abnormalities after ablation; however, left anterior fascicular block and incomplete right bundle branch block each occurred in 1 patient with left accessory pathway ablation. Repolarization abnormalities observed after ablation were similar to T-wave abnormalities during the absence of preexcitation before ablation and persisted up to 5 weeks after the procedure. Patients with repolarization abnormalities after ablation had significantly longer preexcited QRS durations than those without such changes, suggesting that the initial contribution of the pathway to ventricular activation is an important determinant of T-wave changes after ablation. The proposed mechanism for repolarization abnormalities after ablation is the phenomenon of T-wave "memory."     

Two-catheter approach for ablation of accessory pathways in different locations

Radiofrequency ablation is the treatment of choice for patients with Wolff-Parkinson-White syndrome and symptomatic tachyarrhythmias. The technique involves localising the pathway with multiple catheters at various sites followed by radiofrequency energy application at that site. Single catheter approach has been described for ablation of manifest left-sided accessory pathways. In this article, we report the ablation of accessory pathways in different locations in patients with Wolff-Parkinson-White syndrome by using a two-catheter approach. Twenty-three consecutive patients with symptomatic Wolff-Parkinson-White syndrome were taken up for radiofrequency ablation with this approach. Pathways could be successfully ablated in 11 out of 13 patients with left free wall, 5 out of 7 with right posteroseptal, one patient of left posteroseptal and each of the 2 patients of right mid septal locations giving an overall success in 19/23 (82.6%) patients. Hence, two-catheter approach can be used safely to ablate accessory pathways in different locations with high success rate, thus minimising the procedure time associated with conventional approach.     

Slow and wide QRS complex tachycardia as a unique complication following radiofrequency catheter ablation of a left-sided accessory pathway in a child

Radiofrequency lesions can, theoretically, be the substrate for new persistent arrhythmias. As far as we know, this has never previously been encountered after transcatheter ablation of accessory pathways. A child with Wolff-Parkinson-White syndrome was referred for radiofrequency catheter ablation of a left-sided accessory pathway. After successful ablation of the accessory pathway using a retrograde transaortic approach, the child developed an incessant wide QRS complex tachycardia at slow rate that was resistant to pharmacologic interventions. The focus of the tachycardia was identical to the ventricular site of insertion of the eliminated accessory pathway.     

Repolarization abnormalities after catheter ablation of differently located overt accessory pathways.

PURPOSE: Electrical repolarization abnormalities are usually seen after radiofrequency catheter ablation in overt accessory atrio-ventricular pathways. These abnormalities have been recognised as "cardiac memory". The aim of this study was to assess the relationships between electrical repolarization abnormalities and the location of the accessory atrioventricular pathway in the atrio-ventricular junction. We also assessed the relationship between electrical repolarization abnormalities and the degree of ventricular preexcitation. MATERIAL AND METHODS: Our group consisted of 45 patients with overt and persistent preexcitation who were successfully submitted to radiofrequency catheter ablation. Mean age was 38.9 +/- 14.9 years (14 to 64), 28 of whom (62.2%) were male and 17 (37.8%) female. The location of accessory pathways the was left lateral in 14 patients, right posteroseptal in 14 patients, right mesoseptal in eight patients, right anteroseptal in four patients and other locations in the remaining four. Surface electrocardiograms were performed immediately following ablation, 24 hours later and three or more months after the procedure. RESULTS: T wave abnormalities (flattened, inverted or peaked) were detected on the first day in 51% of patients, being more frequent after right accessory pathway ablation (86.9% versus 13.1% in left accessory pathways). These electrocardiographic changes were particularly frequent in patients with right mesoseptal (5/8, 62.5%) and posteroseptal (13/14, 93.3%) pathways, of which 62.5% and 71.5%, respectively, showed marked preexcitation before ablation. These findings were significantly different from those observed in patients with left lateral pathways--only 35.7% showed marked preexcitation and only two of fourteen patients (14.3%) presented T wave abnormalities after ablation. After the third month, most of the patients that had undergone successful ablation presented completed electrocardiographic normalization. CONCLUSIONS: Patients undergoing radiofrequency catheter ablation for right accessory pathways show more frequently repolarization abnormalities than those submitted to ablation of the left lateral accessory pathways. The occurrence of these changes after preexcitation resolution may depend on the degree of previous preexcitation.     

经冠状静脉窦标测和消融后间隔心外膜房室旁道

报道心外膜房室旁道的特点和经冠状静脉窦射频消融术的结果。3例后间隔显性房室旁道患者先经心内膜标测和消融,不成功后改由经冠状静脉窦内标测和消融。术中冠状动脉造影,观察冠状静脉窦形态。结果: 2例冠状静脉窦近端有一憩室,并在憩室的颈部消融阻断房室旁道。成功靶点图为标测到振幅较大的旁道电位,其振幅大于A波和V波。结论:经心内膜标测和消融失败的旁道可能是心外膜旁道,行冠状静脉窦内标测与消融可有效阻断旁道,冠状静脉窦憩室与后间隔旁道可能存在着解剖关系。     

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.     

经静脉穿房间隔和经动脉逆行消融左侧旁道的比较

目的探讨经静脉穿房间隔和经动脉逆行途径行左侧旁道消融的有效性和安全性。方法133例左侧旁道患者,71例经主动脉逆行标测消融(经主动脉逆行组),62例经静脉穿房间隔心房侧旁道消融(经静脉穿房间隔组)。比较两组放电时间及次数、X线曝光时间、手术总时间,手术效果及安全性。结果经静脉穿房间隔组的放电时间及次数、X线曝光时间、手术总时间较经动脉逆行组均明显缩短(P<0.01),即刻成功率100%;经主动脉逆行组有3例左前外侧旁道者需改经静脉穿房间隔消融成功,即刻成功率96%(68/71)。两组均无并发症。随访15.3±11.3个月,共有3例复发经再次消融成功;其中经动脉逆行组有2例复发,复发率为2.8%;而经静脉穿房间隔组有1例复发,复发率为1.6%。结论经静脉穿房间隔心房侧左侧旁道消融可行、安全、有效,消融导管易于到位,消融时间及放电时间减少。     

Radiofrequency catheter ablation for treatment of Wolff-Parkinson-White syndrome--short- and long-term follow-up.

One hundred and twenty-five patients with accessory pathways mediated tachyarrhythmias underwent radiofrequency ablation. Right-sided accessory pathways were ablated from the atrial aspect of the tricuspid anulus (all from the femoral vein approach) and the left-sided accessory pathways were ablated from the atrial or ventricular aspect of the mitral anulus. Immediately after the procedures, 3 of 8 accessory pathways (38%) and 131 of 137 accessory pathways (95%) were ablated successfully with radiofrequency through a small-tip (2 mm) and a large-tip (4 mm) electrode catheter, respectively. Seven of the 11 accessory pathways that failed radiofrequency ablation had a later successful direct current ablation. During follow-up (3 to 22 months), serial electrophysiological study showed that 11 of the 114 patients (10%) with successful ablation had return of accessory pathway conduction (2 had recurrence of tachycardia, 2%). Complications included accidental AV block (1 patient), cardiac tamponade (1 patient) and possible aortic dissection (1 patient). Transient proarrhythmic effects (more atrial and ventricular premature beats) were seen during the first week and sustained ventricular tachyarrhythmias were not inducible. In a successful session, procedure and radiation exposure times (including the time for diagnostic procedures) were 3.8 +/- 0.2 h and 45 +/- 4 min, respectively. This study confirms that radiofrequency ablation with a large-tip electrode catheter is an effective and relatively safe nonsurgical method for treatment of Wolff-Parkinson-White syndrome, with a low complication and recurrence rate.