持续性Ⅲ度房室传导阻滞患者起搏器植入后房室传导功能的观察

回顾2004年1月至2011年12月因持续性Ⅲ度房室传导阻滞(AVB)植入起搏器的患者资料,观察房室传导的情况。393例因持续性Ⅲ度AVB植入起搏器,46例起搏器不具有计算心室起搏比例功能的患者被除外。341例分为心室起搏比例≥90%组(NAVC组,n=300)和心室起搏比例90%组(AVC组,n=41)。两组在年龄、性别、民族、心律及合并疾病间均无显著性差异。AVC组QRS波群时限小于NAVC组(P0.05)。QRS波时限120 ms是持续性Ⅲ度AVB术后有房室传导的预测因素[OR 11.060(95%CI 2.396~51.050),P=0.002]。结论:约有12%的持续性Ⅲ度AVB患者出现房室传导,QRS波群时限小于120 ms可能是持续性Ⅲ度AVB患者术后有房室传导的预测因素。     

房室结改良术中Ⅲ度房室传导阻滞的发生与预防

34例房室结改良术中3例发生Ⅲ度房室传导阻滞(AVB)。2例永久性Ⅲ度AVB发生在消融快通道时,1例—过性Ⅲ度AVB发生在下位法消融慢通道时。3例均发生在放电出现频率较快的非阵发性交界性心动过速时。针对这3例情况,本文讨论了发生Ⅲ度AVB的原因及预防措施。     

急性心肌梗死合并Ⅲ°房室传导阻滞恢复正常房室结传导的影响因素分析

目的:探讨急性心肌梗死(AMI)合并Ⅲ°房室传导阻滞(Ⅲ°AVB)患者恢复正常的房室结传导的影响因素。方法:选择AMI合并Ⅲ°AVB患者82例,根据Ⅲ°AVB是否恢复正常房室结传导分为恢复组51例,未恢复组31例(其中安装永久人工心脏起搏器3例,死亡28例)。观察两组Killip分级、心源性休克等因素的差异。结果:AMI合并Ⅲ°AVB患者中,房室结传导恢复组与未恢复组在年龄、性别比例、吸烟史、高血压病史、糖尿病史、缺血预适应、到达急诊室时间、入院心率水平、入院收缩压、血红蛋白水平及实施早期再灌注治疗方面,差异无显著性(P0.05)。与恢复组比较,未恢复组Killip≥II级(39.2%比80.6%)、心源性休克(21.6%比45.2%)、前壁梗死比例(7.8%比32.3%)、肌酐水平[(107.25±6.69)μmol/L比(132.43±11.52)μmol/L]及死亡率(0%比90.3%)显著升高,而下壁梗死比例(92.2%比67.7%)显著降低,P0.05或0.01。多因素Logstic回归分析显示,Killip分级为影响AMI合并Ⅲ°AVB患者房室结功能恢复正常的独立预测因素(OR=0.190,P=0.002)。结论:Killip分级为影响急性心肌梗死合并Ⅲ°房室传导阻滞患者房室结功能恢复的独立预测因素。     

急性心肌梗死患者Ⅲ度房室传导阻滞与房室结动脉血供的关联性

目的 观察和分析急性心肌梗死(AMI)患者Ⅲ度房室传导阻滞(AVB)与房室结动脉血供的关系。方法 将入选的AMI患者,按是否并发Ⅲ度AVB分为两组:病例组为AMI并发Ⅲ度AVB的患者（n=35例）,对照组为AMI未并发Ⅲ度AVB的患者（n=215例）,通过观察梗死相关动脉并分析房室结动脉血供来源情况,分析AMI患者不同房室结动脉血供来源发生Ⅲ度AVB的几率,并观察AMI并发Ⅲ度AVB的患者,房室结动脉血运改善后Ⅲ度AVB恢复时间。结果 房室结动脉血供来源于右冠状动脉的右上降支动脉和回旋支的kugel’s动脉之一或二者双重血供。病例组患者,其房室结动脉血供仅来源于右冠状动脉的右上降支或回旋支的kugel’s动脉,无前降支来源,并且右冠状动脉较回旋支多见（P<0.01）。当梗死相关动脉得到再灌注,恢复血运后,AVB均恢复到窦性心律。结论 急性心肌梗死Ⅲ度AVB发生患者与其房室结动脉血供中断有关,恢复房室结动脉血供后AVB恢复窦性心律。     

心脏瓣膜术后Ⅲ度房室传导阻滞的临床分析

目的 探讨心脏瓣膜术后Ⅲ度房室传导阻滞（Ⅲ°AVB）的发生原因、影响因素及相关治疗措施.方法 回顾性分析我院2000年1月至2008年12月3674例心脏瓣膜术后9例发生持续性Ⅲ°AVB并行永久性起搏器置入术患者的临床资料.心脏病因：风湿性心脏瓣膜病2例,感染性心内膜炎2例,主动脉瓣二叶畸形2例（其中合并感染性心内膜炎1例）,退行性主动脉瓣病变1例,先天性房室管畸形1例（既往有心脏手术史）,二尖瓣脱垂及非对称性肥厚性心肌病各1例.行主动脉瓣置换4例、二尖瓣置换2例、二尖瓣置换及三尖瓣成形1例、Bentall术1例、左室流出道疏通及二尖瓣置换1例.结果 本组9例患者,术后早期出现Ⅲ°AVB 7例,术后24～48 h出现Ⅲ°AVB 1例,术后4年出现Ⅲ°AVB 1例.出现Ⅲ°AVB持续时间超过2～3周不能恢复者,均行永久性起搏器置入术,其中采用DDD起搏器4例、VVI起搏器5例.无晚期死亡患者.结论 心脏瓣膜术后出现Ⅲ°AVB大多发生于术后早期,与手术部位有一定关系.术中注重心脏瓣膜结构与房室结及传导束的解剖关系,是预防术后出现Ⅲ°AVB的关键.Ⅲ°AVB持续时间超过2～3周者需行永久性起搏器置入术.     

房室结双径路慢径消融时连续AV非1∶1比例与短暂房室传导阻滞的相关性

目的分析房室结双径路导管射频消融时出现连续AV非1∶1比例与房室传导阻滞(AVB)发生的相关性及放电导致AVB的特点,为消融时预防AVB提供思路与方法。方法回顾113例房室结双径路的导管消融电生理资料,分析放电时AV的比例、波幅比值及患者性别、年龄等因素与出现AVB的相关性。结果放电时出现连续AV非1∶1比例时,短暂AVB的发生率显著高于无AV非1∶1比例者(36.84%vs 0.52%,P<0.05)。靶点腔内心电图呈小A大V,A波较宽、碎裂,不带有H波,在此基础上放电是否出现AVB与AV波幅比值无关(P>0.05)。女性AVB的发生率高于男性(34.78%vs 6.82%,P<0.05)。随访中未见AVB发生及室上性心动过速复发。结论放电时出现连续AV非1∶1比例可能发生AVB,须立即停止放电;女性患者更易出现AVB。     

运动试验诱发房室传导阻滞二例

1例男性,36岁,活动劳累时反复心悸、胸痛一月余。运动试验诱发胸痛伴V1导联ST段上抬4～5 mm,恢复早期出现Ⅱ度房室传导阻滞(AVB),发生机制可能为冠状动脉病变导致房室结供血不足,影响房室传导功能而导致AVB;1例女性,52岁,活动时心悸、胸闷二月余,加重伴乏力十天。运动试验诱发Ⅲ度AVB,发生机制可能因先天性的房室传导障碍或传导系统及房室结心肌组织退行性改变。运动时频率增快的窦性激动在通过房室结下传过程中可连续落入房室结不应期,不能下传心室而产生房室传导的延缓或中断。     

房室结慢径改良发生Ⅲ度房室传导阻滞的探讨

目的：探讨房室结慢径改良发生Ⅲ度房室传导阻滞（AVB）的特异性心电改变及预防，方法：232例房室结折返性心动过速（AVNRT）患者分三组：一组：81例，任何一次放电过程中无特异性心电改变；二组：82例，有一次或一次以上的放电过程中特异性心电改变701次，且放电时间小于3s，三组：69例，有一次或一次以上的放电过程中特异性心电改变97次，但放电时间大于3s，结果：232例患者均消融成功，其中发生一次性Ⅲ度AVB11例，永久性Ⅲ度AVB7例，结论：射频消融术改良房室结慢径时可发生Ⅲ度AVB，但只要我们术中发现特异性心电改变立即停止放电并选择适当的消融方法。可将Ⅲ度AVB降低到最低限度。     

射频消融房室结慢径后迟发性房室传导阻滞一例

患者女,43岁,因房室结折返性心动过速共行3次房室结慢径射频消融,术后9 h发生Ⅲ度房室传导阻滞;第2～6天由Ⅲ度房室传导阻滞逐渐转为P波10∶1,6∶2,3∶1,4∶2下传心室;第7～10天患者休息时P波1∶1下传心室;第11天休息和体力活动时P波均1∶1下传心室,房室传导功能恢复。     

房室阻滞部位的心电图诊断(上)

正房室阻滞(AVB)的心电图临床常见,AVB是指心脏特殊传导系统的电活动从心房下传心室的过程中出现了传导延缓或传导中断的现象。根据传统概念,房室阻滞分为不全性和完全性AVB,前者包括一度AVB,二度AVB和高度AVB,而完全性AVB又称三度AVB。房室传导阻滞总述一.AVB的心电图分类人体心脏有着完整的特殊传导系统(图1),自主心电激动从窦房结发出后先激动心房,再经房室结、     

房室结改良术终点与复发率的关系

为探讨房室结改良术成功后不同电生理终点对复发率的影响，观察了８０例房室结改良术患者复发情况。其中双径现象消失（Ａ组）５１例；仍有双径现象，但无心房回波（Ｂ组）２１例；有双径现象，且有１个心房回波（Ｃ组）８例。消融成功后观察３０ｍｉｎ，急性复发４例（５．８％）；术后随访１４．７±５．６（６～３９）个月慢性复发３例（３．８％），共复发７例（８．８％）。７例中，Ａ组与Ｂ组各２例、Ｃ组３例，复发率分别为３．９％、９．５％、３７．５％。其中Ａ组与Ｃ组比较复发率差异非常显著（Ｐ＜０．０１），其余差异无显著性（Ｐ＞０．０５）。此结果表明，选用三种终点中的任何一种，术后大多数患者都未复发。而为了降低复发率，除了消融成功后至少应观察３０ｍｉｎ以消除急性复发外，在技术成熟的单位，可力争以双径现象消失为改良术终点。     

射频消融术后发生迟发性房室阻滞的治疗体会

报道射频消融术(RFCA)后发生迟发性房室阻滞(AVB)发生的时间、心电图特征及用大剂量激素治疗的体会。9例迟发性AVB者中7例于放电过程中出现一过性Ⅲ度AVB。每日氢化考的松用量平均为500(300～800)mg,用药时间最短5天、最长15天。9例中8例完全恢复,平均恢复时间为8.3(5～15)天;1例遗留Ⅰ度AVB。平均随访5.6(0.5～9)年,1例出院时有Ⅰ度AVB的患者,于3年后复查显示Ⅱ度Ⅰ型及Ⅱ度Ⅱ型AVB,并安置心脏起搏器治疗。结论:RFCA后发生的迟发性AVB与放电时发生的一过性Ⅲ度AVB有关;经大剂量激素治疗后绝大多数可完全恢复,预后一般良好。     

射频导管消融房室结改良术心电监测分析

为探讨射频导管消心室改良术所致心律失常的发生规律，分析射频导管消融房室结改良术２２例术中及术后２４ｈ的心电监测资料，并与预激旁道消融术２２例进行对比研究。     

房室结内折返性心动过速慢径路消融中房室传导阻滞的预防

目的 探讨房室结内折返性心动过速(AVNRT)慢径路消融中房室传导阻滞的预防措施。方法 72例AVNRT患者从小功率(5W)开始放电，逐步增加放电功率，根据放电时的反应，及时改换安全的放电部位；放电过程中不苛求房室交接区心律从有到无的规律；慢径路改良，不苟求慢径路消失，以不诱发心动过速为宗旨。结果 72例慢径路消融均成功，无一例发生房室传导阻滞的并发症，无一例远期复发。结论 从小功率开始放电，慢径路改良等措施，可有效预防房室传导阻滞，且对远期复发无影响。     

射频消融术前后血浆心肌酶变化的临床研究

目的 通过动态观察射频消融术患者血浆心肌酶的变化,评价射频消融术对心肌的损伤。方法 ６０例患者,男性２７例,女性３３例,年龄６￣６７岁,均无器质性心脏病。其中,房室结交界区折返性心动过速１６例,房室旁路参与的房室折返性心动过速３７例（左侧旁路２２例,右侧旁路１５例）,房性心动过速１例,特发性室性心动过速２例,心房扑动４例。分别在术前、术中、术后即刻及术后１ｄ采血３ｍｌ,测定血浆心肌酶的水平。结果     

Change in delay of atrioventricular conduction after radiofrequency catheter ablation for atrioventricular nodal re-entry tachycardia.

OBJECTIVE--To monitor atrioventricular conduction after radiofrequency ablation for atrioventricular nodal re-entry tachycardia. DESIGN--Measurement of PR interval from 12 lead surface electrocardiograms before; at 0, 24, 48, 72, and 96 hours; and at 1 and 6 months after radiofrequency ablation. PATIENTS--40 consecutive patients with atrioventricular nodal re-entry tachycardia. The anterior approach was used in 23 patients, the posterior approach in 17. RESULTS--With the anterior approach the PR interval increased significantly and progressively until 48 hours after ablation (maximum 282 (SD 62.2) ms, before ablation 142 (29.5) ms; P < 0.0001). Up to 96 hours no further change was observed, but one month after ablation the PR interval had decreased to a value not significantly different from that 24 hours after the procedure (231 (51.2) ms). In one patient total atrioventricular block developed 24 hours after an uncomplicated procedure and a permanent pacemaker was implanted. With the posterior approach the PR interval increased slightly in the first 24 hours (156 (22.7) ms, before ablation 144 (21.2) ms P = 0.004), but it had returned to preablation values at 1 month. One patient developed second degree atrioventricular block during the first 24 hours after ablation, despite delivery of all radiofrequency pulses posterior to Koch's triangle at sites without His bundle deflection. PR intervals at 6 months did not differ significantly from the values at 1 month. CONCLUSION--After the anterior approach the progressive delay in atrioventricular conduction up to 48 hours after radiofrequency ablation for atrioventricular nodal re-entry tachycardia warrants continuous in hospital monitoring of patients for at least two days after the procedure.     

Perinodal slow potential as a local guide for transcatheter radiofrequency ablation of atrioventricular nodal reentrant tachycardia: therapeutic efficacy and electrophysiological mechanisms of success.

BACKGROUND--A specific local indicator in the Koch's triangle could be critical to the complication-free treatment of atrioventricular nodal reentrant tachycardia by transcatheter radiofrequency ablation. Recording of perinodal slow potential reflects a slow conduction area, and probably indicates the location of the slow pathway component of the circuit. Specific ablation of the slow pathway would carry the least risk of atrioventricular block. METHOD AND RESULTS--Guided by the mapped perinodal slow potential, atrioventricular nodal reentrant tachycardia was successfully eliminated in all of 55 consecutive patients in one session. Fifty two patients (94.5%) had confirmed slow potential at the final success sites. Despite the good result, the underlying electrophysiological mechanisms of early success from slow-potential-guiding catheter ablation were heterogeneous: selective slow pathway eradication in 31 patients (56.4%, group A), selective slow pathway modification in 18 patients (32.7%, group B), inadvertent fast pathway damage in six patients (10.9%, group C). Group B patients had the preservation of dual atrioventricular nodal pathways, adequate atrio-Hisian delay, fast pathway facilitation, and a higher frequency of inducible, single non-conducted nodal echo (15/18, 83.3% v 6/31, 19.4% in group A, P << 0.001). The upper communicating path of the circuit was implicated as another site of radiofrequency destruction. Three recurrences were documented in follow up study. However, reablation by the same approach caused complete atrioventricular block in one patient (1.7%, 1/58 procedures). None of the local characteristics of ablation sites was an independent predictor of procedure outcome. CONCLUSIONS--Perinodal slow potential is not a specific slow pathway indicator in transcatheter radiofrequency ablation of atrioventricular nodal reentrant tachycardia. Multiple strategic sites of the reentry circuit may be damaged through similar local signals.     

Catheter ablation of the atrioventricular junction with radiofrequency energy

Catheter ablation of the atrioventricular junction using direct-current defibrillator discharges requires general anesthesia and may have serious side effects. Sixteen patients with drug-refractory supraventricular tachycardia underwent catheter ablation of the atrioventricular junction using radiofrequency energy. A standard 7F quadripolar electrode catheter was positioned to record the largest unipolar His potential (580 +/- 640 microV) from the distal electrode. An electrocoagulator (Microvasive Bicap 4005) supplied continuous, unmodulated energy at 550 kHz. One to 14 applications of radiofrequency current were delivered between the distal electrode and a large-diameter chest wall electrode. Transient, mild chest discomfort was reported by seven of 16 patients. None had significant arrhythmias or blood pressure changes during radiofrequency ablation. Complete atrioventricular block was produced in nine of 16 patients and high-grade second-degree atrioventricular block was produced in one patient with radiofrequency current. Attenuated His bundle electrograms could still be recorded in the remaining six patients, four of whom underwent successful atrioventricular junctional ablation using direct-current shock during the same session. Atrioventricular block persisted in all 10 patients successfully treated with radiofrequency ablation during a mean follow-up of 4.2 months. Compared with a group of historic control subjects treated with direct-current shock ablation, the 10 patients successfully treated with radiofrequency current had significantly less creatine kinase-MB isoenzyme release (5.7 +/- 5.1 vs. 22 +/- 13 IU, p = 0.006). A junctional escape rhythm was present in all patients after radiofrequency-induced atrioventricular block. In contrast, three of 10 control patients had an idioventricular escape after direct current shock ablation, and four patients had no escape rhythm at all.(ABSTRACT TRUNCATED AT 250 WORDS)     

右侧壁房室旁道再次射频消融成功的体会

右侧壁是右侧房室旁道导管射频消融（ＲＦＣＡ）较困难区域。对６例ＲＦＣＡ失败和（或）复发的右侧壁房室旁道再次消融成功进行分析，以探讨其消融的方法学。选用８Ｆ加硬大头或温控导管，部分病例使用Ｓｗａｒｔｚ鞘辅助操作，均经静脉途径于三尖瓣环上进行消融。６例患者术中均成功阻断旁道，有效放电１１次、射频电流功率平均４３±６（３０～５０）Ｗ、放电时间平均３７９±８１（２７０～４８０）ｓ，与５０例右侧其它部位旁道消融功率（平均３６±４Ｗ）和时间（平均２４０±２３ｓ）分别相比，Ｐ均＜０．０５。５例患者随访期间停用抗心律失常药物，无心动过速发作；１例术后１６ｈ再次复发。体会：采用高功率、长时间放电可取得一定疗效；常规选用加硬导管，部分使用温控导管，辅以适当的Ｓｗａｒｔｚ鞘管和提高导管操作技巧等有助于提高右侧壁旁道ＲＦＣＡ的成功率。     

Comparison of late results of surgical or radiofrequency catheter modification of the atrioventricular node for atrioventricular nodal reentrant tachycardia.

AIMS: Although arrhythmia surgery and radiofrequency catheter ablation to cure atrioventricular nodal reentrant tachycardia differ in technical concept, the late results of both methods, in terms of elimination of the arrhythmogenic substrate and procedure-related new and different arrhythmias, have never been compared. This constituted the purpose of this prospective follow-up study. METHODS AND RESULTS: Between 1988 and 1992, 26 patients were surgically treated using perinodal dissection or 'skeletonization', and from 1991 up to 1995, 120 patients underwent radiofrequency modification of the atrioventricular node for atrioventricular nodal reentrant tachycardia. The acute success rates of surgery and radiofrequency catheter ablation were 96% and 92%, respectively. Late recurrence, rate in the surgical and radiofrequency catheter ablation groups was 12% and 17%, respectively. Mean follow-up was 53 months in the surgical group and 28 months in the radiofrequency catheter ablation group. The final success rate after repeat intervention was 100% in the surgical group and 98% in the radiofrequency catheter ablation group. Comparison of the initial and recent series of radiofrequency catheter ablated patients showed an increased initial success rate with fewer applications. In the radiofrequency catheter ablation group, a second- or third-degree block developed in three patients (2%), requiring permanent pacing, whereas in the surgical group no complete atrioventricular block was observed. Inappropriate sinus tachycardia needing drug treatment was observed in 13 patients (11%), mostly after fast pathway ablation, but was never observed after surgery. New and different supraventricular tachyarrhythmias arose in 27% of the patients in the surgical group and in 11% of the radiofrequency catheter ablation group, but did not clearly differ. CONCLUSION: This one-institutional follow-up study demonstrated comparable initial and late success rates as well as incidence of new and different supraventricular arrhythmias following arrhythmia surgery and radiofrequency catheter ablation for atrioventricular nodal reentrant tachycardia. Today radiofrequency catheter ablation has replaced arrhythmia surgery for various reasons, but the late arrhythmic side-effects warrant refinement of technique.