左侧游离壁旁路消融中阻滞左心房峡部导致沿二尖瓣环左心房内传导阻滞

目的 探讨在左侧游离壁房室旁路(AP)射频消融中发生沿二尖瓣环心房激动顺序明显改变，且能排除多条AP和其它机制所致心动过速病例可能的电生理机制。方法 240例左侧AP患者，经逆行主动脉途径行射频消融，对在消融中发生明显心房激动顺序改变，且能排除多条AP的患者进行分析。结果 在240例左侧AP患者的消融中，5例(2％)出现沿二尖瓣环(冠状静脉窦电极导管)心房逆传顺序明显改变，此5例患者均为左后上AP(距冠状静脉窦口≥5．0cm，以往称为左前AP)，占全部58例左后上AP消融病例的9％。尽管消融中出现沿二尖瓣环心房逆传顺序明显改变，但左后上AP仍然存在，5例均可诱发心动过速，酷似多条AP或房室结快径逆传。5例均有经主动脉逆行途径在二尖瓣环左心房侧反复消融的过程，而在消融中发生心房逆传顺序改变，5例最终消融成功靶点距冠状静脉窦口5．5～7．0cm(平均6．4cm)。结论 在左后上AP射频消融中阻滞左侧峡部(二尖瓣环和左下肺静脉之间)可以导致明显的沿二尖瓣环心房逆传顺序改变，在二尖瓣环更靠后上侧可成功消融此AP。     

左侧房室旁道消融过程中伴发的二尖瓣峡部阻滞

目的评估房室旁道消融过程中二尖瓣峡部阻滞的发生率,并探讨其电生理特性。方法以2003年7月至2011年1月本中心接受射频消融治疗的左侧房室旁道患者为研究对象,分析旁道分布特点、手术方法、手术时间、成功率及术中峡部阻滞的影响因素,探讨不同类型峡部阻滞的电生理特性。结果在402例患者中共有8例出现峡部阻滞现象(2.0%)。峡部阻滞多数出现于左侧游离壁旁道消融过程(87.5%);多于房间隔穿刺法消融术中出现(87.5%);其手术时间更长[(213.6±36.5)min vs(76.4±23.5)min,P0.05],更可能是再次接受射频消融治疗患者(62.5%vs 1.5%,P0.05)。术中峡部阻滞时可出现冠状窦电极VA间期延长或心房激动顺序改变,但局部His束电极上VA间期及心动过速周长不变;旁道附近的VA间期不变。结论左侧旁道消融过程中可伴发二尖瓣峡部阻滞,并有其相应电生理特性。     

左侧旁道消融伴发二尖瓣峡部阻滞的临床观察

目的:探讨经房间隔途径行左侧旁道射频消融过程中,不经意二尖瓣峡部阻滞发生的解剖机制及电生理特征。方法:回顾性分析2016年1月至2018年1月贵州省人民医院单中心收治的左侧旁道并房室折返性心动过速患者,研究纳入经房间隔途径行左侧旁道射频消融患者共59例,经股静脉途径送入二极电极至右心室,经左锁骨下静脉或右股静脉送入十级电极至冠状窦。行心房及心室期前刺激,递减刺激及快速刺激诱发心动过速,必要时静滴异丙肾上腺素辅助诱发。经房间隔顺行性途径送入消融电极至左心房室环标测房室旁道,行射频消融治疗。并对消融过程中发生二尖瓣峡部阻滞的患者进行电生理研究并探讨可能发生机制。结果:59例经房间隔途径消融的左侧旁道患者中,4例患者消融过程中发生二尖瓣峡部阻滞,发生率约6.8%。其中3例患者二尖瓣峡部阻滞后心动过速周长不变,体表心电图节律整齐;1例患者二尖瓣峡部阻滞后心动过速周长长短不等,体表心电图心动过速发作频率减慢,节律完全不整齐。4例患者消融过程中二尖瓣峡部阻滞均表现为冠状窦电极室房逆传间期延长,心动过速未能终止,激动顺序由离心性传导转为向心性传导,经调整消融电极至原消融部位更远端消融成功。结论:左侧旁道消融过程中可能不经意导致二尖瓣峡部阻滞,其发生率低。掌握其心内电生理特征及心内电图的变化有助于缩短手术时间,避免无效消融。     

射频消融治疗左侧隐匿性旁道伴发二尖瓣峡部阻滞一例

正1临床资料62岁女性,反复心悸3年余,加重3 d。静息心电图(图1A)未见预激波,发作心电图可见RP’间期约90 ms(图1B),考虑房室旁道可能性大。余辅助检查未见明显异常。心内电生理检查及射频消融术治疗:术中右心室S1S1 450 ms刺激(图2A)以及心动过速发作时(图2B)冠状静脉窦(CS)心房波(A波)逆传呈偏心性,其中CS远端(CS1-2)可见心室波(V波)与逆     

穿房间隔途径左侧游离壁旁路消融致心包填塞原因分析

目的:分析穿房间隔途径左侧游离壁旁路消融致心包填塞的发生率及可能原因。方法:分析2014年1月～2018年12月3个中等手术量电生理中心的1 332例室上性心动过速患者,其中男性723例,女性609例,中位年龄52 (35～61)岁。经电生理检查证实为房室结双径路折返性心动过速、左侧旁路参与的房室折返性心动过速或右侧旁路参与的房室折返性心动过速,然后再行房室旁路或者房室结双径路消融。分析左侧旁路参与的房室折返性心动过速患者,经主动脉逆行途径或者穿房间隔途径消融左侧旁路消融过程中心包填塞发生情况及可能原因。结果:1 332例患者接受1 440次射频消融术。左侧旁路参与的房室折返性心动过速453(34%)例,其中经主动脉逆行140例(31%)和穿房间隔途径313例(69%)。穿房间隔途径心包填塞发生3例(0.9%),靶点位置在左侧游离壁或左前游离壁。经心包穿刺引流后心包填塞症状缓解,无外科开胸修补发生。结论:左侧旁路射频消融相关的心包填塞发生率相对较低,原因可能与过度消融、机械操作损伤和误消融毗邻结构相关。     

经冠状静脉窦射频消融左侧游离壁心外膜旁路一例

患者冯某,男性40岁,因22年前剧烈活动后,出现心慌、胸闷,休息5～10 min自行缓解,后反复发作心悸,心电图诊断为室上性心动过速.近几年来,心动过速发作频繁,持续时间逐渐延长,发作频率达210次/分,发作时血压降至90/60 mmHg,伴心慌、胸闷、气短、恶心、呕吐,持续3～4 h不能缓解.曾到多家医院诊治,用药效果不佳,后在国内某大医院住院行射频消融治疗,诊断为左侧隐匿旁道,先后进行两次射频消融手术(包括穿间隔行射频消融治疗).     

射频消融治疗二尖瓣置换术后伴发隐性左侧旁路

目的本文报告3例风湿性心脏病二尖瓣人工机械瓣膜置换术后伴发左侧隐性旁路的射频消融治疗的经验.     

射频导管消融阻断二尖瓣环-左下肺静脉峡部导致左心房激动顺序改变一例

报道 1例在经房间隔途径消融左侧房室旁路过程中 ,位于二尖瓣环与左下肺静脉 (ＭＶ ＬＩＰＶ)之间的峡部被消融阻断 ,导致左心房激动顺序变化。患者女性 ,32岁。预激综合征病史 6年。入院体格检查、Ｘ线胸片和超声心动图未发现器质性心脏病。根据心电图上δ波和ＱＲＳ波向量 ,判断为左侧游离壁显性旁路。穿刺股静脉后 ,将 3根 4极导管放置于高位右心房、希氏束部位、右心室心尖部。经右颈内静脉将 10极导管送入冠状静脉窦 ,双极法 (按近端至远端的次序 ,5对电极依次为ＣＳ5、ＣＳ4 、ＣＳ3、ＣＳ2 、ＣＳ1,图 1)标测和记录左心房后壁的激动…     

二尖瓣峡部的解剖及射频导管消融

射频导管消融电隔离肺静脉是目前治疗心房颤动（房颤）的主要方法之一。然而单纯电隔离肺静脉的患者中有20％～40％的复发率,为了提高房颤射频导管消融的成功率,在成功电隔离肺静脉后,加左心房关键部位线（如顶部线、二尖瓣峡部线）的消融提高了房颤消融的成功率。     

经主动脉逆行至二尖瓣环房侧消融左侧房室旁路的方法学探讨

目的:探讨经主动脉逆行至二尖瓣环房侧消融左侧旁路的可行性。方法:左侧旁路消融病例159例,消融导管均经主动脉逆行置入,于二尖瓣环房侧或室侧进行消融。根据消融部位分组,记录手术时间、曝光时间、放电功率、放电次数等参数,并进行对比研究。结果:所有病例均获得了手术成功,其中2例首次消融后复发,而接受了再次手术,故共完成了161次手术,消融了165条左侧旁路。其中109条旁路(66.1%)于房侧消融成功。比较房侧及室侧消融病例各项参数,前者最大放电功率大于后者(P<0.01),而手术时间、曝光时间及放电次数均差异无统计学意义(P>0.05)。2例复发病例首次手术时均于室侧消融,再次手术时于房侧消融,未再复发。结论:经主动脉逆行至二尖瓣环房侧消融左侧旁路这一方法可提高左侧旁路消融成功率及降低复发率,并在多数情况下可取代经房间隔穿刺消融的方法。     

Block of the mitral-pulmonary isthmus during ablation of a single left-sided accessory pathway causing different patterns of retrograde atrial activation

The case of a 16-year-old patient with atrioventricular tachycardia caused by a single left anterolateral accessory pathway is reported. When the patient underwent radiofrequency ablation, a lesion on the mitral annulus lateral wall produced changes in the retrograde atrial activation pattern determined by that pathway; changes ranged from a delay in depolarization of the annulus posterior portions to full left atrium counterclockwise activation. Such phenomena were probably caused by a block in the isthmus between the annulus and the lower left pulmonary vein ostium. This case illustrates the importance of the mitral-pulmonary isthmus in the process of left atrium activation, an alert to changes induced by its unintentional block during accessory pathway ablation.     

Intra-atrial conduction block along the mitral valve annulus during accessory pathway ablation: evidence for a left atrial "isthmus"

INTRODUCTION: We observed a change in the atrial activation sequence during radiofrequency (RF) energy application in patients undergoing left accessory pathway (AP) ablation. This occurred without damage to the AP and in the absence of a second AP or alternative arrhythmia mechanism. We hypothesized that block in a left atrial "isthmus" of tissue between the mitral annulus and a left inferior pulmonary vein was responsible for these findings. METHODS AND RESULTS: Electrophysiologic studies of 159 patients who underwent RF ablation of a left free-wall AP from 1995 to 1999 were reviewed. All studies with intra-atrial conduction block resulting from RF energy delivery were identified. Fluoroscopic catheter positions were reviewed. Intra-atrial conduction block was observed following RF delivery in 11 cases (6.9%). This was evidenced by a sudden change in retrograde left atrial activation sequence despite persistent and unaffected pathway conduction. In six patients, reversal of eccentric atrial excitation during orthodromic reciprocating tachycardia falsely suggested the presence of a second (septal) AP. A multipolar coronary sinus catheter in two patients directly demonstrated conduction block along the mitral annulus during tachycardia. CONCLUSION: An isthmus of conductive tissue is present in the low lateral left atrium of some individuals. Awareness of this structure may avoid misinterpretation of the electrogram during left AP ablation and may be useful in future therapies of atypical atrial flutter and fibrillation.     

Persistent inappropriate sinus tachycardia after radiofrequency ablation of left lateral accessory pathway

A patient with palpitations and narrow QRS tachycardia was evaluated. In the EP study an atrioventricular reentrant tachycardia mediated by a left lateral accessory pathway was identified and catheter ablation was performed with success. A week later she returned with palpitations and pre-syncope. The resting ECG showed a sinus tachycardia with 110 bpm. After unsuccessful clinical treatment with beta-blockers, diltiazem and digoxin she underwent sinus node modification using radiofrequency catheter ablation with success. We postulated that RF application to ablate the lateral accessory pathway damaged the parasympathetic innervation in the left atrioventricular groove, causing inappropriate sinus tachycardia.     

Infectious mitral endocarditis after radiofrequency catheter ablation of a left lateral accessory pathway

A 2-years-old child with Wolff-Parkinson-White syndrome associated with life-threatening symptoms underwent radiofrequency ablation of a left lateral accessory pathway. A deflectable 5F bipolar electrode catheter positioned above the atrioventricular groove by transeptal approach was used for ablation. The catheters were repeatedly used after ethylene oxide sterilisation. Although immediate post-ablation echocardiography demonstrated no complications, the patient was readmitted two days later with fever and a new mitral murmur. Penicillin-susceptible Staphylococcus aureus was isolated and intravenous antibiotics were administered. In the following weeks, the patient developed constrictive pericarditis requiring surgical treatment and acute hemiplegia caused by brain embolism arising from valvular vegetation. At 5 years of follow-up the patient presents residual hemiparesia and grade II/IV mitral insufficiency.     

Acute coronary occlusion secondary to radiofrequency catheter ablation of a left lateral accessory pathway

A case of asymptomatic acute coronary occlusion secondary toradiofrequency catheter ablation of a left lateral accessorypathway is reported. Due to post-procedural ST modificationsof the surface ECG, a coronary angiography was performed whichdisclosed total occlusion of the first marginal branch of theleft circumflex coronary artery. A cute myocardial infarctionwas confirmed by moderate cardiac enzyme release, abnormal myocardialperfusion scan and mild lateral hypokinesia at echocardiographv.This rare but potentially harmful complication of interventionalelectrophysiology should be kept in mind and coronary angiographyperformed immediately when coronary occlusion related to radiofrequencyapplication is suspected.     

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。结论 心室感知S2心室程序刺激中止心动过速是鉴别房性心动过速的可靠方法，成功消融靶点A波较冠状窦标测导管最早A波提前8～22ms。     

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。