射频导管消融术中心脏穿孔的原因、临床表现和处理

目的 报道8例射频导管消融术中发生的心脏穿孔，总结可能的原因、临床表现和治疗结果。方法 1991年11月至2003年5月，共4323例快速心律失常患者接受射频导管消融治疗。8例患者在消融左侧房室旁路(6例)或阵发性心房颤动(房颤)(2例)的过程发生心脏穿孔，发生率为0．19％。结果 心脏穿孔的原因包括电极导管、房间隔穿刺或消融导管引起冠状静脉窦、心房、左心室或肺静脉破裂。X线透视和超声心动图证实心包积液，7例发生心脏压塞和急性血流动力学恶化。剑突下穿刺心包6例，成功5例并抽出心包积血30～1400mL。2例患者在心包穿刺引流后，仍需外科开胸缝合穿孔。结论 心脏穿孔是射频导管消融术的严重并发症，及时发现和有效救治是十分重要的。     

心脏介入性治疗中并发急性心脏压塞的诊断与治疗体会

目的 总结心脏介入性治疗中发生急性心脏压塞诊断和处理的经验与教训。方法 回顾性分析1986年1月至2003年6月1442例心脏病介入手术导致急性心脏压塞的资料。结果 4例患者在介入治疗术中或术后即刻出现胸闷、烦躁、大汗淋漓、血压下降、心率加快或减慢，X线示心脏搏动减弱或超声心动图示心包积液，诊断为急性心脏压塞，发生率0．3％，其中1例发生在植入起搏器术后即刻，1例在二尖瓣球囊扩张行房间隔穿刺时，2例发生于射频导管消融过程中。3例经心包穿刺引流成功，1例因射频导管消融导致左心房穿孔，心包穿刺失败，未能及时开胸切开心包，患者死亡。结论 心脏病介入性治疗操作术中并发急性心脏压塞可危及生命，及时诊断与处理非常重要，心包穿刺引流是首选的方法，必要时应及时开胸切开心包减压。     

射频导管消融术心脏压塞原因、临床表现及处理

射频导管消融治疗各种心动过速是近年来心律失常治疗方法的重大进展之一 ,是一种比较安全的技术 ,心脏压塞是其严重的并发症之一。资料和方法自 1991年 1月～ 2 0 0 3年 4月连续 4 0 0 0例射频消融术(左侧旁路 16 0 0例、右侧旁路 70 6例、房室双径路 15 94例 ,心房扑动、房性心动过速 10 0例 ) ,其中 4例发生心脏压塞 ,女性 3例 ,男性 1例 ,3例穿孔位于左心室游离壁 ,1例位于右心室游离壁。电生理检查及射频消融操作程序常规放置冠状静脉窦(CS) 10极导管 ,高位右心房、右心室心尖部 (RVA)和希氏束4极导管。经RVA快速起搏和程序刺激证实…     

心律失常导管消融治疗中并发心包填塞的识别及处理

目的:总结心律失常导管消融治疗中并发心包填塞的识别及处理方法。方法:回顾性分析我院1999年12月至2017年12月连续完成的12 959例心律失常导管消融患者并发心包填塞30例患者[其中男性17例,女性13例,平均年龄(59.5±9.7)岁]的临床特点、诊断及处理方法。结果:(1)12 959例心律失常导管消融患者并发心包填塞30例,发生率0.2%;其中心房颤动(房颤)消融并发心包填塞19例,左侧旁路消融并发心包填塞6例,右心室流出道室性早搏消融并发心包填塞5例。(2)29例(96.7%)为在导管室诊断的早发心包填塞,1例(3.3%)为术后1小时发生的延迟心包填塞。(3)首诊早发心包填塞的临床表现包括主诉胸闷、胸痛2例;术中血压、心率异常11例。X线胸片显示:心影搏动减弱或消失12例;穿刺房间隔出现造影剂渗漏2例;射频消融过程中出现爆裂音2例。(4)2例患者接受药物保守治疗,其余28例均行心包穿刺引流术。共4例患者接受外科开胸手术。全部抢救成功。结论:早期识别心包填塞的临床表现,及早实施心包穿刺引流,必要时外科开胸手术是抢救成功的关键。     

射频导管消融术并发心脏压塞的临床分析

目的 通过分析射频消融术并发心脏压塞的临床特点，为预防及治疗这个并发症提供临床经验。方法 对发生心脏压塞的患者的临床资料进行回顾性分析，探讨可能的机制并提出预防措施。结果 850例接受射频消融治疗的患者中，4例发生心脏压塞。其中3例为老年患者，平均年龄67岁，1例为8岁儿童。所有患者均为左侧旁路，左前侧2例，左后侧2例。术中常规放置冠状静脉窦电极导管并经主动脉逆行插管进行射频消融，常规使用了肝素。发生心脏压塞后4例患者均给予心包穿刺，2例进行了外科开胸手术，1例经剑突下直接切开心包。术中证实2例为冠状静脉窦破裂，1例为左心室游离壁穿孔。结论 射频消融术中心脏压塞多发于左侧旁路的老年患者，冠状静脉窦破裂是最常见的原因，也与不恰当心室内导管操作及肝素使用有关。发生心脏压塞后即刻行心包穿刺是维持生命及后续治疗的必要保证。穿刺后仍不能维持血压则应尽早开放心包减压。     

心房颤动射频消融术并发急性心脏压塞心包穿刺的早期拔管临床分析

目的:分析心房颤动射频消融术并发急性心脏压塞心包引流后导管早期拔管的安全性及临床疗效。方法:回顾性分析2005年1月至2018年7月,北京安贞医院行射频消融术并发急性心脏压塞经心包引流的心房颤动患者,分为导管早期拔管组(ER组)和延迟拔管组(DR组),两组进行临床比较。结果:共纳入急性心脏压塞心包引流患者51例, ER组25例,DR组26例,两组基线特征差异无统计学意义。DR组术中心包引流量显著高于ER组[250(205,400)vs.440(310,700)mL,P=0.002]。两组术后无一例再次出现心脏压塞征象,DR组7例患者于拔管前从引流管抽出淡红色液体(≤70 mL)。术后与DR组相比,ER组胸痛率(24.0%vs.88.5%,P=0.000)、发热率(24.0%vs.69.2%,P=0.001)、恶心发生率(零vs.42.3%,P=0.000)、术后院内心房颤动复发率(16.0%vs.50.0%,P=0.010)、抗生素使用率(52.0%vs.84.6%,P=0.012)均较低,重启抗凝治疗[15.5(11.4,21.9)vs.26.8(16.1,36.0)h,P=0.009]较早,术后住院时间[3(2,3)vs.5(3,9)d,P=0.001]较短。结论:心房颤动射频消融于导管并发急性心脏压塞心包引流后,导管早期拔管是安全的,显著改善术后患者的医疗和生活质量,缩短术后住院日,临床上值得借鉴和推广。     

经皮冠状动脉介入治疗并发急性心脏压塞的临床分析

目的:分析8例经皮冠状动脉介入治疗(PCI)并发的急性心脏压塞原因、临床表现和治疗结果。方法:2005年1月至2008年12月对5 241例冠心病患者进行了PCI术,8例患者并发急性心脏压塞。采用心包穿刺引流术处理,无效时采用外科手术。结果:急性心脏压塞的发生率为0.15%。8例患者早期均表现为胸闷、血压下降。7例患者行紧急心包穿刺引流,其中2例因引流后仍继续出血而行外科修补手术。1例患者未行心包穿刺引流死亡。结论:急性心脏压塞是PCI术的严重并发症,及时发现和有效救治是十分重要的。     

经皮冠状动脉介入性治疗并发急性心脏压塞15例的诊断与处理

目的 急性心脏压塞是经皮冠状动脉介入性洽疗少见但严重的并发症之一。本文旨在总结分析此并发症的诊断、处理方法与临床效果。方法 回顾分析西京医院自1992年2月至2003年5月间行经皮冠状动脉介入性治疗的2326例冠心病患者，其中确诊为心脏压塞的患者15例占同期冠状动脉介入性治疗病例的0．64％。冠状动脉介入术中或术后患者突然出现烦躁、难以纠正的低血压、心率减慢等提示心脏压塞的症状与体征，X线示心脏搏动减弱伴心影扩大，超声心动图发现心包内液性暗区、冠状动脉造影发现局部造影剂外渗漏人心包腔。除一般抢救与治疗措施外，尽快采用常规心包穿刺抽液或中心静脉导管置入法引流心包积血。采用灌注球囊或带膜支架治疗制止冠状动脉出血，必要时行外科手术治疗。结果 15例心脏压塞患者中，8例在导管室行介入性治疗术中诊断，7例在术后延迟出现(30min～8h，平均4．5h)。8例患者仅行心包穿刺引流而解除心脏压塞；4例患者行灌注球囊／带膜支架治疗及心包穿刺引流后解除心脏压塞；3例病情严重者经外科处理。6例患者采用常规心包穿刺抽液方法，其中4例成功解除心脏压塞，2例经外科处理成功；9例患者采用中心静脉导管置入法，其中8例成功解除心脏压塞，1例经外科处理。结论 急诊床旁超声心动图和X线检查对于诊断冠状动脉介入治疗并发的急性心脏压塞有重要意义。心包穿刺引流是解除心脏压塞的首选治疗方法，中心静脉导管置入引流法是一种快速、安全、准确的方法。灌注球囊、带膜支架治疗及外科手术是处理心脏压塞的重要措施。     

积极仔细地处理急性心脏压塞

急性心脏压塞是心脏病介入性诊断和治疗最严重的并发症之一 ,若处理不当可致患者死亡或呈植物人状态等严重后果 ,但若能做到及时诊断和果断处理 ,绝大多数患者可以转危为安 ,且无需开胸手术。心律失常射频导管消融术中发生的急性心脏压塞多与导管操作粗暴、经验不足有关 ,穿孔部位包括左心室、冠状静脉窦、右心室及心房等 ,经动脉逆行法消融左侧旁路时导管操作经验不足导致左心室穿孔尤为常见。本期刊出有关射频导管消融术中急性心脏压塞的论文 1 2篇 ,提供了非常丰富的实际病例 ,旨在交流经验与教训 ,进一步提高我国心律失常射频导管消融技…     

心脏介入性治疗术并发急性心脏压塞的临床表现和处理

目的 探讨心脏介入手术并发急性心脏压塞的临床特征和防治要点。方法 回顾性分析在心脏介入治疗中并发急性心脏压塞的患者4例，并重点分析导致心脏压塞的原因。结果 4例中，经皮冠状动脉腔内成形术(PTCA)及支架置人术1例，二尖瓣球囊扩张术2例，射频消融术1例。原因是导引钢丝损伤冠状动脉分支；房间隔穿刺位置过高损伤右心房；电极导管损伤冠状静脉窦。全部病例均因及早发现心脏压塞症状并经床旁超声心动图和X线透视所证实，及时采取抢救措施，包括心包穿刺和引流，输血，输液及用升压药等，全部病例均抢救成功。结论 心脏压塞是介入性治疗中少见并发症，抢救中最重要的是及时发现，立即行心包穿刺引流等急救措施。     

Radiofrequency catheter ablation of septal accessory atrioventricular pathways.

OBJECTIVE--Septal accessory atrioventricular pathways are recognised as being more difficult to ablate than pathways in other locations. This paper describes an experience of 48 consecutive patients with septal accessory pathways who had catheter ablation with radiofrequency current. PATIENTS AND METHODS--There were 28 male and 20 female patients, mean (SD) age 35 (17). 43 patients had a single accessory pathway and 5 patients had multiple accessory pathways. Pre-excitation was present in 37 patients, and 11 patients had concealed accessory pathways. 21 patients had had a previous electrophysiological study. Catheter ablation was undertaken with radiofrequency current delivered by a standard unipolar technique or by delivery of current across the septum (the bipolar technique). RESULTS--The median total procedure time was 167 (83) minutes including a 30-40 minute observation period after the abolition of conduction by the accessory pathway. The median total fluoroscopic time was 56 (30) minutes. 42 (88%) out of 48 patients had successful ablation of the pathway during the first session. In the six patients in whom the procedure failed, five had a midseptal pathway and one had a right anteroseptal pathway. A second attempt at ablation was made in two patients and succeeded in both. In total, 49 accessory pathways were successfully ablated in 44 (92%) out of 48 patients. The bipolar technique was used in 11 patients and succeeded in 10 patients. Standard unipolar current delivery had previously failed in seven of the 11 patients. Complications developed in two patients with a mid septal pathway (one with complete atrioventricular block and the other with a small pericardial effusion). CONCLUSION--Radiofrequency catheter ablation of septal accessory pathways is efficacious and safe. The procedure time can be shortened and success rate can be increased after improvement of the technique--that is, consideration of a bipolar approach for energy delivery in difficult cases.     

Radiofrequency ablation of multiple accessory pathways.

The aim of the study was to review the clinical and electrophysiological characteristics and results of radiofrequency catheter ablation in patients with multiple accessory pathways to compare them with those of patients with single accessory pathways. Electrophysiological study and radiofrequency catheter ablation were performed in 1010 consecutive cases with Wolff Parkinson White Syndrome. Presence of multiple accessory pathways was documented in 31 patients (3.1%); 30 had two, and 1 had three accessory pathways. Of the 63 accessory pathways, 42 were manifest and 21 concealed. Nine patients had Ebstein's anomaly associated with atrioventricular bypass tracts. The most common combination was right posteroseptal with right free wall bypass tracts (15 patients with 30 accessory pathways). Fifty-one of the sixty-three accessory pathways (81%) were ablated successfully without complications. The duration of the procedure was 100 +/- 58 min and the fluoroscopic time 40 +/- 17 min. A follow up of 5 +/- 3 years after ablation, demonstrated recurrences of six accessory pathways (9.5%). In conclusion, patients with multiple accessory pathways can be treated by radiofrequency ablation in only one session with a high success rate although slightly less than that in patients with a single accessory pathway (81% vs 93%, P<0.01).     

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.     

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.     

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.     

Transesophageal echocardiographically guided atrial transseptal catheterization in patients with normal-sized atria: Incidence of complications

The incidence of cardiac complications from atrial transseptal catheterization has never been quantified in patients with normal-sized atria. Series defining the complication rate are derived from diseased hearts with structural changes that may alter the complication rate of the procedure. The generation of a standardized incidence of perforation in a population of structurally normal atria has important implications. A total of 46 atrial transseptal catheterizations guided by transesophageal echocardiography (TEE) for radiofrequency ablation of left-sided accessory pathways was performed in 42 patients during a 3-year period (1990–1993). Clinical and echocardiographic data were analyzed, with special attention given to TEE reports pre- and post-transseptal catheterization. Only one complication occurred in the 46 procedures (2.2%): a perforation of the left atrium that led to pericardial effusion and cardiac tamponade. In a small series of patients with normal sized atria, we have demonstrated that TEE-guided transseptal catheterization is a procedure with a low complication rate.     

心脏介入性治疗并发心脏压塞的原因分析、诊断与治疗

目的总结心脏介入性治疗过程中发生心脏压塞诊断和处理的经验和教训。方法回顾分析快速性心律失常射频消融术、经皮冠状动脉腔内成形术(PTCA)及支架术以及先天性心脏病封堵术中心脏压塞的临床特点、诊断及处理。结果18例与心脏介入性诊治操作有关的心脏压塞患者,17例为急性心脏压塞,1例在术后72小时延迟出现。18例中9例与射频消融术有关;5例与PTCA有关;3例与先天性心脏病房间隔缺损修补术有关;1例与临时起搏器安装术有关。共有3例死亡。结论心脏介入性治疗可引起即刻和迟缓性两类心脏压塞,多与操作不当有关。及时诊断与处理非常重要,心包穿刺引流是首选方法,必要时应及时切开心包减压或开胸修补。     

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。     

Profile of cardiac tamponade in the medical emergency ward of a North Indian hospital.

OBJECTIVE: To determine the profile of patients presenting to the medical emergency ward with cardiac tamponade. DESIGN: Retrospective observational study. SETTING: Tertiary care hospital in North India. PATIENTS: Thirty patients (19 men and 11 women) presenting to the medical emergency ward with cardiac tamponade from March 1, 1995 to March 31, 1997. MAIN RESULTS: The mean age was 36.5+/-7.6 years for the men and 34+/-12.4 years for the women. Breathlessness, fever, cough, chest pain and easy fatigability were present in 97%, 90%, 70%, 57% and 37% of patients, respectively. Etiologically, tuberculosis accounted for 60%, malignant disease for 33% and hypothyroidism for 7% of cases of cardiac tamponade. Echocardiographically guided pericardiocentesis was carried out in all patients without any complications. Six patients underwent catheter pericardial drainage and, of these, four required pericardiostomy. CONCLUSIONS: Tuberculosis ranked as the most common cause of cardiac tamponade in Northern India, followed by malignancy. Therapeutically, echocardiographically guided pericardiocentesis for cardiac tamponade is a safe and effective procedure. For those with recurrent pericardial effusions, catheter pericardial drainage is a safe option until the underlying cause can be treated or surgery planned.