经动脉逆行法射频导管消融房室结折返性心动过速

房室结折返性心动过速（AVNRT）通常在右侧Koch三角沿三尖瓣环消融慢径，需在左侧间隔部消融者罕见。现报道1例经动脉逆行法于左侧中间隔部位消融慢径成功，随访1年无复发。     

Percutaneous catheter modification of the atrioventricular node. A potential cure for atrioventricular nodal reentrant tachycardia

Our purpose was to describe a technique of atrioventricular (AV) node modification for patients with drug refractory AV nodal reentrant tachycardia (AVNRT). Nine patients (mean age, 45 +/- 20; range, 14-82) with recurrent drug refractory AVNRT (n = 8) or sudden cardiac death thought to be precipitated by AVNRT (n = 1) underwent a percutaneous catheter procedure to modify AV nodal function. The area between the electrode recording the maximal His-bundle electrogram and the ostium of the coronary sinus was divided into three zones. Perinodal direct current shocks of 100-300 J were delivered to one (n = 2), two (n = 3), or three (n = 4) zones without complications. The procedure endpoints were modification of AV conduction (either first degree AV block or complete retrograde ventriculo-atrial [VA] block) and failure to induce AVNRT before or after isoproterenol and/or atropine administration. Six of nine patients (67%) have had no inducible or spontaneous AVNRT over a mean follow-up of 12.3 +/- 4.1 months (range, 4.5-17). One of the six underwent repeat, successful modification, because AVNRT was inducible at restudy 2 days after the initial procedure. AVNRT recurred in three patients (33%), one early (3 days) and two late (3-4 months). Two of these patients underwent complete ablation of the AV junction and permanent pacemaker placement, whereas one is controlled with drug therapy. Therefore, AV nodal modification resulted in tachycardia control without antiarrhythmic drugs in six of nine (67%) and obviated the need for complete AV junctional ablation in seven of nine patients (78%). Elimination of AVNRT appears to result from either block in the retrograde fast pathway or modification of the antegrade slow pathway, such that AVNRT cannot be sustained. Additional findings suggest that an atrio-Hisian accessory connection may not be involved in AVNRT in some of these patients. Percutaneous catheter AV nodal modification appears to be a promising technique for treatment of refractory AVNRT and may obviate need for complete AV junctional ablation in a substantial number of patients with drug/pacemaker refractory AVNRT.     

房室结折返性心动过速射频消融术后复发机制探讨

目的: 探讨房室结折返性心动过速射频消融术后复发原因。方法: 对356 例房室结折返性心动过速患者射频消融术后进行随访,回顾性分析其电生理资料。结果: 356例中10例复发,复发率2.8%,320例患者射频术后无心房回波,无跳跃现象,一直未复发;术后有心房回波无跳跃现象未诱发出室上速17例,其中3例复发;术后有跳跃及心房回波未诱发出室上速11例,其中5例复发;术后有跳跃无心房回波未诱发出室上速8例,2例复发。10例复发患者,第2次射频消融术后房室结不应期均较第1次术后延长,且与术前快径不应期差值明显减小,第2次射频消融术后随访至今（>9个月）,无1例复发。结论: 慢径残存是房室结折返性心动过速射频消融术后复发的主要原因。     

三维标测引导房室结折返性心动过速射频消融的疗效及其优势

目的 观察Ensite Navx三维标测引导射频消融治疗房室结折返性心动过速(AVNRT)的有效性及安全性。方法 射频消融治疗AVNRT患者213例,将其分为三维标测组（101例）和常规治疗组（112例）,三维标测组在Ensite Navx三维标测系统引导下,必要时联合短暂X线透视进行射频消融;常规治疗组在传统X线透视下行射频消融治疗。观察指标:①放置标测导管过程中X线曝光时限和射线剂量;②操作消融导管进行建模消融过程中X线曝光时限和射线剂量;③手术时间;④即刻成功率与总体成功率;⑤并发症的发生率（血气胸、心脏压塞、III度房室传导阻滞）。结果 ①放置标测导管过程中两组的X线曝光时间、曝光剂量分别为:三维标测组(2.3±1.3)min、(1.7±1.1)mGy,常规治疗组（2.4±1.1）min、（1.6±1.0）mGy,二者无统计学差异;②操作消融导管消融过程中,三维标测组X线曝光时间、曝光剂量为:（2.6±1.8）min、（3.5±1.8）mGy,显著低于常规治疗组的（8.9±2.0）min、（11.8±2.6）mGy(均P<0.01);③手术时间:三维标测组、常规治疗组分别为（48±16）min,（47±13）min,无显著差异;④术中两组患者均消融成功;术后随访6个月,三维标测组无复发病例,常规治疗组有1例复发,在Ensite Navx三维标测系统引导下再次消融成功,两组总体成功率无显著差异;⑤并发症:射频术中两组均未出现相关并发症。结论 应用Ensite Navx三维标测引导射频消融能够治疗AVNRT安全有效,且不增加手术时间和并发症,X线曝光时间、曝光剂量显著降低。     

射频消融治疗儿童房室结折返性心动过速的体会

目的　讨论射频消融术 (RFCA)治疗儿童房室经折返性心动过速的体会。方法　 1992年 3月至 2 0 0 1年 12月 ,应用射频消融术 (RFCA)治疗儿童房室结折返性心动过速共 5 2例 ,男 3 0例 ,女 2 2例 ,平均年龄 (8 4± 3 2 )岁 (3 5～15岁 )。全部病例均行食道心房调搏术及心内电生理检查 ,选择消融慢径路。结果　食道心房调搏术S2 R跳跃延长(63 1± 10 3 )ms(5 0～ 110ms) ,心内电生理检查AH跳跃延长 (5 2 4± 15 8)ms(3 0～ 10 5ms)。总消融成功率 97 6% ,输出功率 (18 2± 3 2 )W ,放电次数 (12 1± 4 2 )次 ,手术时间(1 5± 0 5 )h ,X线曝光时间 (18 5± 5 4)min。结论　射频消融术治疗儿童房室结折返性心动过速是安全、有效的 ,但应严格掌握适应证     

磁导航系统在房室结折返性心动过速导管射频消融中的应用

目的评价磁导航系统对房室结折返性心动过速导管射频消融的指导作用。方法将经过心内电生理检查确诊的房室结折返性心动过速患者随机分为两组,A组采用常规技术和4mm温控导管消融,B组采用磁导航系统和温控磁大头导管消融。两组各入选10例患者,其年龄、性别、心动过速病史和基础心血管疾病具有可比性。比较两组患者如下参数：消融操作时间、患者透视时间、术者透视时间、放电次数、消融能量、成功率、并发症、手术费用。结果两组患者全部一次消融成功,无并发症,术后住院时间相同,随访（7.1±1.4）个月,无心动过速复发。磁导航消融组的操作时间、患者和术者透视时间、放电次数和实际消融能量均明显低于常规消融组,但手术费用高于常规消融组。结论采用磁导航系统指导房室结慢径路导管射频消融能明显缩短消融操作时间及患者和术者的透视时间,减少放电次数,降低实际消融能量。     

经上腔静脉途径行房室结慢径消融24例疗效分析

经股静脉途径行房室结慢径消融(RFCA)术后常需压迫止血、卧床制动等有可能引起下肢静脉血栓等并发症。为此,我院从2007年始开展经上腔静脉途径行房室结慢径消融术,现报道如下。1资料和方法1.1病例选择选择我院2007—2011年临床上有阵发性     

快慢型房室结折返性心动过速的电生理机制和经导管射频消融

目的探讨快慢型房室结折返性心动过速(AVNRT)的电生理机制和经导管射频消融。方法快慢型AVNRT消融患者42例。消融方法为在心室起搏或心动过速时标测最早逆传慢径心房激动部位,然后在窦性心律下或心动过速时消融。消融成功的标准为消除逆传慢径、1:1前传慢径及不能诱发任何类型AVNRT。结果所有42例均消融成功。逆传慢径消融成功部位在三尖瓣环和冠状静脉窦(CS)口之间(传统慢径区域)36例(86%),其最早逆传心房激动也位于上述区域;逆传慢径在CS近端或/和二尖瓣环心房侧消融成功6例(14%),其最早逆传心房激动多位于CS近端1～3cm处。结论多数快慢型AVNRT可在传统慢径区域(房室结右侧后延伸)消融成功,但部分病例需要在CS近端和/或二尖瓣环房侧(左侧后延伸)消融成功。     

Laser catheter ablation of atrial flutter and of atrioventricular nodal reentrant tachycardia in a single session

This report describes an adolescent with refractory atrial flutter(AF) and atrioventricular (AV) nodal reentrant tachycardia whowas cured by Nd: YAG, 1064 nm, laser application. Two impactsof 30 s each (power 30 W and irradiated spot diameter 2.0–2.5mm), applied via a novel laser catheter system, abolished bothAF and AV nodal reentrant tachycardia. The procedure was withoutcomplications or recurrent arrhythmias.     

儿童房室结折返性心动过速患者经冷冻消融和射频消融的结果比较

目的 比较经导管冷冻消融和射频消融治疗儿童房室结折返性心动过速（AVNRT）的临床效果。方法 73例年龄在18岁以下，诊断为AVNRT的患者入选本研究，根据治疗方法分为冷冻消融组（冷冻组）和射频消融组（射频组），记录并分析比较两组的临床特点、冷冻标测次数、消融次数、X线曝光时间、消融术总时间、成功率、并发症发生率以及复发率。结果 共73例患者入选，冷冻组33例，男性16例，女性17例，平均年龄（12．4±2．8）岁；射频组40例，男性18例，女性22例，平均年龄（13．6±2．2）岁。冷冻组和射频组的消融次数分别为（2．7±1．7）次和（11±6．3）次（P〈0．001），X线曝光时间分别为（20±7）min和（25±9）min（P〈0．05），消融术总时间分别为（214±33）min和（164±36）min（P〈0．05），消融成功率88％（29／33）对100％（40／40）（P〈0．01），一过性房室阻滞的并发症发生率为12％对2．5％（P〈0．01）。冷冻组所有术中发生的传导阻滞均在5min内恢复。两组的复发率差异无统计学意义（6％与2．5％，P=NS）。结论 经导管冷冻消融治疗儿童AVNRT安全有效，但成功率低于射频消融，目前可作为后者的一种补充。     

射频消融治疗房室结或房室折返性心动过速的多中心随机临床试验

目的 通过与国外进口温控射频消融导管的比较,评价国产温控射频消融导管在房室结折返性心动过速(AVNRT)和房室折返性心动过速(AVRT)的临床疗效和安全性.方法 自2008年6月至11月共入选AVNRT或AVRT患者1342例.采用多中心随机平行对照开放试验设计,应用解放军第四军医大学设计的最小化随机统计方法进行动态随机分为二组,国产导管组应用国产温控射频消融导管,进口导管组应用强生或圣犹达等公司的进口温控射频消融导管.采用常规方法在X线透视下进行心内电生理检查和射频消融.结果 国产导管组672例,即时消融成功率97.9%,进口导管组670例,即时消融成功率99.1%,两组成功率均达到96.0%以上,差异无统计学意义.国产导管组与进口导管组的手术时间[(68±36)min与(67±34)min]、曝光时间[(14±14)min与(10±11)min]、放电次数[(4.5±4.5)次与(4.6±3.9)次]、放电时间[(260±218)s与(257±207)8]、导管性能总体评分[(4.4±0.5)分与(4.5±0.4)分],两组间差异均无统计学意义.发生并发症3例,均为心包积液(国产导管组1例,进口导管组2例),经心包穿刺引流后转为正常出院,差异无统计学意义.随访3个月,复发30例,分别为国产导管组14例、进口导管组16例(2.1%与2.4%),差异无统计学意义.结论 国产温控射频消融导管可安全有效治疗AVNRT或AVRT.     

Radiofrequency ablation in a patient with atrioventricular reentrant tachycardia and atrioventricular nodal reentrant tachycardia with 2:1 atrioventricular block.

The authors report the case of 15-year-old girl with a history of palpitations and shortness of breath during exercise. The electrocardiogram showed ventricular preexcitation suggesting a Wolff-Parkinson-White syndrome with a posteroseptal accessory pathway. During the electrophysiological study a left posterospetal accessory pathway was identified and an orthodromic atrioventricular reentry tachycardia was reproducibly induced (cycle length 400 ms). After disappearance of the ventricular pre-excitation with radiofrequency ablation, a dual physiology of atrioventricular node condution was documented and a slow-fast atrioventricular nodal reentrant tachycardia was repeatedly induced. Upon induction, this tachycardia presented a proximal atrioventricular block with 2:1 condution converted to 1:1 condution with overdrive pacing from the proximal coronary sinus (cycle length 270 ms). Radiofrequency ablation of the slow pathway was performed with success. We discuss the need to suspect and seek different arrhythmogenic substracts of tachycardia in a single patient, the electrophysiologic conditions that could explain the inducibility of different arrhythmias in this case, and the controversy regarding ablation of more than one reentry circuit in a single procedure.     

复杂心脏畸形伴房室结折返性心动过速的射频消融（附二例报告）

报告２例先天性复杂心脏畸形伴房室结双径路患者在心脏直视手术前作房室结折返性心动过速的射频消融。例１为先心病紫绀型、法乐氏四联症伴无肺动脉瓣综合征，慢径消融靶点在希氏束上１ｃｍ。例２为先心病紫绀型、三尖瓣闭锁、单心房，慢径消融靶点在冠状窦口和希氏束电极之间中下１／３处。消融术后安全渡过了心脏手术和围术期，随访４～１２个月无心动过速发作，本文探讨了消融终点判定，复杂畸形的房室结定位和心脏直视手术前消融房室结折返性心动过速的意义。     

Predictors of long-term success in catheter ablation of atrioventricular nodal reentrant tachycardia: a multivariate regression analysis

BACKGROUND: To investigate the predictors of long-term success after catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT). METHODS: One-hundred and fourteen consecutive patients underwent slow pathway ablation using anteroseptal (n=24), midseptal (n=65) and posteroseptal approach (n=25). The correlation between ablation approaches, electrophysiological characteristics during and after ablation and the recurrence rate of AVNRT was analyzed by a multivariate regression analysis. RESULTS: During ablation, transient AV block in the anteroseptal, midseptal and posteroseptal approach occurred in 8.3, 4.6 and 0%, respectively (P<0.01). AVNRT recurred in seven patients after 5 years follow-up. Five recurrences (20.8%) were from anteroseptal approach group and two (3.1%) were from midseptal approach group. Multivariate regression analysis revealed that anteroseptal ablation approach and residual dual atrioventricular nodal pathway following apparently successful ablation were the predictors for recurrence of AVNRT (R=0.645, P<0.001). CONCLUSION: Anteroseptal approach of slow pathway ablation is associated with a higher incidence of transient AV block and AVNRT recurrence than other approaches. Residual dual atrioventricular nodal pathway after apparently successful ablation also carries a high risk of recurrence.     

Cryoablation versus radiofrequency ablation of atrioventricular nodal reentrant tachycardia

Background

Ablation of the slow pathway is an established cure for atrioventricular nodal reentrant tachycardia (AVNRT). Periprocedural damage to the conduction system is a major concern during AVNRT ablation, and cryoablation (CRYO) has been suggested to improve the procedural safety compared to standard radiofrequency (RF) ablation, without reducing the procedural success.

Objective

We performed a systematic review and meta-analysis of studies comparing CRYO with RF ablation of AVNRT.

Methods

We searched PubMed, CENTRAL, the BioMed Central, EMBASE, CardioSource, clinicaltrials.gov, and ISI Web of Science (January 1980 to July 2013). No language restriction was applied. Two independent reviewers screened titles and abstracts to identify studies that compared the procedural outcomes of AVNRT ablation with either CRYO or RF energy. Two independent reviewers assessed the risk of bias according to the Cochrane Collaboration, and extracted patient, study characteristics, and procedural outcome data. Results are expressed as odds ratio (OR) or as weighted mean difference (WMD) with their 95 % confidence interval (CI).

Results

Fourteen studies (5 prospective randomized and 9 observational) with 2,340 patients (mean age range 13 to 53 years, 1,522 (65 %) females) were included in the analysis. RF ablation was performed in 1,262 (54 %) patients, while CRYO in 1,078 (46 %) patients. Acute success (abolition of dual atrioventricular node physiology or single echo beats) was achieved in 88 % of patients treated with RF versus 83 % of those treated with CRYO (OR?=?0.72, 95 % CI 0.46 to 1.13; P?=?0.157). RF ablation was associated with shorter total procedure time (WMD?=??13.7 min, 95 % CI ?23 to ?4.3 min; P?=?0.004), but slightly longer fluoroscopy time (WMD?=?+4.6 min 95 % CI +1.7 to +7.6 min; P?=?0.002). Permanent atrioventricular block occurred in 0.87 % RF cases and in no CRYO case (OR?=?3.60, 95 % CI 1.09 to 11.81; P?=?0.035). Over a median follow-up of 10.5 months (range 6 to 12 months), freedom from recurrent AVNRT was 96.5 % in the RF group versus 90.9 % in the CRYO group (OR?=?0.40, 95 % CI 0.28 to 0.58; P?<?0.001). At meta-regression analysis, no clinical or procedural variable had a significant interaction with the results above.

Conclusions

In patients undergoing AVNRT ablation, RF significantly reduces the risk of long-term arrhythmia recurrence compared to CRYO, but is associated with a higher risk of permanent atrioventricular block.     

Radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia in children aided by the LocaLisa mapping system.

AIMS: In young patients, slow pathway ablation for treatment of atrioventricular nodal reentrant tachycardia (AVNRT) carries a small but definite risk of permanent AV block. The aim was to assess the efficacy of slow pathway ablation aided by the LocaLisa mapping system. PATIENTS AND METHODS: Radiofrequency (RF) modification of the slow AV nodal pathway was performed in 26 children < 19 years of age (median age 9.8 years, range 3-18.9). Three measures to limit the risk of AV block were applied: (1) use of LocaLisa, a non-fluoroscopic mapping system, to determine and mark the location of the AV node/His bundle axis, and monitor ablation catheter position, (2) continuous atrial stimulation during RF delivery to monitor AV conduction, and (3) gradual increase of RF power during RF ablation. RESULTS: AVNRT was rendered non-inducible in all patients. Dual AV physiology was abolished in 24/26 patients; 2 patients had single atrial echoes at the end of the procedure. At follow-up, AVNRT recurred in 3 patients (including the above 2), necessitating a second procedure. The median number of RF applications was 4 (3-8); median fluoroscopy time was 16 (7-33)min. One patient developed transient second-degree AV block, with full recovery within 6 weeks of the procedure. CONCLUSIONS: RF modification of the slow AV nodal pathway in children can be safely accomplished, achieving the ideal end-point of abolishing dual AV physiology, aided by use of the LocaLisa mapping system.