左侧房室旁道射频消融中特殊心电现象与处理对策

目的 报道24例左侧房室旁道射频消融的特殊心电现象与处理对策.方法 1例左后侧壁显性房室旁道经心内膜标测和消融不成功,改冠状静脉窦标测和消融.术中冠状静脉窭造影了解其结构.2例射频消融后旁道呈间歇性逆传.采用心室RS2刺激法进行标测与消融.6例冠状窦电极显示激动的先后顺序不明显,其中1例消融导管在二尖瓣环心室侧和心房侧均未标测到满意靶点图,多次试放电失败,最终在左中间隔消融;另5例消融导管在明显高于冠状窦电极的部位才标侧到满意靶图.10例消融导管在二尖瓣环心室侧始终未标测到满意靶点图,或反复消融仅能一过性阻断旁道,改动脉途径逆行法心房侧消融.7例心室起搏下消融不成功而采用窦性心律下放电.结果 全部病例消融成功.结论 极少数左侧房室旁道由于其特殊的电生理现象往往需采用不同的标测和消融策略.     

左侧房室旁道射频消融中特殊心电现象与处理对策

目的报道24例左侧房室旁道射频消融的特殊心电现象与处理对策。方法1例左后侧壁显性房室旁道经心内膜标测和消融不成功，改冠状静脉窦标测和消融，术中冠状静脉窦造影了解其结构。2例射频消融后旁道呈间歇性逆传，采用心室RS2刺激法进行标测与消融。6例冠状窦电极显示激动的先后顺序不明显，其中1例消融导管在二尖瓣环心室侧和心房侧均未标测到满意靶点图，多次试放电失败，最终在左中间隔消融；另5例消融导管在明显高于冠状窦电极的部位才标侧到满意靶图。10例消融导管在二尖瓣环心室侧始终未标测到满意靶点图，或反复消融仅能一过性阻断旁道，改动脉途径逆行法心房侧消融。7例心室起搏下消融不成功而采用窦性心律下放电。结果全部病例消融成功。结论极少数左侧房室旁道由于其特殊的电生理现象往往需采用不同的标测和消融策略。     

左侧房室旁道射频消融的几点体会

目前,应用射频消融术(RFCA)治疗快速性心律失常已在越来越多的医院逐步开展,为了有助于更好地开展这项工作,结合我们对左侧房室旁道射频消融治疗的资料浅谈几点体会。     

射频消融治疗前中间隔房室旁道24例

由于前中间隔旁道所处部位解剖结构复杂 ,邻近正常房室传导系统———希氏束和房室结 ,导致其电生理现象复杂 ,射频消融时造成完全房室阻滞的危险性较大 ,因此技术要求高 ,难度大[1,2 ] 。作者总结本人所完成的 2 4例前中间隔旁道射频消融术方法和经验 ,目的是为了进一步提高对该部位旁道诊断的准确性及射频消融的安全性和成功率。1　资料与方法1 1　一般资料　选自本人 1994年 1月～ 2 0 0 1年 1月在北京安贞医院 ,2 0 0 1年 9月～ 2 0 0 2年 1月在厦门心脏中心完成的2 4例前中间隔旁道患者。所有患者均因反复发作心动过速或每次发作不能自…     

多重房室旁道的射频消融策略

目的 分析我院因室上速而作电生理检查和射频消融的患者中符合多重房室旁道标准病例。根据电生理表现分类，并总结有效的消融策略。结果 在457例室上速病例中符合多重旁道诊断标准的有8例(1．75％)，其中间歇性B型预激合并左侧旁道3例；B型预激合并左旁道2例；A型预激合并左侧双旁道1例；隐匿性双侧房室旁道1例；隐匿性左侧双旁道1例，均消融成功。对消融和标测策略作了分析。结论 MAP及时诊断和成功消融的关键在于电极的正确定位和完整的电生理检查以及对可疑情况的仔细分析。对于不能稳定检出且不诱发室上速的旁道。可随访观察，以免增加病人痛苦和手术时间。     

52例右侧房室旁道射频消融治疗体会

目的 总结右侧房旁道射频消融治疗经验。方法 心内电生理检查与射频消融同时进行。结果 52例患者中经射频消融治疗最终成功51例，成功率98％。其中1例出现一过性Ⅲ度房室传导阻滞，2例出现短暂I度房室传导阻滞，其余未见其它并发症。结论 准确标定靶点电位图，是消融术成功的前提，注意详细分析心电图变化，是防止多旁道遗漏的方法。     

经房间隔经股动脉途径行射频消融左侧房室旁道疗效分析

目的 研究三维标测下经房间隔和二维下经股动脉途径行射频消融左侧房室旁道的比较分析.方法 选取2014年7月至2017年11月行射频消融的86例左侧旁道阵发性室上性心动过速患者,按患者手术方式不同,分为两组,一组是三维标测下经房间隔途径消融左侧旁道,共46例,另一组是二维下经股动脉途径消融左侧旁道,共40例.比较两组的手术时间、即刻成功率、复发率、严重并发症和X线曝光时间.结果 三维标测下经房间隔途径消融左侧旁道室上速手术时间和X线曝光时间,均明显短于二维下经股动脉途径(P<0.01).两组患者消融的即刻成功率、复发率和严重并发症差异无统计学意义(P>0.05).结论 三维标测下经房间隔消融左侧旁道室上性心动过速相比二维下经股动脉途径可明显减少手术时间和X线曝光时间,但两种方法在手术即刻成功率、复发率和严重并发症方面差异无统计学意义.     

低功率射频消融房室旁道治疗室上性心动过速13例

目的：探讨低功率射频消融房室治疗上性过动过速（室上速）的临床意义，方法：使用国产射频消顺治疗１３例室上速，采用较低的功率（１５－２５Ｗ）消融工侧旁道１２例，右侧旁道１例。结果：１３例（１３条旁道）中阻断１２条，其中左侧壁８条，左后侧壁３条，右前间隔１条，结论：低功率射频消融对心脏组织损伤轻，安全，有效，无严重并发症发生。     

右侧房室旁道射频消融治疗室上性心动过速

目的：总结右侧房室旁道经导管射频消融治疗的操作技巧。方法：采用导管射频消融阻断右侧房室旁道治疗房室折返性心动过速70例（男性29例，女性41例），其中双旁道5例。结果：70例患者中经射频消融治疗首次成功68例（97.14%），随访11个月～5年，复发6例（8.82%），5例再次成功消融，其中1例共消融3次。消融手术时间154.57&#177;73.22min，X线曝光时间15.17&#177;11.33min。有2例患者出现完全性房室传导阻滞。结论：射频消融治疗右侧房室旁道成功率较高，准确的靶点定位及导管和靶组织的稳定接触是减少复发的关键，希氏束旁旁道的消融易并发房室传导阻滞，需更加注意靶点的准确性以及采取适宜的消融能量和时间。     

房室双旁道并房室结功能不良致AVRT 1例

房室双旁道伴房室结功能不良临床少见。本文报告房室双旁道伴房室结功能不良并发房室折返性心动过速（AVRT）,治疗时？肖融仅有逆传功能的左侧旁道,保留具有递减传导功能的右侧旁道,随访18个月,无心动过速复发。     

Radiofrequency Catheter Ablation of an Accessory Pathway in Dextrocardia

A 60-year-old woman with situs inversus and paroxysmal supraventricular tachycardias utilizing an AV accessory pathway underwent successful, uncomplicated RF ablation. Using biplane fluoroscopy, accessory pathway catheter ablation in dextrocardia is as safe, easy, and useful as that for normal heart structure cases, and does not require a lengthy procedure.     

Radiofrequency Catheter Ablation of an Accessory Pathway in a Young Man with Dextroversion

We report an observation of a radiofrequency catheter ablation of an accessory pathway (AP) in a patient with Wolff-Parkinson-White syndrome (WPW) and dextroversion. Atrioventricular rings were mapped by the ablation catheter to locate the shortest local atrioventricular conduction time in sinus rhythm and ventriculoatrial conduction time during orthodromic tachycardia or ventricular pacing. Successful ablation confirmed a right posteroseptal AP localization. Thus, the electrocardiographic modifications due to an AP in this location in the presence of dextroversion were defined.     

Catheter Induced Mechanical Stunning of Accessory Pathway Conduction: Useful Guide to Successful Transcatheter Ablation of Accessory Pathways

Established electrophysiological criteria indicating anatomical proximity to an accessory pathway include early ventricular or atrial activation during antegrade or retrograde accessory pathway conduction, recording of accessory pathway potentials, and pace map concordance. This article describes two cases of RF catheter ablation of accessory pathways, during which positioning of the mapping catheter at specific sites on the endocardial aspect of the atrioventricular annulus led to prolongation of accessory pathway refractoriness and/or slowing of conduction. HF energy application at these sites successfully abolished accessory pathway conduction. When observed on an "intentional" basis during catheter mapping, catheter induced stunning of accessory pathway conduction provides evidence of satisfactory electrode-tissue contact in addition to anatomical proximity, and may give additional predictive value to successful transcatheter accessory pathway ablation.     

Radiofrequency Ablation of Left-Sided Accessory Atrioventricular Pathways in Patients with Unusual Coronary Sinus

Four patients with left-sided accessory pathways (APs)and unusual coronary sinus (CS)received radiofrequency ablation. Unusual CS included occlusion of CS (patient 1), acute anguJation of proximal CS (patients 2 and 3), and narrowing of CS orifice and proximal segment (patient 4). CS catheterization and AP mapping along the CS could not be performed in the four patients. Radiofrequency ablation by left ventricular retrograde technique for the manifest left posteroseptal AP (patient 1), concealed left posterior AP (patient 2), and transseptai left atrial technique for the manifest left posteroseptal AP (patient 3)and manifest left posterior AP (patient 4)were performed successfully without CS catheter guidance. This study suggests that radiofrequency ablation of left-sided AP with unusual CS is feasible by some special techniques.     

Radiofrequency Catheter Ablation of Concealed Atrioventricular Accessory Pathways Using a "Simultaneous Pacing Method"

The retrograde atrial potential at a successful ablation site is usually obscured by the wide and large ventricular potential during atrioventricular reentrant tachycardia or ventricular pacing, which makes it difficult to determine the appropriate ablation site for concealed accessory pathway. A pacing maneuver named the “simultaneous pacing method” is proposed herein to differentiate the retrograde atrial potential from the ventricular potential for a successful ablation of the concealed accessory pathway. Catheter ablation was performed in 12 patients with a single left free-wall concealed accessory pathway. The atrial insertion site was determined by the simultaneous pacing method in six patients (group I) and by ventricular pacing in six patients (group II), In the simultaneous pacing method, electrograms recorded during ventricular pacing in the earliest retrograde atrial activation site are a fusion of the ventricular potential and the following retrograde atrial potential. When atrial and ventricular pacings are performed simultaneously (simultaneous pacing), the end portion of the electrograms recorded at the same site is solely the ventricular component, because atrial is activated earlier. The atrial potential can be confirmed during ventricular pacing in comparison with the electrograms during the “simultaneous pacing.” Radiofrequency catheter ablation was successful in eliminating conduction through the accessory pathway in all 12 patients. The radiofrequency applications in group I were significantly fewer than those in group II (1.7 ± 1.0 in group I, 5.3 ± 3.2 in group II, P < 0.05). The total procedure time in group I was significantly shorter than in group II (57.8± 15.7 vs 106.7 ± 41.6 mins in group II. respectively, P < 0.05). The fluoroscopy time in group I was significantly shorter than in group II (54.0 ± 7.9 vs 81.3± 26.3 mins, respectively, P < O.05). We were able to determine the atrial insertion site of accessory pathways by the simultaneous pacing method. The simultaneous pacing method was useful in eliminating concealed left free-wall accessory pathways.     

The Role of Isoproterenol Testing Following Radiofrequency Catheter Ablation of Accessory Pathways in Children

LIBERMAN, L., et al .: The Role of Isoproterenol Testing Following Radiofrequency Catheter Ablation of Accessory Pathways in Children. Isoproterenol (ISO) testing following radiofrequency catheter ablation (RFCA) of accessory pathways (APs) in children is often performed to assess efficacy. However, its role in postablative testing for this indication has not been previously studied. In view of a recent national shortage of ISO, this study reviewed the results of ISO testing in pediatric patients after acutely successful RFCA to evaluate its role in postablative testing. Seventy patients (median age 13.0 years, range 2.8–24 years) underwent acutely successful RFCA for APs. If AP conduction was not present and tachycardia was not inducible with programmed stimulation 30 minutes following RFCA, repeat testing was performed during continuous infusion ISO. ISO infusion resulted in the induction of arrhythmias in 3 (4%) of 70 patients that required further ablative therapy. None of these patients had inducible arrhythmias or AP conduction during postablative testing without ISO infusion. One patient, with the permanent form of junctional reciprocating tachycardia (PJRT), had persistence of AP conduction requiring further RFCA applications. Two patients had inducible AV nodal reentrant tachycardia (AVNRT) that was treated with slow pathway modification. At a median follow-up of 7.3 months, two (3%) patients had recurrence of tachycardia. These patients did not have inducible tachycardia, AP conduction, or dual AVN physiology with ISO testing. Although ISO may improve AP conduction in patients with PJRT and uncover AVNRT, these results suggest that ISO testing after an apparently successful AP ablation may not be necessary to confirm acute success. In addition, lack of AP conduction on ISO did not rule out the possibility of medium-term recurrence. (PACE 2003; 26[Pt. I]:559–561)     

Radiofrequency Catheter Ablation of a Concealed Accessory Atrioventricular Pathway After Heart Transplantation

Three months after orthotopic cardiac transplantation, a 46-year-old man developed paroxysmal supraventricular tachycardia. Electrophysiological investigation of the arrhythmia led to the diagnosis of an atrioventricular reentrant tachycardia involving a left lateral concealed accessory pathway. When antiarrhythmic drugs failed to suppress the arrhythmia, radiofrequency catheter ablation of the accessory pathway was performed without complication.     

Transesophageal Echocardiographic Evaluation for Mural Thrombus Following Radiofrequency Catheter Ablation of Accessory Pathways

Background: Catheter ablation of accessory pathways (APs) provides a definitive therapy for patients with Wolff-Parkinson-White Syndrome. The reported incidence of thrombus formation on ablation-induced injuries with direct current shock varies from 0%-20% in animal studies. The purpose of this study was to determine the prevalence of mural thrombus following catheter ablation with radiofrequency current of accessory pathways in humans. Methods and Results: Radiofrequency current (30–35 warts) was applied through a catheter electrode placed against the mitral or tricuspid annulus guided by catheter recordings of AP potentials. Transthoracic (TTE) and transesophageal echocardiography (TEE) were performed in 95 of 111 patients, at 18 ± 6 hours following catheter ablation. After ablation. no thrombus was identified at or near the ablation site in any patient. Two out of 95 patients had a mural thrombus at a remote site that was detected by TEE but not by TTE. No new wall motion abnormality was detected in any patient. No significant regurgitant valvular lesion was found in any patient. Conclusion: Intracardiac thrombus was not identified at the site of catheter ablation, possibly owing to the small lesions produced by radiofrequency energy and high blood flow normally present in those areas. However, patients may be at small risk for mural thrombus at a remote site from prolonged placement of catheters.     

Analysis of Local Electrogram Characteristics Correlated with Successful Radiofrequency Catheter Ablation of Accessory Atrioventricular Pathways

Due to the limited myocardial lesions produced by radiofrequency current, the ablation of accessory pathways (AP) requires precise localization of such connections. The purpose of this study was to ascertain which characteristic(s) of the local bipolar electrogram, recorded from the ablation and adjacent electrode immediately prior to the application of radiofrequency current, correlated with precision in localization adequate to permit AP ablation. Signal analysis was performed for 326 sets of electrograms preceding the attempted ablation of 107 APs in 100 consecutive patients. For 80 antegrade APs, the following variables were evaluated: (1) the presence or absence of an AP potential; (2) the local atrial-AP interval; (3) the local atrioventricular (AV) interval; and (4) the relationship between the onset of local ventricular depolarization and onset of delta wave of the surface electrocardiogram. For the 27 concealed APs, the following characteristics were evaluated: (1) the presence or absence of an AP potential; and (2) the local VA interval during reciprocating tachycardia or ventricular pacing. RESULTS: Antegrade APs: By statistical analysis, the best correlate of successful ablation of an antegrade AP was a local AV interval less than or equal to 40 msec (positive predictive value = 94%; 95% confidence intervals [CI] = 81%-100%). Local AV intervals less than or equal to 50 msec preceded 88% of successful AP ablations, compared to only 8% of failed radiofrequency current applications. The positive predictive value of the other variables were: presence of an AP potential: 35% (95% CI = 27%-40%); local atrial-AP intervals less than or equal to 40 msec: 54% (95% CI = 43%-66%); and local ventricular depolarization preceding onset of the delta wave 43% (95% CI = 34%-52%). For concealed APs, the positive predictive value of a VA interval less than 60 msec was 71% (95% CI = 48%-88%); the positive predictive value for the presence of an AP potential was 58% (95% CI = 32%-81%). CONCLUSIONS: No single electrogram characteristic had a positive predictive value and a sensitivity greater than 90% for AP localization adequate for radiofrequency current ablation. For antegrade APs, the best correlate of adequate localization was a local AV interval less than or equal to 40 msec; as a corollary, radiofrequency current applications at sites where the local AV was greater than 60 msec, were unlikely to be effective. Objective criteria for the localization of concealed APs were less certain. Electrogram analysis, as a guide to AP localization and ablation, requires careful analysis of multiple variables, with analysis of the local AV interval a salient objective factor.