以冠状静脉窦壁心肌为心房插入点的后间隔旁路

后间隔旁路是心脏房室旁路中变异较大的一类，对其中一些较为特殊的类型在导管射频消融治疗中难以进行标测和定位，其原因是后间隔部位较为复杂的解剖结构使旁路心房端插入点的变异程度增大。本组介绍5例经导管标测和消融证实的以冠状静脉窦壁心肌为心房插入点的后间隔旁路。     

射频消融位于冠状静脉窦憩室处的后间隔房室旁路

目的报道５例冠状静脉窦憩室处后间隔房室旁路的射频消融结果。方法对５例后间隔显性房室旁路患者进行电生理检查和射频消融术。术后冠状动脉造影,以观察冠状静脉窦形态。结果所有患者的冠状静脉窦近端有一憩室,并在憩室的颈部消融阻断房室旁路。成功靶点图：心室激动较体表心电图Δ波提前（３１±３．７）ｍｓ,其中４例患者伴有旁路电位。结论冠状静脉窦憩室与后间隔旁路存在着解剖关系。术中冠状静脉窦造影检查有助于发现憩室和确定有效的消融部位。     

右侧游离壁心房多插入点旁路的临床电生理特点分析

目的 右侧游离壁旁路伴心房多插入点是一种罕见的旁路类型,本研究旨在探讨右侧游离壁旁路伴心房多插入点的电生理特点.方法 纳入2011年1月至2018年1月于北京安贞医院行射频消融术的右侧游离壁心房多插入点旁路患者8例(多插入点旁路组),同时连续纳入行射频消融术的典型右侧游离壁旁路患者24例(对照组).在三维电解剖标测系统...     

主动脉无冠窦内射频消融前间隔房室旁路

目的 报道经主动脉无冠窦内射频消融前间隔房室旁路.方法 7例患者,男性4例,女性3例,平均年龄（38.4±14.7）岁.电生理检查证实存在房室旁路,并检查其前传逆传功能和诱发旁路参与的房室折返性心动过速.在心动过速时标测最早心房逆传激动点作为消融靶点.结果 7例心动过速时最早心房激动部位均位于前间隔区域,但经右心房途径反复消融均不能成功阻断旁路,而在无冠窦内可标测到最早逆传心房激动点并消融成功,无并发症出现.结论 主动脉无冠窦内消融可作为治疗前间隔房室旁路的一种新途径,特别适用于右心房前间隔区域消融失败的病例.     

冠状静脉窦研究进展

人类冠状窦 (CS)系统是心脏静脉系统的一个主要组成部分 ,Bing等[1] 1947年开始了对经CS冠状血流的研究。近来 ,CS又成为许多心脏疾病诊断、治疗的通道和标志 ,如逆行灌注治疗冠状动脉血栓、逆行灌注心脏造影、心脏超声诊断心肌血流时减声微泡的注入、心律失常标测导管和消融导管的插入、经CS心外膜起搏电极的置入等等。随着研究的深入 ,发现CS解剖结构的变异不仅是一部分需经CS逆行灌注治疗心肌缺血病人介入途径操作失败的原因 ,也是与CS解剖结构相关的心律失常介入治疗失败的根基。因此对CS的研究一直倍受关注。笔者综述近年来对CS解剖、生理、影象以及临床的研究进展     

中间隔旁路导管射频消融

中间隔旁路紧邻房室结及希氏束 ,在消融时有造成心脏传导阻滞的较大危险。因此 ,应避免在心室起搏下放电 ,同时 ,应密切观察心电图改变。对左中间隔旁路可采用经主动脉逆行法在左心室侧消融 ,对右中间隔旁路的消融则应尽量靠近三尖瓣环心室侧。1　右中间隔旁路在消融右中间隔旁路时 ,采用如下方法避免完全性房室传导阻滞 :1在窦性预激下放电。2在放电过程中密切监视心电图变化。一旦心电图 QRS波变宽 ,立即停止放电并检查正常传导系统功能。 3放电中出现交界性心动过速说明影响到了房室结系统 ,要立即停止放电 ,重新调整消融靶点后以低功…     

间隔旁路射频消融59例分析

目的 :探讨间隔旁路消融方法对其成功率和安全性的影响。方法 :我们对 5 9例间隔旁消融的病人进行回顾分析。患者中男性 2 8例 ,女性 31例 ;年龄 18～ 6 6 (平均 38± 10 )岁 ,显性旁路 2 4条 ,隐性旁路 35条。结果 :1间隔旁路分布主要位于左右后间隔 ,其次是右前间隔 ,再次是右中间隔 ;2消融成功率为 98.3% ;3房室结损伤发生率为 8.5 % ,3例 (5 .1% )需安装心脏永久起搏器。结论 :结果表明间隔旁路消融是一种有效的治疗方法 ,但在右前、中间隔旁路消融时发生房室结损伤的可能性较大。如采用小功率开始消融 ,可降低房室阻滞的发生率     

经冠状静脉窦标测和消融后间隔心外膜房室旁道

报道心外膜房室旁道的特点和经冠状静脉窦射频消融术的结果。3例后间隔显性房室旁道患者先经心内膜标测和消融,不成功后改由经冠状静脉窦内标测和消融。术中冠状动脉造影,观察冠状静脉窦形态。结果: 2例冠状静脉窦近端有一憩室,并在憩室的颈部消融阻断房室旁道。成功靶点图为标测到振幅较大的旁道电位,其振幅大于A波和V波。结论:经心内膜标测和消融失败的旁道可能是心外膜旁道,行冠状静脉窦内标测与消融可有效阻断旁道,冠状静脉窦憩室与后间隔旁道可能存在着解剖关系。     

二尖瓣置换术后左后间隔旁路射频消融一例

患者女性 ,32岁 ,主因反复发作性心悸 9年 ,加重 1个月住院。多次发作时经心电图证实为阵发性室上性心动过速 ,经静脉注射普罗帕酮或维拉帕米可终止心动过速。心动过速发作时体表心电图提示为房室折返性心动过速 ,平时体表心电图为窦性心律 ,无预激波。既往于 9个月前因劳累后心悸气短确诊为风湿性心脏病伴二尖瓣狭窄并关闭不全 ,进行了二尖瓣置换术 ,植入双叶人工机械瓣 ,术后长期应用华法林抗凝治疗 ,心功能基本恢复正常。本次住院经超声心动图证实各心腔大小均正常 ,机械瓣功能正常。体格检查未见特殊异常。于 2 0 0 1年 12月 2 0日行心…     

Closed-chest ablation of left lateral atrioventricular accessory pathways

Thirty patients with a left lateral accessory pathway and drugrefractory tachycardia underwent attempted transcatheter ablationof the accessory pathway. Three had a concealed accessory pathwayand 27 had the Wolff-Parkinson-White syndrome. A quadripolarelectrode catheter was positioned within the coronary sinusin order to locate the earliest retrograde atrial activationduring orthodromic reciprocating tachycardia. The appropriatebipole was used as the radiographic and electrophysiologic referenceof the insertion of the accessory pathway. A catheter was thenintroduced into the left atrium, through a patent foramen ovale(six patients) or after transseptal catheterization (14 patients)according to Croft's technique, or using a retrograde transaorticapproach (10 patients). The mitral annulus was mapped with the left atrial catheterin order to record a synchronous or earlier atrial deflectionthan reference during reciprocating tachycardia. VA' time atthe preablation site was 82 ± 12 ms. Two to seven 160J cathodal shocks (650 ± 205 J cumulative per patient)were delivered at this site in 38 sessions. No significant side-effectsoccurred except for one case of right coronary artery spasmleading to inferior wall infarction. Following fulguration, accessory pathway conduction was abolishedin all patients but one with a second accessory pathway. Duringfollow-up of 1–34 months, all patients but one were freeof tachycardia: reciprocating tachycardia recurred in one patient,who had a concealed accessory pathway, on the third day. Accessorypathway conduction, assessed in 10 other patients 3–26months after the procedure, was absent. Coronary arteriographyperformed in seven patients was normal. Catheter ablation of left free-wall accessory pathways is bothsafe and effective with shocks directly delivered to the mitralannulus through a transseptal or transaortic catheter. It isan attractive alternative to surgical ablation of these accessorypathways.     

Decreased amplitude of left ventricular posterior wall motion with notch movement to determine the left posterior septal accessory pathway in Wolff-Parkinson-White syndrome

OBJECTIVE—To determine preoperatively, by analysing asynchronous left ventricular wall motion, whether to approach through the right ventricle or the left ventricle when carrying out catheter ablation of the accessory pathway in Wolff-Parkinson-White syndrome, especially in patients with the pathway located on the septum.
METHODS—73 patients with manifest Wolff-Parkinson-White syndrome who underwent successful catheter ablation were studied. Location of accessory pathway was classified as right ventricular side: right anterior paraseptum, right anterior, right lateral, right posterior, anterior septum, midseptum, right posterior septum; left ventricular side: left posterior septum, left posterior, left lateral, left anterior. Asynchronous systolic wall motion was analysed by cross sectional echocardiography.
RESULTS—Echocardiography showed that the amplitude of left ventricular posterior systolic wall motion was reduced when the pathway was located on the left ventricular side as opposed to the right ventricular side (mean (SD), 11.1 (1.7) v 12.9 (1.1) mm, p < 0.001), especially in patients with left posterior septal accessory pathway (9.7 (0.8) mm). There were no overlapping values between the left posterior septal accessory pathway and the right ventricular side accessory pathway. Posterior wall notch motion was observed in all patients with a left posterior septal accessory pathway (9/9), but not at all in patients with pathways located on the right ventricular side of the septum. In patients with a septal accessory pathway, an ECG algorithm provided poor information (relatively low sensitivity, specificity, and predictive value) for determining whether the subsite faced either the left (left posterior septum) or the right ventricle (anterior septum, midseptum, right posterior septum).
CONCLUSIONS—Decreased amplitude of left ventricular posterior wall motion with notch movement is an important finding for accessory pathways located on the left posterior septum. These findings provided clinically useful information for determining whether to approach catheter ablation from the right or the left ventricle.


     

房室旁道间歇性逆传阻滞的探讨ioven

为探讨房室旁道间歇性逆传阻滞的发生机制及临床意义 ,对房室旁道患者射频导管消融术中作腔内电生理检查 ,观察房室顺传和室房逆传功能及途径。结果显示261例中有7例 (4例为隐匿性预激综合征 )为旁道逆向 (或双向 )传导阻滞 (2.7% )。尽管旁道间歇性逆传阻滞是一种少见现象 ,但由于旁道传导阻滞 ,无法对旁道进行定位及射频导管消融 ,因此了解旁道有无间歇性逆传阻滞 ,对射频导管消融治疗有临床意义     

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。     

三维电解剖标测指导疑难右侧游离壁旁路的导管消融

Objective To demonstrate the electroanatomic substrates of right-sided free wall (RFW)accessory pathways (APs) which were refractory to conventional catheter ablation utilizing three-dimensional (3D) mapping. Methods Seventeen patients with RFW APs that failed initial conventional catheter ablation(s)by a mean of 1～3(1.8±0.6) attempts were enrolled in the study. Electroanatomic mapping of the right atrium was performed during right ventricular pacing in 14 patients and orthodromic reciprocating tachycardia in 3patients. Radiofrequency energy was delivered via irrigation catheter to the earliest atrial activation site. Results The earliest atrial activation site, which represented the atrial insertion of the APs, was separated from the tricuspid annulus by an average of 9 ～ 20 ( 13.6 ± 3.4 ) mm, and the local activation time was 18 ～ 80(31.5±16.3) ms earlier than that of the corresponding annular point. The target electrogram demonstrated AP potential in fourteen patients and ventriculoatrial fusion in the rest three. Accessory pathway was blocked in one case during moving the catheter and RF ablation delivery on the areas. One patient exhibited an AP with wide branching on the atrial side during mapping. RF ablation with an irrigated catheter successfully interrupted AP conduction in remaining 16 patients without complications. After a mean follow-up of 3 ～ 41 (18.6±12.7) months, there were no recurrences of ventricular preexcitation or episodes of tachycardia. Conclusion RFW APs refractory to conventional catheter ablation might be due to unique anatomic AP features such as more epicardial course at the annulus level with atrial insertion distance from the tricuspid annulus. Electroanatomic mapping is helpful to accurately localize the atrial insertion sites of these APs and facilitates catheter ablation.     

三维电解剖标测指导疑难右侧游离壁旁路的导管消融

目的应用三维电解剖标测技术详述常规消融无效的右侧游离壁旁路电解剖特征。方法本组共入选17例常规消融无效的右侧游离壁旁路患者,消融失败1～3（1．8±0．6）次。3例在顺向型心动过速下构建右心房电激动模型,14例在右心室心尖部起搏下构建右心房电激动模型。逆向传导的心房最早激动点代表旁路的心房插入端,冷盐水消融最早心房激动点。结果17例患者中,最早激动点距离对应部位三尖瓣环的宽度为9—20（13．6±3．4）mm,较相对部位三尖瓣环的局部激动时间提前18～80（31．5±16．3）ms。共14例患者记录到独立的旁路电位。1例患者在导管标测时阻断旁路逆传,冷盐水局部巩固消融;16例患者冷盐水消融均成功阻断所有旁路的传导,其中1例患者的旁路心房插入端呈广泛分布而行片状消融。无消融术相关并发症。随访了3～41（18．6±12．7）个月,无旁路传导恢复及心动过速发作。结论常规方法消融失败的右侧游离壁旁路可能具有特殊的解剖特征,如旁路在三尖瓣环水平沿心外膜走行,旁路的心房插入部位远离瓣环。三维电解剖标测有助于精确定位旁路的心房插入端并指导消融。     

后间隔房室旁路体表心电图的定位诊断

目的 探讨预激综合征在左、右及后间隔旁路的位置与体表心电图特征性改变的相关关系。方法 以80例预激综合征射频消融前后作对照,寻找体表心电图的特征性改变与左、右及后间隔旁路位置关系,确定体表心电图定位左、右及后间隔旁路的鉴别诊断标准,并计算其鉴别诊断的敏感性、特异性和准确率。结果 体表心电图的8大特征变化与预激左右后间隔旁路定位鉴别诊断有关,即V1导联QRS波形态、Δ波方向;Δ波及QRS波的额面电轴及二者差值;Ⅲ导联R／S波比值;胸前导联R／S＞1的转折点;PV1-PE间距。根据以上8大特点对术前80例预激重新定位,其鉴别诊断敏感性、特异度及准确率在右后间隔旁路分别是88．2％、83．3％和77．5％,而左后间隔是83．3％、88．2％、87．5％。结论 B型预激旁路绝大部分位于右后间隔旁路,但也不排除左后间隔旁路,尤其是左后旁路预激不安全时可出现B型预激改变,上述体表心电图的8大特征有助于二者鉴别诊断。     

经冠状窦消融后间隔房室旁路

８２例后间隔房室旁路的射频消融术中，５例在常规左后和右后间隔部位消融失败后，经冠状窦消融成功。５例均为预激综合征。体表心电图Ⅱ、Ⅲ、ａＶＦ导联Δ波向下，心室波呈ＱＳ型；Ｖ１导联Δ波４例向上，１例向下，心室波呈Ｒ、ｒＳ或ＱＳ型。除放电中均出现一过性胸痛、１例伴窦性心动过缓外，无其他严重并发症。     

Transradial catheter ablation of left accessory pathway in patient with severe chest deformity

A 45-year-old woman with severe chest deformity and great vessel tortuosity successfully underwent left accessory pathway ablation of atrioventricular reentrant tachycardia via right transradial arterial access. Transradial catheter ablation of left accessory pathway was safe and efficacious without complications. When transfemoral or transseptal access was impossible, transradial access was a good alternative route.