采用三尖瓣环～二尖瓣环双电极接法释放射频电流消隔后间隔旁道

０３１采用三尖瓣环～二尖瓣环双电极接法释放射频电流消隔后间隔旁道［ＢａｓｈｉｒＹ等．ＪＡＣＣ，１９９３，２２：５５０（英文）］本报道描述一种消融疑难后间隔旁道的新型技术。背景：虽然房室旁道射频消融术能在≥９０％的病人中获得成功，但对某些位于后间隔而解...     

导管射频消融房室旁道23例报告

目的：总结导管射频消融（ＲＦＣＡ）治疗房室旁道２３例的效果。方法：左侧旁路的消融在二尖瓣环左室侧进行，右侧旁路则在三尖瓣环心房侧进行，结果：２５条旁路有２３条旁路消融成功，有效率９２％，结论：表明ＲＦＣＡ是治疗房室旁道安全有效的方法。     

Carto系统指导下右心耳显性旁道射频消融一例

患者男性,53岁,术前经心电图诊断为B型预激综合征。常规行心内电生理检查及射频消融术,但术中沿二尖瓣环、三尖瓣环反复标测,始终未能标测到AV融合之靶点,于AV相对较近处多次放电无效,后在Carto系统指导下行射频消融术,心动过速下Carto系统激动顺序标测示右心耳基底部电位最早,此处放电消融成功。提示对于右侧显性旁道消融,三尖瓣环不能标测到理想靶点消融无效时,应考虑到右心耳旁道等少见类型。     

右侧壁房室旁道再次射频消融成功的体会

右侧壁是右侧房室旁道导管射频消融（ＲＦＣＡ）较困难区域。对６例ＲＦＣＡ失败和（或）复发的右侧壁房室旁道再次消融成功进行分析，以探讨其消融的方法学。选用８Ｆ加硬大头或温控导管，部分病例使用Ｓｗａｒｔｚ鞘辅助操作，均经静脉途径于三尖瓣环上进行消融。６例患者术中均成功阻断旁道，有效放电１１次、射频电流功率平均４３±６（３０～５０）Ｗ、放电时间平均３７９±８１（２７０～４８０）ｓ，与５０例右侧其它部位旁道消融功率（平均３６±４Ｗ）和时间（平均２４０±２３ｓ）分别相比，Ｐ均＜０．０５。５例患者随访期间停用抗心律失常药物，无心动过速发作；１例术后１６ｈ再次复发。体会：采用高功率、长时间放电可取得一定疗效；常规选用加硬导管，部分使用温控导管，辅以适当的Ｓｗａｒｔｚ鞘管和提高导管操作技巧等有助于提高右侧壁旁道ＲＦＣＡ的成功率。     

经它种导管径路射频消融治疗阵发性室上性心动过速的意义

本文报告５例阵发性室上性心动过速（ＰＳＶＴ）射频消融术（ＲＦＣＡ）采用的它种导管径路与消融结果：１例因双髂动脉迂曲改由右腋动脉穿刺送入大头导管至左室消融左侧壁旁道（ＡＰ）成功；１例为伴永存左上腔静脉的房室结双径路（ＤＡＶＮＰ），导管由左锁骨下静脉送入不成，改由右颈内静脉送入冠状窦（ＣＳ）标测电极消融成功；１例为中间隔主ＡＰ和右游离壁次ＡＰ，两种房室折返性心动过速（ＡＶＲＴ），分别经右股静脉和右颈内静脉径路消融无复发；ＣＳ内消融２例，１例为ＣＳ近端消融左后间隔隐匿性ＡＰ（ＣＡＰ），即刻成功，术后复发，再于左室侧消融阻断ＡＰ；１例于左室侧行ＲＦＣＡ二次未成，第三次先后于左室侧，导管逆行推进入左房和经房间隔穿刺于左房侧消融亦未成，最后将大头导管送入ＣＳ内一次成功阻断左侧壁ＡＰ。提示：对于特殊患者采用它种导管径路可提高ＲＦＣＡ成功率。     

二尖瓣环间隔起源局灶性房性心动过速电生理特征与射频消融

目的探讨二尖瓣环间隔起源局灶性房性心动过速(房速)心电图(ECG)特性,电生理特性和射频消融治疗(RFA)。方法 13例患者经心内电生理检查证实起源于二尖瓣环间隔侧房速(简称二尖瓣间隔房速),其中男性6例,女性7例,年龄23~47(35±12)岁,心动过速病史1~6年。结果 12例患者经穿房间隔途径标测消融成功,1例经主动脉逆行途径标测消融成功。根据局部电位特征,X线影像和三维标测系统确定成功消融位点分别为:二尖瓣环前间隔旁8例,二尖瓣环中间隔到前间隔之间3例,二尖瓣环后间隔2例。所有房速心电图V1导P波均表现出负正双向,右房激动标测显示最早右房激动点位于间隔侧(希氏束区域或冠状窦近端)。13例患者成功靶点局部电位均为小A大V,9例局部电位A波为复杂或碎裂的。所有患者均无明显并发症,12例长期随访无心动过速复发。结论二尖瓣环间隔区域是重要的房速起源点,常见于前间隔旁,其有独特P波形态和心内激活顺序。经穿间隔或逆行主动脉途径消融二尖瓣环间隔房速,安全有效。     

射频消融治疗阵发性室上性心动过速62例体会

目的总结室上性心动过速(PSVT)射频消融治疗的经验。方法左房室旁路消融二尖瓣室侧，右房室旁路消融三尖瓣房侧；房室结双径路通过下位能量递增消融法改良房室结慢径。结果房室折返型心动过速38例，左侧旁道30条右侧旁道9条，消融成功37条，成功率95％，房室结折返型心动过速24例，房室结双径路改良全部成功，成功率100％，总成功率97％。无1例复发。结论射频消融治疗室上速安全、有效、复发率低。’     

单用消融电极标测和消融左侧隐匿性旁道

目的 单用消融电极于二尖瓣下直接标测（不放置冠状窦电极）对35例左侧隐匿性旁道进行射频消融。方法 右室心尖起搏下用消融电极沿三尖瓣口标测,确认旁道不在右侧后,将消融电极送至二尖瓣下进行标测和消融。结果 34例左侧隐匿性旁道标测到消融靶点,33例消融成功,1例消融失败,1例复发。与使用冠状窦电极标测相比,消融电极直接标测的X线曝光时间、手术时间均增加。结论 单用消融电极可标测和消融左侧隐匿性旁道。     

经上腔静脉途径射频消融右侧前上和前间隔房室旁道

报道经上腔静脉途径射频消融右侧前上和前间隔房室旁道的体会。 13例右侧前上或前间隔单一房室旁道患者 ,常规下腔静脉途径消融未能成功 ,失败原因包括 :消融电极与心肌接触不良或难以固定于三尖瓣环上。改经上腔静脉途径成功消融阻断所有房室旁道。平均放电 1.8± 0 .7次 ,输出功率 33± 4W ,消融靶点电图振幅明显高于下腔静脉途径 (1.4± 0 .3mVvs 0 .6± 0 .4mV ,P <0 .0 5 )。术后随访 17± 9个月 ,无 1例复发。作者认为对经下腔静脉途径消融失败的右侧前上和前间隔房室旁道采用上腔静脉途径消融可获得成功。     

导管射频消融治疗房性心动过速的体会

总结５例房性心动过速的电生理特点，探讨提高导管射频消融成功率的标测与消融方法。男１例、女４例，平时心电图正常，心动过速发作时心室率１５０～２２０ｂｐｍ，ＲＰ＞ＰＲ。大头电极在右房内标测到最早的心房激动点，在心动过速时放电。２例在冠状窦口附近、２例在右房侧壁（双大头法标测）消融成功，靶点局部电位较体表心电图的Ｐ波提前２９ｍｓ以上；１例窦房折返性心动过速，消融失败。结果表明：激动标测是最基本的方法，结合拖带或隐匿性拖带、起搏标测、机械阻断等选择靶点的方法可以提高成功率；适当选择双大头法标测能够缩短手术时间。     

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。     

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.     

29例房束型和短房室型Mahaim纤维的电生理特点与射频消融结果

目的报道29例房束型和短房室型Mahaim纤维的电生理特点与射频消融结果。方法对29例Mahaim纤维患者（房束型10例,短房室型19例）进行心内电生理检查和射频导管消融治疗。结果29例患者Mahaim纤维只存在递减性前向传导功能,其中2例合并隐匿性房室旁路（左侧游离壁和右侧中间隔各1例）,2例合并三尖瓣峡部依赖型心房扑动,3例合并房室结双径路（均为慢快型）。经Mahaim纤维前传的逆向性房室折返性心动过速时,房束型心室最早激动点在右心室心尖部,短房室型心室最早激动点在三尖瓣环消融靶点处。于三尖瓣环的心房侧成功消融所有Mahaim纤维,其中28例于三尖瓣环游离壁的心房侧消融成功,1例于右心房中间隔消融成功。13例标测到明显的Mahaim纤维电位,25例（房束型9例,短房室型16例）有效消融时出现加速性Mahaim纤维的自主心律。合并房室结双径路、隐匿性房室旁路和三尖瓣峡部依赖型心房扑动者,分别给予以慢径改良、旁路消融和右心房峡部线性消融。随访（17＋8）个月,无1例心动过速复发。结论Mahaim纤维多位于三尖瓣环游离壁。导管消融是Mahaim纤维介导的心动过速安全、有效的治疗方法。消融中出现加速性Mahaim纤维自主心律可以作为判定有效消融的预测指标。消融术前和术后应进行详尽的电生理检查以明确是否合并其他的心动过速。     

A unique mapping strategy for localization and ablation of the atrial input of an antegrade only conducting accessory pathway

The standard technique for accessory pathway ablation involves mapping along the mitral and tricuspid annulus to localize the regions of earliest ventricular activation during antegrade pathway conduction, earliest atrial activation during retrograde conduction or detection of an accessory pathway potential. In some cases despite what appears to be appropriate mapping, catheter positioning and adequate power delivery the ablation is not successful. In many of these cases, the pathway is felt to be inaccessible because of a location remote from the mitral or tricuspid annulus that cannot be affected by endocardial power delivery along the annulus. In the case of difficult left sided pathways, some may be reached and ablated via the coronary sinus or its branches. Right sided pathways cannot be approached in this fashion since there is no venous structure analogous to the coronary sinus around the tricuspid annulus. Alternative mapping and ablation techniques for these difficult pathways have included epicardial mapping via direct pericardial access or attempts to localize pathway insertion areas remote from the valve annulus which may be amenable to endocardial ablation. We describe the use of post-pacing interval mapping to localize the atrial input of a right sided antegrade only accessory pathway that was resistant to conventional mapping and ablation strategies.     

冠状静脉形态与左侧旁路关系的研究

目的 :观察冠状静脉形态与左侧旁路的关系。　　方法 :6 7例左侧游离壁旁路和后间隔旁路的患者在旁路成功射频导管消融后行冠状静脉窦逆行显影 ,测量射频导管消融靶点距冠状静脉分支开口的距离 ,小于 5 mm认为二者相关。　　结果 :全部 6 7例成功的进行了冠状静脉造影 ,5 7例 (85 .1% )旁路位于冠状静脉分支开口处 ,4例位于冠状静脉狭窄或扩张处。　　结论 :左侧旁路与冠状静脉形态具有一定相关性     

Site of Accessory Pathway Block After Radiofrequency Catheter Ablation in Patients with the Wolff-Parkinson-White Syndrome

Site of Accessory Pathway Block. Introduction: Recent studies have demonstrated that the most common site of accessory pathway conduction block following the introduction of a premature atrial stimulus during atrial pacing is between the accessory pathway potential and the ventricular electrogram. consistent with block at the ventricular insertion of the accessory pathway. However, no prior study has evaluated the site of conduction block during radiofrequency catheter ablation procedures. Therefore, the objective of this study was to determine the site of conduction block after catheter ablation of accessory pathways by analyzing and comparing the local electrograms recorded before and after radiofrequency energy delivery at successful ablation sites. Methods and Results: The electrograms evaluated in this study were obtained from 85 consecutive patients who underwent successful radiofrequency catheter ablation of a manifest accessory pathway. The 50 left free-wall accessory pathways were ablated using a ventricular approach and the 35 right free-wall or posteroseptal accessory pathways were ablated using an atrial approach. The characteristics of local electrograms recorded immediately before and immediately after successful ablation of the accessory pathway were determined in each patient. The site of accessory pathway block was determined by comparing the amplitude, timing, and morphology of the local eleclrograms at successful sites of radiofrequency catheter ablation before and after delivery of radiofrequency energy. A putative accessory pathway potential was present at the successful target site in 74 of the 85 patients (87%). Conduction block occurred between the atrial electrogram and the accessory pathway potential in 66 patients (78%) and between the accessory pathway potential and the ventricular electrogram in eight patients (9%). The site of block could not be determined in 11 patients (13%) in whom an accessory pathway potential was absent. Conduction block occurred most frequently between the atrial electrogram and the accessory pathway potential regardless of accessory pathway location. No electrogram parameter or accessory pathway characteristic was predictive of the site of conduction block. Conclusion: The results of this study demonstrate that conduction block occurs most frequently between the local atrial electrogram and the accessory pathway potential during radiofrequency catheter ablation of accessory pathways. This is true regardless of whether the accessory pathway is ablated from the atrial or ventricular aspect of the mitral or tricuspid annulus.     

Coronary sinus stenosis as a late complication of catheter ablation in Wolff-Parkinson-White syndrome

This report describes a patient who developed stenosis of coronary sinus and cardiac veins five years after application of electric shock currents to the posterior mitral annulus and posteroseptal region of the tricuspid annulus for ablation of a left posterior accessory pathway and a right posteroseptal accessory pathway. This is the first angiographic documentation of coronary sinus stenosis as a late complication of electric ablation of accessory pathway. Cathet. Cardiovasc. Diagn. 42:70–72, 1997. © 1997 Wiley-Liss, Inc.     

A unipolar coronary sinus mapping study of patients with left-sided atrioventricular accessory pathways

So-called unipolar 'PQS pattern' is widely accepted as a hallmark of successful catheter ablation of the left-sided atrioventricular accessory pathway. However, the unipolar nature of the electrogram and the site-dependent appearance of this characteristic pattern are poorly understood. Therefore, unipolar coronary sinus (CS) mapping was performed using a multipolar fine electrode in patients with Wolff-Parkinson-White (WPW) syndrome associated with an antegrade left-sided accessory pathway (case group) and those with a concealed left-sided accessory pathway or atrioventricular nodal reentrant tachycardia (control group) under sinus rhythm and fixed high right atrial, CS ostial, and distal pacing. In both groups, the unipolar CS atrial electrogram showed intrinsic negative deflection (initial positive followed by negative parts) with considerable variation depending on the recording site. This unipolar configuration of the atrial electrogram was not influenced by different activation sequences during pacing at various sites. The case group exhibited a unipolar 'PQS pattern' at successful ablation sites for the left lateral to anterolateral accessory pathway. However, this was not true for the left posteroseptal accessory pathway, possibly because the negative part of the atrial electrogram distorted the 'PQS pattern' as an intervening dip. In conclusion, the site-dependent variations of the unipolar CS atrial electrogram underlie the limited usefulness of the 'PQS pattern' in left posteroseptal accessory pathway localization.     

Variable location of accessory pathways associated with the permanent form of junctional reciprocating tachycardia and confirmation with radiofrequency ablation.

Permanent junctional reciprocating tachycardia (PJRT) occurs primarily in young patients and causes nearly incessant tachycardia that is frequently refractory to pharmacologic treatment. Previous nonpharmacologic therapy has included surgical or direct-current catheter ablation of either the His bundle or the accessory pathway. The accessory pathway in PJRT has been described as having retrograde and anterograde decremental conduction properties, and is typically identified in the posteroseptal location. This report describes radiofrequency catheter ablation of accessory pathways in 8 patients with PJRT. All ablations were successful and without adverse effects. Accessory pathway potentials were detected just before atrial activation in 6 of 8 patients. A new finding was that 5 of the 8 pathway locations, as identified by the site of successful ablation, were not in the typical posteroseptal region. In 1 patient it was located in the right posteroseptal region, 2 were in the right atrial freewall, 1 was in the right anterior septum and 1 was in the left posterior region just outside of the septal region. In conclusion, radiofrequency catheter ablation can be a highly effective and safe method for treatment of young patients with PJRT. Because the accessory pathways can be located outside of the posteroseptal region, careful mapping of both the right and left atrioventricular groove may be necessary for successful ablation.     

Radiofrequency Application to the Posteroseptal Region Alters Retrograde Accessory Pathway Activation

Introduction: Radiofrequency applications to the posteroseptal region can ablate the atrioventricular accessory pathway residing in this area. In conjunction with the adjacent anatomic structures, however, ablative lesions which do not effectively ablate the accessory pathway could markedly alter retrograde atrial activation sequence and confound interpretation of further mapping of an accessory pathway.Methods and Results: Electrophysiologic studies, endocardial activation mapping and radiofrequency catheter ablation were undertaken in three patients with recurrent supraventricular tachycardia. Patients were initially thought to have a single posteroseptal accessory pathway; earliest ventrioatrial activation during tachycardias and during ventricular pacing was at the coronary sinus ostium, but initial radiofrequency applications were unsuccessful to ablate the pathway. After initial radiofrequency applications to the posteroseptal region, the earliest retrograde atrial activation changed to the right atrial free wall in two patients. Additional radiofrequency application to the posteroseptal area was able to ablate the single posteroseptal accessory pathway in one patient. Radiofrequency application to the right atrial free wall was required to stop tachycardia initiation in other patient. The third patient was suspected of having a slow-slow atrioventricular nodal reentry tachycardia. Radiofrequency application to the posteroseptal area changed the earliest retrograde atrial activation to the distal coronary sinus recording site, mimicking an accessory pathway at the left atrial free wall. Radiofrequency application to the anteroseptum was able to ablate the concealed accessory pathway.Conclusion: Radiofrequency applications to the posteroseptal region can markedly alter retrograde atrial activation, thereby confounding further mapping of the accessory pathway.