三磷酸腺苷对房室结双径路的快径路前传和慢径路前传不同效应的临床研究

目的 :比较三磷酸腺苷 (ATP)对房室结双径路 (DAVNP)快径路前传 (AFP)和慢径路前传 (ASP)的抑制作用 ,并观察小剂量ATP能否诱发房室结折返性心动过速 (AVNRT)。方法 :经心内电生理研究 (EPS)证实为可诱发的慢快型房室结折返性心动过速 (SF AVNRT)患者 2 1例为ATP试验研究组 ,同期经EPS和射频导管电消融证实无DAVNP征象 ,且不能诱发AVNRT的患者 14例为对照组 ,在心房起搏下给予递增的ATP剂量。结果 :ATP试验显示 ,研究组患者 2 1例中 17例显示DAVNP电生理征象 ,其中 ,小剂量ATP诱发房室结回波 1例 ,AVNRT 3例 ,对照组无一例显示DAVNP电生理征象和诱发房室结回波或AVNRT。阻断AFP的ATP剂量明显小于阻断ASP的ATP剂量〔(5 .9± 1.6 )mg对 (11.9± 2 .2 )mg ,P <0 .0 1〕。结论 :AFP比ASP对ATP更敏感 ,提示AFP比ASP进入房室结的N区更广泛。对于部分SF AVNRT患者 ,小剂量ATP可诱发之     

三磷酸腺苷和腺苷在诊断房室结双径路现象时剂量比较初探

目的:研究窦性心律时静脉注射三磷酸腺苷(ATP)或腺苷诱发房室结双径路现象的最小有效剂量.同时比较ATP和腺苷的剂量相关性.方法:窦性心律下,42例患者经外周静脉快速注射ATP和腺苷,诱发房室结双径路现象(相邻2个心搏之间,PR间期时限增加或者减少≥50 mS,出现1个以上的房室结回波)或者出现Ⅱ度以上的房室传导阻滞.ATP的起始剂量为10 mg,递增量为5 mg;腺苷的起始剂量为6 mg,递增量为3 mg.42例患者分成2组:试验组(n=22)为心内电生理检查明确为慢-快型房室结双径路折返性心动过速患者,对照组(n=20)为非慢-快型房室结折返性心动过速患者.结果:在试验组中静脉注射ATP或腺苷,20例患者出现房室结双径路现象.对照组中2例出现房室结双径路现象.该试验的特异性为91%,敏感性为90%.诱发房室结双径路现象时ATP最小剂量为10 mg,最大剂量为20 mg,平均有效剂量为(15.00±4.29)mg.腺苷的最小剂量为6 mg,最大剂量为18 mg,平均有效剂量为(9.75±3.62)mg.诱发房室结双径路现象时ATP和腺苷剂量呈显著相关性,但ATP和腺苷剂量与年龄体重没有相关性.结论:在窦性心律时外周静脉注射ATP和腺苷可以鉴别房室结双径路现象,本试验研究设计了一种小剂量递增法来鉴别这种现象.并发现ATP和腺苷有显著相关性.     

心动过速RR间期交替的发生机制及导管射频消融治疗

目的　分析QRS心动过速伴RR间期长短交替的发生机制及导管射频消融情况。方法　对 6例心动过速伴RR间期长短交替患者 ,常规行动态心电图及食管电生理检查。心内电生理检查提示存在房室旁路或房性心动过速伴房室结双径路 ,先进行旁路或房性心动过速的消融 ,消融成功后再进行心内电生理检查 (包括应用异丙肾上腺素进行心动过速诱发 ) ,如不能诱发心动过速则终止手术。若提示存在房室结多径路 ,则进行慢路径改良术。结果　食管电生理检查提示 :4例患者存在房室旁路伴房室结双径路 ;2例患者存在房室结三径路。心内电生理检查及消融结果显示 :3例患者为房室旁路伴房室折返性心动过速 ,成功消融后不能诱发房室结折返性心动过速 ;1例患者同时存在房室及房室结折返性心动过速 ,成功消融房室旁路后再改良慢路径 ;2例患者为房室结三径路 ,经慢径路改良后房室结传导曲线连续 ,未诱发心动过速。 6例患者无并发症发生 ,随访期间无心动过速发作。结论　室上性心动过速伴RR间期交替发生率较低 ,且均与房室结传导不连续有关。心动过速伴RR间期交替发生机制较为复杂 ,除了与房室结纵向传导的不连续有关外 ,还与其不应期密切相关。食管电生理检查与心内电生理检查相比对揭示RR间期交替的发生机制具有较高的诊断价值。     

经导管射频电消蚀治疗房室结折返性心动过速的疗效观察

采用射频电消蚀(RFCA)对14例房室结双径路(AVNDP)合并房室结折返性心动过速(AVNRT)患者进行房室结改良术.结果是,13例房室结双径路电生理特征及房室结折返性心动过速诱发窗口消失,成功率达92.8%(13/14),无严重并发症.随访l～12月,2例复发.表明采用RFCA治疗AVNRT效果良好,且无副作用.     

心悸患者窦性心律时静脉注射三磷酸腺苷对室上性心动过速的诊断作用

目的 探讨窦性心律时静脉注射三磷酸腺苷(adenosine triphosphate，ATP)对病因不明的心悸患者诊断房室结折返性心动过速(atrioventricular nodal reentrant tachycardia，AVNRT)和房室折返性心动过速(atrioventricular reentrant tachycarclia，AVRT)的价值。方法 97例疑为室上性心动过速(SVT)的心悸患者，其中心悸发作时无心电图记录者33例，有心电图记录但机制不明者64例。在窦性心律时静脉注射递增剂量ATP(5～40mg)，全部受试者均接受心内电生理检查。结果 95例完成了研究，其中ATP试验阳性67例(70．5％)，包括出现房室结双径路(atrioventricular node dual pathway，AVNDP)征象者44例(46．3％)、出现隐匿性旁路(concealed accessory pathway)征象者23例(24．2％)。ATP试验对AVNRT或AVRT的阳性预测值为94％，敏感性为86.3％，阴性预测值为64.3％，特异性为81．8％。结论 窦性心律时静脉注射ATP对心悸患者AVNRT和AVRT的阳性预测值高，是判明心悸病因的一个有价值的诊断方法。     

钙剂与阿托品在TEAP诱发房室结折返性心动过速中的应用

目的 比较葡萄糖酸钙与阿托品作为诱导剂对房室结折返性心动过速(AVNRT)的诱发结果.方法 62例以阵发性心悸就诊行食道心房调搏(TEAP)患者,检测出现房室结双径路(DAVNP),但未诱发心动过速且排除葡萄糖酸钙和阿托品禁忌证,随机分为葡萄糖酸钙组30例和阿托品组32例,分别予10％葡萄糖酸钙20 mL稀释后缓慢静脉注射和阿托品0.04 mg/kg静脉推注后重复TEAP,记录用药前后的电生理检查结果,比较房室结折返性心动过速(AVNRT)的诱发情况.结果 葡萄糖酸钙组和阿托品组分别有18例及16例作出DAVNP所致AVNRT、单个或成对房室结折返激动及心房回波的诊断,二者之间不存在显著差异;而阿托品组不能再次作出DAVNP诊断的例数明显多于葡萄糖酸钙组(P＜0.01).结论 葡萄糖酸钙不掩盖房室结双径路的显现,其对AVNRT、单个或成对房室结折返激动及心房回波的总体诱发率稍高于阿托品.     

慢径路持续前传的顺向性房室折返性心动过速心电图及食管电生理检查特点

目的探讨慢径路持续前传的顺向性房室折返性心动过速心电图及食管电生理检查特点。方法回顾性分析17例体表心电图诊断为顺向性房室折返性心动过速,且频率≤150次/分的患者的食管电生理检查资料。结果 S1S2扫描中,S2-R间期在跳跃性延长后诱发出与检查前相同的顺向性房室折返性心动过速,证实存在房室结双径路。结论在心率≤150次/分的顺向性房室折返性心动过速的患者中有必要行食管电生理检查以明确房室结双径路的存在。     

三磷酸腺苷对室房传导的电生理作用

目的　探讨三磷酸腺苷 (adenosine triphosphate,ATP)对房室结双径路参与的房室交界区折返性心动过速和旁路参与的房室折返性心动过速患者的室房传导的电生理作用。　方法　 39例房室交界区折返性心动过速和 6 7例房室折返性心动过速患者在右心室起搏 (频率 140次 / m in)时 ,经股静脉快速注射 ATP 2 0 mg,连续记录体表心电图和心内电图 ,观察室房传导变化。　结果　房室交界区折返性心动过速组 33例 (84.6 % )在注射 ATP后出现室房阻滞 ,其余 6例无变化。6 7例房室旁路患者在消融前 ,6 1例 (91% )室房传导无变化 ,另 6例出现室房阻滞 ,其中 2例具递减性传导 ;而在消融后 2 4例右心室起搏频率超过 16 0次 / m in,仍为 1∶ 1逆传 ,注射 ATP后 2 3例出现室房阻滞 ,仅 1例不受影响。　结论　 ATP对房室结及旁路的电生理作用不同 ,注射 ATP后出现室房阻滞对鉴别经房室结或旁路逆传有一定价值 ,是旁路消融成功的一个判别指标 ,但并不一定完全可靠     

伴RR间期交替的室上性心动过速的射频消融

目的:探讨伴RR间期交替的窄QRS波心动过速的电生理机制和射频消融策略.方法:10例伴RR间期交替的心动过速患者接受了电生理检查,明确其心动过速类型后,首先消融旁路或诱发的心动过速,如仍能诱发房室结折返性心动过速(AVNRT)则消融慢径路,并随访了解心动过速复发情况.结果:10例患者中9例为左侧游离壁旁路合并房室结双径路,消融旁路后3例诱发AVNRT,一并成功消融了慢径路,另6例没有诱发AVNRT者未再消融,1例为房室结三径路,成功消融了慢径路.在6个月～8.4年随访中,无心动过速复发.结论:伴RR间期交替的心动过速具共同特点,即存在房室结双径路.在消融基础心动过速后,如不能诱发AVNRT,可不消融慢径路.     

双房室旁道合并房室结双径路二例

2例患者经心脏电生理检查证实为左、右侧房室旁道伴房室结双径路,并诱发多种室上性心动过速(PSVT),其折返机制及途径各不相同。射频消融一侧房室旁道后,还能诱发其它折返机制及途径的PSVT。提示:QRS波群频率或形态不同的PSVT可为多发性旁道或(和)伴房室结双径路等多种折返机制。仔细的电生理检查,逐一消融阻断旁道或(和)房室结慢径路才能根治PSVT。     

Adenosine-5'-triphosphate test for the noninvasive diagnosis of concealed accessory pathway

OBJECTIVES: This study assessed the use of adenosine triphosphate (ATP) in the noninvasive diagnosis of concealed accessory pathway (AP) and dual atrioventricular (AV) node physiology in patients with inducible AV reentrant tachycardia (AVRT). BACKGROUND: Administration of ATP during sinus rhythm identifies dual AV node physiology in 76% of patients with inducible sustained slow/fast AV nodal reentry tachycardia (AVNRT). METHODS: Incremental doses of ATP were intravenously administered during sinus rhythm to 34 patients with inducible sustained AVRT involving a concealed AP and to 27 control patients without AP or dual AV node physiology. One study group patient could not complete the study and was excluded from analysis. RESULTS: The AV reentrant echo beats (AVRE), or AVRT, suggestive of the presence of concealed AP, were observed after ATP administration in 24 (73%) study patients and in none of the control group. Electrocardiographic signs suggestive of dual AV node physiology were observed after ATP administration in 7 (21%) study patients and in none of the control group. Most instances of AVRE/AVRT were preceded by a slight increase (<50 ms) in PR interval. In 8 of 9 patients tested, neither AVRE nor AVRT was no longer observed following ATP administration after successful radiofrequency ablation of the AP. In the remaining patient, a different AVRE due to the presence of an additional AP was observed. CONCLUSIONS: Administration of ATP during sinus rhythm may be a useful bedside test for identifying patients with concealed AP who are prone to AVRT and those with associated dual AV node pathways.     

Simplified "ATP test" for noninvasive diagnosis of dual AV nodal physiology and assessment of results of slow pathway ablation in patients with AV nodal reentrant tachycardia

INTRODUCTION: We recently reported that administration of adenosine triphosphate (ATP) during sinus rhythm identifies dual AV nodal physiology (DAVNP) in 76% of patients with inducible sustained AV nodal reentrant tachycardia (AVNRT) at electrophysiologic (EP) study. In that report, however, the ATP test was considered positive for DAVNP only when the results were reproducible at a given dose of ATP. The aim of the present study was to assess the value of a simplified ATP test for noninvasive diagnosis of DAVNP and abolition or modification of the slow pathway (SP) after radiofrequency ablation (RFA) in patients with inducible sustained AVNRT. METHODS AND RESULTS: The value of a single dose of ATP was studied in 105 patients with inducible sustained AVNRT and in 31 control patients before placement of EP catheters in the cardiac chambers. ATP (10 to 60 mg, in 10-mg increments) was injected during sinus rhythm until ECG signs of DAVNP (> or = 50 msec increase or decrease in PR interval in two consecutive beats, or occurrence of > or = 1 AV nodal echo beat) or > or = second-degree AV block was observed. DAVNP was observed in only 1 (3.2%) control patient. The test could be completed in 96 study patients. DAVNP was found by ATP test in 72 (75%) patients, whereas it was diagnosed by EP criteria in 82 (85%) patients. DAVNP by ATP test disappeared in 27 (96%) of 28 patients who underwent SP abolition and in 18 (60%) of 30 patients who underwent SP modification. In the 12 patients with persistent DAVNP determined by ATP test after SP modification, the number of beats conducted over the SP was significantly reduced (from 6.3+/-3.3 to 2.5+/-2.2 beats; P = 0.002). CONCLUSION: A single administration of ATP during sinus rhythm (at a given dose) enables noninvasive diagnosis of DAVNP in a high percentage of patients with inducible AVNRT and reliably confirms the results of RFA of the SP.     

Noninvasive diagnosis of dual AV nodal physiology in patients with AV nodal reentrant tachycardia by adenosine triphosphate test

Atrioventricular nodal reentrant tachycardia (AVNRT) is a relatively common paroxysmal supraventricular tachycardia. This study investigated whether adenosine-5'-triphosphate (ATP) injection during sinus rhythm might be useful in the noninvasive diagnosis of dual AV nodal pathways. The study group consisted of 9 patients with slow/fast AVNRT and 11 control patients without antegrade dual AV nodal physiology (DAVNP). ATP (2.5 to 30 mg, in 2.5-mg increments was injected during sinus rhythm until signs of DAVNP (> or = 50 msec increase or decrease in AH or PR interval in two consecutive beats) or > or = second-degree AV block was observed. DAVNP was diagnosed by ATP test in all 9 patients with slow/fast AVNRT. DAVNP was observed by ATP test in 3 of the 11 control patients. Thus, the test had a sensitivity of 100% and specificity of 73%. ATP test given during sinus rhythm is useful for identifying patients with dual AV nodal pathways who are prone to AVNRT.     

房室结双径路合并房室旁路的折返性心动过速及射频消融治疗

目的本研究旨在探讨房室结双径路（ＤＡＶＮＰ）合并房室旁路（ＡＰ）的电生理特征和射频消融要求。方法对２１８例阵发性室上性心动过速（ＰＳＶＴ）进行电生理检查，观察ＰＳＶＴ的前传和逆传途径，然后对ＡＰ或房室结慢径（ＳＰ）进行消融治疗。结果２１８例ＰＳＶＴ中检出ＤＡＶＮＰ＋ＡＰ１０例，检出率为４．６％。其中ＳＰ前传、ＡＰ逆传（ＳＰ－ＡＰ折返）４例，快径（ＦＰ）前传、ＡＰ逆传（ＦＰ－ＡＰ折返）１例，ＳＰ－ＡＰ折返并ＦＰ－ＡＰ折返或ＳＰ／ＦＰ交替前传折返４例，ＳＰ前传、ＦＰ逆传（ＡＰ旁观）１例。１０例患者均作ＡＰ消融，诱发房室结折返性心动过速（ＡＶＮＲＴ）的３例加作ＳＰ消融，术后随访均无复发。结论ＤＡＶＮＰ合并ＡＰ者ＡＰ均作为逆传途径，阻断ＡＰ是消融关键；ＡＰ旁观者也应作ＡＰ消融；仅有ＡＨ跳跃延长者不必接受房室结改良；ＡＰ消融者应作ＤＡＶＮＰ电生理检查。     

Indications for modification of coexisting dual atrioventricular node pathways in patients undergoing surgical ablation of accessory atrioventricular connections

Concomitant susceptibility to atrioventricular (AV) node reentrant tachycardia has been demonstrated in certain patients having reentrant tachycardia utilizing accessory AV connections. For those patients undergoing accessory connection ablation, AV node surgical modification may be warranted during the same operative procedure. To assess indications for a combined operative procedure, this study evaluated potential predictors of subsequent spontaneous AV node reentrant tachycardia in patients undergoing ablation of accessory AV connections. Among 62 consecutive patients undergoing surgical ablation of an accessory AV connection, 13 (21%) manifested dual AV node pathways. The latter were identified preoperatively in five patients (four with concealed and one with bidirectional accessory connections) and postoperatively in seven (all seven with bidirectional accessory connections). In one patient with a bidirectional accessory connection, dual AV node pathways could not be demonstrated preoperatively, but AV node reentrant tachycardia was induced. Operative ablation of an accessory connection was successful in all patients. However, postoperatively, 2 of the 13 patients had inducible AV node reentrant tachycardia, 5 had AV node "echo" beats and 6 had no inducible arrhythmia. During 26 +/- 7 months of follow-up study, the two patients with inducible AV node reentrant tachycardia postoperatively had symptomatic AV node reentrant tachycardia. In addition, the one patient with inducible AV node reentrant tachycardia preoperatively had recurrence of this tachycardia 4 months after attempted surgical modification of the AV node. Consequently, although dual AV node pathways appear to be common in patients undergoing surgical ablation of an accessory AV connection (21%), only a small group (3 of 13) of these patients are at risk for subsequent clinical AV node reentrant tachycardia.(ABSTRACT TRUNCATED AT 250 WORDS)     

房室结改良术终点与复发率的关系

为探讨房室结改良术成功后不同电生理终点对复发率的影响，观察了８０例房室结改良术患者复发情况。其中双径现象消失（Ａ组）５１例；仍有双径现象，但无心房回波（Ｂ组）２１例；有双径现象，且有１个心房回波（Ｃ组）８例。消融成功后观察３０ｍｉｎ，急性复发４例（５．８％）；术后随访１４．７±５．６（６～３９）个月慢性复发３例（３．８％），共复发７例（８．８％）。７例中，Ａ组与Ｂ组各２例、Ｃ组３例，复发率分别为３．９％、９．５％、３７．５％。其中Ａ组与Ｃ组比较复发率差异非常显著（Ｐ＜０．０１），其余差异无显著性（Ｐ＞０．０５）。此结果表明，选用三种终点中的任何一种，术后大多数患者都未复发。而为了降低复发率，除了消融成功后至少应观察３０ｍｉｎ以消除急性复发外，在技术成熟的单位，可力争以双径现象消失为改良术终点。     

Electrophysiologic effects and clinical efficacy of flecainide in children with recurrent paroxysmal supraventricular tachycardia

The electrophysiologic effects of intravenous flecainide were evaluated in 16 patients aged 9 +/- 4 years: 15 with recurrent paroxysmal supraventricular tachycardia (SVT) and 1 with overt accessory pathway and history of syncope. Eleven patients had an accessory pathway; it was concealed in 2, overt in 9 and in 10 of these patients an orthodromic atrioventricular reentrant tachycardia was induced. Five patients without accessory pathway had an atrioventricular nodal reentrant tachycardia. After intravenous flecainide (1.5 mg/kg) the effective refractory period of the atrium and ventricle increased significantly; the anterograde and retrograde effective refractory periods of the atrioventricular node did not. Flecainide blocked retrograde conduction in the accessory pathway in 4 patients (effective refractory period 245 +/- 41 ms) and anterograde conduction in 8 of 9 patients (effective refractory period 284 +/- 57 ms). The mean cycle length of orthodromic reciprocating tachycardia and atrioventricular nodal reentrant tachycardia increased significantly. After flecainide tachycardia was noninducible in 6 patients with orthodromic reciprocating tachycardia and in 1 with atrioventricular nodal reentrant tachycardia. It was inducible but nonsustained (less than or equal to 30 seconds) in 1 patient with orthodromic reciprocating tachycardia and in 3 with atrioventricular nodal reentrant tachycardia. Fifteen patients continued oral flecainide treatment for 19 +/- 11 months.(ABSTRACT TRUNCATED AT 250 WORDS)     

食管电生理诊断阵发性室上性心动过速

目的探讨食管电生理诊断阵发性室上性心动过速(paroxysmal supraventricular tachycardia,PSVT)及分型的准确性。方法收集经食管电生理和心内电生理检查并行射频消融治疗的PSVT42例,将两种电生理对PSVT的诊断及分型进行比较,用X2检验,以P<0.05为差异有统计学意义。结果两种电生理检查诊断房室结双径路、慢快型房室结折返性心动过速、常见的顺向型房室折返性心动过速差异无显著性,食管电生理对房室旁路的粗略定位准确性较高,但对快慢型房室结折返性心动过速、慢房室旁路参予的房室折返性心动过速与房性心动过速不易辨别。结论食管电生理诊断常见类型的PSVT与心内电生理有相似的价值,且具有无创、简便、费用低等优点;但对不常见或复杂的PSVT不易辨别。     

Slow pathway ablation in children with documented reentrant supraventricular tachycardia not inducible during invasive electrophysiologic study

Radiofrequency catheter ablation (RFA) has become the procedure of choice for permanent therapy of atrioventricular nodal reentrant tachycardia (AVNRT). This report presents our experience with atrio-ventricular node (AVN) modification in patients with documented narrow complex reentrant SVT, but no evidence for an accessory pathway, and no inducible tachyarrhythmia during invasive electrophysiology (EP) study. METHODS: The study population consists of nine children, age range 6-13 years (median 9) with previously documented SVT who had no tachyarrhythmia inducible during EP study (at baseline and following isoprenaline infusion). Eight of the 9 EP studies were performed under general anesthesia, and one under conscious sedation. An accessory pathway was excluded in all patients by appropriate atrial and ventricular extrastimulus pacing techniques. Eight of the nine patients had dual AV nodal physiology, and one had single AV nodal echo beats. The slow AV nodal pathway was empirically ablated, by applying RF lesions in the right inferoseptal AV groove, achieving catheter tip temperature of 50 degrees C. The appearance of an accelerated junctional rhythm during RF application was deemed to denote a successful application site. AV conduction during RF application was confirmed by incremental atrial pacing. The catheter position, and its relation to the compact AV node was constantly monitored using the LocaLisa navigation system. The end-point was absence of dual AVN physiology, and/or AV nodal echo beats. RESULTS: Successful slow pathway ablation was achieved in all patients. One patient appeared to have two separate slow pathways with different locations and two AH-jumps, which were both successfully ablated. None of the patients had evidence of temporary or permanent AV block at follow-up (median duration 9 months, range 4 to 36 months); none has had recurrence of symptoms or documented tachyarrhythmia. CONCLUSIONS: In children with structurally normal hearts, a previously documented SVT, absence of an accessory pathway and noninducibility of SVT during EP study, empirical slow pathway ablation appears to be justified.     

快慢型房室结双径路心电图特征

目的 观察和总结快慢型房室结双径路患者临床心电图的表现及特征。方法 8例快慢型房室结双径路的诊断均经心内电生理检查证实。根据心电图、动态心电图、食管心房调搏及心内电生理检查等资料进行心电图特点的观察和总结,8例患者均进行了射频消融术的治疗。结果 8例患者心电图显示隐匿性房室结双径路的特点,同时还有以下几个特点：（1）100％伴有单次快慢型房室结折返性房早：（2）心动过速频率100－150bpm,相对较慢;（3）8例患者房室结前传曲线圆滑而无中断现象。射频消融术均获成功。结论 本文首次提出快慢型房室结双径路是一种隐匿性房室结双径路的概念,其具有较多特征性的心电图表现,注意这些特征对心电图及临床诊断有较大的助益,射频消融术是其安全有效的治疗方法。