显性旁道在心房颤动时的标测与消融

目的　探讨心房颤动 (Af)时对显性旁道 (AP)的标测与消融方法。方法　 7例 AP患者 ,年龄 2 4～ 6 0岁。均有阵发性 Af史。Af发作伴旁道前传时的心室率为 12 0～ 2 0 0 bpm。采用经主动脉逆行法消融左侧旁道 ,经股静脉途径消融右侧旁道 ,以心室前向激动点最早、且有小 A波为靶点。结果　 7例患者标测到了较体表心电图预激波起点提前 2 5～ 5 0 ms的 V波 ,首次消融以 15 W能量放电 ,均在 1s～ 8s内旁道前传阻断。3例在旁道前传阻断的同时转为窦性心律 ;1例 30 min内自行转为窦性心律 ;3例经药物转为窦性心律。行心室起搏 ,6例旁道逆传已阻断 ,1例经消融后逆传阻断。随访 5～ 45个月 ,无旁道前传恢复的证据 ,亦无室上性心动过速发作。结论　在掌握适应证的前提下 ,Af时行射频消融阻断显性旁道是可行的。     

心房颤动时射频消融左侧显性房室旁道（附二例报告）

报道心房颤动（简称房颤）时射频消融左侧显性房室旁道（ＡＰ）成功２例，以探讨房颤时显性ＡＰ准确定位和成功射频消融的可能性。２例患者分别随访４和６个月，未发作室上性心动过速及房颤。提示房颤时射频消融左侧显性ＡＰ是可行的。消融成功的靶点电图特点为：①不规则小Ａ波和大Ｖ波。②振幅较大的ＡＰ电位。提出ＡＰ前传阻滞后，应于窦性心律时检测其逆传功能     

心房颤动时射频消融左侧显性房室旁道

报道心房颤动（简称房颤）时射频融左侧显性房室旁道（ＡＰ）成功２例，以探讨房颤时显性ＡＰ准确定位和成功射频消融的可能性２例患者分别随访４和６个月，未发作室上性心动过速及房颤。提示房颤时射频消融左侧显性ＡＰ是可行的。消融成功的靶点电图特点为：（１）不规则小ＡＩ皮和大Ｖ波。（２）振幅较大的ＡＰ电位。提出ＡＰ前传阻滞后，应于窦性心律时检测其逆传功能。     

利用单极标测在心房颤动时消融显性房室旁道

对12例预激综合征患者在心房颤动时以单极标测指导消融房室旁道，其中左侧显性旁道9例、右侧显性旁道3例。在消融成功的靶点图上，单极标测的心室激动较体表心电图QRS波群显示预激成分最明显的Delta波平均提前46±7ms。全部病例消融成功。平均随访7．9±5．1个月，除1例右侧旁道4个月后恢复旁道前向传导需再次消融外，其余11例常规和动态心电图既未见Delta波，也无房室折返性心动过速和心房颤动发生。结果提示对于心房颤动合并显性房室旁道的患者，采用单极标测，其图形易于迅速辨认、测量方法亦简单，用以指导消融成功率高。     

胺碘酮对预激综合征合并心房颤动患者射频消融时心房颤动发作的预防作用

探讨胺碘酮对预激综合征合并阵发性心房颤动 (简称房颤 )患者房室旁道电生理特性的影响及其在射频消融术中对房颤发作的预防价值。选择有阵发性房颤史的预激综合征患者 4 7例 ,在行射频消融术前 2周口服胺碘酮0 .2g,每日 2次 ;4 5例未服胺碘酮和其他抗心律失常药者作对照组。心电生理检查测定旁道前传、逆传不应期(ERP) ,记录房室折返性心动过速 (AVRT)的诱发率和房颤的发生次数、发作时间及发作时的心室率 ,所有患者均同时行射频消融治疗。结果 :胺碘酮组旁道前传、逆传ERP均较对照组显著延长 ( 3 19± 4 8vs 2 3 5± 2 6ms ;3 0 5± 5 6vs2 4 0± 2 3ms,P均 <0 .0 1)。射频消融术中旁道存在逆传者在两组间无显著差别 ( 85 .1%vs 87.2 %) ,而胺碘酮组房颤的发作次数显著降低 ( 19.1%vs 60 .0 %,P <0 .0 1) ,发作时间显著缩短 ( 8.2± 4 .3vs2 3 .6± 11.7min ,P <0 .0 1) ,房颤发作时的心室率显著减慢 ( 12 7± 2 8vs 165± 3 4次 /分 ,P <0 .0 1) ,胺碘酮组消融治疗成功率与对照组无显著性差异 ( 10 0 %vs 95 .6%,P >0 .0 5 ) ,但手术操作与X线透视时间均显著低于对照组 ( 115 .6± 4 1.2vs 15 3 .1± 5 0 .6min ;3 5 .8± 16.4vs 4 9.3± 2 0 .2min ,P均 <0 .0 1)。结论 :胺碘酮可以有效预防射频消融     

冷冻导管消融治疗各种心律失常的初步观察

目的探讨冷冻导管消融术在治疗不同心律失常中的安全有效性。方法2004年12月1日至6月30日82例心律失常的患者入选本研究进行冷冻消融治疗。其中男42例,女40例,年龄54.8±15.5岁。共计84例次心律失常接受冷冻消融术。对于手术的急性成功率,临床长期有效性以及术后的并发症进行评价。结果70例为非心房颤动(简称房颤)心律失常的总急性成功率为93%,其中房室结折返性心动过速(AVNRT)的成功率为92%(22/24);左、右侧旁道参与的房室折返性心动过速(AVRT)的成功率分别为88%(15/17)、83%(5/6);心房扑动的成功率为100%(19/19)。1例进行了房室结、3例进行了右室流出道室性心动过速冷冻消融,均获成功。1例AVNRT发生了肺栓塞并发症。随访7.0±4.0个月,1例左侧旁道参与的AVRT及1例心房扑动患者复发。14例阵发性房颤患者,共对51根肺静脉进行了冷冻电隔离,急性成功率为100%。1例发生心包压塞。随访6.8±5.0个月,12例临床症状得到改善,其中9例不需服用抗心律失常药而无房颤发生。3例服药维持窦性心律,2例患者房颤复发。结论冷冻消融是一种安全有效的消融方法,可作为各种心律失常包括房颤的首选消融方法。     

右侧显性房室旁道合并右后隔慢旁道的电生理特点和消融治疗

报道两例右侧显性房室旁道合并右后隔慢旁道的电生理特点和消融治疗。两例显性预激综合征接受射频消融治疗 ,心房和心室程控刺激评价消融前后电生理变化。心脏标测证实两例病人存在右侧显性房室旁道 ,阻断该旁道后AV间期延长达 16 3和 16 7ms,QRS波群变宽呈完全预激形 ,程控刺激和标测证实为右后隔慢旁道 ,前传速度慢但无递减传导 ,无VA传导 (例 1)或VA递减传导 (例 2 )。消融阻断慢旁道后AV再次延长达 188ms和 2 17ms,心室预激消失 ,QRS波群呈右束支阻滞形 ,心室刺激见VA分离。结论 :两例病人为右侧游离壁显性房室旁道合并右后隔慢旁道 ,前者掩盖后者的前向传导。正常房室传导束 (AVN HPS)的传导速度慢于慢旁道是其显现前传的原因。     

腺苷终止房室结和房室旁道折返性心动过速的心内电生理评价

探讨腺苷对阵发性室上性心动过速 (PSVT)的终止效果 ,观察PSVT终止后出现的心律失常。 2 5例患者 ,其中房室结折返性心动过速 (AVNRT) 11例、房室折返性心动过速 (AVRT) 14例 ,于心内电生理检查时 ,由前臂静脉注射(简称静注 )腺苷 6～ 12mg ,观察其终止心动过速的疗效和作用部位。结果 :11例AVNRT患者静注腺苷后 ,10例恢复窦性心律 ,其中 9例终止AVNRT于慢径前传 ,1例于快径逆传 ;14例AVRT患者静注腺苷后 ,14例均恢复窦性心律 ,终止AVRT 12例于房室结前传 ,2例于旁道逆传。心动过速终止后最常出现的心律失常是房性早搏和一过性Ⅰ和Ⅱ度房室阻滞 ;此外 ,室性早搏也很常见 ,部分患者可出现短阵室性心动过速 ,1例患者出现预激综合征伴心房颤动。结论 :腺苷终止PSVT有较高的成功率 ,但有潜在的促心律失常作用。     

射频消融房室交界区慢、快经区域对犬和人心房颤动时心室率的影响

本文观察经导管射频消融房室交界区慢、快径区域对大和人心房颤动时心室率的影响.方法 杂种犬4条,体重11±1.2kg.房室结折返性心动过速患者7例,年龄29～65岁.阵发性房颤患者4例,年龄62～70岁,其中2例为短P-R间期综合征.均先采用“下位法”消融慢径区域后,若房室结有效不应期或房颤时平均R-R间期无明显变化,则加行“快径”区域消融.房颤诱发采用猝发脉冲电刺激(人)或静滴氯化乙酰胆碱后猝发脉冲电刺激(犬).结果 7例房室结折返性心动过速患者中5例经下位法射频消融阻断慢径,房室结前传有效不应期及诱发房颤时平均R-R间期明显延长(222±33ms vs 285±42ms和539±44ms vs 656±53ms P<0.01),无并发症.4条大及4例阵发性房颤患者经心内电生理检查证实均无房室结双径路表现,选择性消融“慢径区域”后,房室结有效不应期和房颤时平均R—R间期无明显变化,加行“快径区域”消融后,房室结有效不应期和房颤时平均R—R间期明显延长(犬145±16ms vs 185±22ms和305±13ms vs 403±17ms P<0.01,人220ms vs 490ms和367ms vs 690msP<0.01),1例房颤患者术后3天出现Ⅲ°AVB,2周后恢复为Ⅰ°AVB.本文还在动物实验中观察到消融快径区域时,房侧靶点(A/V>1)较室侧靶点(A/V<1)更易于造成Ⅲ°AVB.结论 选择性射频消融慢径区域对减?     

阵发性室上性心动过速的分型、诊断和治疗

<正> 一、阵发性室上性心动过速(PSVT) 是指起源于希氏束以上的心动过速,按其发生机制可分为三型。 (一)折返型室上速 (1)房室结折返性心动过速(AVNRT),此型最常见。其由房室结内纵向分离的慢、快通道形成折返径路。常见的为慢通道前传型,而由快通道前传的非典型AVNRT少见。(2)房室反复性心动过速(AVRT)。折返环包括心房、心室、房室结和房室旁道(Kent束)。可分为经房室结前传的顺向型和经旁道前传的逆向型二种,前者占90％。隐匿型预激因其旁道仅有逆向传导能力,窦性心律     

Localization and radiofrequency catheter ablation of left-sided accessory pathways during atrial fibrillation Feasibility and electrogram criteria for identification of appropriate target sites

Objectives. The purpose of the present study was to assess the feasibility of and electrophysiologic criteria for successful radio-frequency catheter ablation of left-sided accessory pathways during atrial fibrillation in patients with Wolff-Parkinson-White syndrome.Background. The onset of recurrent or sustained atrial fibrillation can complicate or significantly prolong accessory pathway catheter ablation procedures.Methods. We studied 19 consecutive patients (mean age [±SD] 44 ± 16 years) with Wolff-Parkinson-White syndrome who had ongoing atrial fibrillation with rapid anterograde conduction over the accessory pathway (mean ventricular rate [±SD] 173 ± 26 beats/min, range 130 to 220) at the beginning of the localization procedure during radiofrequency catheter ablation. Localization and ablation of the accessory pathway were performed with a 7F deflectable catheter (4-mm tip) that was placed underneath the mitral valve annulus. The electrophysiologic criteria from unipolar and bipolar local electrograms were compared for successful (n = 18) and unseccessful (n = 39) sites.Results. The accessory pathways were localized in the left posteroseptal (n = 6), posterior (n = 1), posterolateral (n = 7) and lateral (n = 5) regions and successfully ablated during atrial fibrillation in 18 (95%) of 19 patients with a mean of 3 ± 2 radiofrequency pulses (range 1 to 8, median 2). Presence of an accessory pathway potential (94% vs. 44%), early activation time of the ventricular electrogram (−3.2 ± 9.2 vs.−15.3 ± 12.6 ms) and recording of atrial activation (88% vs. 61%) from the ablation catheter were helpful in identifying successful sites (p < 0.001, p < 0.001 and p < 0.05, respectively, compared with unsuccessful sites). In addition, the ventricular activation time in relation to the intrinsic deflection of the unipolar electrogram was significantly earlier at successful than unsuccessful sites (18.1 ± 4.8 vs. 24.4 ± 6.6 ms, p < 0.01). A QS complex on the unipolar electrogram was observed at 96% of successful sites and at 94% of unsuccessful sites (p = 0.74). Multivariate logistic regression analysis revealed that the presence of an accessory pathway potential (p < 0.002) and early ventricular activation time in relation to the onset of the QRS complex (p < 0.001) were independent predictors of ablation success.Conclusions. Localization and radiofrequency catheter ablation of left-sided accessory pathways is possible in patients with sustained atrial fibrillation and rapid anterograde conduction over the accessory pathway during the ablation procedure. The electrophysiologic criteria described here can be used to reliably identify successful sites for radiofrequency ablation.     

Mahaim纤维的电生理特征和导管射频消融

探讨Mahaim纤维的电生理特征和导管射频消融的可行性。 1996年 5月至 1999年 4月对 4例拟诊为Mahaim纤维引起的逆向型房室折返性心动过速的病人进行了电生理检查和射频导管消融。男 3例、女 1例 ,年龄 31± 19岁 ,心动过速发作史 15± 14年 ,频率 2 0 1± 17(180～ 2 2 0 )次 /分 ,发作时均有明显的心悸症状。 4例窦性心律时心电图除 1例轻微预激外均正常。心房程序电刺激可以诱发心动过速。心室起搏时从房室结逆传 ,静脉注射ATP 2 0mg室房分离。 4例Mahaim心动过速均只有前传并呈递减传导特性。 1例同时合并房室结折返性心动过速。 2例导管操作发生心房颤动并经过Mahaim纤维前传 ,1例持续发作、1例短暂发作。 4例分别在心房起搏、心动过速和心房颤动时三尖瓣心房侧标测和消融。心室预激较体表V1导联QRS波起始处提前 40± 6 (34～ 46 )ms处消融均获成功 ,1例靶点位于右前侧壁、3例位于右后侧壁。能量 35± 5W ,消融 5± 3次 ,X线透视时间 38± 2 1min。无手术相关的并发症。合并房室结折返性心动过速 1例同时作了慢径改良。分别随访 3个月～ 3年无 1例心动过速复发。临床研究证实 ,导管射频消融是治疗Mahaim介导的心动过速的有效、可行和安全的方法     

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.     

Reappraisal of intermediate-term follow-up of radiofrequency ablation of accessory atrioventricular pathways for treatment of Wolff-Parkinson-White syndrome.

To evaluate the safety and efficacy of catheter mediated radiofrequency (RF) ablation in patients with Wolff-Parkinson-White syndrome, 125 patients with accessory pathway (AP) mediated tachyarrhythmias underwent RF ablation. Right-sided APs were ablated from the atrial aspect of the tricuspid annulus (all from the femoral vein approach) and the left-sided APs were ablated from the atrial or ventricular aspect of the mitral annulus. Immediately after ablation, 3 of 8 APs (38%) and 131 of 137 APs (95%) were ablated successfully with RF through a small-tip (2 mm) and a large-tip (4 mm) electrode catheter, respectively. Seven of the 11 APs where RF ablation failed had a later successful DC ablation. During follow-up (3 to 22 months), 11 of the 114 patients (10%) with successful ablation had return of accessory pathway conduction (2 had recurrence of tachycardia (2%)). Complications included transient myocardial injury (peak CK-MB 15 +/- 3 IU/l), transient proarrhythmic effects (more atrial and ventricular premature beats), accidental AV block (1 patient), cardiac tamponade (1 patient) and suspicion of aortic dissection (1 patient). In successful sessions, procedure and radiation exposure time were 3.8 +/- 0.2 h and 45 +/- 4 min, respectively. This study confirms that RF ablation with a large-tip electrode catheter is an effective and relatively safe nonsurgical method for treatment of Wolff-Parkinson-White syndrome.     

右前间隔房室旁路的自右房侧射频消融术

右前间隔房室旁路是整个导管消融中较为困难的部位。我们以射频电流消融4例均获成功。消融部位为希氏束导管正上方。3例患者记录到旁路电位。旁路与希氏束的平均距离为4.9 mm。当大头导管记录到大A小V波且无或仅有微小希氏束波时放电。1例并发不完全性右束支阻滞。平均随访8个月无复发。     

射频消融改良房室结控制特发性心房颤动所致快速心室率

采用射频消融改良房室结的方法控制７例特发性心房颤动（简称房颤）病人的快速心室率。５例持续性房颤在房颤时消融，２例阵发性房颤在窦性心律时消融，平均放电６±４次，６例成功，１例失败。成功的病例术后复查动态心电图示静息时房颤的平均最大心室率和平均心室率分别从术前的１６５±１１和１３６±１０ｂｐｍ下降到１１１±１４和８８±１１ｂｐｍ（Ｐ均＜０．００１）。平均随访５±４月患者无明显症状，不服药静息心室率均低于１１０ｂｐｍ，有１例阵发性房颤发作显著减少。结果提示：对于症状明显、药物治疗无效的特发性快速房颤的病例，射频消融改良房室结是控制心室率安全和有效的方法。有关机理和远期疗效有待进一步评价