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.     

房性期前收缩揭示房室结双径路与食管电生理检查结果的对比观察

目的探讨房性期前收缩对房室结双径路的诊断价值及其与食管电生理检查结果的符合情况。方法回顾性分析9例体表心电图中由房性期前收缩揭示为房室结双径路的患者,并行食管电生理检查。结果 9例体表心电图房性期前收缩揭示房室结双径路的患者,经食管电生理检查在S1S2程控期前刺激中,均观察到S2-R间期有跳跃性延长,证实存在房室结双径路传导现象,其中2例诱发慢快型房室结折返性心动过速。结论体表心电图中若房性期前收缩的P′-R间期存在跳跃性延长,可提示房室结双径路,但需食管电生理检查明确。     

经食管心脏电生理检查误诊房室折返性心动过速的不典型房室结折返性心动过速的特点及分析

目的探讨食管电生理检查中被误诊为房室折返性心动过速的不典型的慢快型房室结折返性心动过速的特点。方法回顾性分析5例误诊为房室折返性心动过速患者的食管电生理及心内电生理资料。结果 5例患者在食管电生理检查S1S2程控期前刺激中,均未观察到S2-R间期有跳跃性延长,心动过速的R-P-EB间期70ms;逆行P-波在V1导联直立,下壁导联倒置;食管电生理诊断为左后间隔隐匿性旁道参与的房室折返性心动过速。心内电生理诊断为慢快型房室结折返性心动过速,并成功消融慢径路。结论部分R-P-EB间期70ms的不典型慢快型房室结折返性心动过速食管电生理特点与后间隔隐匿性旁道参与的房室折返性心动过速类似,必要时需心内电生理检查加以明确。     

1∶2房室传导诱发房室结非折返性心动过速1例

基于动态心电图及食管电生理检查,以心内电生理检查为金标准,确诊1例为1∶2房室传导诱发房室结非折返性心动过速,经射频消融改良慢径后,最终根治心动过速.     

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。     

射频消融治疗多条折返径路的心动过速12例

目的 总结实用而有效的常规消融方法。方法 回顾分析了12例具有多条折返径路的心动过速病例的电生理检查结果，总结了其消融操作流程。结果 12例中，同时具有三条房室旁路1例，两条房室旁路者7例，一条房室旁路伴房室结多径路者2例，房室结三径路者2例。共计消融慢径2条、旁路19条（包括左侧旁路7条、右侧旁路12条，其中显性旁路10条，隐匿性旁路9条）。结论 消融前后详细，标准的心内电生理检查可提高多折返径路心动过速的检出率。     

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。     

怀疑AVNRT患者的经验性导管消融

目的探讨经验性慢径导管消融治疗临床疑似房室结折返性心动过速(AVNRT)的可行性。方法回顾分析本院1998年10月~2015年10月368例接受房室结慢径消融治疗患者的临床资料、电生理检查与导管射频消融治疗结果及随访结果,比较323例电生理检查证实存在房室结双径传导且能诱发AVNRT和45例存在房室结双径传导但不能诱发AVNRT患者的消融结果及平均7.8年随访期内心动过速复发率,另对21例疑似AVNRT但电生理检查无房室结双径传导,无可诱发心动过速,且未接受慢径消融治疗的患者进行了平均1.4年随访。结果经导管射频消融术中不能诱发AVNRT患者与术中能诱发心动过速患者首次慢径消融的成功率均为100%,且均无严重并发症发生;术中不能诱发心动过速患者随访期心动过速复发率(4.4%)高于术中能诱发AVNRT患者(1.5%)(p0.05%)。术中能诱发AVNRT患者消融后复发病例均为首次消融时未达到主要消融终点(A-H间期跳跃现象消失)者,术中未诱发心动过速患者消融后复发病例再次电生理检查时均未发现存在房室结双径传导现象,亦未再诱发心动过速。在平均1.4年随访期内38%的疑似AVNRT但未接受经验性慢径消融治疗的患者再次发生心动过速。结论对于电生理检查证实存在房室结双径传导但不能诱发心动过速的疑似AVNRT患者,经验性慢径导管消融治疗安全有效,但应尽量以A-H间期跳跃现象消失作为消融终点。对于电生理检查未证实存在房室结双径传导,且不能诱发心动过速的疑似AVNRT患者,应酌情选择经验性慢径导管消融治疗。     

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。     

长R-P’室上性心动过速(附5例报告)

报告在食管电生理检查中发现的5例长R-P＇室上性心动过速.这种心动过速一般包括:①持续性交界性折返性心动过速;②异位房性心动过速;③Ebstein畸形合并附加旁路;④快一慢型AV结内折返性心动过速;⑤隐匿性旁路伴长V-A传导时间.患者室上性心动过速常反复发作,对药物治疗反应极差,需依赖于详细的心内电生理检查确诊.由于多数类型的长R-P＇心动过速可通过手术和消融治愈,因此.对这类心动过速的诊断和鉴别诊断甚为重要.     

Suppressive effect of SUN1165 on supraventricular tachycardia

The electrophysiologic properties of SUN1165 and its suppressive effect on supraventricular tachycardia were assessed in 14 patients, nine with atrioventricular reentrant tachycardia (AVRT) and five with atrioventricular nodal reentrant tachycardia (AVNRT). This new agent prolonged the PR interval and QRS duration but did not alter the QT interval or the corrected QT interval. It did not alter the sinus cycle length or sinus node recovery time. The drug prolonged the AH interval, HV interval, and intraatrial conduction time but did not change the effective refractory periods of the right atrium or right ventricle. SUN1165 prevented the induction of tachycardia in six of nine patients with AVRT by a complete retrograde block of the accessory pathway and prevented AVNRT in four of five patients by a complete retrograde block of the fast atrioventricular nodal pathway as well. We conclude that SUN1165 is very effective in preventing AVRT or AVNRT. Larger studies with more patients are warranted.     

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。     

室性心动过速合并室上性心动过速的射频消融

目的报道7例室性心动过速（VT）合并室上性心动过速（sVT）的射频消融。方法7例患者男6例,女1例,平均年龄（21±9）岁。阵发性心动过速病史（3．7±2．0）年。术中心房和心室刺激诱发VT和SVT,并进行消融。结果7例患者心房或心室刺激能反复诱发和终止VT合并SVT。法洛四联症矫治术后右心室VT合并三尖瓣环峡部依赖性心房扑动（AFL）1例,其余6例均为维拉帕米敏感性左心室特发性室速（ILVT）,分别合并AFL1例,左后间隔旁路参与的顺向型房室折返性心动过速（AVRT）1例,冠状静脉窦口慢旁路参与的顺向型AVRT1例,慢慢型房室结折返性心动过速（AVNRT）1例,左侧游离壁旁路参与的顺向型AVRT2例。7例患者的两种心动过速均成功消融,所有患者消融术后随访2年,无一例VT或SVT复发。结论VT合并SVT并不少见,消融术中应放置必需的心腔内电极导管,完成详细电生理检查,避免漏诊。一次消融应根除两种疾病。     

aVR导联ST段抬高对阵发性室上性心动过速的鉴别价值

目的探讨aVR导联ST段抬高及其持续时间对阵发性室上性心动过速(PSVT)的鉴别价值。方法126例行射频消融治疗成功的PSVT患者,其中房室折返性心动过速(AVRT)65例,房室结折返性心动过速(AVNRT)61例。分析其aVR导联ST段抬高幅度及持续时间。结果65例AVRT中aVR导联ST抬高且持续时间≥0.08s有46例,61例AVNRT中有13例,诊断AVRT的敏感性、特异性及阳性预测值分别为70.8%,78.7%,78.0%;46例aVR导联ST段抬高的AVRT中左侧旁道占38例,诊断左侧旁道的敏感性、特异性及阳性预测值分别为79.2%,52.9%,82.6%。结论aVR导联ST段抬高及其持续时间有助于鉴别阵发性室上性心动过速,且其多发生于左侧旁道。     

Differentiating atrioventricular nodal reentrant tachycardia from atrioventricular reentrant tachycardia by DeltaHA values during entrainment from the ventricle

BACKGROUND: Differentiating atrioventricular nodal reentrant tachycardia (AVNRT) from orthodromic atrioventricular reentrant tachycardia (AVRT) can be difficult. The His bundle and atria are activated sequentially over the AV node during entrainment of AVNRT from the ventricle but simultaneously during supraventricular tachycardia (SVT). They are activated in parallel during entrainment of AVRT but sequentially during SVT. OBJECTIVE: The purpose of this study was to test the hypothesis that a DeltaHA (HA((entrainment)) - HA((SVT))) cutoff value of 0 reliably differentiates AVNRT from AVRT. METHODS AND RESULTS: Of 61 patients undergoing electrophysiologic evaluation for paroxysmal SVT, retrograde His-bundle potentials were recorded in 57 (93%) and entrainment performed in 49 (34 AVNRT, 15 AVRT). DeltaHA values during entrainment from the ventricle were significantly longer during AVNRT than AVRT (31 +/- 24 ms vs -38 +/- 31 ms, P <.001). All DeltaHA values were positive (minimum: 3 ms) for AVNRT and negative (maximum: -2 ms) for AVRT. DeltaHA of 0 had sensitivity, specificity. and positive predictive value of 100% for correct diagnosis. CONCLUSION: The DeltaHA criterion during entrainment of tachycardia from the ventricle reliably differentiates AVNRT (positive values) from AVRT (negative values).     

Unusual induction of slow-fast atrioventricular nodal reentrant tachycardia. Report of two cases

INTRODUCTION: Generally, the induction of typical atrioventricular nodal reentrant tachycardia (AVNRT) occurs with a premature atrial stimulus that blocks in the fast pathway and proceeds down the slow pathway slowly enough to allow the refractory fast pathway time to recover. We describe two cases in which a typical AVNRT was induced in an unusual fashion. RESULTS: The first case is a 41-year-old man with paroxysmal supraventricular tachycardia. During the electrophysiology study, the atrial extrastimulus inducing the typical AVNRT was conducted simultaneously over the fast (AH) and the slow pathway (AH'). A successful ablation of the slow pathway was performed. During the follow-up no recurrence was noted. The second case is a 52-year-old woman with a Wolff-Parkinson-White syndrome due to a left posterior accessory pathway. After 5 minutes of atrioventricular reentrant tachycardia (AVRT) induced by a ventricular extrastimulus, a variability of the antegrade conduction was noted in presence of the same VA conduction. In fact, a short AH interval (fast pathway) alternated with a more prolonged AH intervals (slow pathway) that progressively lengthened until a typical AVNRT was induced. The ablation of the accessory pathway eliminated both tachycardias. DISCUSSION: A rare manifestation of dual atrioventricular nodal pathways is a double ventricular response to an atrial impulse that may cause a tachycardia with an atrioventricular conduction of 1:2. In our first case, an atrial extrastimulus was simultaneously conducted over the fast and the slow pathway inducing an AVNRT. This nodal reentry implies two different mechanisms: 1) a retrograde block on the slow pathway impeding the activation of the slow pathway from the impulse coming down the fast pathway, and 2) a critical slowing of conduction in the slow pathway to allow the recovery of excitability of the fast pathway. Interestingly, in the second case, during an AVRT the atrial impulse suddenly proceeded alternately over the fast and the slow pathway. The progressive slowing of conduction over the slow pathway until a certain point which allows the recovery of excitability of the fast pathway determines the AVNRT. This is a case of "tachycardia-induced tachycardia" as confirmed by the fact that the ablation of the accessory pathway eliminated both tachycardias.     

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。     

下位法射频消融慢径路改良房室结治疗室上性心动过速23例

用下位法射频消融慢径路改良房室结治疗房室结折返性心动过速(AVNRT)18例,房室折返性心动过速(AVRT)5例.AVNRT中16例为慢—快型,1例快—慢型,1例慢—快型与快—慢型并存,18例慢径路全部阻断成功.AVRT中1例显性预激,4例隐性预激,有5例慢径路和3例房室旁路消融成功.射频放电时21例出现结性心律.无严重并发症出现.AVNRT病人中随仿1—15个月有1例复发,第二次射频成功.认为下位法射频消融阻断慢径路成功率高,并发症少.     

Electrophysiological effects and clinical efficacy of flecainide in childhood patients with supraventricular reciprocating paroxysmal tachycardia

The electrophysiologic effects of intravenous (i.v.) flecainide were evaluated in 13 patients (pts) with recurrent paroxysmal supraventricular tachycardia (PSVT): 6 pts had an overt accessory pathway, 2 a concealed anomalous pathway and 5 had an idionodal reentrant tachycardia (AVNRT). Another patients with overt preexcitation underwent electrophysiologic testing as part of a diagnostic investigation for syncope. After flecainide the effective refractory period of the right atrium and retrograde AV node, and anterograde and retrograde Wenckebach point significantly increased. The drug blocked retrograde conduction on the accessory pathway in 3 pts whereas anterograde conduction was blocked in all 7 pts with overt anomalous pathway. The mean cycle length of the atrioventricular reentrant tachycardia (AVRT) and of the AVNRT increased respectively from 269 +/- 34 msec to 332 +/- 25 msec (P less than .005) and from 286 +/- 9 msec to 380 +/- 64 msec (P less than .05). After i.v. flecainide, reentrant supraventricular tachycardia was no longer inducible in pts with AVRT and 1 with AVNRT, inducible but non sustained (less than or equal to 30 seconds in duration) in 1 pt with AVRT and in 3 with AVNRT. Thirteen pts continued oral flecainide treatment for a mean of 7.2 +/- 3.6 months (range 3 to 12 months). Tachycardia recurred in all 3 pts whose arrhythmia remained inducible and sustained after i.v. flecainide, and in 1 of 10 pts whose re-entrant supraventricular tachycardia was suppressed (6 pts) or inducible but non sustained (4 pts). Thus flecainide is an highly effective and well tolerated drug for the control of PSVT in infancy. The electrophysiologic drug testing with flecainide predicts its efficacy during chronic therapy in most patients.     

Pseudo-atrial fibrillation, rare manifestation of multiple anterograde atrioventricular nodal pathways

In patients with dual or multiple atrioventricular (AV) nodal pathways manifesting nonreentrant tachycardia or unusual forms of AV nodal reentry, paroxysmal atrial fibrillation is often misdiagnosed and patients may erroneously be considered for pulmonary vein isolation. Multiple anterograde slow AV nodal pathways, identified by >1 discontinuity in the anterograde AV nodal conduction curve, are not rare in patients with slow-fast AV nodal reentrant tachycardia (AVNRT). However, only 1 slow AV nodal pathway is usually involved in anterograde conduction during tachycardia. It was reported that patients with multiple anterograde slow AV nodal pathways presented with different tachycardia cycle lengths. For the first time, 2 patients with AVNRT in which maintenance of tachycardia was strictly dependent on participation of 3 different anterograde slow AV nodal pathways in an uniquely alternating sequence are reported. In both patients, a single application of radiofrequency energy in the posterior aspect of Koch's triangle eliminated simultaneously all evidence of anterograde slow pathway conduction. These findings implied that functional differences in a determined circuit based on nonuniform anisotropy rather than anatomically distinct pathways form the electrophysiologic basis for this rare variant of AVNRT. In conclusion, particularly in patients with lone atrial fibrillation who are potential candidates for pulmonary vein isolation, careful analysis of the surface electrocardiogram during irregular supraventricular tachycardia and invasive electrophysiologic examination helps identify rare arrhythmia mechanisms that can be cured by slow pathway ablation alone.