起源于冠状静脉窦口内的房性心动过速1例

1　临床资料　男性 ,18岁 ,发现心悸 ,心动过速 14年。患者4岁时因感冒后出现心悸、气短、脉搏短绌去当地医院就诊 ,心电图诊断为房性心动过速 ,最高心率达 180～ 190 / min。以后一直按心肌炎、心律失常治疗 ,效果不明显 ,口服异搏定、心律平、胺碘酮等药物无效 ,为行射频消融入院。胸片、心脏超声检查正常 ;心电图提示 :房性心动过速 , , , ,a VF,V4,V5,V6导联 P波为负 ;a VL,V1 ,V2 ,V3 导联 P波为正。根据 P波情况 ,考虑为起源于冠状静脉窦口附近的房性心动过速 ,但不排除左房下部房速。于 2 0 0 0 - 0 8- 0 3在导管室行心内电生…     

起源于冠状静脉窦口的房性心动过速九例

目的报道9例起源于冠状静脉窦口附近的房性心动过速(简称房速)。方法回顾分析2005年11月至2009年1月行射频消融治疗的59例房速患者,发现9例起源于冠状静脉窦口。其定义为标测的最早激动点位于冠状静脉窦口周1 cm范围以内的区域并在此消融成功。结果9例靶点局部A波激动时间领先体表P波起点39±12(30~53)m s。房速体表P波具有以下特点:Ⅱ、Ⅲ、aVF导联P波呈负向波,I导联呈等电位线或低幅正向波,aVL导联呈正向波,多数病例V1导联P波前半部分为等电位线,后半部分为正向波,胸前导联P波由右向左在V3~V6导联逐渐移行为负向。结论冠状静脉窦口是右房房速的一个重要起源点,其体表心电图有明确特征。     

预激综合征左心房与冠状静脉窦电连接伴双心房电位一例

外科手术已证实，左心房与冠状静脉窦之间存在电连接。解剖学研究结果表明，形态学与心房肌相同的肌束环绕于冠状静脉窦，这些肌束以不同方式与左心房相连，这种连接越靠近远端越少。犬心脏实验表明，左心房起搏时冠状静脉窦电图上的双心房电位分别来自左心房和冠状静脉肌束。我们观察到1例预激综合征患，在阵发性室上性心动过速（PSVT）和心室起搏时冠状静脉窦电图记录到双心房电位，现报道如下。     

冠状静脉窦起搏治疗阵发性心房颤动

心房颤动 (房颤 )的治疗一直是临床难点 ,起搏治疗是临床的选择之一。 1997年 ,Papageorgiou等[1] 的电生理研究表明冠状静脉窦起搏能有效防止房颤发生 ,但冠状静脉窦起搏治疗阵发房颤的长期临床应用尚未见报道。资料和方法患者 6例 ,男性 ,年龄 6 4～ 79(平均 6 9 2 )岁。 6例均为病态窦房结综合征 (病窦 )患者 ,其中 3例合并高血压性心脏病。超声心动图测定左心房直径为 2 7 3～ 37 5 (平均33 7)mm ,其中 3例左心房增大。 6例患者均反复发生阵发性房颤 ,其中 2例合并心房扑动、1例合并二度房室阻滞 ,5例窦性心律时体表心电图P波时限≥ 0 …     

冠状静脉窦口起搏对心房激动时间影响及方法学探讨

目的观察冠状静脉窦口起搏对心房激动时间的影响，并探讨该部位起搏的方法学。方法包括两部分，首先对20例射频消融的患者行心内电生理检查，术中分别给予高位右心房（HRA）、冠状静脉窦口（CS9-10）、左心房游离壁（CS1-2）起搏，记录刺激信号至腔内电图最远A波为心房激动时间；HRA至CS1-2的AA间期作为左、右心房间激动时间差，同时测量体表心电图最长P波时限。第二部分研究在可控弯导丝系统的辅助下将心房主动电极导线固定在冠状静脉窦口，比较冠状静脉窦口起搏与HRA起搏的起搏参数及起搏后体表心电图P波时限。结果冠状静脉窦口起搏时P波时限、心房激动时间及左、右心房激动时间差较窦性心律下、高位右心房及左心房游离壁起搏时均明显缩短。两组患者术中及术后起搏参数差异无统计学意义，冠状静脉窦口起搏患者体表心电图P波宽度明显缩短。结论冠状静脉窦口起搏时心房激动时间明显缩短，左、右心房间激动时间差最短。采用可控弯导丝系统的辅助可实现冠状静脉窦口起搏。     

起搏预防阵发性快速性房性心律失常

阵发性快速性房性心律失常主要包括阵发性房性心动过速 (房速 )、心房扑动 (房扑 )及心房颤动 (房颤 ) ,临床较常见 ,呈反复、交替、频繁发作。这一方面可抑制窦房结自律性 ,导致窦房结功能障碍 ;另一方面可使心房发生电重塑 ( electrical remodeling)及收缩功能障碍。这些结果又反过来促进快速性房性心律失常发作 ,形成恶性循环。多数患者最终将演变成永久性房颤 ,使心功能明显减退 ,可诱发或加重心力衰竭 ,严重影响患者的生活质量。另外 ,房颤尤其是阵发性房颤是血栓栓塞的主要原因。抗心律失常药物对此类心律失常疗效较差 ,长期服用抗心…     

永存左上腔静脉患者发生冠状静脉窦口房性心动过速射频消融一例

1例女性患者,心动过速病史10年,心脏超声检查发现永存左上腔静脉。三维激动标测提示房性心动过速起源于冠状静脉窦口前壁,成功消融后随访半年房性心动过速无复发。     

房性心动过速的心电图诊断

房性心动过速(房速)是指起源于心房组织，与房室结传导无关的室上性心动过速。房速的发生率约占全部室上速的7％-10％，随着射频消融术的开展，到1998年Duke大学医学中心的心律失常登记的资料显示房速的发生率在其登记的资料上已上升到18％。房速在儿童中发生率较高，占儿童室上速的第     

Iterative Atrial Tachycardia Originating from the Coronary Sinus Musculature

A case of iterative atrial tachycardia leading to dilated cardiomyopathy is reported. During electrophysiologic study, the tachycardia showed a markedly irregular cycle length associated with changes in atrial activation breakthrough as demonstrated by coronary sinus (CS) recordings and frequently degenerated into self-terminating atrial fibrillation. Left atrial transseptal mapping demonstrated the earliest endocardial atrial activation close to the posterolateral mitral annulus, but this was invariably later than that recorded within the CS, where low-energy radiofrequency applications eliminated the tachycardia. No acute vessel damage was observed at postablation CS angiography. In accordance with previously published experimental data, we hypothesized that the muscular sleeves surrounding the CS might be involved in the genesis of this tachycardia. During 6-month follow-up, the patient remained asymptomatic without tachycardia recurrences and with complete recovery of left ventricular function, confirming the reversible nature of the tachycardia-induced cardiomyopathy.     

Atrial Macroreentry Involving the Myocardium of the Coronary Sinus: A Unique Mechanism for Atypical Flutter

Macroreentry Involving the Coronary Sinus. Atrial flutter involving either clockwise or counterclockwise rotation around the tricuspid annulus utilizing the subeustachian isthmus has been well described. However, macroreentrant atrial circuits in atypical atrial flutter in patients who have not undergone previous surgery or without atrial disease are not well defined. We describe a patient without structural heart disease who presented with an atrial macroreentrant rhythm. Entrainment mapping demonstrated a critical isthmus within the coronary sinus. Activation mapping demonstrated double potential throughout the length of the coronary sinus with disparate activation sequences. A circuit involving the myocardium of the coronary sinus, exiting in the lateral left atrium, down the interatrial septum, and reentering into the coronary sinus was identified. Successful ablation of the rhythm was accomplished by a circumferential radiofrequency application within the coronary sinus.     

Left Atrial Conduction Along the Coronary Sinus During Ectopic Atrial Tachycardia and Atrial Fibrillation:

Introduction: Correlation function analysis was applied to endocardial electrograms to investigate conduction patterns along the coronary sinus (CS) during sinus rhythm (SR) and atrial tachycardias.
Methods and Results: Eighteen recordings were obtained from 14 patients with supraventricular tachycardias. Five atrial fibrillation (AF) recordings were compared to 10 SR recordings and 3 ectopic atrial tachycardia (EAT) recordings. The maximum correlation coefficient was used to assess similarity between signals, i.e., if they originate from the same wavefront. The cumulative time delay, calculated as pairwise summation of interelectrode time delays, was used as an indicator of activation sequence along the CS. Method validation using SR showed right-to-left conduction with high correlations in 8 of 10 recordings indicating one single wavefront. EAT recordings showed consistent left-to-right conduction with left atrial foci and right-to-left with right atrial focus and lower correlations than SR. All 5 AF recordings showed predominantly left-to-right conduction direction, also with correlations lower than SR.
Conclusion: (1) Correlation function analysis can be used to assess agreement between signals and direction of activation spread. (2) Due to the position of CS, the results can be used to derive mechanisms of interatrial conduction. (3) Consistency in electrical activity propagation along CS is common in AF. (J Cardiovasc Electrophysiol, Vol. 14, pp. S148-S153, October 2003, Suppl.)     

Supraventricular Tachycardia Due to Multiple Atrial Ectopic Foci: A Relatively Common Problem

Multiple Atrial Ectopic Foci. Atrial ectopic focus is a common mechanism for chronic incessant supraventricular tachycardia in children. The majority of patients require treatment because of symptoms or tachycardia-induced cardiomyopathy. Management with traditional drugs fails to restore sinus rhythm and surgery has heen thought to be curative. We have had 54 patients with atrial ectopic focus tachycardia; 40 right atrial (36 with normal P waves simulating sinus tachycardia), and 14 left atrial. Surgical treatment of tachycardia was performed in 28 patients; all 28 had a single abnormal P wave axis before surgery, had mapping in the electrophysiology lab, and were thought to have a single focus. However, in 14/28 (50%) after surgical removal of this focus, additional foci became apparent. In 11/14, the next focus appeared during surgery; between 3–15 additional foci were identifled and surgically treated. This resulted in cure in 9/11, but 2/11 despite almost total atrial disconnection, continued to have atrial ectopic focus tachycardia. The other three patients with multiple foci had atrial ectopic focus tachycardia recur with a diflPerent P wave axis from 1 week to 2 months postoperatively. Since the overall initial success rate for multiple foci was different from single foci, patients with multiple foci and single foci were compared to try to predict multiple foci. Patients with multiple foci had: (1) the same incidence of cardiomyopathy (78%); (2) faster maximum atrial rate on Holter (89% of multiple foci had a rate faster than 160/min vs 43% of single foci, (P < 0.05); (3) faster minimum atrial rate on Holter (89% of multiple foci had a minimum rate faster than 70/min vs 0% single foci, (P < 0.05); and (4) different preoperative electrocardiogram (0% multiple foci had left atrial P waves vs 44% of single foci, (P < 0.025). In conclusion: (1) approximately half the patients with atrial ectopic tachycardia had multiple foci; (2) surgical treatment of multiple foci was less successful than single foci, although with improvement in surgical techniques, even multiple foci were successfully eliminated by surgery, and surgery was successful in 100% of the last 10 cases; (3) multiple foci were unlikely with left atrial P waves and slower atrial rates. We speculate that atrial ectopic focus tachycardia may have different etiologies: multiple foci may be due to extensive atrial disease such as that found in primary cardiomyopathy or after myocarditis, whereas single foci may be a developmental aberration. (J Cardiovasc Electrophysiol, Vol. J, pp. 132–138, April 1990)     

P‐P Cycle Alternans During Atrial Tachycardia:

Background: A‐63 year‐old man complaining of palpitations underwent a 24‐hour ambulatory ECG monitoring that revealed the presence of recurrent episodes of nonsustained supraventricular tachycardia. Analysis of the tracings suggests an atrial origin of the arrhythmia. Tachycardias, quite regular at the beginning, suddenly showed a P‐P cycle alternans, namely, P‐P intervals alternately short and long. The evidence of two separate cycle ranges can be explained by the presence of a longitudinal dissociation within a discrete zone of the atrial circuit.     

双房单室三腔起搏器治疗病窦综合征并快速房性心律失常

观察双心房、单心室三腔起搏器治疗病窦综合征合并阵发性房性快速心律失常患者的疗效。三根电极导线分别置入冠状静脉窦内、右心耳和右室心尖部行三腔起搏。冠状窦电极导线与右心房电极导线通过一个Y型转接器构成心房部分。结果 :10例患者 ,9例经左锁骨下静脉径路置入导线 ,1例因存在残存左上腔静脉 ,从右锁骨下静脉置入。 10例中 9例冠状窦电极导线置于冠状静脉窦中部、1例置于冠状静脉窦远端。冠状窦起搏阈值为 1.0 6±0 .2 0V、起搏阻抗 6 11± 115 .8Ω、P波振幅为 4.0 7± 0 .88mV ;右室电极起搏阈值为 0 .5 3± 0 .12V、起搏阻抗 6 70 .3±191.7Ω、R波振幅为 9.6 6± 1.87mV。随访 5～ 2 4个月有 9例起搏器呈DDD工作方式 ,1例呈AAT工作方式。起搏和感知功能良好。 10例中 8例快速性房性心律失常完全控制 ,2例发作次数减少 ,持续时间明显缩短。无一例出现并发症。结论 :三腔起搏器技术安全、可靠。适合于缓慢型心律失常合并阵发性房性快速性心律失常     

Catheter Ablation for the Treatment of Paroxysmal Supraventricular Tachycardia

Catheter Ablation for PSVT. Radiofrequency catheter ablation has evolved into a front-line curative therapy for patients who have paroxysmal supraventricular tachycardia secondary to Wolff-Parkinson-White syndrome, AV nodal reentrant tachycardia, and atrial tachycardia. In patients with accessory pathways, cure rates exceed 90% in almost all anatomic locations. Equally high success rates are noted in patients with atriofascicular pathways and the permanent form of junctional reciprocating tachycardia. Complications secondary to catheter ablation of accessory pathways occur in 1% to 3% of patients and include cardiac perforation, tamponade, AV block, and stroke. In patients with AV nodal reentrant tachycardia, selective slow pathway ablation is curative in over 95% of patients with a very low risk of AV block. Atrial tachycardias originating in both the left and right atria can he successfully ablated in over 80% of patients. Given the overall effectiveness of this procedure, radiofrequency catheter ablation should be considered as front-line therapy in patients with recurrent or drug-refractory paroxysmal supraventricular tachycardia. Although an effective therapy, the risks and benefits of this procedure need to be assessed in all patients who are candidates for this procedure.     

Analysis of Posterior Mitral Annular Activation During Entrainment and Catheter Ablation of Mitral Isthmus Ventricular Tachycardia Using a Coronary Sinus Catheter

A detailed analysis of the ventricular activation along the posterior aspect of the mitral annulus was made using a multipolar catheter positioned in the coronary sinus in a patient with mitral isthmus ventricular tachycardia (VT) associated with a remote inferior myocardial infarction and prior cryosurgical ablation for the elimination of a different preexisting VT. A change in the timing and sequence of the ventricular activation along the isthmus could be observed during induction of the VT and entrainment pacing. A radiofrequency (RF) current application directed at the posterolateral region of the isthmus successfully eliminated this tachycardia. During the RF delivery, complete conduction block was confirmed by a sudden change in the activation sequence during sinus rhythm.