Nonpharmacologic Management of Supraventricular Tachycardia

This paper reviews three recent large scale studies on the use of catheter ablation for elderly patients with supraventricular tachycardia. These patients underwent catheter ablation of the atrioventricular junction for control of atrial fibrillation, ablation of the slow atrioventricular nodal pathway for those with atrioventricular nodal, reentry tachycardia, and ablation of the accessary pathway for those with atrioventricular reentry tachycardia. There was a higher incidence of atrioventricular junctional ablation and lesser incidence of junctional tachycardia compared to other series involving younger individuals. There was no significant difference in the incidence of successful procedures comparing the elderly with younger patients. In addition, there was no significant difference in the incidence of adverse effects between the two groups. In summary, catheter ablation appears to be safe and effective for elderly patients and the procedure should not be omitted solely on the basis of patient age.     

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。     

射频消融术治疗阵发性室上性心动过速的临床疗效分析

目的分析射频消融术治疗阵发性室上性心动过速的临床疗效。方法选择我院2010年3月—2013年3月收治的阵发性室上性心动过速患者180例,采用随机分层法将其分成对照组和观察组,各90例。对照组患者给予常规药物保守治疗,观察组患者给予射频消融术治疗,比较两组患者治疗效果、并发症发生率及复发率。结果观察组治疗总有效率为88.9%(80/90),高于对照组的66.7%(60/90)(P0.05);并发症发生率为5.6%(5/90)、复发率为0,低于对照组的26.7%(24/90)、40.0%(36/90)(P0.05)。结论射频消融术治疗阵发性室上性心动过速疗效较好,且术后并发症发生率及复发率较低,具有较高的临床应用价值。     

三磷酸腺苷治疗阵发性室上性心动过速的疗效和电生理作用

目的　评价三磷酸腺苷快速静脉注射治疗室上性心动过速的疗效、安全性和作用机制。方法　 45例患者应用食管电生理检查诱发持续性室上性心动过速 ,观察 2 0 mg三磷酸腺苷快速静脉注射转复室上性心动过速时的心电图改变 ,并比较了阿托品对之的作用。结果　三磷酸腺苷转复成功率为 95 .6% (4 3 /45 ) ,起效时间为 1 2～ 3 9(2 2± 9)秒 ;3 9/43例终止部位为房室结前向传导 ;瞬间心律失常发生率达 5 8% (2 5 /43 ) ,其中 2例患者发生严重心室静止分别达 9.3和 1 0秒 ,87%患者出现明显的头晕、胸闷、面色潮红、胸痛等副反应 ;曾应用阿托品诱发者似有较高的转复有效率 ,窦性 P波恢复时间明显缩短 (670± 2 3 0 ms对 980± 3 70 ms,p<0 .0 5 ) ,心脏外副反应的发生率减少 ,程度减轻 ,且未见高度房室传导阻滞发生。结论　三磷酸腺苷快速静脉注射治疗室上性心动过速具有高效、快速等特点 ,但副反应发生率较高 ,其主要作用机制可能为其对房室结的直接抑制作用     

Management of the Child with Wolff-Parkinson-White Syndrome and Supraventricular Tachycardia:

Management of the Child with WPW. In the next decade, "better" management will be defined by cost effectiveness including morbidity, mortality, and cost. We used a cost-effectiveness model for children with Wolff-Parkinson-White syndrome (WPW) and supraventricular tachycardia (SVT) comparing medical, surgical, and catheter ablative treatment between age 5 years (estimated average age at first recurrence after infancy) and age 21. Charges were quantitated from actual hospital bills; mortality was estimated from the literature; morbidity was assessed by estimating the number of hours in SVT, hours in clinic, hours in routine hospital bed, and hours in hospital intensive care; and the hours were then multiplied by a severity factor, normalized to 1.0 for 1 hour of SVT (0.5 for 1 hour in clinic, 0.75 for routine hospital, and 2.0 for intensive care). Overall charges (5 to 21 years old) for catheter ablation ($17,236) were 39% of surgical management and 57% of medical management; estimated mortality for catheter ablation (5 to 21 years old including failures that reverted to medical management) was 0.15%, which was 10% of medical management and 28% of surgical management; morbidity for catheter ablation was 27.6 units, which was 32% of medical management and 36% of surgical management. Sensitivity analysis demonstrated that the catheter ablation strategy remained preferable throughout the range of plausible values of cost, mortality, and morbidity (including a repeat procedure for initial failures). Therefore, catheter ablation has lower cost, mortality, and morbidity than either medical management or surgery and is the treatment of choice for the child 5 years of age or older with WPW and SVT. This type of analysis can be used for other forms of chronic disease in children.     

Paroxysmal Supraventricular Tachycardia in the General Population

Objectives. We sought to determine the epidemiology and clinical significance of paroxysmal supraventricular tachycardia (PSVT) in the general population.Background. Current knowledge of PSVT has been derived primarily from otherwise healthy patients referred to specialized centers.Methods. We used the resources of the Marshfield Epidemiologic Study Area, a region covering practically all medical care received by its 50,000 residents. A review of 1,763 records identified prevalent cases as of July 1, 1991 and all new cases of PSVT diagnosed from that day until June 30, 1993. A mean follow-up period of 2 years was completed in all incident patients. Patients without other cardiovascular disease were labeled as having “lone PSVT.”Results. The prevalence was 2.25/1,000 persons and the incidence was 35/100,000 person-years (95% confidence interval, 23 to 47/100,000). Other cardiovascular disease was present in 90% of males and 48% of females (p = 0.0495). Compared with patients with other cardiovascular disease, those with lone PSVT were younger (mean 37 vs. 69 years, p = 0.0002), had a faster PSVT heart rate (mean 186 vs. 155 beats/min, p = 0.0006) and were more likely to have their condition first documented in the emergency room (69% vs. 30%, p = 0.0377). The onset of symptoms occurred during the childbearing years in 58% of females with lone PSVT versus 9% of females with other cardiovascular disease (p = 0.0272).Conclusions. There are ∼89,000 new cases/year and 570,000 persons with PSVT in the United States. In the general population, there are two distinct subsets of patients with PSVT: those with other cardiovascular disease and those with lone PSVT. Our data suggest etiologic heterogeneity in the pathogenesis of PSVT and the need for more population-based research on this common condition.     

《2019 ESC室上性心动过速患者管理指南》解读

<正>2019年9月欧洲心脏病学年会发布了《2019 ESC室上性心动过速患者管理指南》^[1]。新版指南对一些概念进行了修订,更加详细地解释了支持机构的来源及相关条件的客观性,对临床实践提出了最新的共识建议,总结了该领域的最新进展,并对许多推荐药物进行了删减和推荐级别的调整。此外,导管消融技术的适应证也发生了变化。现从室上性心动过速(SVT)诊治的总体原则及不同类型SVT的诊断和治疗等方面对新版指南的推荐建议作出解读。     

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.     

Use of Propafenone in Patients With Supraventricular Tachycardia

Propafenone prolongs refractoriness and slows conduction of the atrium, atrioventricular node, and accessory atrioventricular pathway. By interfering with conduction in locations necessary to support supraventricular tachycardia, propafenone effectively treats several mechanisms of rhythm disturbance. Early experience shows that propafenone, when administered in the electrophysiology laboratory, effectively terminates or prevents reinduction of paroxysmal supraventricular reentrant tachycardia in 50% to 75% of patients. The most effective dose associated with the fewest side effects has been 2 mg/kg infused over 10 minutes. Long-term success with propafenone has been demonstrated in patients with paroxysmal atrial fibrillation, paroxysmal atrial flutter, atrioventricular node reentrant tachycardia, atrioventricular reentrant tachycardia using a concealed accessory pathway, and tachycardias associated with the Wolff-Parkinson-White syndrome, including paroxysmal atrial fibrillation and atrioventricular reentrant tachycardia. In 67% (range, 27% to 89%) of patients receiving long-term therapy with propafenone, episodes of supraventricular tachycardia have been either eliminated or significantly reduced in frequency and treatment has not had to be stopped because of side effects. The effective daily dose for longterm therapy has been 550 to 750 mg administered in three or four divided doses. Although the number of patients reported in the literature at this time is small, propafenone appears to be an effective agent for treating supraventricular tachycardia due to one of several mechanisms.     

心电图aVL导联对阵发性室上性心动过速折返途径的鉴别作用

目的:研究体表心电图aVL导联对阵发性室上性心动过速的鉴别诊断作用。方法:选取2009-01至2009-11因症状性阵发性室上性心动过速在我院行心脏射频消融术(RFCA)治疗的连续病例112例,按心动过速类型分为房室结折返性心动过速(AVNRT,n=60)和房室折返性心动过速(AVRT,n=52),比较两者心电图特点。结果:AVNRT与AVRT患者在年龄上差异没有统计学意义(P0.05),但是AVNRT中女性患者的比例多于AVRT(55.6%和33.3%,P=0.04)。aVL切迹与V1导联伪R波及下壁导联伪S波(标准心电图算法)发生在AVNRT的比例均大于AVRT(P均0.001)。aVR导联ST段抬高发生在AVNRT的比例小于AVRT(P=0.0001),并且在AVRT患者中71.4%为左侧旁道。QRS电交替在AVRT和AVNRT间差异没有统计学意义(P0.05)。aVL切迹和V1导联伪R波及下壁导联伪S波诊断AVNRT的敏感性分别为53.3%、46.7%,42.2%,特异性分别是82.1%、84.6%、94.9%。aVL切迹诊断AVNRT的敏感性高于V1导联伪R波及下壁导联伪S波(标准心电图算法),但是三者之间差异没有统计学意义(P0.05)。结论:aVL切迹多发生于AVNRT并有助于AVNRT和AVRT的鉴别诊断。     

Influence of Beta-Adrenergic and Vagal Activity on the Effect of Exogenous Adenosine on Supraventricular Tachycardia Termination

Adenosine, which binds to cell surface receptors and couples with guanosine triphosphate-binding inhibitory proteins (G_i), is potent in terminating supraventricular tachycardia (SVT). However, whether the differences in autonomic tone will influence this effect remains unknown. This study was designed to investigate the role of

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-adrenergic and vagal activity on the action of adenosine. Forty patients with clinically documented SVT (22 with atrioventricular node reentrant tachycardia and 18 with atrioventricular reciprocating tachycardia) were divided into 4 groups with 10 patients in each group. In groups 1 and 2, adenosine was intravenously injected during the baseline state and during infusion of isoproterenol (2 and 4

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, respectively). Group 2 patients received atropine (0.04 mg/kg) injection before isoproterenol infusion. In groups 3 and 4, intravenous injection of adenosine was given during the baseline state and after injection of atropine (0.02 and 0.04 mg/kg, respectively). Group 4 patients received propranolol (0.2 mg/kg) before atropine injection. The minimal dose of adenosine to terminate tachycardia during isoproterenol infusion of 2

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was greater than that during the baseline state in both groups 1 and 2. The minimal dose of adenosine during isoproterenol infusion with 4

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was higher than that with 2

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in group 2, but not in group 1 patients. In both groups 3 and 4, the minimal dose of adenosine required to terminate tachycardia during atropine injection with 0.02 mg/kg was greater than that during the baseline state. The minimal effective dose of adenosine during atropine injection with 0.04 mg/kg was higher than that with 0.02 mg/kg in group 4, but not in group 3 patients. In conclusion, either limb of the autonomic nervous system may modulate the adenosine dosage required for termination of SVT. Patients taking drugs such as

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blockers or vagolytic agents may need alterations in the dose of adenosine for therapy.Infusion of isoproterenol or atropine increased the minimal effective dose of intravenous adenosine required for termination of supraventricular tachycardia. This suggested that differences in autonomic tone may influence the effects of adenosine.     

Speech‐Induced Atrial Tachycardia: An Unusual Presentation of Supraventricular Tachycardia

A 63‐year‐old male radio announcer was admitted with a narrow complex, long RP tachycardia. While in the awake state, the patient spoke in his radio voice, initiating and maintaining the tachycardia. Three‐dimensional electroanatomic mapping during electrophysiology study localized the tachycardia to the ostium of the right superior pulmonary vein. After single radiofrequency energy application, no further arrhythmias were inducible with speech. At more than 1 year of follow‐up, the patient had no recurrences and continues to work as a radio announcer.     

射频消融治疗室上性心动过速的临床疗效评价

采用射频电流导管消融（ＲＦＣＡ）治疗室上性心动过速（ＳＶＴ）５１９例，总成功率为９５．０％（４９３／５１９）。其中旁道参与的ＳＶＴ３７９例（共３８４条旁道），离断３７５条，成功率（９７．７％）；房室结折返性心动过速１３４例，阻断慢径成功率９４．７％（１２６／１３３）；房性心动过速６例，成功４例，成功率６６．７％。８例患者出现并发症。随访１～５２月，２４例ＳＶＴ复发（４．６％），再次接受ＲＦＣＡ后均获成功。     

Influence of Ventriculoatrial Timing on Hemodynamics and Symptoms During Supraventricular Tachycardia

Aims: Patients with reentrant supraventricular tachycardia (SVT) are often highly symptomatic and the mechanism of symptoms is not well understood. We hypothesized that variation in ventriculoatrial interval (QRS to P) modulates the left atrial pressure and symptoms during tachycardia.
Methods and Results: Three hundred twenty-six patients awaiting electrophysiological study completed a questionnaire regarding "neck pounding" or "shirt flapping" during tachycardia. Mean left atrial pressure was measured during simulated atrioventricular reentry tachycardia (AVRT) and atrioventricular nodal reentry tachycardia (AVNRT) in 18 patients. Pulmonary venous flow reversal was assessed using transesophageal echocardiography in 12 dogs when pacing at 220 bpm with different VA delays (0 to 250 ms). "Shirt flapping" is present more often during AVNRT than during AVRT (58.6% vs 43.8%, respectively, P < 0.05). Simulated AVNRT is associated with higher left atrial pressure compared with AVRT (19.4 ± 4.8 mmHg vs 13.7 ± 3.9 mmHg, respectively, P < 0.05). In dogs, pulmonary venous flow reversal during atrial systole was observed with significantly decreasing amplitude as VA delays increased: 668 ± 167% at 0 ms; 492 ± 138% at 100 ms; 278 ± 148% at 180/ms; and 134 ± 91% at 220 ms.
Conclusion: " Shirt flapping" and "neck pounding" frequently occur during AVNRT. LA contractions during AV valve closure increase left atrial pressure and may explain differences in certain symptoms between AVNRT and AVRT.     

阵发性室上性心动过速时晕厥原因的多因素分析

目的:了解阵发性室上性心动过速时发生晕厥的影响因素.方法:310例反复发作的阵发性室上性心动过速患者,其中22例既往心动过速发作时并发晕厥者为晕厥组,288例为无晕厥组.阵发性房室结折返性心动过速62例,房室折返性心动过速248例,所有患者心动过速类型由心内电生理检查确定.多因素分析其性别、年龄,心动过速时心率(次/分)、心动过速病史(年)和类型等与室上性心动过速时发生晕厥的关系.结果:晕厥组女性患者晕厥比例显著多于非晕厥组(P=0.02);房室结折返性心动过速患者比例亦显著多于非晕厥组(P=0.03).而两组间平均年龄、心动过速时的平均心率、心动过速病史均无显著性差异(P＞0.05).结论:女性及房室结折返性心动过速与晕厥相关,而患者年龄、心动过速病史、心动过速时的心率与晕厥无关.