灌注盐水大头电极导管在射频消融中的应用

目的初步探讨灌注盐水大头电极导管在射频消融中的方法和应用价值.方法 6例心动过速患者,经常规心内电生理检查诊断为Ⅰ型房扑2例,右室流出道室速2例,左、右心外膜旁道各1例,年龄34.2±16.7岁,男性4例,女性2例,上述患者均经普通的大头电极导管消融失败.常规穿刺静脉和放置电极导管行心内电生理检查.应用冷盐水灌注大头电极导管(Biosense Webster)标测、消融(方法同普通射频消融术).结果 6例均成功消融.2例房扑患者于三尖瓣环与下腔静脉之间的峡部行线性消融,AF终止,转为窦律,并且分别于冠状窦口和低位右房刺激呈峡部双向阻滞.2例右室流出道室速患者消融后行心室刺激及异丙肾上素激发试验均未诱发.2例心外膜旁道患者消融后心室刺激,出现VA文氏传导及室房分离,放电次数为3.4±1.2,手术时间为92.4±30.3分钟,曝光时间29.3±12.6分钟,无心肌穿空及血管并发症发生.随访6个月,无病例复发.结论灌注盐水大头电极导管对难治性心动过速行射频消融是安全有效的.     

慢传导带传导阻滞作为心房扑动消融终点的意义（附Halo导管应用一例报告）

应用Ｈａｌｏ导管标测技术，结合冠状静脉窦与希氏束电图识别心房扑动折返环的慢传导带，在下腔静脉口到三尖瓣环峡部作射频线性消融，并以慢传导带出现双向阻滞作为心房扑动消融成功的标志，治疗了１例Ｉ型心房扑动患者。随访１个月心动过速未发。由于Ｈａｌｏ导管能在右房内全面记录右房激动顺序，便于了解峡部的传导情况，在心房扑动消融中有助于明确其诱发与终止的机制，并为慢传导带传导阻滞作为成功消融终点提供了可靠的手段。     

先天性心脏病术后下腔静脉口-三尖瓣环峡部依赖性心房扑动的导管消融疗效分析

目的:报道先天性心脏病术后下腔静脉口-三尖瓣环峡部依赖性心房扑动的相对发生率及导管消融的疗效和安全性。方法:选择2002年1月-2006年4月在我院因先天性心脏病术后心房内折返性心动过速行射频消融的40例患者,应用常规电生理标测方法或三维标测方法(Carto和Ensite)指导导管消融,观察下腔静脉口-三尖瓣环峡部心房扑动相对发生率及其导管消融结果。结果:40例患者共诱发出50种房性心动过速,具有典型下腔静脉口-三尖瓣环峡部依赖性心房扑动心电图表现,且成功靶点在下腔静脉口和三尖瓣环峡部者31种(31／50,62．0％)。另外19种(19／50,38．0％)房性心动过速临床心电图表现与典型心房扑动不同,表现为P’波,其中11种(11／50,22．0％)成功靶点在右心房游离壁疤痕-下腔静脉峡部,瘢痕-上腔静脉峡部者2种,瘢痕与瘢痕之间峡部者2种;在瘢痕和三尖瓣环之间2种。房间隔补片和上腔静脉之间、房间隔补片和三尖瓣环之间各消融成功1种。40例患者射频消融成功,无并发症。随访1例患者心动过速复发,二次消融成功;1例患者出现持续性心房颤动伴RR长间歇,植入永久性起搏器。结论:先天性心脏病术后心房内折返性心动过速常常为下腔静脉口-三尖瓣环峡部心房扑动,导管消融具有较高的疗效和安全性。     

下腔静脉、三尖瓣环峡部的射频消融治疗心房朴动

目的：报道以下腔静脉、三尖瓣环峡部双向传导阻滞作为终点的心房扑动射顿消融方法，观察该终点对长期疔效的作用。方法；对5例Ⅰ型心房扑动患者的下腔静脉、三尖瓣环峡部进行射频消融。根据右房下侧壁和冠状静脉窦口起搏的右房激动顺序和传导时间变化、评竹蚨部传导阻滞。术后门诊随访观察。结果：5例患者分别于心房扑动(2例)和赛性心律(3例)时接受射频消融治疗，消融后峡部均发生双向传导阻滞。右房下侧壁和冠状静脉赛口起搏的右房激动顺序分别呈顺时针和逆时针单一方向，右房传导时间分别延长82和78ms。随访4个月无一例复发。结论：峡部双向传导阻滞是射频消融心房扑动成功的可靠标志在赛性心律下，亦可对Ⅰ型心房扑动患者进行消融。     

慢传导带传导阻滞和为心房扑动消融终点的意义

应用Ｈａｌｏ导管标测技术，结合冠状动脉窦与希氏束电图识别心房扑动折返环的慢传导带，在下腔静脉口到三尖瓣环峡部作射频线性消融，并以慢传导带出现双向阻滞作为心房扑动消融成功的标志，治疗了１例Ｉ型心房扑动患者。随访１个月心动过速未发。     

典型心房扑动的CARTO系统标测和消融

评价非X线CARTO系统在指导导管射频消融典型心房扑动 (简称房扑 )中的临床应用。 5例典型房扑 ,均为男性 ,年龄 40 .4± 15 .7岁。除 1例为先天性三房心 (经外科矫正 )外 ,余均无器质性心脏病。心动过速周期 2 0 5± 2 8ms。位于三尖瓣环和下腔静脉口间的峡部为消融部位。运用CARTO系统实时标测右房三维结构 ,并指导导管标测和消融峡部。消融后分别在冠状静脉窦和低位后外侧右房以 5 0 0ms起搏重建三维电解剖图 ,判定完全双向传导阻滞。 5例均消融成功 ,房扑不再诱发及产生确定的峡部双向传导阻滞。放电次数为 12 .7± 6 .5。手术时间为 2 78± 49min ,曝光时间为 16± 7min。随访 1～ 3个月无病例复发。结论 :本研究表明在房扑标测和消融中应用CARTO系统是安全有效的。消融后峡部两侧分别起搏重建峡部三维电解剖图 ,可准确判断线性损伤的连续性 ,证实完全双向传导阻滞 ,有利减少复发率。同时可减少X线曝光时间。     

对比观察射频消融右房后位峡部和间隔峡部治疗典型心房扑动的疗效

对比观察射频消融右房后位峡部和间隔峡部治疗心房扑动 (简称房扑 )两种方法的疗效。 41例房扑患者随机分为后位峡部组 ( 18例 )和间隔峡部组 ( 2 3例 ) ,消融线径分别为三尖瓣环—下腔静脉和三尖瓣环—欧氏嵴。成功消融终点为房扑不能诱发和峡部呈完全性双向阻滞。结果 :40例消融成功 ( 97.6 % ) ,无并发症。后位峡部组 3例和间隔峡部组 2例在首选消融方法失败后 ,改用另一种消融方法获得成功。两组患者的放电次数和手术时间均无显著性差异。平均随访 12 .4± 6 .8个月 ,在后位峡部消融成功者中 ,有 2例房扑复发。结论 :射频消融右房后位峡部和间隔峡部治疗房扑均安全有效 ,两种方法互补可以提高消融的成功率     

典型心房扑动导管射频消融终点评价

目的 :探讨峡部双向阻滞在射频导管消融 (RFCA)典型心房扑动 (AF)中的临床意义。方法 :将完成RFCA的 4 3例典型AF患者分为 3组 :①A组 ,12例 ,为静脉滴注 (静滴 )异丙肾上腺素 (1～ 5 μg/min)下不能诱发AF者 ;②B组 ,16例 ,为峡部发生双向传导阻滞者 ;③C组 ,15例 ,为在静滴异丙肾上腺素下 (1～ 5 μg/min)峡部双向传导阻滞者。对上述 3组患者进行常规的心内电生理检查及标测 ,下腔静脉至三尖瓣后叶或 (和 )三尖瓣隔叶至冠状窦口的欧氏嵴进行线性消融 ,以静滴异丙肾上腺素下不能诱发AF或峡部双向阻滞为消融终点。结果 :4 3例AF患者全部消融成功。A组中有 1例伴房室结折返性心动过速患者 ,进行房室结慢径改良后 ,AF不能被诱发。B组中有 1例并发房性心动过速及心房颤动患者 ,经过对AF线性消融后房性心动过速及心房颤动亦消失。随访 1～ 6 0个月 ,A组中有 4例复发 ,B组中有 2例复发 ,C组中无一例复发。结论 :下腔静脉、三尖瓣环和冠状窦口之间的峡部是典型AF折返环的一部分 ,RFCA治疗典型AF安全、可靠 ;静滴异丙肾上腺素下峡部双向传导阻滞作为典型AF的终点 ,可减少AF的复发     

Swartz鞘支撑下射频消融治疗心房扑动经验初步探讨

目的　了解８ ＦＳＡＦＬ型Ｓｗ ａｒｔｚ长鞘在心房扑动消融中的作用。方法　左前斜４５度影像定位下，在三尖瓣环５～６ 点处划线消融三尖瓣环与下腔静脉开口之峡部。结果　１１ 例普通型心房扑动患者全部消融成功，随访４～１８个月，１ 例复发，再次消融获得成功。结论　在峡部消融中应用Ｓｗａｒｔｚ长鞘能使大头导管良好固定，并使峡部组织与大头接触密切，较易做到峡部线性消融，达到相当于完全性双向阻滞的满意消融效果，且缩短透视和操作时间     

单导管标测在心房扑动射频消融中的意义

目的:探讨单导管标测法在心房扑动(房扑)射频消融中的应用方法和效果。方法:阵发性心房颤动并发房扑患者行肺静脉电隔离术时采用单导管标测法消融房扑30例。所有患者行肺静脉电隔离术后,将10极冠状静脉窦(CS)导管远端2对电极放置于CS内,余位于CS外,并使之有一定的张力,使导管贴靠于三尖瓣环和低右房。用冷盐水灌注消融导管线性消融三尖瓣峡部,房扑发作患者在房扑下消融,窦律患者在CS远端电极起搏下消融,可在术中随时把大头消融导管置于希氏束部位,用于评价是否已完全达双向阻滞,即:起搏CS远端电极,刺激信号至CS近端电极A波的距离大于至希氏束A波的距离,则CS口至低右房单向阻滞;CS近端电极起搏,刺激信号至CS远端电极A波的距离大于至希氏束A波的距离,则低右房至CS口单向阻滞,从而达双向阻滞,CS近端电极起搏所需电压较高,有的患者可达24mA。结果:所用阵发性心房颤动并发房扑患者均成功行三尖瓣峡部线性射频消融,达到双向阻滞,无手术相关并发症,随访4个月～2年,无房扑复发。结论:单导管标测法对房扑患者行三尖瓣峡部线性射频消融操作简单、快速,可完全用于评价消融结果,成功率高,并且节省手术费用。     

局部电位标测与影象定位法射频消融心房扑动的对比研究

对１６例心房扑动（简称房扑）患者，８例采用局部电位标测法，８例采用影象定位法进行射频消融。１２例普通型房扑全部消融成功，４例合并非普通型房扑者１例消融成功。局部电位标测法（消融成功５例）平均放电１１．８±４．４次、手术时间２２８．４±６．６ｍｉｎ、Ｘ线照射时间６０．８±１０．１ｍｉｎ；影象定位法（消融成功８例）依次平均为５．３±６．２次、１２２．５±２６．８ｍｉｎ、２９．８±１１．１ｍｉｎ，与前一种方法比较均有显著性差异，Ｐ值分别＜０．０５，０．００５，０．００１。提示后种方法优于前种方法。随访４５．５±２５．５周，３例复发。     

Right Coronary Artery Occlusion During RF Ablation of Typical Atrial Flutter

RCA Occlusion During RF Ablation . Right coronary artery (RCA) occlusion and acute myocardial infarction are rare during radiofrequency (RF) ablation of the cavotricuspid isthmus. Ventricular fibrillation (VF) or cardiac arrest in the periprocedural period may be the initial or only clinical manifestation. Septal or lateral RF delivery may increase the risk. We report 2 cases of RCA occlusion during ablation of typical atrial flutter (AFL). Angiographic and anatomical correlations are illustrated. One patient was ablated with a septal approach, the other with a lateral approach, and in each instance the RCA occluded near the ablative lesions. If septal or lateral ablation lines are contemplated during ablation of isthmus‐dependent atrial flutter, fluoroscopic or electroanatomic confirmation of catheter position is pivotal. Smaller tipped catheters, energy titration (to minimally effective dose), saline irrigation, or cryoablation should also be considered to help avoid this serious complication. (J Cardiovasc Electrophysiol, Vol. pp. 818‐821, July 2010)     

右房射频消融术治疗心房扑动

对５例阵发性心房扑动（简称房扑）患者行右房射频消融术。３例单型房扑消融成功，２例复合型房扑／房颤失败。３例成功者随访６个月无复发。房扑与右房内大折返运动有密切关系。射频消融结果与右房结构、房扑的类型及折返运动有关。右房射频消融的远期效果仍有待研究     

Randomized Comparison of Multipolar,Duty‐Cycled,Bipolar‐Unipolar Radiofrequency Versus Conventional Catheter Ablation for Treatment of Common Atrial Flutter

Comparison of Radiofrequency Versus Conventional Catheter Ablation. Introduction: Radiofrequency (RF) catheter ablation has been established as an effective and curative treatment for atrial flutter (AFL). Approved methods include a drag‐and‐drop method, as well as a point‐by‐point ablation technique. The aim of this study was to compare the acute efficacy and procedural efficiency of a multipolar linear ablation catheter with simultaneous energy delivery to multiple catheter electrodes against conventional RF for treatment of AFL. Methods: Patients presenting to our department with symptomatic, typical AFL were enrolled consecutively and randomized to conventional RF ablation with an 8‐mm tip catheter (ConvRF) or a duty‐cycled, bipolar‐unipolar RF generator delivering power to a hexapolar tip‐versatile ablation catheter (T‐VAC) group. For both groups, the procedural endpoint was bidirectional cavotricuspid isthmus block. Results: Sixty patients were enrolled, 30 patients each assigned to ConvRF and T‐VAC groups. Total procedure time (40.2 ± 15.8 min vs 60.5 ± 12.7 min), energy delivery time (8.5 ± 3.7 min vs 14.7 ± 5.2 min), radiation dose (14.5 ± 3.5 cGy/cm² vs 31.7 ± 12.1 cGy/cm²), and the minimum number of RF applications needed to achieve block (4.2 ± 2.4 vs 8.9 ± 7.2) were significantly lower in the T‐VAC group. In 7 patients treated with the T‐VAC catheter, bidirectional block was achieved with less than 3 RF applications, versus no patients with conventional RF energy delivery. Conclusion: The treatment of typical AFL using a hexapolar catheter with a multipolar, duty‐cycled, bipolar‐unipolar RF generator offers comparable effectiveness relative to conventional RF while providing improved procedural efficiency. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1109‐1113)     

Catheter inversion to achieve complete isthmus block in patients with typical atrial flutter

Endocardial catheter ablation is now considered as the therapy of first choice in highly symptomatic patients with recurrent atrial flutter. Despite of primary success rates between 90 and 100% complete isthmus block is sometimes hard to achieve. We present ablation results of 100 consecutive patients suffering from typical right atrial flutter. After a mean of 18 energy applications persistent bidirectional isthmus block could not be achieved in 16 patients and right atrial angiography was performed in all of them. In 9 patients a large Eustachian valve was detected and considered responsible for failure of endocardial catheter ablation of atrial flutter. Catheter manipulation targeting the anterior region of the Eustachian ridge was successful in all patients after looping the ablation catheter within the right atrium. With a mean of 3 additional RF applications, 6 of the 9 affected patients could be successfully ablated. Large Eustachian ridges are not a rare finding in patients undergoing ablation of typical right atrial flutter. Inversion of the ablation catheter within the right atrium is a simple technique providing excellent tissue contact of the ablation electrode with the anterior region of the Eustachian Ridge. Using this approach, the creation of bidirectional isthmus block is possible in the majority of the respective patients.     

典型心房扑动的经导管射频消融治疗

回顾分析 35例典型心房扑动 (简称房扑 )患者电生理检查和射频消融治疗的临床结果。心内激动标测显示沿三尖瓣环 (TA)逆钟向折返性房扑 2 7例 ,顺钟向折返 2例 ,同时存在二种折返 6例。 8例行TA峡部拖带起搏者均呈隐匿性拖带 ,起搏后间期与房扑周长差值为 1± 4(- 3～ 5 )ms。采用TA峡部双线性消融、后峡部或 /和间隔峡部消融的方法治疗所有患者均成功。 15例以房扑不能再诱发为手术终点 ,随访 10例 ,3例复发 ,复发率 30 % ;2 0例达到TA峡部双向阻滞 ,随访 19例 ,1例复发 ,复发率 5 % ,两组比较P <0 .0 5。随访的 2 9例中 ,7例发生心房颤动 (简称房颤 ) ,发生率 2 4%。与无房颤发作者相比 ,合并器质性心脏病、心房扩大和有房颤病史者的比例明显增加 (6 / 7比 9/ 2 2 ,6 / 7比 4/ 2 2和 7/ 7比 2 / 2 2 ,均P <0 .0 5 )。结果表明 ,心内激动标测结合拖带起搏技术可确定典型房扑的诊断 ,后峡部或间隔峡部消融是治疗房扑的有效方法 ,以TA峡部双向阻滞为手术终点较房扑不能被再诱发为终点可明显降低复发率。房扑消融术后发生房颤与合并器质性心脏病、心房扩大和术前存在房颤有关     

不纯心房扑动发生机制的心内电生理探讨

目的：心内电生理检查研究体表心电图不纯心房扑动的可能发生机制。方法6例患者经体表心电图证实有不纯心房扑动,射频消融时进行了心内电生理检查,并进行峡部阻断法消融心房扑动。结果：体表心电图与心心内电图同步记录证实,6例不纯心房扑动发作时均为右心房扑动、左心房颤动的心房脱节,心房扑动射频消融均获成功。随访期中2例复发,再次消融成功。结论：不纯心房扑动的发生可能是在右心房扑动的同时,左心房发生一过性颤动的结果。     

Successful radiofrequency catheter ablation of common atrial flutter at the bottom of a coronary sinus diverticulum

We describe a patient who underwent radiofrequency (RF) catheter ablation of cavo-tricuspid isthmus-dependent atrial flutter (AFL). Extensive ablation at the isthmus failed to terminate the AFL. A coronary sinus (CS) diverticulum arising from the proximal portion of the middle cardiac vein was found near the isthmus. An RF energy application at the bottom of the CS diverticulum resulted in completion of a bidirectional block line at the isthmus, as well as AFL termination.     

Electrophysiologic Characteristics and Radiofrequency Catheter Ablation in Patients with Clockwise Atrial Flutter

RF Catheter Ablation of Clockwise Atrial Flutter. introduction: Although the mechanism and radiofrequency catheter ablation of counterclockwise (typical) atrial flutter have been studied extensively, information about the electrocardiographic and electropbysiologic characteristics and effects of radiofrequency ablation in patients with clockwise atrial flutter is limited. Methods and Results: Thirty consecutive patients with clinically documented paroxysmal clockwise atrial flutter were studied. Endocardial recordings and entrainment study using a “halo” catheter with 10 electrode pairs in the right atrium were performed. Radiofrequency energy was applied to the inferior vena cava-tricuspid annulus (IVC-TA) and/or coronary sinus ostium-tricuspid annulus (CSO-TA) isthmus to evaluate the effects of linear catheter ablation. Eighteen patients had both counterclockwise and clockwise atrial flutters, and 12 patients had only clockwise atrial flutter. Both forms of atrial flutter had similar flutter cycle lengths (232 ± 30 vs 226 ± 25 msec, P = 0.526) but reverse activation sequences. Right atrial pacing at a cycle length 20 msec shorter than the flutter cycle length from the CSO-TA isthmus, IVC-TA isthmus, and the area between the two isthmuses revealed concealed entrainment with stimulus-to-P wave intervals of 32 ± 19, 95 ± 14, and 50 ± 17 msec (P = 0.022) in the counterclockwise form, and 110 ± 12, 40 ± 20, and 60 ± 15 msec (P = 0.018) in the clockwise form. In clockwise atrial flutter, 20 patients with biphasic P waves in the inferior leads had the presumed exit site of slow conduction area located at the low posterolateral right atrium; 10 patients with positive P waves in the inferior leads had the presumed exit site located at the mid-high posterolateral right atrium. Among the 18 patients with both forms of atrial flutter, linear ablation lesions directed at the IVC-TA isthmus eliminated both forms of atrial flutter in 14 patients; in the remaining 4 patients. CSO-TA linear lesions eliminated the counterclockwise form and IVC-TA lesions eliminated the clockwise form. Among the 12 patients with the clockwise form only, CSO-TA linear lesions eliminated flutter in 2 and IVC-TA linear lesions eliminated flutter in 10 patients. Successful ablation was confirmed by creation of bidirectional conduction block in the IVC-TA and/or CSO-TA isthmus during pacing from the proximal coronary sinus and right posterolateral atrium sandwiching the linear lesions. During the follow-up period of 17 ± 8 months, 2 patients had recurrence of clockwise atrial flutter, 1 patient had new onset of atypical atrial flutter, and 2 patients had new onset of atrial fibrillation. Conclusions: Counterclockwise and clockwise atrial flutters may have overlapping slow conduction areas with different exit sites. Radiofrequency catheter ablation using the linear method directed at the IVC-TA and CSO-TA isthmuses was feasible and effective in treating both forms of atrial flutter.