食管心电图辅助的心腔单导管消融房室旁路的方法学和临床意义

目的　 Kuck等提出的单导管消融房室旁路 (旁路 )的技术因缺乏心房电图而不适合隐匿旁路消融 ,也难以完整评价显性旁路消融的效果。本组报道经食管心电图 (TEE)辅助的心腔单导管法消融旁路的临床意义。　方法　 2 8例患者中显性旁路 1 3例 (左侧 9例 ,右侧 4例 ) ,隐匿性旁路 1 5例 (左侧1 3例 ,右侧 2例 )。同步记录心电图、TEE和消融电极局部电图。显性旁路在窦性心律标测和消融 ,隐匿性旁路诱发顺向型房室折返性心动过速 (AVRT)时标测和消融。消融导管刺激心室观察 TEE房波评价消融疗效。　结果　 2 8例均为单旁路参与的 AVRT,单导管消融成功 2 6例 (92 .9% )。左侧旁路消融的手术时间和 X线透视时间分别为 (2 5± 8) min和 (3 .9± 1 .3 ) min,右侧旁路消融则分别为 (3 4.2± 6.1 )min和 (1 0 .1± 5.1 ) min。　结论　 TEE辅助的心腔内单导管消融法可有效阻断旁路和评价消融效果 ,是一种在熟练掌握常规消融技术的基础上可采用的消融方法。     

Successful ablation of a concealed parahisian accessory pathway using a remote magnetic navigation system following failure by conventional methods

Objective Using conventional catheters, ablation of concealed parahisian accessory pathways may be difficult and high risk for heart block. Methods and results We describe the case of a concealed parahisian accessory pathway with three prior attempts to ablate using conventional methods (RF and cryotherapy). Using a remote magnetic navigation system, successful ablation occurred following a single RF lesion (total fluoroscopy time 17 min). In contrast to previous attempts, the patient remained asymptomatic during follow-up (12 months). Conclusions This is the first report of successful remote magnetic catheter ablation of a concealed parahisian AP. Magnetic catheter stability during RF application likely contributed to the success of this procedure and may have minimized the risk of AV block     

心外膜旁路的识别和射频消融治疗

目的　报道左侧心外膜旁路的特点和经冠状静脉窦射频消融术的结果。　方法　 5例左侧旁路患者先经心内膜标测和消融 ,由于不成功改由经冠状静脉窦标测 (左心室心外膜标测 ) ,记录到旁路电位即进行消融。　结果　 5例患者全部成功 ,成功消融靶点 :左侧游离壁 2例 ,左后间隔冠状静脉窦憩室 3例。有效靶点均标测到振幅较大的旁路电位 ,其振幅大于 A波和 V波。　结论　冠状静脉内标测到振幅较大的旁路电位是左侧心外膜旁路的重要标志 ;经冠状静脉窦消融可以有效的阻断心外膜旁路     

Radiofrequency catheter ablation of accessory pathways. Outcome and use of antiarrhythmic drugs during follow-up.

AIMS: The purpose of this study was to assess the acute and long-term success of accessory pathway ablation in a single large-volume centre, concentrating on long-term recurrences and the clinical use of antiarrhythmic drugs. METHODS AND RESULTS: A total of 519 consecutive patients (mean age 40+/-14 years) underwent radiofrequency ablation of manifest or concealed accessory pathways. The patients were seen in the hospital or by the referring physician at 6 and 12 months. Long-term follow-up information was obtained by questionnaire. Pathway conduction was abolished in 476 cases (91.7%). 'Redo' procedures, due to recurrence, were performed in 38 patients (7.3%) and were successful in 30 (78.9%). Follow-up data were obtained from 454 patients (87.5%) with a follow-up duration of 22. 6+/-12.4 months. Among the 398 patients with successful ablations who responded to the questionnaire, 340 (85.4%) were asymptomatic with only 10.6% taking antiarrhythmic drugs. An additional 20 patients (5.0%) had symptoms suspicious of recurrence. In total, 66 out of 398 successfully treated patients (16.6%) were taking antiarrhythmic drugs. Twenty-three out of 56 (41.1%) patients with failed ablations were asymptomatic, 12 of whom (21.4% of patients with failed ablations) had not been administered antiarrhythmic drugs. In the total group of 454 patients with ablation attempts and available follow-up data, 99 (21.8%) were still taking antiarrhythmic drugs during follow-up. CONCLUSIONS: Patients with successful ablation of accessory pathways show excellent long-term results. However, 17% of successfully treated patients were still taking antiarrhythmic drugs during the period of long-term follow-up. On the other hand, 21% of patients with failed ablations were symptom-free without antiarrhythmic drugs. On an intention-to-treat basis, 22% of the patients with ablation attempts were still taking antiarrhythmic drugs during follow-up.     

左中间隔房室旁道的射频消融

对 12例左中间隔房室旁道的心内电生理特点及其导管射频消融的方法学进行了分析。男 5例、女 7例 ,心动过速史 5～ 2 0年 ,年龄 46± 2 1岁 ,显性旁道 5例、隐匿性旁道 7例。显性旁道的体表心电图有Ⅰ、Ⅱ两种类型。结果 :显性旁道中心电图呈Ⅰ型者 3例、呈Ⅱ型者 2例。患者均成功地进行了射频消融 ,靶点位于左中间隔 ,其中 1例为慢旁道。操作时间 90± 30min、X线曝光时间 30± 11min、放电 13± 5次。 1例患者在消融时将His束和旁道同时阻断 ,导致Ⅲ度房室阻滞 ,另 1例为完全性左束支阻滞。结果提示左中间隔旁道较罕见 ,对左、右后间隔附近的旁道反复标测未找到理想靶点时 ,应考虑左中间隔旁道的可能 ;左中间隔旁道消融时应避免损伤His束     

Closed-chest ablation of left lateral atrioventricular accessory pathways

Thirty patients with a left lateral accessory pathway and drugrefractory tachycardia underwent attempted transcatheter ablationof the accessory pathway. Three had a concealed accessory pathwayand 27 had the Wolff-Parkinson-White syndrome. A quadripolarelectrode catheter was positioned within the coronary sinusin order to locate the earliest retrograde atrial activationduring orthodromic reciprocating tachycardia. The appropriatebipole was used as the radiographic and electrophysiologic referenceof the insertion of the accessory pathway. A catheter was thenintroduced into the left atrium, through a patent foramen ovale(six patients) or after transseptal catheterization (14 patients)according to Croft's technique, or using a retrograde transaorticapproach (10 patients). The mitral annulus was mapped with the left atrial catheterin order to record a synchronous or earlier atrial deflectionthan reference during reciprocating tachycardia. VA' time atthe preablation site was 82 ± 12 ms. Two to seven 160J cathodal shocks (650 ± 205 J cumulative per patient)were delivered at this site in 38 sessions. No significant side-effectsoccurred except for one case of right coronary artery spasmleading to inferior wall infarction. Following fulguration, accessory pathway conduction was abolishedin all patients but one with a second accessory pathway. Duringfollow-up of 1–34 months, all patients but one were freeof tachycardia: reciprocating tachycardia recurred in one patient,who had a concealed accessory pathway, on the third day. Accessorypathway conduction, assessed in 10 other patients 3–26months after the procedure, was absent. Coronary arteriographyperformed in seven patients was normal. Catheter ablation of left free-wall accessory pathways is bothsafe and effective with shocks directly delivered to the mitralannulus through a transseptal or transaortic catheter. It isan attractive alternative to surgical ablation of these accessorypathways.     

射频消融希氏束旁旁道的回顾性分析

目的 对10名希氏（His）束旁旁道（Ap）致倾向型房室折返性心动过速（O-AVRT）患进行射频消融（RFCA）治疗，综合分析X线曝光时间、操作时间、术后复发率和严重并发症发生率等因素，指出，His束电极的准确放置、尽量避免大头电极导管重复使用、术丰富的射频消融手术经验：包括介入操作技术和靶点图的识别，是安全有效进行His束旁旁道RFCA治疗的关键。     

Ablation of difficult right-sided accessory pathways aided by mapping of tricuspid annular activation using a Halo™ catheter

Objective To demonstrate that the use of a 20-pole catheter (Halo™) positioned around the tricuspid valve annulus (TVA) is helpful in rapidly localising right free wall accessory pathways (AP), enhancing catheter stability during ablation, and leading to increased success in ablating these challenging pathways. Patients and methods Seven consecutive patients who underwent Halo-mapping of right-sided AP were studied. All but one had previously failed ablation. With a Halo catheter deployed at TVA, the accessory pathway location was rapidly identified using the sites of earliest atrial (A) activation during ventricular (V) pacing or orthodromic tachycardia, or earliest V-activation during sinus rhythm or A-pacing were identified. The stability of the ablation catheter was guided fluoroscopically (with reference to the stationary Halo), and electrically (contact artefact between the ablation catheter and Halo poles). Results AP locations were identified by the Halo (anterior in one patient, antero-lateral in one, lateral in two, and postero-lateral in three) where similar local VA/AV intervals were recorded at both the ablation catheter and Halo bipoles recording the shortest VA/AV intervals (four of seven patients), contact artefact between the ablation catheter and those Halo bipoles was seen (six of seven patients), or both (three of seven patients). All APs were ablated successfully after a mean RF duration of 5±2 min, and 25±17 min post Halo deployment without clinical recurrence at 12±4 months follow-up. Conclusion A Halo positioned at the TVA can ease the localisation of right-sided AP, facilitate catheter stability during ablation, and guides successful ablation. Dr Wong is supported by a Wellcome Trust grant (071249/Z/03/Z).     

三维标测指导下邻希氏束旁路消融的安全性和有效性

目的 描述邻希氏束旁路的电解剖特点,同时评价三维标测下邻希氏束旁路消融的安全性和有效性.方法 连续入选19例邻希氏束房室旁路折返性心动过速患者(男13例),年龄11 ～70(31.16±19.54)岁,采用三维标测指导旁路的射频消融治疗.所有患者旁路传导在放电后(3.57±1.71)s内阻断(即刻成功率100％).结果 顺向性房室折返性心动过速时靶点处室房间期(38.56±7.51) ms,明显短于希氏束区域[(51.11±8.07) ms,P＜0.001]和冠状静脉窦近端[(78.01±13.09)ms,P＜0.001].成功消融靶点与希氏束距离(6.42±1.71)mm,希氏束距离冠状静脉窦口(26.53±3.15) mm.靶点处的室/房波幅比为3.62±2.27,明确的希氏束电位(0.152±0.093) mV.平均随访(12.79±6.64)个月,18例患者无复发(远期成功率94.7％),且无房室传导损伤发生.结论 通过定量测量发现邻希氏束旁路极为靠近希氏束.采用三维标测指导消融邻希氏束旁路是安全有效的.     

磁导航指导下心房颤动导管消融与床旁操作消融的临床比较研究

目的 比较磁导航指导下心房颤动（房颤）导管消融与床旁操作消融的有效性和安全性.方法 2012年11月至2013年11月在南京医科大学附属无锡市人民医院心内科住院的78例房颤患者,分为磁导航指导下消融组（MNS组,28例）和床旁操作消融对照组（CON组,50例）.MNS组穿刺房间隔后采用盐水灌注磁消融导管行左心房建模和左右肺静脉前庭电隔离,隔离后采用牛眼图确认;CON组在电解到标测（Carto）系统指导下采用常规床旁操作消融方法.记录并分析两组的手术操作时间、X线曝光时间、X线曝光量和手术相关并发症.术后3～6个月内每月随访1次动态心电图.结果 78例房颤患者均成功实施消融治疗.MNS组和CON组的手术操作时间分别为110.0～ 210.0（152.7±24.0） min和90.0～ 180.0（145.5±18.2） min（P＞0.05）;MNS组和CON组X线曝光时间分别为7.5～35.0（17.2±7.3）min和15.1～61.0（30.8± 14.2） min（P＜0.05）;MNS组和CON组X线曝光量为165.0～1 988.0（603.0±496.6） mGy和321.5～2 512.6（850.6±624.3） mGy（P＜0.05）,而MNS组28例患者中前14例和后14例的手术X线曝光量分别为250.0～1 988.0 （810.3±583.3） mGy和165.0～715.0（396.3±159.4） mGy（P＜0.01）.MNS组除1例血胸外,无其他手术相关并发症,CON组出现1例心脏压塞、1例肺静脉狭窄、1例新发腔隙性脑梗死、1例血胸和3例血肿.随访3～6个月,两组手术成功率差异无统计学意义.结论 磁导航可安全有效地应用于房颤患者的导管消融.与床旁操作消融相比,手术成功率相似,但具有明显减少医患X线曝光量、缩短医生房颤导管消融学习曲线和可能降低患者手术并发症等优点.     

Percutaneous epicardial mapping during ablation of difficult accessory pathways as an alternative to cardiac surgery

OBJECTIVES: The aim of this study was to define the role of percutaneous epicardial mapping for the ablation of previous failed ablation of accessory pathways. BACKGROUND: Cardiac surgery is the only curative option for failed radiofrequency (RF) catheter ablation of accessory pathway (AP)-mediated tachycardias. We investigated a combined percutaneous epicardial and endocardial approach for failed AP ablations. METHODS: We present our experience in a series of 6 cases (7 APs) with previous failed attempts at catheter ablation (median 2 attempts, range 1-4) and persistent symptomatic tachycardias. Endocardial mapping of the APs was performed using conventional techniques. Sites with local electrograms suggestive of AP location were selected. When initial endocardial mapping was not successful for ablation of the pathway, percutaneous transthoracic pericardial puncture was performed via a subxiphoid approach, and an ablation catheter was positioned at the epicardial aspect of the putative AP location for epicardial-endocardial electrogram comparison. Endocardial RF energy was applied to locations considered appropriate. Epicardial RF applications were delivered when endocardial applications failed. Coronary arteriography was performed to assess the proximity of coronary arteries to the ablation catheter. RESULTS: APs were located in the right free wall (4 patients, 5 APs) and the right (1 patient) and left (1 patient) posteroseptal regions. In all patients, epicardial mapping assisted in identifying successful ablation sites. In 3 patients, the earliest atrial activation during orthodromic tachycardia was present in an epicardial electrogram. Successful AP ablation was achieved with an epicardial RF application in 2 patients, either alone or with simultaneous endocardial-epicardial delivery. In the remaining 4 patients, APs were successfully ablated endocardially after epicardial mapping. These patients represent 18% of all cases referred to our institution for ablation of previously failed accessory pathways (6/32 patients). CONCLUSIONS: A combined endocardial-epicardial approach to mapping and RF ablation can facilitate successful endocardial ablation in most cases. In selected cases, APs can be ablated by epicardial delivery of RF. Epicardial mapping is an effective alternative to cardiac surgery for patients in whom prior attempts at AP ablation have failed.     

Catheter ablation of anteroseptal accessory pathway in the non-coronary aortic sinus.

We report a patient with atrioventricular reentrant tachycardia (AVRT) with bidirectional conduction over an anteroseptal accessory pathway (AP) who underwent successful ablation in the non-coronary aortic sinus (AS). In three previous attempts, the intracardiac recordings showed an anteroseptal AP with antegrade and retrograde conduction that failed to be ablated in spite of radiofrequency (RF) applications from the right and left anteroseptal regions. During the study, the earliest atrial activation during tachycardia was recorded in the non-coronary AS preceding the atrial activation at the His bundle (HB) region by 24 ms, and the anteroseptal AP was successfully blocked by one single ablation in the non-coronary AS. These data strongly suggest that careful mapping of an anteroseptal AP in the non-coronary AS may provide an alternative ablation approach in patients with previously failed ablation.     

Chrome congestive heart failure: Radiofrequency ablation of accessory pathways: implications of accumulated experience and time dedicated to procedures

Previous reports on radiofrequency ablation of accessory pathwayshave shown that the experience of the operator is of crucialimportance in reducing fluoroscopy time and achieving highersuccess rates. However, a detailed analysis of this importantissue has not been previously attempted We analysed 71 consecutive ablation procedures undertaken atSt George's Hospital by the same electrophysiology group andalways with the same first operator. Of all procedures, 66 (916%)were successful, as judged by abolition of accessory pathwayconduction without recurrence within the next 24 h. Failuresincluded two out of 38 left-sided pathway procedures (5·3%),one out of 11 intermediate septal (9·1%) and four outof 22 right-sided pathway procedures (18·2%). These differencewere not statistically significant. Average procedure and screeningtimes for all procedures were 162·9±86·0min and 56·8±48·2 mm respectively, whereasthe median of the number of discharges was 12, ranging fromone to 51. There was no significant difference between pathwaygroups or between concealed and non-concealed pathways in respectto procedure and screening time or number of discharges. Therewas a significant tendency towards decreased procedure and screeningtimes with accwnulating experience and this was similar forall pathway groups. There was also a tendency towards improvedcwnulative success rates with time dedicated to procedures. We conclude that a certain amount of ablation experience isrequired, even by experienced electrophysiologists, before arelatively high success rate without long radiation exposurecan be achieved, regardless of the location or the mode of conductionof the pathway. Success rates increase with procedure time,suggesting that early abandonment of the procedure may resultin higher failure rates in diffcult cases.     

主动脉无冠窦内射频消融前间隔房室旁路

目的 报道经主动脉无冠窦内射频消融前间隔房室旁路.方法 7例患者,男性4例,女性3例,平均年龄（38.4±14.7）岁.电生理检查证实存在房室旁路,并检查其前传逆传功能和诱发旁路参与的房室折返性心动过速.在心动过速时标测最早心房逆传激动点作为消融靶点.结果 7例心动过速时最早心房激动部位均位于前间隔区域,但经右心房途径反复消融均不能成功阻断旁路,而在无冠窦内可标测到最早逆传心房激动点并消融成功,无并发症出现.结论 主动脉无冠窦内消融可作为治疗前间隔房室旁路的一种新途径,特别适用于右心房前间隔区域消融失败的病例.     

Late clinical outcome after successful radiofrequency catheter ablation of accessory pathways.

AIMS: To evaluate the long-term clinical results of patients who underwent successful radiofrequency catheter ablation of a symptomatic drug-resistant accessory-pathway-mediated tachycardia. METHODS AND RESULTS: Clinical follow-up was done by direct contact with the patients and their physicians. One hundred and eighty consecutive patients (113 males, 67 females) were followed during a median period of 48.1 months. There were seven procedure related complications (4%). During the follow-up period, 79% of the patients remained asymptomatic; 14% complained of short bouts of palpitations due to isolated or short runs of atrial or ventricular premature beats; 7% had sustained palpitations due either to accessory pathway recurrence (4%) or supraventricular tachyarrhythmias not associated with an accessory pathway (3%). Symptoms due to accessory pathway recurrence appeared either in the first month following the ablation or at least later than 3 months when sustained supraventricular arrhythmias occurred related to another cause. CONCLUSIONS: Initially successful radiofrequency catheter ablation has a low, long-term recurrence rate (4%). Recurrence of accessory-pathway-mediated tachycardia is observed during the first month while later symptoms suggest supraventricular arrhythmias from another cause.     

磁导航系统在心房颤动导管消融中的应用研究

目的探讨磁导航（MNS）指导下心房颤动（房颤）导管消融的有效性和安全性。 方法纳入2012年10月至2021年3月南京医科大学附属无锡人民医院心内科住院的成功实施了MNS指导下导管消融的433例房颤患者（磁导航组）,穿刺房间隔后,MNS指导下,盐水灌注MNS消融导管行左心房建模和肺静脉前庭电隔离,隔离后采用“牛眼图”软件确认。同期112例患者作为对照组（手动组）完成传统手动消融。记录并比较两组患者的手术操作时间、X线曝光时间、X线曝光量、手术成功率和手术相关并发症等临床情况。术后12个月内每月随访一次。磁导航组根据入组时间,将最初50例患者作为学习曲线组,后续383例患者按时间分成磁导航1组（190例）和磁导航2组（193例）,分析该手术的学习曲线。 结果①磁导航组和手动组患者性别、年龄、身高、体重、左心房内径和左心室射血分数等基线情况差异无统计学意义。与手工组相比,磁导航组肺静脉前庭隔离急性成功率略低（98.8％对98.2％,P>0.05）,手术操作时间略长［（152.7±27.8）min对（149.7±27.3）min,P>0.05］,X线曝光时间明显短［（8.4±4.3）min对（16.8±10.9）min,P<0.05］。②学习曲线组、磁导航1组与磁导航2组间年龄、性别和体重等基线情况差异无统计学意义（P>0.05）。与学习曲线组比较,磁导航1组与磁导航2组X线曝光时间显著减少［（13.2±7.2）min对（8.0±3.5）min、（7.6±3.3）min,P<0.05］;而磁导航1组与2组间差异无统计学意义（P>0.05）。③围术期磁导航组有2例血胸（锁骨下静脉穿刺所致）和3例腹股沟血肿,无其他手术相关并发症。手工组出现1例心脏压塞、1例肺静脉狭窄、1例脑梗死和3例腹股沟血肿。④磁导航组阵发性房颤与非阵发性房颤1年消融成功率均略高于手工组（71.0％对68.9％,P>0.05;57.2％对55.3％,P>0.05）差异均无统计学意义。 结论与手动消融相比,MNS指导下的房颤导管消融术中X线曝光时间和手术并发症发生率显著减少,学习曲线较短,表明MNS指导下的房颤导管消融有较好的安全性和有效性。     

三维电解剖标测指导疑难右侧游离壁旁路的导管消融

Objective To demonstrate the electroanatomic substrates of right-sided free wall (RFW)accessory pathways (APs) which were refractory to conventional catheter ablation utilizing three-dimensional (3D) mapping. Methods Seventeen patients with RFW APs that failed initial conventional catheter ablation(s)by a mean of 1～3(1.8±0.6) attempts were enrolled in the study. Electroanatomic mapping of the right atrium was performed during right ventricular pacing in 14 patients and orthodromic reciprocating tachycardia in 3patients. Radiofrequency energy was delivered via irrigation catheter to the earliest atrial activation site. Results The earliest atrial activation site, which represented the atrial insertion of the APs, was separated from the tricuspid annulus by an average of 9 ～ 20 ( 13.6 ± 3.4 ) mm, and the local activation time was 18 ～ 80(31.5±16.3) ms earlier than that of the corresponding annular point. The target electrogram demonstrated AP potential in fourteen patients and ventriculoatrial fusion in the rest three. Accessory pathway was blocked in one case during moving the catheter and RF ablation delivery on the areas. One patient exhibited an AP with wide branching on the atrial side during mapping. RF ablation with an irrigated catheter successfully interrupted AP conduction in remaining 16 patients without complications. After a mean follow-up of 3 ～ 41 (18.6±12.7) months, there were no recurrences of ventricular preexcitation or episodes of tachycardia. Conclusion RFW APs refractory to conventional catheter ablation might be due to unique anatomic AP features such as more epicardial course at the annulus level with atrial insertion distance from the tricuspid annulus. Electroanatomic mapping is helpful to accurately localize the atrial insertion sites of these APs and facilitates catheter ablation.     

三维电解剖标测指导疑难右侧游离壁旁路的导管消融

目的应用三维电解剖标测技术详述常规消融无效的右侧游离壁旁路电解剖特征。方法本组共入选17例常规消融无效的右侧游离壁旁路患者,消融失败1～3（1．8±0．6）次。3例在顺向型心动过速下构建右心房电激动模型,14例在右心室心尖部起搏下构建右心房电激动模型。逆向传导的心房最早激动点代表旁路的心房插入端,冷盐水消融最早心房激动点。结果17例患者中,最早激动点距离对应部位三尖瓣环的宽度为9—20（13．6±3．4）mm,较相对部位三尖瓣环的局部激动时间提前18～80（31．5±16．3）ms。共14例患者记录到独立的旁路电位。1例患者在导管标测时阻断旁路逆传,冷盐水局部巩固消融;16例患者冷盐水消融均成功阻断所有旁路的传导,其中1例患者的旁路心房插入端呈广泛分布而行片状消融。无消融术相关并发症。随访了3～41（18．6±12．7）个月,无旁路传导恢复及心动过速发作。结论常规方法消融失败的右侧游离壁旁路可能具有特殊的解剖特征,如旁路在三尖瓣环水平沿心外膜走行,旁路的心房插入部位远离瓣环。三维电解剖标测有助于精确定位旁路的心房插入端并指导消融。     

单用消融电极标测和消融左侧隐匿性旁道

目的 单用消融电极于二尖瓣下直接标测（不放置冠状窦电极）对35例左侧隐匿性旁道进行射频消融。方法 右室心尖起搏下用消融电极沿三尖瓣口标测,确认旁道不在右侧后,将消融电极送至二尖瓣下进行标测和消融。结果 34例左侧隐匿性旁道标测到消融靶点,33例消融成功,1例消融失败,1例复发。与使用冠状窦电极标测相比,消融电极直接标测的X线曝光时间、手术时间均增加。结论 单用消融电极可标测和消融左侧隐匿性旁道。