经股静脉放置冠状静脉窦导管的临床体会

报道 2 2 1例因反复发作室上性心动过速行射频消融术的患者 ,使用顶端弯度可调控导管经股静脉径路送入冠状静脉窦标测电极的临床体会。 2 2 1例患者中 ,成功地经股静脉途径放置冠状静脉窦电极 2 0 0例 (90 .5 % )。其中房室结双径路者的放置成功率为 98% ,房室旁道为 81.5 % ,房性心动过速及心房扑动为 93.3%。 2 1例失败者穿刺左锁骨下静脉 ,19例经该静脉成功地送入冠状静脉窦电极 ,2例失败。所有病人无与放置冠状静脉窦导管有关的并发症。因而 ,使用顶端弯度可调控的导管经股静脉途径放置冠状静脉窦电极效果良好 ,尤其在房室结双径路的患者。此方法安全 ,避免了穿刺锁骨下静脉以及由此引起的并发症。     

经股静脉途径放置冠状窦电极的方法及注意事项

心脏电生理检查时冠状窦标测电极的放置比较重要，国内心脏电生理中心常规的放置方法是经颈内静脉或左锁骨下静脉穿刺将十级冠状窦电极放入冠状静脉窦。用标准四级电极经股静脉途径放置冠状窦的方法，国内外少见报道。笔者在北京安贞医院学习心房颤动射频消融时，马长生教授他们电生理团队从2005年始，凡是心房颤动消融患者均经股静脉插管放置冠状窦标测电极，笔者经该中心同意总结了经股静脉及左锁骨下静脉途径放置冠状窦电极方法、成功率、并发症及操作时间上的差异。现将该方法及注意事项介绍如下。     

经股静脉放置冠状静脉导管指引冠状静脉鞘置入2例

例1 患者男性,36岁。因“反复胸闷气促半年,加重10d”入院。入院时体检：颈静脉充盈,肝颈静脉反流征（＋）。两肺呼吸音粗,两侧中下肺可闻及湿性啰音。     

经锁骨下静脉及股静脉途径置入冠状窦电极的比较

目的:比较经锁骨下静脉及股静脉途径放置冠状窦电极的有效性及安全性。方法:连续纳入2010年1月2012年5月行电生理检查及射频消融641例患者,分为2组:锁骨下静脉组(321例)穿刺锁骨下静脉放置固定弯十极冠状窦电极;股静脉组(320例)穿刺股静脉放置可调弯十极冠状窦电极。比较两组成功率及并发症发生率。结果:锁骨下静脉组中穿刺成功317例(穿刺成功率98.8%),其中3例术后检查出现气胸,1例因误置入6F鞘管到锁骨下动脉停止手术,气胸患者中1例因面积>30%行闭式引流,另2例未行特殊处理自行吸收,4例患者均未留下后遗症,该组并发症发生率为1.2%。该组置入鞘管的320例患者中307例成功放置固定弯冠状窦电极,置入电极成功率为95.9%。13例(4.1%)不成功者改经股静脉途径12例成功置入电极。股静脉组333例(锁骨下静脉组电极置入不成功者也改用股静脉途径,该组实际人数:320+13=333)均穿刺成功,其穿刺成功率为100%,3例未能成功置入冠状静脉电极,置入电极成功率为99.1%。此3例未能置入患者行逆行冠状静脉造影后经股静脉成功置入电极。股静脉组电极置入成功率显著高于锁骨下静脉组(99.1%vs.95.9%,P<0.01)。锁骨下静脉组并发症稍多于股静脉组,但差异无统计学意义。两组穿刺成功率和曝光时间[(77±40)s vs.(75±46)s],无显著差异。股静脉组总成功率显著高于锁骨下静脉组[99.1%vs.94.7%,P<0.01]。结论:两种途径放置冠状窦电极成功率均较高,并发症发生率较低,股静脉组总成功率显著高于锁骨下静脉组。     

冠状静脉窦的介入治疗

冠状静脉窦的介入治疗第一军医大学珠江医院心内科傅向阳综述刘品明校审经冠状静脉窦的介入治疗（ｃｏｒｏｎａｒｙｓｉ－ｎｕｓｉｎｔｅｒｖｅｎｔｉｏｎ）是一个有临床意义但又十分复杂的问题。１简史１８９８年，Ｐｒａｔ根据其对猫心冠状静脉窦灌注可维持数小时心脏收...     

射频导管消融术阻滞经冠状静脉窦传导通路的实验研究

目的　探讨利用射频导管消融术阻滞经冠状静脉窦的电传导通路的方法及可行性。方法　冠状静脉窦口内 5～ 10mm处射频导管消融 ,低位右心房起搏下 ,观察最早激动部位、冠状静脉窦激动顺序和时间、房间隔激动时间、心房激动时间。结果　 (1)冠状静脉窦口或近端射频导管消融可造成经冠状静脉窦电传导通路的完全或部分阻滞。表现在消融前 ,低位右心房起搏时 ,窦口处的电激动明显早于Bachmann束。消融后 ,窦口处的电激动迟于Bachmann束或两者基本一致 ;(2 )消融前后 ,心房激动时间由 (6 1 14± 8 36 )ms延长至 (88 4 3± 19 2 2 )ms,说明低位心房起搏时冠状静脉窦是优势传导通路 ;(3)消融前后的房间隔激动时间及冠状静脉窦激动时间分别为 (2 6 4 3± 8 87)ms对(15 2 8± 10 13)ms和 (39 4 3± 9 78)ms对 (38 0 0± 5 86 )ms。结论　冠状静脉窦近端射频导管消融术阻断经冠状静脉窦的电传导通路的方法是可行的     

经冠状静脉窦射频导管消融房室旁路的疗效和安全性

目的 :探讨经冠状静脉窦低能量射频导管消融房室旁路的适应证、疗效和安全性。　　方法 :2 2例左侧房室旁路患者先经心内膜射频导管消融 ,不成功改由经冠状静脉窦标测途径。　　结果 :2 2例患者全部成功 ,17例 (77.3% )成功靶点与冠状静脉分支或畸形有关。 15例有效靶点记录到振幅较大的房室旁路电位 ,其振幅于 A波和 V波之比大于 1,前传 V波和逆传 A波较心内膜标测分别提前 2 6 .1± 5 .1m s和 2 2 .5±9.2 m s。　　结论 :低能量冠状静脉窦射频导管消融可以安全、有效的阻断房室旁路。     

经下腔静脉放置冠状静脉窦电极导管对操作者放射剂量影响的研究

目的 经下腔静脉(IVC)放置冠状静脉窦(CS)电极导管理论上存在减少操作者放射剂量的可能性.本文在对比经IVC可调弯电极导管与经上腔静脉(SVC)固定弯电极导管置入CS操作的可行性和操作者所受的放射剂量.方法 202例患者,经下腔静脉组(IVC组)122例、经上腔静脉组(SVC组)80例,两组患者年龄、性别、超声心动图和心律失常类型方面差异均无统计学意义.IVC组采用可控弯10极电极导管,SVC组使用固定弯10极电极导管,由同一组术者操作.记录两组患者导管放置时曝光时间,并测定操作者所受放射剂量.结果 IVC组122例患者中有2例电极导管不能到位,改经SVC途径仍未成功;SVC组80例全部放置成功.两组平均每例曝光时间相似[(105±12)s vs(108±19)s;P=0.925].单位时间所受放射剂量平均值在IVC组为0.25×10-2uGy/s,SVC组为1.38×10-2uGy/s.IVC组和SVC组操作者平均每例接受放射剂量分别为(0.30±0.04)uGy和(1.49±0.27)uGy(P＜0.001).两组皆未发现心脏和血管并发症.结论 与固定弯电极导管经SVC途径比较,可控弯电极导管经IVC途径置入CS电极导管的单位时间放射量明显降低,在不增加操作时间的同时可显著减少操作者所受放射剂量.     

经下腔静脉放置冠状静脉窦电极导管对操作者放射剂量影响的研究

Objective To evaluate and compare the dosages of operator-incurred-radiation during the implantation of coronary sinus (CS) catheter between the approaches through inferior vena cava (IVC) with the steerable catheter and through supra vena cava (SVC) with the fixed curve catheter. Methods Two hundred and two patients were divided into two groups according to the different approaches of CS catheter insertion. IVC group (n = 122) :a deca-polar catheter with steerable curve was placed into CS through the femoral vein and the IVC. SVC group (n =80) :a fixed curve deca-polar catheter was inserted into CS through the jugular vein and the SVC. There was no obvious difference in gender, age, and echocardiogram between the two groups. All procedures were performed by the same three operators. The exposure time of each case and the dosage of operator-incurred-radiation during the procedure were measured. Results The catheters were positioned successfully inl20 patients in the IVC group and in all patients in the SVC group. The 2 failured in the IVC group were also failed in by attempting through SVC with fixed curve catheter. There was no significant difference in the exposure time between IVC group and SVC group[( 105 ± 12)s and ( 108 ± 19)s,P =0. 925]. The per sec operator-incurred-radiation was 0. 25 × 10-2 uGy/s in WC group and 1.38 × 10 -2 uGy/s in SVC group. This lead to significant decrease in the dosage of operator-incurred-radiation in IVC group[(0. 30 ± 0. 04) uGy vs ( 1.49 ±0. 27) uGy,P ＜ 0. 001]. No cardiac or vascular complication was observed in both groups. Conclusions Insertion of coronary sinus catheter through IVC with the steerable catheter is associated with significantly less radiation than that through SVC with the fixed curve catheter without increasing time of the procedure.     

经下腔静脉放置冠状静脉窦电极导管对操作者放射剂量影响的研究

Objective To evaluate and compare the dosages of operator-incurred-radiation during the implantation of coronary sinus (CS) catheter between the approaches through inferior vena cava (IVC) with the steerable catheter and through supra vena cava (SVC) with the fixed curve catheter. Methods Two hundred and two patients were divided into two groups according to the different approaches of CS catheter insertion. IVC group (n = 122) :a deca-polar catheter with steerable curve was placed into CS through the femoral vein and the IVC. SVC group (n =80) :a fixed curve deca-polar catheter was inserted into CS through the jugular vein and the SVC. There was no obvious difference in gender, age, and echocardiogram between the two groups. All procedures were performed by the same three operators. The exposure time of each case and the dosage of operator-incurred-radiation during the procedure were measured. Results The catheters were positioned successfully inl20 patients in the IVC group and in all patients in the SVC group. The 2 failured in the IVC group were also failed in by attempting through SVC with fixed curve catheter. There was no significant difference in the exposure time between IVC group and SVC group[( 105 ± 12)s and ( 108 ± 19)s,P =0. 925]. The per sec operator-incurred-radiation was 0. 25 × 10-2 uGy/s in WC group and 1.38 × 10 -2 uGy/s in SVC group. This lead to significant decrease in the dosage of operator-incurred-radiation in IVC group[(0. 30 ± 0. 04) uGy vs ( 1.49 ±0. 27) uGy,P ＜ 0. 001]. No cardiac or vascular complication was observed in both groups. Conclusions Insertion of coronary sinus catheter through IVC with the steerable catheter is associated with significantly less radiation than that through SVC with the fixed curve catheter without increasing time of the procedure.     

Coronary Sinus Lead Placement Via the Internal Jugular Vein in Patients with Advanced Heart Failure: A Simplified Percutaneous Approach

Background: Placement of coronary sinus (CS) leads is usually achieved via the left cephalic-axillary-subclavian (CAS) venous system. In some cases, however, such as lack of venous access a right side approach is required. Cannulation of the CS via the right CAS vein is often technically difficult, leaving the right IJ vein as a suitable alternative.Objective: The feasibility of IJ vein as a conduit for transvenous left ventricular (LV) pacing in patients with heart failure (HF) has not been reported.Methods and Results: Between July 2002 and April 2004, we implanted 339 biventricular devices in patients with moderate-to-severe HF. In 15 patients with similar clinical characteristics, in whom the left CAS vein could not be used, the CS leads were placed via the right CAS venous system (n = 5) or the IJ vein (n = 10). The ten patients (6 men and 4 women; age 66 ± 15 years; LV ejection fraction .19 ± .07; QRS duration 183 ± 35 ms) who required IJ CS lead placement had no procedure related complications and all retained appropriate LV pacing and showed significant improvement in HF symptoms after a median follow-up of 12 months (6 to 22 months).Conclusions: Thus, in patients with HF for whom the traditional CAS venous approach cannot be used (left side) or is technically difficult (right side), CS leads can be deployed safely via the right IJ vein. In these situations, it seems appropriate to consider this approach prior to the more invasive epicardial approaches.     

Mapping of the Coronary Sinus and Great Cardiac Vein Using a 2-French Electrode Catheter and a Right Femoral Approach

Coronary Sinus Mapping. Introduction: Local electrogranis recorded from the coronary sinus and great cardiac vein provide important information for the diagnosis of various arrhythmias and identification of target sites for ablation of left-sided accessory pathways. One limitation of present techniques is the inability, in many cases, to probe the great cardiac vein at the anterior mitral annulus. We tested the feasibility of a new technique for catheterization of the coronary sinus and great cardiac vein by means of a small-diameter electrode catheter advanced via a right femoral approach through an angiography catheter. Methods and Results: Of 22 patients (12 men and 10 women; ages 44.5 ± 13.4 years) undergoing radiofrequency ablation of a supraventricular tachycardia, cannulation of the coronary sinus orifice using a 6-French 1L or 2L Amplatz catheter was achieved in 20 patients (91%) within 0.9 ± 0.6 minutes; after cannulation, a 2-French octapolar electrode catheter with a soft radiopaque tip and a 3-mm interelectrode distance could he advanced in all 20 patients through the guiding catheter to the great cardiac vein in the anterior region of the AV sulcus within 0.8 ± 0.7 minutes. Atrial and ventricular local potentials were recorded all along the mitral annulus during sinus rhythm, atrial and ventricular pacing, or supraventricular tachycardia. Variation of local potential amplitude never exceeded 20% of the mean and presented similar stability at all annular regions. The arrhythmogenic substrate was identified in all patients. Of 18 patients with 21 left-sided accessory pathways, an accessory pathway potential could he recorded at the ablation site by one or more adjacent epicardial electrode pairs in 10 pathways. No procedure-related complications were observed. Conclusions: The technique introduced in this study proved feasible in 91% of patients. Its main advantages are the simplicity and rapidity of coronary sinus cannulation and the ability to advance the electrode catheter to the anterior cardiac vein. In addition, closely spaced bipolar electrograms resulted in enhanced atrial, ventricular, and accessory pathway potential resolution.     

锁骨下静脉穿刺与头静脉切开途径安置心脏起搏器的随机对照研究

为比较锁骨下静脉穿刺与头静脉切开途径安置心脏起搏器的价值 ,将 1 0 0例需安置心脏起搏器的病人随机分为锁骨下静脉穿刺组和头静脉切开组 (均包括单腔亚组和双腔亚组 ) ,每组各 5 0例。观察两种手术径路安置起搏器的手术时间、X线曝光时间、手术并发症及病人对手术切口及囊袋的满意度。结果 :无论是手术时间 ,还是X线曝光时间 ,锁骨下静脉组中单腔亚组及双腔亚组均比头静脉组中的对应亚组为短 ( 64.1± 1 4.2minvs 73.8± 1 1 .6min ,86.4± 1 3.2minvs 1 0 6.5± 1 9.4min和 3.45± 0 .83minvs 4.5 1± 2 .2 7min ,5 .5 9± 0 .78minvs 8.2 7± 4.91min ,P均 <0 .0 5 )。锁骨下静脉穿刺组心室电极导线放置成功率为 1 0 0 % ,而头静脉切开组则为 5 6% ,二者亦有显著性差异 (P <0 .0 5 )。而两组并发症发生率无差异。病人对切口及囊袋满意程度的积分 ,锁骨下静脉组明显高于头静脉组 ( 2 .2 4± 0 .5 6vs 1 .92± 0 .5 7,P <0 .0 1 )。结论 :只要锁骨下静脉穿刺技术熟练 ,安置心脏起搏器可首选锁骨下静脉穿刺     

An Experimental Study of Transvenous Defibrillation Using a Coronary Sinus Catheter

The efficacy of a transvenous defibrillating system, utilizing bipolar right ventricular and coronary sinus catheters was evaluated in 14 normal mongrel dogs. Two groups of seven animals each were studied. During all shocks, the right ventricular apex electrode served as the anode. In both groups, defibrillation was performed using the proximal pole of the right ventricular catheter (superior vena cava), as the cathode served as a control (configuration A). In group 1, a coronary sinus cathode (configuration B) was compared to control. The mean energy at which 50% or more of the shocks were successful was similar for configuration B (20.7 ± 7.9 joules) and for configuration A (18.8 ± 9.4 joules). In group 2, the superior vena cava and coronary sinus electrodes served as a common cathode (configuration C). Mean defibrillation energy at which 50% or more of the shocks was successful was 21.4 ± 9.0 joules for configuration C and 27.1 ± 9.5 joules for configuration A (P < 0.01). Leading edge voltage was similar for all three configurations, hut shock duration was longer for configuration A (11.3 ± 2.8 msec) than configuration B (6.6 ± 1.8 msec) or C (6.1 ± 1.5; P < 0.05). Nonsustained ventricular tachycardia and transient heart block were common, but no damage to the coronary sinus was noted despite the delivery of up to 38 shocks. Conclusions: (1) With the catheter system used, coronary sinus to right ventricular apex defibrillation system offered no advantages over a superior vena cava to right ventricular apex system; (2) A three-electrode system with the high right atrium and coronary sinus serving as the common cathode reduced defibrillation thresholds significantly without any severe short-term adverse consequences; and (3) Improvements in catheter design may make a coronary sinus catheter part of a feasible transvenous defibrillating system.     

Myocardium of the Superior Vena Cava,Coronary Sinus,Vein of Marshall,and the Pulmonary Vein Ostia: Gross Anatomic Studies in 620 Hearts

Anatomy of Myocardial Extensions in Thoracic Veins. Introduction: Radiofrequency ablation for atrial fibrillation (AF) frequently involves energy delivery at the ostia of the thoracic veins. Detailed evaluation of the myocardium extending into the caval veins, vein of Marshall, as well as at the pulmonary vein ostia has not been completely evaluated. Methods and Results: Post‐mortem assessment of 620 formalin‐fixed hearts (mean age 60 ± 23 years, 44% female) was performed. The hearts were examined for integrity of venous structures and their atrial connections. Systematic gross anatomic evaluation including measurements on myocardial extensions in these veins was performed. Macroscopic myocardial extensions into pulmonary veins were noted in 99% of specimens evaluated and were circumferentially symmetric (99.6%). Myocardial extensions into the superior vena cava (SVC) occurred in 78% with the majority being circumferentially asymmetric (61%). Occasionally, myocardium extended into the azygos vein (6%). There were no myocardial extensions in the inferior vena cava (IVC). In some cases, the right atrial pectinate muscle extended into the coronary sinus (7%). The vein of Marshall was consistently located anterior to the left‐sided pulmonary veins and posterior to the left atrial appendage, overlying the left atrial endocardial ridge. Conclusions: Myocardial extensions into the pulmonary veins are usually circumferential at the ostia validating the necessity for wide area rather than segmental ablation to isolate these veins during AF ablation. Myocardial extensions into the SVC are common and less likely to be circumferential, whereas extensions into the IVC are not present. The left atrial ridge is a reliable endocardial target for radiofrequency ablation of the vein of Marshall. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1304‐1309, December 2012)     

Specific Electrocardiographic Features of Manifest Coronary Vein Posteroseptal Accessory Pathways

Coronary Vein Accessory Pathways. Introduction: Some posteroseptal accessory pathways (APs) can be successfully ablated by radiofrequency current only from inside the coronary sinus (CS) or its branches, because of an absolute or relatively epicardial location. The aim of this study was to identify ECG features of manifest posteroseptal APs requiring ablation in the CS or the middle cardiac veins (MCVs). Methods and Results: One hundred seventeen consecutive patients with manifest posteroseptal APs successfully ablated: (1) ≥ 1 cm deep inside the MCV (group MCV: n = 13); (2) inside the CS, including the area adjacent to the MCV ostium (group CS: n = 10); (3) at the right (group R: n = 60); or (4) the left posteroseptal endocardial region (group L: n = 34) were included. We reviewed delta wave polarity (initial 40 msec) and QRS morphology during sinus rhythm and atrial pacing as well as electrogram characteristics in these patients. The local target site electrogram in groups MCV and CS was characterized by a longer atrial to ventricular electrogram interval, suggesting a longer course of the pathway and more frequent recording of a presumptive AP potential compared to the group ablated at the right or left endocardium. The most sensitive ECG feature for group CS or group MCV was a negative delta wave in lead II in sinus rhythm (87%), but specificity (79%) and positive predictive value (50%) were relatively low. A steep positive delta wave in aVR during maximal preexcitation possessed the highest specificity and positive predictive value (98% and 88%, sensitivity 61%) which increased to 99% and 91%, respectively, when combined with a deep S wave in V₆ (R wave ≤ S wave). Conclusion: These data suggest that posteroseptal APs ablated inside the coronary venous system have highly specific features, including the combination of a steep positive delta wave in lead aVR and a deep S wave in lead V₆ (R wave ≤ S wave) during maximal preexcitation. The highest sensitivity is provided by a negative delta wave in lead II. These findings may be helpful for anticipating and planning an epicardial ablation strategy.     

头静脉切开途径与锁骨下静脉穿刺安置永久性心脏起搏器的比较

目的比较头静脉切开与锁骨下静脉穿刺途径安置永久性心脏起搏器的价值。方法121例需安置永久性心脏起搏器的病人随机分为头静脉切开组和锁骨下静脉穿刺组(均包括单腔和双腔亚组),双察两种的手术时间、X线曝光时间、导线放置失败率、手术并发症并随访切口及囊袋情况、起搏器工作状态等。结果头静脉切开组(单腔或双腔亚组)手术时间长于锁骨下静脉穿刺组(73.27±13.53min vs 66.63±15.09min;60.68±5.21min vs 52.46±6.27min;83.62±7.81min vs 78.52±8.46min,P<0.05~0.01),导线放置失败率略高于锁骨下静脉穿刺组(P>0.05),X线曝光时间及并发症发生率两组无显著差异(P>0.05)。2组各有1例术后出现需处理的囊袋血肿,锁骨下静脉穿刺组有2例发生导线脱位、5例误穿锁骨下动脉。2组术后随访2~19个月未见其他并发症,起搏器工作状态良好。结论头静脉切开途径可避免气胸、血胸、导线折断及误穿锁骨下动脉等并发症,只要熟练掌握头静脉分离技术,安置永久性心脏起搏器应首选头静脉切开途径。     

Pseudo Sinus Rhythm Originating from the Left Superior Pulmonary Vein in a Patient with Paroxysmal Atrial Fibrillation

We report the case of a patient with paroxysmal atrial fibrillation in whom the background cardiac rhythm falsely mimicked sinus rhythm but actually originated from the left superior pulmonary vein. P waves during the ectopic rhythm were flat in lead I, negative in lead aVL, and without a typical "dome-and-dart" feature in precordial leads. Radiofrequency applications inside the left superior pulmonary vein eliminated both atrial fibrillation and the ectopic pacemaker.