冠状静脉形态与左侧旁路关系的研究

目的 :观察冠状静脉形态与左侧旁路的关系。　　方法 :6 7例左侧游离壁旁路和后间隔旁路的患者在旁路成功射频导管消融后行冠状静脉窦逆行显影 ,测量射频导管消融靶点距冠状静脉分支开口的距离 ,小于 5 mm认为二者相关。　　结果 :全部 6 7例成功的进行了冠状静脉造影 ,5 7例 (85 .1% )旁路位于冠状静脉分支开口处 ,4例位于冠状静脉狭窄或扩张处。　　结论 :左侧旁路与冠状静脉形态具有一定相关性     

Catheter Ablation in the Canine Coronary Sinus Using Radiofrequency Energy

This study was performed to evaluate the effects of radiofrequency catheter ablation in the coronary sinus as a potential means of eliminating conduction over left-sided accessory pathways in humans. Radiofrequency current at a frequency of 500 kHz was delivered by electrode catheter to two sites in the coronary sinus of each often dogs. Left coronary arteriography with venous phase visualization of the coronary sinus was performed before, immediately after, and 2 weeks following ablation. Unipolar electrograms from the ablating electrode were recorded before and immediately after ablation. Coronary arteriography revealed no evidence of damage to the adjacent left circumflex coronary artery or its branches as a result of ablation. Contrast visualization of the coronary sinus showed persistent contrast staining following ablation at two of the ablated sites. Angiographically apparent stenosis of the coronary sinus was seen both acutely and chronically in two cases. Unipolar electrogram recordings from the ablating electrode showed an increase in atrial repolarization voltage (atrial current of injury) of 1.53 ± 1.03 mV (P = 0.00004), and an increase in ventricular repolarization voltage of 0.73 ± 0.84 mV (P = 0.005). There was a 23% decrease in amplitude of atrial electrograms (P = 0.006) and a 7% decrease in amplitude of ventricular electrograms (P = 0.02) recorded from the ablating electrode following ablation. Lesions could be identified grossly and microscopically at 16 of the 20 ablated sites. Perforation of the coronary sinus did not occur. Microscopical observation showed normal healing with granulation tissue and fat necrosis extending outward from the coronary sinus involving the atrial epicardium in 13 lesions, the ventricular epicardium in 5 lesions, and the adventitia of the left circumflex coronary artery in 5 lesions. No medial or intimal involvement of the coronary artery was seen. The coronary sinus itself showed luminal organized thrombus in 4 lesions, with near occlusion of the lumen in 1 case. Radiofrequency ablation in the coronary sinus thus results in lesions of a size and extent that would be expected to successfully ablate some left-sided accessory pathways if delivered in humans. Monitoring of the unipolar electrogram provides insight into the extent of injury during ablation. In some cases, thrombosis of the coronary sinus occurs, the long-term effects of which are not known.     

Cannulation of the coronary sinus via the femoral vein—A new technique

Background: Cannulation of the coronary sinus usually has been accomplished by advancing a catheter through the subclavian or internal jugular veins. Hypothesis: We have developed a new technique for cannulation of the coronary sinus with a modified 6F Judkins L5 coronary catheter positioned through the femoral vein. Results: The technique was tried successfully in 20 consecutive patients by the same operator and the average fluoroscopy time for coronary sinus cannulation was 1.6 ± 1.0 min. Conclusion: Analysis of the results showed evidence of a learning curve with improvement of time with an increasing number of patients. The method provides a safe and inexpensive solution for catheterization of the coronary sinus, easily accessible to every catheter laboratory.     

The Valve of Vieussens: An Important Cause of Difficulty in Advancing Catheters into the Cardiac Veins

INTRODUCTION: The coronary sinus and cardiac veins are useful conduits for the passage of electrode catheters for mapping the origin of cardiac arrhythmias. However, sometimes it is difficult to advance catheters an adequate distance into the cardiac veins. The aim of this study was to determine the reasons for this. METHODS AND RESULTS: In 50 cadaveric hearts, a deflectable 7-French electrode catheter was passed from the right atrium into the coronary sinus and advanced to the anterior interventricular portion of the great cardiac vein (GCV). Causes of obstruction were determined. The catheter was obstructed by the valve of Vieussens in 23 of 50 hearts (46%). Once the valve was negotiated, obstruction was caused by an acute bend in the GCV in 28 of 50 hearts (56%). Clinical studies were undertaken in 10 patients in whom electrode catheters could not be advanced as far as required. Using contrast venography, the most frequent cause of obstruction was determined to be the valve of Vieussens in 8 of 10 cases (80%). An acute bend in the GCV caused obstruction in 2 cases (20%). CONCLUSIONS: The valve of Vieussens is a frequent cause of obstruction to passage of a catheter in postmortem and in vivo studies. An acute bend in the vein, with or without lodgment in a tributary, is the other common cause. In adults, venous luminal diameter is not a cause of obstruction to the passage of a 7-French catheter in the coronary sinus or proximal GCV.     

Complete occlusion of the left circumflex coronary artery after radiofrequency catheter ablation in an infant

Radiofrequency catheter ablation of a left lateral accessory atrioventricular pathway was performed in a 5-week-old infant with drug-refractory supraventricular tachycardia. Energy application via a 5-French mapping and ablation catheter in the temperature-controlled mode (60 degrees C, 30 W) at the atrial aspect of the mitral valve annulus repeatedly resulted in termination of the tachycardia by conduction block within the pathway. Tachycardia remained inducible subsequently. After a safety energy application during sinus rhythm, significant ST-segment elevation in the inferior, mid precordial, and left lateral leads was noted. Selective left coronary angiography revealed complete occlusion of the circumflex coronary artery. Moderate-to-severe mitral valve regurgitation developed, finally requiring mitral valve replacement.     

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     

Temperature-controlled Radiofrequency Catheter Ablation of Accessory Pathways and Atrioventricular Nodal Reentrant Tachycardia: The 5-French Catheter Approach

Ablation with Temperature-Controlled 5-French Catheters. Introduction: In the present study, we assessed the feasibility of radiofrequency (RF) ablation of accessory pathways and AV nodal reentrant tachycardias with novel 5-French catheters with 4-mm tip electrodes using established mapping criteria and temperature-controlled power output control. Methods and Results: In this prospective study, 60 consecutive adult patients (mean age 36 ± 20 years) with accessory pathways (n = 37; 24 left-sided) or AV nodal reentrant tachycardia (n = 23) underwent RF catheter ablation. A 5-French catheter with a 4-mm tip electrode and an embedded thermistor was used for RF application. The surface of the tip electrodes was 26 mm2 compared to 38 mm² of 7-French catheters with 4-mm tip electrodes from the same catheter series. Power output was automatically and continuously adjusted according to the preset catheter tip temperature of 60° to 70°C. Pulse duration was 90 seconds. For left-sided accessory pathways, the retrograde route via the femoral artery was used. After removing the 5-French sheaths, only 4 hours of bed rest were advised. For ablation of AV nodal reentrant tachycardia, the so-called slow pathway was targeted for ablation. Acute success was achieved in 34 (92%) of 37 patients with accessory pathways and 23 (100%) of 23 patients with AV nodal reentrant tachycardia. A mean of 3 ± 4 RF pulses (median 2 pulses; range 1 to 20 pulses) was applied. The mean fluoroscopy time was 26 ± 21 minutes. No complete AV block or other procedure-related complications were observed. Recurrences occurred in 2 patients with accessory pathways and in 2 patients with AV nodal reentrant tachycardia during a follow-up of 9 ± 4 months. Conclusions: Temperature-controlled RF ablation of accessory pathways and AV nodal reentrant tachycardia in adults using 5-French catheters is feasible, effective, and safe. Ablation with 5-French catheters might help to reduce the complication rate of catheter ablation techniques.     

Coronary Sinus Ostial Atresia and Persistent Left-Sided Superior Vena Cava: Clinical Significance and Strategies for Cardiac Resynchronization Therapy

A 48-year-old male patient underwent cardiac resynchronization therapy defibrillator implantation, and he was found to have atresia of the coronary sinus ostium with venous drainage occurring via a persistent left-sided superior vena cava, which was connected to the right-sided superior vena cava by the innominate vein. This is a rare benign cardiac anomaly that can pose problems when the coronary sinus needs to be cannulated. To identify the course of the coronary sinus, a coronary angiogram can be performed with attention directed to the venous phase of the angiogram. Although the technical difficulty of coronary sinus cannulation increases, various catheters, wires, and delivery systems can be utilized and this anomaly does not usually prevent successful left ventricular lead placement in cardiac resynchronization therapy via a left-sided superior vena cava approach. There however needs to be consideration regarding caliber of the left-sided superior vena cava being sufficiently large to avoid compromise of venous drainage after lead insertion.     

Anatomy of the Coronary Sinus and Epicardial Coronary Venous System in 620 Hearts: An Electrophysiology Perspective

Anatomy of the Coronary Venous System . Introduction: Cannulation of the coronary sinus (CS) is a prerequisite for left ventricular (LV) pacing and certain ablation procedures. The detailed regional anatomy for the coronary veins and potential anatomic causes for difficulty with these procedures has not been established. Methods and Results: Therefore, we performed macroscopic measurements in 620 autopsied hearts (mean age 60 ± 23 years, 44% female). The CS was preserved for analysis in 96%. Sixty‐three percent had a Thebesian valve that covered the posterior aspect of the CS ostium with extension to the superior (50%) and inferior aspects (18%) and was obstructive with fenestrations in 3 specimens. Partial or near occlusive valves were present occasionally at the ostium of the great cardiac vein (Vieussens; 8%) and middle cardiac vein (5%). Ninety‐three percent had left atrial branches, and 41% had at least one branch with lumen > 3 French. For CRT lead placement, the mid‐lateral LV was accessible from the middle cardiac vein (20%), the left posterior vein (92%) or the anterior interventricular vein (86%). Among specimens where the left phrenic nerve was preserved it crossed the LV mid‐lateral wall in 45%. Conclusions: Epicardial coronary vein anatomy is variable, and the mid‐lateral LV wall can potentially be accessed through various tributaries of the epicardial veins. The orientation of the Thebesian valve favors cannulation of the CS from an anterior (ventricular) and inferior approach. Anterobasal, mid‐lateral, and inferior apical LV coronary veins lie in proximity to the course of the phrenic nerve. (J Cardiovasc Electrophysiol, Vol. 24, pp. 1‐6, January 2013)     

射频消融位于冠状静脉窦憩室处的后间隔房室旁路

目的报道５例冠状静脉窦憩室处后间隔房室旁路的射频消融结果。方法对５例后间隔显性房室旁路患者进行电生理检查和射频消融术。术后冠状动脉造影,以观察冠状静脉窦形态。结果所有患者的冠状静脉窦近端有一憩室,并在憩室的颈部消融阻断房室旁路。成功靶点图：心室激动较体表心电图Δ波提前（３１±３．７）ｍｓ,其中４例患者伴有旁路电位。结论冠状静脉窦憩室与后间隔旁路存在着解剖关系。术中冠状静脉窦造影检查有助于发现憩室和确定有效的消融部位。     

Atrial double potential associated with electrical connection between the coronary sinus musculature and the left atrium in a patient with Wolff-Parkinson-White syndrome

We reported a case of Wolff-Parkinson-White syndrome with atrial double potential in coronary sinus (CS) electrograms during paroxysmal supraventricular tachycardia and ventricular pacing. The first component was low in frequency, and its timing was the same as atrial potential recorded by ablation catheter above the mitral annulus by transseptal approach; the second portion was high in frequency. The accessory pathway conduction was completely eliminated after ablation on the atrial site. We speculated that the discrete musculature connection between left atrium and CS was responsible for the pattern of double potential activation in the CS electrograms during paroxysmal supraventricular tachycardia and ventricular pacing.     

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。     

经桡动脉途径射频消融A型预激综合征的方法学研究

目的 探讨桡动脉途径建立方法,评价该途径用于左侧房室旁路消融的疗效和安全性.方法 选择20例A型预激综合征(左侧房室旁路)为研究对象;采用桡动脉穿刺置入6 F长鞘作为5 F消融导管进行左心室二尖瓣环标测和消融途径;经锁骨下或颈内静脉穿刺置人两个6 F动脉鞘并插入冠状静脉窦和右心室电极导管,用于心房和心室局部记录和刺激的途径.结果 20例病人顺利经桡动脉插入鞘管和消融导管,二尖瓣环标测局部电图稳定,左侧旁路均被成功阻断;消融后顺利拔除消融导管和鞘管,无严重并发症.平均随访(3±1.7)个月无复发,穿刺手臂活动正常.结论 桡动脉途径配合锁骨下或颈内静脉插管可安全有效地消融左侧旁路.     

经冠状静脉窦射频消融心外膜旁道

报道 13例左侧心外膜旁道的特点和经冠状静脉窦射频消融的结果。 13例左侧旁道患者先经心内膜标测和消融 ,如不成功改由经冠状静脉窦标测 ,记录到旁道电位或最早激动的V波或逆传A波即进行消融。结果 :13例患者全部成功 ,平均放电 1.5± 0 .6次 ,能量 2 1± 4W ,时间 2 1± 9s。成功消融靶点 :左侧游离壁 2例、左后间隔冠状静脉窦憩室 4例、心中静脉 7例。 11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 ,与二者之比均大于 1。结论 :冠状静脉窦标测到振幅较大的旁道电位是左侧心外膜旁道的重要标志 ;冠状静脉窦消融可以有效地阻断心外膜侧旁道     

Accessory pathway automaticity after radiofrequency ablation

Mapping in a patient undergoing radiofrequency ablation for a left-sided concealed accessory pathway showed that the site with the shortest VA conduction time was in the great cardiac vein. Epicardial radiofrequency delivery at that site was successful. After ablation, a potential dissociated from both atrial and ventricular activity during sinus rhythm and atrial pacing was noted on the distal bipole of the ablation catheter. During incremental ventricular pacing, intermittent ventricular to potential conduction was observed. This indicates complete block at the atrial-accessory pathway interface and impaired conduction at the ventricular interface. This dissociated activity originating neither from the ventricle nor from the atria provides evidence of automatic accessory pathway activity.     

射频消蚀治疗预激综合征81例报告

以射频电流对81例预激综合征伴阵发性室上性心动过速患者的房室旁路进行消蚀。76例(93.8％)患者的83条旁路(94.3％)被阻断。平均放电12次,平均消蚀时程2.3小时,随访7个月,2例(2.5％)复发但成功地进行第二次消蚀,无严重并发症。     

Prospective evaluation of the coronary sinus anatomy in patients undergoing electrophysiologic study.

BACKGROUND: Previous retrospective studies could find a predominant incidence of coronary sinus (CS) anomalies in patients with accessory pathways and a characteristic anatomy of the CS ostium in patients with atrioventricular nodal reentrant tachycardias (AVNRT). HYPOTHESIS: In the present prospective study, CS angiograms were prospectively performed to analyze the incidence of CS anomalies and to measure the diameters of the CS ostium. METHODS: The study included patients referred for electrophysiologic study and catheter ablation of various tachyarrhythmias. The anatomy of the CS and its side branches was visualized [left anterior oblique (LAO) 30 degrees, right anterior oblique (RAO) 30 degrees] by retrograde angiography in 204 consecutive patients (82 women, 122 men, age 45 +/- 15 years); of these, 120 presented with 123 accessory pathways (45 left-sided, 33 right-sided, 45 septal). The diagnosis in the remaining patients was atrioventricular nodal reentrant tachycardia in 43 cases, atrial tachycardia or atrial fibrillation in 12, and ventricular tachycardia in 15. In 14 patients, the indication for the electrophysiologic study was an unexplained syncope. The CS angiogram was evaluated for anomalies and the size of the CS ostium was manually measured in both projections. RESULTS: Anomalies of the CS defined as diverticula, persistent left superior vena cava, or enlarged CS ostia were found in 18 patients (9%). Of those, CS diverticula were found in nine patients, all with a posteroseptal or left posterior manifest accessory pathway, which was abolished within the neck of the diverticulum in seven patients and at the posteroseptal tricuspid annulus in two patients. Persistence of the left superior vena cava was found in five patients, four had atrioventricular reentrant tachycardia secondary to five accessory pathways (left free wall in four, right midseptal in one), and one patient had atrioventricular nodal reentrant tachycardia (AVNRT). Enlargement of the CS ostium of > 25 mm width was detected in nine patients (5%), of whom four had AVNRT. However, the width of the CS ostium generally did not differ significantly between patients with AVNRT (LAO: 14.4 +/- 5.6; RAO 9.3 +/- 2.4 mm) compared with the control group (LAO 13.4 +/- 4.1; 8.2 +/- 1.9 mm). CONCLUSIONS: Anomalies of the CS as diverticula, persistent superior vena cava, or enlargement of the CS ostium are predominantly found in patients with accessory pathway-related tachycardias. Diverticula of the proximal CS were found in 7% of patients with accessory pathways; in these cases, ablation succeeded mostly by radiofrequency (RF) current delivery in the neck of the diverticulum. Enlargement of the CS ostium was more often seen in patients with AVNRT than in all other patients. However, in general the measurements of the coronary sinus ostium did not significantly differ in patients with AVNRT compared with the control group.     

经冠状静脉窦标测和消融后间隔心外膜房室旁道

报道心外膜房室旁道的特点和经冠状静脉窦射频消融术的结果。3例后间隔显性房室旁道患者先经心内膜标测和消融,不成功后改由经冠状静脉窦内标测和消融。术中冠状动脉造影,观察冠状静脉窦形态。结果: 2例冠状静脉窦近端有一憩室,并在憩室的颈部消融阻断房室旁道。成功靶点图为标测到振幅较大的旁道电位,其振幅大于A波和V波。结论:经心内膜标测和消融失败的旁道可能是心外膜旁道,行冠状静脉窦内标测与消融可有效阻断旁道,冠状静脉窦憩室与后间隔旁道可能存在着解剖关系。     

Coronary sinus stenosis as a late complication of catheter ablation in Wolff-Parkinson-White syndrome

This report describes a patient who developed stenosis of coronary sinus and cardiac veins five years after application of electric shock currents to the posterior mitral annulus and posteroseptal region of the tricuspid annulus for ablation of a left posterior accessory pathway and a right posteroseptal accessory pathway. This is the first angiographic documentation of coronary sinus stenosis as a late complication of electric ablation of accessory pathway. Cathet. Cardiovasc. Diagn. 42:70–72, 1997. © 1997 Wiley-Liss, Inc.     

心腔内单极电图旁道定位和消融靶点的图形特征

采用冠状窦和二尖瓣环单极记录标测左侧显性旁道和确定消融靶点指导射频消融治疗20例预激综合征。同步记录多部位冠状窦单极电图均清楚显示房波(UP)和室波(UR),其旁道定位点表现为 UP 降支和 UR 起始几乎融合构成特征性的复合波——PQS 波,而远离旁道的单极电图显示 UP 和 UR 分离构成 P—QS 或 P—rS 波。二尖瓣环单极记录时其图形变化类同冠状窦。比较冠状窦标测点和二尖瓣环单极电图的图形特征能迅速、直观地确定消融靶点。