射频消融位于冠状静脉窦憩室处的后间隔房室旁路.doc

射频消融位于冠状静脉窦憩室处的后间隔房室旁路中华心律失常学杂志 1999年第2期第3卷 临床研究作者：牟瑞起马坚李克清郑昭芬李传昶王方正单位：253014 山东省德州市人民医院(牟瑞起李克清);中国医学科学院中国协和医科大学心血管病研究所阜外心血管病医院(马坚王方正)；湖南医科大学湘雅医院(郑昭芬李传昶)关键词： 射频消融；冠状静脉窦憩室；旁路【摘要】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波提前(313.7)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。adiofrequency catheter ablation of a posteroseptal accessory pathway within a coronary sinus diverticulumMU Ruiqi,MA Jian,LI Keqing,et al.Peoples Hospital of Dezhou City,Dezhou 253014【Abstract】ObjectiveTo report the result of radiofrequency catheter ablation for five patients with posteroseptal accessory pathway within coronary sinus diverticulum.MethodsElectrophysiologic study and radiofrequency catheter ablation were performed in five patients with overt posteroseptal accessory pathway.The morphologic features of the coronary sinus was also studied with coronary angiography.ResultsA diverticulum attaching the proximal coronary sinus was found and the associated accessory pathway was successfully ablated at the neck of diverticulum in all of these five patients.Local ventricular activation at the successful sites was (313.7) ms earlier than the delta wave,and in four patients an accessory pathway potential was recorded.ConclusionsCoronary sinus diverticulum is anatomically intimately related to the posteroseptal accessory pathway.Coronary venography during the ablation session is very helpful to detect the diverticulum and identify the effective ablation site.【Key words】Radiofrequency ablationCoronary sinus diverticulumAccessory pathway冠状静脉窦憩室是一种少见的先天性心脏静脉系统畸形,常合并有位于心外膜侧的后间隔房室旁路14。本文报道5例此类患者的房室旁路射频消融结果,并结合文献报道,就其冠状静脉窦憩室的解剖结构特点和相关房室旁路的射频消融方法作一初步探讨。资料和方法1.病例5例患者,男性1例,女性4例,平均年龄36.611.2岁。阵发性室上性心动过速病史711年。体表心电图表现为预激综合征,查体、超声心动图和X线胸片未发现异常。既往史中,3例患者曾接受过1次射频消融治疗,但未成功。2.心内电生理检查和消融方法经静脉途径放置电极导管于高位右房(HRA)、冠状静脉窦(CS)、希氏束(HBE)记录部位和右室心尖部(RV)。进行心房和/或心室刺激诱发室上性心动过速,根据心动过速时最早的心房激动部位和希氏束不应期内的心室期前刺激(RS2),判定为后间隔旁路参与的房室折返性心动过速。窦性心律下,经右股静脉或股动脉,将4 mm消融电极导管先后送至三尖瓣环或二尖瓣环的后间隔区域进行标测。如果未能标测到理想的消融靶点电图(局部电图有旁路电位或提前的心室波)或试放电不成功,则将消融电极导管经股静脉送入冠状静脉窦。在冠状静脉窦的标测过程中,导管顶端弯曲向下,若记录到上述理想消融电图,以1015 W输出功率试消融。放电10 s内预激消失,在此部位多次巩固消融或将功率增至2025 W。之后,起搏心室以检查旁路的逆向传导功能是否被阻断。3.造影检查经右股动脉将6 F Judkins左冠状动脉造影导管送入左冠状动脉内,取右前斜(30度)和左前斜(45度)体位推注造影剂8 ml,观察延迟显影的冠状静脉窦形态。结果1.体表心电图特点(图1) 图1体表12导联心电图5例患者、aVF导联波负向,心室除极波呈QS形;V1导联的QRS波为qrS或rS,2例的波为等电位线,另3例则为正向;V2导联QRS波为Rs。2.电生理检查冠状静脉窦近端电极记录到窦性心律的最早心室激动和心动过速的最早心房激动。心室程序期前刺激(S1S2),3例患者的旁路逆向传导呈递减性。心动过速时,于希氏束不应期的心室期前刺激使心房激动提前。3.消融结果在5例患者的左、右后间隔部位均不能标测到提前的心室激动,并多次试消融未成功。消融电极进入冠状静脉窦内后,于憩室的颈部(经造影证实,图2)记录到较体表心电图波提前(313.7)ms的心室激动,局部电图为小心房(A)波和大心室(V)波。4例患者伴有明确的旁路电位(AP电位),并且AV波不融合(图3)。放电后5例患者的预激波很快消失,心室起搏证实室房分离。消融过程中,3例患者感明显胸痛。2例以20 W或25 W消融时阻抗急骤上升,撤出消融电极,见附有碳化组织。未发生并发症。 图2冠状静脉窦憩室的X线影像(右前斜体位)ABL消融电极；CSD冠状静脉窦憩室 图3成功消融靶点图A心房波；V心室波；AP旁路电位4.造影结果5例患者的冠状静脉窦近端下方有一个直径24 cm的囊状憩室(图2),并以一狭窄的颈部与冠状静脉窦相连。憩室的显影时间晚于冠状静脉窦。讨论冠状静脉窦憩室系先天性畸形,是胚胎早期与静脉窦(sinus venosus)相通的左脐静脉或卵黄静脉未能完全退化闭塞的结果4。冠状静脉窦憩室位于心脏的后间隔部位,由椭圆形的“囊状结构”和狭窄的“颈部”所组成(图4)。憩室的脏层紧贴于左室后上部的心肌,壁层则在心外膜的下方。Ho1和Gerlis等2对猝死者的尸检发现,4例预激综合征患者合并有冠状静脉窦憩室,而且预激波向量符合后间隔房室旁路的特点,提示冠状静脉窦憩室与该房室旁路之间存在着一定的解剖关系。病理组织学检查结果进一步证实了这一观点,冠状静脉窦憩室的壁层上有着连接心房与心室或冠状静脉窦与心室的肌束,即行走于心外膜下的后间隔房室或窦室(sinoventricular)旁路2,3。 图4冠状静脉窦憩室的解剖示意图(心脏背面)，右下角为冠状静脉窦憩室的矢状面解剖示意图LA左心房；RA右心房；LV左心室；RV右心室；LCX左冠状动脉回旋支；PDA右冠状动脉后降支；CS冠状静脉窦；CSD冠状静脉窦憩室；MCV心中静脉与过去外科手术的有效切除部位一样,此类后间隔房室旁路的成功消融靶点是局限于冠状静脉窦憩室的颈部3,57,本文5例也都在此处消融成功。有效消融靶点电图除明显提前的心室激动和小A大V波外,常伴有旁路电位;有时AV并不融合。因冠状静脉窦憩室的血流速度缓慢,消融部位又邻近心外膜,放电过程中易发生阻抗升高和碳化,同时患者常有胸痛症状,应从小功率开始或短时多次消融。Pfeiffer等6报道,消融术后憩室内有血栓形成。本文5例患者的整个消融过程较为艰难,其中3例曾有过1次消融失败史,属于射频消融术的疑难病例。所谓的“疑难”可能与术者是否意识到冠状静脉窦憩室这一特殊的解剖结构有关。据文献报道3,8,约10%18%的后间隔房室旁路患者具有冠状静脉窦憩室。因此 ,对在常规心内膜部位未能标测到理想靶点电图或消融失败的后间隔旁路,应行冠状静脉窦造影检查,以便及时发现憩室和确定有效的消融部位。体表心电图对术前判断冠状静脉窦憩室处的后间隔房室旁路有一定的帮助9,主要特点是、aVF导联的波负向,QRS波呈QS形;V2导联QRS波为Rs,而V1导联QRS波的变化较多,可表现为rS或R。此外,术前的超声心动图检查也能发现冠状静脉窦憩室10。参考文献1Ho SY,Russell G,Rowland E.Coronary venous aneurysms and accessory atrioventricular connection.Br Heart J,1988,60:348-351.2Gerlis LM,Davies MJ,Boyle R,et al.Pre-excitation due to accessory sinoventricular connexions associated with coronary sinus aneurysms.A report of two cases.Br Heart J,1985,53:314-322.3Guiraudon GM,Guiraudon CM,Klein GJ,et al.The coronary sinus diverticulum:A pathologic entity associated with the Wolff-Parkinson-White syndrome.Am J Cardiol,1988,62:733-735.4Jazayeri MR,Dhala A,Deshpande S,et al.Posteroseptal accessory pathway:An overview of anatomical characteristics,electrocardiographic patterns,electrophysiological features,and ablative therapy.J Interven Cardiol,1995,8:89-101.5Lesh MD,Hare GV,Kao AK,et al.Radiofrequency catheter ablation for Wolff-Parkinson-White syndrome associated with a coronary sinus diverticulum.PACE,1991,14:1479-1484.6Pfeiffer D,Tebbenjohanns J,Schumacher B,et al.Radiofrequency catheter ablation of septal accessory pathways.J Interven Cardiol,1995,8:69-76.7商丽华,杨新春,胡大一.经冠状窦憩室行房室旁路射频消融三例.中华心血管病杂志,1997,25:149-150.8Schumacher B,Tebbenjohanns J,Pfeiffer D,et al.Prospective study of retrograde coronary venography in patients with posteroseptal and left-sided accessory atrioventricular pathways.Am Heart J,1995,130:1031-1039.9Arruda MS,McClelland JH,Wang X,et al.Development and validation of an ECG algorithm for identifying accessory pathway ablation site in Wolff-Parkinson-White syndrome.J Cardiovasc Electrophysiol,1998,9:2-12.10Omran H,P