射频消融失败的房室折返性心动过速患者旁道的电生理定位及手术治

1、射频消融失败的房室折返性心动过速患者旁道的电生理定位及手术治疗 2009-08-06 李莉汪曾炜张宝仁朱家麟郝家骅陆方林李建红郭素华 摘要对11例射频消融(RFCA失败的房室折返性心动过速(AVRT患者(8例合并有器质性心脏病进行电生理定位及外科治疗。10例心外膜标测定位结果与术前心内电生理定位一致。11例旁道(AP切割均获成功。1例死于围术期急性肾功能衰竭，2例分别于术后第2及30日复发，再次RFCA成功。2例左后间隔显性AP遗留有delta波。10例随访15.3±12.8个月，无心动过速复发，合并的器质性心脏病均获治愈，心功能级。3例无器质性心脏病，2例为左后间隔AP，1例为右后

2、游离壁AP，手术中证实RFCA失败系消融电极未能抵达有效靶点消融所致；2例Ebsteins畸形合并房间隔缺损，1例为重度三尖瓣返流使消融电极不能稳定贴靠靶点，另1例为AP靠近心外膜面而致RFCA失败；1例风湿性心脏病联合瓣膜病因瓣膜及瓣下结构病理改变致RFCA失败；1例重度二尖瓣返流RFCA失败与病人不能耐受RFCA与AP定位于24区消融导管难以抵达有关；先天性心脏病大房间隔缺损、重度主动脉关闭不全及矫正性大动脉转位右旋心伴三尖瓣返流各1例，RFCA失败与解剖畸形、心内大分流等血液动力学障碍有关。结果提示RFCA失败的AVRT在电生理标测指导下外科治疗可获得满意疗效；AP切断后遗留delta波

3、的原因有待研究。 关键词心动过速，房室折返性电生理学导管消融，射频电流心脏外科手术 Electrophysiologic Study and Surgical Treatment of Atrioventricular Reentrant Tachycardia in Patients Failed With Radiofrequency Ablation Li Li,Wang Zengwei,Zhang Baoren,et al (Changhai Hospital,Second Military Medical University,PLA,Shanghai,200433 Abstract

4、Eleven patients with atrioventricular reentrant tachycardia(AVRT who had failed from radiofrequency catheter ablation (RFCA were treated by surgical operation.Eight patients had associated structural heart diseases.All patients had problematical preexcitation syndrome.Electrophysiological studies be

5、fore operation in 11 patients and epicardial mapping during operation in 10 patients were performed and their localization showed no difference.All accessory pathways (AP were successfully ablated and there were no intraoperative complications.One patient died of acute renal failure 5 days postopera

6、tively.Two patients had recurrence of right lateral AP and were successfully treated by RFCA.In all,10 patients were cured after mean follow-up 15.3±12.8 months.The causes of RFCA failure were demonstrated in surgical operation.In 3 patients without structural heart disease,ablation catheters w

7、ere not located in distinct target sites during ablation of 2 left posteroseptal pathways and 1 right posterior wall pathway.In 2 cases of Ebsteins anomaly,ablations were failed by serious tricuspid regurgitation and AP at epicardium.In one case with rhumatic valvular disease,ablation catheter did n

8、ot achieve mitral annulus because of pathologic changes.Other 4 cases with congenital heart disease were associated with anotomical anomaly and serious hemodynamic disturbance.The results indicated that AVRT in patients with structural heart disease or problematical preexcitation syndrome can be suc

9、cessfully treated by surgical operation with electrophysiological mapping. Key wordsTachycardia,atrioventricular reentrantElectrophysiologyCatheter ablation,radiofrequency currentHeart surgery 经导管射频消融(RFCA治疗房室折返性心动过速(AVRT已成为公认的安全和有效的治疗方法，国内外大系列临床研究证实左、右侧旁道(AP的RFCA成功率分别达91%97%及82%92%1。我院1995年5月1998年4

10、月共对11例RFCA失败的病例进行了AP切割手术，现将结果报道如下。 1资料与方法 1.1手术对象11例患者，男6例、女5例，年龄34.9±14.7(1360岁。8例合并器质性心脏病，其中风湿性心脏病(简称风心病主动脉瓣、二尖瓣狭窄并关闭不全合并快速心房颤动(简称房颤、心力衰竭(简称心衰1例；感染性心内膜炎、主动脉关闭不全、急性左心衰竭肺水肿1例；先天性心脏病重度二尖瓣关闭不全、主动脉瓣关闭不全各1例；Ebstein's畸形伴房间隔缺损(简称房缺2例；大房缺、校正性大动脉转位右旋心伴重度三尖瓣返流各1例。均经心电图及Holter证实为室上性心动过速，病史320年，6例有晕厥史

11、。心功能级1例、级2例、级7例、级1例。11例病人均经有百例以上射频消融经验的医生行1.9±1.0(14次RFCA。 1.2心内电生理检查及定位除2例病情危重不宜进行电生理检查而参考以往电生理定位外，其余均在术前停用抗心律失常药至少5个半衰期后行心内电生理检查。从右颈内静脉送入10极电极导管入冠状静脉窦(CS，经左、右股静脉送入3根4极电极导管分别置于高位右房(HRA、His束、右室心尖(RVA。行心房和心室程序刺激，明确心动过速发生机制及判别左、右侧AP。左侧AP取右前斜位30 °，消融电极沿二尖瓣环细标心室最早激动点(EVA或心房最早激动点(EAA。右侧AP取左前斜位5

12、0 °，消融电极沿三尖瓣环细标EVA或EAA。消融无效时左前斜位50 °、右前斜30 °和后前位拍摄显示消融电极标测靶点位置的X线片，为外科手术作标测定位。 1.3心外膜标测心脏插管后于前房间沟中下1/3的心外膜面缝心房双极参照电极，于右室前壁14区缝心室双极参照电极。在窦性心律或刺激HRA增加前向预激状态下用双极标测棒或5导双极同步标测电极沿房室环14 个区的心室侧进行标测，以寻找领先于心室参照电极的EVA；在RVA刺激或诱发AVRT的情况下，沿房室环心房侧作14个区定位标测，寻找领先于心房参照电图的EAA。根据EVA和EAA判定AP的心房、心室插入点，确认AP的心外膜定位。采用Gallagher 53区心外膜分区法进行分区：右房室环标测点由前向后依次为1，2，3，4，5，46，45区，1区为右前游离壁，25区为右侧游离壁，46，45区为右后游离壁