房室结双径路合并房室旁路的折返性心动过速及射频消融治疗

1、房室结双径路合并房室旁路的折返性心动过速及射频消融治疗 2010-06-02 Reentrant tachycardia and radiofrequency ablation of dual atrioventricular nodal pathways with atrioventricular accessory pathways 盛晓东 刘志华 宋建平 惠杰 汪康平 蒋文平 Sheng Xiaodong, Liu Zhihua, Song Jianping, et al 【摘要】 目的 本研究旨在探讨房室结双径路(DAVNP合并房室旁路(AP的电生 理特征和射频消融要求。方法 对218

2、例阵发性室上性心动过速(PSVT进行电生理 检查，观察PSVT的前传和逆传途径，然后对AP或房室结慢径(SP进行消融治疗。结 果 218例PSVT中检出DAVNP+AP 10例，检出率为4.6%。其中SP前传、AP逆传(SP-AP 折返4例，快径(FP前传、AP逆传(FP-AP折返1例，SP-AP折返并FP-AP折返或SP/FP 交替前传折返4例，SP前传、FP逆传(AP旁观1例。10例患者均作AP消融，诱发房室 结折返性心动过速(AVNRT的3例加作SP消融，术后随访均无复发。结论 DAVNP合 并AP者AP均作为逆传途径，阻断AP是消融关键；AP旁观者也应作AP消融；仅有AH跳 跃延长者不

3、必接受房室结改良；AP消融者应作DAVNP电生理检查。 【关键词】 心动过速，室上性 电生理学 导管消融术 Reentrant tachycardia and radiofrequency ablation of dual atrioventricular nodal pathways with atrioventricular accessory pathways Sheng Xiaodong, Liu Zhihua, Song Jianping, et al. The First Affliated Hospital of Suzhou Medical College, Suzhou 21

4、5006 【Abstract】 Objective To examine the electrophysiologic characteristics of dual atrioventricular nodal pathways (DAVNP with accessory pathways (AP and evaluate the criteria for radiofrequency catheter ablation. Methods Electrophysiologic study were performed on 218 patients with paroxysmal supra

5、ventricular tachycardia (PSVT. The antegrade and retrograde conduction pathways were examined, and the AP or slow pathway (SP was ablated if necessary. Results Among the 218 patients with PSVT, 10 patients (4.6% with DAVNP and AP were found. Of the 10 patients, the reentrant pattern with antegrade c

6、onduction by SP and retrograde conduction by AP was induced in 4 patients, the pattern with antegrade conduction by fast pathway (FP in one patient. Four patients manifested antegrade conduction by SP or FP alternatively, and the last one had SP and FP reentry (AP as a bystander. Radiofrequency abla

7、tion of AP was performed on all patients and ablation of SP was performed on 3 patients with the initiation of atrioventricular nodal reentrant tachycardia (AVNRT. No recurrence was found during follow-up. Conclusion The results suggest that it is crucial to break the conduction of AP in patients wi

8、th DAVNP and AP. The bystander AP should be ablated also. Patients with AVNRT attacked in the history or initiated during electrophysiologic testing should accept ablation of SP. It seems unneces sary to modifiy the AVN in patients only with the discontinuity of the AH interval. Patients with atriov

9、entricular reentrant tachycardia should undergo electrophysiologic study on DAVNP. 【Key words】 tachycardia, supraventricular electrophysiology catheter ablation 预激综合征常可合并房室结双径路(DAVNP14，使折返性心动过速复杂化。 本文报告10例由射频消融治疗(RFCA证明房室旁路(AP合并DAVNP(简称DAVNP+AP的 患者，旨在探讨不同折返的电生理特征和RFCA的要求。 资料和方法 1.病例选择：218例阵发性室上性心动过速

10、(PSVT接受RFCA，其中有10例DAVNP+AP， 男6例，女4例，平均年龄34±11(1548岁。全部病人均无器质性心脏病存在，术前停用 抗心律失常药物至少5个半衰期。 DAVNP：在程控心房S1S2刺激时，A1A2间期缩短10ms，A2H2突然延长50ms，并诱发 房室结折返性心动过速(AVNRT5，6。 慢径(SP-AP：即SP前向传导，AP逆向传导构成的房室折返性心动过速(AVRT，表现 为A2H2跳跃延长后诱发PSVT，逆传心房激动呈偏心型，其激动顺序取决于AP位置。 快径(FP-AP：即FP前向传导，AP逆向传导构成的AVRT，表现为A2H2未跳跃延长而诱 发AVRT

11、，在AP消融后，心房程控刺激见A2H2跳跃延长现象，且FP有效不应期小于AP消融 前AVRT诱发窗口上限。 AVNRT(AP旁观：程控刺激诱发PSVT，逆传心房激动顺序呈向心型，而终止PSVT后心 电图呈显性预激图形或心室刺激显示隐匿性AP存在，则表明由房室结快、慢径构成AVNRT， AP仅作为旁观者。 2.电生理检查和射频消融：详见文献7。 3.随访：门诊随访并作食管电生理检查。 结 果 消融前电生理检查诱发SP-AP折返4例，FP-AP折返1例，SP-AP并FP-AP折返4例，SP-FP折返1例。 1.SP-AP折返(4例：逆传心房激动顺序均为CSHBEHRA，呈偏心型。RFCA阻断AP 后1例又诱发出心动过速，但逆传心房激动顺序为HBEHRACS，提示为房室结内折返， 遂予房室结SP改良。其余未诱发出AVNRT的3例未作SP消融。术后随访11±8个月，均无复 发。食管电生理检查见未作SP消融的3例仍有SR跳跃现象，4例均不能诱发心动过速。 2.FP-AP折返(1例：RFCA阻断AP后重复电生理检查见A