CAJ | 학술논문

目的探讨不同部位心外膜房室旁路(AP)的电生理特点及射频导管消融的方法学及结果.方法 36例心外膜AP患者,男性17例,年龄9～74岁,均伴房室折返性心动过速,7例有1～3次导管消融失败病史,经心内膜途径标测无理想消融靶点和/或经导管消融失败后,分别经冠状静脉系统(尤心中静脉)、无冠窦、右心耳、右侧游离壁标测到理想AP电位或AV(VA)相对最近或融合处,应用普通射频导管或换用盐水灌注射频导管,分别于上述部位消融.结果 36例中,在心脏静脉系统内消融成功28例,其中25例在心中静脉内或其口部附近消融成功;无冠窦内消融成功1例;右心耳内消融成功2例,其中1例复发后再次消融失败,最终经心外科手术成功;5例右侧游离壁心外膜AP,经沿三尖瓣环心房侧线性消融成功电隔离AP 4例,失败1例.结论心外膜AP的发生率为1.9%,多数(78%)位于心脏静脉系统(尤心中静脉)内,部分位于右侧游离壁,心耳内或无冠窦内罕见.术前通过分析体表心电图预激波极性可预测多数伴显性预激的心脏静脉系统心外膜旁路,在经心内膜标测和/或导管消融AP过程中如有疑问时应注意排除心外膜AP.盐水灌注射频导管可能有助于提高心外膜AP的消融成功率.
목적 탐토불동부위심외막방실방로(AP)적전생리특점급사빈도관소융적방법학급결과.방법 36례심외막AP환자,남성17례,년령9～74세,균반방실절반성심동과속,7례유1～3차도관소융실패병사,경심내막도경표측무이상소융파점화/혹경도관소융실패후,분별경관상정맥계통(우심중정맥)、무관두、우심이、우측유리벽표측도이상AP전위혹AV(VA)상대최근혹융합처,응용보통사빈도관혹환용염수관주사빈도관,분별우상술부위소융.결과 36례중,재심장정맥계통내소융성공28례,기중25례재심중정맥내혹기구부부근소융성공;무관두내소융성공1례;우심이내소융성공2례,기중1례복발후재차소융실패,최종경심외과수술성공;5례우측유리벽심외막AP,경연삼첨판배심방측선성소융성공전격리AP 4례,실패1례.결론 심외막AP적발생솔위1.9%,다수(78%)위우심장정맥계통(우심중정맥)내,부분위우우측유리벽,심이내혹무관두내한견.술전통과분석체표심전도예격파겁성가예측다수반현성예격적심장정맥계통심외막방로,재경심내막표측화/혹도관소융AP과정중여유의문시응주의배제심외막AP.염수관주사빈도관가능유조우제고심외막AP적소융성공솔.
Objective To investigate the electrophysiological characteristics,the techniques and results of radiofrequency catheter ablation in patients with epicardial atrioventricular accessory pathway (AP).Methods Thirty-six patients (17 male) with epicardial AP and atrioventricular reentrant tachycardia (AVRT) underwent electrophysiological study and catheter ablation were studied. Seven patients had failed catheter ablation for 1 to 3 times. After initial endocardial mapping did not achieve optimized target site or ablation failed to eliminate AP conduction,the ablation catheter was introduced into the coronary sinus (especially the middle cardiac vein),the noncoronary cusp, the right or left appendage, and/or the right atrial free wall around the tricuspid annulus to map the AP potential or the relatively earlier A-V or V-A site. Radiofrequency ablation was delivered at these sites using the common 4-mm tip catheter or shifting to saline-irrigated tip catheter if the common catheter failed to eliminate the AP. Results Twenty-eight of the 36 patients (78%) had successful ablation in the coronary vein system, including 25 patients having AP ablated in the middle cardiac vein or its near site. AP was eliminated inside the noncoronary cusp in 1 patient. In 2 patients who had a successful AP ablation inside the right appendage. One of them had AVRT recurrence and failed re-ablation and was eventually cured by cardiac surgery. Among the 5 patients with the right-sided lateral free wall AP, linear ablation along the atrial side of the tricuspid annulus isolated the AP from atrium in 4 patients, and the other 1 patient had a failed ablation. Conclusion The incidence of epicardial AP is 1.9% . Most of them ( 78% )were located in the coronary vein system ( especially in the middle cardiac vein or its near site ), some in the right-sided free wall, and rare in the right appendage. The epicardial AP should be considered if endocardial mapping did not show ideal target site or radiofrequency current failed to eliminate the AP. The saline-irrigated radiofrequency catheter may increase the success rate for epicardial AP ablation.