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

Reentrant tachycardia and radiofrequency ablation of dual atrioventricular nodal pathways with atrioventricular accessory pathways

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＋ＡＰ１０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跳跃延长者不必接受房室结改良；ＡＰ消融者应作ＤＡＶＮＰ电生理检查。

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 supraventricular 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 conduction 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 ablation 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 with 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 unnecessary to modifiy the AVN in patients only with the discontinuity of the AH interval. Patients with atrioventricular reentrant tachycardia should undergo electrophysiologic study on DAVNP.