以冠状静脉窦壁心肌为心房插入点的后间隔旁路

Coronary sinus wall as the atrial insertion site of posterior septal atrioventricular accessory pathway

目的介绍５例经导管标测和射频消融证实的以冠状静脉窦（ＣＳ）壁心肌为心房插入点的后间隔旁路。方法常规电生理检查定位旁路在后间隔，以７Ｆ大头导管标测左、右后间隔和二尖瓣环左心房侧（房间隔穿刺），均找不到比ＣＳ电极处更理想的标测电图，多次高能量消融不成功。经右心房将大头电极送至ＣＳ口或ＣＳ内，标测到典型靶点图，低能量消融成功。结果５例患者男性３例，女性２例，年龄３８±１７岁。旁路以ＣＳ口１ｃｍ内为插入点者３例，２ｃｍ内者２例。心动过速中放电３例，右室起搏时放电２例，能量１０～２０Ｗ，旁路均在２ｓ内阻断。随访１４±６个月无心动过速复发。结论ＣＳ壁全程都可成为房室旁路的心房插入点。这种旁路走行偏心外膜，如果在左、右后间隔心内膜难以有效标测和消融，应仔细标测ＣＳ壁，准确定位后以低能量或温控方式在ＣＳ壁上消融。

Objectives Not infrequnently it is difficult to map and ablate the posterior septal accessory pathway(PSAP)due to the complicated anatomy of the posterior septal region involved which makes the AP's atrial insertion sites variable.Five patients(3 males and 2 females,age averaging 3817)with the coronary sinus wall as the atrial insertion site of PSAP are reported. Methods Regular electrophysiologic mapping and radiofrequency(RF) ablation procedures were carried out.The target sites at posterior septum were approached first from RA and LV(by both retroaortic and transseptal way)cavity,and then in coronary sinus. Results The atrial insertion sites of the PSAP's were found to be located in the coronary sinus proper,within 10 mm from the coronary sinus ostium in 3 cases,and within 20 mm from the coronay sinus ostium in 2 cases.They were all successfully interrupted by RF application with 1020 W for 2 seconds.RF were applied during AVRT in 3 cases and during RV pacing in 2 cases.At the end of average 6 month followup,none was found to have tachycardia recurrence. ConclusionBZFor PSAP,mapping should be carried out in the coronary sinus if routine approach is unsuccessful.Once when the atrial insertion site was confirmed to be on the coronary sinus wall,RF ablation should be performed with temperaturecontrolled mode.