射频导管消融治疗小儿不同类型快速型心律失常1000例

Effect of radiofrequency catheter ablation for different types of tachyarrhythmias in 1000 children

目的探讨射频导管消融（RFCA）治疗小儿不同类型快速型心律失常的成功率、复发因素、安全性及年龄对消融效果的影响。方法接受心内电生理学检查及RFCA的快速型心律失常患儿1000例，年龄0．33～16．50岁[（7．6±3．8）岁]。分析不同心动过速类型RFCA方法及效果、心动过速复发及并发症的发生情况，比较不同年龄组RFCA效果。结果接受心内电生理检查患儿1000例，经心内电生理学检查证实房室折返性心动过速（AVRT）560例（56％），房室结折返性心动过速（AVNRT）210例（21％），室性心动过速／室性期前收缩（VT／PVC）159例（15．9％），局灶性房性心动过速（FAT）49例（4．9％），心房扑动／切口折返性房性心动过速（AF／IRAT）22例（2．2％）。958例患儿接受RFCA，首次消融成功率96．2％，复发率8．1％，其中经心电生理检查证实为原旁路／消融点复发5．3％，新的旁路／起源部位／心律失常类型2．8％。AVRT接受RFCA533例，消融成功率98．0％，复发率8．4％，其中原旁路复发4．0％，新的旁路／心动过速类型4．4％。右前／中间隔旁路消融成功率较低（85．3％），原旁路复发率较高（31．0％）。AVNRT接受RFCA205例，消融成功率100％，复发率5．9％，其中原消融点复发4．9％。AF／IRAT接受RFCA22例，消融成功率95．5％，随访无复发。FAT接受RFCA46例，消融成功率84．8％。其中采用二维标测，消融成功率62．5％；采用三维标测指导冷盐水灌注消融成功率96．7％；2种方法消融成功率比较差异具有统计学意义（P〈0．05）；复发10例（25．6％），其中7例起源于左／右心耳，均经外科心耳切除术后房性心动过速得以根治。VT／PVC接受RFCA152例，消融成功率89．5％，复发率6．6％，其中原消融点复发5．9％。不同年龄组消融成功率比较差异无统计学意义。开展RFCA早期与晚期总体消融成功率及不同类型心动过速消融消融成功率比较差异无统计学意义，开展消融早期房室结折返性心动过速及左前侧壁房室旁路复发率显著高于晚期，差异有统计学意义（P〈0．05）。RFCA并发症8例（0．84％），其中完全性房室传导阻滞2例、麻醉意外1例均发生于射频消融早期阶段，血管并发症5例，无死亡病例。结论RFCA手术可安全而有效地用于治疗小儿快速型心律失常，成功率高，复发率低，是根治某些类型小儿快速型心律失常的首选方法；低龄儿RFCA成功率、复发率及并发症与其他年龄组患儿比较差异无统计学意义，但手术难度有所增加，需谨慎选择；采用三维标测指导射频导管消融可明显提高难治性心律失常的消融成功率；丰富的经验及熟练的操作是避免并发症发生的重要因素。

Objective To investigate the success rate, factors associated with recurrence, safety and effect of age on results of radiofrequency catheter ablation（RFCA） for different types of tachyarrhythmias in children. Methods A thousand children diagnosed as tachyarrhythmias underwent eleetrophysiological study （EPS）, with mean age （7.6 ±3.8 ）years old （0.33 - 16.50 years old）. RFCA methods and results for different kinds of tachyarrhythmias a- long with recurrence and complications were analyzed. RFCA results for different age groups were compared. Results A thousand children underwent EPS. The number of atrioventricular reentrant taehycardia（AVRT） was 560 （56%） , at- rioventricular nodal reentrant taehycardia （AVNRT） was 210 （21%）, ventrieular tachycardia/ventricular premature contraction （ VT/PVC ） was 159 （ 15.9% ）, focal atrial taehycardia （ FAT ） was 49 （ 4.9 % ）, and atrial flutter/incisional reentrant atrial tachyeardia （AF/IRAT）was 22 （2.2%）. Totally 958 children underwent RFCA, among whom success rate was 96.2% and recurrence rate was 8.1%. EPS performed on recurred cases showed restoration of primary path- way/origin was 5.3% ,while appearance of new pathway/origin was 2.8%. Five hundred and thirty-three AVRT cases underwent RFCA, among whom success rate was 98.0%, recurrence rate was 8.4%, restoration of primary pathway was 4.0% , and appearance of new pathway was 4.4%. Success rate of right anterior/mid septal pathway was relatively low （ 85.3 % ）, but its rate of restoration of primary pathway was high （ 31.0% ）, as 205 cases of AVNRT underwent RFCA, among whom success rate was 100% ,recurrence rate was 5.9% , and restoration of primary origin was 4.9% ,while 22 cases of AF/IRAT underwent RFCA,among whom success rate was 95.5% with no recurrence,46 cases of FAT under- went RFCA,in which success rate was 84.8% ; success rates for two-dimensional mapping group and three-dimensional mapping combined with cool-tip ablation group were 62.5% and 96.7% respectively and the difference was significant （P 〈 0.05 ）, as 10 cases recurred in which 7 originated from atrial appendages, and these 7 cases were successfully cured by appendectomy, 152 cases of VT/PVC underwent RFCA,in which success rate was 89.5%, recurrence rate was 6.6% ,restoration of primary origin was 5.9%. There was no difference in success rate between different age groups.The gross success rates and success rates for different types of arrhythmias between early and late periods were not dif- ferent,while recurrence rates for AVNRT and left anterior pathways in early periods were significantly higher than late periods （ P 〈 0.05 ）. There were totally 8 cases with complications （0.84%）, including 2 cases of complete atrioventri- cular block and 1 case of anesthetic accident which happened in early period. The other 5 were vascular complications, and there was no death. Conclusions RFCA can be safely used as frontline treatment to cure some kinds of tachya- rrhythmias in children with high success rate and low recurrence rate. There is no difference in rates of success, recur- rence and complication between younger and older children, while difficulty for procedure increased for the former so that caution should be made for selection of patients. Application of three-dimensional mapping for difficult arrhythmias can increase success rate for ablation. Proficient experience and skillful manipulation are the main factors to avoid com- plications.