全国儿童心内电生理检查及射频消融多中心资料分析

Pediatric intra-cardiac electrophysiological study and radiofrequency catheter ablation of tachyarrhythmia——a national multicenter clinical study

目的 探讨射频导管消融（RFCA）治疗小儿不同类型快速心律失常的成功率、复发率、安全性及对消融效果的影响因素.方法 收集国内8家医院小儿心内科1994年4月26日至2012年9月30日接受心内电生理检查及RFCA的快速型心律失常患儿3 058例,年龄0.33-16.50（7.6＆#177;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,比较不同年龄组的RF-CA效果及复发情况.结果 接受心内电生理检查患儿共计3 058例,包括室上性心动过速（SVT）2 561例（83.7％）及室性心动过速/室性早搏（VT/PVC） 497例（16.3％）.SVT患儿经心内电生理检查证实房室折返性心动过速（AVRT）1 630例（63.6％）,房室结折返性心动过速（AVNRT） 750例（29.3％）,心房扑动/切口折返性房性心动过速（AFL/IRAT） 40例（1.6％）,局灶性房性心动过速（FAT）141例（5.5％）.2 958例患儿接受RFCA,首次消融成功率96.8％,复发率4.8％,其中经电生理检查证实为原旁路/消融点复发3.6％,新的旁路/起源部位/心律失常类型1.2％.1 580例AVRT患者接受RFCA,首次消融成功率97.7％,复发率4.0％,其中原旁路复发2.4％,新的旁路/心动过速类型复发1.6％.右前/中间隔旁路首次消融成功率较低（88.2％）,原旁路复发率较高（19.4％）.740例AVNRT患者接受RFCA,首次消融成功率99.3％,复发率4.4％,其中原消融类型复发4.0％.40例AFL/IRAT患者接受RFCA,首次消融成功率97.5％,随访无复发.131例FAT患者接受消融,首次消融成功率84.7％.其中采用二维标测成功率81.0％;采用三维标测指导冷盐水灌注导管消融成功率91.5％.FAT患者消融复发率12.6％,其中原消融点复发率11.7％.467例VT/PVC接受RFCA,首次消融成功率93.1％,其中采用二维标测成功率92.1％;采用三维标测指导冷盐水灌注导管消融成功率100％.起源于不同部位VT/PVC首次消融成功率以左心室中后间隔起源为最高,达96.9％;最低为多源性VT/PVC,为66.7％.VT/PVC消融复发率6.4％,其中原消融点复发5.5％.不同年龄组首次消融成功率比较差异无统计学意义.RFCA并发症17例（0.55％）,包括完全性房室阻滞4例（0.13％）,二度房室阻滞6例（0.20％）,血气胸1例（0.03％）,麻醉意外1例（0.03％）及血管并发症5例（0.16％）.结论 RFCA可安全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.低龄患儿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,但消融术难度有所增加,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 safety and efficacy of radiofrequency catheter ablation（RFCA） for different kinds of pediatric tachyarrhythmias.Methods Clinical materials （April 26,1994-September 30,2012）included 3 058 pediatric patients [（7.6＆#177;3.8） years old] who received intra-cardiac electrophysiological （EP） study and RFCA for tachyarrhythmia from 8 hospitals in China.The efficacy and recurrence rates for different age groups were compared.Results Totally 3 058 patients received EP study including 2 561（83.7%） cases of supraventricular tachycardia（SVT） and 497（16.3%） cases of ventricular tachycardia/premature ventricular contraction（VT/PVC）.SVT group includes 1 630 （63.6%） cases of atrioventricular reentrant tachycardia （AVRT）,750 （29.3%） cases of atrioventricular nodular reentrant tachycardia （AVNRT）,141 （5.5%） cases of focal atrial tachycardia（FAT） and 40 （1.6%）cases of atrial flutter/incisional reentrant atrial tachycardia （AF/ IRAT）.RFCAs were performed on 2 958 cases of patients,success rate for the first procedure was 96.8%,recurrence rate was 4.8% （primary ablated accessory pathway/origin 3.6%,new accessory pathway/origin/tachycardia type 1.2%）.One thousand five hundreds and eighty cases of AVRT were ablated with success rate 97.7%,recurrence rate 4.0% （primary ablated accessory pathway 2.4%,new accessory pathway 1.6%）.Seven hundred and forty cases of AVNRT were ablated with success rate 99.3%,recurrence rate 4.4% （primary ablated site 2.4%）.Forty cases of AF/IRAT were ablated with success rate 97.5% with no recurrence.One hundred and thirty-one cases of FAT were ablated with success rate 84.7%.Success rate for two-dimensional mapping group was 81.0%,that for three-dimensional mapping combined with cooled saline irrigated tip ablation was 91.5%.Recurrence rate for FAT ablation was 12.6% （primary origin 11.7%）.Four hundreds and sixty-seven cases of VT/PVC were ablated with success rate 93.1%.Success rate for two-dimensional mapping group was 92.1%,that for three-dimensional mapping combined with cooled saline irrigated tip ablation was 100%.VT/PVC originating from left mid-posterior ventricular septum had the highest success rate 96.9%,the lowest was 66.7% for VT/PVC of multiple origins.Recurrence rate for VT/PVC ablation was 6.4% （primary origin 5.5%）.There are no differences of success rates among different age groups.There are 17 （0.55%）cases of complications,including 4 cases of complete atrioventricular block（0.13%）,6 cases of Ⅱ degree atrioventricular block（0.20%）,1 case of hematopneumo thorax（0.03%）,1 case of anesthetic accident （0.03%） and 5 cases of vascular complication （0.16%）.Conclusions RFCA can be effectively and safely applied to cure pediatric tachyarrhythmias with high success rate and low recurrence rate.RFCA can be the first choice therapy for some categories of pediatric tachyarrhythmias.The success rate,recurrence rate and complication rate for younger are no different from those older.While the procedure is technically more difficult so that selection of patients should be careful.Three dimensional mapping can significantly improve the success rate for complicated tachyarrhythmias.Experienced and sophisticated manipulations can help to avoid the occurrence of complications.