左侧房室旁路射频导管消融中特殊现象

Clinical Observation of the Special Phenomena of Radiofrequency Catheter Ablation in the Left Accessory Pathway

目的探讨特殊左侧旁路射频导管消融中的策略。方法选取2013年全年行射频导管消融的左侧旁路患者288例,其中,11例在消融中有一定特殊性,包括6例存在裂隙现象,3例为左侧慢旁路,1例合并小儿麻痹,外周血管严重迂曲,1例为阵发性房颤、房扑合并房室显性旁路。经主动脉逆行途径在二尖瓣心室侧、穿间隔途径在二尖瓣心房侧及冠状静脉窦内行射频消融。结果 11例患者均消融成功。6例经主动脉逆行途径,在二尖瓣心室侧消融成功;4例经房间隔穿刺,在二尖瓣心房侧消融成功;1例经冠状静脉窦内消融成功。术后无并发症。6例在低频率(周长400 ms以上)刺激时无室房逆传,在高频率(低于350 ms周长)刺激时出现旁路逆传,室房逆传呈现裂隙现象。3例为左侧慢旁路,心室逆传时VA间期明显延长,靶点处VA不融合。1例为外周血管严重迂曲,经主动脉逆行途径无法到达靶点,后改为经房间隔穿刺途径消融成功。1例为阵发性房颤、房扑合并左前壁房室显性旁路,成功隔离肺静脉电位及阻滞三尖瓣环峡部线后,在距离冠状窦口约7 cm处,左心耳根部及冠状静脉窦内远端消融成功。结论左侧房室旁路导管射频消融存在特殊情况时,需仔细鉴别,通过不同的方法及途径消融,仍可获得较高的成功率。

Objective To explore the strategy of radiofrequency catheter ablation in special left accessory pathway.Methods In 2013,total 288 patients with left accessory pathway were ablated in our hospital. Among them,special left accessory pathways were found in 11 patients. Gap phenomenon was found in 6 patients,slow accessory pathway in 3 patients,peripheral vascular serious circuity in 1 patient and combination with atrial fibrillation and atrial flutter in 1 patient. All the patients were ablated through aortic retrograde approach,transseptal approach and via coronary sinus approach. Results Eleven patients were all ablated successfully. Six patients were ablated through aortic retrograde approach. Four patients with left side accessory pathway were accomplished through transseptal approach. One patient was ablated via coronary sinus. The success rate was 100%,and complication was not occurred. Gap phenomenon was found in 6 patients with no adverse transmission above 400 ms stimulation and with adverse transmission under 350 ms stimulation. Three patients with slow accessory pathway were ablated in left free wall where VA was not fused. One patient with peripheral vascular serious circuity was ablated through transseptal approach after failure via aortic retrograde approach. One patient with atrial fibrillation and atrial flutter was ablated in coronary vein successfully. Conclusion During ablation in left accessory pathway,we may get into trouble in some cases. After identifying carefully and ablating through different methods,high success rate still can be obtained.