冠状窦呈偏心性激动的不典型房室结折返性心动过速的电生理特征及导管消融

Characteristics and catheter ablation of atypical atrioventricular nodal reentry tachycardia with eccentric excitation in coronary sinus

目的总结冠状窦(coronary sinus,CS)呈偏心性激动的不典型房室结折返性心动过速(atrioventricular nodal reentry tachycardia,AVNRT)的电生理特点、鉴别诊断及消融方法。方法回顾性收集2014年1月至2018年12月在复旦大学附属中山医院心内科进行射频消融治疗的524例AVNRT患者的临床资料。其中,CS呈偏心性激动的不典型AVNRT患者共16例,男性6例、女性10例,平均年龄(56.6±11.4)岁。分析16例不典型AVNRT患者的体表心电图和腔内心电图特点、诱发方式、鉴别诊断及射频消融策略。结果16例CS呈偏心性激动的AVNRT患者的心电图均表现为RP间期>PR间期,P波在Ⅱ、Ⅲ、aVF导联中倒置;发作时12例患者房室传导比例为1∶1,4例患者为2∶1或3∶1;13例患者可以轻易通过心室拖带的方式进行鉴别,2例患者需要多次拖带才能成功,1例患者多次拖带下心房-心室(atrioventricular,VA)仍然分离;14例患者在右心房后间隔靠近三尖瓣环处成功消融,3例患者在CS内成功消融。结论CS呈偏心性激动的不典型AVNRT可以优先通过心室拖带进行鉴别诊断,多数患者采用常规的消融策略可以安全有效地治愈,而少部分患者需要在CS内进行消融。

Objective To summarize the electrophysiological characteristics,differential diagnosis and ablation methods of atypical atrioventricular nodal reentry tachycardia(AVNRT)with eccentric activation in coronary sinus(CS).Methods The clinical data of 524 patients with AVNRT who underwent ablation in the Department of Cardiology,Zhongshan Hospital from January 2014 to December 2018 were collected retrospectively.Among them,there were 16 atypical AVNRT patients with eccentric activation in CS,including 6 males and 10 females,with an average age of(56.6±11.4)years.The electrocardiogram(ECG)and intracardiac eletrogram(IEGM)features,induction mode,differential diagnosis and ablation strategy were analyzed.Results Generally,the ECG of AVNRT with eccentric activation pattern in the CS electrical signals demonstrated a negative P waves in leadⅡ,Ⅲ,AVF and a longer RP interval than PR interval.During the occurrence of an arrhythmia,12 patients exhibited 1∶1 atrioventricular conduction,4 patients exhibited AV dissociation with 2∶1 or 3∶1 conduction.Additionally,13 patients could be easily identified by apical ventricular entrainment,2 patients needed multiple ventricular entrainments to succeed,and 1 patient had occurred atrioventricular dissociation during multiple ventricular entrainments.14 patients could be successfully ablated at the posterior septum of right atrium near the tricuspid annulus,whilst 3 patients required CS ablation.Conclusion Atypical AVNRT with eccentric activation in CS can be differentiated by ventricular entrainments.Most patients can be treated safely and effectively by conventional ablation strategy,whilst a few patients need CS ablation to be successfully treated.