左侧旁道消融伴发二尖瓣峡部阻滞的临床观察  

The Anatomic and Electrophysiological Feature of Mitral Isthmus Interatrial Conduction Block During Ablation for Left Accessory Pathway

作　　者：刘启方[1] 黄晶[1] 田龙海[1] 田水[1] 蒋智[1] 田野[1] 杨龙[1] LIU Qifang;HUANG Jing;TIAN Longhai;TIAN Shui;JIANG Zhi;TIAN Ye;YANG Long(Department of Cardiology,Guizhou Provincial People’s Hospital,Guiyang(550002),Guizhou,China)

机构地区：[1]贵州省人民医院心内科

出　　处：《中国循环杂志》2019年第9期913-918,共6页Chinese Circulation Journal

基　　金：贵州省科技支撑计划项目(黔科合SY字【2015】3045号);国家临床重点专科建设项目(国卫办医函【2013】544号);贵州省科学技术厅临床研究中心项目(黔科合平台人才【2017】5405号)

摘　　要：目的:探讨经房间隔途径行左侧旁道射频消融过程中,不经意二尖瓣峡部阻滞发生的解剖机制及电生理特征。方法:回顾性分析2016年1月至2018年1月贵州省人民医院单中心收治的左侧旁道并房室折返性心动过速患者,研究纳入经房间隔途径行左侧旁道射频消融患者共59例,经股静脉途径送入二极电极至右心室,经左锁骨下静脉或右股静脉送入十级电极至冠状窦。行心房及心室期前刺激,递减刺激及快速刺激诱发心动过速,必要时静滴异丙肾上腺素辅助诱发。经房间隔顺行性途径送入消融电极至左心房室环标测房室旁道,行射频消融治疗。并对消融过程中发生二尖瓣峡部阻滞的患者进行电生理研究并探讨可能发生机制。结果:59例经房间隔途径消融的左侧旁道患者中,4例患者消融过程中发生二尖瓣峡部阻滞,发生率约6.8%。其中3例患者二尖瓣峡部阻滞后心动过速周长不变,体表心电图节律整齐;1例患者二尖瓣峡部阻滞后心动过速周长长短不等,体表心电图心动过速发作频率减慢,节律完全不整齐。4例患者消融过程中二尖瓣峡部阻滞均表现为冠状窦电极室房逆传间期延长,心动过速未能终止,激动顺序由离心性传导转为向心性传导,经调整消融电极至原消融部位更远端消融成功。结论:左侧旁道消融过程中可能不经意导致二尖瓣峡部阻滞,其发生率低。掌握其心内电生理特征及心内电图的变化有助于缩短手术时间,避免无效消融。Objectives:To investigate the anatomic and electrophysiological properties of mitral isthmus interatrial conduction block in patients with orthodromic reciprocating tachycardia undergoing left accessory pathway(AP)ablation.Methods and Results:A total of 59 patients with left free-wall AP,who underwent RF ablation by a transseptal approach from 2016 to 2018,were included in this study.Four patients developed mitral isthmus interatrial conduction block during RF ablation(6.8%)and electrophysiological studies were performed to rate the potential mechanisms for the occurrence of mitral isthmus interatrial conduction block.This change of activation sequence from distal to proximal CS was not a sudden process,but rather a gradual process.The tachycardia cycle length was constant and ECG rhythm was regular in 3 cases,and tachycardia cycle length was inconstant,and ECG showed that the rate of tachycardia was reduced and rhythm became irregular in 1 case.All 4 cases presented with prolonged CS electrode VA duration,consistent tachycardia and the activation sequence became concentric transduction from eccentric transduction.Successful RF ablation was achieved in all 4 patients through adjusting the position of ablation electrode to more distant end from original ablation position.Conclusions:The mitral isthmus interatrial conduction block is responsible for a change of atrial activation sequence in patients undergoing left accessory pathway ablation.Awareness of mitral isthmus interatrial conduction block may avoid misinterpretation of the electrogram during left AP ablation.

关 键 词：二尖瓣峡部房内阻滞 左侧旁道 解剖机制 电生理特征 

分 类 号：R541.4[医药卫生—心血管疾病]