- 经未闭卵圆孔途径消融左侧房室旁路
- 作者:易忠|发布时间:2010-07-03|浏览量:928次
易忠1 王斌1 周学继2 李小龙1
【摘要】目的:探讨经未闭卵圆孔途径消融左侧房室旁路的可能性及安全性。方法:2008年1月-2009年3月间,共41例左侧房室折返性心动过速患者(平均年龄51.0 ± 16.8岁)接受射频消融治疗。经电生理检查证实左侧旁道后,所有患者均先用导管探试是否存在未闭卵圆孔。存在未闭卵圆孔者经未闭卵圆孔消融;反之,经股动脉途径消融。比较经卵圆孔途径和经动脉途径两种方法的射频消融的手术成功率、手术时间、X线透光时间以及副作用发生情况。术后所有患者接受电话随访。结果:共11例经未闭卵圆孔途径完成,其余30例患者经穿刺右侧股动脉途径消融(其中2例改经穿刺房间隔途径消融成功)。其中两组手术时间分别为56.3 ± 14.2 min和60.3 ± 18.2 min ( p = 0.076 ),X线曝光时间分别为9.1 ± 3.9 min和9.5 ± 4.2 min(p = 0.115)。探测是否存在未闭卵圆孔需要4.7 ± 1.2 min。股动脉途径组有穿刺部位血肿、瘀斑5人,心包填塞1人。术后随访平均13个月(3~21月),两组均无心动过速复发,亦未见其他并发症。结论:经未闭卵圆孔途径消融左侧房室折返性心动过速安全、简单、快捷,值得在穿刺股动脉之前确定患者是否存在未闭卵圆孔。航天中心医院心血管内科易忠
【关键词】未闭卵圆孔 左侧房室旁路 导管消融
1. 北京大学航天临床医学院 心脏中心
2. 唐山市丰润区第二人民医院 心内科
Atrioventricular Reentrant Tachycardia Ablation Performed via Patent Foramen Ovale
【Abstract】 Objective: To evaluate the possibility and safety of left accessory pathway ablation from the patent foramen ovale. Methods: From Jan. 2008 to Mar. 2009, a total of 41 patients with left atrioventricular reentrant tachycardia patients (mean age 51.0 ± 16.8 years) received radiofrequency ablation. After confirmed the left side of the bypass by electrophysiological examination, all patients were received first test the existence of patent foramen ovale with the catheter probe. After confirmed the left accessory pathway, the patients were ablated through the patent foramen ovale,while the remaining patients underwent RFCA via the transfemoral approach (controls). These two methods were compared with the ablation success rate, the total procedure time, the fluoroscopic time and the occurrence of side effects. After 3-18 months, all patients received telephone follow-up. Results: All patients had successful ablation, of which 11 patients ablated from patent foramen ovale and the remaining 30 patients via the right femoral artery approach. In control group, 5 patients suffered from hematoma in puncture site and 1 case suffered from acute cardiac tamponade during ablation. She was received second RFCA via transseptal approach 20 days after the fist procedure. The total procedure time was 56.3 ± 14.2 min vs. 60.3 ± 18.2 min, p=0.076; the fluoroscopic time was 9.1 ± 3.9 min vs. 9.5 ± 4.2 min, p=0.115. To detect the existence of the foramen ovale required additional 4.7 ± 1.2 min. There was no recurrence of arrhythmia in either group during follow up. Neither cerebral infarction, embolism, nor migraine headache were detected during the follow up. Conclusion: The left-sided Aps ablation performed via Patent Foramen Ovale is simple, fast and safe. It’s worth to test the existence of the patent foramen ovale before the left-sided APs ablation.
Key words: patent foramen ovale; left accessory pathway; catheter ablation
经股动脉途径和穿刺房间隔途径均能有效射频消融左侧房室旁路引起的房室折返性心动过速[1],但这两种方法存在引起局部血肿、深静脉血栓以及心包填塞等潜在并发症风险[2,3]。
未闭卵圆孔有一定的发生率,如能经未闭卵圆孔进入左心系统消融理应可避免相应并发症。经未闭卵圆孔途径消融左侧心动过速最早由Stephen N报道[4]。此后,有几篇个例报道,多在射频过程中无意发现。此外,由于房间隔在心房靠前、靠上的部位,经过未闭卵圆孔消融是否可用于所有左侧旁道的消融,以及该方法是否会增加脑栓塞、偏头痛等并发症尚未见相关报道。本研究旨在评价经未闭卵圆孔途径消融左侧旁道的可行性及安全性。
1. 研究方法
1.1 病例资料 2008年1月-2009年3月间,我院共有113例连续患者接受阵发性室上性心动过速射频消融治疗,经电生理检查证实为左侧旁道的41例患者入选。其中男25例,女16例,平均年龄47.0 ± 16.8(11~78)岁,均无器质性心脏病病史。患者有反复发作、突发突止的心动过速病史,心动过速病史9.0 ± 4.8年。均为第一次射频消融病例。
1.2 心内导管放置及电生理检查 术前所有患者停用抗心律失常药物至少5个半衰期。1%利多卡因局部麻醉,常规穿刺双侧股静脉、左锁骨下静脉,经股静脉穿刺分别送入4极标测电极导线(强生公司.美国)到高位右心房、希氏束、右室心尖部;经穿刺的左侧锁骨下静脉(个别左锁骨下静脉穿刺失败则改经右侧颈内静脉)送入4极标测导管到冠状静脉窦。穿刺左侧锁骨下静脉并随锁骨下静脉鞘管送入冠状静脉窦电极;穿刺左侧股静脉,送入高位右心房电极;2次穿刺右股静脉,分别送入希氏束电极和右室起搏电极。右室心尖部起搏,可见最早心房激动点在冠状窦远端,呈“左偏心”传导;且右室起搏时,室房逆传无文氏递减现象,提示为左侧房室旁道[5]。
1.3 探测是否存在未闭卵圆孔及分组 在股动脉穿刺或房间隔穿刺前,将可控弯头的4极导管(强生公司,美国)经右股静脉送入右心房,在LAO45°,将可控弯头导管送至间隔3-4点处(记录第一次影像作为开始探测未闭卵圆孔时间),探寻是否存在未闭卵圆孔。如果此法未能