RS_2在慢径消融靶点定位中的应用研究
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摘要
目的 探讨RS2标测法在房室结折返性心动过速（AVNRT）慢径消融靶
点定位中的作用。
方法 将40例AVNRT患者随机分成二组（每组20例）即RS2组和解剖电
图组，分别采用RS2标测、解剖电图标测法进行慢径标测与射频消融。RS2标测法：大头导管在Kock三角区心内电图记录到小A大V波、无H波，且心电波形稳定后，诱发心动过速，经大头导管发放RS2刺激，从少于心动过速周长20ms起搏频率开始，每次以10ms步长负扫，直至心动过速终止（或刺激不能夺获心房），最后在以最长联律间期RS2终止心动过速的位点消融。解剖电图标测法：
左前斜45°，大头导管在希氏束至冠状静脉窦口之间记录到房波明显小于室波
（A：V<0.5）、碎裂、呈双向、无H波且心电波形稳定，作为靶点试消融。比较
两组标测靶点时间、手术操作时间、X线曝光时间、放电时间及并发症。
结果 RS2组的标测时间、手术操作时间、X线曝光时间、放电时间，均少
于解剖电图组，具有显著差异（P<0.01），两组消融成功率均为100%，且均未见三度房室传导阻滞（Ⅲ°AVB）等并发症。
结论 RS2标测法指导慢径消融优于解剖电图标测法。
Objective: To investigate the value of using RS2 in mapping the target site for
slow pathway ablation.
Methods:40 patients with AVNRT (atrioventricular nodal reentrant tachycardia)
were randomly dividied into RS2 mapping group(20 cases) and ananatomic- electrogram mapping group (20 cases).In RS2 group,as the catheter was at the Kock triangle steady,with little A-wave and big V-wav, tachycardia was initiated with HAR stimulation , then single extrastimuli (RS2) were delivered from the ablation catheter tip beginning by 20 ms less than the tachycardia cycle length and decrementing by 10 ms until tachycardia terminated or loss of capture occurred . At last, the slow pathway was ablated at the site at which AVNRT was terminated with the longest coupling interval. In anatomic-electrogram group,between His and coronary sinus ostium with LAO 45°as the atrial wave was smaller than ventricular wave (A:V<0.5) , and fragmentive, two-dimensional,steady,without His potential.The radiofrequency current was delivered.The mapping time, procedure duration,fluoroscopy time,radiofrequency ablation time were studied.The radiofrequency energy,impedance and complication such as third-degree atrial ventricular block （Ⅲ°AVB）were observed.
Results:Mapping time, procedure duration,fluoroscopy time,radiofrequency ablation time were less in RS2 group than those in anatomic-electrogram group(P<0.01). Ablation Suceess rate was 100% in two groups without the complication of Ⅲ°AVB.
Conclusion: RS2 mapping should be superior to anatomic-electrogram mapping
in guiding ablation for slow pathway.
点定位中的作用。
方法 将40例AVNRT患者随机分成二组（每组20例）即RS2组和解剖电
图组，分别采用RS2标测、解剖电图标测法进行慢径标测与射频消融。RS2标测法：大头导管在Kock三角区心内电图记录到小A大V波、无H波，且心电波形稳定后，诱发心动过速，经大头导管发放RS2刺激，从少于心动过速周长20ms起搏频率开始，每次以10ms步长负扫，直至心动过速终止（或刺激不能夺获心房），最后在以最长联律间期RS2终止心动过速的位点消融。解剖电图标测法：
左前斜45°，大头导管在希氏束至冠状静脉窦口之间记录到房波明显小于室波
（A：V<0.5）、碎裂、呈双向、无H波且心电波形稳定，作为靶点试消融。比较
两组标测靶点时间、手术操作时间、X线曝光时间、放电时间及并发症。
结果 RS2组的标测时间、手术操作时间、X线曝光时间、放电时间，均少
于解剖电图组，具有显著差异（P<0.01），两组消融成功率均为100%，且均未见三度房室传导阻滞（Ⅲ°AVB）等并发症。
结论 RS2标测法指导慢径消融优于解剖电图标测法。
Objective: To investigate the value of using RS2 in mapping the target site for
slow pathway ablation.
Methods:40 patients with AVNRT (atrioventricular nodal reentrant tachycardia)
were randomly dividied into RS2 mapping group(20 cases) and ananatomic- electrogram mapping group (20 cases).In RS2 group,as the catheter was at the Kock triangle steady,with little A-wave and big V-wav, tachycardia was initiated with HAR stimulation , then single extrastimuli (RS2) were delivered from the ablation catheter tip beginning by 20 ms less than the tachycardia cycle length and decrementing by 10 ms until tachycardia terminated or loss of capture occurred . At last, the slow pathway was ablated at the site at which AVNRT was terminated with the longest coupling interval. In anatomic-electrogram group,between His and coronary sinus ostium with LAO 45°as the atrial wave was smaller than ventricular wave (A:V<0.5) , and fragmentive, two-dimensional,steady,without His potential.The radiofrequency current was delivered.The mapping time, procedure duration,fluoroscopy time,radiofrequency ablation time were studied.The radiofrequency energy,impedance and complication such as third-degree atrial ventricular block （Ⅲ°AVB）were observed.
Results:Mapping time, procedure duration,fluoroscopy time,radiofrequency ablation time were less in RS2 group than those in anatomic-electrogram group(P<0.01). Ablation Suceess rate was 100% in two groups without the complication of Ⅲ°AVB.
Conclusion: RS2 mapping should be superior to anatomic-electrogram mapping
in guiding ablation for slow pathway.
引文
1.黄宛主编. 临床心电图学. 北京:人民出版社,2001,327
2.Lee MA,Morady F,Kadish A,et al.Catheter modification of the atrioventricular juntion with radiofrequency energy for control of atrioventricular nodal reentry tachycardia.Circulation,1991,83:827-83
3.中国生物医学会工程学会心脏起搏与电生理分会导管消融学组.射频导管消融治疗快速心律失常指南.中国心脏起搏与心电生理杂志,1996,10(3)114
4.Schuger CD,Steinman RT,Lehman WH.The excitable gap in atrioventricular nodal reentrant tachycardia;characterization with ventricular extrastimuli and pharmacol
-ogic intervention.Circulation,1989,80:324-334
5.Jazayeri MR,Sra JS,Akhtar M.Atrioventricular nodal reentrant tachycardia:electrop
-hysiologic characteristics,therapeutic interventions,and specific reference to anatomic boundzry of the reentrant circuit.Cardia Clin,1993,11:151-181
6.Rosenthal ME, Sramato NJ, Alnendral JM, Marchlinski FE,Buxton AE, Miller JM,Josephson ME. Influence of the site of stimulation on the resetting phenomenonin ventricular tachcardia.AM J Cardiol,1996,58:970-976
7.Almendral JM,Stamto NJ,Rrosenthal ME,Marchlinski FE,Miller JM,Josephon ME. Resetting response patterns during sustained ventricular tachycardia:relationship to the excitable gap.Circulation,1986,74:722-730
8.Sra J, Jazayeri M, Natale A, et al.Termination of atrioventricular nodal reentrant tachycardia by premature stimulation from ablation catheter:A reliable guide to identify site for slow pathway ablation.Circulation,1995,91:1095
9.马长生，盖鲁粤，张奎俊等主编. 介入心脏病学. 北京：人民卫生出版社. 1998, 782
10.Kottkamp H, Hindricks G, Willems S, et al. An anatomically and electrogram guided stepwise approach for effective and safe catheter ablation of the fast pathway for elinination of atrioventricular node reentrant tachycardia. J Am Coll Cardiol, 1995, 22: 974-981
11.叶文胜,李公信,钱学贤,等. 选择性消融逆传快径治疗房室结折返性心动过速. 中国心脏起搏与心电生理杂志, 1999, 13(4): 205
12 .陈新主编. 临床心律失常学. 北京: 人民卫生出版社. 2000, 1340-1341
13.Jazayeri M, Hempe S, Sra J, et al.Selective transcatheter ablation of the slow pathway for the treatment of atrioventricular nodal reentrant tachycardia.
Circulation,1992, 85: 1318-1328
14.Wathen M, Natale A, Wolfe K, et al. An anatomically guided approach to
atrioventricular node slow pathway ablation. Am J Cardiol,1992, 70: 886-889
15.Moulton K, Miller B, Scott J, et al. Radiofrequency cateter bal-ation for AV nodal reentry: a technique for rapid transection of the slow AV nodal pathway. PACE，1993, 16: 760-768
16.Wu D, Yeh S, Wang C, et al. A simple technique for selective radiofrequency ablation of the slow pathway in atrioventricular node reentrant tachcardia. J Am Coll cardiol，1993, 21: 1612-1621
17.Jackman W, Beckman K, Mcclelland J, et al. Treatment of supraventricular tachycardia due to atrioventricular nodal reentry by radiofrequency catheter ablation of slow pathnay conduction. N Egl J Med,1992, 327: 313-318
18.Gaita F, Haissaguerre M, Di Donnap, et al. Nodal reentry tachycardia:short and long term effectiveness and safty of a selective ablation technique of the slow pathway. G Ital Cardiol，1993, 23: 563-574
19.Haissaguerre M, Garta, Fishcher B, et al. Elimination of atrioventricular nodal reentrant tachycardia using discrete slow potentials to guide application of radiofrequency energy. Circulation,1992, 85: 2162-2175
20.Trohman RG, Pinski SL, Sterba R, et al. Evoling concepts in radiofrequency catheter ablation of atrioventricular nodal reentry tachycardia. Am Heart J,1994, 128: 586-595
21.Lin JL, Lin FY, Lo HM, et al. Perinodal slow potential as a local guide for transcatheter radiofrequency ablation of atrioventricular nodal reentrant tachycardia:therapeutic efficacy and electriphysiological mechanisms of success. Br Heart J,1995, 74: 268-276
22.陈明龙. 房室交接区慢电位与房室结慢径的关系及意义. 临床心电学杂志，1999,8(2): 113-115
23.Sousa J, Carpinteiro L, et al. The catheter ablation of atrioventricular nodal reentry tachycardia:the results of amixed electrophysiological/anatomical techniq-
ue. Rev Port Cardiol, 1995, 14: 497-705
24.Fisher WG, Pelini MA, Bacon ME, et al. Adjuntive intracardiac echocardiography to guide slow pathway ablation in human atrioventricular nodal reentrant tachycardia.Anatomic insights. Circulation,1997, 96: 3021
25.Willems S, Weiss C, Hofmann T, et al. Subthreshould stimulation in the region of the slow pathway during atrioventricular node reentrant tachycardia: correlation with effect of radiofrequency catheter ablation. J Am Coll Cardiol ，1997, 29: 408
26.方咸宏, 吴书林, 杨平珍, 等. Carto系统电解剖标测和消融治疗房室结折返性心动过速. 中华医学会心电生理和起搏分会第四次学术会议论文摘要汇
编，2000，149
27.方咸宏, 吴书林, 杨平珍, 等. 隐匿性拖带时起搏后间期与慢径消融成功靶点的关系. 中国心脏起搏与心电生理杂志, 2000, 14(3): 151
28.蒋金法, 徐方俊, 戚秀卿, 等. 射频能量测试交界性心律消融房室结折返性心动过速. 中国心脏起搏与心电生理杂志, 2000, 14(4): 239.
29.李莹, 周聊生, 娄兹谟, 等. A波延迟电位在慢径消融靶点定位中的应用. 中国心脏起搏与心电生理杂志, 2000, 14(3): 147
30.马长生, 董建增, 杨新春, 等. 放电过程中房室结改良已经成功的征象.中华心血管杂志,1995,8(23):246
31.黄徳嘉, 姜建, 文山, 等. 射频消融房室结慢径过程中房室传导阻滞的預防. 中华心血管杂志，1995，23（2）：124
32.马长生, 胡大一. 心律失常复杂病例射频消融的经验与教训. 中国心脏起搏与心电生理杂志, 1996，10（1）：9-10
33.江洪. 有关慢径消融的终点及方法学探讨. 中国心脏起搏与心电生理杂志,2000,14(3):145
34.Gianfranchi L, Brignole M, Delise P, et al. Modification of antegrade slow pathway is not crucial for successful catheter ablation of common atrioventricular nodal reentrant tachycardia .PACE,1999,22:263
35.Li HG, Klein G, Stites W, et al. Elimination of slow pathway conduction;An accurate indicator of clinical success after radiofrequency atrioventricular node modification .J Am Coll Cardiol,1993,22:1849
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46.Thakur RK, Klein GJ, Yee R, et al. Junctional tachycardia: a useful maker during
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yes of the atrioventricular nodal and clinical implixations. J Cardiovasc Electrophysiol, 1996, 7: 689-696
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of slow pathway in patients with atrioventricular nodal reentrant tachycardia. Am J
Cardiol, 1995 , 76: 131-137
51.Manolis AS, Wang PJ, Estes M, et al.Radiofrequency ablation of slow pathway in
patients with atrioventricular nodal reentrant tachycardia: Do arrhythmia
recurrences correlate with persistent slow pathway conduction or site of successful
ablation? Circulation, 1994, 90: 2815-2819
52.Hummel JD, Strickberger SA, Williamson BG, et al. The course of recurrences of
atrioventricular nodal reentrant tachycardia after radiofrequency ablation of the
slow pathway. Am J Cardiol,1995, 75: 628-630.
53.Kay G, Epstein A, Dailey S, et al. Role of radiofrequency ablation in the mangement of supraventricular arrhythmias: experence in 760 consecutive
patients. J Cardiovasc Electrophysiol , 1993, 4: 371-389
54.Akhtar M, Jazayeri MR, Sra J, et al. Atrioventricular nodal reentry: clinical, electrophysiological,and therapeutic consideration. Circulation, 1993, 88: 282-295
55.杨海玉等. 射频繁消融治疗房室结折返性心动过速术后复发原因分析. 临床心血管病杂志, 2001,17(5):199
2.Lee MA,Morady F,Kadish A,et al.Catheter modification of the atrioventricular juntion with radiofrequency energy for control of atrioventricular nodal reentry tachycardia.Circulation,1991,83:827-83
3.中国生物医学会工程学会心脏起搏与电生理分会导管消融学组.射频导管消融治疗快速心律失常指南.中国心脏起搏与心电生理杂志,1996,10(3)114
4.Schuger CD,Steinman RT,Lehman WH.The excitable gap in atrioventricular nodal reentrant tachycardia;characterization with ventricular extrastimuli and pharmacol
-ogic intervention.Circulation,1989,80:324-334
5.Jazayeri MR,Sra JS,Akhtar M.Atrioventricular nodal reentrant tachycardia:electrop
-hysiologic characteristics,therapeutic interventions,and specific reference to anatomic boundzry of the reentrant circuit.Cardia Clin,1993,11:151-181
6.Rosenthal ME, Sramato NJ, Alnendral JM, Marchlinski FE,Buxton AE, Miller JM,Josephson ME. Influence of the site of stimulation on the resetting phenomenonin ventricular tachcardia.AM J Cardiol,1996,58:970-976
7.Almendral JM,Stamto NJ,Rrosenthal ME,Marchlinski FE,Miller JM,Josephon ME. Resetting response patterns during sustained ventricular tachycardia:relationship to the excitable gap.Circulation,1986,74:722-730
8.Sra J, Jazayeri M, Natale A, et al.Termination of atrioventricular nodal reentrant tachycardia by premature stimulation from ablation catheter:A reliable guide to identify site for slow pathway ablation.Circulation,1995,91:1095
9.马长生，盖鲁粤，张奎俊等主编. 介入心脏病学. 北京：人民卫生出版社. 1998, 782
10.Kottkamp H, Hindricks G, Willems S, et al. An anatomically and electrogram guided stepwise approach for effective and safe catheter ablation of the fast pathway for elinination of atrioventricular node reentrant tachycardia. J Am Coll Cardiol, 1995, 22: 974-981
11.叶文胜,李公信,钱学贤,等. 选择性消融逆传快径治疗房室结折返性心动过速. 中国心脏起搏与心电生理杂志, 1999, 13(4): 205
12 .陈新主编. 临床心律失常学. 北京: 人民卫生出版社. 2000, 1340-1341
13.Jazayeri M, Hempe S, Sra J, et al.Selective transcatheter ablation of the slow pathway for the treatment of atrioventricular nodal reentrant tachycardia.
Circulation,1992, 85: 1318-1328
14.Wathen M, Natale A, Wolfe K, et al. An anatomically guided approach to
atrioventricular node slow pathway ablation. Am J Cardiol,1992, 70: 886-889
15.Moulton K, Miller B, Scott J, et al. Radiofrequency cateter bal-ation for AV nodal reentry: a technique for rapid transection of the slow AV nodal pathway. PACE，1993, 16: 760-768
16.Wu D, Yeh S, Wang C, et al. A simple technique for selective radiofrequency ablation of the slow pathway in atrioventricular node reentrant tachcardia. J Am Coll cardiol，1993, 21: 1612-1621
17.Jackman W, Beckman K, Mcclelland J, et al. Treatment of supraventricular tachycardia due to atrioventricular nodal reentry by radiofrequency catheter ablation of slow pathnay conduction. N Egl J Med,1992, 327: 313-318
18.Gaita F, Haissaguerre M, Di Donnap, et al. Nodal reentry tachycardia:short and long term effectiveness and safty of a selective ablation technique of the slow pathway. G Ital Cardiol，1993, 23: 563-574
19.Haissaguerre M, Garta, Fishcher B, et al. Elimination of atrioventricular nodal reentrant tachycardia using discrete slow potentials to guide application of radiofrequency energy. Circulation,1992, 85: 2162-2175
20.Trohman RG, Pinski SL, Sterba R, et al. Evoling concepts in radiofrequency catheter ablation of atrioventricular nodal reentry tachycardia. Am Heart J,1994, 128: 586-595
21.Lin JL, Lin FY, Lo HM, et al. Perinodal slow potential as a local guide for transcatheter radiofrequency ablation of atrioventricular nodal reentrant tachycardia:therapeutic efficacy and electriphysiological mechanisms of success. Br Heart J,1995, 74: 268-276
22.陈明龙. 房室交接区慢电位与房室结慢径的关系及意义. 临床心电学杂志，1999,8(2): 113-115
23.Sousa J, Carpinteiro L, et al. The catheter ablation of atrioventricular nodal reentry tachycardia:the results of amixed electrophysiological/anatomical techniq-
ue. Rev Port Cardiol, 1995, 14: 497-705
24.Fisher WG, Pelini MA, Bacon ME, et al. Adjuntive intracardiac echocardiography to guide slow pathway ablation in human atrioventricular nodal reentrant tachycardia.Anatomic insights. Circulation,1997, 96: 3021
25.Willems S, Weiss C, Hofmann T, et al. Subthreshould stimulation in the region of the slow pathway during atrioventricular node reentrant tachycardia: correlation with effect of radiofrequency catheter ablation. J Am Coll Cardiol ，1997, 29: 408
26.方咸宏, 吴书林, 杨平珍, 等. Carto系统电解剖标测和消融治疗房室结折返性心动过速. 中华医学会心电生理和起搏分会第四次学术会议论文摘要汇
编，2000，149
27.方咸宏, 吴书林, 杨平珍, 等. 隐匿性拖带时起搏后间期与慢径消融成功靶点的关系. 中国心脏起搏与心电生理杂志, 2000, 14(3): 151
28.蒋金法, 徐方俊, 戚秀卿, 等. 射频能量测试交界性心律消融房室结折返性心动过速. 中国心脏起搏与心电生理杂志, 2000, 14(4): 239.
29.李莹, 周聊生, 娄兹谟, 等. A波延迟电位在慢径消融靶点定位中的应用. 中国心脏起搏与心电生理杂志, 2000, 14(3): 147
30.马长生, 董建增, 杨新春, 等. 放电过程中房室结改良已经成功的征象.中华心血管杂志,1995,8(23):246
31.黄徳嘉, 姜建, 文山, 等. 射频消融房室结慢径过程中房室传导阻滞的預防. 中华心血管杂志，1995，23（2）：124
32.马长生, 胡大一. 心律失常复杂病例射频消融的经验与教训. 中国心脏起搏与心电生理杂志, 1996，10（1）：9-10
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