Ablation treatment for right-sided accessory pathways in patients after failure of conventional radiofrequency ablation
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摘要: 目的 对本中心近3年来常规射频消融失败的右侧旁路患者进行回顾总结，为复杂右侧旁路的消融治疗提供借鉴和参考。方法 选择于2019年1月—2021年12月在西安交通大学第二附属医院心内科常规射频消融失败和(或)消融后复发的11例右侧房室旁路患者进行回顾性研究，分析其病历资料，收集临床基线、电生理资料及长期随访结果。结果 所有11例患者均即刻消融成功。7例患者采用冷盐水灌注大头消融成功，其中1例合并右位心患者术中同时采用心腔内超声心动图(ICE)指导心腔三维重建及导管操作；4例用普通SR0长鞘导管难以到达靶点，更换可调弯鞘后稳定贴靠靶点消融成功，其中3例于三尖瓣环下心室侧消融成功。术中放电消融(7.5±3.4)次，放电消融过程中旁路阻断时间(7.1±3.0) s，所有患者术中旁路均达到双向阻滞。随访(18.3±12.3)个月，无心动过速复发和(或)旁路传导恢复，围术期及随访期间无并发症出现。结论 冷盐水灌注消融导管、可调弯鞘、ICE等器械的应用以及经三尖瓣环下心室侧途径，提高了右侧房室旁路消融的成功率，尤其是对于部分消融失败、复发病例或合并解剖异常的复杂右室旁路效果明显。Abstract: Objective To review and summarize the patients with right-sided accessory pathways(RAPs) resistant to conventional catheter ablation in our center in recent 3 years, providing reference for the ablation treatment of complex right side bypass.Methods Eleven patients with RAPs who had previously failed with conventional radiofrequency ablation and(or) recurrence after ablation from January 2019 to December 2021 in the Department of Cardiology of the Second Affiliated Hospital of Xi'an Jiaotong University were enrolled.Results All 11 patients were ablated successfully immediately. Seven cases were successfully ablated by using irrigated-tip catheters, including one case of dextrocardia with intracardiac echocardiography(ICE) to guide the three-dimensional reconstruction of the heart cavity and catheter operation. Four cases were successfully ablated after replacing the Agilis sheath for which traditional SR0 was difficult to reach the target, including 3 patients ablated under the tricuspid valve. The mean number of radiofrequency ablation applications was 7.5±3.4, and the mean time from the ablation start to accessory pathways(AP) conduction block was(7.1±3.0) seconds. Bidirectional AP conduction block was the endpoint. Patients were free of tachycardia or recurrence of AP conduction during a median follow-up of(18.3±12.3) months. No complications were found during the procedure or follow-up period.Conclusion The application of irrigated-tip catheters, Agilis sheath, ICE and radiofrequency ablation under the tricuspid valve has improved the success rate of RAPs, especially for those complex RAPs with partially failed ablation, relapsed cases or complicated anatomical abnormalities.
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表 1 11例患者的基线资料及电生理/消融资料
Table 1. Baseline data and electrophysiological/ablation data of 11 patients
病例 性别 年龄/岁 合并结构性心脏病 窦性心律时有无预激 消融失败/ 复发 成功消融靶点 消融途径 消融大头 Swartz长鞘/ 可调弯鞘/ICE 放电消融次数 放电消融时旁路阻断时间/s 随访时间/月 1 男 55 无 有 失败 右后间隔 心房侧 冷盐水灌注大头 SR0 6 5 41 2 男 27 无 有 失败 右中间隔 心房侧 普通大头更换为冷盐水灌注大头 SR0 6 5 21 3 女 12 无 有 失败 后侧壁 心房侧 普通大头更换为冷盐水灌注大头 SR0 8 12 17 4 男 71 无 无 失败 右后间隔 心房侧 普通大头更换为冷盐水灌注大头 SR0 6 4 20 5 女 72 无 有 失败 后侧壁 心室侧 普通消融大头 SR0更换为A鞘 4 10 6 6 女 24 无 无 失败 后侧壁 心室侧 普通消融大头 SR0更换为A鞘 12 8 17 7 男 38 无 有 失败 后侧壁 心室侧 普通消融大头 SR0更换为A鞘 14 5 12 8 男 19 无 有 失败 前侧壁 心室侧 普通消融大头 SR0更换为A鞘 6 8 10 9 女 56 无 无 复发 右后间隔 心房侧 冷盐水灌注大头 SR0 5 3 41 10 男 67 无 无 复发 希氏束旁 心房侧 冷盐水灌注大头 SR0 4 11 7 11 女 46 右位心 无 失败 希氏束旁 心房侧 冷盐水灌注大头 SR0及ICE 11 7 9 
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