目的 总结经右心房游离壁切口术后双环折返性房性心动过速(房速)的发生率及射频消融后长期随访的结果.方法 2007年1月至2012年12月共入选48例在南京医科大学第一附属医院心脏科行经右心房游离壁切口治疗先天性心脏病或获得性心脏病后发作房速的患者.双环折返性房速的定义为心房同时存在两个折返环,同时在折返的可能路径上进行多部位拖带均为隐匿性.结果 共观察到8例患者术中存在双环折返性房速,男4例,平均年龄(40.4±22.0)岁.第1次外科术后至房速发作时间为(79.0±65.2)个月,第1次房速发作至第1次消融的时间为(20.8±28.3)个月,所有患者房速均持续发作.所有患者的双环折返性房速均与三尖瓣峡部以及右心房游离壁切口相关.5例患者在消融三尖瓣峡部过程中,心动周期突然变化;1例患者消融三尖瓣峡部时,心动周期无变化,右心房游离壁多部位拖带为右心房游离壁折返性房速,间隔部位拖带证实此部位不在折返环内,可能提示右心房游离壁折返性房速为主导折返环,;1例患者消融过程中心动过速终止,同样行切口致下腔的线性消融;1例患者消融三尖瓣峡部时心动过速无明显变化,但冠状静脉窦的激动有细微变化,拖带标测提示三尖瓣峡部不在折返环内,右心房游离壁多部位拖带提示为围绕右心房切口瘢痕折返的心动过速,行外科切口下部至下腔静脉消融时,房速终止.平均随访(33.6±16.7)个月,3例复发患者均为风湿性心脏病换瓣术后,其中1例复发房速,另外2例复发房颤.结论 经右心房游离壁切口术后双环折返性房速主要与三尖瓣峡部以及切口相关,三尖瓣峡部以及切口至下腔静脉线性消融常能够治疗这类心律失常.
Objective The purpose of the study was to demonstrate the prevalence and to define the optimal mapping and ablation strategy of atrial tachycardia (AT) after an incision of the right atrial free wall.Methods Forty-eight consecutive patients with AT after an incision of the right atrial free wall to the treatment of congenital heart disease or acquired heart disease.Dual-loop atrial tachycardia was defined as the presence of two simultaneous circuits,entrainment of tachycardia from several site around the atriotomy scar and septum demonstrated PPI ≤ (tachycardia cycle length +20 ms).Results Dual-loop AT was demonstrated in eight patients(4 men,mean age 40.4±22.0 years).The mean interval between the occurrence of symptomatic AT and the surgical intervention was(79.0±65.2) months.The initial procedure was performed(20.8±28.3)months after first onset of AT.Dual-loop included an isthmus-dependant atrial flutter combined with the reentry around the incisional scar.Abrupt change sequence of coronary sinus activation was observed in five patients during radiofrequency ablation at cavotricuspid isthmus,while one with no change; and one patient with the termination of tachycardia.All tachycardia were terminated during creation of a ablation line connecting the incision of right free wall and inferior vena cava.After a mean follow-up of(33.6±16.7)months,two and one of the patients with rheumatic heart disease had AT recurrence and the development of atrial fibrillation,respectively.Conclusion Dual-loop atrial tachycardias after heart surgery were related to the incision of right free wall and cavotricuspid isthmus,radiofrequency ablation of the two distinct isthmuses is effective to cure the arrhythmia.