Delacretaz E, Ganz L I, Soejima K, Friedman P L, Walsh E P, Triedman J K, Sloss L J, Landzberg M J, Stevenson W G
Cardiac Arrhythmia Service and Clinical Electrophysiology Laboratory, Children's Hospital, Boston, Massachusetts, USA.
J Am Coll Cardiol. 2001 May;37(6):1665-76. doi: 10.1016/s0735-1097(01)01192-5.
We sought to characterize re-entry circuits causing intra-atrial re-entrant tachycardias (IARTs) late after the repair of congenital heart disease (CHD) and to define an approach for mapping and ablation, combining anatomy, activation sequence data and entrainment mapping.
The development of IARTs after repair of CHD is difficult to manage and ablate due to complex anatomy, variable re-entry circuit locations and the frequent co-existence of multiple circuits.
Forty-seven re-entry circuits were mapped in 20 patients with recurrent IARTs refractory to medical therapy. In the first group (n = 7), ablation was guided by entrainment mapping. In the second group (n = 13), entrainment mapping was combined with a three-dimensional electroanatomic mapping system to precisely localize the scar-related boundaries of re-entry circuits and to reconstruct the activation pattern.
Three types of right atrial macro-re-entrant circuits were identified: those related to a lateral right atriotomy scar (19 IARTs), the Eustachian isthmus (18 IARTs) or an atrial septal patch (8 IARTs). Two IARTs originated in the left atrium. Radiofrequency (RF) lesions were applied to transect critical isthmuses in the right atrium. In three patients, the combined mapping approach identified a narrow isthmuses in the lateral atrium, where the first RF lesion interrupted the circuit; the remaining circuits were interrupted by a series of RF lesions across a broader path. Overall, 38 (81%) of 47 IARTs were successfully ablated. During follow-up ranging from 3 to 46 months, 16 (80%) of 20 patients remained free of recurrence. Success was similar in the first 7 (group 1) and last 13 patients (group 2), but fluoroscopy time decreased from 60 +/- 30 to 24 +/- 9 min/procedure, probably related to the increasing experience and ability to monitor catheter position non-fluoroscopically.
Entrainment mapping combined with three-dimensional electroanatomic mapping allows delineation of complex re-entry circuits and critical isthmuses as targets for ablation. Radiofrequency catheter ablation is a reasonable option for treatment of IARTs related to repair of CHD.
我们试图对先天性心脏病（CHD）修复术后晚期引起房内折返性心动过速（IART）的折返环路进行特征描述，并确定一种结合解剖结构、激动顺序数据和拖带标测的标测与消融方法。
CHD修复术后IART的发生因解剖结构复杂、折返环路位置多变以及多个环路常并存而难以处理和消融。
对20例药物治疗无效的复发性IART患者的47个折返环路进行了标测。第一组（n = 7），消融由拖带标测引导。第二组（n = 13），拖带标测与三维电解剖标测系统相结合，以精确确定折返环路与瘢痕相关的边界并重建激动模式。
识别出三种类型的右房大折返环路：与右侧房壁切开术瘢痕相关的（19例IART）、欧氏嵴峡部相关的（18例IART）或房间隔补片相关的（8例IART）。2例IART起源于左房。射频（RF）消融用于横断右房关键峡部。在3例患者中，联合标测方法在侧房识别出一个狭窄峡部，第一个RF消融阻断了环路；其余环路通过一系列更宽路径的RF消融被阻断。总体而言，47例IART中有38例（81%）成功消融。在3至46个月的随访期间，20例患者中有16例（80%）未复发。前7例（第一组）和后13例患者（第二组）的成功率相似，但透视时间从60±30分钟/手术降至24±9分钟/手术，这可能与经验增加以及非透视监测导管位置的能力提高有关。
拖带标测与三维电解剖标测相结合能够描绘复杂的折返环路和关键峡部作为消融靶点。射频导管消融是治疗与CHD修复相关的IART的合理选择。
