Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Department of Cardiology and Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain.
Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
JACC Clin Electrophysiol. 2018 Oct;4(10):1328-1337. doi: 10.1016/j.jacep.2018.05.026. Epub 2018 Jul 25.
The purpose of this study was to assess the safety and efficacy of cryoablation for perinodal substrates in patients with congenital heart disease (CHD) and a displaced atrioventricular (AV) conduction system or an AV conduction system location that was difficult to predict.
Catheter ablation for perinodal arrhythmias in patients with CHD may incur higher risks due to unconventional or difficult to predict locations of the AV conduction system. Cryoablation carries theoretical advantages for such patients but has not been studied in this setting.
A total of 35 patients with CHD underwent cryoablation for perinodal substrates at the Montreal Heart Institute between 2006 and 2016. Ten of these patients, age 33 ± 13 years, 60% male, had AV conduction systems that were displaced or of uncertain location and underwent cryoablation (6-mm electrode-tip catheter) for 12 perinodal arrhythmias: AV nodal re-entrant tachycardia (n = 4), non-automatic focal atrial tachycardia (n = 4), septal intra-atrial re-entrant tachycardia (n = 3), and para-Hisian automatic focal atrial tachycardia (n = 1). Four patients had single-ventricle physiology and had undergone Fontan palliation (3 atriopulmonary and 1 intracardiac total cavopulmonary connection), 4 underwent repair of AV septal defects, 1 had congenitally corrected transposition of the great arteries (TGA), and 1 had TGA with a Mustard baffle.
Cryoablation was acutely successful in 9 of 12 targeted arrhythmias (75%) with no procedural complication. Crossover to radiofrequency ablation successfully eliminated the remaining 3 arrhythmias at sites deemed safe by cryoablation, with no complication. Over a follow-up period of 26 (interquartile range: 15 to 64) months, 1 of 9 successfully cryoablated arrhythmias recurred.
Cryoablation is feasible, safe, and moderately effective for perinodal arrhythmia substrates in patients with various forms of CHD associated with AV conduction systems that are displaced or in locations that cannot be reliably predicted.
本研究旨在评估冷冻消融治疗先天性心脏病（CHD）患者心外膜旁道的安全性和有效性，这些患者的房室（AV）传导系统位置发生移位或难以预测。
由于 AV 传导系统位置非常规或难以预测，CHD 患者的旁道消融术可能会带来更高的风险。冷冻消融术对这类患者具有理论上的优势，但尚未在该环境中进行研究。
2006 年至 2016 年间，共有 35 例 CHD 患者在蒙特利尔心脏研究所接受冷冻消融治疗心外膜旁道。其中 10 例患者（年龄 33±13 岁，60%为男性）的 AV 传导系统发生移位或位置不确定，并接受冷冻消融（6 毫米电极导管）治疗 12 种心外膜旁道心律失常：房室结折返性心动过速（AVNRT，n=4）、非自动局灶性房性心动过速（n=4）、间隔内房性折返性心动过速（n=3）和希氏旁自动局灶性房性心动过速（n=1）。4 例患者为单心室生理学，已行 Fontan 姑息术（3 例为三尖瓣肺动脉连接，1 例为心内全腔静脉肺动脉连接），4 例患者行房室间隔缺损修复术，1 例患者患有矫正型大动脉转位（TGA），1 例患者患有 TGA 并 Mustard 分流术。
12 种目标心律失常中，有 9 种（75%）在冷冻消融治疗后即刻成功，无手术并发症。在冷冻消融认为安全的部位，改用射频消融术成功消除了其余 3 种心律失常，且无并发症。在 26 个月（中位数：15-64）的随访中，有 1 例在冷冻消融成功的心律失常中复发。
冷冻消融术对于各种形式的 CHD 患者心外膜旁道的治疗是可行的、安全的，并且具有中度疗效，尤其适用于 AV 传导系统位置发生移位或难以预测的患者。
