Cardiovascular Division, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
Cardiovascular Division, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
Heart Rhythm. 2020 Feb;17(2):243-249. doi: 10.1016/j.hrthm.2019.08.023. Epub 2019 Aug 27.
Right free-wall (RFW) accessory pathway (AP) with branched atrial insertions is a rare, underrecognized AP that may be associated with initial ablation failure.
The purpose of this study was to investigate the clinical and electrophysiological characteristics of this AP.
From January 2011 to March 2018, 10 patients identified with branched RFW-AP were enrolled in this study, and 30 consecutive patients with conventional RFW-APs served as control group. Right atrium (RA) was activation-mapped and 3-dimensionally reconstructed during AP-mediated orthodromic tachycardia or right ventricular pacing. Atrial insertions were defined as the earliest breakout sites, and their relationship with the tricuspid annulus (TA) were described and analyzed.
An average of 3 separate atrial insertions on the atrial side were documented among these 10 cases (5 female and 5 male; mean age 38.0 ± 13.9 years). All atrial insertions were away from the TA. The nearest atrial insertions averaged 15.9 ± 3.4 mm away from the TA, and the farthest atrial insertions were 22.6 ± 5.7 mm away from the TA. Anterograde and retrograde AP conduction remained unaffected after ablation of the first earliest breakout site but were eliminated by ablating all insertions after an average of 2.5 (range 2-2.5) remaps, 3 sites of ablation (range 2.5-4.5), 21 (range 15.5-37.8) radiofrequency applications, and 659.5 (range 464.3-1144.3) seconds of radiofrequency ablation duration. After 12-month follow-up, no patients reported AP conduction recovery or recurrent tachycardia.
RFW-AP with branched atrial insertions is an atypical AP variant and featured by >1 distinct atrial insertions on atrial side. Stepwise ablation rather than single focal ablation is required to eliminate all retrograde conduction.
右游离壁（RFW）旁道（AP）伴分支心房插入是一种罕见的、认识不足的 AP，可能与初始消融失败有关。
本研究旨在探讨该 AP 的临床和电生理特征。
从 2011 年 1 月至 2018 年 3 月，共纳入 10 例诊断为分支 RFW-AP 的患者，作为研究组，并纳入 30 例连续的常规 RFW-AP 患者作为对照组。在 AP 介导的顺向性心动过速或右心室起搏时进行右心房（RA）激动标测和三维重建。心房插入部位定义为最早的突破点，并对其与三尖瓣环（TA）的关系进行描述和分析。
这 10 例患者共记录到 3 个独立的心房侧插入部位（5 例女性，5 例男性；平均年龄 38.0±13.9 岁）。所有心房插入部位均远离 TA。最近的心房插入部位距离 TA 平均为 15.9±3.4mm，最远的心房插入部位距离 TA 为 22.6±5.7mm。消融第一个最早突破点后，顺向和逆向 AP 传导不受影响，但平均进行 2.5（范围 2-2.5）次重映射、消融 3 个部位（范围 2.5-4.5）、21 次（范围 15.5-37.8）射频消融应用和 659.5（范围 464.3-1144.3）秒射频消融时间后，所有插入部位均被消除。随访 12 个月，无患者报告 AP 传导恢复或复发性心动过速。
RFW-AP 伴分支心房插入是一种非典型的 AP 变异，其特征是心房侧有>1 个独立的心房插入部位。需要逐步消融而非单一焦点消融来消除所有逆向传导。
