Williamson B D, Man K C, Daoud E, Niebauer M, Strickberger S A, Morady F
Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0022.
N Engl J Med. 1994 Oct 6;331(14):910-7. doi: 10.1056/NEJM199410063311404.
In some patients with atrial fibrillation, the ventricular rate may be difficult to control with medications. We evaluated a radiofrequency catheter technique to modify atrioventricular conduction in atrial fibrillation in order to control the ventricular rate without creating pathologic atrioventricular block.
We studied 19 consecutive patients with atrial fibrillation and uncontrolled ventricular rates refractory to drug therapy. They had had atrial fibrillation for a mean (+/- SD) of 5.5 +/- 4.9 years, had had 4.9 +/- 0.9 unsuccessful drug trials, and were 62 +/- 15 years old. Before the procedure, the maximal ventricular rate during exercise was 180 +/- 39 beats per minute. A total of 11 +/- 5 radiofrequency-energy applications were delivered to the posterior septal or midseptal right atrium, near the ostium of the coronary sinus.
Successful control of the ventricular rate without pathologic atrioventricular block was achieved in 14 of the 19 patients (74 percent). Persistent third-degree atrioventricular block requiring a permanent pacemaker occurred inadvertently in four patients (21 percent). Atrioventricular conduction was intentionally ablated in one patient. The 14 patients who had successful modification of conduction had persistent reductions in maximal ventricular rate during exercise (rate at three months, 126 +/- 24 beats per minute; P < 0.01). These patients had resolution of symptoms related to rapid rates during 8 +/- 2 months of follow-up. One patient had a recurrence of a rapid ventricular rate but was again asymptomatic after a second modification procedure. One patient with dilated cardiomyopathy died suddenly, five months after a successful procedure.
A catheter technique to modify atrioventricular conduction without creating pathologic atrioventricular block is feasible in the majority of patients with symptomatic atrial fibrillation and a rapid ventricular rate refractory to drug therapy.
在一些心房颤动患者中，心室率可能难以通过药物控制。我们评估了一种射频导管技术，用于改变心房颤动时的房室传导，以控制心室率而不产生病理性房室传导阻滞。
我们研究了19例连续的心房颤动患者，其心室率控制不佳且对药物治疗无效。他们患心房颤动的平均（±标准差）时间为5.5±4.9年，平均有4.9±0.9次药物治疗失败，年龄为62±15岁。在手术前，运动时的最大心室率为每分钟180±39次。总共向靠近冠状窦口的后间隔或中隔右心房施加了11±5次射频能量。
19例患者中有14例（74%）成功控制了心室率且未出现病理性房室传导阻滞。4例患者（21%）意外发生了需要植入永久起搏器的持续性三度房室传导阻滞。1例患者的房室传导被有意消融。14例传导成功改变的患者运动时的最大心室率持续降低（三个月时的心率为每分钟126±24次；P<0.01）。这些患者在8±2个月的随访期间与快速心率相关的症状得到缓解。1例患者心室率再次快速发作，但在第二次改良手术后再次无症状。1例扩张型心肌病患者在手术成功五个月后突然死亡。
对于大多数有症状的心房颤动且心室率快速且对药物治疗无效的患者，一种不产生病理性房室传导阻滞的改变房室传导的导管技术是可行的。
