Kalman J M, VanHare G F, Olgin J E, Saxon L A, Stark S I, Lesh M D
Department of Medicine, University of California, San Francisco 94143-1354, USA.
Circulation. 1996 Feb 1;93(3):502-12. doi: 10.1161/01.cir.93.3.502.
Intra-atrial reentrant tachycardia occurs frequently after surgery for congenital heart disease and is difficult to treat. We tested the hypotheses that intra-atrial reentrant tachycardia in patients who had undergone prior reparative surgery for congenital heart disease could be successfully ablated by targeting a protected isthmus of conduction bounded by natural and surgically created barriers and that entrainment techniques could be used to identify these zones.
Eighteen consecutive patients with 26 intra-atrial reentrant tachycardias complicating surgery for congenital heart disease (9 atrial septal defect repair, 4 Fontan, 2 Mustard, 2 Senning, and 1 Rastelli procedure) underwent electrophysiological study and ablation attempts. Mapping of activation was facilitated by the deployment of catheters with multiple electrodes. Sites for ablation were sought that demonstrated entrainment with concealed fusion and at which the postpacing interval minus the tachycardia cycle length and the stimulus to P wave minus the activation time were < 30 ms. These sites were considered to be within a narrow isthmus critical to the tachycardia mechanism. Anatomic barriers bordering the critical isthmus of conduction were identified on anatomic grounds, by the presence of areas of electrical silence or by the demonstration of split potentials signifying a line of block. Success was achieved in 15 patients with 21 arrhythmias. The median number of radiofrequency applications was 5. There was a wide range of activation times at successful sites (-30 to -250 ms). At a mean duration of follow-up of 17 +/- 8 months, 11 patients were asymptomatic and 9 did not require antiarrhythmia therapy.
Successful ablation of intra-atrial reentrant tachycardia complicating surgery for congenital heart disease may be achieved by creation of an ablative lesion in a critical isthmus of conduction bounded by anatomic barriers. This isthmus may be identified by the presence of entrainment with concealed fusion and an analysis of the relationship between the postpacing interval and the tachycardia cycle length and between the activation time and the stimulus time. Because this isthmus is invariably confined on at least one aspect by a surgical repair site that is of central importance to the tachycardia mechanism, we suggest that this type of arrhythmia be given the descriptive designation of "incisional reentry."
房内折返性心动过速在先天性心脏病手术后频繁发生且难以治疗。我们检验了以下假设：对于曾接受先天性心脏病修复手术的患者，通过靶向由天然和手术造成的屏障所界定的受保护传导峡部，房内折返性心动过速能够成功消融，并且拖带技术可用于识别这些区域。
18例连续患者共发生26次房内折返性心动过速，均为先天性心脏病手术后的并发症（9例房间隔缺损修补术、4例Fontan手术、2例Mustard手术、2例Senning手术和1例Rastelli手术），接受了电生理研究及消融尝试。通过使用多电极导管促进激动标测。寻找能够显示隐匿性融合拖带且起搏后间期减去心动过速周期长度以及刺激信号至P波间期减去激动时间<30 ms的消融部位。这些部位被认为位于对心动过速机制至关重要的狭窄峡部内。通过解剖学依据、电静止区域的存在或表示阻滞线的分裂电位的显示来确定与关键传导峡部相邻的解剖学屏障。15例患者的21次心律失常消融成功。射频应用的中位数为5次。成功部位的激动时间范围很广（-30至-250 ms）。平均随访17±8个月时，11例患者无症状，9例患者无需抗心律失常治疗。
通过在由解剖学屏障界定的关键传导峡部制造消融灶，可成功消融先天性心脏病手术后并发的房内折返性心动过速。该峡部可通过隐匿性融合拖带的存在以及对起搏后间期与心动过速周期长度之间以及激动时间与刺激时间之间关系的分析来识别。由于该峡部至少在一个方面总是被对心动过速机制至关重要的手术修复部位所限制，我们建议将这种类型的心律失常命名为“切口折返”。
