Morady F, Strickberger A, Man K C, Daoud E, Niebauer M, Goyal R, Harvey M, Bogun F
Division of Cardiology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan 48109-0022, USA.
J Am Coll Cardiol. 1996 Mar 1;27(3):683-9. doi: 10.1016/0735-1097(95)00493-9.
The purpose of this study was to categorize the reasons for a prolonged or failed procedure in a series of patients undergoing catheter ablation of an accessory pathway.
Radiofrequency ablation of accessory pathways at times requires a lengthy procedure or a second ablation session, or both, and not prior studies have systematically investigated the reasons for this.
In a consecutive series of 619 patients undergoing catheter ablation of an accessory pathway, the mean ablation time +/- SD was 68 +/- 64 min. The subjects of this study were 14 patients who had an ablation time >2 SD greater than the mean (>196 min) and 51 patients who required a second ablation session for a successful outcome. The accessory pathway in the 65 patients in this study was located in the right free wall in 19 patients (29%), septum in 14 (22%) and left free wall in 32 (49%).
The primary reasons for a lengthy or failed ablation attempt were 1) inability to position the ablation catheter at the effective target site (16 patients, 25%); 2) instability of the ablation catheter or inadequate tissue contact at the target site, or both (15 patients, 23%); 3) mapping error due to an oblique course of the accessory pathway (7 patients, 11%); 4) failure to recognize a posteroseptal accessory pathway as being left-sided instead of right-sided (4 patients, 6%); 5) other errors in accessory pathway localization (6 patients, 9%); 6) epicardial location of the accessory pathway (5 patients, 8%); 7) recurrent atrial fibrillation (2 patients, 3%); 8) occurrence of a complication (2 patients, 3%); 9) unusual right-sided accessory pathway that inserted in the anterior right ventricle, 2 cm away from the lateral tricuspid annulus (1 patient, 1.5%); and 10) unexplained factors (7 patients, 11%). The most common effective strategies employed to achieve a successful outcome in these patients were 1) substitution of a more experienced operator; 2) use of ablation catheters of varying configurations; 3) switching from a retrograde aortic to a trans-septal approach; 4) switching from an inferior to a superior vena caval approach; 5) use of a 60-cm guiding sheath; 6) detailed mapping of the atrial or ventricular insertion of the accessory pathway; and 7) searching within the coronary sinus for a presumed accessory pathway potential.
A lengthy or failed attempt at catheter ablation of an accessory pathway may be due to a variety of reasons, the most common of which are problems related to some aspect of catheter manipulation and errors in accessory pathway localization. Knowledge of the most common reasons for a lengthy or ineffective procedure may facilitate successful outcome of accessory pathway ablation.
本研究旨在对一系列接受旁路导管消融术的患者手术时间延长或手术失败的原因进行分类。
旁路射频消融术有时需要较长的手术时间或进行第二次消融手术，或两者皆需，但此前尚无研究系统地探究其原因。
在连续的619例接受旁路导管消融术的患者中，平均消融时间±标准差为68±64分钟。本研究的对象为14例消融时间比平均值超出2个标准差以上（>196分钟）的患者以及51例需要进行第二次消融手术才能成功的患者。本研究中65例患者的旁路位于右游离壁19例（29%）、间隔14例（22%）和左游离壁32例（49%）。
消融尝试时间延长或失败的主要原因如下：1）无法将消融导管置于有效靶点（16例患者，25%）；2）消融导管不稳定或靶点处组织接触不充分，或两者皆有（15例患者，23%）；3）由于旁路走行倾斜导致标测错误（7例患者，11%）；4）未识别出后间隔旁路为左侧而非右侧（4例患者，6%）；5）旁路定位的其他错误（6例患者，9%）；6）旁路位于心外膜（5例患者，8%）；7）复发性房颤（2例患者，3%）；8）出现并发症（2例患者，3%）；9）异常的右侧旁路插入右心室前部，距三尖瓣环外侧2厘米（1例患者，1.5%）；10）不明原因（7例患者，11%）。在这些患者中，为实现成功结果所采用的最常见有效策略如下：1）更换经验更丰富的术者；2）使用不同构型的消融导管；3）从逆行主动脉途径改为经间隔途径；4）从下腔静脉途径改为上腔静脉途径；5）使用60厘米的引导鞘；6）详细标测旁路的心房或心室插入点；7）在冠状窦内寻找推测的旁路电位。
旁路导管消融术尝试时间延长或失败可能有多种原因，其中最常见的是与导管操作某些方面相关的问题以及旁路定位错误。了解手术时间延长或无效的最常见原因可能有助于旁路消融术取得成功结果。
